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Background: End‐of‐life (EOL) care patterns may differ by physician age given differences in how physicians are trained or changes associated with aging. We sought to compare patterns of EOL care delivered to older Americans according to physician age. Methods: We conducted a cross‐sectional study of a 20% sample of Medicare fee‐for‐service beneficiaries aged ≥66 years who died in 2016–2019 (n = 487,293). We attributed beneficiaries to the physician who had >50% of primary care visits during the last 6 months of life. We compared beneficiary‐level outcomes by physician age (<40, 40–49, 50–59, or ≥60) in two areas: (1) advance care planning (ACP) and palliative care; and (2) high‐intensity care at the EOL. Results: Beneficiaries attributed to younger physicians had slightly higher proportions of billed ACP (adjusted proportions, 17.1%, 16.1%, 15.5%, and 14.0% for physicians aged <40, 40–49, 50–59, and ≥60, respectively; p‐for‐trend adjusted for multiple comparisons <0.001) and palliative care counseling or hospice use in the last 180 days of life (64.5%, 63.6%, 61.9%, and 60.8%; p‐for‐trend <0.001). Similarly, physicians' younger age was associated with slightly lower proportions of emergency department visits (57.4%, 57.0%, 57.4%, and 58.1%; p‐for‐trend <0.001), hospital admissions (51.2%, 51.1%, 51.4%, and 52.1%; p‐for‐trend <0.001), intensive care unit admissions (27.8%, 27.9%, 28.2%, and 28.3%; p‐for‐trend = 0.03), or mechanical ventilation or cardiopulmonary resuscitation (14.2, 14.9%, 15.2%, and 15.3%; p‐for‐trend <0.001) in the last 30 days of life, and in‐hospital death (20.2%, 20.6%, 21.3%, and 21.5%; p‐for‐trend <0.001). Conclusions: We found that differences in patterns of EOL care between beneficiaries cared for by younger and older physicians were small, and thus, not clinically meaningful. Future research is warranted to understand the factors that can influence patterns of EOL care provided by physicians, including initial and continuing medical education. [ABSTRACT FROM AUTHOR]

In the article, the authors present their cross-sectional study to estimate the wasteful spending on aducanumab dispensing for treating Alzheimer's disease in the U.S. Also cited are how the widespread use of the drug could strain Medicare's budget, and the conduct of the study on Medicare beneficiaries with mild dementia or mild cognitive impairment (MCI).

Background: The Centers for Medicare & Medicaid Services (CMS) Home Health Quality Reporting Program (HHQRP) uses performance measurement to spur improvements in home health agencies' (HHAs') quality of care. We examined quality improvement (QI) activities HHAs reported making to improve on HHQRP quality measures, and whether reported QI activities were associated with better measure performance. Methods: We used responses (N = 1052) from a Web‐ and mail‐based survey of a stratified random sample of HHAs included in CMS Home Health Compare in October 2019. We estimated national adoption rates for 27 possible QI activities related to organizational culture, health information technology, care process redesign, provider incentives, provider training, changes to staffing responsibilities, performance monitoring, and measure‐specific QI initiatives and technical assistance. We used multivariate linear regression to examine the associations between HHA characteristics and QI adoption, and between QI adoption and CMS Home Health Quality of Patient Care Star Rating. Results: HHAs reported implementing an average of 16 QI activities (interquartile range 11–19 activities). Larger HHA size was associated with adopting 1.6 additional QI activities (p < 0.001). HHAs with higher proportions of disabled, black, or Hispanic patients adopted QI activities at similar or higher rates as other HHAs. Of the 27 QI activities, 23 were considered helpful by more than 80% of adopting HHAs. Compared with adopting 44% of QI activities (10th percentile among HHAs), adopting 89% of QI activities (90th percentile) was associated with a 0.4‐star higher Star Rating (95% confidence interval 0.2–0.6). Conclusions: HHAs report implementing a significant number of QI activities in response to CMS measurement programs; implementation of a greater number of activities is associated with better performance on publicly reported measures. To guide future HHA QI investments, work is needed to identify the optimal combination of QI activities and the specific QI activities that yield the greatest performance improvements. [ABSTRACT FROM AUTHOR]

