Healthcare-The Journal of Delivery Science and Innovation最新文献

Background

A growing literature documents how primary care practices adapted to the COVID-19 pandemic. We examine a topic that has received less attention—how participants in an advanced alternative payment model perceive the model influenced their ability to meet patients’ care needs during the pandemic.

Methods

Analysis of closed- and open-ended questions from a 2021 survey of 2496 practices participating in the Comprehensive Primary Care Plus (CPC+) model (92% response rate) and a 2021 survey of 993 randomly selected primary care physicians from these practices (55% response rate). Both surveys asked whether respondents agreed or disagreed that they or their practice was “better positioned to meet patients' care needs during the coronavirus pandemic” because of participation in CPC+. Both also included an open-ended question about CPC+’s effects.

Results

Half of practices and one-third of physicians agreed or strongly agreed that participating in CPC+ better positioned them to meet patients' care needs during the pandemic. One in 10 practices and 2 in 10 physicians, disagreed or strongly disagreed, while 4 in 10 practices and slightly more than half of physicians neither agreed nor disagreed (or, for physicians, didn't know). The most commonly identified CPC+ activities that facilitated meeting patient care needs related to practices' work on care management (e.g., risk stratification), access (e.g., telehealth), payment outside of fee-for-service (FFS), and staffing (e.g., supporting care managers).

Conclusions

Most CPC+ practices and physicians were positive or neutral about participating in CPC+ in the context of COVID-19, indicating more benefit than risk to payment alternatives to FFS.

The COVID-19 pandemic generated tremendous interest in using real world data (RWD). Many consortia across the public and private sectors formed in 2020 with the goal of rapidly producing high-quality evidence from RWD to guide medical decision-making, public health priorities, and more. Experiences were gathered from five large consortia on rapid multi-institutional evidence generation during the COVID-19 pandemic. Insights have been compiled across five dimensions: consortium composition, governance structure and alignment of priorities, data sharing, data analysis, and evidence dissemination. The purpose of this piece is to offer guidance on building large-scale multi-institutional RWD analysis pipelines for future public health issues.

The composition of each consortium was largely influenced by existing collaborations. A central set of priorities for evidence generation guided each consortium, however different approaches to governance emerged. Challenges surrounding limited access to clinical data due to various contributors were overcome in unique ways. While all consortia used different methods to construct and analyze patient cohorts ranging from centralized to federated approaches, all proved effective for generating meaningful real-world evidence. Actionable recommendations for clinical practice and public health agencies were made from translating insights from consortium analyses.

Each consortium was successful in rapidly answering questions about COVID-19 diagnosis and treatment despite all taking slightly different approaches to data sharing and analysis. Leveraging RWD, leveraged in a manner that applies scientific rigor and transparency, can complement higher-level evidence and serve as an important adjunct to clinical trials to quickly guide policy and critical care, especially for a pandemic response.

Hispanic patients disproportionally suffer from disparities in care delivery in the setting of acute myocardial infarction (AMI). More specifically, Hispanic patients have higher 30-day readmission rates post-AMI and are less likely to be referred to cardiac rehab. Because of the challenges Hispanic patients face with post-AMI care, the Hispanic Acute Myocardial Infarction Discharge Intervention Study (HAMIDI) was launched to provide a culturally sensitive discharge framework to improve readmission and mortality rates in this population. Patients enrolled in this study participate in a comprehensive post-discharge program involving follow-up with a Spanish-speaking cardiologist, a two-part educational virtual group visit program, and access to support throughout the study. During the initial year of the study, 35 patients enrolled and successfully participated in the program. This case study reviews the implementation process, initial outcomes, challenges, and future plans of the program.

Objectives

To describe approaches that public health and social entrepreneurs take to address health equity, and identify strategies for equitable collaborations with these entrepreneurs.

Methods

We leveraged data from semi-structured interviews, conducted August to October 2022, with 20 public health and social entrepreneurs who focus on drivers of health and health equity. Two researchers employed content analysis, guided by a prior framework.

