The patient-centered medical home (PCMH) model of primary care is being implemented widely, although its effects on quality are unclear. The PCMH typically involves electronic health records (EHRs), ...organizational practice change, and payment reform.
To compare quality of care provided by physicians in PCMHs with that provided by physicians using paper medical records and, separately, with that provided by physicians using EHRs without the PCMH (to determine whether effects were driven by EHRs).
Prospective cohort study (2008 to 2010). (ClinicalTrials.gov: NCT00793065).
The Hudson Valley, a 7-county, multipayer, multiprovider region in New York.
675 primary care physicians in 312 practices and 143,489 patients.
Claims for 10 quality measures from the Healthcare Effectiveness Data and Information Set were used. Differences in quality were determined using generalized estimating equations adjusted for 8 physician characteristics and 4 patient characteristics.
The PCMH group improved significantly more over time than either the paper group or the EHR group for 4 of the 10 measures (by 1 to 9 percentage points per measure): eye examinations and hemoglobin A1c testing for patients with diabetes, chlamydia screening, and colorectal cancer screening (adjusted P < 0.05 for each). The odds of overall quality improvement in the PCMH group were 7% higher than in the paper group and 6% higher than in the EHR group (adjusted P < 0.01 for each).
This study was observational, and the possibility of unmeasured confounders cannot be excluded.
The PCMH was associated with modest quality improvement. The aspects of the PCMH that drive improvement are distinct from but may be enabled by the EHR.
The Commonwealth Fund and the New York State Department of Health.
Topological states of matter exhibit fascinating physics combined with an intrinsic stability. A key challenge is the fast creation of topological phases, which requires massive reorientation of ...charge or spin degrees of freedom. Here we report the picosecond emergence of an extended topological phase that comprises many magnetic skyrmions. The nucleation of this phase, followed in real time via single-shot soft X-ray scattering after infrared laser excitation, is mediated by a transient topological fluctuation state. This state is enabled by the presence of a time-reversal symmetry-breaking perpendicular magnetic field and exists for less than 300 ps. Atomistic simulations indicate that the fluctuation state largely reduces the topological energy barrier and thereby enables the observed rapid and homogeneous nucleation of the skyrmion phase. These observations provide fundamental insights into the nature of topological phase transitions, and suggest a path towards ultrafast topological switching in a wide variety of materials through intermediate fluctuating states.
Background
Diabetes places patients with cancer at an increased risk of infections, hospitalizations, and mortality. The objective of the current study was to characterize diabetes care management ...patterns among patients with cancer in the year before and, separately, after cancer diagnosis. The authors hypothesized that diabetes care declines after a diagnosis of cancer.
Methods
The Surveillance, Epidemiology, and End Results (SEER) cancer registry linked to Medicare claims data was used. The authors included diabetic beneficiaries aged ≥65 years who were diagnosed with incident, nonmetastatic breast, prostate, or colorectal cancer between 2008 and 2013. Controls were diabetic Medicare beneficiaries in SEER regions who did not have cancer. Cases were matched to controls based on age, sex, Charlson Comorbidity Index, and diabetes severity. Primary outcomes were diabetes care received over 12 months: 1) hemoglobin A1c testing; 2) eye examination; and 3) low‐density lipoprotein testing. Using a difference‐in‐difference (DID) approach, the authors examined use differences 12 months before to after diagnosis for patients with cancer and controls. To avoid capturing testing related to diagnosis and not diabetes management, the authors implemented a 90‐day washout period (45 days before and/or after diagnosis).
Results
A total of 32,728 diabetic patients with cancer and 32,728 matched noncancer controls were included. After diagnosis, patients with cancer were found to have modest, but significantly lower, rates of diabetes care use compared with controls. Patients with cancer had greater declines in hemoglobin A1c testing (DID, 2.4%; 95% CI, 1.7%‐3.0%), low‐density lipoprotein testing (DID, 4.3%; 95% CI, 3.6%‐5.0%), and receipt of all diabetes indicators (DID, 2.7%; 95% CI, 1.8%‐3.5%) 12 months before to after diagnosis.
