Jim Bellows
Publications
-
1.50Impact points
Patient experiences of transitioning from hospital to home: An ethnographic quality improvement project.
Journal of hospital medicine : an official publication of the Society of Hospital Medicine. 02/2012;
BACKGROUND: Little is known about patient perspectives of the transition from hospital to home. OBJECTIVE: To develop a richly detailed, patient-centered view of patient and caregiver needs in the hospital-to-home transition. DESIGN: An ethnographic approach including participant observation and in-... [more] BACKGROUND: Little is known about patient perspectives of the transition from hospital to home. OBJECTIVE: To develop a richly detailed, patient-centered view of patient and caregiver needs in the hospital-to-home transition. DESIGN: An ethnographic approach including participant observation and in-depth, semi-structured video recorded interviews. SETTING: Kaiser Permanente's Southern California, Colorado, and Hawaii regions. PATIENTS: Twenty-four adult inpatients hospitalized for a range of acute and chronic conditions and characterized by variety in diagnoses, illness severity, planned or unplanned hospitalization, age, and ability to self manage. RESULTS: During the hospital-to-home transition, patients and caregivers expressed or demonstrated experiences in 6 domains: 1) translating knowledge into safe, health-promoting actions at home; 2) inclusion of caregivers at every step of the transition process; 3) having readily available problem-solving resources; 4) feeling connected to and trusting providers; 5) transitioning from illness-defined experience to "normal" life; and 6) anticipating needs after discharge and making arrangements to meet them. The work of transitioning occurs for patients and caregivers in the hours and days after they return home and is fraught with challenges. CONCLUSIONS: Reducing readmissions will remain challenging without a broadened understanding of the types of support and coaching patients need after discharge. We are piloting strategies such as risk stratification and tailoring of care, a specialized phone number for recently discharged patients, standardized same-day discharge summaries to primary care providers, medication reconciliation, follow-up phone calls, and scheduling appointments before discharge. Journal of Hospital Medicine 2012; © 2012 Society of Hospital Medicine.
-
2.74Impact points
Medication use, emergency hospital care utilization, and quality-of-life outcome disparities by race/ethnicity among adults with asthma.
The American journal of managed care. 11/2010; 16(11):821-8.
To examine the association of race/ethnicity with medication use, emergency hospital care (EHC) utilization, and quality-of-life outcomes in a population with persistent asthma and to determine if factors related to severity of illness, treatment characteristics, and demographic, socioeconomic, and ... [more] To examine the association of race/ethnicity with medication use, emergency hospital care (EHC) utilization, and quality-of-life outcomes in a population with persistent asthma and to determine if factors related to severity of illness, treatment characteristics, and demographic, socioeconomic, and smoking status explain differences in study outcomes. Retrospective analysis. We examined survey and administrative data for 974 adults with persistent asthma enrolled in a group-model health maintenance organization. Patients with persistent asthma were identified in 1999 using Healthcare Effectiveness Data and Information Set inclusion criteria. In 2000, the same patients were surveyed regarding quality of life using the Mini Asthma Quality of Life Questionnaire. In 2001, the use of controller medications, the ratio of controller medications to rescue medications, and EHC utilization were identified by electronic medical record. Multiple logistic regression and linear regression analyses were used to evaluate the independent association of race/ethnicity with study outcomes after adjusting for severity of illness, treatment characteristics, and demographic, socioeconomic, and smoking status. Compared with whites, African Americans (standardized β coefficient, -0.12) and Native Americans/Aleutians/Eskimos (standardized β coefficient, -0.14) had lower Mini Asthma Quality of Life Questionnaire scores (P <.05 for both). African Americans were significantly (P <.05) more likely to report EHC utilization (odds ratio, 5.2; 95% confidence interval, 2.6-10.3). Disparities existed in 2 outcome measures, Mini Asthma Quality of Life Questionnaire scores and EHC utilization. A concerning finding is that African Americans were at least 5 times more likely to report higher EHC utilization, even after adjusting for factors such as income and education.
-
1.66Impact points
Is the Kaiser Permanente model superior in terms of clinical integration?: a comparative study of Kaiser Permanente, Northern California and the Danish healthcare system.
BMC health services research. 04/2010; 10:91.