Objective: To test the hypothesis that health systems provide better care to patients with high needs by comparing differences in quality between system‐affiliated and nonaffiliated physician organizations (POs) and to examine variability in quality across health systems. Data Sources: 2015 Medicare Data on Provider Practice and Specialty linked physicians to POs. Medicare Provider Enrollment, Chain, and Ownership System (PECOS) and IRS Form 990 data identified health system affiliations. Fee‐for‐service Medicare enrollment and claims data were used to examine quality. Study Design: This cross‐sectional analysis of beneficiaries with high needs, defined as having more than twice the expected spending of an average beneficiary, examined six quality measures: continuity of care, follow‐up visits after hospitalizations and emergency department (ED) visits, ED visits, all‐cause readmissions, and ambulatory care‐sensitive hospitalizations. Using a matched‐pair design, we estimated beneficiary‐level regression models with PO random effects to compare quality of care in system‐affiliated and nonaffiliated POs. We then limited the sample to system‐affiliated POs and estimated models with system random effects to examine variability in quality across systems. Principal Findings: Among 2 323 301 beneficiaries with high needs, 52.3% received care from system‐affiliated POs. Rates of ED visits were statistically significantly different in system‐affiliated POs (117.5 per 100) and nonaffiliated POs (106.8 per 100, P <.0001). Small differences in the other five quality measures were observed across a range of sensitivity analyses. Among systems, substantial variation was observed for rates of continuity of care (90% of systems had rates between 70.8% and 89.4%) and follow‐up after ED visits (90% of systems had rates between 56.9% and 73.5%). Conclusions: Small differences in quality of care were observed among beneficiaries with high needs receiving care from system POs and nonsystem POs. Health systems may not confer hypothesized quality advantages to patients with high needs. [ABSTRACT FROM AUTHOR]

Objective: To explore why and how health systems are engaging in care delivery redesign (CDR)-defined as the variety of tools and organizational change processes health systems use to pursue the Triple Aim.Study Setting: A purposive sample of 24 health systems across 4 states as part of the Agency for Healthcare Research and Quality's Comparative Health System Performance Initiative.Study Design: An exploratory qualitative study design to gain an "on the ground" understanding of health systems' motivations for, and approaches to, CDR, with the goals of identifying key dimensions of CDR, and gauging the depth of change that is possible based on the particular approaches to redesign care being adopted by the health systems.Data Collection: Semi-structured telephone interviews with health system executives and physician organization leaders from 24 health systems (n = 162).Principal Findings: We identify and define 13 CDR activities and find that the health systems' efforts are varied in terms of both the combination of activities they are engaging in and the depth of innovation within each activity. Health system executives who report strong internal motivation for their CDR efforts describe more confidence in their approach to CDR than those who report strong external motivation. Health system leaders face uncertainty when implementing CDR due to a limited evidence base and because of the slower than expected pace of payment change.Conclusions: The ability to validly and reliably measure CDR activities-particularly across varying organizational contexts and markets-is currently limited but is key to better understanding CDR's impact on intended outcomes, which is important for guiding both health system decision making and policy making. [ABSTRACT FROM AUTHOR]