Results

To support health equity, public health and social entrepreneurs: center equity, critique biases, innovate for inclusion, engage translational expertise, catalyze capacity, and activate equitable systems. Equitable collaborations are supported by re-examining roles, de-conflicting organizational barriers, prioritizing representation, mitigating bias in generating evidence, and employing equitable capital.

Conclusions

Public health and social entrepreneurs can uplift equity across health service design and delivery. More equitable collaborations can advance this work.

Background

There are large and persistent racial and ethnic disparities in the use of mental health care in the United States. Medicaid managed care plans have the potential to reduce racial and ethnic disparities in use of mental health care through monitoring of need and active management of use of services across the populations they cover. This study compares racial and ethnic disparities among Medicaid beneficiaries in managed care with those not in managed care.

Methods

We compared Medicaid beneficiaries enrolled health maintenance organizations (HMOs) with those in fee-for-service (FFS) using data from the 2007–2015 Medical Expenditure Panel Survey (N = 26,113). We specified two-part propensity score adjusted models to estimate differences in mental health related emergency department visits, hospital stays, prescription fills, and outpatient visits overall and by race/ethnicity.

Results

HMO enrollment was associated with lower odds of having a mental health prescription (OR = 0.86, 95 % CI 0.78–0.96) or outpatient visit (OR = 0.82 95 % CI 0.73–0.92). These differences were similar across racial and ethnic groups or larger among Non-Hispanic Black and Hispanic beneficiaries than among Non-Hispanic White beneficiaries.

Conclusions

Medicaid managed care has not improved the inequitable allocation of mental health care across racial and ethnic groups. Explicit attention to monitoring of racial and ethnic differences in use of mental health care in Medicaid managed care is warranted.

Implications

Improvement in racial and ethnic disparities in mental health care in Medicaid manage care is unlikely to occur without targeted accountability mechanisms, such as required reporting or other contracting requirements.

Electronic health records (EHRs) have provided physicians with user-friendly self-service reporting tools to extract patient data from the EHR. Despite such benefits, physician training on how to use these tools has been limited. At our institution, physicians were faced with prolonged wait time for EHR data extraction requests and were unaware of self-service reporting tool availability in the EHR. Our goal was to develop an EHR data reporting curriculum for physicians and staff and examine the effectiveness of such training. In 2019, physician informaticists developed two interactive sessions to train physicians and staff on self-service reporting tools (Epic® SlicerDicer and Reporting Workbench (RWB)) available in our tertiary children’s hospital EHR. We assessed participants' knowledge, confidence, and tool utilization before, after, and 3-months post training via survey. Training sessions occurred between April and August 2021. Thirty-six participants completed the study, with 25 surveys collected immediately post and 22 surveys collected at 3-months post training. Data literacy knowledge pre-test average score improved from 62% to 93% (p < 0.05) immediately post-session and 74% at 3-months post assessment (p = 0.05). Regular tool utilization increased from 29% (RWB) and 34% (SlicerDicer) pre-session to 56% and 44% at 3-months post, respectively. Participants reported increased confidence in performing SlicerDicer model selection, criteria selection, and data visualization as well as RWB report navigation, report creation, report visualization, and describing report’s benefits/limitations. Ultimately, physician and staff self-service reporting tools training were effective in increasing data literacy knowledge, tool utilization, and confidence.

This case study examines how a public delivery system hospital implemented a heart monitoring patch in place of existing electrocardiogram (ECG) monitoring by pursuing a holistic value proposition. For example, leaders identified opportunity costs embedded in the existing ECG monitoring staffing. Stakeholders also rallied around values such as patient safety, patient experience, and quality of care.

Implementation also benefited from external philanthropic and industry partnerships, which facilitated a pilot period to implement new workflows, demonstrate proof-of-concept, and evaluate process improvements.

Despite implementation success, ongoing procurement and reimbursement challenges demonstrate the messiness of innovation, even after reaching a “maintenance” phase. Availability of patient-facing material in multiple languages is one example of an implementation gap in safety net settings. New policies by health systems, payers, and others are needed to establish pathways for future high-value innovations.