Integration of medical care across clinicians and settings could enhance the quality of care for patients. To date, there is limited data on the levels of integration in practice. Our objective was to compare primary care clinicians' perceptions of clinical integration and three sub-aspects in t... [more] Integration of medical care across clinicians and settings could enhance the quality of care for patients. To date, there is limited data on the levels of integration in practice. Our objective was to compare primary care clinicians' perceptions of clinical integration and three sub-aspects in two healthcare systems: Kaiser Permanente, Northern California (KPNC) and the Danish healthcare system (DHS). Further, we examined the associations between specific organizational factors and clinical integration within each system. Comparable questionnaires were sent to a random sample of primary care clinicians in KPNC (n = 1103) and general practitioners in DHS (n = 700). Data were analysed using multiple logistic regression models. More clinicians in KPNC perceived to be part of a clinical integrated environment than did general practitioners in the DHS (OR = 3.06, 95% CI: 2.28, 4.12). Further, more KPNC clinicians reported timeliness of information transfer (OR = 2.25, 95% CI: 1.62, 3.13), agreement on roles and responsibilities (OR = 1.79, 95% CI: 1.30, 2.47) and established coordination mechanisms in place to ensure effective handoffs (OR = 6.80, 95% CI: 4.60, 10.06). None of the considered organizational factors in the sub-country analysis explained a substantial proportion of the variation in clinical integration. More primary care clinicians in KPNC reported clinical integration than did general practitioners in the DHS. Focused measures of clinical integration are needed to develop the field of clinical integration and to create the scientific foundation to guide managers searching for evidence based approaches.
-
Is the Kaiser Permanente model superior in terms of clinical integration?: a comparative study of Kaiser Permanente, Northern California and the Danish healthcare system
BMC Health Services Research. 01/2010;
Abstract Background Integration of medical care across clinicians and settings could enhance the quality of care for patients. To date, there is limited data on the levels of integration in practice. Our objective was to compare primary care clinicians' perceptions of clinical integration and ... [more] Abstract Background Integration of medical care across clinicians and settings could enhance the quality of care for patients. To date, there is limited data on the levels of integration in practice. Our objective was to compare primary care clinicians' perceptions of clinical integration and three sub-aspects in two healthcare systems: Kaiser Permanente, Northern California (KPNC) and the Danish healthcare system (DHS). Further, we examined the associations between specific organizational factors and clinical integration within each system. Methods Comparable questionnaires were sent to a random sample of primary care clinicians in KPNC (n = 1103) and general practitioners in DHS (n = 700). Data were analysed using multiple logistic regression models. Results More clinicians in KPNC perceived to be part of a clinical integrated environment than did general practitioners in the DHS (OR = 3.06, 95% CI: 2.28, 4.12). Further, more KPNC clinicians reported timeliness of information transfer (OR = 2.25, 95% CI: 1.62, 3.13), agreement on roles and responsibilities (OR = 1.79, 95% CI: 1.30, 2.47) and established coordination mechanisms in place to ensure effective handoffs (OR = 6.80, 95% CI: 4.60, 10.06). None of the considered organizational factors in the sub-country analysis explained a substantial proportion of the variation in clinical integration. Conclusions More primary care clinicians in KPNC reported clinical integration than did general practitioners in the DHS. Focused measures of clinical integration are needed to develop the field of clinical integration and to create the scientific foundation to guide managers searching for evidence based approaches.