Objective: We explore if there are ways to characterize health systems-not already revealed by secondary data-that could provide new insights into differences in health system performance. We sought to collect rich qualitative data to reveal whether and to what extent health systems vary in important ways across dimensions of structural, functional, and clinical integration.Data Sources: Interviews with 162 c-suite executives of 24 health systems in four states conducted through "virtual" site visits between 2017 and 2019.Study Design: Exploratory study using thematic comparative analysis to describe factors that may lead to high performance.Data Collection: We used maximum variation sampling to achieve diversity in size and performance. We conducted, transcribed, coded, and analyzed in-depth, semi-structured interviews with system executives, covering such topics as market context, health system origin, organizational structure, governance features, and relationship of health system to affiliated hospitals and POs.Principal Findings: Health systems vary widely in size and ownership type, complexity of organization and governance arrangements, and ability to take on risk. Structural, functional, and clinical integration vary across systems, with considerable activity around centralizing business functions, aligning financial incentives with physicians, establishing enterprise-wide EHR, and moving toward single signatory contracting. Executives describe clinical integration as more difficult to achieve, but essential. Studies that treat "health system" as a binary variable may be inappropriately aggregating for analysis health systems of very different types, at different degrees of maturity, and at different stages of structural, functional, and clinical integration. As a result, a "signal" indicating performance may be distorted by the "noise."Conclusions: Developing ways to account for the complex structures of today's health systems can enhance future efforts to study systems as complex organizations, to assess their performance, and to better understand the effects of payment innovation, care redesign, and other reforms. [ABSTRACT FROM AUTHOR]

Objective: To assess racial and ethnic disparities in care for Medicare fee‐for‐service (FFS) beneficiaries and whether disparities differ between health system‐affiliated physician organizations (POs) and nonaffiliated POs. Data Sources: We used Medicare Data on Provider Practice and Specialty (MD‐PPAS), Medicare Provider Enrollment, Chain, and Ownership System (PECOS), IRS Form 990, 100% Medicare FFS claims, and race/ethnicity estimated using the Medicare Bayesian Improved Surname Geocoding 2.0 algorithm. Study Design: Using a sample of 16 007 POs providing primary care in 2015, we assessed racial/ethnic disparities on 12 measures derived from claims (2 cancer screenings; diabetic eye examinations; continuity of care; two medication adherence measures; three measures of follow‐up visits after acute care; all‐cause emergency department (ED) visits, all‐cause readmissions, and ambulatory care‐sensitive admissions). We decomposed these "total" disparities into within‐PO and between‐PO components using models with PO random effects. We then pair‐matched 1853 of these POs that were affiliated with health systems to similar nonaffiliated POs. We examined differences in within‐PO disparities by affiliation status by interacting each nonwhite race/ethnicity with an affiliation indicator. Data Collection/Extraction methods: Medicare Data on Provider Practice and Specialty identified POs billing Medicare; PECOS and IRS Form 990 identified health system affiliations. Beneficiaries age 18 and older were attributed to POs using a plurality visit rule. Principal Findings: We observed total disparities in 12 of 36 comparisons between white and nonwhite beneficiaries; nonwhites received worse care in 10. Within‐PO disparities exceeded between‐PO disparities and were substantively important (>=5 percentage points or>=0.2 standardized differences) in nine of the 12 comparisons. Among these 12, nonaffiliated POs had smaller disparities than affiliated POs in two comparisons (P <.05): 1.6 percentage points smaller black‐white disparities in follow‐up after ED visits and 0.6 percentage points smaller Hispanic‐white disparities in breast cancer screening. Conclusions: We find no evidence that system‐affiliated POs have smaller racial and ethnic disparities than nonaffiliated POs. Where differences existed, disparities were slightly larger in affiliated POs. [ABSTRACT FROM AUTHOR]

