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Julie K. Johnson Donna M. Woods David P. Stevens Judith L. Bowen Lloyd P. Provost Connie S. Sixta Ed H. Wagner 《Journal of general internal medicine》2010,25(4):581-585
BACKGROUND
Two chronic care collaboratives (The National Collaborative and the California Collaborative) were convened to facilitate implementing the chronic care model (CCM) in academic medical centers and into post-graduate medical education.OBJECTIVE
We developed and implemented an electronic team survey (ETS) to elicit, in real-time, team member’s experiences in caring for people with chronic illness and the effect of the Collaborative on teams and teamwork.DESIGN
The ETS is a qualitative survey based on Electronic Event Sampling Methodology. It is designed to collect meaningful information about daily experience and any event that might influence team members’ daily work and subsequent outcomes.PARTICIPANTS
Forty-one residency programs from 37 teaching hospitals participated in the collaboratives and comprised faculty and resident physicians, nurses, and administrative staff.APPROACH
Each team member participating in the collaboratives received an e-mail with directions to complete the ETS for four weeks during 2006 (the National Collaborative) and 2007 (the California Collaborative).KEY RESULTS
At the team level, the response rate to the ETS was 87% with team members submitting 1,145 narrative entries. Six key themes emerged from the analysis, which were consistent across all sites. Among teams that achieved better clinical outcomes on Collaborative clinical indicators, an additional key theme emerged: professional work satisfaction, or “Joy in Work”. In contrast, among teams that performed lower in collaborative measures, two key themes emerged that reflected the effect of providing care in difficult institutional environments—“lack of professional satisfaction” and awareness of “system failures”.CONCLUSIONS
The ETS provided a unique perspective into team performance and the day-to-day challenges and opportunities in chronic illness care. Further research is needed to explore systematic approaches to integrating the results from this study into the design of improvement efforts for clinical teams.3.
Adeyemi Okunogbe Lisa S. Meredith Evelyn T. Chang Alissa Simon Susan E. Stockdale Lisa V. Rubenstein 《Journal of general internal medicine》2018,33(1):65-71
Background
Care coordination is a critical component of managing high-risk patients, who tend to have complex and multiple medical and psychosocial problems and are typically at high risk for increased hospitalization and incur high health care expenditures. Primary care models such as the patient-centered medical homes (PCMHs) are designed to improve care coordination and reduce care fragmentation. However, little is known about how the burden of care coordination for high-risk patients influences PCMH team members’ stress.Objective
To evaluate the relationship between provider stress and care coordination time in high-risk patient care and whether availability of help is associated with reduced stress.Study design
Multivariable regression analysis of a cross-sectional survey of PCMH primary care providers (PCPs) and nurses.Participants
A total of 164 PCPs and 272 nurses in primary care practices at five geographically diverse Veteran Health Administration (VA) medical center health systems.Main measures
The main outcome variable was provider stress due to high-risk patient care. Independent variables were the reported proportion of high-risk patients in PCP/nurse patient panels, time spent coordinating care for these patients, and provider satisfaction with help received in caring for them.Key results
The response rate was 44%. Spending more than 8 h per week coordinating care was significantly associated with a 0.21-point increase in reported provider stress compared to spending 8 h or less per week (95% CI: 0.04–0.39; p = 0.015). The magnitude of the association between stress and care coordination time was diminished when provider satisfaction with help received was included in the model.Conclusions
Perceived provider stress from care of high-risk patients may arise from challenges related to coordinating their care. Our findings suggest that the perception of receiving help for high-risk patient care may be valuable in reducing provider stress.4.
