A Cluster Randomized Trial of Primary Care Practice Redesign to Integrate Behavioral Health for Those Who Need It Most: Patients With Multiple Chronic Conditions.

PURPOSE: Patient outcomes can improve when primary care and behavioral health providers use a collaborative system of care, but integrating these services is difficult. We tested the effectiveness of a practice intervention for improving patient outcomes by enhancing integrated behavioral health (IBH) activities. METHODS: We conducted a pragmatic, cluster randomized controlled trial. The intervention combined practice redesign, quality improvement coaching, provider and staff education, and collaborative learning. At baseline and 2 years, staff at 42 primary care practices completed the Practice Integration Profile (PIP) as a measure of IBH. Adult patients with multiple chronic medical and behavioral conditions completed the Patient-Reported Outcomes Measurement Information System (PROMIS-29) survey. Primary outcomes were the change in 8 PROMIS-29 domain scores. Secondary outcomes included change in level of integration. RESULTS: Intervention assignment had no effect on change in outcomes reported by 2,426 patients who completed both baseline and 2-year surveys. Practices assigned to the intervention improved PIP workflow scores but not PIP total scores. Baseline PIP total score was significantly associated with patient-reported function, independent of intervention. Active practices that completed intervention workbooks (n = 13) improved patient-reported outcomes and practice integration (P ≤ .05) compared with other active practices (n = 7). CONCLUSION: Intervention assignment had no effect on change in patient outcomes; however, we did observe improved patient outcomes among practices that entered the study with greater IBH. We also observed more improvement of integration and patient outcomes among active practices that completed the intervention compared to active practices that did not. Additional research is needed to understand how implementation efforts to enhance IBH can best reach patients.

Have racial disparities in home dialysis utilization changed over time?

OBJECTIVES: The Medicare end-stage kidney disease (ESKD) prospective payment system (PPS) for maintenance dialysis, implemented in 2011, resulted in modestly increased access to both home-based peritoneal dialysis (PD) and home hemodialysis (HHD) treatment modalities, but it is unclear whether regional disparities in home dialysis (PD and HHD) were affected. We compared regional home dialysis use by White and non-White individuals over time. STUDY DESIGN: Retrospective cohort study of dialysis facilities offering home dialysis in 2006-2016 and of 1,098,579 patients with prevalent ESKD in 2006-2016. METHODS: We compared hospital referral region (HRR) utilization rates of home dialysis between White and non-White patients over time using a generalized estimating equation model with a negative binomial distribution adjusting for regional characteristics. RESULTS: The mean number of facilities offering home dialysis operating in each HRR increased from 15.6 in 2006 to 22.1 in 2016. Observed mean HRR home dialysis rates increased overall, but White patients maintained greater home dialysis use than non-White patients: 19.7% in 2006 and 26.2% in 2016 among White patients vs 13.0% in 2006 and 17.8% in 2016 among non-White patients. In adjusted analysis, there was no evidence of changes in White/non-White disparities in home dialysis use over time (P = .84) or after the Medicare ESKD PPS in 2011 (incidence rate ratio, 0.97; 95% CI, 0.92-1.02; P = .29). CONCLUSIONS: Even after modest increases in dialysis facility availability and patient utilization after the implementation of the Medicare ESKD PPS in 2011, significant racial disparities in home dialysis remain.

Development of a Medicare plan dashboard to promote health equity.

OBJECTIVE: To describe a multistage process of designing and evaluating a dashboard that presents data on how equitably health plans provide care for their members. STUDY DESIGN: We designed a dashboard for presenting summative and finer-grained data to health plans for characterizing how well plans are serving individuals who belong to racial/ethnic minority groups and individuals with low income. The data presented in the dashboard were based on CMS' Health Equity Summary Score (HESS) for Medicare Advantage plans. METHODS: Interviews and listening sessions were conducted with health plan representatives and other stakeholders to assess understanding, perceived usefulness, and interpretability of HESS data. Usability testing was conducted with individuals familiar with quality measurement and reporting to evaluate dashboard design efficiency. RESULTS: Listening session participants understood the purpose of the HESS and expressed a desire for this type of information. Usability testing revealed a need to improve dashboard navigability and to streamline content. CONCLUSIONS: The HESS dashboard is a potentially useful tool for presenting data on health equity to health plans. The multistage process of continual testing and improvement used to develop the dashboard could be a model for targeting and deciding upon quality improvement efforts in the domain of health equity.