Conclusions
Compared with controls, less diabetes care use was observed among patients with cancer in the year after diagnosis. Understanding and addressing the reasons for this may improve outcomes in this population.
Herein, the authors report less use of diabetes care among patients with cancer in the year after their cancer diagnosis compared with noncancer controls. Understanding and addressing the reasons for this may improve cancer and diabetes outcomes in this population.
Effects of the patient-centered medical home (PCMH) are unclear. Previous studies had relatively short follow-up and may not have distinguished effects of the PCMH (which involves electronic health ...records EHRs plus organizational changes) from those of EHRs alone.
To determine effects of the PCMH on health care quality and utilization compared with paper records alone and EHRs alone, with extended follow-up.
Prospective cohort study (2008 to 2012), including 3 years after PCMH implementation. (ClinicalTrials.gov: NCT00793065).
The Hudson Valley, a multipayer, multiprovider region in New York.
438 primary care physicians in 226 practices, with 136 480 patients across 5 health plans.
Level III PCMH, as defined by the National Committee for Quality Assurance.
Claims-based outcomes included 8 quality and 7 utilization measures. Generalized estimating equations were used to compare adjusted differences in rates of change across study groups.
Patterns of quality were fairly similar across groups. Utilization patterns were similar across groups from 2008 to 2011 but showed modest differences between the PCMH and control groups on most measures in 2012. For example, hospitalizations were relatively stable from 2008 to 2011 (approximately 3.9 to 5.2 per 100 patients per year) but decreased in the PCMH group in 2012 (incidence rate ratio, 0.79 95% CI, 0.69 to 0.90 compared with paper records). Emergency department visits were highest for the PCMH group (16.7 per 100 patients at baseline and 15.4 per 100 patients at the end of the study period) and lowest for the paper group (14.3 per 100 patients at baseline and 12.2 per 100 patients at the end of the study period), but the rate of change did not differ across groups.
Possible unmeasured confounding.
The PCMH was associated with modest changes in most utilization measures and provided similar quality compared with EHRs and paper records.
The Commonwealth Fund and the New York State Department of Health.
Abstract
The origin of SARS-CoV-2 variants of concern remains unclear. Here, we test whether intra-host virus evolution during persistent infections could be a contributing factor by characterizing ...the long-term SARS-CoV-2 infection dynamics in an immunosuppressed kidney transplant recipient. Applying RT-qPCR and next-generation sequencing (NGS) of sequential respiratory specimens, we identify several mutations in the viral genome late in infection. We demonstrate that a late viral isolate exhibiting genome mutations similar to those found in variants of concern first identified in UK, South Africa, and Brazil, can escape neutralization by COVID-19 antisera. Moreover, infection of susceptible mice with this patient’s escape variant elicits protective immunity against re-infection with either the parental virus and the escape variant, as well as high neutralization titers against the alpha and beta SARS-CoV-2 variants, B.1.1.7 and B.1.351, demonstrating a considerable immune control against such variants of concern. Upon lowering immunosuppressive treatment, the patient generated spike-specific neutralizing antibodies and resolved the infection. Our results suggest that immunocompromised patients could be a source for the emergence of potentially harmful SARS-CoV-2 variants.
ABSTRACT
CONTEXT
The US Federal Government is investing up to $29 billion in incentives for meaningful use of electronic health records (EHRs). However, the effect of EHRs on ambulatory quality is ...unclear, with several large studies finding no effect.
OBJECTIVE
To determine the effect of EHRs on ambulatory quality in a community-based setting.
DESIGN
Cross-sectional study, using data from 2008.
SETTING
Ambulatory practices in the Hudson Valley of New York, with a median practice size of four physicians.