Objective: To understand how health systems are facilitating primary care redesign (PCR), examine the PCR initiatives taking place within systems, and identify barriers to this work.Study Setting: A purposive sample of 24 health systems in 4 states.Study Design: Data were systematically reviewed to identify how system leaders define and implement initiatives to redesign primary care delivery and identify challenges. Researchers applied codes which were based on the theoretical PCR literature and created new codes to capture emerging themes. Investigators analyzed coded data then produced and applied a thematic analysis to examine how health systems facilitate PCR.Data Collection: Semi-structured telephone interviews with 162 system executives and physician organization leaders from 24 systems.Principal Findings: Leaders at all 24 health systems described initiatives to redesign the delivery of primary care, but many were in the early stages. Respondents described the use of centralized health system resources to facilitate PCR initiatives, such as regionalized care coordinators, and integrated electronic health records. Team-based care, population management, and care coordination were the most commonly described initiatives to transform primary care delivery. Respondents most often cited improving efficiency and enhancing clinician job satisfaction, as motivating factors for team-based care. Changes in payment and risk assumption as well as community needs were commonly cited motivators for population health management and care coordination. Return on investment and the slower than anticipated rate in moving from fee-for-service to value-based payment were noted by multiple respondents as challenges health systems face in redesigning primary care.Conclusions: Given their expanding role in health care and the potential to leverage resources, health systems are promising entities to promote the advancement of PCR. Systems demonstrate interest and engagement in this work but face significant challenges in getting to scale until payment models are in alignment with these efforts. [ABSTRACT FROM AUTHOR]

OBJECTIVES The Centers for Medicare & Medicaid Services (CMS) Nursing Home Quality Initiative aims to improve quality through performance measurement. We describe quality improvement (QI) changes that skilled nursing facilities (SNFs) reported making in response to CMS performance measurements and whether reported QI changes were associated with better performance on CMS performance measures. DESIGN Nationally representative survey. SETTING A total of 15,475 SNFs that reported quality performance on Nursing Home Compare in 2016. PARTICIPANTS A total of 1,182 SNFs (58% of random sample of 2,045 SNFs). MEASUREMENTS Adoption of 22 possible QI changes, grouped into seven categories (organizational culture, health information technology, care process redesign, provider incentives, changes to staffing responsibilities, performance monitoring, and measure‐specific QI initiatives and technical assistance); performance on the CMS Nursing Home Compare Five‐Star Quality Rating System's quality measure rating. RESULTS: SNFs reported making an average of 13 QI changes (interquartile range = 11‐16 changes). SNFs mostly commonly reported becoming a learning organization (87%) and providing training to staff on QI strategies (87%). After controlling for patient and facility characteristics, larger SNFs were more likely to obtain assistance on measure reporting from QI organizations and use provider champions than smaller SNFs by 14 and 11 percentage points, respectively. Rural SNFs and SNFs with higher proportions of disabled, black, or Hispanic residents adopted QI changes at similar rates as other SNFs. Of the 22 QI changes, 20 were considered at least somewhat helpful by more than 80% of adopting SNFs. Implementation of all 22 QI changes (vs no changes) was associated with a.48‐star higher quality measure rating (95% confidence interval =.003‐.98 stars; P =.05). CONCLUSION: In response to CMS measurement programs, SNFs reported making substantial QI investments that were associated with better performance on CMS quality measures. To guide future SNF investments in QI, work is needed to identify the QI changes that yield the greatest performance improvements. [ABSTRACT FROM AUTHOR]

