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Pay-for-quality (P4Q) initiatives are becoming an increasingly popular mechanism for improving quality performance and reducing health care costs in the United States. Because these programs often target primary care physicians, it is important to understand how these physicians perceive and respond to P4Q to design successful programs going forward. This study reports results of a survey regarding attitudes toward P4Q among physicians participating in such programs in Massachusetts and California. Findings indicate physicians have generally positive attitudes toward the concept of P4Q, but are ambivalent about certain features of these programs as currently designed and implemented. [ABSTRACT FROM AUTHOR]

This article identifies and discusses key conceptual issues in designing and implementing pay-for-quality programs. Such programs offer financial incentives to providers for achieving predefined quality targets. The purpose of the article is to provide health care professionals with a framework for designing, implementing, and evaluating pay-for-quality programs. Examples are drawn from the Rewarding Results demonstration project for which the authors serve as the national evaluation team. [ABSTRACT FROM AUTHOR]

Objective: To develop a risk adjustment method for HbA1c, based solely on administrative data and to determine the extent to which risk-adjusted HbA1c changes the identification of high- or low-performing medical facilities.Research Design and Methods: Through use of pharmacy records, 204,472 diabetic patients were identified for federal fiscal year 1996 (FY96). Complete information (HbA1c levels, demographic data, inpatient records, outpatient pharmacy utilization records) was available on 38,173 predominantly male patients from 48 Veterans Health Administration (VHA) medical facilities. Hierarchical mixed-effects models were used to estimate risk-adjusted unique facility-level HbA1c.Results: Predicted HbA1c demonstrated expected patterns for major factors known to influence glycemic control. Poorer glycemic control was seen in minorities and patients with greater disease severity, longer duration of disease (using treatment type or presence of amputation as surrogates), and more extensive comorbidity (measured by an adapted Charlson index). Better glycemic control was seen in Caucasians, older diabetic patients, and patients with higher outpatient utilization. The number of performance outliers was reduced as a result of risk adjustment. For mean HbA1c levels, 7 facilities that were initially identified as statistically significant outliers were no longer outliers after risk adjustment. For high-risk HbA1c (>9.5%) rates, 12 facilities that were initially identified as statistically significant outliers were no longer outliers after risk adjustment.Conclusions: Risk adjustment using only administrative data resulted in substantial changes in identification of high or low performers compared with non-risk-adjusted HbA1c. Although our findings are exploratory, risk adjustment using administrative data may be a necessary and achievable step in quality assessment of diabetes care measured by rates of high-risk HbA1c (>9.5%). [ABSTRACT FROM AUTHOR]

Objective: To investigate the relationship between physician-hospital integration within accountable care organizations (ACOs) and inpatient care utilization and expenditure., Data Sources: The primary data were Massachusetts All-Payer Claims Database (2009-2013)., Study Setting: Fifteen provider organizations that entered a commercial ACO contract with a major private payer in Massachusetts between 2009 and 2013., Study Design: Using an instrumental variable approach, the study compared inpatient care delivery between patients of ACOs demonstrating high versus low integration. We measured physician-hospital integration within ACOs by the proportion of primary care physicians in an ACO who billed for outpatient services with a place-of-service code indicating employment or practice ownership by a hospital. The study sample comprised non-elderly adults who had continuous insurance coverage and were attributed to one of the 15 ACOs. Outcomes of interest included total medical expenditure during an episode of inpatient care, length of stay (LOS) of the index hospitalization, and 30-day readmission. An inpatient episode was defined as 30, 45, and 60 days from the admission date., Data Collection/extraction Methods: Not applicable., Principal Findings: The study examined 33,535 admissions from patients served by the 15 ACOs. Average medical expenditure within 30 days of admission was $24,601, within 45 days was $26,447, and within 60 days was $28,043. Average LOS was 3.5 days, and 5.4% of patients were readmitted within 30 days. Physician-hospital integration was associated with a 10.6% reduction in 30-day expenditure (95% CI, -15.1% to -5.9%). Corresponding estimates for 45 and 60 days were - 9.7% (95%CI, -14.2% to -4.9%) and - 9.6% (95%CI, -14.3% to -4.7%). Integration was associated with a 15.7% decrease in LOS (95%CI, -22.6% to -8.2%) but unrelated to 30-day readmission rate., Conclusions: Our instrumental variable analysis shows physician-hospital integration with ACOs was associated with reduced inpatient spending and LOS, with no evidence of elevated readmission rates., (© 2024 Health Research and Educational Trust.)

Abstract: Physician-hospital integration among accountable care organizations (ACOs) has raised concern over impacts on prices and spending. However, characteristics of ACOs with greater integration between physicians and hospitals are unknown. We examined whether ACOs systematically differ by physician-hospital integration among 16 commercial ACOs operating in Massachusetts.Using claims data linked to information on physician affiliation, we measured hospital integration with primary care physicians for each ACO and categorized them into high-, medium-, and low-integrated ACOs. We conducted cross-sectional descriptive analysis to compare differences in patient population, organizational characteristics, and healthcare spending between the three groups. In addition, using multivariate generalized linear models, we compared ACO spending by integration level, adjusting for organization and patient characteristics. We identified non-elderly adults (aged 18-64) served by 16 Massachusetts ACOs over the period 2009 to 2013.High- and medium-integrated ACOs were more likely to be an integrated delivery system or an organization with a large number of providers. Compared to low-integrated ACOs, higher-integrated ACOs had larger inpatient care capacity, smaller composition of primary care physicians, and were more likely to employ physicians directly or through an affiliated hospital or physician group. A greater proportion of high-/medium-integrated ACO patients lived in affluent neighborhoods or areas with a larger minority population. Healthcare spending per enrollee in high-integrated ACOs was higher, which was mainly driven by a higher spending on outpatient facility services.This study shows that higher-integrated ACOs differ from their counterparts with low integration in many respects including higher healthcare spending, which persisted after adjusting for organizational characteristics and patient mix. Further investigation into the effects of integration on expenditures will inform the ongoing development of ACOs., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Large-scale adverse events (LSAEs) involve unsafe clinical practices stemming from system issues that may affect multiple patients. Although literature suggests a supportive organizational culture may protect against system-related adverse events, no study has explored such a relationship within the context of LSAEs. This study aimed to identify whether staff perceptions of organizational culture were associated with LSAE incidence., Methods: The team conducted an exploratory analysis using the 2008-2010 data from the US Department of Veterans Affairs (VA) All Employee Survey (AES). LSAE incidence was the outcome variable in two facilities where similar infection control practice issues occurred, leading to LSAEs. For comparison, four facilities where LSAEs had not occurred were selected, matched on VA-assigned facility complexity and geography. The AES explanatory factors included workgroup-level (civility, employee engagement, leadership, psychological safety, resources, rewards) and hospital-level Likert-type scales for four cultural factors (group, rational, entrepreneurial, bureaucratic). Bivariate analyses and logistic regressions were performed, with individual staff as the unit of analysis from the anonymous AES data., Results: Responses from 209 AES participants across the six facilities in the sample indicated that the four comparison facilities had significantly higher mean scores compared to the two LSAE facilities for 9 of 10 explanatory factors. The adjusted analyses identified that employee engagement significantly predicted LSAE incidence (odds ratio = 0.58, 95% confidence interval = 0.37-0.90)., Conclusion: Staff at the two exposure facilities in this study described their organizational culture to be less supportive. Lower scores in employee engagement may be a contributing factor for LSAEs., Competing Interests: Conflicts of Interest Dr. George is currently employed by IBM Watson Health. All research and manuscript development were conducted while Dr. George was employed by the VA. All other authors report no conflicts of interest., (Copyright © 2020 The Joint Commission. All rights reserved.)

