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The coproduction learning health system (CLHS) model extends the definition of a learning health system to explicitly bring together patients and care partners, health care teams, administrators, and scientists to share the work of optimizing health outcomes, improving care value, and generating new knowledge. The CLHS model highlights a partnership for coproduction that is supported by data that can be used to support individual patient care, quality improvement, and research. We provide a case study that describes the application of this model to transform care within an oncology program at an academic medical center.

Clinicians can use data to improve daily clinical practice. This paper offers eight principles for using data to support improvement in busy clinical settings: 1) seek usefulness, not perfection, in the measurement; 2) use a balanced set of process, outcome, and cost measures; 3) keep measurement simple (think big, but start small); 4) use qualitative and quantitative data; 5) write down the operational definitions of measures; 6) measure small, representative samples; 7) build measurement into daily work; and 8) develop a measurement team. The following approaches to using data for improvement are recommended. First, begin with curiosity about outcomes or a need to improve results. Second, try to avoid knee-jerk, obstructive criticism of proposed measurements. Instead, propose solutions that are practical, goal-oriented, and good enough to start with. Third, gather baseline data on a small sample and check the findings. Fourth, try to change and improve the delivery process while gathering data. Fifth, plot results over time and analyze them by using a control chart or other graphical method. Sixth, refine your understanding of variation in processes and outcomes by dividing patients into clinically homogeneous subgroups (stratification) and analyzing the results separately for each subgroup. Finally, make further changes while measuring key outcomes over time. Measurement and improvement are intertwined; it is impossible to make improvements without measurement. Measuring and learning from each patient and using the information gleaned to test improvements can become part of daily medical practice in local settings., A method for incorporating data collection and analysis into medical practice is described. Physicians should evaluate the care they give in order to find better ways of doing things and to improve care for future patients. It is best to begin with a pilot test and to incorporate the data collection into regular patient visits. Data collection can be done by a team rather than a single individual. Graphs can show whether a change in care results in a significant change in patient outcomes provided that baseline data were recorded.

Objective. To prospectively compare inpatient and outpatient utilization rates between prepaid (PPD) and fee-for-service (FFS) insurance coverage for patients with chronic disease. Data Source/Study Setting. Data from the Medical Outcomes Study, a longitudinal observational study of chronic disease patients conducted in Boston, Chicago, and Los Angeles. Study Design. A four-year prospective study of resource utilization among 1,681 patients under treatment for hypertension, diabetes, myocardial infarction, or congestive heart failure in the practices of 367 clinicians. Data Collection/Extraction Methods. Insurance payment system (PPD or FFS), hospitalizations, and office visits were obtained from patient reports. Disease and severity indicators, sociodemographics, and self-reported functional status were used to adjust for patient mix and to compute expected utilization rates. Principal Findings. Compared to FFS, PPD patients had 31 percent fewer observed hospitalizations before adjustment for patient differences (p = .005) and 15 percent fewer hospitalizations than expected after adjustment (p = .078). The observed rate of FFS hospitalizations exceeded the expected rate by 9 percent. These results are not explained by system differences in patient mix or trends in hospital use over four years. Half of the PPD/FFS difference in hospitalization rate is due to intrinsic characteristics of the payment system itself. Conclusions. PPD patients with chronic medical conditions followed prospectively over four years, after extensive patient-mix adjustment, had 15 percent fewer hospitalizations than their FFS counterparts owing to differences intrinsic to the insurance reimbursement system. Key Words. Prepaid health plans, managed care, fee-for-service plans, resource utilization, system comparisons, The current interest in promoting prepaid managed care systems and in extending insurance benefits to people who lack coverage increases the importance of evaluating healthcare systems based on indicators of [...]

