A Bayesian Difference-in-Difference Framework for the Impact of Primary Care Redesign on Diabetes Outcomes.
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ABSTRACT:
SUBMITTER: Normington J
PROVIDER: S-EPMC6703166 | biostudies-literature | 2019
REPOSITORIES: biostudies-literature
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A Bayesian Difference-in-Difference Framework for the Impact of Primary Care Redesign on Diabetes Outcomes.
Normington James J Lock Eric E Carlin Caroline C Peterson Kevin K Carlin Bradley B
Statistics and public policy (Philadelphia, Pa.) 20190718 1
Although national measures of the quality of diabetes care delivery demonstrate improvement, progress has been slow. In 2008, the Minnesota legislature endorsed the patient-centered medical home (PCMH) as the preferred model for primary care redesign. In this work, we investigate the effect of PCMH-related clinic redesign and resources on diabetes outcomes from 2008 to 2012 among Minnesota clinics certified as PCMHs by 2011 by using a Bayesian framework for a continuous difference-in-differences ...[more]
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Project description:BackgroundPrimary care networks are a newer model of primary care that focuses on improved access to care and the use of multidisciplinary teams for patients with chronic disease. We sought to determine the association between enrolment in primary care networks and the care and outcomes of patients with diabetes.MethodsWe used administrative health care data to study the care and outcomes of patients with incident and prevalent diabetes separately. For patients with prevalent diabetes, we compared those whose care was managed by physicians who were or were not in a primary care network using propensity score matching. For patients with incident diabetes, we studied a cohort before and after primary care networks were established. Each cohort was further divided based on whether or not patients were cared for by physicians enrolled in a network. Our primary outcome was admissions to hospital or visits to emergency departments for ambulatory care sensitive conditions specific to diabetes.ResultsCompared with patients whose prevalent diabetes is managed outside of primary care networks, patients in primary care networks had a lower rate of diabetes-specific ambulatory care sensitive conditions (adjusted incidence rate ratio 0.81, 95% confidence interval [CI] 0.75 to 0.87), were more likely to see an ophthalmologist or optometrist (risk ratio 1.19, 95% CI 1.17 to 1.21) and had better glycemic control (adjusted mean difference -0.067, 95% CI -0.081 to -0.052).InterpretationPatients whose diabetes was managed in primary care networks received better care and had better clinical outcomes than patients whose condition was not managed in a network, although the differences were very small.
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Project description:IMPORTANCE:Primary health care is rapidly developing as an occupational therapy practice area. Yet, to date, little evidence supports occupational therapy's feasibility and efficacy in primary care settings. OBJECTIVE:To report on the implementation and preliminary clinical outcomes of a Lifestyle Redesign® (LR)-occupational therapy (LR-OT) diabetes management intervention in a primary care clinic. DESIGN:Patients were randomized to be offered LR-OT or to a no-contact comparison group (data not reported). We assessed implementation outcomes using mixed methods. SETTING:Safety-net primary care clinic. PARTICIPANTS:Clinic providers and staff; English- or Spanish-speaking clinic patients ages 18-75 yr with diabetes and a current hemoglobin A1c (HbA1c) ? 9.0%. INTERVENTION:Eight 1-hr individual sessions of LR-OT focused on diabetes management. OUTCOMES AND MEASURES:Clinical and health behavior outcomes were assessed via electronic medical record (EMR) review and self-report surveys of patients receiving LR-OT at initial evaluation and discharge. We assessed implementation outcomes (acceptability, appropriateness, feasibility, fidelity, efficiency, and timeliness) using patient and staff surveys, interviews, focus groups, and observations. RESULTS:Seventy-three patients were offered LR-OT: 51 completed one or more sessions, and 38 completed the program. Clinical outcomes among program completers indicate beneficial changes in HbA1c, diabetes self-care, and health status. Implementation challenges included a need for patient and staff education, securing adequate workspace, and establishing a referral process. Factors contributing to implementation success included strong buy-in from clinic leadership, colocation, and shared EMR documentation. CONCLUSIONS AND RELEVANCE:LR-OT is a feasible approach to enhancing service delivery and clinical outcomes in primary care. WHAT THIS ARTICLE ADDS:This study provides insight into factors that may create challenges or contribute to the success of implementing occupational therapy services within primary health care settings. In addition, this study provides preliminary evidence of occupational therapy's effectiveness in improving clinical outcomes among ethnically diverse, low-income patients with diabetes in a safety-net primary care setting.
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Project description:ObjectiveTo test a conceptual model of relationships, reflection, sensemaking, and learning in primary care practices transitioning to patient-centered medical homes (PCMH).Data sources/study settingPrimary data were collected as part of the American Academy of Family Physicians' National Demonstration Project of the PCMH.Study designWe conducted a cross-sectional survey of clinicians and staff from 36 family medicine practices across the United States. Surveys measured seven characteristics of practice relationships (trust, diversity, mindfulness, heedful interrelation, respectful interaction, social/task relatedness, and rich and lean communication) and three organizational attributes (reflection, sensemaking, and learning) of practices.Data collection/extraction methodsWe surveyed 396 clinicians and practice staff. We performed a multigroup path analysis of the data. Parameter estimates were calculated using a Bayesian estimation method.Principal findingsTrust and reflection were important in explaining the characteristics of practice relationships and their associations with sensemaking and learning. The strongest associations between relationships, sensemaking, and learning were found under conditions of high trust and reflection. The weakest associations were found under conditions of low trust and reflection.ConclusionsTrust and reflection appear to play a key role in moderating relationships, sensemaking, and learning in practices undergoing practice redesign.