PARTICIPANTS
We included all general internists, pediatricians and family medicine physicians who: were members of the Taconic Independent Practice Association, had patients in a data set of claims aggregated across five health plans, and had at least 30 patients per measure for at least one of nine quality measures selected by the health plans.
IINTERVENTION
Adoption of an EHR.
MAIN OUTCOME MEASURES
We compared physicians using EHRs to physicians using paper on performance for each of the nine quality measures, using t-tests. We also created a composite quality score by standardizing performance against a national benchmark and averaging standardized performance across measures. We used generalized estimation equations, adjusting for nine physician characteristics.
KEY RESULTS
We included 466 physicians and 74,618 unique patients. Of the physicians, 204 (44 %) had adopted EHRs and 262 (56 %) were using paper. Electronic health record use was associated with significantly higher quality of care for four of the measures: hemoglobin A1c testing in diabetes, breast cancer screening, chlamydia screening, and colorectal cancer screening. Effect sizes ranged from 3 to 13 percentage points per measure. When all nine measures were combined into a composite, EHR use was associated with higher quality of care (sd 0.4,
p
= 0.008).
CONCLUSIONS
This is one of the first studies to find a positive association between EHRs and ambulatory quality in a community-based setting.
Background Hospital readmissions are common, costly, and offer opportunities for utilization reduction. Electronic health information exchange (HIE) systems may help prevent readmissions by improving ...access to clinical data by ambulatory providers after discharge from the hospital.
Objective We sought to determine the association between HIE system usage and 30-day same-cause hospital readmissions among patients who consented and participated in an operational community-wide HIE during a 6-month period in 2009–2010.
Methods We identified a retrospective cohort of hospital readmissions among adult patients in the Rochester, New York area. We analyzed claims files from two health plans that insure more than 60% of the area population. To be included in the dataset, patients needed to be continuously enrolled in the health plan with at least one encounter with a participating provider in the 6 months following consent to be included in the HIE system. Each patient appeared in the dataset only once and each discharge could be followed for at least 30 days.
Results We found that accessing patient information in the HIE system in the 30 days after discharge was associated with a 57% lower adjusted odds of readmission (OR 0.43; 95% CI 0.27 to 0.70). The estimated annual savings in the sample from averted readmissions associated with HIE usage was $605 000.
Conclusions These findings indicate that usage of an electronic HIE system in the ambulatory setting within 30 days after hospital discharge may effectively prevent hospital readmissions, thereby supporting the need for ongoing HIE efforts.
To determine associations between a large-scale primary care redesign-the Comprehensive Primary Care Plus (CPC+) Initiative-and the extent of continuity or fragmentation of ambulatory care for ...Medicare fee-for-service beneficiaries during the first 3 years of CPC+.
We used a difference-in-differences framework with a comparison group of practices that were similar to CPC+ practices at baseline (eg, practice size, demographics, Medicare spending). Regressions controlled for clustering, baseline patient characteristics, and practice fixed effects. Our study covered January 2016 through December 2019 and included 1,085,707 beneficiaries attributed to 2883 CPC+ practices and 2,274,068 beneficiaries attributed to 6912 comparison practices.
We focused on beneficiaries with highly fragmented care at baseline because they may have changed the most in response to CPC+. Key outcome measures were the numbers of ambulatory visits and unique practitioners, reported by specialty category; the percentage of visits with the usual provider of care (measuring continuity); and the reversed Bice-Boxerman Index (rBBI; measuring fragmentation).
Medicare beneficiaries with high fragmentation (rBBI ≥ 0.85) at baseline (40% of the sample) had a mean of 13 ambulatory visits across 7 practitioners; the most frequent provider of care accounted for only 28% of visits. By contrast, the remaining beneficiaries had a mean of 10 visits across 4 practitioners, with the most frequent provider accounting for 54% of visits. There were no differences in continuity or fragmentation of care for CPC+ vs comparison beneficiaries.
We find no evidence that CPC+ increased continuity or decreased fragmentation of care.
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