Susan L. Zickmund Kelly H. Burkitt Shasha Gao Roslyn A. Stone Audrey L. Jones Leslie R. M. Hausmann Galen E. Switzer Sonya Borrero Keri L. Rodriguez Michael J. Fine 《Journal of general internal medicine》2018,33(3):305-331
Background
Patient satisfaction is an important dimension of health care quality. The Veterans Health Administration (VA) is committed to providing high-quality care to an increasingly diverse patient population.Objective
To assess Veteran satisfaction with VA health care by race/ethnicity and gender.Design and Participants
We conducted semi-structured telephone interviews with gender-specific stratified samples of black, white, and Hispanic Veterans from 25 predominantly minority-serving VA Medical Centers from June 2013 to January 2015.Main Measures
Satisfaction with health care was assessed in 16 domains using five-point Likert scales. We compared the proportions of Veterans who were very satisfied, somewhat satisfied, and less than satisfied (i.e., neither satisfied nor dissatisfied, somewhat dissatisfied, or very dissatisfied) in each domain, and used random-effects multinomial regression to estimate racial/ethnic differences by gender and gender differences by race/ethnicity.Key Results
Interviews were completed for 1222 of the 1929 Veterans known to be eligible for the interview (63.3%), including 421 white, 389 black, and 396 Hispanic Veterans, 616 of whom were female. Veterans were less likely to be somewhat satisfied or less than satisfied versus very satisfied with care in each of the 16 domains. The highest satisfaction ratings were reported for costs, outpatient facilities, and pharmacy (74–76% very satisfied); the lowest ratings were reported for access, pain management, and mental health care (21–24% less than satisfied). None of the joint tests of racial/ethnic or gender differences in satisfaction (simultaneously comparing all three satisfaction levels) was statistically significant (p > 0.05). Pairwise comparisons of specific levels of satisfaction revealed racial/ethnic differences by gender in three domains and gender differences by race/ethnicity in five domains, with no consistent directionality across demographic subgroups.Conclusions
Our multisite interviews of a diverse sample of Veterans at primarily minority-serving sites showed generally high levels of health care satisfaction across 16 domains, with few quantitative differences by race/ethnicity or gender.5.
Joseph J. Gallo Seungyoung Hwang Jin Hui Joo Hillary R. Bogner Knashawn H. Morales Martha L. Bruce Charles F. ReynoldsIII 《Journal of general internal medicine》2016,31(4):380-386
Background
Two-thirds of older adults have two or more medical conditions that often take precedence over depression in primary care.Objective
We evaluated whether evidence-based depression care management would improve the long-term mortality risk among older adults with increasing levels of medical comorbidity.Design
Longitudinal analyses of the practice-randomized Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT). Twenty primary care practices randomized to intervention or usual care.Patients
The sample included 1204 older primary care patients completing the Charlson Comorbidity Index (CCI) and other interview questions at baseline.Intervention
For 2 years, a depression care manager worked with primary care physicians to provide algorithm-based care for depression, offering psychotherapy, increasing the antidepressant dose if indicated, and monitoring symptoms, medication adverse effects, and treatment adherence.Main Measures
Depression status based on clinical interview, CCI to evaluate medical comorbidity, and vital status at 8 years (National Death Index).Key Results
In the usual care condition, patients with the highest levels of medical comorbidity and depression were at increased risk of mortality over the course of the follow-up compared to depressed patients with minimal medical comorbidity [hazard ratio 3.02 (95 % CI, 1.32 to 8.72)]. In contrast, in intervention practices, patients with the highest level of medical comorbidity and depression compared to depressed patients with minimal medical comorbidity were not at significantly increased risk [hazard ratio 1.73 (95 % CI, 0.86 to 3.96)]. Nondepressed patients in intervention and usual care practices had similar mortality risk.Conclusions
Depression management mitigated the combined effect of multimorbidity and depression on mortality. Depression management should be integral to optimal patient care, not a secondary focus.6.