Follow-up Post-discharge and Readmission Disparities Among Medicare Fee-for-Service Beneficiaries, 2018.

BACKGROUND: Previous studies have identified disparities in readmissions among Medicare beneficiaries hospitalized for the Hospital Readmissions Reduction Program's (HRRP's) priority conditions. Evidence suggests timely follow-up is associated with reduced risk of readmission, but it is unknown whether timely follow-up reduces disparities in readmission. OBJECTIVE: To assess whether follow-up within 7 days after discharge from a hospitalization reduces risk of readmission and mitigates identified readmission disparities. DESIGN: A retrospective cohort study using Cox proportional hazards models to estimate the associations between sociodemographic characteristics (race and ethnicity, dual-eligibility status, rurality, and area social deprivation), follow-up, and readmission. Mediation analysis was used to examine if disparities in readmission were mitigated by follow-up. PARTICIPANTS: We analyzed data from 749,402 Medicare fee-for-service beneficiaries hospitalized for acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, or pneumonia, and discharged home between January 1 and December 1, 2018. MAIN MEASURE: All-cause unplanned readmission within 30 days after discharge. KEY RESULTS: Post-discharge follow-up within 7 days of discharge was associated with a substantially lower risk of readmission (HR: 0.52, 95% CI: 0.52-0.53). Across all four HRRP conditions, beneficiaries with dual eligibility and beneficiaries living in areas with high social deprivation had a higher risk of readmission. Non-Hispanic Black beneficiaries had higher risk of readmission after hospitalization for pneumonia relative to non-Hispanic Whites. Mediation analysis suggested that 7-day follow-up mediated 21.2% of the disparity in the risk of readmission between dually and non-dually eligible beneficiaries and 50.7% of the disparity in the risk of readmission between beneficiaries living in areas with the highest and lowest social deprivation. Analysis suggested that after hospitalization for pneumonia, 7-day follow-up mediated nearly all (97.5%) of the increased risk of readmission between non-Hispanic Black and non-Hispanic White beneficiaries. CONCLUSIONS: Improving rates of follow-up could be a strategy to reduce readmissions for all beneficiaries and reduce disparities in readmission based on sociodemographic characteristics.

Development and validation of the patient centeredness index for primary care.

AIMS AND OBJECTIVES: To describe the development of the Patient Centeredness Index (PCI), evaluate its psychometric characteristics and evaluate the relationships between scores on the PCI and an established measure of empathy. BACKGROUND: Patient centeredness helps patients manage multiple chronic conditions with their providers, nurses and other team members. However, no instrument exists for evaluating patient centeredness within primary care practices treating this population. DESIGN: Multi-site instrument development and validation. STROBE reporting guidelines were followed. METHODS: To identify themes, we consulted literature on patient centeredness and engaged stakeholders who had or were caring for people with multiple chronic conditions (n = 7). We composed and refined items to represent those themes with input from clinicians and researchers. To evaluate reliability and convergent validity, we administered surveys to participants (n = 3622) with chronic conditions recruited from 44 primary care practices for a large-scale cluster randomised clinical trial of the effects of a practice-level intervention on patient and practice-level outcomes. Participants chose to complete the 16-item survey online, on paper or by phone. Surveys assessed demographics, number of chronic conditions and ratings of provider empathy. We conducted exploratory factor analysis to model the interrelationships among items. RESULTS: A single factor explained 93% of total variance. Factor loadings ranged from 0.55-0.85, and item-test correlations were ≥.67. Cronbach's alpha was .93. A moderate, linear correlation with ratings of provider's empathy (r = .65) supports convergent validity. CONCLUSIONS: The PCI is a new tool for obtaining patient perceptions of the patient centeredness of their primary care practice. The PCI shows acceptable reliability and evidence of convergent validity among patients managing chronic conditions. RELEVANCE TO CLINICAL PRACTICE: The PCI rapidly identifies patients' perspectives on patient centeredness of their practice, making it ideal for administration in busy primary care settings that aim to efficiently address patient-identified needs. TRIAL REGISTRATION: Clinicaltrials.org Protocol ID: WLPS-1409-24372. TITLE: Integrating Behavioural Health and Primary Care for Comorbid Behavioural and Medical Problems (IBHPC).