Quality of care worries and rising costs have resulted in a widespread interest in enhancing the efficiency of health care delivery. One area of increasing interest is in promoting teamwork as a way of coordinating efforts to reduce costs and improve quality, and identifying the characteristics of the work environment that support teamwork. Relational climate is a measure of the work environment that captures shared employee perceptions of teamwork, conflict resolution, and diversity acceptance. Previous research has found a positive association between relational climate and quality of care, yet its relationship with costs remains unexplored. We examined the influence of primary care relational climate on health care costs incurred by diabetic patients at the U.S. Department of Veterans Affairs between 2008 and 2012. We found that better relational climate is significantly related to lower costs. Clinics with the strongest relational climate saved $334 in outpatient costs per patient compared with facilities with the weakest score in 2010. The total outpatient cost saving if all clinics achieved the top 5% relational climate score was $20 million. Relational climate may contribute to lower costs by enhancing diabetic treatment work processes, especially in outpatient settings.

Dense breast tissue is a common finding that decreases the sensitivity of mammography in detecting cancer. Many states have recently enacted dense breast notification (DBN) laws to provide patients with information to help them make better-informed decisions about their health. To test whether DBN legislation affected the probability of screening mammography follow-up by ultrasound and magnetic resonance imaging (MRI), we examined the proportion of times screening mammography was followed by ultrasound or MRI for a series of months pre- and post-legislation. The subjects were women aged 40 to 64 years, covered by private health insurance, undergoing screening mammography from 2007 to 2014. Except for Hawaii, Maryland, and New York, DBN legislation significantly increased the probability of ultrasound follow-up in all states that implemented DBN legislation before December 2014. It also increased the probability of MRI follow-up in California, North Carolina, Pennsylvania, and Texas. The financial and access consequences merit further study.

Difference-in-differences (DID) analysis is used widely to estimate the causal effects of health policies and interventions. A critical assumption in DID is "parallel trends": that pre-intervention trends in outcomes are the same between treated and comparison groups. To date, little guidance has been available to researchers who wish to use DID when the parallel trends assumption is violated. Using a Monte Carlo simulation experiment, we tested the performance of several estimators (standard DID; DID with propensity score matching; single-group interrupted time-series analysis; and multi-group interrupted time-series analysis) when the parallel trends assumption is violated. Using nationwide data from US hospitals (n = 3737) for seven data periods (four pre-interventions and three post-interventions), we used alternative estimators to evaluate the effect of a placebo intervention on common outcomes in health policy (clinical process quality and 30-day risk-standardized mortality for acute myocardial infarction, heart failure, and pneumonia). Estimator performance was assessed using mean-squared error and estimator coverage. We found that mean-squared error values were considerably lower for the DID estimator with matching than for the standard DID or interrupted time-series analysis models. The DID estimator with matching also had superior performance for estimator coverage. Our findings were robust across all outcomes evaluated.

Objective: To examine the relationship between cost and quality in Veterans Health Administration (VA) nursing homes (called Community Living Centers, CLCs) using longitudinal data., Data Sources/study Setting: One hundred and thirty CLCs over 13 quarters (from FY2009 to FY2012) were studied. Costs, resident days, and resident severity (RUGs score) were obtained from the VA Managerial Cost Accounting System. Clinical quality measures were obtained from the Minimum Data Set, and resident-centered care (RCC) was measured using the Artifacts of Culture Change Tool., Study Design: We used a generalized estimating equation model with facilities included as fixed effects to examine the relationship between total cost and quality after controlling for resident days and severity. The model included linear and squared terms for all independent variables and interactions with resident days., Principal Findings: With the exception of RCC, all other variables had a statistically significant relationship with total costs. For most poorer performing smaller facilities (lower size quartile), improvements in quality were associated with higher costs. For most larger facilities, improvements in quality were associated with lower costs., Conclusions: The relationship between cost and quality depends on facility size and current level of performance., (Published 2018. This article is a U.S. Government work and is in the public domain in the USA.)

Background: Increased breast tissue density may mask cancer and thus decrease the diagnostic sensitivity of mammography. A patient group advocacy led to the implementation of laws to increase the awareness of breast tissue density and to improve access to supplemental imaging in many states. Given limited evidence about best practices, variation exists in several characteristics of adopted policies., Objective: To identify which characteristics of state-level policies with regard to dense breast tissue were associated with increased use of downstream breast ultrasound., Research Design: This was a retrospective series of monthly cross-sections of screening mammography procedures before and after implementation of laws., Subjects: A sample of 13,481,554 screening mammography procedures extracted from the MarketScan Research database performed between 2007 and 2014 on privately insured women aged 40-64 years that resided in a state that had implemented relevant legislation during that period., Measures: The outcome was an indicator of whether breast ultrasound imaging followed a screening mammography procedure within 30 days. The main independent variables were policy characteristics indicators., Results: Notification of patients about issues surrounding increased breast density was associated with increased follow-up by ultrasound by 1.02 percentage points (P=0.016). Some policy characteristics such as the explicit suggestion of supplemental imaging or mandated coverage of supplemental imaging by health insurance augmented that effect. Other policy characteristics moderated the effect., Conclusions: The heterogeneous effect of state legislation with regard to dense breast tissue on screening mammography follow-up by ultrasound may be explained by specific and unique characteristics of the approaches taken by a variety of states.

Objective: To assess the influence of relational climate on quality of diabetes care., Data Sources/study Setting: The study was conducted at the Department of Veterans Affairs (VA). The VA All Employee Survey (AES) was used to measure relational climate. Patient and facility characteristics were gathered from VA administrative datasets., Study Design: Multilevel panel data (2008-2012) with patients nested into clinics., Data Collection/extraction Methods: Diabetic patients were identified using ICD-9 codes and assigned to the clinic with the highest frequency of primary care visits. Multiple quality indicators were used, including an all-or-none process measure capturing guideline compliance, the actual number of tests and procedures, and three intermediate continuous outcomes (cholesterol, glycated hemoglobin, and blood pressure)., Principal Findings: The study sample included 327,805 patients, 212 primary care clinics, and 101 parent facilities in 2010. Across all study years, there were 1,568,180 observations. Clinics with the highest relational climate were 25 percent more likely to provide guideline-compliant care than those with the lowest relational climate (OR for a 1-unit increase: 1.02, p-value <.001). Among insulin-dependent diabetic veterans, this effect was twice as large. Contrary to that expected, relational climate did not influence intermediate outcomes., Conclusions: Relational climate is positively associated with tests and procedures provision, but not with intermediate outcomes of diabetes care., (© Health Research and Educational Trust.)