Quyen Ngo-Metzger Dara H. Sorkin Russell S. Phillips Sheldon Greenfield Michael P. Massagli Brian Clarridge Sherrie H. Kaplan 《Journal of general internal medicine》2007,22(2):324-330
Background
Provider–patient language discordance is related to worse quality care for limited English proficient (LEP) patients who speak Spanish. However, little is known about language barriers among LEP Asian-American patients.Objective
We examined the effects of language discordance on the degree of health education and the quality of interpersonal care that patients received, and examined its effect on patient satisfaction. We also evaluated how the presence/absence of a clinic interpreter affected these outcomes.Design
Cross-sectional survey, response rate 74%.Participants
A total of 2,746 Chinese and Vietnamese patients receiving care at 11 health centers in 8 cities.Measurements
Provider–patient language concordance, health education received, quality of interpersonal care, patient ratings of providers, and the presence/absence of a clinic interpreter. Regression analyses were used to adjust for potential confounding.Results
Patients with language-discordant providers reported receiving less health education (β?=?0.17, p?<?0.05) compared to those with language-concordant providers. This effect was mitigated with the use of a clinic interpreter. Patients with language-discordant providers also reported worse interpersonal care (β?=?0.28, p?<?0.05), and were more likely to give low ratings to their providers (odds ratio [OR]?=?1.61; CI?=?0.97–2.67). Using a clinic interpreter did not mitigate these effects and in fact exacerbated disparities in patients’ perceptions of their providers.Conclusion
Language barriers are associated with less health education, worse interpersonal care, and lower patient satisfaction. Having access to a clinic interpreter can facilitate the transmission of health education. However, in terms of patients’ ratings of their providers and the quality of interpersonal care, having an interpreter present does not serve as a substitute for language concordance between patient and provider.7.
Ellen H. Chen David H. Thom Danielle M. Hessler La Phengrasamy Hali Hammer George Saba Thomas Bodenheimer 《Journal of general internal medicine》2010,25(4):610-614
Background
Team care can improve management of chronic conditions, but implementing a team approach in an academic primary care clinic presents unique challenges.Objectives
To implement and evaluate the Teamlet Model, which uses health coaches working with primary care physicians to improve care for patients with diabetes and/or hypertension in an academic practice.Design
Process and outcome measures were compared before and during the intervention in patients seen with the Teamlet Model and in a comparison patient group.Participants
First year family medicine residents, medical assistants, health workers, and adult patients with either type 2 diabetes or hypertension in a large public health clinic.Intervention
Health coaches, in coordination with resident primary care physicians, met with patients before and after clinic visits and called patients between visits.Measurements
Measurement of body mass index, assessment of smoking status, and formulation of a self-management plan prior to and during the intervention period for patients in the Teamlet Model group. Testing for LDL and HbA1C and the proportion of patients at goal for blood pressure, LDL, and HbA1C in the Teamlet Model and comparison groups in the year prior to and during implementation.Results
Teamlet patients showed improvement in all measures, though improvement was significant only for smoking, BMI, and self-management plan documentation and testing for LDL (p?=?0.02), with a trend towards significance for LDL at goal (p?=?0.07). Teamlet patients showed a greater, but non-significant, increase in the proportion of patients tested for HbA1C and proportion reaching goal for blood pressure, HgbA1C, and LDL compared to the comparison group patients. The difference for blood pressure was marginally significant (p?=?0.06). In contrast, patients in the comparison group were significantly more likely to have had testing for LDL (P?=?0.001).Conclusions
The Teamlet Model may improve chronic care in academic primary care practices.8.