Association of Implementation and Social Network Factors With Patient Safety Culture in Medical Homes: A Coincidence Analysis.

OBJECTIVES: The patient-centered medical home (PCMH) may provide a key model for ambulatory patient safety. Our objective was to explore which PCMH and patient safety implementation and social network factors may be necessary or sufficient for higher patient safety culture. METHODS: This was a cross-case analysis study in 25 diverse U.S. PCMHs. Data sources included interviews of a clinician and an administrator in each PCMH, surveys of clinicians and staff, and existing data on the PCMHs' characteristics. We used coincidence analysis, a novel method based on set theory and Boolean logic, to evaluate relationships between factors and the implementation outcome of patient safety culture. RESULTS: The coincidence analysis identified 5 equally parsimonious solutions (4 factors), accounting for all practices with higher safety culture. Three solutions contained the same core minimally sufficient condition: the implementation factor leadership priority for patient safety and the social network factor reciprocity in advice-seeking network ties (advice-seeking relationships). This minimally sufficient condition had the highest coverage (5/7 practices scoring higher on the outcome) and best performance across solutions; all included leadership priority for patient safety. Other key factors included self-efficacy and job satisfaction and quality improvement climate. The most common factor whose absence was associated with the outcome was a well-functioning process for behavioral health. CONCLUSIONS: Our findings suggest that PCMH safety culture is higher when clinicians and staff perceive that leadership prioritizes patient safety and when high reciprocity among staff exists. Interventions to improve patient safety should consider measuring and addressing these key factors.

Health Plans Struggle to Report on Depression Quality Measures That Require Clinical Data.

OBJECTIVE: Depression quality measures aligned with evidence-based practices require that health care organizations use standardized tools for tracking and monitoring patient-reported symptoms and functioning over time. This study describes challenges and opportunities for reporting 5 HEDIS measures which use electronic clinical data to assess adolescent and perinatal depression care quality. METHODS: Two learning collaboratives were convened with 10 health plans from 5 states to support reporting of the depression measures. We conducted content analysis of notes from collaborative meetings and individual calls with health plans to identify key challenges and strategies for reporting. RESULTS: Health plans used various strategies to collect the clinical data needed to report the measures, including setting up direct data exchange with providers and data aggregators and leveraging data captured in health information exchanges and case management records. Health plans noted several challenges to reporting and performance improvement: 1) lack of access to clinical data sources where the results of patient-reported tools were documented; 2) unavailability of the results of patient-reported tools in usable data fields; 3) lack of routine depression screening and ongoing assessment occurring in provider practices. CONCLUSIONS: Our findings demonstrate ongoing challenges in collecting and using patient-reported clinical data for health plan quality measurement. Systems to track and improve outcomes for individuals with depression will require significant investments and policy support at the point of care and across the healthcare system.

Evaluation of a Chronic Pain Screening Program Implemented in Primary Care.

