Available studies have shown few quality-related advantages of electronic health records (EHRs) over traditional paper records. We compared achievement of and improvement in quality standards for ...diabetes at practices using EHRs with those at practices using paper records. All practices, including many safety-net primary care practices, belonged to a regional quality collaborative and publicly reported performance.
We used generalized estimating equations to calculate the percentage-point difference between EHR-based and paper-based practices with respect to achievement of composite standards for diabetes care (including four component standards) and outcomes (five standards), after adjusting for covariates and accounting for clustering. In addition to insurance type (Medicare, commercial, Medicaid, or uninsured), patient-level covariates included race or ethnic group (white, black, Hispanic, or other), age, sex, estimated household income, and level of education. Analyses were conducted separately for the overall sample and for safety-net practices.
From July 2009 through June 2010, data were reported for 27,207 adults with diabetes seen at 46 practices; safety-net practices accounted for 38% of patients. After adjustment for covariates, achievement of composite standards for diabetes care was 35.1 percentage points higher at EHR sites than at paper-based sites (P<0.001), and achievement of composite standards for outcomes was 15.2 percentage points higher (P=0.005). EHR sites were associated with higher achievement on eight of nine component standards. Such sites were also associated with greater improvement in care (a difference of 10.2 percentage points in annual improvement, P<0.001) and outcomes (a difference of 4.1 percentage points in annual improvement, P=0.02). Across all insurance types, EHR sites were associated with significantly higher achievement of care and outcome standards and greater improvement in diabetes care. Results confined to safety-net practices were similar.
These findings support the premise that federal policies encouraging the meaningful use of EHRs may improve the quality of care across insurance types.
Although regional health improvement collaboratives have been adopted nationwide to improve primary care quality, their effects on avoidable hospitalizations and costs remain unclear. We quantified ...the association of the Better Health Partnership, a primary care-led regional health improvement collaborative operating in Cuyahoga County, Ohio (Cleveland and surrounding suburbs), with hospitalization rates for ambulatory care-sensitive conditions. The partnership uses a positive deviance approach to identify, disseminate publicly, and accelerate adoption of best practices for care of patients with diabetes, heart failure, and hypertension. Using a difference-in-differences approach, we compared rates of hospitalizations for ambulatory care-sensitive conditions in six Ohio counties before (2003-08) and after (2009-14) the establishment of the partnership. Age- and sex-adjusted hospitalization rates for targeted ambulatory care-sensitive conditions in Cuyahoga County declined significantly more than the rates in the comparator counties in 2009-11 (106 fewer hospitalizations per 100,000 adult residents) and 2012-14 (91 fewer hospitalizations). We estimated that 5,746 hospitalizations for ambulatory care-sensitive conditions were averted in 2009-14, leading to cost savings of nearly $40 million.
Many goods and services can be readily provided through a series of unconnected transactions, but in health care, close coordination over time and within care episodes improves both health outcomes ...and efficiency. Close coordination is problematic in the U.S. healthcare system because the financing and delivery of care is distributed across a variety of distinct and often competing entities, each with its own objectives, obligations, and capabilities. These fragmented organizational structures lead to disrupted relationships, poor information flows, and misaligned incentives that combine to degrade care quality and increase costs. We illustrate our argument with examples taken from the insurance and hospital industries, and discuss possible responses to the problems resulting from organizational fragmentation.
Background
Accountable care organizations (ACOs), patient-centered medical homes (PCMHs), and the meaningful use of electronic health records (EHRs) generated particular attention during the last ...decade. Translating these reforms into meaningful increases in population health depends on improving the quality and clinical integration of primary care providers (PCPs). However, if these innovations spread more quickly among PCPs in urban and wealthier areas, then they could potentially worsen existing geographic disparities in health outcomes.
Objective
To determine the market penetration of Medicare Shared Savings Program (MSSP) ACOs, PCMHs, and the meaningful use of EHRs among PCPs across urban and rural counties in Ohio.
Design
Retrospective, observational study of the percent of PCPs in a county who are affiliated with PCMH, ACO, and meaningful use (MU) of EHR.
Participants
PCPs in all of Ohio’s 88 counties from 2011 to 2015.
Main Measures
Primary care market penetration of ACO, PCMH, and meaningful use of EHR
Key Results
In 2015, the Ohio primary care market penetration of PCMH was 23.4%, ACO was 27.7%, MU stage 1 was 55.8%, and MU stage 2 was 26.6%. During the study period, PCMH and ACO market penetration increased faster in urban counties relative to rural counties, and market penetration of meaningful use of EHR increased faster in rural counties.
Conclusions
Market penetration of PCMH and ACOs increased faster in urban markets compared to rural markets. However, the adoption of EHRs increased faster in rural markets. The results are a cause for optimism as well as a call to action: although recent efforts to increase PCMH and ACO adoption were less effective among the rural population in Ohio, federal programs to accelerate adoption of EHRs were overwhelmingly successful in rural areas.