Objective: To identify space-time clusters of changes in prescribing aripiprazole for bipolar disorder among providers in the VA., Data Sources: VA administrative data from 2002 to 2010 were used to identify prescriptions of aripiprazole for bipolar disorder. Prescriber characteristics were obtained using the Personnel and Accounting Integrated Database., Study Design: We conducted a retrospective space-time cluster analysis using the space-time permutation statistic., Data Extraction Methods: All VA service users with a diagnosis of bipolar disorder were included in the patient population. Individuals with any schizophrenia spectrum diagnoses were excluded. We also identified all clinicians who wrote a prescription for any bipolar disorder medication., Principal Findings: The study population included 32,630 prescribers. Of these, 8,643 wrote qualifying prescriptions. We identified three clusters of aripiprazole prescribing centered in Massachusetts, Ohio, and the Pacific Northwest. Clusters were associated with prescribing by VA-employed (vs. contracted) prescribers. Nurses with prescribing privileges were more likely to make a prescription for aripiprazole in cluster locations compared with psychiatrists. Primary care physicians were less likely., Conclusions: Early prescribing of aripiprazole for bipolar disorder clustered geographically and was associated with prescriber subgroups. These methods support prospective surveillance of practice changes and identification of associated health system characteristics., (© Health Research and Educational Trust.)

Background: Composite measures, which aggregate performance on individual measures into a summary score, are increasingly being used to evaluate facility performance. There is little understanding of the unique perspective that composite measures provide., Objective: To examine whether high/low (ie, high or low) performers on a composite measures are also high/low performers on most of the individual measures that comprise the composite., Methods: We used data from 2 previous studies, one involving 5 measures from 632 hospitals and one involving 28 measures from 112 Veterans Health Administration (VA) nursing homes; and new data on hospital readmissions for 3 conditions from 131 VA hospitals. To compare high/low performers on a composite to high/low performers on the component measures, we used 2-dimensional tables to categorize facilities into high/low performance on the composite and on the individual component measures., Results: In the first study, over a third of the 162 hospitals in the top quintile based on the composite were in the top quintile on at most 1 of the 5 individual measures. In the second study, over 40% of the 27 high-performing nursing homes on the composite were high performers on 8 or fewer of the 28 individual measures. In the third study, 20% of the 61 low performers on the composite were low performers on only 1 of the 3 individual measures., Conclusions: Composite measures can identify as high/low performers facilities that perform "pretty well" (or "pretty poorly") across many individual measures but may not be high/low performers on most of them.

Background: The collaborative care model is an evidence-based practice for treatment of depression in which designated care managers provide clinical services, often by telephone. However, the collaborative care model is infrequently adopted in the Department of Veterans Affairs (VA). Almost all VA medical centers have adopted a co-located or embedded approach to integrating mental health care for primary care patients. Some VA medical centers have also adopted a telephone-based collaborative care model where depression care managers support patient education, patient activation, and monitoring of adherence and progress over time. This study evaluated two research questions: (1) What does a dedicated care manager offer in addition to an embedded-only model? (2) What are the barriers to implementing a dedicated depression care manager?, Methods: This study involved 15 qualitative, multi-disciplinary, key informant interviews at two VA medical centers where reimbursement options were the same- both with embedded mental health staff, but one with a depression care manager. Participant interviews were recorded and transcribed. Thematic analysis was used to identify descriptive and analytical themes., Results: Findings suggested that some of the core functions of depression care management are provided as part of embedded-only mental health care. However, formal structural attention to care management may improve the reliability of care management functions, in particular monitoring of progress over time. Barriers to optimal implementation were identified at both sites. Themes from the care management site included finding assertive care managers to hire, cross-discipline integration and collaboration, and primary care provider burden. Themes from interviews at the embedded site included difficulty getting care management on leaders' agendas amidst competing priorities and logistics (staffing and space)., Conclusions: Providers and administrators see depression care management as a valuable healthcare service that improves patient care. Barriers to implementation may be addressed by team-building interventions to improve cross-discipline integration and communication. Findings from this study are limited in scope to the VA healthcare system. Future investigation of whether alternative barriers exist in implementation of depression care management programs in non-VA hospital systems, where reimbursement rates may be a more prominent concern, would be valuable.

Background: Patient, physician, and environmental factors were identified, and the authors examined the contribution of these factors to demographic and health variation in colonoscopy follow-up after a positive fecal occult blood test/fecal immunochemical test (FOBT/FIT) screening., Methods: In total, 76,243 FOBT/FIT-positive patients were identified from 120 Veterans Health Administration (VHA) facilities between August 16, 2009 and March 20, 2011 and were followed for 6 months. Patient demographic (race/ethnicity, sex, age, marital status) and health characteristics (comorbidities), physician characteristics (training level, whether primary care provider) and behaviors (inappropriate FOBT/FIT screening), and environmental factors (geographic access, facility type) were identified from VHA administrative records. Patient behaviors (refusal, private sector colonoscopy use) were estimated with statistical text mining conducted on clinic notes, and follow-up predictors and adjusted rates were estimated using hierarchical logistic regression., Results: Roughly 50% of individuals completed a colonoscopy at a VHA facility within 6 months. Age and comorbidity score were negatively associated with follow-up. Blacks were more likely to receive follow-up than whites. Environmental factors attenuated but did not fully account for these differences. Patient behaviors (refusal, private sector colonoscopy use) and physician behaviors (inappropriate screening) fully accounted for the small reverse race disparity and attenuated variation by age and comorbidity score. Patient behaviors (refusal and private sector colonoscopy use) contributed more to variation in follow-up rates than physician behaviors (inappropriate screening)., Conclusions: In the VHA, blacks are more likely to receive colonoscopy follow-up for positive FOBT/FIT results than whites, and follow-up rates markedly decline with advancing age and comorbidity burden. Patient and physician behaviors explain race variation in follow-up rates and contribute to variation by age and comorbidity burden. Cancer 2017;123:3502-12. Published 2017. This article is a US Government work and is in the public domain in the USA., (© 2017 American Cancer Society.)