J. Daryl Thornton Catherine Sullivan Jeffrey M. Albert Maria Cedeño Bridget Patrick Julie Pencak Kristine A. Wong Margaret D. Allen Linda Kimble Heather Mekesa Gordon Bowen Ashwini R. Sehgal 《Journal of general internal medicine》2016,31(8):832-839
BACKGROUND
Low organ donation rates remain a major barrier to organ transplantation.OBJECTIVE
We aimed to determine the effect of a video and patient cueing on organ donation consent among patients meeting with their primary care provider.DESIGN
This was a randomized controlled trial between February 2013 and May 2014.SETTING
The waiting rooms of 18 primary care clinics of a medical system in Cuyahoga County, Ohio.PATIENTS
The study included 915 patients over 15.5 years of age who had not previously consented to organ donation.INTERVENTIONS
Just prior to their clinical encounter, intervention patients (n?=?456) watched a 5-minute organ donation video on iPads and then choose a question regarding organ donation to ask their provider. Control patients (n?=?459) visited their provider per usual routine.MAIN MEASURES
The primary outcome was the proportion of patients who consented for organ donation. Secondary outcomes included the proportion of patients who discussed organ donation with their provider and the proportion who were satisfied with the time spent with their provider during the clinical encounter.KEY RESULTS
Intervention patients were more likely than control patients to consent to donate organs (22 % vs. 15 %, OR 1.50, 95%CI 1.10–2.13). Intervention patients were also more likely to have donation discussions with their provider (77 % vs. 18 %, OR 15.1, 95%CI 11.1–20.6). Intervention and control patients were similarly satisfied with the time they spent with their provider (83 % vs. 86 %, OR 0.87, 95%CI 0.61–1.25).LIMITATION
How the observed increases in organ donation consent might translate into a greater organ supply is unclear.CONCLUSION
Watching a brief video regarding organ donation and being cued to ask a primary care provider a question about donation resulted in more organ donation discussions and an increase in organ donation consent. Satisfaction with the time spent during the clinical encounter was not affected.TRIAL REGISTRATION
clinicaltrials.gov Identifier: NCT016971379.
Grant R. Martsolf Ryan Kandrack Robert A. Gabbay Mark W. Friedberg 《Journal of general internal medicine》2016,31(7):723-731
Background
Medical home initiatives encourage primary care practices to invest in new structural capabilities such as patient registries and information technology, but little is known about the costs of these investments.Objectives
To estimate costs of transformation incurred by primary care practices participating in a medical home pilot.Design
We interviewed practice leaders in order to identify changes practices had undertaken due to medical home transformation. Based on the principles of activity-based costing, we estimated the costs of additional personnel and other investments associated with these changes.Setting
The Pennsylvania Chronic Care Initiative (PACCI), a statewide multi-payer medical home pilot.Participants
Twelve practices that participated in the PACCI.Measurements
One-time and ongoing yearly costs attributed to medical home transformation.Results
Practices incurred median one-time transformation-associated costs of $30,991 per practice (range, $7694 to $117,810), equivalent to $9814 per clinician ($1497 to $57,476) and $8 per patient ($1 to $30). Median ongoing yearly costs associated with transformation were $147,573 per practice (range, $83,829 to $346,603), equivalent to $64,768 per clinician ($18,585 to $93,856) and $30 per patient ($8 to $136). Care management activities accounted for over 60% of practices’ transformation-associated costs. Per-clinician and per-patient transformation costs were greater for small and independent practices than for large and system-affiliated practices.Limitations
Error in interviewee recall could affect estimates. Transformation costs in other medical home interventions may be different.Conclusions
The costs of medical home transformation vary widely, creating potential financial challenges for primary care practices—especially those that are small and independent. Tailored subsidies from payers may help practices make these investments.Primary Funding Source
Agency for Healthcare Research and Quality10.