BACKGROUND: Older adults are particularly vulnerable to complications from proton pump inhibitor (PPI) drugs. We sought to characterize the prevalence of potentially low‐value PPI prescriptions among older adults to inform a quality improvement (QI) intervention. METHODS: We created a cohort of patients, aged 65 years or older, receiving primary care at a large academic health system in 2018. We identified patients currently prescribed any PPI using the electronic health record (EHR) medication list (current defined as September 1, 2018). A geriatrician, a gastroenterologist, a QI expert, and two primary care physicians (PCPs) created multidisciplinary PPI appropriateness criteria based on evidenced‐based guidelines. Supervised by a gastroenterologist and PCP, two internal medicine residents conducted manual chart reviews in a random sample of 399 patients prescribed PPIs. We considered prescriptions potentially low value if they lacked a guideline‐based (1) short‐term indication (gastroesophageal reflux disease [GERD]/peptic ulcer disease/Helicobacter pylori gastritis/dyspepsia) or (2) long‐term (>8 weeks) indication (severe/refractory GERD/erosive esophagitis/Barrett esophagus/esophageal adenocarcinoma/esophageal stricture/high gastrointestinal bleeding risk/Zollinger‐Ellison syndrome). We used the Wilson score method to calculate 95% confidence intervals (CIs) on low‐value PPI prescription prevalence. RESULTS: Among 69 352 older adults, 8729 (12.6%) were prescribed a PPI. In the sample of 399 patients prescribed PPIs, 63.9% were female; their mean age was 76.2 years, and they were seen by 169 PCPs. Of the 399 prescriptions, 143 (35.8%; 95% CI = 31.3%‐40.7%) were potentially low value—of which 82% began appropriately (eg, GERD) but then continued long term without a guideline‐based indication. Among 169 PCPs, 32 (18.9%) contributed to 59.2% of potentially low‐value prescriptions. CONCLUSION: One in eight older adults were prescribed a PPI, and over one‐third of prescriptions were potentially low‐value. Most often, appropriate short‐term prescriptions became potentially low value because they lacked long‐term indications. With most potentially low‐value prescribing concentrated among a small subset of PCPs, interventions targeting them and/or applying EHR‐based automatic stopping rules may protect older adults from harm. J Am Geriatr Soc 67:2600–2604, 2019 [ABSTRACT FROM AUTHOR]

Objectives: To develop and assess the reliability and validity of composite measures of reasons for disenrollment from Medicare Advantage (MA) and prescription drug plans (PDPs).Data Source: Medicare beneficiaries who responded to the Medicare Advantage and Prescription Drug Plan Disenrollment Reasons Survey.Study Design: Separate multilevel factor analyses of MA and PDP data suggested groupings of survey items to form composite measures, for which internal consistency and interunit reliability were estimated. The association of each composite with an overall plan rating was examined to evaluate criterion validity.Principal Findings: Five composites were identified: financial reasons for disenrollment; problems with prescription drug benefits and coverage; problems getting information and help from the plan; problems getting needed care, coverage, and cost information; and problems with coverage of doctors and hospitals. Beneficiary-level internal consistency reliability exceeded 0.70 for all but one composite (financial reasons); plan-level internal consistency reliability exceeded 0.80 for all composites; average interunit reliability for plans with ≥ 30 survey completes exceeded 0.75 for 3 of 5 composites. As expected, greater endorsement of reasons for disenrollment was associated with lower overall plan ratings.Conclusions: The Disenrollment Reasons Survey provides a reliable and valid assessment of beneficiaries' reasons for leaving their plans. Multiple reasons for disenrollment may indicate especially poor experiences. [ABSTRACT FROM AUTHOR]

Objective: To sample 40 physician organizations stratified on the basis of longitudinal cost of care measures for qualitative interviews in order to describe the range of care delivery structures and processes that are being deployed to influence the total costs of caring for patients.Data Sources: Three years of physician organization-level total cost of care data (n = 156 in California) from the Integrated Healthcare Association's value-based pay-for-performance program.Study Design: We fit total cost of care data using mixture and K-means clustering algorithms to segment the population of physician organizations into sampling strata based on 3-year cost trajectories (ie, cost curves).Principal Findings: A mixture of multivariate normal distributions can classify physician organization cost curves into clusters defined by total cost level, shape, and within-cluster variation. K-means clustering does not accommodate differing levels of within-cluster variation and resulted in more clusters being allocated to unstable cost curves. A mixture of regressions approach focuses overly on anomalous trajectories and is sensitive to model coding.Conclusions: Statistical clustering can be used to form sampling strata when longitudinal measures are of primary interest. Many clustering algorithms are available; the choice of the clustering algorithm can strongly impact the resulting strata because various algorithms focus on different aspects of the observed data. [ABSTRACT FROM AUTHOR]