Background: In 2011, fee-for-service patients with both Medicare and Medicaid (dual eligible) sustained $319.5 billion in health care costs., Objective: To describe the emergency department (ED) use and hospital admissions of adult dual eligible patients aged under 65 years who used an urban safety net hospital., Methods: This was a retrospective database analysis of patients aged between 18 and 65 years with Medicare and Medicaid, who used an urban safety net academic health center between January 1, 2011, and December 31, 2011. We compared patients with and without behavioral health illness. The main outcome measures were hospital admission and ED use. Chi-square and Wilcoxon rank-sum tests were used for descriptive statistics on categorical and continuous variables, respectively. Greedy propensity score matching was used to control for confounding factors. Rate ratios (RR) and 95% confidence intervals (CI) were determined after matching and after adjusting for those variables that remained significantly different after matching., Results: In 2011, 10% of all fee-for-service dual eligible patients aged less than 65 years in Massachusetts were seen at Boston Medical Center. Data before propensity score matching showed significant differences in age, sex, race/ethnicity, marital status, education, employment, physical comorbidities, and Charlson Comorbidity Index score between patients with and without behavioral health illness. Analysis after propensity score matching found significant differences in sex, Hispanic race, and other education and employment status. Compared with patients without behavioral health illness, patients with behavioral health illness had a higher RR for hospital admissions (RR = 2.07; 95% CI = 1.81-2.38; P < 0.001) and ED use (RR = 1.61; 95% CI = 1.46-1.77; P < 0.001). Results were robust after adjusting for characteristics that remained statistically significantly different after propensity score matching., Conclusions: Adult dual eligible patients aged less than 65 years with behavioral health illness in the Medicaid fee-for-service plan had significantly higher rates of hospital admission and ED use compared with dual eligible patients without behavioral health illness at the largest urban safety net medical center in New England. Safety net hospitals care for a large proportion of dual eligible patients with behavioral health illness. Further research is needed to elucidate the systems-related and patient-centered factors contributing to the utilization behaviors of this patient population., Disclosures: This research was funded in part by a National Research Service Award (T3HP10028-14-01). The authors have no conflicts of interests to disclose. Cancino had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design were contributed by Cancino, Jack, and Burgess, with assistance from Cremieux. Cancino and Cremieux took the lead in data collection, along with Jack and Burgess, and data interpretation was performed by Jarvis, Cummings, and Cooper, along with the other authors. The manuscript was written primarily by Cancino, along with Jack and Burgess, and revised primarily by Cancino, along with the other authors.

We evaluate consumption responses to the non-linear Medicare Part D prescription drug benefit. We compare propensity-matched older patients with diabetes and Part D Standard or low-income-subsidy (LIS) coverage. We evaluate monthly adherence to branded oral anti-diabetics, with high end-of-year donut hole prices (>$200) for Standard patients and consistent, low (≤$6) prices for LIS. As an additional control, we examine adherence to generic anti-diabetics, with relatively low, consistent prices for Standard patients. If Standard patients are forward looking, they will reduce branded adherence in January, and LIS-Standard differences will be constant through the year. Contrary to this expectation, branded adherence is lower for Standard patients in January and diverges from LIS as the coverage year progresses. Standard-LIS generic adherence differences are minimal. Our findings suggest that seniors with chronic conditions respond myopically to the nonlinear Part D benefit, reducing consumption in response to high deductible, initial coverage and gap prices. Thus, when the gap is fully phased out in 2020, cost-related nonadherence will likely remain in the face of higher spot prices for more costly branded medications. These results contribute to studies of Part D plan choice and medication adherence that suggest that seniors may not make optimal healthcare decisions. Copyright © 2016 John Wiley & Sons, Ltd., (Copyright © 2016 John Wiley & Sons, Ltd.)

Background: Participant recruitment is an ongoing challenge in health research. Recruitment may be especially difficult for studies of access to health care because, even among those who are in care, people using services least often also may be hardest to contact and recruit. Opt-out recruitment methods (in which potential participants are given the opportunity to decline further contact about the study (opt out) following an initial mailing, and are then contacted directly if they have not opted out within a specified period) can be used for such studies. However, there is a dearth of literature on the effort needed for effective opt-out recruitment., Methods: In this paper we describe opt-out recruitment procedures for two studies on access to health care within the U.S. Department of Veterans Affairs. We report resource requirements for recruitment efforts (number of opt-out packets mailed and number of phone calls made). We also compare the characteristics of study participants to potential participants via t-tests, Fisher's exact tests, and chi-squared tests., Results: Recruitment rates for our two studies were 12 and 21%, respectively. Across multiple study sites, we had to send between 4.3 and 9.2 opt-out packets to recruit one participant. The number of phone calls required to arrive at a final status for each potentially eligible Veteran (i.e. study participation or the termination of recruitment efforts) were 2.9 and 6.1 in the two studies, respectively. Study participants differed as expected from the population of potentially eligible Veterans based on planned oversampling of certain subpopulations. The final samples of participants did not differ statistically from those who were mailed opt-out packets, with one exception: in one of our two studies, participants had higher rates of mental health service use in the past year than did those mailed opt-out packets (64 vs. 47%)., Conclusions: Our results emphasize the practicality of using opt-out methods for studies of access to health care. Despite the benefits of these methods, opt-out alone may be insufficient to eliminate non-response bias on key variables. Researchers will need to balance considerations of sample representativeness and feasibility when designing studies investigating access to care.

We examined moderating effects of professional satisfaction on physicians' motivation to adhere to diabetes guidelines associated with pay-for-performance incentives. We merged cross-sectional survey data on attitudes, from 156 primary physicians, with prospective medical record-sourced data on guideline adherence and census data on ambulatory-care population characteristics. We examined moderating effects by testing theory-driven models for satisfied versus discontented physicians, using partial least squares structural equation modeling. Results show that attitudes motivated, while norms suppressed, adherence to guidelines among discontented physicians. Separate models for satisfied versus discontented physicians revealed motivational differences. Satisfied physicians disregarded intrinsic and extrinsic influences and biases. Discontented physicians, alienated by social pressure, favored personal inclinations. To improve adherence to guidelines among discontented physicians, incentives should align with personal attitudes and incorporate promotional campaigns countering resentment of peer and organizational pressure.

Background: Large-scale implementation of evidence-based psychotherapies (EBPs) such as cognitive processing therapy (CPT) for posttraumatic stress disorder can have a tremendous impact on mental and physical health, healthcare utilization, and quality of life. While many mental health systems (MHS) have invested heavily in programs to implement EBPs, few eligible patients receive EBPs in routine care settings, and clinicians do not appear to deliver the full treatment protocol to many of their patients. Emerging evidence suggests that when CPT and other EBPs are delivered at low levels of fidelity, clinical outcomes are negatively impacted. Thus, identifying strategies to improve and sustain the delivery of CPT and other EBPs is critical. Existing literature has suggested two competing strategies to promote sustainability. One emphasizes fidelity to the treatment protocol through ongoing consultation and fidelity monitoring. The other focuses on improving the fit and effectiveness of these treatments through appropriate adaptations to the treatment or the clinical setting through a process of data-driven, continuous quality improvement. Neither has been evaluated in terms of impact on sustained implementation., Methods: To compare these approaches on the key sustainability outcomes and provide initial guidance on sustainability strategies, we propose a cluster randomized trial with mental health clinics (n = 32) in three diverse MHSs that have implemented CPT. Cohorts of clinicians and clinical managers will participate in 1 year of a fidelity oriented learning collaborative or 1 year of a continuous quality improvement-oriented learning collaborative. Patient-level PTSD symptom change, CPT fidelity and adaptation, penetration, and clinics' capacity to deliver EBP will be examined. Survey and interview data will also be collected to investigate multilevel influences on the success of the two learning collaborative strategies. This research will be conducted by a team of investigators with expertise in CPT implementation, mixed method research strategies, quality improvement, and implementation science, with input from stakeholders in each participating MHS., Discussion: It will have broad implications for supporting ongoing delivery of EBPs in mental health and healthcare systems and settings. The resulting products have the potential to significantly improve efforts to ensure ongoing high quality implementation and consumer access to EBPs., Trial Registration: NCT02449421 . Registered 02/09/2015.