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Project description:ObjectiveTo understand how health systems are facilitating primary care redesign (PCR), examine the PCR initiatives taking place within systems, and identify barriers to this work.Study settingA purposive sample of 24 health systems in 4 states.Study designData were systematically reviewed to identify how system leaders define and implement initiatives to redesign primary care delivery and identify challenges. Researchers applied codes which were based on the theoretical PCR literature and created new codes to capture emerging themes. Investigators analyzed coded data then produced and applied a thematic analysis to examine how health systems facilitate PCR.Data collectionSemi-structured telephone interviews with 162 system executives and physician organization leaders from 24 systems.Principal findingsLeaders at all 24 health systems described initiatives to redesign the delivery of primary care, but many were in the early stages. Respondents described the use of centralized health system resources to facilitate PCR initiatives, such as regionalized care coordinators, and integrated electronic health records. Team-based care, population management, and care coordination were the most commonly described initiatives to transform primary care delivery. Respondents most often cited improving efficiency and enhancing clinician job satisfaction, as motivating factors for team-based care. Changes in payment and risk assumption as well as community needs were commonly cited motivators for population health management and care coordination. Return on investment and the slower than anticipated rate in moving from fee-for-service to value-based payment were noted by multiple respondents as challenges health systems face in redesigning primary care.ConclusionsGiven their expanding role in health care and the potential to leverage resources, health systems are promising entities to promote the advancement of PCR. Systems demonstrate interest and engagement in this work but face significant challenges in getting to scale until payment models are in alignment with these efforts.
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Project description:BackgroundLack of healthcare access to due to physician shortages is a significant driver of telemedicine expansion in rural areas. Telemedicine is effective for management of chronic conditions such as diabetes but its effectiveness in primary care settings is unknown.ObjectiveTo evaluate differences in diabetes care before and after implementation of a longitudinal virtual primary care program.DesignPropensity score-matched cohort study utilizing difference-in-differences analysis.ParticipantsPatients with diabetes who received care at VA primary care clinics between January 2018 and December 2019 where the Virtual Integrated Multisite Patient Aligned Care Teams (V-IMPACT) program was implemented.ExposurePatient participation in at least one V-IMPACT visit while usual care patients did not participate in V-IMPACT.Main measuresThe primary outcome was change in hemoglobin A1C (HbA1C) and secondary outcomes included change in the proportion of patients meeting diabetes quality indicators: blood pressure control, statin use, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (ACEi/ARB) use, and annual microalbuminuria testing.Key resultsOur propensity-matched cohort included 9010 patients split evenly between those who participated in V-IMPACT and those who remained in usual in-person care. Among individuals with diabetes who participated in V-IMPACT, the change in mean HbA1C was - 0.055% (95% CI - 0.088 to - 0.022%) while those in usual care had a - 0.047% (95% CI - 0.080 to - 0.014%) change before and after program implementation. We observed a 5.1% (95% CI 2.4 to 7.7%) absolute increase in the proportion prescribed statins in the V-IMPACT group, a 5.3% (95% CI 2.5 to 8.2%) increase prescribed ACE/ARBs, and a 4.6% (95% 1.7 to 7.5%) increase in completed yearly microalbuminuria testing. V-IMPACT was not associated with a significant difference in the proportion with controlled blood pressure at < 140/90 or < 130/90 mmHg thresholds.ConclusionsQuality of diabetes care delivered by a longitudinal virtual primary care model was similar if not better than traditional in-person care.
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Project description:BackgroundIn response to growing pressures on primary care, leaders have introduced a wide range of workforce and practice innovations, including team redesigns that delegate some physician tasks to nonphysicians. One important question is how such innovations affect care team members, particularly in view of growing dissatisfaction and burnout among healthcare professionals. We examine the work experiences of primary care physicians and staff after implementing Lean-based workflow redesigns. This included co-locating physician and medical assistant dyads, delegating significant responsibilities to nonphysician staff, and mandating greater coordination and communication among all care team members.MethodsThe redesigns were implemented and scaled in three phases across 46 primary care departments in a large ambulatory care delivery system. We fielded 1164 baseline and 1333 follow-up surveys to physicians and other nonphysician staff (average 73% response rate) to assess workforce engagement (e.g., job satisfaction, motivation), perceptions of the work environment, and job-related burnout. We conducted multivariate regressions to detect changes in experiences after the redesign, adjusting for respondent characteristics and clustering of within-clinic responses.ResultsWe found that both physicians and nonphysician staff reported higher levels of engagement and teamwork after implementing redesigns. However, they also experienced higher levels of burnout and perceptions of the workplace as stressful. Trends were the same for both occupational groups, but the increased reports of stress were greater among physicians. Additionally, members of all clinics, except for the pilot site that developed the new workflows, reported higher burnout, while perceptions of workplace stress increased in all clinics after the redesign.ConclusionsOur findings partially align with expectations of work redesign as a route to improving physician and staff experiences in delivering care. Although teamwork and engagement increased, the redesigns in our study were not enough to moderate long-standing challenges facing primary care. Yet higher levels of empowerment and engagement, as observed in the pilot clinic, may be particularly effective in facilitating improvements while combating fatigue. To help practices cope with increasing burdens, interventions must directly benefit healthcare professionals without overtaxing an already overstretched workforce.