-
Effective population management practices in diabetes care - an observational study
BMC Health Services Research. 01/2010;
Abstract Background Ensuring that evidence based medicine reaches patients with diabetes in the US and internationally is challenging. The chronic care model includes evidence based management practices which support evidence based care. However, despite numerous studies, it is unclear which practic... [more] Abstract Background Ensuring that evidence based medicine reaches patients with diabetes in the US and internationally is challenging. The chronic care model includes evidence based management practices which support evidence based care. However, despite numerous studies, it is unclear which practices are most effective. Few studies assess the effect of simultaneous practices implemented to varying degrees. The present study evaluates the effect of fifteen practices applied concurrently and takes variation in implementation levels into account while assessing the impact of diabetes care management practices on glycemic and lipid monitoring. Methods Fifteen management practices were identified. Implementation levels of the practices in 41 medical centres caring for 553,556 adults with diabetes were assessed from structured interviews with key informants. Stepwise logistic regression models with management practices as explanatory variables and glycemic and lipid monitoring as outcome variables were used to identify the diabetes care practices most associated with high performance. Results Of the 15 practices studied, only provider alerts were significantly associated with higher glycemic and lipid monitoring rates. The odds ratio for glycemic monitoring was 4.07 (p < 0.00001); the odds ratio for lipid monitoring was 1.63 (p < 0.006). Weaker associations were found between action plans and glycemic monitoring (odds ratio = 1.44; p < 0.03) and between guideline distribution and training and lipid monitoring (odds ratio = 1.46; p < 0.03). The covariates of gender, age, cardiac disease and depression significantly affected monitoring rates. Conclusions Of fifteen diabetes care management practices, our data indicate that high performance is most associated with provider alerts and more weakly associated with action plans and with guideline distribution and training. Lack of convergence in the literature on effective care management practices suggests that factors contributing to high performance may be highly context-dependent or that the factors involved may be too numerous or their implementation too nuanced to be reliably identified in observational studies.
-
1.66Impact points
Effective population management practices in diabetes care - an observational study.
BMC health services research. 01/2010; 10:277.
Ensuring that evidence based medicine reaches patients with diabetes in the US and internationally is challenging. The chronic care model includes evidence based management practices which support evidence based care. However, despite numerous studies, it is unclear which practices are most effectiv... [more] Ensuring that evidence based medicine reaches patients with diabetes in the US and internationally is challenging. The chronic care model includes evidence based management practices which support evidence based care. However, despite numerous studies, it is unclear which practices are most effective. Few studies assess the effect of simultaneous practices implemented to varying degrees. The present study evaluates the effect of fifteen practices applied concurrently and takes variation in implementation levels into account while assessing the impact of diabetes care management practices on glycemic and lipid monitoring. Fifteen management practices were identified. Implementation levels of the practices in 41 medical centres caring for 553,556 adults with diabetes were assessed from structured interviews with key informants. Stepwise logistic regression models with management practices as explanatory variables and glycemic and lipid monitoring as outcome variables were used to identify the diabetes care practices most associated with high performance. Of the 15 practices studied, only provider alerts were significantly associated with higher glycemic and lipid monitoring rates. The odds ratio for glycemic monitoring was 4.07 (p < 0.00001); the odds ratio for lipid monitoring was 1.63 (p < 0.006). Weaker associations were found between action plans and glycemic monitoring (odds ratio = 1.44; p < 0.03) and between guideline distribution and training and lipid monitoring (odds ratio = 1.46; p < 0.03). The covariates of gender, age, cardiac disease and depression significantly affected monitoring rates. Of fifteen diabetes care management practices, our data indicate that high performance is most associated with provider alerts and more weakly associated with action plans and with guideline distribution and training. Lack of convergence in the literature on effective care management practices suggests that factors contributing to high performance may be highly context-dependent or that the factors involved may be too numerous or their implementation too nuanced to be reliably identified in observational studies.
-
2.74Impact points
Preventing myocardial infarction and stroke with a simplified bundle of cardioprotective medications.
The American journal of managed care. 10/2009; 15(10):e88-94.
OBJECTIVE: To assess the effect of promoting a bundle of fixed doses of a generic statin and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB), delivered with minimal outpatient visits, laboratory testing, and dosage titration, to people with diabetes, coronary artery d... [more] OBJECTIVE: To assess the effect of promoting a bundle of fixed doses of a generic statin and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB), delivered with minimal outpatient visits, laboratory testing, and dosage titration, to people with diabetes, coronary artery disease (CAD), or both in a large integrated healthcare system. STUDY DESIGN: Three-year observational study of 170,024 Kaiser Permanente members with diabetes, CAD, or both. METHODS: Using instrumental variable analysis, we assessed the impact of promoting the cardioprotective bundle on hospitalization rates for stroke and myocardial infarction (MI). RESULTS: In 2004 and 2005, 47,268 of 170,024 individuals received "low exposure" (medication possession on 1 to 365 days). Their risk of hospitalization for MI or stroke in 2006 was lowered by 15 events per 1000 person-years (95% confidence interval [CI] = 1, 30), preventing events in 726 people. Furthermore, 21,292 of 170,024 individuals received "high exposure" (medication possession on 366 to 730 days). Their risk of hospitalization for MI or stroke was reduced by 26 events per 1000 person-years (95% CI = 17, 34), preventing events in 545 people. CONCLUSION: A simplified method for bundling fixed doses of a generic statin and an ACEI/ARB was successfully implemented in a large, diverse population in an integrated healthcare delivery system, reducing the risk of hospitalization for MI and stroke.