Objective: To compare performance between Medicare Advantage (MA) and Fee-for-Service (FFS) Medicare during a time of policy changes affecting both programs.Data Sources/study Setting: Performance data for 16 clinical quality measures and 6 patient experience measures for 9.9 million beneficiaries living in California, New York, and Florida.Study Design: We compared MA and FFS performance overall, by plan type, and within service areas associated with contracts between CMS and MA organizations. Case mix-adjusted analyses (for measures not typically adjusted) were used to explore the effect of case mix on MA/FFS differences.Data Collection/extraction Methods: Performance measures were submitted by MA organizations, obtained from the nationwide fielding of the Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) Survey, or derived from claims.Principal Findings: Overall, MA outperformed FFS on all 16 clinical quality measures. Differences were large for HEDIS measures and small for Part D measures and remained after case mix adjustment. MA enrollees reported better experiences overall, but FFS beneficiaries reported better access to care. Relative to FFS, performance gaps were much wider for HMOs than PPOs. Excluding HEDIS measures, MA/FFS differences were much smaller in contract-level comparisons.Conclusions: Medicare Advantage/Fee-for-Service differences are often large but vary in important ways across types of measures and contracts. [ABSTRACT FROM AUTHOR]

Objective. Evaluate short-term effects of the Patient Safety Improvement Corps (PSIC), an Agency for Healthcare Research and Quality–sponsored program to train state teams in patient safety skills/tools, to assess its contribution to building a national infrastructure supporting effective patient safety practices. Data Source. Self-reported information gathered from (1) group interviews at the end of each year; (2) individual telephone interviews 1 year later; (3) faxed information forms 2 years later. Study Design. Program evaluation of immediate and short-term process and impact (use of skills/tools, information sharing, changes in practice). Data Collection. Semistructured interviews; faxed forms. Principal Findings. One year after training, approximately half of Year 1 and 2 state agency representatives reported they had initiated or modified legislation to strengthen safe practices, and modified adverse event oversight procedures. Approximately three-quarters of hospital representatives said training contributed to modifications to adverse event oversight procedures and promotion of patient safety culture. Two years posttraining, approximately three-quarters of Year 1 trainees said they continued to use many skills/tools. Conclusions. The PSIC contributed to building a national infrastructure supporting effective patient safety practices. Expanded training is needed to reach a larger fraction of the population for which this training is important. [ABSTRACT FROM AUTHOR]

Objectives. To document and assess the experiences of 104 Agency for Healthcare Research and Quality (AHRQ)-funded health information technology (health IT) grantees in planning and implementing health IT systems. Data Source. Grant proposals and interviews with the AHRQ health IT grantees. Data Collection Method. Extracted descriptive data from the health IT grant proposals; conducted telephone interviews with principal investigators. Principal Findings. AHRQ funding of the health IT projects provided important support for health IT development work in various health care settings. Successful implementation required commitment from top management, dedicated staff and financial resources, an open process to encourage buy-in and enthusiasm by end users, and sheer persistence. Technologies required tailoring to the specific organization's needs. Grantees felt their projects could be replicated by others, if organizations had ample IT expertise and resources. Evaluating the value of health IT was hampered by the absence of validated instruments and measures, organizational demands that competed with data collection, and lack of evaluation expertise among health IT implementers. Conclusions. Experiences of the health IT grantees provide rich information for use by health care providers, AHRQ, and other policy makers to help strengthen future health IT development efforts, including the need to improve evaluation design and standards to assess impact. [ABSTRACT FROM AUTHOR]

Objectives. To document the numbers and types of interorganizational partnerships within the national patient safety domain, changes over time in these networks, and their potential for disseminating patient safety knowledge and practices. Data Sources. Self-reported information gathered from representatives of national-level organizations active in promoting patient safety. Study Design. Social network analysis was used to examine the structure and composition of partnership networks and changes between 2004 and 2006. Data Collection. Two rounds of structured telephone interviews ( n=35 organizations in 2004 and 55 in 2006). Principal Findings. Patient safety partnerships expanded between 2004 and 2006. The average number of partnerships per interviewed organization increased 40 percent and activities per reported partnership increased over 50 percent. Partnerships increased in all activity domains, particularly dissemination and tools development. Fragmentation of the overall partnership network decreased and potential for information flow increased. Yet network centralization increased, suggesting vulnerability to partnership failure if key participants disengage. Conclusions. Growth in partnerships signifies growing strength in the capacity to disseminate and implement patient safety advancements in the U.S. health care system. The centrality of AHRQ in these networks of partnerships bodes well for its leadership role in disseminating information, tools, and practices generated by patient safety research projects. [ABSTRACT FROM AUTHOR]