Objective: To compare patients' and physicians' opinions on the importance of discrete elements of health care as determinants of the quality of outpatient care. Design: Analysis of results of a mailed survey. Setting Community-based internal medicine practices. Participants: 74 general internists and 814 patients randomly selected from the practices of these internists. Measures: 125 elements of care that covered nine domains were identified: physician clinical skill, physician interpersonal skill, support staff, office environment, provision of information, patient involvement, nonfinancial access, finances, and coordination of care. Participants rated each element on its importance to high-quality care on a 4-point scale: 1 = not important; 2 = of medium importance; 3 = of high importance; and 4 = essential. Patients' and physicians' ratings were compared for individual elements of care and for elements aggregated into domains. Results: Survey response rates were 93% for physicians and 60% for patients. In an element-by-element comparison of ratings, ratings by the two groups differed substantially for 58% of the attributes. The most striking difference was seen in the domain of provision of information (median ratings, 3.56 for patients and 2.85 for physicians; P < 0.001). Ratings by the two groups also differed in the domains of clinical skill (3.75 for patients and 3.35 for physicians; P< 0.001), nonfinancial access (3.00 for patients and 2.87 for physicians; P< 0.001), and finances (3.00 for patients and 2.80 for physicians; P = 0.006). When relative rankings of the domains were compared, both groups agreed that clinical skill is most important; however, patients ranked provision of information second in importance whereas physicians ranked it sixth. Conclusions: Patients and physicians agreed that the most crucial element of outpatient care is clinical skill, but they disagreed about the relative importance of other aspects of care, particularly effective communication of health-related information. These differences in perception may influence the quality of interactions between physicians and patients., Patients may be much more concerned about receiving health information from physicians than physicians are. Researchers surveyed 74 physicians specializing in internal medicine and 814 patients under the care of these doctors. Both patients and physicians believed that the physician's clinical skill was the most important ingredient in health care. Patients placed much more importance on physicians' ability to clearly communicate health-related information than did physicians. Medical education and training that puts more emphasis on teaching doctors to communicate clearly to their patients may improve American health care.

Background. Many significant problems of adolescents are undetected and untreated. To aid in the discovery of these problems, we have developed and tested picture-and-word charts for use in the classroom [...]

Background: Health systems worldwide are experiencing increasing cost-cutting pressures with more intense competition and rising customer requirements. We aimed to find out and compare the characteristics and successes of two different sustainable business cases in healthcare delivery from an innovation-driven, organizational perspective. Subject and methods: The data for the two cases were collected through structured literature research as well as personal interviews with the founders of the two healthcare business models. Data were analyzed using the business model canvas as a structured framework, as well as by cross-case analysis. Results: The two business models operate successfully, but pursue different approaches to healthcare innovation. We were able to show that one model pursues a very complex, network-based approach that is focused on one specific rural region, while the structure of the other is characterized by a scalable concept. In addition, we observed that the founders had a decisive influence on the development and success of the healthcare business models. Conclusion: Our study highlights the multitude of complex relationships required to build and establish innovative and successful business models for providing high-quality and cost-effective services in two of the world’s largest healthcare systems. Moreover, it could be shown that the business model canvas offers a suitable methodological framework to compare and analyze in a structured manner the extent to which innovative care approaches also require an economically successful and sustainable business model. Results give a holistic, structured description of specific organizational features and environments, whch can then serve decision-makers in health and health economics as lessons learned and aid them in decision-making.

* BACKGROUND Abusive relationships are associated with several demographic factors and many clinical problems in women. However, practices often do not screen for abuse. * METHODS This is a descriptive [...]

Background:Little is known about the organization of clinical services for Huntington’s disease (HD). Objective:To describe how health care services are organized and delivered in HD-clinics taking part in or eligible for the Enroll-HD study. Methods:In 2014, a 69-item survey was administered to sites taking part in or eligible for the Enroll-HD study. Results:Of 231 sites surveyed, 121 (52.2%) sites in Europe, North America, Latin America, and Oceania responded. Most sites in the sample serve large populations, with 61.1% serving more than 1.5 million people, and a further 33% serving >500,000. Almost all (86.0%) centers see patients from outside their region. The majority of centers (59.7%) follow 50–199 patients, 21.9% care for more than 200. Most centers provide care in all stages of HD, and nearly all review pre-symptomatic cases. Multidisciplinary case reviews are offered in 54.5% of sites, with outreach clinics offered by 48.1%. Videoconferencing and telemedicine are used by 23.6%. Separate consultations for caregivers are offered in more than half of the centers. Most centers (70.4%) report following published guidelines or local care pathways for HD. Conclusions:Most centers serve a large population and use a multidisciplinary approach. The survey gives insight into factors underpinning HD service delivery globally. There is a need for more in-depth studies of clinical practice to understand how services are organized and how such features may be associated with quality of care.

The purpose of this study was to determine how many patients are needed to provide reliable patient ratings of care at the individual clinician level.

Patient noncompliance with medical regimens is a major obstacle in achieving hypertension control. In this study the relationships between patients' perceptions of health, disease and medical treatment and compliance were examined in personal interviews with 142 patients under treatment for hypertension. Compliance was measured in terms of blood pressure control, self-reported medication-taking, and appointment keeping. A multivariate log linear technique was used to control confounding. Blood pressure control was found to be associated with the perceived efficacy of the antihypertensive regimen, having medications prescribed for other chronic conditions, a high level of anxiety when hypertension was first diagnosed, the impact of hypertension and its treatment on lifestyle, and a higher educational level. For self-reported medication-taking, the perceived severity of hypertension, having medications prescribed for other chronic conditions and older age were predictive. Blood pressure control and self-reported medication-taking were highly correlated with each other (p .02). Older age and being employed were the only variables that contributed independently to improved appointment keeping behavior. From these findings, it might be expected that emphasis on the effectiveness of treatment and on the potential threat posed by hypertension would motivate improved blood pressure control.