-
3.24Impact points
Coordination of Diabetes Care in Four Delivery Models Using an Electronic Health Record.
Medical care. 08/2009;
BACKGROUND:: Care coordination is essential to effective chronic care, but knowledge of processes by which health care professionals coordinate their activities when caring for chronically ill patients is limited. Electronic health records (EHRs) are expected to facilitate coordination of care, but ... [more] BACKGROUND:: Care coordination is essential to effective chronic care, but knowledge of processes by which health care professionals coordinate their activities when caring for chronically ill patients is limited. Electronic health records (EHRs) are expected to facilitate coordination of care, but whether they do so completely-and under what conditions-is not well understood. OBJECTIVES:: To identify processes by which providers worked together to provide care using an EHR and to examine factors supporting coordination of care. DESIGN:: Qualitative multiple case study in 4 sites with diverse care delivery models, using semi-structured in-person interviews with 46 physicians and staff and telephone interviews with 65 adult patients with diabetes. SETTING:: Four Kaiser Permanente medical centers. RESULTS:: Across all care models, physicians and staff acted sequentially as loosely coupled links in a chain, relying on EHR-enabled informational continuity to coordinate care. Of providers, 94% were highly satisfied with the availability of patient information, and 89% of patients were satisfied or very satisfied with the coordination of their care. However, 6 of 65 patients described experiences of uncoordinated care, and 5 of 12 primary care providers identified coordination issues. These pertained to unreconciled differences of opinion, conflicting role expectations, and discipline-specific views of patient needs. CONCLUSIONS:: Diabetes care can be coordinated across providers, but some coordination issues persist despite the informational continuity provided by an EHR. Multidisciplinary care teams should be alert to potential coordination challenges, and possible solutions should be explored, including longitudinal care planning with structured communications at key points in care.
-
1.66Impact points
A Retrospective Analysis of Health Systems in Denmark and Kaiser Permanente.
BMC health services research. 01/2009; 8(1):252.
ABSTRACT: BACKGROUND: To inform Danish health care reform efforts, we compared health care system inputs and performance and assessed the usefulness of these comparisons for informing policy. METHODS: Retrospective analysis of secondary data in the Danish Health Care System (DHS) with 5.3 million ci... [more] ABSTRACT: BACKGROUND: To inform Danish health care reform efforts, we compared health care system inputs and performance and assessed the usefulness of these comparisons for informing policy. METHODS: Retrospective analysis of secondary data in the Danish Health Care System (DHS) with 5.3 million citizens and the Kaiser Permanente integrated delivery system (KP) with 6.1 million members in California. We used secondary data to compare population characteristics, professional staff, delivery structure, utilisation and quality measures, and direct costs. We adjusted the cost data to increase comparability. RESULTS: A higher percentage of KP patients had chronic conditions than did patients in the DHS: 6.3% vs. 2.8% (diabetes) and 19% vs. 8.5% (hypertension), respectively. KP had fewer total physicians and staff compared to DHS, with134 physicians/100,000 individuals versus 311 physicians/100,000 individuals. KP physicians are salaried employees; in contrast, DHS primary care physicians own and run their practices, remunerated by a mixture of capitation and fee-for-service payments, while most specialists are employed at largely public hospitals. Hospitalisation rates and lengths of stay (LOS) were lower in KP, with mean acute admission LOS of 3.9 days versus 6.0 days in the DHS, and, for stroke admissions, 4.2 days versus 23 days. Screening rates also differed: 93% of KP members with diabetes received retinal screening; only 46% of patients in the DHS with diabetes did. Per capita operating expenditures were PPP$1,951 (KP) and PPP $1,845 (DHS). CONCLUSIONS: Compared to the DHS, KP had a population with more documented disease and higher operating costs, while employing fewer physicians and resources like hospital beds. Observed quality measures also appear higher in KP. However, simple comparisons between health care systems may have limited value without detailed information on mechanisms underlying differences or identifying translatable care improvement strategies. We suggest items for more in-depth analyses that could improve the interpretability of findings and help identify lessons that can be transferred.