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Charles Elder Lynn DeBar Cheryl Ritenbaugh John Dickerson William M. Vollmer Richard A. Deyo Eric S. Johnson Mitchell Haas 《Journal of general internal medicine》2018,33(9):1469-1477
Background
Chiropractic care is a popular alternative for back and neck pain, with efficacy comparable to usual care in randomized trials. However, the effectiveness of chiropractic care as delivered through conventional care settings remains largely unexplored.Objective
To evaluate the comparative effectiveness of usual care with or without chiropractic care for patients with chronic recurrent musculoskeletal back and neck pain.Study design
Prospective cohort study using propensity score-matched controls.Participants
Using retrospective electronic health record data, we developed a propensity score model predicting likelihood of chiropractic referral. Eligible patients with back or neck pain were then contacted upon referral for chiropractic care and enrolled in a prospective study. For each referred patient, two propensity score-matched non-referred patients were contacted and enrolled. We followed the participants prospectively for 6 months.Main measures
Main outcomes included pain severity, interference, and symptom bothersomeness. Secondary outcomes included expenditures for pain-related health care.Key results
Both groups’ (N?=?70 referred, 139 non-referred) pain scores improved significantly over the first 3 months, with less change between months 3 and 6. No significant between-group difference was observed. (severity ??0.10 (95% CI ??0.30, 0.10), interference ??0.07 (??0.31, 0.16), bothersomeness ??0.1 (??0.39, 0.19)). After controlling for variances in baseline costs, total costs during the 6-month post-enrollment follow-up were significantly higher on average in the non-referred versus referred group ($1996 [SD?=?3874] vs $1086 [SD?=?1212], p?=?.034). Adjusting for differences in age, gender, and Charlson comorbidity index attenuated this finding, which was no longer statistically significant (p?=?.072).Conclusions
We found no statistically significant difference between the two groups in either patient-reported or economic outcomes. As clinical outcomes were similar, and the provision of chiropractic care did not increase costs, making chiropractic services available provided an additional viable option for patients who prefer this type of care, at no additional expense.14.
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BACKGROUND
There is suggestive evidence that lower rates of health insurance coverage increases the gaps in quality and access to care among Latinos as compared with non-Latino whites. In order to examine these potential disparities, we assessed the effects of insurance coverage and multiple covariates on perceived quality of care.OBJECTIVE
To assess the distribution of perceived quality of care received in a national Latino population sample, and the role of insurance in different patient subgroups.DESIGN
Telephone interviews conducted between 2007 and 2008 using the Pew Hispanic Center/Robert Wood Johnson Foundation Latino Health Surveys (Waves 1 and 2).PARTICIPANTS
Randomly selected Latino adults aged ≥18 years living in the United States.MEASUREMENTS
Pearson χ2 tests identified associations among various demographic variables by quality of care ratings (poor, fair, good, excellent) for the insured and uninsured (Wave 1: N?=?3545). Subgroup analyses were conducted among Wave 2 participants reporting chronic conditions (N?=?1067). Bivariate and multivariate analyses were conducted to estimate the effects of insurance, demographic variables and consumer characteristics on quality of care.RESULTS
Insurance availability had an odds ratio of 1.47 (95% CI, 1.22–1.76) net of confounders in predicting perceived quality of care among Latinos. The largest gap in rates of excellent/good ratings occurred among the insured with eight or more doctor visits compared to the uninsured (76.2% vs. 54.6%, P?<?.05).CONCLUSIONS
Future research can gain additional insights by examining the impact of health insurance on processes of care with a refined focus on specific transactions between consumers and providers’ support staff and physicians guided by the principles of patient-centered care.16.
Background
Optimal management of hypertension requires frequent monitoring and follow-up. Novel, pragmatic interventions have the potential to engage patients, maintain blood pressure control, and enhance access to busy primary care practices. “Virtual visits” are structured asynchronous online interactions between a patient and a clinician to extend medical care beyond the initial office visit.Objective
To compare blood pressure control and healthcare utilization between patients who received virtual visits compared to usual hypertension care.Design
Propensity score-matched, retrospective cohort study with adjustment by difference-in-differences.Participants
Primary care patients with hypertension.Exposure
Patient participation in at least one virtual visit for hypertension. Usual care patients did not use a virtual visit but were seen in-person for hypertension.Main measures
Adjusted difference in mean systolic blood pressure, primary care office visits, specialist office visits, emergency department visits, and inpatient admissions in the 180 days before and 180 days after the in-person visit.Key results
Of the 1051 virtual visit patients and 24,848 usual care patients, we propensity score-matched 893 patients from each group. Both groups were approximately 61 years old, 44% female, 85% White, had about five chronic conditions, and about 20% had a mean pre-visit systolic blood pressure of 140–160 mmHg. Compared to usual care, virtual visit patients had an adjusted 0.8 (95% CI, 0.3 to 1.2) fewer primary care office visits. There was no significant adjusted difference in systolic blood pressure control (0.6 mmHg [95% CI, ??2.0 to 3.1]), specialist visits (0.0 more visits [95% CI, ??0.3 to 0.3]), emergency department visits (0.0 more visits [95% CI, 0.0 to 0.01]), or inpatient admissions (0.0 more admissions [95% CI, 0.0 to 0.1]).Conclusions
Among patients with reasonably well-controlled hypertension, virtual visit participation was associated with equivalent blood pressure control and reduced in-office primary care utilization.17.