Background: Increasing numbers of women veterans present an organizational challenge to a health care system that historically has served men. Women veterans require comprehensive women's health services traditionally not provided by the Veterans Health Administration., Objective: Examine the association of organizational factors and adoption of comprehensive women's health care., Study Design: Cross-sectional analysis of the 2007 Veterans Health Administration National Survey of Women Veterans Health Programs and Practices., Methods: Dependent measures included a) model of women's health care: separate women's health clinic (WHC), designated women's health provider in primary care (DWHP), both (WHC+DWHP), or neither and b) the availability of five women's health services: cervical cancer screening and evaluation and management of vaginitis, menstrual disorders, contraception, and menopause. Exposure variables were organizational factors drawn from the Greenhalgh model of diffusion of innovations including measures of structure, absorptive capacity, and system readiness for innovation., Results: The organizational factors of a gynecology clinic, an academic affiliation with a medical school, a women's health representative on one or more high-impact committees, and a greater caseload of women veterans were more common at sites with WHCs and WHC+DWHPs, compared with sites relying on general primary care with or without a DWHP. Academic affiliation and high-impact committee involvement remained significant in multivariable analysis. Sites with WHCs or WHC+DWHPs were more likely to offer all five women's health services., Conclusion: Facilities with greater apparent absorptive capacity (academic affiliation and women's health representation on high-impact committees) are more likely to adopt WHCs. Facilities with separate WHCs are more likely to deliver a package of women's health services, promoting comprehensive care for women veterans., (Copyright © 2016 Jacobs Institute of Women's Health. All rights reserved.)

Background Context: Comparing research studies of low back pain is difficult because of heterogeneity. There is no consensus among researchers on inclusion criteria or the definition of an episode., Purpose: This study aimed to determine pattern(s) of recurrent non-specific low back pain from data collected over 27 months., Study Design/setting: This study used retrospective cohort study using administrative claims from multiple payers. Although claims are designed for capturing costs, not clinical complexity, they are valid for describing utilization patterns, which are not affected by potential "upcoding.", Patient Sample: The patient sample consisted of population-based, nationally generalizable sample of 65,790 adults with continuous medical and pharmaceutical commercial health insurance who received health care for incident, non-specific low back pain. Potential subjects were excluded for plausible cause of the pain, severe mental illness, or cognitive impairment., Outcome Measures: Diagnostic and therapeutic health-care services, including medical, surgical, pharmaceutical, and complementary, received in inpatient, outpatient, and emergency settings were the outcome measures for this study., Methods: The methods used for this study were latent class analysis of health-care utilization over 27 months (9 quarters) following index diagnosis of non-specific low back pain occurring in January-March 2009 and an analysis sample with 60% of subjects (n=39,597) and validation sample of 40% (n=26,193)., Results: Four distinct groups of patients were identified and validated. One group (53.4%) of patients recovered immediately. One third of patients (31.7%) may appear to recover over 6 months, but maintain a 37-48% likelihood of receiving care for low back pain in every subsequent quarter, implying frequent relapse. Two remaining groups of patients each maintain very high probabilities of receiving care in every quarter (65-78% and 84-90%), predominantly utilizing therapeutic services and pain medication, respectively. Probabilistic grouping relative to alternatives was very high (89.6-99.3%). Grouping was not related to demographic or clinical characteristics., Conclusions: The four distinct sets of patient experiences have clear implications for research. Inclusion criteria should specify incident or recurrent cases. A 6-month clean period may not be sufficiently long to assess incidence. Reporting should specify the proportion recovering immediately to prevent mean recovery rates from masking between-group differences. Continuous measurement of pain or disability may be more reliable than measuring outcomes at distinct endpoints., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objectives: Health care organizations have used different strategies to implement quality improvement (QI) programs but with only mixed success in implementing and spreading QI organization-wide. This suggests that certain organizational strategies may be more successful than others in developing an organization's improvement capability. To investigate this, our study examined how the primary focus of grant-funded QI efforts relates to (1) key measures of grant success and (2) organization-level measures of success in QI and organizational learning., Methods: Using a mixed-methods design, we conducted one-way analyses of variance to relate Veterans Affairs administrative survey data to data collected as part of a 3.5-year evaluation of 29 health care organization grant recipients. We then analyzed qualitative evidence from the evaluation to explain our results., Results: We found that hospitals that focused on developing organizational infrastructure to support QI implementation compared with those that focused on training or conducting projects rated highest (at α = .05) on all 4 evaluation measures of grant success and all 3 systemwide survey measures of QI and organizational learning success., Conclusions: This study adds to the literature on developing organizational improvement capability and has practical implications for health care leaders. Focusing on either projects or staff training in isolation has limited value. Organizations are more likely to achieve systemwide transformation of improvement capability if their strategy emphasizes developing or strengthening organizational systems, structures, or processes to support direct improvement efforts.

Background: Little is known regarding the interaction between acupuncture and biomedical healthcare among vulnerable patient populations. In particular, the association between acupuncture and total cost of healthcare has not been characterized., Methods: Total hospital system visits and associated charges were retrospectively reviewed among patients who received acupuncture at a large safety-net hospital system from 2007 to 2014. Inclusion criteria were Medicare or Medicaid insurance coverage, older than age 18 years, and one or more on-site acupuncture appointments. Patients were stratified into five groups based on the number of acupuncture visits: 1-3, 4-6, 7-9, 10-12, or 13-15 treatments. The total number of biomedical hospital visits and total associated charges were compared 6 months before and 6 months after initiation of acupuncture., Results: A total of 329 patients met our inclusion criteria. Although not statistically significant, there appeared to be an association between acupuncture treatment and a decrease in total hospital charges. The group receiving 1-3 acupuncture treatments showed a per-patient average increase in total charges in the 6-month period after acupuncture ($1771.34; p = 0.38). The patients who received 7-9 treatments showed the largest average decrease in total charges ($8967.24; p = 0.17)., Conclusion: This study shows a previously unreported aggregate relationship between number of treatments and total healthcare charges in a single urban safety-net hospital. Given the sample size available and the heterogeneity of the patient population, no statistically significant associations could be established between initiation of acupuncture treatment and charges. However, some suggestive patterns were observed. Further prospective studies with a matched-group control are warranted to further explore this relationship. Additional study across wider locations is warranted to best guide practitioners and hospitals in designing efficacious, high-value integrative medicine programs.

Sustaining ongoing relationships with patients is a strategic, clinically relevant goal of health care systems. This study develops and tests a conceptual model that aims to account for the influence of organization design, perceptions of quality of patient care, and other patient-level factors on the extent to which patients sustain reliance on a health care system. We use a longitudinal survey design and structural equation modeling to predict increases or decreases in patient reliance on the Department of Veterans Affairs health care system across a 4-year period for Veterans with Parkinson's Disease. Our findings show that specialized and integrated clinical practices have a positive association with the quality of patient care. Health care systems may be able to foster long-term relations with patients and improve service quality by allocating resources to form integrated, specialized, disease-specific centers of care designed for patients with chronic illnesses., (© The Author(s) 2016.)