-
Rapid spread of complex change: a case study in inpatient palliative care
BMC Health Services Research. 01/2009;
Abstract Background Based on positive findings from a randomized controlled trial, Kaiser Permanente's national executive leadership group set an expectation that all Kaiser Permanente and partner hospitals would implement a consultative model of interdisciplinary, inpatient-based palliative c... [more] Abstract Background Based on positive findings from a randomized controlled trial, Kaiser Permanente's national executive leadership group set an expectation that all Kaiser Permanente and partner hospitals would implement a consultative model of interdisciplinary, inpatient-based palliative care (IPC). Within one year, the number of IPC consultations program-wide increased almost tenfold from baseline, and the number of teams nearly doubled. We report here results from a qualitative evaluation of the IPC initiative after a year of implementation; our purpose was to understand factors supporting or impeding the rapid and consistent spread of a complex program. Methods Quality improvement study using a case study design and qualitative analysis of in-depth semi-structured interviews with 36 national, regional, and local leaders. Results Compelling evidence of impacts on patient satisfaction and quality of care generated 'pull' among adopters, expressed as a remarkably high degree of conviction about the value of the model. Broad leadership agreement gave rise to sponsorship and support that permeated the organization. A robust social network promoted knowledge exchange and built on an existing network with a strong interest in palliative care. Resource constraints, pre-existing programs of a different model, and ambiguous accountability for implementation impeded spread. Conclusions A complex, hospital-based, interdisciplinary intervention in a large health care organization spread rapidly due to a synergy between organizational 'push' strategies and grassroots-level pull. The combination of push and pull may be especially important when the organizational context or the practice to be spread is complex.
-
Care coordination and electronic health records: connecting clinicians.
AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 01/2009; 2009:208-12.
To examine the association between use of electronic health records (EHR) and care coordination. Two surveys, in 2005 and again in 2006, of primary care clinicians working in a prepaid integrated delivery system during the staggered implementation of an EHR system. Using multivariate logistic regres... [more] To examine the association between use of electronic health records (EHR) and care coordination. Two surveys, in 2005 and again in 2006, of primary care clinicians working in a prepaid integrated delivery system during the staggered implementation of an EHR system. Using multivariate logistic regression to adjust for clinician characteristics, we examined the association between EHR use and clinicians' perceptions of three dimensions of care coordination: timely access to complete information; treatment goal agreement; and role/responsibility agreement. Compared to clinicians without EHR, clinicians with 6+ months of EHR use more frequently reported timely access to complete information, and being in agreement on treatment goals with other involved clinicians. There was no significant association between EHR use and being in agreement on roles and responsibilities with other clinicians. EHR use is associated with aspects of care coordination involving information transfer and communication of treatment goals.
-
1.66Impact points
Rapid spread of complex change: a case study in inpatient palliative care.
BMC health services research. 01/2009; 9:245.
Based on positive findings from a randomized controlled trial, Kaiser Permanente's national executive leadership group set an expectation that all Kaiser Permanente and partner hospitals would implement a consultative model of interdisciplinary, inpatient-based palliative care (IPC). Within one ... [more] Based on positive findings from a randomized controlled trial, Kaiser Permanente's national executive leadership group set an expectation that all Kaiser Permanente and partner hospitals would implement a consultative model of interdisciplinary, inpatient-based palliative care (IPC). Within one year, the number of IPC consultations program-wide increased almost tenfold from baseline, and the number of teams nearly doubled. We report here results from a qualitative evaluation of the IPC initiative after a year of implementation; our purpose was to understand factors supporting or impeding the rapid and consistent spread of a complex program. Quality improvement study using a case study design and qualitative analysis of in-depth semi-structured interviews with 36 national, regional, and local leaders. Compelling evidence of impacts on patient satisfaction and quality of care generated 'pull' among adopters, expressed as a remarkably high degree of conviction about the value of the model. Broad leadership agreement gave rise to sponsorship and support that permeated the organization. A robust social network promoted knowledge exchange and built on an existing network with a strong interest in palliative care. Resource constraints, pre-existing programs of a different model, and ambiguous accountability for implementation impeded spread. A complex, hospital-based, interdisciplinary intervention in a large health care organization spread rapidly due to a synergy between organizational 'push' strategies and grassroots-level pull. The combination of push and pull may be especially important when the organizational context or the practice to be spread is complex.
