Population Health Management最新文献

This study aimed at examining the effect of continued use of home health care resources on end-of-life care at home in older patients with cancer. This retrospective cohort study was conducted using medical and long-term care claims data of 6435 older patients with cancer who died between April 2016 and March 2019 in Fukuoka Prefecture. The main explanatory variables were enhanced home care support clinics and hospitals (HCSCs), enhanced HCSCs with beds, conventional HCSCs, other HCSCs, and home visit nursing care. The covariates were sex, age, required level of care, and the Charlson Comorbidity Index. A logistic regression model was used. The results of the multilevel logistic regression analysis showed that the following were significantly associated with end-of-life care at home: use of enhanced HCSCs with beds (odds ratio, OR: 8.66; 95% confidence interval, CI: [4.31-17.40]), conventional HCSCs (OR: 5.78; 95% CI: [1.86-17.94]), enhanced HCSCs (OR: 4.44; 95% CI: [1.47-13.42]), home-visit nursing care (OR: 1.86; 95% CI: [1.42-2.44]), and a severe need for care (OR: 3.89; 95% CI: [2.92-5.18]). The results suggest that the continued use of home health care resources in older patients with cancer who require out-of-hospital care may lead to increased end-of-life care at home. Particularly, use of enhanced HCSCs with beds is most strongly associated with end-of-life care at home.

Urinary tract infection (UTI) is a common reason for emergency department (ED) utilization that could potentially be treated by a primary care provider (PCP). This study assessed patient perceived value of a home UTI test kit plus educational materials and its impact on ED utilization for a UTI symptom episode. Women aged 18-75 years with Medicaid insurance and a history of 1-3 uncomplicated UTIs in the past year were prospectively identified and randomized to the intervention, intervention plus (intervention plus a patient portal message before its delivery), or standard of care group. A telephone survey was conducted 3-5 months after the mailing. Site of care for each UTI symptom episode was measured 12 months before and 6 months after the intervention. Test kit packages were mailed to 266 intervention individuals, and 150 responded to the telephone survey. Utilization outcomes were compared between a combined intervention group and a control group. Approximately one-third of the intervention patients experienced UTI symptoms within 5 months, and 73% used the test kit. Of those who experienced UTI symptoms, 58% contacted their PCP to seek care and 96% reported that the test kit was helpful. ED utilization was not significantly different in the intervention groups before and after the intervention, nor between the intervention and control groups postintervention. A home UTI test kit plus educational materials mailed to patients with a history of uncomplicated UTI was deemed helpful but did not have a measurable impact on ED utilization.

Primary care practices are under pressure to address patients' social determinants of health (SDOH). However, the extent to which these practices have this ability remains unknown. The objective of this study was to examine the association between physician, practice, and community characteristics and the ability of family medicine practices to address patients' SDOH. This cross-sectional study used data from the American Board of Family Medicine Continuing Certification Questionnaire from 2017 to 2019, with a 100% response rate. Respondents rated their practice's ability to address SDOH, which was dichotomized as high or low. Sequential multivariate logistic regression determined the association of the reported ability to address SDOH with physician, practice, and community characteristics. Among 19,300 respondents, 55.6% reported a high ability to address patients' SDOH. Across models controlling for different groups of variables, characteristics persistently positively associated with ability to address SDOH included employment at a federally qualified health center (Odds Ratios [OR] = 2.111-3.012), federally funded clinic (OR = 1.999-2.897), managed care organization (OR = 2.038-2.303), and working collaboratively with a social worker (OR = 2.000-2.523) or care coordinator (OR = 1.482-1.681). Characteristics persistently negatively associated with the ability to address SDOH were practicing at an independently owned (OR = 0.726-0.812) or small practice (OR = 0.512-0.863). While results varied across models, these findings are important for developing evidence-based policies and recommendations for resource sharing and allocation in clinics and communities. Ensuring availability and access to allied health professionals and community resources may be key components in Family Medicine clinics addressing SDOH.