Background & Aims: Cancelled and missed colonoscopy appointments waste resources, increase colonoscopy delays, and can adversely affect patient outcomes. We examined individual and organizational factors associated with missed and cancelled colonoscopy appointments in Veteran Health Administration facilities., Methods: From 69 facilities meeting inclusion criteria, we identified 27,994 patients with colonoscopy appointments scheduled for follow-up, on the basis of positive fecal occult blood test results, between August 16, 2009 and September 30, 2011. We identified factors associated with colonoscopy appointment status (completed, cancelled, or missed) by using hierarchical multinomial regression. Individual factors examined included age, race, sex, marital status, residence, drive time to nearest specialty care facility, limited life expectancy, comorbidities, colonoscopy in the past decade, referring facility type, referral month, and appointment lead time. Organizational factors included facility region, complexity, appointment reminders, scheduling, and prep education practices., Results: Missed appointments were associated with limited life expectancy (odds ratio [OR], 2.74; P = .0004), no personal history of polyps (OR, 2.74; P < .0001), high facility complexity (OR, 2.69; P = .007), dual diagnosis of psychiatric disorders and substance abuse (OR, 1.82; P < .0001), and opt-out scheduling (OR, 1.57; P = .02). Cancelled appointments were associated with age (OR, 1.61; P = .0005 for 85 years or older and OR, 1.44; P < .0001 for 65-84 years old), no history of polyps (OR, 1.51; P < .0001), and opt-out scheduling (OR, 1.26; P = .04). Additional predictors of both outcomes included race, marital status, and lead time., Conclusions: Several factors within Veterans Health Administration clinic control can be targeted to reduce missed and cancelled colonoscopy appointments. Specifically, developing systems to minimize referrals for patients with limited life expectancy could reduce missed appointments, and use of opt-in scheduling and reductions in appointment lead time could improve both outcomes., (Copyright © 2016 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of the study was to investigate whether the increase in utilization of advanced diagnostic imaging for privately insured patients in 2011 was the beginning of a new trend in imaging utilization growth, or an isolated deviation from the declining trend that began in 2008., Methods: We extracted outpatient and inpatient CT, diagnostic ultrasound, MRI, and PET procedures from databases, for the years 2007 to 2013. This study extended previous work, covering 2012 to 2013, using the same methodology. For every year of the study period, we calculated the following: number of procedures per person-year covered by private health insurance; proportion of office and emergency visits that resulted in an imaging session; average payments per procedure; and total payments per person-year covered by private health insurance., Results: Outpatient utilization of CT and PET decreased in both 2012 and 2013; outpatient utilization of MRI mildly increased in 2012, but then decreased in 2013. Outpatient utilization of diagnostic ultrasound showed a very different pattern, increasing throughout the study period. Inpatient utilization of all imaging modalities except PET decreased in both 2012 and 2013. Adjusted payments for all imaging modalities increased in 2012, and then dropped substantially in 2013, except the adjusted payments for diagnostic ultrasound that increased in 2013 again., Conclusions: The trend of increasing utilization of advanced diagnostic imaging seems to be over for some, but not all, imaging modalities. A combination of policy (eg, breast density notification laws), technologic advancement, and wider access seems to be responsible for at least part of an increasing utilization of diagnostic ultrasound., (Copyright © 2015 American College of Radiology. All rights reserved.)

Background: Percent time in therapeutic range (TTR) and international normalized ratio (INR) variability both measure warfarin control and are associated with outcomes independently. Here, we examine the advantages of a warfarin composite measure (WCM), which summarizes the 2 when measuring patient outcomes. We also examine how the measure chosen would affect anticoagulation clinic performance rankings., Methods and Results: We constructed WCM using an equally weighted method, adding standardized TTR to standardized log-transformed INR variability using 103 897 warfarin-experienced patients from 100 anticoagulation clinics. We examined the association of WCM with ischemic stroke, major bleeding, and fatal bleeding, using a subset of patients with atrial fibrillation (n=40 404). We divided patients into quintiles based on their level of control for TTR, log INR variability, and WCM. We calculated the hazard ratios for ischemic stroke, major bleeding, and fatal bleeding stratified by these quintiles. WCM hazard ratios for stroke and fatal bleeding showed the largest difference between excellent control and poorest control quintile compared with TTR and log INR variability, but not for major bleeding. In addition, we compared site rankings obtained using each of our 3 performance measures. Kappa scores for identifying outlier and nonoutlier clinics between WCM and its components were moderate (κ=0.56 for TTR and κ=0.62 for log INR variability) but was weak between TTR and log INR variability (κ=0.13)., Conclusions: WCM produces the largest range of risk for warfarin complications, widening the floor ceiling effects that limit the use of TTR and INR variability as separate measures. Anticoagulation clinics ranking changed considerably according to the anticoagulation measure that was selected.

Background: Integrating health care across specialized work units has the potential to lower costs and increase quality and access to mental health care. However, a key challenge for healthcare managers is how to develop policies, procedures, and practices that coordinate care across specialized units. The purpose of this study was to identify how organizational factors impacted coordination, and how to facilitate implementation of integrated care., Methods: Semi-structured interviews were conducted in August 2009 with 30 clinic leaders and 35 frontline staff who were recruited from a convenience sample of 16 primary care and mental health clinics across eight medical centers. Data were drawn from a management evaluation of primary care-mental health integration in the US Department of Veterans Affairs. To protect informant confidentiality, the institutional review board did not allow quotations., Results: Interviews identified antecedents of organizational coordination processes, and highlighted how these antecedents can impact the implementation of integrated care. Overall, implementing new workflow practices were reported to create conflicts with pre-existing standardized coordination processes. Personal coordination (i.e., interpersonal communication processes) between primary care leaders and staff was reported to be effective in overcoming these barriers both by working around standardized coordination barriers and modifying standardized procedures., Discussion: This study identifies challenges to integrated care that might be solved with attention to personal and standardized coordination. A key finding was that personal coordination both between primary care and mental health leaders and between frontline staff is important for resolving barriers related to integrated care implementation., Conclusion: Integrated care interventions can involve both new standardized procedures and adjustments to existing procedures. Aligning and integrating procedures between primary care and specialty care requires personal coordination amongst leaders. Interpersonal relationships should be strengthened between staff when personal connections are important for coordinating patient care across clinical settings.

Objective: To evaluate the effects of specification choices on the accuracy of estimates in difference-in-differences (DID) models., Data Sources: Process-of-care quality data from Hospital Compare between 2003 and 2009., Study Design: We performed a Monte Carlo simulation experiment to estimate the effect of an imaginary policy on quality. The experiment was performed for three different scenarios in which the probability of treatment was (1) unrelated to pre-intervention performance; (2) positively correlated with pre-intervention levels of performance; and (3) positively correlated with pre-intervention trends in performance. We estimated alternative DID models that varied with respect to the choice of data intervals, the comparison group, and the method of obtaining inference. We assessed estimator bias as the mean absolute deviation between estimated program effects and their true value. We evaluated the accuracy of inferences through statistical power and rates of false rejection of the null hypothesis., Principal Findings: Performance of alternative specifications varied dramatically when the probability of treatment was correlated with pre-intervention levels or trends. In these cases, propensity score matching resulted in much more accurate point estimates. The use of permutation tests resulted in lower false rejection rates for the highly biased estimators, but the use of clustered standard errors resulted in slightly lower false rejection rates for the matching estimators., Conclusions: When treatment and comparison groups differed on pre-intervention levels or trends, our results supported specifications for DID models that include matching for more accurate point estimates and models using clustered standard errors or permutation tests for better inference. Based on our findings, we propose a checklist for DID analysis., (© Health Research and Educational Trust.)