-
2.65Impact points
Patient Assessment of Chronic Illness Care (PACIC) and improved patient-centered outcomes for chronic conditions.
Journal of general internal medicine : official journal of the Society for Research and Education in Primary Care Internal Medicine. 02/2008; 23(1):77-80.
BACKGROUND: The Patient Assessment of Chronic Illness Care (PACIC) has potential for use as a patient-centered measure of the implementation of the Chronic Care Model (CCM), but there is little research on the relationship between the PACIC and important behavioral and quality measures for patients ... [more] BACKGROUND: The Patient Assessment of Chronic Illness Care (PACIC) has potential for use as a patient-centered measure of the implementation of the Chronic Care Model (CCM), but there is little research on the relationship between the PACIC and important behavioral and quality measures for patients with chronic conditions. OBJECTIVE: To examine the relationship between PACIC scores and self-management behaviors, patient rating of their health care, and self-reported quality of life. DESIGN: Cross-sectional survey with a 61% response rate. PARTICIPANTS: Included in the survey were 4,108 adults with diabetes, chronic pain, heart failure, asthma, or coronary artery disease in the Kaiser Permanente Medical Care program across 7 regions nationally. MEASUREMENTS: The PACIC was the main independent variable. Dependent variables included use of self-management resources, self-management behaviors such as regular exercise, self-reported adherence to medications, patient rating of their health care, and quality of life. RESULTS: PACIC scores were significantly, positively associated with all measures (odds ratio [ORs] ranging from 1.20 to 2.36) with the exception of self-reported medication adherence. CONCLUSIONS: Use of the PACIC, a practical, patient-level assessment of CCM implementation, could be an important tool for health systems and other stakeholders looking to improve the quality of chronic disease care.
-
Understanding panel management: a comparative study of an emerging approach to population care.
The Permanente journal. 01/2007; 11(3):12-20.
Context: Panel management is an innovative approach for population care that is tightly linked with primary care. This approach, which is spreading rapidly across Kaiser Permanente, represents an important shift in population-care structure and emphasis, but its potential and implications have not b... [more] Context: Panel management is an innovative approach for population care that is tightly linked with primary care. This approach, which is spreading rapidly across Kaiser Permanente, represents an important shift in population-care structure and emphasis, but its potential and implications have not been previously studied.Objective: To inform the ongoing spread of panel management by providing an early understanding of its impact on patients, physicians, and staff and to identify barriers and facilitators.Design: Qualitative studies at four sites, including patient focus groups, physician and staff interviews, and direct observation.Findings: Panel management allows primary care physicians to use dedicated time to direct proactive care for their patients, uses staff support to conduct outreach, and leverages new panel-based information technology tools. Patients reported appreciating the panel management outreach, although some also reported coordination issues. Two of four study sites seemed to provide a more coordinated patient experience of care; factors common to these sites included longer maturation of their panel management programs and a more circumscribed role for outreach staff. Some physicians reported tension in the approach's implementation: All believed that panel management improved care for their patients but many also expressed feeling that the approach added more tasks to their already busy days. Challenges yet to be fully addressed include providing program oversight to monitor for safe and reliable coordination of care and incorporation of self-management support.Conclusion: Subsequent spread of panel management should be informed by these lessons and findings from early adopters and should include continued monitoring of the impact of this rapidly developing approach on quality, patient satisfaction, primary care sustainability, and cost.
-
2.74Impact points
How well do the HEDIS asthma inclusion criteria identify persistent asthma?
The American journal of managed care. 11/2005; 11(10):650-4.