Value-based care arrangements have been the cornerstone of accountable care for decades. Risk arrangements with government and commercial insurance plans are ubiquitous, with most contracts focusing on upside risk only, meaning payers reward providers for good performance without punishing them for poor performance on quality and cost. However, payers are increasingly moving into downside risk arrangements, bringing to mind global capitation in the 1990s wherein several health systems failed. In this article, the authors focus on their framework for succeeding in value-based arrangements at University Hospitals Accountable Care Organization, including essential structural elements that provider organizations need to successfully assume downside risk in value-based arrangements. These elements include quality performance and reporting, risk adjustment, utilization management, care management and clinical services, network integrity, technology, and contracting and financial reconciliation. Each of these elements has an important place in the strategic roadmap to value, even if downside risk is not taken. This roadmap was developed through an applied approach and intends to fill the gap in published practical models of how provider organizations can maneuver value-based arrangements.

Accountable care organizations (ACOs) are often tasked with helping providers to deliver care efficiently and with higher quality outcomes. For an ACO to succeed in delivering efficient care, it is important to direct resources toward patients who exhibit the greatest levels of opportunity while focusing attention toward mitigating their needs. Home-based palliative care (HBPC) services are known to address patient needs for those with serious illness while decreasing the total cost of care (TCC). In this retrospective review, ACO researchers reviewed cost, quality, and utilization patterns for 3418 beneficiaries within a Medicare Shared Saving Program approaching the end of life comparing decedents who received HBPC versus those who did not receive the service. Those individuals who received HBPC services were significantly less likely to be hospitalized (51% reduction in the HBPC group), more likely to use hospice (70% vs. 43%; P = 0.001), and their TCC was less than that of those who did not receive the service ($27,203 vs. $36,089: P = 0.0163). Although more research needs to be done to understand the specific components of care delivery that are helpful in decreasing unnecessary utilization, in this retrospective review in an accountable care population, HBPC is associated with a significant decrease in cost and utilization in a population approaching end of life.

Out-of-pocket (OOP) health care expenditures in the United States have increased significantly in the past 5 decades. Most research on OOP costs focuses on expenditures related to insurance and cost-sharing payments or on costs related to specific conditions or settings, and does not capture the full picture of the financial burden on patients and unpaid caregivers. The aim for this systematic literature review was to identify and categorize the multitude of OOP costs to patients and unpaid caregivers, aid in the development of a more comprehensive catalog of OOP costs, and highlight potential gaps in the literature. The authors found that OOP costs are multifarious and underestimated. Across 817 included articles, the authors identified 31 subcategories of OOP costs related to direct medical (eg, insurance premiums), direct nonmedical (eg, transportation), and indirect spending (eg, absenteeism). In addition, 42% of articles studied an expenditure that the authors did not label as "OOP." A holistic and comprehensive catalog of OOP costs can inform future research, interventions, and policies related to financial barriers to health care in the United States to ensure the full range of costs for patients and unpaid caregivers are acknowledged and addressed.

The objective was to assess the value of routinely collected patient-reported health-related social needs (HRSNs) measures for predicting utilization and health outcomes. The authors identified Mayo Clinic patients with cancer, diabetes, or heart failure. The HRSN measures were collected as part of patient-reported screenings from June to December 2019 and outcomes (hospitalization, 30-day readmission, and death) were ascertained in 2020. For each outcome and disease combination, 4 models were used: gradient boosting machine (GBM), random forest (RF), generalized linear model (GLM), and elastic net (EN). Other predictors included clinical factors, demographics, and area-based HRSN measures-area deprivation index (ADI) and rurality. Predictive performance for models was evaluated with and without the routinely collected HRSN measures as change in area under the curve (AUC). Variable importance was also assessed. The differences in AUC were mixed. Significant improvements existed in 3 models of death for cancer (GBM: 0.0421, RF: 0.0496, EN: 0.0428), 3 models of hospitalization (GBM: 0.0372, RF: 0.0640, EN: 0.0441), and 1 of death (RF: 0.0754) for diabetes, and 1 model of readmissions (GBM: 0.1817), and 3 models of death (GBM: 0.0333, RF: 0.0519, GLM: 0.0489) for heart failure. Age, ADI, and the Charlson comorbidity index were the top 3 in variable importance and were consistently more important than routinely collected HRSN measures. The addition of routinely collected HRSN measures resulted in mixed improvement in the predictive performance of the models. These findings suggest that existing factors and the ADI are more important for prediction in these contexts. More work is needed to identify predictors that consistently improve model performance.