A study to evaluate the impact of a medical self-care program on older adults was conducted. The test group (n=161) participated in an 11-session educational interven tion with training in clinical skills, lifestyle, and the use of health services. The compar ison group (n=164) received no intervention. The test group was assessed pre-interven tion, post-intervention, and six months post-intervention and the comparison group was assessed at corresponding intervals. The results indicated that medical self-care instruction produces substantial improvements in health-related knowledge, health skills performance, and health actions. This study produced no evidence, however, that medical self-care instruction has any effect on health status, the utilization of medical care, or other aspects of life quality.

In this article, a description of how a comprehensive health promotion program for older adults was developed, tested with a quasi-experimental study design, and then revised to become a nationwide AARP and Red Cross program is presented. Teaching and learning methods used in the course are described with supporting education and behavioral theory. The course content for instructors, facilitators, and course partici pants is outlined. The key elements in the preparation of instructors and facilitators are identified. Results of the implementation of the program are given.

We conducted a controlled study of the impact of an education program on the health outcomes and perceptions of patients with varying degrees of airway obstruction in two communities. In one community, patients with chronic obstructive airway disease (COAD) were identified, assessed and offered an educational program. In the other community, patients were identified, assessed and advised of the findings only. Patients at both sites were given the same pretest and, one year later, the same posttest. These tests measured physical and social function, and health outcomes (eg, respiratory symptoms, exercise tolerance, mental health), plus patients' health perceptions. Posttest results showed a significant difference between groups on a health perception measure and locus of control, but no difference on health outcomes. We conclude that education programs for COAD are unlikely to improve patients' health status unless they are part of a comprehensive medical program that includes physical reconditioning.

Physicians wishing to maintain the functional capacity of their patients often need, but usually do not have, practical measures of function. The Dartmouth COOP, a primary care research network, developed nine pictorial Charts to efficiently measure patient function in busy office practice. Each Chart has a five-point scale, is illustrated, and can be self-administered or administered by office staff. The Charts are used to measure the patients' overall functional health just as Snellen Charts are used to measure vision. Studies to assess the Charts' reliability, validity, acceptability and clinical utility were conducted on over 2,000 patients in four diverse clinical settings. Results show that the Charts are both reliable and valid. One-hour test-retest intraclass correlations for elderly patients ranged from 0.78 to 0.98 and from 0.73 to 0.98 for low income patients. The average Pearson product-moment correlation between Charts and previously validated measures of function was 0.61 and the Charts were as capable of detecting the association between disease and functioning as were longer, standard measures. Most clinicians and patients report that the Charts are easy to use and provide a valuable tool to measure overall function in busy office practice. For the 25 of patients in which the Charts uncovered new information, changes in clinical management were initiated for 40% of them. We conclude that the COOP Charts are practical, reliable, valid, sensitive to the effects of disease and useful for quickly measuring patient function.

In what proportion of a patient's total health care is the primary physician involved? By means of calendar diaries and telephone interviews, 211 primary care patients from community practices of the Dartmouth Primary Care Cooperative Information Project were followed prospectively for one year. We found that a substantial proportion of care was managed (that is, either actually provided or coordinated in advance) by the patient's primary physician. Specifically, criteria for a primary physician's role in management were met by 75% of 1379 ambulatory visits to physicians, 33% of 786 visits to nonphysician health care providers, 81% of 26 nonemergency hospitalizations, and 78% of 2769 prescriptions. Primary physicians in these settings appear to function as case managers even when they are not participating in formal managed-care systems.(JAMA 1988;259:3145-3149)

Functional status measurement and the assessment of health status are reaching their maturity as technical disciplines. Good tools exist that meet requirements such as brevity, validity, reliability, ease of administration, and ease of scoring, which make them potentially suitable for use in clinical practice. Despite this progress, widespread adoption of measurement tools has not occurred in the clinical world. The authors analyze both the potential and the barriers to use of health assessment tools in practice and note the need for better scientific evidence of their clinical utility, as opposed to their information content. Dissemination of these tools among practitioners will require, above all, evidence and conviction that the use of measurement instruments will actually enhance the very health status outcomes they assess.