OBJECTIVES: (1) To determine if the Health Plan Employer Data and Information Set (HEDIS) asthma inclusion criteria consistently identify persistent asthma on a year-to-year basis and (2) to explore whether variation in the number of years of qualification is associated with medication and resource ... [more] OBJECTIVES: (1) To determine if the Health Plan Employer Data and Information Set (HEDIS) asthma inclusion criteria consistently identify persistent asthma on a year-to-year basis and (2) to explore whether variation in the number of years of qualification is associated with medication and resource utilization outcomes. STUDY DESIGN: Retrospective observational study. METHODS: We identified 132 414 patients in a large healthcare program who were included in 1 or more HEDIS persistent asthma cohorts between 1999 and 2002 and who had continuous insurance and pharmacy benefit coverage for the entire 4-year observation period. Medication, emergency department, and hospital use in 2002 was identified using electronic claims and pharmacy information. RESULTS: Overall, 47.9% of the patients were identified as having persistent asthma in only 1 of 4 years, 40.8% had at least 2 consecutive years, and 28.2% had at least 3 consecutive years. In bivariate and multivariate analyses, more consecutive years of HEDIS persistent asthma qualification significantly increased the likelihood of frequent short-acting b-agonist use, inhaled antiinflammatory corticosteroid use, at least 1 emergency department visit, and at least 1 hospitalization. The strongest relationship was for 3 or more consecutive years of HEDIS qualification. CONCLUSIONS: A significant portion of the HEDIS persistent asthma cohort does not qualify on a year-to-year basis, suggesting that the current 1-year qualification period or the underlying administrative case definition for persistent asthma may be suboptimal. Further clinical validation studies are needed to determine the optimal criteria for a more useful HEDIS persistent asthma case definition.
-
Is the Kaiser Permanente Model Superior in Terms of Clinical Integration?: A Comparative Study of Kaiser Permanente, Northern California and the Danish Healthcare System
Background: Integration of medical care across clinicians and settings could enhance the quality of care for patients. To date, there is limited data on the levels of integration in practice. Our objective was to compare primary care clinicians' perceptions of clinical integration and three sub-... [more] Background: Integration of medical care across clinicians and settings could enhance the quality of care for patients. To date, there is limited data on the levels of integration in practice. Our objective was to compare primary care clinicians' perceptions of clinical integration and three sub-aspects in two healthcare systems: Kaiser Permanente, Northern California (KPNC) and the Danish healthcare system (DHS). Further, we examined the associations between specific organizational factors and clinical integration within each system. Methods: Comparable questionnaires were sent to a random sample of primary care clinicians in KPNC (n = 1103) and general practitioners in DHS (n = 700). Data were analysed using multiple logistic regression models. Results: More clinicians in KPNC perceived to be part of a clinical integrated environment than did general practitioners in the DHS (OR = 3.06, 95% CI: 2.28, 4.12). Further, more KPNC clinicians reported timeliness of information transfer (OR = 2.25, 95% CI: 1.62, 3.13), agreement on roles and responsibilities (OR = 1.79, 95% CI: 1.30, 2.47) and established coordination mechanisms in place to ensure effective handoffs (OR = 6.80, 95% CI: 4.60, 10.06). None of the considered organizational factors in the sub-country analysis explained a substantial proportion of the variation in clinical integration. Conclusions: More primary care clinicians in KPNC reported clinical integration than did general practitioners in the DHS. Focused measures of clinical integration are needed to develop the field of clinical integration and to create the scientific foundation to guide managers searching for evidence based approaches.
-
Is patient activation associated with outcomes of care for adults with chronic conditions?
The Journal of ambulatory care management. 30(1):21-9.
We examined the patient activation measure's (PAM's) association with process and health outcomes among adults with chronic conditions. Patients with high PAM scores were significantly more likely to perform self-management behaviors, use self-management services, and report high medication ... [more] We examined the patient activation measure's (PAM's) association with process and health outcomes among adults with chronic conditions. Patients with high PAM scores were significantly more likely to perform self-management behaviors, use self-management services, and report high medication adherence, compared to patients with the lowest PAM scores. This population was 10 times more likely to report high patient-satisfaction scores, 5 times more likely to report high quality-of-life scores, and reported significantly higher physical and mental functional status scores, compared to those with the lowest scores. These results suggest that PAM scores are associated with key process and health outcome measures.
Following (9)
-
Judith Hibbard
University of Oregon -
Anne Frølich
Bispebjerg Hospital -
robert James Dudl
Care Management Institute Kaiser Permanente -
Esther Estee B Neuwirth
Kaiser Permanente, Care Management Institute -
Jennifer Rice
University of California at Berkeley
