Objective
To investigate (a) the magnitude of the independent associations of neighborhood‐level and person‐level social risk factors (SRFs) with quality, (b) whether neighborhood‐level SRF ...associations may be proxies for person‐level SRF associations, and (c) how the association of person‐level SRFs and quality varies by neighborhood‐level SRFs.
Data sources
2015–2016 Medicare Advantage HEDIS data, Medicare beneficiary administrative data, and 2016 American Community Survey (ACS).
Study design
Mixed effects linear regression models (1) estimated overall inequities by neighborhood‐level and person‐level SRFs, (2) compared neighborhood‐level associations to person‐level associations, and (3) tested the interactions of person‐level SRFs with corresponding neighborhood‐level SRFs.
Data collection/extraction methods
Beneficiary‐level SES and disability administrative data and five‐year ACS neighborhood‐level SRF information were each linked to HEDIS data.
Principal findings
For all or nearly all HEDIS measures, quality was worse in neighborhoods lower in SES and in neighborhoods with higher proportions of residents with a disability. Quality by neighborhood racial and ethnic composition was mixed. Accounting for corresponding person‐level SRFs reduced neighborhood SRF associations by 25% for disability, 43% for SES, and 74%–102% for racial and ethnic groups. Person‐level SRF coefficients were not consistently reduced in models that added neighborhood‐level SRFs. In 19 of 35 instances, there were significant (p < 0.05) interactions between neighborhood‐level and corresponding person‐level SRFs. Significant interactions were always positive for disability, SES, Black, and Hispanic, indicating more negative neighborhood effects for people with SRFs that did not match their neighborhood and more positive neighborhood effects for people with SRFs that matched their neighborhood.
Conclusions
Relying solely on neighborhood‐level SRF models that omit similar person‐level SRFs overattributes inequities to neighborhood characteristics. Neighborhood‐level characteristics account for much less variation in these measures' scores than similar person‐level SRFs. Inequity‐reduction programs may be most effective when targeting neighborhoods with a high proportion of people with a given SRF.
Quality improvement (QI) may be aimed at improving care for all patients, or it may be targeted at only certain patient groups. Health care providers have little guidance when determining when ...targeted QI may be preferred.
The aim was to develop a method for quantifying performance inconsistency and guidelines for when inconsistency indicates targeted QI, which we apply to the performance of health plans for different patient groups.
Retrospective analysis of 7 Health Care Effectiveness Data and Information Set (HEDIS) measures of clinical care quality.
All Medicare Advantage (MA) beneficiaries eligible for any of 7 HEDIS measures 2015-2018.
MA plans with higher overall performance tended to be less inconsistent in their performance (r=-0.2) across groups defined by race-and-ethnicity and low-income status (ie, dual eligibility for Medicaid or receipt of Low-Income Subsidy). Plan characteristics were usually associated with only small differences in inconsistency. The characteristics associated with differences in consistency eg, size, Health Maintenance Organization (HMO) status were also associated with differences in overall performance. We identified 9 (of 363) plans that had large inconsistency in performance across groups (>0.8 SD) and investigated the reasons for inconsistency for 2 example plans.
This newly developed inconsistency metric may help those designing and evaluating QI efforts to appropriately determine when targeted QI is preferred. It can be used in settings where performance varies across groups, which can be defined by patient characteristics, geographic areas, hospital wards, etc. Effectively targeting QI efforts is essential in today's resource-constrained health care environment.
Abstract Purpose We aimed to advance the internal and external validity of research by sharing our empirical experience and recommendations for systematically reporting contextual factors. Methods ...Fourteen teams conducting research on primary care practice transformation retrospectively considered contextual factors important to interpreting their findings (internal validity) and transporting or reinventing their findings in other settings/situations (external validity). Each team provided a table or list of important contextual factors and interpretive text included as appendices to the articles in this supplement. Team members identified the most important contextual factors for their studies. We grouped the findings thematically and developed recommendations for reporting context. Results The most important contextual factors sorted into 5 domains: (1) the practice setting, (2) the larger organization, (3) the external environment, (4) implementation pathway, and (5) the motivation for implementation. To understand context, investigators recommend (1) engaging diverse perspectives and data sources, (2) considering multiple levels, (3) evaluating history and evolution over time, (4) looking at formal and informal systems and culture, and (5) assessing the (often nonlinear) interactions between contextual factors and both the process and outcome of studies. We include a template with tabular and interpretive elements to help study teams engage research participants in reporting relevant context. Conclusions These findings demonstrate the feasibility and potential utility of identifying and reporting contextual factors. Involving diverse stakeholders in assessing context at multiple stages of the research process, examining their association with outcomes, and consistently reporting critical contextual factors are important challenges for a field interested in improving the internal and external validity and impact of health care research.
Directly involving patients and families in care improvement increasingly is viewed as an important component of patient-centered care. To assess the extent to which practices actually involve ...patients, we surveyed 112 patient-centered medical home practices in twenty-two states. Nearly all of these practices sought patient feedback. However, only 29 percent involved patients and families as advisers and sought feedback through surveys, and only 32 percent involved patients in a continuing role in quality improvement. Interviews showed that practices that highly value patient involvement overcame barriers to ongoing patient participation. We argue that a cultural shift is needed in how practices view patients as partners, not just in areas such as personal responsibility and self-management, but also in quality improvement and governance. Practices must gain more experience and see more examples of the benefits of engaging patients, and they may need more incentives and support for engaging them.
To examine rates and predictors of receiving a psychosocial service before initiating antipsychotic treatment among young people in the Medicaid program.