Objective. To present overall findings from the 4-year evaluation of the national patient safety initiative operated by the Agency for Healthcare Research and Quality (AHRQ). Data Sources. Interviews with AHRQ staff, grantees, and other patient safety stakeholders; published materials; and internal AHRQ documents. Study Design. The evaluation was structured to address a system framework of five components involved in improving safety. The initiative's contributions to improving each system component were assessed qualitatively, comparing results from three separate analyses—AHRQ's achievement of its patient safety goals, our own assessment of the initiative's activities, and independent stakeholder ratings of AHRQ's contributions. Findings and Conclusions. AHRQ has faced a daunting challenge for improving patient safety, given the complex problems of the U.S. health care system and the limited resources AHRQ has had to address them. The patient safety initiative achieved strongest progress for its contributions to knowledge of patient safety epidemiology and effective practices, where AHRQ has considerable experience, and to strengthening infrastructure to support adoption of safe practices. Progress was slower in establishing a national monitoring capability and dissemination of safe practices for adoption. AHRQ needs to expand efforts to apply new knowledge for stimulating use of safe practices in the field. [ABSTRACT FROM AUTHOR]

Objectives. To synthesize lessons learned from the experiences of Agency for Healthcare Research and Quality-funded patient safety projects in implementing safe practices. Data Sources. Self-reported data from individual and group interviews with Original, Challenge, and Partnerships in Implementing Patient Safety (PIPS) grantees, from 2003 to 2006. Study Design. Interviews with three grantee groups ( n=60 total) implementing safe practice projects, with comparisons on factors influencing project implementation and sustainability. Data Collection. Semi-structured protocols contained open-ended questions on lessons learned and more structured questions on factors associated with project implementation and sustainability. Principal Findings. The grantees shared common experiences, frequently identifying lessons learned regarding structural components needing to be in place before implementation, components of the implementation process, components of interventions' results needed for sustainability, changes in timelines or activities, unanticipated issues, and staff acceptance/adoption. Also, fewer Original grants had many of the factors related project to implementation/sustainability than the PIPS or Challenge grantees had. Conclusions. Although much of what was reported seemed like common sense, surprisingly few projects actually planned for or expected many of the barriers or facilitators they experienced during their project implementation. Others implementing practice improvements likely will share the experiences and issues identified by these implementation projects and can learn from their lessons. [ABSTRACT FROM AUTHOR]

Objective. The validity of quality of care measurement has important implications for practicing clinicians, their patients, and all involved with health care delivery. We used empirical data from managed care patients enrolled in west coast physician organizations to test the hypothesis that observed changes in health-related quality of life across a 2.5-year window reflecting process of care. Data Sources/Study Setting. Patient self-report data as well as clinically detailed medical record review regarding 963 patients with chronic disease associated with managed care from three west coast states. Study Design. Prospective cohort study of change in health-related quality of life scores across 30 months as measured by change in SF-12 physical component scores. Data Collection/Extraction Methods. Patient self-report and medical record abstraction. Principal Findings. We found a positive relationship between better process scores and higher burden of illness ( p<.05). After adjustment for burden of illness, using an instrumental variables approach revealed better process is associated with smaller declines in SF-12 scores across a 30-month observation window ( p=.014). The application of the best quartile of process of care to patients currently receiving poor process is associated with a 4.24 increment in δ SF-12-physical component summary scores. Conclusions. The use of instrumental variables allowed us to demonstrate a significant relationship between better ambulatory process of care and better health-related quality of life. This finding underscores the importance of efforts to improve the process of care. [ABSTRACT FROM AUTHOR]