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Project description:ObjectiveThe aim of this study was to measure the relationship between days spent waiting for primary care and health outcomes among patients diagnosed with diabetes, especially among the elderly population.Data sourceSecondary data from VA administrative databases and Medicare claims.Study designThis is a retrospective observational study. Outcome variables include primary care utilization, mortality, heart attack, stroke, and ambulatory-care sensitive condition (ACSC) hospitalization. The main explanatory variable of interest is VA primary care wait time. Negative binomial models predict utilization and stacked logistic regression models predict the probability of experiencing each health outcome. Models are stratified by the presence of a selected health condition and age.Principal findingsLonger wait times were predicted to decrease utilization between 2 and 4 percent. There was no significant relationship between wait times and health outcomes for the overall sample. In stratified analyses, longer waits were associated with undesirable outcomes for those over age 70 with one of the selected health conditions or in certain narrower 5-year age groups, but the overall pattern of results does not indicate a systematic and significant effect.ConclusionsThere was a modest effect of long wait times on primary care utilization but no robust effect of longer wait times on health outcomes. Waiting for care did not significantly compromise long-term health outcomes for veterans with diabetes.
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Project description:ObjectiveIn England, two primary care incentive schemes were introduced to increase dementia diagnosis rates to two-thirds of expected levels. This study assesses the effectiveness of these schemes.MethodsWe used a difference-in-differences framework to analyse the individual and collective impacts of the incentive schemes: (1) Directed Enhanced Service 18 (DES18: facilitating timely diagnosis of and support for dementia) and (2) the Dementia Identification Scheme (DIS). The dataset included 7529 English general practices, of which 7142 were active throughout the 10-year study period (April 2006 to March 2016). We controlled for a range of factors, including a contemporaneous hospital incentive scheme for dementia. Our dependent variable was the percentage of expected cases that was recorded on practice dementia registers (the "rate").ResultsFrom March 2013 to March 2016, the mean rate rose from 51.8% to 68.6%. Both DES18 and DIS had positive and significant effects. In practices participating in the DES18 scheme, the rate increased by 1.44 percentage points more than the rate for non-participants; DIS had a larger effect, with an increase of 3.59 percentage points. These combined effects increased dementia registers nationally by an estimated 40 767 individuals. Had all practices fully participated in both schemes, the corresponding number would have been 48 685.ConclusionThe primary care incentive schemes appear to have been effective in closing the gap between recorded and expected prevalence of dementia, but the hospital scheme had no additional discernible effect. This study contributes additional evidence that financial incentives can motivate improved performance in primary care.
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Project description:BACKGROUND:It is not known whether equity-oriented primary care investment that seeks to scale up the delivery of effective care in disadvantaged communities can reduce health inequality within high-income settings that have pre-existing universal primary care systems. We provide some non-randomised controlled evidence by comparing health inequality trends between two similar jurisdictions-one of which implemented equity-oriented primary care investment in the mid-to-late 2000s as part of a cross-government strategy for reducing health inequality (England), and one which invested in primary care without any explicit equity objective (Ontario, Canada). METHODS:We analysed whole-population data on 32,482 neighbourhoods (with mean population size of approximately 1,500 people) in England, and 18,961 neighbourhoods (with mean population size of approximately 700 people) in Ontario. We examined trends in mortality amenable to healthcare by decile groups of neighbourhood deprivation within each jurisdiction. We used linear models to estimate absolute and relative gaps in amenable mortality between most and least deprived groups, considering the gradient between these extremes, and evaluated difference-in-difference comparisons between the two jurisdictions. RESULTS:Inequality trends were comparable in both jurisdictions from 2004-6 but diverged from 2007-11. Compared with Ontario, the absolute gap in amenable mortality in England fell between 2004-6 and 2007-11 by 19.8 per 100,000 population (95% CI: 4.8 to 34.9); and the relative gap in amenable mortality fell by 10 percentage points (95% CI: 1 to 19). The biggest divergence occurred in the most deprived decile group of neighbourhoods. DISCUSSION:In comparison to Ontario, England succeeded in reducing absolute socioeconomic gaps in mortality amenable to healthcare from 2007 to 2011, and preventing them from growing in relative terms. Equity-oriented primary care reform in England in the mid-to-late 2000s may have helped to reduce socioeconomic inequality in health, though other explanations for this divergence are possible and further research is needed on the specific causal mechanisms.
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