This paper provides a broad overview of the assessment of health status in clinical practice in three parts. YesterdayThe nation has undergone a paradigm shift in health-related thinking. The former paradigm emphasized only disease; the new emphasizes health, functioning, well-being, and disease. Measures of health and disease have evolved to reflect the new paradigm. Many are designed for clinical settings, based on measurement science, and are relatively brief. These newer measures have been used to document the natural history of disease, evaluate treatment effectiveness, and improve clinical case management. TodayTwo barriers block full-scale use in clinical settings. The first barrier involves the meaning and interpretation of health status scores. Patients' scores are influenced by several types of patient mix variables and the timing of measurements. Interpretation is enhanced by valid normative data displaying the variability in health status among homogenous patient groups. The second barrier is utilization and mainstreaming. It involves all of the issues associated with changing the day-to-day behavior of clinicians and providers' routine processes to facilitate routine use of health status measures in clinical settings. TomorrowIn the next decade, the nation will attempt to overhaul the health care system. As it does so, it will struggle with many issues 1) clarifying the true aim of health care; 2) standardizing measures of health across patients, providers, and settings to evaluate benefit; 3) establishing cause and effect among structural-input factors, care delivery processes, and health outcomes valued by society; and 4) determining if and when cost containment actions have adverse effects on health outcomes. In this context, the importance of interpreting change in health status has a central role.

The Dartmouth Primary Care Cooperative Information (COOP) Project conducted a controlled trial on the impact of antismoking advice from office-based physicians. Eighteen primary care medical practices were randomly assigned to be intervention or customary care practices. Medical personnel assigned to the intervention practices were to systematically identify cigarette smokers (among patients aged 35 to 59 years making an office visit), advise them to quit smoking, and provide educational materials. A random sample of 258 smokers was identified and followed-up four months later. Intervention-group smokers were more likely to report being advised to quit smoking (77 percent versus 47 percent) and to attempt quitting (39 percent versus 31 percent), but had success rates similar to those of the other group (6 percent versus 7 percent).

Patients of physicians using physician's assistants in their practices were surveyed to determine attitudes toward these assistants. Fifty-four percent of the patients responded and 12% of the nonrespondents were interviewed to insure that respondents were representative of the sample. Patients rate the physician's assistants highly in terms of technical competence (89%), professional manner (86%), and report improvements in the quality of care (71%) and access to services (79%), since the physician's assistants began working. Eighty-seven percent of the patients who received physical examinations from physician's assistants were very satisfied. Patient's age, social class, and access to medical services are significantly related to certain attitudes toward physician's assistants.(JAMA 228:63-67, 1974)

With increasing pressure to measure quality, patient- based assessments of medical care are becoming increasingly important. Patients offer a unique perspec tive for evaluating the nontechnical aspects of medical care. This study reviews the importance of utilizing pa tients' perceptions to measure quality of care in office settings. It also reviews the principles required to con duct a well done survey. The concept of patient percep tions differs from the more commonly measured concept of patient satisfaction, in that perceptions measure whether a patients' needs and expectations are met, in addition to satisfaction. One of the most accurate and efficient means of measuring patients' perceptions is through the use of surveys. As with all standardized data collection, creating and performing high quality surveys of patients' perceptions can be challenging. Valid and reliable patient survey data can enable prac titioners to identify areas for improvement, and demon strate to external reviewers the quality of care they provide to their patients.

BackgroundThe Institute for Health Metrics and Evaluation (IHME) developed a risk model to estimate 10-year mortality risk compared with a population with optimum risk factors in adults aged 30 years and older. IHME used data on exposure distributions of 12 behavioural and biometric risks in the US population, mortality rates by cause, and estimates of the proportional hazards of risk factor exposure from systematic reviews. The model has been validated using National Health and Nutrition Examination Survey (NHANES) data collected during 1988–94 and 1999–2004 (n=8331).

BackgroundExisting health risk measures are narrow in scope, often limited to specific diseases or clinical subpopulations. Modifiable risks account for a large fraction of death, but existing health risk measures do not produce estimates of the fraction of an individual's risk that is potentially avoidable by clinical or behavioural intervention. The aim of this work is to develop and validate a risk prediction model to measure the modifiable risk of all-cause mortality for patients and populations.

To enhance the efficient utilization of health providers, medical care researchers are increasingly concerned with the measurement of task performance. One job analysis methodology that is widely used is the task inventory technique, characterized by retrospective self-reporting. The purpose of this study was to validate the task inventory method by using the observational technique. Two data collection instruments were developed, a Task Inventory and an Observer Check List; both contained the same set of task statements. Trained observers shadowed 13 primary care physicians in their offices for one week recording the frequency and duration of task performance on the Observer Check Lists. At the end of the week, the 13 physicians completed a Task Inventory indicating how often they had performed each task in their offices and how long it normally took. The observers’ and physicians’ respective sets of data were analyzed to determine the degree of agreement The results indicate that the agreement is not sufficient between the task data obtained by the two different methods to conclude that one is substitutable for the other. The validity of the Task Inventory method is therefore not supported by the results.