To create an efficient imputation algorithm for imputing the SF-12 physical component summary (PCS) and mental component summary (MCS) scores when patients have one to eleven SF-12 items missing.Primary data collection was performed between 1996 and 1998.Multi-pattern regression was conducted to impute the scores using only available SF-12 items (simple model), and then supplemented by demographics, smoking status and comorbidity (enhanced model) to increase the accuracy. A cut point of missing SF-12 items was determined for using the simple or the enhanced model. The algorithm was validated through simulation.Thirty-thousand-three-hundred and eight patients from 63 physician groups were surveyed for a quality of care study in 1996, which collected the SF-12 and other information. The patients were classified as“chronic” patients if they reported that they had diabetes, heart disease, asthma/chronic obstructive pulmonary disease, or low back pain. A follow-up survey was conducted in 1998.Thirty-one percent of the patients missed at least one SF-12 item. Means of variance of prediction and standard errors of the mean imputed scores increased with the number of missing SF-12 items. Correlations between the observed and the imputed scores derived from the enhanced models were consistently higher than those derived from the simple model and the increments were significant for patients with≥6 missing SF-12 items (p<.03).Missing SF-12 items are prevalent and lead to reduced analytical power. Regression-based multi-pattern imputation using the available SF-12 items is efficient and can produce good estimates of the scores. The enhancement from the additional patient information can significantly improve the accuracy of the imputed scores for patients with≥6 items missing, leading to estimated scores that are as accurate as that of patients with<6 missing items. [ABSTRACT FROM AUTHOR]

Objective. To illustrate, using empirical data, methodological challenges associated with patient responses to longitudinal surveys regarding the quality of process of care and health status, including overall response rate, differential response rate, and stability of responses with time. Data Sources/Study Setting. Primary patient self‐report data were collected from 30,308 patients in 1996 and 13,438 patients in 1998 as part of a two‐year longitudinal study of quality of care and health status of patients receiving care delivered by 63 physician organizations (physician groups) across three West Coast states. Study Design. We analyzed longitudinal, observational data collected by Pacific Business Group on Health (PBGH) from patients aged 18–70 using a four‐page survey in 1996 and a similar survey in 1998 to assess health status, satisfaction, use of services, and self‐reported process of care. A subset of patients with self‐reported chronic disease in the 1996 study received an enriched survey in 1998 to more fully detail processes of care for patients with chronic disease. Data Collection/Extraction Methods. We measured response rate overall and separately for patients with chronic disease. Logistic regression was used to assess the impact of 1996 predictors on response to the follow‐up 1998 survey. We compared process of care scores without and with nonresponse weights. Additionally, we measured stability of patient responses over time using percent agreement and kappa statistics, and examined rates of gender inconsistencies reported across the 1996 and 1998 surveys. Principal Findings. In 1998, response rates were 54 percent overall and 63 percent for patients with chronic disease. Patient demographics, health status, use of services, and satisfaction with care in 1996 were all significant predictors of response in 1998, highlighting the importance of analytic strategies (i.e., application of nonresponse weights) to minimize bias in estimates of care and outcomes associated with longitudinal quality of care and health outcome analyses. Process of care scores weighted for nonresponse differed from unweighted scores (p <.001). Stability of responses across time was moderate, but varied by survey item from fair to excellent. Conclusions. Longitudinal analyses involving the collection of data from the same patients at two points in time provide opportunities for analysis of relationships between process and outcomes of care that cannot occur with cross‐sectional data. We present empirical results documenting the scope of the problems and discuss options for responding to these challenges. With increasing emphasis in the United States on quality reporting and use of financial incentives for quality in the health care market, it is important to identify and address methodological challenges that potentially threaten the validity of quality‐of‐care assessments. [ABSTRACT FROM AUTHOR]