Prospective Interventions to Reduce Stroke Care Variation in a Hub-and-Spokes System.

BACKGROUND: Care variation reduction (CVR) is a central objective of quality management to decrease wasted spending. OBJECTIVE: To analyze stroke care variation at a hub-and-spokes system and determine interventions to prospectively reduce unwarranted variation. METHODS: In this prospective cohort single arm intervention study providers were blinded to pre-specified endpoints. Care variation was measured for DRGs 61-66 and 69 in USD, and severity level by Case Mix Index (CMI) by provider. A multi-disciplinary task force chaired by Vascular Neurologist analyzed data extracted from Crimson, a patient centric data analysis tool, and determined interventions. The primary measure outcome was change in CMI post intervention. RESULTS: Annualized baseline care variation was $ 0.7-1.2M (2017) in a drip-and-ship thrombolytic treatment model within the hub-and-spokes system. Pharmacy expenses contributed to 42% of variation followed by laboratory 12%, physical therapy 11%, supplies 11% and imaging 9%. Interventions to achieve CVR were prospectively implemented in 2018 and CVR was measured in January 2019. Based on 2017 CMI of 1.28, the goal of intervention was set to achieve 7% increase to 1.37 with projected increased revenue of $774,144. After implementation of interventions the actual achieved average CMI in 2018 was 1.40 paralleled by improvement in secondary outcomes of length of stay, observed over expected mortality and re-admission. CONCLUSIONS: A drip-and-ship stroke model within a single hub-and-spokes healthcare system can achieve substantial reduction in care variation and associated cost along with improvement in patient care indicators.

Accessibility of antiretroviral therapy in Ghana: convenience of access.

The convenience of accessing antiretroviral therapy (ART) is important for initial access to care and subsequent adherence to ART. We conducted a qualitative study of people living with HIV/AIDS (PLWHA) and ART healthcare providers in Ghana in 2005. The objective of this study was to explore the participants' perceived convenience of accessing ART by PLWHA in Ghana. The convenience of accessing ART was evaluated from the reported travel and waiting times to receive care, the availability, or otherwise, of special considerations, with respect to the waiting time to receive care, for those PLWHA who were in active employment in the formal sector, the frequency of clinic visits before and after initiating ART, and whether the PLWHA saw the same or different providers at each clinic visit (continuity of care). This qualitative study used in-depth interviews based on Yin's case-study research design to collect data from 20 PLWHA and 24 ART healthcare providers as study participants. • Reported travel time to receive ART services ranged from 2 to 12 h for 30% of the PLWHA. • Waiting time to receive care was from 4 to 9 h. • While known government workers, such as teachers, were attended to earlier in some of the centres, this was not a consistent practice in all the four ART centres studied. • The PLWHA corroborated the providers' description of the procedure for initiating and monitoring ART in Ghana. • PLWHA did not see the same provider every time, but they were assured that this did not compromise the continuity of their care. Our study suggests that convenience of accessing ART is important to both PLWHA and ART healthcare providers, but the participants alluded to other factors, including open provider-patient communication, which might explain the PLWHA's understanding of the constraints under which they were receiving care. The current nation-wide coverage of the ART programme in Ghana, however, calls for the replication of this study to identify possible perception changes over time that may need attention. Our study findings can inform interventions to promote access to ART, especially in Africa.

African American patients' attitudes toward proactive health behaviors after exposure to direct-to-consumer advertising.

BACKGROUND: Previous research on direct-to-consumer advertising (DTCA) has not focused exclusively on the African American population. PURPOSES: The purpose of this study was to explore African Americans' attitudes toward proactive health behaviors following exposure to DTCA of atorvastatin calcium (Lipitor, Pfizer Inc). MATERIALS AND METHODS: One-hundred fifty African American patients participated in the study. Participants' functional health literacy and health locus of control were assessed. The participants were asked to view a DTCA of Lipitor, followed by face-to-face interviews. RESULTS: After watching the DTCA of Lipitor, 89.4% of participants agreed that they would talk to their physician about their cholesterol, 88.6% agreed that they would ask their physician to test their cholesterol level, and 47.3% agreed that they would ask their physician to write them a prescription for Lipitor. Those who had a history of high cholesterol were more likely to agree to ask their physician to test their cholesterol levels. Low household income, having public health insurance, and prior experience with taking Lipitor were significant positive predictors of patients agreeing to ask their physician to write a prescription of the advertised drug. CONCLUSIONS: African American patients showed favorable attitudes toward proactive health behaviors after exposure to DTCA of Lipitor.

Diabetic patient experiences in a Medicaid managed care system.

OBJECTIVE: When Tennessee received a federal waiver to place all Medicaid enrollees in managed care organizations (MCOs), patients with chronic conditions such as diabetes were deemed especially vulnerable. This survey assessed patients' perceptions of diabetic care, self-care procedures, and satisfaction with medical care before and after enrollment in a Medicaid MCO. METHODS: A telephone survey was designed and pilot tested before surveying 57 patients meeting inclusion criteria of continuous enrollment in Medicaid for two years before, and in the MCO for two years after, the initiation of Tennessee's Medicaid managed care system (TennCare). RESULTS: On average, patients were 56.1 +/- 8.9 years old (mean +/- SD), African American (87.7%), female (73.7%), disabled (64.8%), with 8.4 +/- 2.8 years of education and annual incomes below $10,000 (54.4%). Mean age at diagnosis was 39.5 +/- 11.5 years, and most (75.5%) were currently prescribed insulin. Over one-third (39.6%) described the quality of healthcare received under managed care as excellent or very good and 38.9% felt prior Medicaid care was worse or much worse. Compared to Medicaid, patients reported no difference in being denied a test under managed care because of lack of approval (P = .754). However, significant improvements were reported in receiving detailed information about diabetes (89.5% vs. 73.7%, P = .022), and diet (89.5% vs. 77.2%, P = .039) for the TennCare period. Patients were more likely to perform finger stick blood glucose tests under the MCO (76.8% vs. 40.7%, P = .001), but did not report that blood glucose was controlled more of the time (P = .332). CONCLUSION: Most patients were satisfied with their MCO care, and most reported that finger stick glucose monitoring increased under the MCO. However, no significant gains in controlling blood sugar were reported. From the perspective of most patients, enrollment in an MCO had positive outcomes and resulted in improved access to diabetes-related health information.