Importance: Although pain is among the most common symptoms reported by patients, primary care practitioners (PCPs) face substantial challenges identifying and assessing pain. Objective: To evaluate a 2-step process for chronic pain screening and follow-up in primary care. Design, Setting, and Participants: A cross-sectional study of patients with a primary care visit between July 2, 2018, and June 1, 2019, was conducted at a statewide, multisite federally qualified health center. Participants included 68 PCPs and 58 medical assistants from 13 sites who implemented the screening process in primary care, and 38 866 patients aged 18 years or older with a primary care visit during that time. Exposures: Single-question assessment of pain frequency, followed by a 3-question PEG (pain, enjoyment of life, general activity) functional assessment for patients with chronic pain. Main Outcomes and Measures: Adherence to a 2-step chronic pain screening and PEG process, proportion of patients with positive screening results, mean PEG pain severity greater than or equal to 7, and documented chronic painful condition diagnosis in patient's electronic health record between 1 year before and 90 days after screening. Results: Of 38 866 patients with a primary care visit, 31 600 patients (81.3%) underwent screening. Mean (SD) age was 46.2 (15.4) years, and most were aged 35 to 54 years (12 987 [41.1%]), female (18 436 [58.3%]), Hispanic (14 809 [46.9%]), and English-speaking (22 519 [71.3%]), and had Medicaid insurance (18 442 [58.4%]). A total of 10 262 participants (32.5%) screened positive and, of these, 9701 (94.5%) completed the PEG questionnaire. PEG responses indicated severe pain interference with activities of daily living (PEG ≥7) in 5735 (59.1%) participants. A chronic painful condition had not been diagnosed in 4257 (43.9%) patients in the year before screening. A new chronic painful condition was diagnosed at screening or within 90 days in 2250 (52.9%) patients. Care teams found the workflow acceptable, but cited lengthy administration time, challenges with comprehension of the PEG questions, and limited comprehensiveness as implementation barriers. Conclusions and Relevance: A systematic, 2-step process for chronic pain screening and functional assessment in primary care appeared to identify patients with previously undocumented chronic pain and was feasible to implement. Patient-provided information on the frequency of pain, pain level, and pain interference can help improve the assessment and monitoring of pain in primary care.

Implementation of Patient Safety Structures and Processes in the Patient-Centered Medical Home.

ABSTRACT: Although most patient-clinician interactions occur in ambulatory care, little research has addressed measuring ambulatory patient safety or how primary care redesign such as the patient-centered medical home (PCMH) addresses patient safety. Our objectives were to identify PCMH standards relevant to patient safety, construct a measure of patient safety activity implementation, and examine differences in adoptions of these activities by practice and community characteristics. Using a consensus process, we selected elements among a widely adopted, nationally representative PCMH program representing activities that, according to a physician panel, represented patient safety overall and in four domains (diagnosis, treatment delays, medications, and communication and coordination) and generated a score for each. We then evaluated this score among 5,007 practices with the highest PCMH recognition level. Implementation of patient safety activities varied; the few military practices (2.4%) had the highest, and community clinics the lowest, patient safety score, both overall (82.0 and 72.0, respectively, p < .001) and across specific domains. Other practice and community characteristics were not associated with the patient safety score. Understanding better what factors are associated with implementation of patient safety activities may be a key step in improving ambulatory patient safety.

Annual wellness visits and care management before and after dialysis initiation.

INTRODUCTION: Demands of dialysis regimens may pose challenges for primary care provider (PCP) engagement and timely preventive care. This is especially the case for patients initiating dialysis adjusting to new logistical challenges and management of symptoms and existing comorbid conditions. Since 2011, Medicare has provided coverage for annual wellness visits (AWV), which are primarily conducted by PCPs and may be useful for older adults undergoing dialysis. METHODS: We used the OptumLabs® Data Warehouse to identify a cohort of 1,794 Medicare Advantage (MA) enrollees initiating dialysis in 2014-2017 and examined whether MA enrollees (1) were seen by a PCP during an outpatient visit and (2) received an AWV in the year following dialysis initiation. RESULTS: In the year after initiating dialysis, 93 % of MA enrollees had an outpatient PCP visit but only 24 % received an annual wellness visit. MA enrollees were less likely to see a PCP if they had Charlson comorbidity scores between 0 and 5 than those with scores 6-9 (odds ratio (OR) = 0.59, 95 % CI: 0.37-0.95), but more likely if seen by a nephrologist (OR = 1.60, 95 % CI: 1.01-2.52) or a PCP (OR = 15.65, 95 % CI: 9.26-26.46) prior to initiation. Following dialysis initiation, 24 % of MA enrollees had an AWV. Hispanic MA enrollees were less likely (OR = 0.57, 95 % CI: 0.39-0.84) to have an AWV than White MA enrollees, but enrollees were more likely if they initiated peritoneal dialysis (OR = 1.54, 95 % CI: 1.07-2.23) or had an AWV in the year before dialysis initiation (OR = 4.96, 95 % CI: 3.88-6.34). CONCLUSIONS: AWVs are provided at low rates to MA enrollees initiating dialysis, particularly Hispanic enrollees, and represent a missed opportunity for better care management for patients with ESKD. Increasing patient awareness and provider provision of AWV use among dialysis patients may be needed, to realize better preventive care for dialysis patients.

