Patient-centered medical home transformation with payment reform: patient experience outcomes.

OBJECTIVE: To examine changes in patient experience across key domains of the patient-centered medical home (PCMH) following practice transformation with Lean quality improvement methodology inclusive of payment reform. STUDY DESIGN: Pre-intervention/post-intervention analysis of intervention with a comparison group, a quasi-experimental design. We surveyed patients following office visits at the intervention (n = 2502) and control (n = 1622) practices during the 15-month period before and 14-month period after PCMH Lean transformation (April-October 2009). METHODS: We measured and compared pre-intervention and post-intervention levels of patient satisfaction and other indicators of patient-centered care. Propensity weights adjusted for potential case-mix differences in intervention and control groups; propensity-adjusted proportions accounted for physician-level clustering. RESULTS: More intervention patients were very satisfied with their care after the PCMH Lean intervention (68%) compared with pre-intervention (62%). Among control patients, there was no corresponding increase in satisfaction (63% very satisfied pre-intervention vs 64% very satisfied post-intervention). This comparison resulted in a statistical trend (P = .10) toward greater overall satisfaction attributable to the intervention. Post-intervention, patients in the intervention practice consistently rated indicators of patient-centered care higher than patients in the control practice, particularly in the personal physician and communication domain. In this domain, intervention patients reported superior provider explanations, time spent, provider concern, and follow-up instructions compared with control participants, whereas control group ratings fell in the post-intervention period (P for difference <.05). CONCLUSIONS: In a pilot PCMH transformation including Lean enhancement with payment reform, patient experience was sustained or improved across key PCMH domains.

The effect of systematic clinical interventions with cigarette smokers on quit status and the rates of smoking-related primary care office visits.

BACKGROUND: The United States Public Health Service (USPHS) Guideline for Treating Tobacco Use and Dependence includes ten key recommendations regarding the identification and the treatment of tobacco users seen in all health care settings. To our knowledge, the impact of system-wide brief interventions with cigarette smokers on smoking prevalence and health care utilization has not been examined using patient population-based data. METHODS AND FINDINGS: Data on clinical interventions with cigarette smokers were examined for primary care office visits of 104,639 patients at 17 Harvard Vanguard Medical Associates (HVMA) sites. An operational definition of "systems change" was developed. It included thresholds for intervention frequency and sustainability. Twelve sites met the criteria. Five did not. Decreases in self-reported smoking prevalence were 40% greater at sites that achieved systems change (13.6% vs. 9.7%, p<.01). On average, the likelihood of quitting increased by 2.6% (p<0.05, 95% CI: 0.1%-4.6%) per occurrence of brief intervention. For patients with a recent history of current smoking whose home site experienced systems change, the likelihood of an office visit for smoking-related diagnoses decreased by 4.3% on an annualized basis after systems change occurred (p<0.05, 95% CI: 0.5%-8.1%). There was no change in the likelihood of an office visit for smoking-related diagnoses following systems change among non-smokers. CONCLUSIONS: The clinical practice data from HVMA suggest that a systems approach can lead to significant reductions in smoking prevalence and the rate of office visits for smoking-related diseases. Most comprehensive tobacco intervention strategies focus on the provider or the tobacco user, but these results argue that health systems should be included as an integral component of a comprehensive tobacco intervention strategy. The HVMA results also give us an indication of the potential health impacts when meaningful use core tobacco measures are widely adopted.

Challenges in the management of positive fecal occult blood tests.

BACKGROUND: Many patients with a positive fecal occult blood test (FOBT) do not undergo follow-up evaluations. OBJECTIVE: To identify the rate of follow-up colonoscopy following a positive FOBT and determine underlying reasons for lack of follow-up. DESIGN: It is a retrospective chart review. PARTICIPANTS: The subject group consisted of 1,041 adults with positive FOBTs within a large physician group practice from 2004 to 2006. MEASUREMENTS: We collected data on reasons for ordering FOBT, presence of prior colonoscopy, completed evaluations, and results of follow-up tests. We fit a multivariable logistic regression model to identify predictors of undergoing follow-up colonoscopy. RESULTS: Most positive FOBTs were ordered for routine colorectal cancer screening (76%), or evaluation of anemia (13%) or rectal bleeding (7%). Colonoscopy was completed in 62% of cases, with one-third of these procedures identifying a colorectal adenoma (29%) or cancer (4%). Factors associated with higher rates of follow-up colonoscopy included obtaining the FOBT for routine colorectal screening (odds ratio (OR) 1.59, 95% confidence interval (CI) 1.11-2.29) and consultation with gastroenterology (OR 1.99, 95% CI 1.46-2.72). Patients were less likely to undergo colonoscopy if they were older than 80 years old (OR 0.54, 95% CI 0.31-0.92), younger than 50 years old (OR 0.44, 95% CI 0.28-0.70), uninsured (OR 0.50, 95% CI 0.27-0.93), or had undergone colonoscopy within the prior five years (OR 0.32, 95% CI 0.23-0.44). CONCLUSIONS: Clinical decisions and patient factors available at the time of ordering an FOBT impact performance of colonoscopy. Targeting physicians' understanding of the use of this test may improve follow-up and reduce inappropriate use of this test.