Variation in Triple Aim Measures: Implications of Clinical Signatures in Family Medicine Residency Programs.

BACKGROUND: Evidence from several specialties suggests that practice patterns developed in residency influence the quality and cost of care long after completion of training. Improving the quality, cost, and patient experience of care (the "Triple Aim") is foundational to future health systems change. OBJECTIVE: We measured variation in Triple Aim measures among family medicine residency programs in a regional quality improvement collaborative (I3 Population Health Collaborative). METHODS: We calculated medians and interquartile ranges for each of 11 Triple Aim measures and compared them with median splits of population and practice characteristics, including payer mix, patient race and age, electronic health record used, registry use, and National Committee for Quality Assurance patient-centered medical home recognition. RESULTS: All 22 participating family medicine residency programs provided baseline data. The number of practices reporting data on individual measures ranged from 9 to 17 (41%-77%). We found variation averaging 51% across all measures, from a low of 12% for readmission rates to 94% for emergency department visit rates. Variations were stable over time. We found no significant relationships between practice or population characteristics and measures, nor between practice characteristics and outcomes variation. CONCLUSIONS: The 22 family medicine residency programs in our study showed substantial variation in quality, cost, and patient experience of care. These variations did not appear to result from differences in practice characteristics, payer mix, or patient demographics.

Does the provision of free intrauterine contraception reduce pregnancy rates among uninsured low-income women? A cohort study: a two North Carolina clinics.

BACKGROUND: Low-income women are disproportionately affected by unintended pregnancy. The Access to Resources in Contraceptive Health Foundation was established to provide free levonorgestrel intrauterine contraceptive systems to uninsured women who meet specific socioeconomic eligibility criteria. The aim of this study was to evaluate the effectiveness of this program at reducing pregnancies among uninsured women attending two North Carolina clinics. STUDY DESIGN: This was a retrospective cohort study including uninsured women (aged 15-44 years) who desired contraception, were deemed eligible for the program and attended one of two North Carolina clinics between January 1, 2003, and June 30, 2009. The primary outcome was pregnancy. Pregnancy rates were compared between those women who had a program-approved intrauterine device placed (exposed group) and those women who were eligible for the program, but did not have a device placed (the unexposed group). Questionnaires were used to determine the numbers of pregnancies (and dates of conception), the types of alternative contraception being used and basic demographic information about program participants. The data were analyzed using survival analysis of time to pregnancy. A Cox proportional hazards model was used to estimate a hazard ratio. RESULTS: We attempted to reach 321 patients and obtained 104 responses. After exclusions, data from 90 participants were analyzed. Sixty-five women received a levonorgestrel device, and 25 eligible women did not. Seven pregnancies occurred in the exposed group (11%), all after the IUD was removed; three of these pregnancies were planned. Eight pregnancies occurred in the unexposed group (32%). The median follow-up time was 2.4 years (range: 0.75-4 years) and 1.8 years (0.05-4 years) in the exposed and unexposed groups, respectively. CONCLUSIONS: Provision of a levonorgestrel-releasing device was associated with significantly lower risk of pregnancy than was use of alternative or no contraception. If these data from North Carolina are representative of experience nationwide, then the public health benefit of the Foundation's philanthropy may be large.