Integrating Behavioral Health and Primary Care (IBH-PC) to improve patient-centered outcomes in adults with multiple chronic medical and behavioral health conditions: study protocol for a pragmatic cluster-randomized control trial.

BACKGROUND: Chronic diseases that drive morbidity, mortality, and health care costs are largely influenced by human behavior. Behavioral health conditions such as anxiety, depression, and substance use disorders can often be effectively managed. The majority of patients in need of behavioral health care are seen in primary care, which often has difficulty responding. Some primary care practices are providing integrated behavioral health care (IBH), where primary care and behavioral health providers work together, in one location, using a team-based approach. Research suggests there may be an association between IBH and improved patient outcomes. However, it is often difficult for practices to achieve high levels of integration. The Integrating Behavioral Health and Primary Care study responds to this need by testing the effectiveness of a comprehensive practice-level intervention designed to improve outcomes in patients with multiple chronic medical and behavioral health conditions by increasing the practice's degree of behavioral health integration. METHODS: Forty-five primary care practices, with existing onsite behavioral health care, will be recruited for this study. Forty-three practices will be randomized to the intervention or usual care arm, while 2 practices will be considered "Vanguard" (pilot) practices for developing the intervention. The intervention is a 24-month supported practice change process including an online curriculum, a practice redesign and implementation workbook, remote quality improvement coaching services, and an online learning community. Each practice's degree of behavioral health integration will be measured using the Practice Integration Profile. Approximately 75 patients with both chronic medical and behavioral health conditions from each practice will be asked to complete a series of surveys to measure patient-centered outcomes. Change in practice degree of behavioral health integration and patient-centered outcomes will be compared between the two groups. Practice-level case studies will be conducted to better understand the contextual factors influencing integration. DISCUSSION: As primary care practices are encouraged to provide IBH services, evidence-based interventions to increase practice integration will be needed. This study will demonstrate the effectiveness of one such intervention in a pragmatic, real-world setting. TRIAL REGISTRATION: ClinicalTrials.gov NCT02868983 . Registered on August 16, 2016.

Incentivizing Excellent Care to At-Risk Groups with a Health Equity Summary Score.

BACKGROUND: Social risk factors (SRFs) such as minority race-and-ethnicity or low income are associated with quality-of-care, health, and healthcare outcomes. Organizations might prioritize improving care for easier-to-treat groups over those with SRFs, but measuring, reporting, and further incentivizing quality-of-care for SRF groups may improve their care. OBJECTIVE: To develop, as a proof-of-concept, a Health Equity Summary Score (HESS): a succinct, easy-to-understand score that could be used to promote high-quality care to those with SRFs in Medicare Advantage (MA) health plans, which provide care for almost twenty million older and disabled Americans and collect extensive quality measure and SRF data. DESIGN: We estimated, standardized, and combined performance scores for two sets of quality measures for enrollees in 2013-2016 MA health plans, considering both current levels of care, within-plan improvement, and nationally benchmarked improvement for those with SRFs (specifically, racial-and-ethnic minority status and dual-eligibility for Medicare and Medicaid). PARTICIPANTS: All MA plans with publicly reported quality scores and 500 or more 2016 enrollees. MAIN MEASURES: Publicly reported clinical quality and patient experience measures. KEY RESULTS: Almost 90% of plans measured for MA Star Ratings received a HESS; plans serving few patients with SRFs were excluded. The summary score was moderately positively correlated with publicly reported overall Star Ratings (r = 0.66-0.67). High-scoring plans typically had sizable enrollment of both racial-and-ethnic minorities (38-42%) and dually eligible beneficiaries (29-38%). CONCLUSIONS: We demonstrated the feasibility of developing and estimating a HESS that is intended to promote and incentivize excellent care for racial-and-ethnic minorities and dually eligible MA enrollees. The HESS measures SRF-specific performance and does not simply duplicate overall plan Star Ratings. It also identifies plans that provide excellent care to large numbers of those with SRFs. Our methodology could be extended to other SRFs, quality measures, and settings.