Background: The Centers for Medicare & Medicaid Services (CMS) publishes star ratings on Medicare Advantage (MA) contracts to measure plan quality of care with implications for reimbursement and bonuses., Objective: To investigate whether MA contract characteristics are associated with quality of care through the Medicare plan star ratings., Design: Retrospective study of MA star ratings in 2010. Unadjusted and adjusted multivariable linear regression models assessed the relationship between 5-star rating summary scores and plan characteristics., Setting: CMS MA contracts nationally., Participants: 409 (71%) of a total of 575 MA contracts, covering 10.56 million Medicare beneficiaries (90% of the MA population) in the United States in 2010., Measurements: The MA quality ratings summary score (stars range from 1 to 5) is a quality measure based on 36 indicators related to processes of care, health outcomes, access to care, and beneficiary satisfaction., Results: Nonprofit, larger, and older MA contracts were more likely to receive higher star ratings. Star ratings ranged from 2 to 5. Nonprofit contracts received an average 0.55 (95% CI, 0.42 to 0.67) higher star ratings than for-profit contracts (P  < 0.001) after controls were set for contract characteristics., Limitation: The study focused on persons aged 65 years or older covered by MA., Conclusion: In 2010, nonprofit MA contracts received significantly higher star ratings than for-profit contracts. When comparing health plans in the future, the CMS should give increasing attention to for-profit plans with lower quality ratings and consider developing programs to assist newer and smaller plans in improving their care for Medicare beneficiaries., Primary Funding Source: None.

Background: This study assessed the contribution of organizational structures and processes identified from facility surveys to follow-up for positive fecal occult blood tests [FOBT-positive (FOBT(+))]., Methods: We identified 74,104 patients with FOBT(+) results from 98 Veterans Health Administration (VHA) facilities between August 16, 2009 and March 20, 2011, and followed them until September 30, 2011, for completion of colonoscopy. We identified patient characteristics from VHA administrative records, and organizational factors from facility surveys completed by primary care and gastroenterology chiefs. We estimated predictors of colonoscopy completion within 60 days and six months using hierarchical logistic regression models., Results: Thirty percent of patients with FOBT(+) results received colonoscopy within 60 days and 49% within six months. Having gastroenterology or laboratory staff notify gastroenterology providers directly about FOBT(+) cases was a significant predictor of 60-day [odds ratio (OR), 1.85; P = 0.01] and six-month follow-up (OR, 1.25; P = 0.008). Additional predictors of 60-day follow-up included adequacy of colonoscopy appointment availability (OR, 1.43; P = 0.01) and frequent individual feedback to primary care providers about FOBT(+) referral timeliness (OR, 1.79; P = 0.04). Additional predictors of six-month follow-up included using guideline-concordant surveillance intervals for low-risk adenomas (OR, 1.57; P = 0.01) and using group appointments and combined verbal-written methods for colonoscopy preparation instruction (OR, 1.48; P = 0.0001)., Conclusion: Directly notifying gastroenterology providers about FOBT(+) results, using guideline-concordant adenoma surveillance intervals, and using colonoscopy preparations instruction methods that provide both verbal and written information may increase overall follow-up rates. Enhancing follow-up within 60 days may require increased colonoscopy capacity and feedback to primary care providers., Impact: These findings may inform organizational-level interventions to improve FOBT(+) follow-up., (©2014 American Association for Cancer Research.)

Objective: To evaluate the impact of hospital value-based purchasing (HVBP) on clinical quality and patient experience during its initial implementation period (July 2011-March 2012)., Data Sources: Hospital-level clinical quality and patient experience data from Hospital Compare from up to 5 years before and three quarters after HVBP was initiated., Study Design: Acute care hospitals were exposed to HVBP by mandate while critical access hospitals and hospitals located in Maryland were not exposed. We performed a difference-in-differences analysis, comparing performance on 12 incentivized clinical process and 8 incentivized patient experience measures between hospitals exposed to the program and a matched comparison group of nonexposed hospitals. We also evaluated whether hospitals that were ultimately exposed to HVBP may have anticipated the program by improving quality in advance of its introduction., Principal Findings: Difference-in-differences estimates indicated that hospitals that were exposed to HVBP did not show greater improvement for either the clinical process or patient experience measures during the program's first implementation period. Estimates from our preferred specification showed that HVBP was associated with a 0.51 percentage point reduction in composite quality for the clinical process measures (p > .10, 95 percent CI: -1.37, 0.34) and a 0.30 percentage point reduction in composite quality for the patient experience measures (p > .10, 95 percent CI: -0.79, 0.19). We found some evidence that hospitals improved performance on clinical process measures prior to the start of HVBP, but no evidence of this phenomenon for the patient experience measures., Conclusions: The timing of the financial incentives in HVBP was not associated with improved quality of care. It is unclear whether improvement for the clinical process measures prior to the start of HVBP was driven by the expectation of the program or was the result of other factors., (© Health Research and Educational Trust.)

Objective: The objective of this research was to apply a new methodology (population-level cost-effectiveness analysis) to determine the value of implementing an evidence-based practice in routine care., Data Sources/study Setting: Data are from sequentially conducted studies: a randomized controlled trial and an implementation trial of collaborative care for depression. Both trials were conducted in the same practice setting and population (primary care patients prescribed antidepressants)., Study Design: The study combined results from a randomized controlled trial and a pre-post-quasi-experimental implementation trial., Data Collection/extraction Methods: The randomized controlled trial collected quality-adjusted life years (QALYs) from survey and medication possession ratios (MPRs) from administrative data. The implementation trial collected MPRs and intervention costs from administrative data and implementation costs from survey., Principal Findings: In the randomized controlled trial, MPRs were significantly correlated with QALYs (p = .03). In the implementation trial, patients at implementation sites had significantly higher MPRs (p = .01) than patients at control sites, and by extrapolation higher QALYs (0.00188). Total costs (implementation, intervention) were nonsignificantly higher ($63.76) at implementation sites. The incremental population-level cost-effectiveness ratio was $33,905.92/QALY (bootstrap interquartile range -$45,343.10/QALY to $99,260.90/QALY)., Conclusions: The methodology was feasible to operationalize and gave reasonable estimates of implementation value., (Published 2014. This article is a U.S. Government work and is in the public domain in the USA.)