Background
Accelerated translation of real-world interventions for hypertension management is critical to improving cardiovascular outcomes and reducing disparities.
Objective
To determine whether a ...positive deviance approach would improve blood pressure (BP) control across diverse health systems.
Design
Quality improvement study using 1-year cross sections of electronic health record data over 5 years (2013–2017).
Participants
Adults ≥ 18 with hypertension with two visits in 2 years with at least one primary care visit in the last year (
N
= 114,950 at baseline) to a primary care practice in Better Health Partnership, a regional health improvement collaborative.
Interventions
Identification of a “positive deviant” and dissemination of this system’s best practices for control of hypertension (i.e., accurate/repeat BP measurement; timely follow-up; outreach; standard treatment algorithm; and communication curriculum) using 3 different intensities (
low
: Learning Collaborative events describing the best practices;
moderate
: Learning Collaborative events plus consultation when requested; and
high
: Learning Collaborative events plus practice coaching).
Main Measures
We used a weighted linear model to estimate the pre- to post-intervention average change in BP control (< 140/90 mmHg) for 35 continuously participating clinics.
Key Results
BP control post-intervention improved by 7.6% 95% confidence interval (CI) 6.0–9.1, from 67% in 2013 to 74% in 2017. Subgroups with the greatest absolute improvement in BP control included Medicaid (12.0%, CI 10.5–13.5), Hispanic (10.5%, 95% CI 8.4–12.5), and African American (9.0%, 95% CI 7.7–10.4). Implementation intensity was associated with improvement in BP control (high: 14.9%, 95% CI 0.2–19.5; moderate: 5.2%, 95% CI 0.8–9.5; low: 0.2%, 95% CI−3.9 to 4.3).
Conclusions
Employing a positive deviance approach can accelerate translation of real-world best practices into care across diverse health systems in the context of a regional health improvement collaborative (RHIC). Using this approach within RHICs nationwide could translate to meaningful improvements in cardiovascular morbidity and mortality.
To evaluate the association between patterns of fragmented care and emergency department (ED) use among adult patients with diabetes and chronic kidney disease.
Observational study in an open ...healthcare system.
The study sample included patients with diabetes and chronic kidney disease (mean estimated glomerular filtration rate, 20-60 mL/min) and with an established primary care provider. Dispersion of care was defined by a fragmentation of care index (range, 0-1), with zero reflecting all care in 1 outpatient clinic and 1 reflecting each visit at a different clinic site. We used a negative binomial model to estimate the influence of fragmentation on ED use after adjusting for patient demographic characteristics, insurance, diabetes control, and number of comorbidities; results are reported as incidence rate ratios and associated 95% confidence intervals (CIs). The main outcome measure was the number of ED visits from 2002 to 2003.
Of 3873 patients with diabetes having an established primary care provider, 623 (16.1%) had chronic kidney disease and comprised the final study sample. On average, patients made 19.0 (95% CI, 18.5-20.4) outpatient visits and 1.2 (95% CI, 1.1-1.4) ED visits over the 2-year period. The median fragmentation of care index was 0.48; 14.3% of subjects had a fragmentation of care index of zero. In the adjusted model, a 0.1-U increase in the fragmentation of care index was associated with a 15% increase in the number of ED visits (incidence rate ratio, 1.15; 95% CI, 1.09-1.21).
The posited benefits of specialist referrals among patients with complex diabetes may be partially negated by care fragmentation. Better models for care coordination and stronger evidence of the marginal benefits of referrals are needed.
Studies of Medicaid expansion have produced conflicting results about whether the expansion is having a positive impact on health and the cost and efficiency of care delivery. To explore the issue ...further, we examined MetroHealth Care Plus, a Centers for Medicare and Medicaid Services (CMS) waiver program in Ohio composed of three safety-net organizations that enrolled 28,295 uninsured poor patients in closed-panel care during 2013. All participating organizations used electronic health records and patient-centered medical homes, publicly reported performance in a regional health improvement collaborative, and accepted a budget-neutral cap approved by CMS. We compared changes between 2012 and 2013 in achieving quality standards for diabetes and hypertension among 3,437 MetroHealth Care Plus enrollees to changes among 1,150 patients with the same conditions who remained uninsured in both years. Compared to continuously uninsured patients with diabetes, MetroHealth Care Plus enrollees with diabetes improved significantly more on composite standards of care and intermediate outcomes. Among enrollees with hypertension, blood pressure control improvements were insignificantly larger than those in the continuously uninsured group with hypertension. Across all 28,295 enrollees, 2013 total costs of care were 28.7 percent below the budget cap, providing cause for optimism that a prepared safety net can meet the challenges of Medicaid expansion.
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