Patient-centered oncology care: impact on utilization, patient experiences, and quality.

OBJECTIVES: To determine whether implementation of patient-centered oncology standards in 5 medical oncology practices improved patient experiences and quality and reduced emergency department (ED) and hospital use. STUDY DESIGN: Retrospective, pre-post study design with a concurrent nonrandomized control group. METHODS: We used insurance claims to calculate all-cause hospitalizations and ED visits and primary care and specialist office visits (n = 28,826 eligible patients during baseline and 30,843 during follow-up) and identify patients for a care experiences survey (n = 715 preintervention and 437 postintervention respondents). For utilization and patient experience outcomes, we compared pilot practices' performance with 18 comparison practices using difference-in-differences (DID) regression models accounting for practice-level clustering. We assessed pilot practice performance on 31 quality measures from the American Society of Clinical Oncology Quality Oncology Practice Initiative program. RESULTS: There were no statistically significant differences in hospital, ED, or primary care visits between the pilot and comparison groups over time, but there was a significant increase in specialty visits for the pilot group (adjusted DID of 0.07; 95% CI, 0.01-0.13; P = .03). For care experiences, pilot practices improved more on shared decision-making (4.03 DID composite score; P = .013), whereas the comparison group improved more on access (-6.36 DID composite score; P < .001) and exchanging information (-4.25 DID composite score; P = .013). On average, pilot practices improved performance on 65% of core quality measures from baseline to follow-up. CONCLUSIONS: This pilot of patient-centered oncology care showed improved quality but no impact on hospitalizations/ED use and mixed results for patient experiences. Findings are consistent with early evaluations of primary care patient-centered medical homes.

Assessing Cancer Patient Experience of Care in Outpatient Oncology Practices in the United States.

INTRODUCTION: Cancer patients' experience of care is an important component of quality that has not previously been used for comparing performance. We administered a new patient experience survey to cancer patients receiving outpatient chemotherapy treatment. We examined its measures for sensitivity to adjustment for case-mix and response tendency (level of general optimism/pessimism) and reliability for making performance comparisons between practices. METHODS: We surveyed 2304 cancer patients who received chemotherapy at 23 medical oncology practices in Southeastern Pennsylvania, receiving 715 responses (response rate 31%; 14 practices had 10 or more responses). We aggregated patient responses to calculate practice-level scores on 5 predefined composites: Affective Communication, Shared Decision-Making, Patient Self-Management, Exchanging Information, and Access. We then ranked the practices on each composite before and after adjustment for standard case-mix variables and supplemental adjustment for response tendency (measured via the Life Orientation Test-Revised). We calculated the reliability of practice scores on each composite using hierarchical linear models and calculated minimum sample sizes necessary to achieve reliabilities exceeding 0.7. RESULTS: After adjusting responses for case-mix and converting to a 0-100 scale, composite scores ranged from 77 for the Patient Self-Management composite to 92 for the Access composite. Adjustment for response tendency had an impact on practice rankings only for the Shared Decision-Making composite. The number of responses necessary to create reliable practice-level measurements ranged from 17 (Access composite) to 96 (Affective Communication composite). CONCLUSIONS: Patient experiences at oncology practices can be measured reliably using reasonable sample sizes. Standard case-mix adjustment is adequate for making comparisons on most composites.

Validation of a Lysis Buffer Containing 4 M Guanidinium Thiocyanate (GITC)/ Triton X-100 for Extraction of SARS-CoV-2 RNA for COVID-19 Testing: Comparison of Formulated Lysis Buffers Containing 4 to 6 M GITC, Roche External Lysis Buffer and Qiagen RTL Lysis Buffer

The COVID-19 pandemic has resulted in increased need for diagnostic testing using reverse transcriptase real-time PCR (RT-PCR). An exponential increase in demand has resulted in a shortage of numerous reagents in particular those associated with the lysis buffer required to extract the viral RNA. Herein, we describe a rapid collective effort by hospital laboratory scientists, academic researchers and the biopharma industry to generate a validated lysis buffer. We have formulated a 4M Guanidinium thiocyanate (GITC)/ Triton X-100 Lysis buffer which provides comparable results with the recommended reagents. This buffer will ease the burden on hospital labs in their heroic efforts to diagnose a large population of patients.