Background: Two approaches are commonly used for identifying high-performing facilities on a performance measure: one, that the facility is in a top quantile (eg, quintile or quartile); and two, that a confidence interval is below (or above) the average of the measure for all facilities. This type of yes/no designation often does not do well in distinguishing high-performing from average-performing facilities., Objective: To illustrate an alternative continuous-valued metric for profiling facilities--the probability a facility is in a top quantile--and show the implications of using this metric for profiling and pay-for-performance., Methods: We created a composite measure of quality from fiscal year 2007 data based on 28 quality indicators from 112 Veterans Health Administration nursing homes. A Bayesian hierarchical multivariate normal-binomial model was used to estimate shrunken rates of the 28 quality indicators, which were combined into a composite measure using opportunity-based weights. Rates were estimated using Markov Chain Monte Carlo methods as implemented in WinBUGS. The probability metric was calculated from the simulation replications., Results: Our probability metric allowed better discrimination of high performers than the point or interval estimate of the composite score. In a pay-for-performance program, a smaller top quantile (eg, a quintile) resulted in more resources being allocated to the highest performers, whereas a larger top quantile (eg, being above the median) distinguished less among high performers and allocated more resources to average performers., Conclusion: The probability metric has potential but needs to be evaluated by stakeholders in different types of delivery systems.

Starting in 2006, Massachusetts enacted a series of health insurance reforms that successfully led to 96.6% of its population being covered by 2011. As the rest of the nation undertakes similar reforms, it is unknown how the Veterans Health Administration (VHA), one of many important Federal health care programs, will be affected. Our state-level study approach assessed the effects of health reform on utilization of VHA services in Massachusetts from 2005 to 2011. Models were adjusted for state-level demographic and economic characteristics, including health insurance rates, unemployment rates, median household income, poverty rates, and percent of population 65 years and older. No statistically significant associative change was observed in Massachusetts relative to other states over this time period. The findings raise important questions about the continuing role of VHA in American health care as health insurance coverage is one of many factors that influence decisions on where to seek health care., (Reprint & Copyright © 2014 Association of Military Surgeons of the U.S.)

Background: As the care of hospitalized patients becomes more complex, intraprofessional coordination among nurses and among physicians, and interprofessional coordination between these groups are likely to play an increasingly important role in the provision of hospital care., Purpose: The purpose of this study was to identify the independent effects of organizational factors on provider ratings of overall coordination in inpatient medicine (OCIM)., Methodology/approach: This was an exploratory cross-sectional, descriptive study. Primary data were collected between June 2010 and September 2011 through surveys of inpatient medicine nurse managers, physicians, and chiefs of medicine at 36 Veterans Health Administration medical centers. Secondary data from the 2011 Veterans Health Administration national survey of nurses were also used. Individual-level data were aggregated and analyzed at the facility level. Multivariate linear regression models were used to assess the relationship between 55 organizational factors and provider ratings of OCIM., Findings: Organizational factors that were common across models and associated with better provider ratings of OCIM included provider perceptions that the goals of senior leadership are aligned with those of the inpatient service and that the facility is committed to the highest quality of patient care, having resources and staff that enable clinicians to do their jobs, and use of strategies that enhance interactions and communication among and between nurses and physicians., Practice Implications: To improve intraprofessional and interprofessional coordination and, consequently, patient care, facilities should consider making patient care quality a more important strategic organizational priority; ensuring that providers have the staffing, training, supplies, and other resources they need to do their jobs; and implementing strategies that improve interprofessional communication and working relationships, such as multidisciplinary rounding.

Background: Advanced practice providers (APPs), including nurse practitioners (NPs) and physician assistants (PAs) are cost-effective substitutes for physicians, with similar outcomes in primary care and surgery. However, little is understood about APP roles in inpatient medicine., Objective: Describe APPs role in inpatient medicine., Design: Observational cross-sectional cohort study., Setting: One hundred twenty-four Veterans Health Administration (VHA) hospitals., Participants: Chiefs of medicine (COMs) and nurse managers., Measurements: Surveys included inpatient medicine scope of practice for APPs and perceived healthcare quality. We conducted bivariate unadjusted and multivariable adjusted analyses., Results: One hundred eighteen COMs (95.2%) and 198 nurse managers (75.0%) completed surveys. Of 118 medicine services, 56 (47.5%) employed APPs; 27 (48.2%) used NPs only, 15 (26.8%) PAs only, and 14 (25.0%) used both. Full-time equivalents for NPs was 0.5 to 7 (mean = 2.22) and PAs was 1 to 9 (mean = 2.23). Daily caseload was similar at 4 to 10 patients (mean = 6.5 patients). There were few significant differences between tasks. The presence of APPs was not associated with patient or nurse manager satisfaction. Presence of NPs was associated with greater overall inpatient and discharge coordination ratings by COMs and nurse managers, respectively; the presence of PAs was associated with lower overall inpatient coordination ratings by nurse managers., Conclusions: NPs and PAs work on half of VHA inpatient medicine services with broad, yet similar, scopes of practice. There were few differences between their roles and perceptions of care. Given their very different background, regulation, and reimbursement, this has implications for inpatient medicine services that plan to hire NPs or PAs., (© 2014 Society of Hospital Medicine.)

Recent studies have reported that the rate of growth in utilization of noninvasive diagnostic imaging has slowed, with a concomitant reduction in total payments to providers in the Medicare Part B fee-for-service population. Utilization and payment growth trends in commercially insured populations, however, are not as well understood. We used the Truven Health Analytics MarketScan® Commercial Claims and Encounters database containing more than 29 million individuals to investigate commercially insured population trends in utilization of and payments for CT, MRI, PET, and ultrasound procedures in the years 2007-2011. We found that imaging use--after a brief downturn in 2010--rose again in 2011, coupled with substantial increases in adjusted payments for all four imaging modalities, raising concerns about future efforts to stem growth in imaging use and associated spending., (Copyright © 2014 American College of Radiology. All rights reserved.)

Purpose: Shared medical appointments (SMAs) are becoming popular, but little is known about their association with patient experience in primary care. We performed an exploratory analysis examining overall satisfaction and patient-centered care experiences across key domains of the patient-centered medical home among patients attending SMAs vs usual care appointments., Methods: We undertook a cross-sectional study using a mailed questionnaire measuring levels of patient satisfaction and other indicators of patient-centered care among 921 SMA and 921 usual care patients between 2008 and 2010. Propensity scores adjusted for potential case mix differences between the groups. Multivariate logistic regression assessed propensity-matched patients' ratings of care. Generalized estimating equations accounted for physician-level clustering., Results: A total of 40% of SMA patients and 31% of usual care patients responded. In adjusted analyses, SMA patients were more likely to rate their overall satisfaction with care as "very good" when compared with usual care counterparts (odds ratio=1.26; 95% CI, 1.05-1.52). In the analysis of patient-centered medical home elements, SMA patients rated their care as more accessible and more sensitive to their needs, whereas usual care patients reported greater satisfaction with physician communication and time spent during their appointment., Conclusions: Overall, SMA patients appear more satisfied with their care relative to patients receiving usual care. SMAs may also improve access to care and deliver care that patients find to be sensitive to their needs. Further research should focus on enhancing patient-clinician communication within an SMA as this model of care becomes more widely adopted., (© 2014 Annals of Family Medicine, Inc.)

The objective of this study was to assess the role of provider coordination on nurse manager and physician perceptions of care quality, while controlling for organizational factors. Findings indicated that nurse-nurse coordination was positively associated with nurse manager perceptions of care quality; neither physician-physician nor physician-nurse coordination was associated with physician perceptions. Organizational factors associated with positive perceptions of care quality included facility support of education for nurses and physicians, and the use of multidisciplinary rounding.