A retrospective new-user cohort study of 8 ...state Medicaid programs focused on children and adolescents 0 to 20 years, initiating antipsychotic treatment (N = 24,372). The proportion receiving a psychosocial service in the 3 months before initiating antipsychotic treatment was calculated and stratified by socio-demographic and diagnostic characteristics arranged in 9 hierarchical groups, as follows: developmental, psychotic/bipolar, disruptive, attention-deficit/hyperactivity, obsessive-compulsive, stress, major depressive, anxiety, and other disorders.
Less than one-half of youth received a psychosocial service before initiating antipsychotic treatment (48.8%). Compared to younger adolescents (12–17 years) initiating antipsychotic treatment (51.5%), corresponding younger children (0–5 years; 39.2%) and older adolescents (18–20 years; 40.1%), but not older children (6–11 years; 51.5%), were significantly less likely to have received a psychosocial service. In relation to youth diagnosed with psychotic or bipolar disorder (52.7%), those diagnosed with attention-deficit/hyperactivity (43.3%), developmental (41.4%), depressive (46.5%), or anxiety (35.6%) disorder were significantly less likely to have received a psychosocial service during the 3 months before antipsychotic initiation. By contrast, youth diagnosed with stress disorders (61.2%) were significantly more likely than those diagnosed with psychotic or bipolar disorders (52.7%) to have received a psychosocial service before starting an antipsychotic.
A majority of Medicaid-insured youth initiating antipsychotic treatment have not received a psychosocial service in the preceding 3 months. This service pattern highlights a critical gap in access to psychosocial services.
To examine access to psychiatric care for adolescents with depression in outpatient specialty clinics within a state mental health system, using a simulated patient approach.
Trained callers posed as ...the mother of a 14-year-old girl with depression, following a script. A stratified random sample (n = 264) of 340 state-licensed outpatient mental health clinics that serve youth was selected. Clinics were randomly assigned to season and insurance condition. We examined whether access varied by season, clinic characteristics, and caller insurance type. Weighted logistic and linear mixed effects regression models were fitted to examine associations with appointment availability and wait times.
Among clinics at which a treatment appointment could be scheduled, appointment availability differed by season. Clinics that had participated in state-sponsored trainings targeting access were more available. Wait times for treatment appointments varied by season and region. Wait times in New York City were shorter than in some other regions. Although callers were 4.1 times more likely to be able to schedule a psychiatry appointment in the spring, wait times for psychiatry appointments were significantly longer in the spring than in the summer (49.9 vs. 36.7 days). Wait times for therapy appointments were significantly shorter in community than in hospital clinics (19.1 days vs. 35.3 days).
Access to psychiatric care for youth with depression was found to be variable in a state system. State-sponsored trainings on strategies to reduce wait times appear to improve care access. The simulated patient approach has promise for monitoring the impact of health care policy reforms on care quality measures.
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).
The prevalence of chronic kidney disease (CKD) in Medicare beneficiaries has quadrupled in the past 2 decades, but little is known about risk factors affecting the progression of CKD. This study aims ...to understand the progression in Medicare Advantage enrollees and whether it differs by provider recognition of CKD, race and ethnicity, or geographic location. In a large cohort of Medicare Advantage (MA) enrollees, we examined whether CKD progression, up to 5 years after study entry, differed by demographic and clinical factors and identified additional risk factors of CKD progression.
In a cohort of 1,002,388 MA enrollees with CKD stages 1-4 based on 2013-2018 labs, progression was estimated using a mixed-effects model that adjusted for demographics, geographic location, comorbidity, urine albumin-to-creatinine ratio, clinical recognition via diagnosed CKD, and time-fixed effects. Race and ethnicity, geographic location, and clinical recognition of CKD were interacted with time in 3 separate regression models.
Mean (median) follow-up was 3.1 (3.0) years. Black and Hispanic MA enrollees had greater kidney function at study entry than other beneficiaries, but their kidney function declined faster. MA enrollees with clinically recognized CKD had estimated glomerular filtration rate levels that were 18.6 units (95% confidence interval CI: 18.5-18.7) lower than levels of unrecognized patients, but kidney function declined more slowly in enrollees with clinical recognition. There were no differences in CKD progression by geography. After removal of the race coefficient from the eGFR equation in a sensitivity analysis, kidney function was much lower in all years among Black MA enrollees, but patterns of progression remained the same.
These results suggest that patients with clinically recognized CKD and racial and ethnic minorities merit closer surveillance and management to reduce their risk of faster progression.
Care for patients with serious illness is an emerging practice area that has gained attention as value-based purchasing has increased. While the number of programs is growing, their impact on care ...quality and outcomes is unknown.
With support from the Gordon and Betty Moore Foundation, the National Committee for Quality Assurance (NCQA) is assessing the feasibility of creating an accountability program focused on serious illness care.
This article describes the process of developing an accountability program, findings from our initial work, and our plans to develop measures for a serious illness care accountability program. We focused on three questions: 1. What patient populations should be targeted for measurement? 2. What entities have accountability for ensuring high-quality care for serious illness? 3. What structures, processes, and outcomes should be evaluated in an accountability program for serious illness care?
Our environmental scan showed that the evidence base for specific patient populations or care models is not sufficiently mature to justify traditional structure and process measures. In visits to serious illness care programs, we observed different staffing models, care models, care settings, and payment structures. We found a gap between recommended inclusion criteria and services when compared to inclusion criteria and services offered by existing programs.
To address the challenges, NCQA intends to develop outcome measures driven by patient and family priorities. Structure and process measures will focus on building organizations' capacity to measure outcomes, including patient engagement and outcomes, linked to patient goals.
PDF