Access to and Engagement in Substance Use Disorder Treatment Over Time.

OBJECTIVE: This study evaluated whether access to and engagement in substance use disorder treatment has improved from 2010 to 2016. METHODS: Data submitted by commercial and Medicaid health plans, representing over 163 million beneficiaries from 2010 to 2016, were analyzed. RESULTS: For commercial plans, identification increased (from 1.0% to 1.6%, p<0.001), the initiation rate declined (from 41.9% to 33.7%, p<0.001), and the engagement rate also declined (from 15.8% to 12.1%, p<0.001). The decline in the initiation and engagement rates could not be explained by the increasing identification rates. For Medicaid plans, the identification rate increased (from 3.3% to 6.7%, p<0.001), and the initiation and engagement rates were unchanged. CONCLUSIONS: Although an increasing proportion of health plan members are being identified with substance use disorders, the majority of these individuals are not engaging in treatment.

Lab-based and diagnosis-based chronic kidney disease recognition and staging concordance.

BACKGROUND: Chronic kidney disease (CKD) is often under-recognized and poorly documented via diagnoses, but the extent of under-recognition is not well understood among Medicare beneficiaries. The current study used claims-based diagnosis and lab data to examine patient factors associated with clinically recognized CKD and CKD stage concordance between claims- and lab-based sources in a cohort of Medicare beneficiaries. METHODS: In a cohort of fee-for-service (FFS) beneficiaries with CKD based on 2011 labs, we examined the proportion with clinically recognized CKD via diagnoses and factors associated with clinical recognition in logistic regression. In the subset of beneficiaries with CKD stage identified from both labs and diagnoses, we examined concordance in CKD stage from both sources, and factors independently associated with CKD stage concordance in logistic regression. RESULTS: Among the subset of 206,036 beneficiaries with lab-based CKD, only 11.8% (n = 24,286) had clinically recognized CKD via diagnoses. Clinical recognition was more likely for beneficiaries who had higher CKD stages, were non-elderly, were Hispanic or non-Hispanic Black, lived in core metropolitan areas, had multiple chronic conditions or outpatient visits in 2010, or saw a nephrologist. In the subset of 18,749 beneficiaries with CKD stage identified from both labs and diagnoses, 70.0% had concordant CKD stage, which was more likely if beneficiaries were older adults, male, lived in micropolitan areas instead of non-core areas, or saw a nephrologist. CONCLUSIONS: There is significant under-diagnosis of CKD in Medicare FFS beneficiaries, which can be addressed with the availability of lab results.

Variation and Change Over Time in PROMIS-29 Survey Results Among Primary Care Patients With Type 2 Diabetes.

PURPOSE: We sought to describe results of patient-reported outcome measures implemented among primary care patients with diabetes and explore factors associated with changes in scores over time. METHODS: Two organizations serving diverse patient populations collected the PROMIS-29 survey at baseline and 3-month follow-up for patients with type 2 diabetes. Bayesian regression analysis was used to examine the relationship between patient characteristics and changes in PROMIS-29 scores. Exploratory analyses assessed relationships between goal-setting and changes in scores. RESULTS: The study population reported substantially more problems with physical functioning (mean: 42.5 at Site 1 and 38.9 at Site 2) and pain interference (mean: 58.0 at Site 1 and 61.1 at Site 2) compared to the general population (mean: 50; standard deviation: 10). At least 33% of patients had a clinically meaningful change (ie, at least half the standard deviation, or 5 points) in each PROMIS domain. For pain interference, 55% had no change, 22% improved by 5 or more points, and 23% worsened by 5 or more points. Bayesian regression analyses suggest that chronic conditions, insurance status, and Hispanic ethnicity are likely associated with decreased functioning over time. Exploratory analyses found that setting a mental health goal did not appear to be associated with improvement for anxiety or depression. CONCLUSIONS: Use of patient-reported outcome measures in routine clinical care identified areas of functional limitations among people with diabetes. However, changes in participants' PROMIS-29 scores over time were minimal. Research is needed to understand patterns of change in global and domain-specific functioning, particularly among racial/ethnic minorities.