Heather Schacht Reisinger, Sheila Barron, Erin Balkenende, Melissa Steffen, Kenda Steffensmeier, Chris Richards, Dan Ball, Emily E Chasco, Jennifer Van Tiem, Nicole L Johnson, DeShauna Jones, Julia E Friberg, Rachael Kenney, Jane Moeckli, Kanika Arora, Borsika Rabin
Objective: To use a practical approach to examining the use of Expert Recommendations for Implementing Change (ERIC) strategies by Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) dimensions for rural health innovations using annual reports on a diverse array of initiatives.
Data sources and study setting: The Veterans Affairs (VA) Office of Rural Health (ORH) funds initiatives designed to support the implementation and spread of innovations and evidence-based programs and practices to improve the health of rural Veterans. This study draws on the annual evaluation reports submitted for fiscal years 2020-2022 from 30 of these enterprise-wide initiatives (EWIs).
Study design: Content analysis was guided by the RE-AIM framework conducted by the Center for the Evaluation of Enterprise-Wide Initiatives (CEEWI), a Quality Enhancement Research Initiative (QUERI)-ORH partnered evaluation initiative.
Data collection and extraction methods: CEEWI analysts conducted a content analysis of EWI annual evaluation reports submitted to ORH. Analysis included cataloguing reported implementation strategies by Reach, Adoption, Implementation, and Maintenance (RE-AIM) dimensions (i.e., identifying strategies that were used to support each dimension) and labeling strategies using ERIC taxonomy. Descriptive statistics were conducted to summarize data.
Principal findings: A total of 875 implementation strategies were catalogued in 73 reports. Across these strategies, 66 unique ERIC strategies were reported. EWIs applied an average of 12 implementation strategies (range 3-22). The top three ERIC clusters across all 3 years were Develop stakeholder relationships (21%), Use evaluative/iterative strategies (20%), and Train/educate stakeholders (19%). Most strategies were reported within the Implementation dimension. Strategy use among EWIs meeting the rurality benchmark were also compared.
Conclusions: Combining the dimensions from the RE-AIM framework and the ERIC strategies allows for understanding the use of implementation strategies across each RE-AIM dimension. This analysis will support ORH efforts to spread and sustain rural health innovations and evidence-based programs and practices through targeted implementation strategies.
{"title":"Tracking implementation strategies in real-world settings: VA Office of Rural Health enterprise-wide initiative portfolio.","authors":"Heather Schacht Reisinger, Sheila Barron, Erin Balkenende, Melissa Steffen, Kenda Steffensmeier, Chris Richards, Dan Ball, Emily E Chasco, Jennifer Van Tiem, Nicole L Johnson, DeShauna Jones, Julia E Friberg, Rachael Kenney, Jane Moeckli, Kanika Arora, Borsika Rabin","doi":"10.1111/1475-6773.14377","DOIUrl":"https://doi.org/10.1111/1475-6773.14377","url":null,"abstract":"<p><strong>Objective: </strong>To use a practical approach to examining the use of Expert Recommendations for Implementing Change (ERIC) strategies by Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) dimensions for rural health innovations using annual reports on a diverse array of initiatives.</p><p><strong>Data sources and study setting: </strong>The Veterans Affairs (VA) Office of Rural Health (ORH) funds initiatives designed to support the implementation and spread of innovations and evidence-based programs and practices to improve the health of rural Veterans. This study draws on the annual evaluation reports submitted for fiscal years 2020-2022 from 30 of these enterprise-wide initiatives (EWIs).</p><p><strong>Study design: </strong>Content analysis was guided by the RE-AIM framework conducted by the Center for the Evaluation of Enterprise-Wide Initiatives (CEEWI), a Quality Enhancement Research Initiative (QUERI)-ORH partnered evaluation initiative.</p><p><strong>Data collection and extraction methods: </strong>CEEWI analysts conducted a content analysis of EWI annual evaluation reports submitted to ORH. Analysis included cataloguing reported implementation strategies by Reach, Adoption, Implementation, and Maintenance (RE-AIM) dimensions (i.e., identifying strategies that were used to support each dimension) and labeling strategies using ERIC taxonomy. Descriptive statistics were conducted to summarize data.</p><p><strong>Principal findings: </strong>A total of 875 implementation strategies were catalogued in 73 reports. Across these strategies, 66 unique ERIC strategies were reported. EWIs applied an average of 12 implementation strategies (range 3-22). The top three ERIC clusters across all 3 years were Develop stakeholder relationships (21%), Use evaluative/iterative strategies (20%), and Train/educate stakeholders (19%). Most strategies were reported within the Implementation dimension. Strategy use among EWIs meeting the rurality benchmark were also compared.</p><p><strong>Conclusions: </strong>Combining the dimensions from the RE-AIM framework and the ERIC strategies allows for understanding the use of implementation strategies across each RE-AIM dimension. This analysis will support ORH efforts to spread and sustain rural health innovations and evidence-based programs and practices through targeted implementation strategies.</p>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":null,"pages":null},"PeriodicalIF":3.1,"publicationDate":"2024-09-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142121214","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Objective: To compare theoretical strengths and limitations of common immortal time adjustment methods, propose a new approach using multiple imputation (MI), and provide practical guidance for using MI in precision medicine evaluations centered on a real-world case study.