Jeffrey D. Clough Kavita Patel William H. Shrank 《Journal of general internal medicine》2016,31(11):1278-1286
Background
Multiple payment reform efforts are under way to improve the value of care delivered to Medicare beneficiaries, yet few directly address the interface between primary and specialty care.Objective
To describe regional variation in outpatient visits for individual specialties and the association between specialty physician-specific payments and patient-reported satisfaction with care and health status.Design
Retrospective cross-sectional study.Patients
A 20 % random sample of Medicare fee-for-service beneficiaries in 2012.Main Measures
Regions were grouped into quartiles of specialist index, defined as the observed/expected regional likelihood of having an outpatient visit to a specialist, for ten common specialties, adjusting for age, sex, and race. Outcomes were per capita specialty-specific physician payments and Medicare Current Beneficiary Survey responses.Key Results
The proportion of beneficiaries seeing a specialist varied the most for endocrinology and gastroenterology (3.7- and 3.9-fold difference between the highest and lowest quartiles, respectively) and least for orthopedics and urology (1.5- and 1.7-fold difference, respectively). Multiple analyses suggested that this variation was not explained by prevalence of disease. Average specialty-specific payments were strongly associated with the likelihood of visiting a specialist. Differences in per capita payments from lowest (Q1) to highest quartiles (Q4) were greatest for cardiology ($89, $135, $172, $251) and dermatology ($46, $64, $82, $124). Satisfaction with overall care (median [interquartile range] across specialties: Q1, 93.3 % [92.6–93.7 %]; Q4, 93.1 % [92.9–93.2 %]) and self-reported health status (Q1, 37.1 % [36.9–37.7 %]; Q4, 38.2 % [37.2–38.4 %]) was similar across quartiles. Satisfaction with access to specialty care was consistently lower in the lowest quartile of specialty index (Q1, 89.7 % [89.2–91.1 %]; Q4, 94.5 % [94.4–94.8 %]).Conclusions
Substantial regional variability in outpatient specialist visits is associated with greater payments with limited benefits in terms of patient-reported satisfaction with care or reported health status. Reducing outpatient physician visits may represent an important opportunity to improve the efficiency of care.18.
Renata Kopach-Konrad Mark Lawley Mike Criswell Imran Hasan Santanu Chakraborty Joseph Pekny Bradley N. Doebbeling 《Journal of general internal medicine》2007,22(3):431-437
Background
In a highly publicized joint report, the National Academy of Engineering and the Institute of Medicine recently recommended the systematic application of systems engineering approaches for reforming our health care delivery system. For this to happen, medical professionals and managers need to understand and appreciate the power that systems engineering concepts and tools can bring to redesigning and improving health care environments and practices.Objective
To present and discuss fundamental concepts and tools of systems engineering and important parallels between systems engineering, health services, and implementation research as it pertains to the care of complex patients.Design
An exploratory, qualitative review of systems engineering concepts and overview of ongoing applications of these concepts in the areas of hemodialysis, radiation therapy, and patient flow modeling.Results
In this paper, we describe systems engineering as the process of identifying the system of interest, choosing appropriate performance measures, selecting the best modeling tool, studying model properties and behavior under a variety of scenarios, and making design and operational decisions for implementation.Conclusions
We discuss challenges and opportunities for bringing people with systems engineering skills into health care.19.
Shannon M. Kehle Nancy Greer Indulis Rutks Timothy Wilt 《Journal of general internal medicine》2011,26(2):689