Study setting and design: Methods comparison, guidance, and real-world case study based on previous literature. We compared landmark analysis, time-distribution matching, time-dependent analysis, and our proposed MI application. Guidance for MI spanned (1) selecting the imputation method; (2) specifying and applying the imputation model; and (3) conducting comparative analysis and pooling estimates. Our case study used a matched cohort design to evaluate overall survival benefits of whole-genome and transcriptome analysis, a precision medicine technology, compared to usual care for advanced cancers, and applied both time-distribution matching and MI. Bootstrap simulation characterized imputation sensitivity to varying data missingness and sample sizes.
Data sources and analytic sample: Case study used population-based administrative data and single-arm precision medicine program data from British Columbia, Canada for the study period 2012 to 2015.
Principal findings: While each method described can reduce immortal time bias, MI offers theoretical advantages. Compared to alternative approaches, MI minimizes information loss and better characterizes statistical uncertainty about the true length of the immortal time period, avoiding false precision. Additionally, MI explicitly considers the impacts of patient characteristics on immortal time distributions, with inclusion criteria and follow-up period definitions that do not inadvertently risk biasing evaluations. In the real-world case study, survival analysis results did not substantively differ across MI and time distribution matching, but standard errors based on MI were higher for all point estimates. Mean imputed immortal time was stable across simulations.
Conclusions: Precision medicine evaluations must employ immortal time adjustment methods for unbiased, decision-grade real-world evidence generation. MI is a promising solution to the challenge of immortal time bias.
目的:比较常见不朽时间调整方法的理论优势和局限性,提出一种使用多重归因(MI)的新方法,并以真实世界案例研究为中心,为在精准医学评估中使用MI提供实用指导:研究设置和设计:方法比较、指导和基于以往文献的真实世界案例研究。我们比较了地标分析、时间分布匹配、时间依赖分析和我们提出的 MI 应用。MI指南包括:(1)选择估算方法;(2)指定并应用估算模型;以及(3)进行比较分析和汇总估计值。我们的案例研究采用匹配队列设计来评估全基因组和转录组分析(一种精准医疗技术)与晚期癌症常规治疗相比所带来的总生存益处,并同时应用了时间分布匹配和MI。数据来源和分析样本:案例研究使用了加拿大不列颠哥伦比亚省 2012 年至 2015 年期间基于人口的行政数据和单臂精准医疗计划数据:虽然所述的每种方法都能减少不朽时间偏差,但多元智能具有理论上的优势。与其他方法相比,MI 最大限度地减少了信息损失,更好地描述了不朽时间真实长度的统计不确定性,避免了错误的精确性。此外,MI 明确考虑了患者特征对不朽时间分布的影响,纳入标准和随访期定义不会无意中造成评估偏差的风险。在真实世界的案例研究中,MI 和时间分布匹配的生存分析结果没有实质性差异,但基于 MI 的标准误差对所有点估计值都较高。在不同的模拟中,平均估算的不朽时间是稳定的:结论:精准医疗评估必须采用不朽时间调整方法,以生成无偏见、决策级的真实世界证据。MI是解决不朽时间偏差挑战的一个很有前景的方案。
{"title":"Addressing immortal time bias in precision medicine: Practical guidance and methods development.","authors":"Deirdre Weymann, Emanuel Krebs, Dean A Regier","doi":"10.1111/1475-6773.14376","DOIUrl":"https://doi.org/10.1111/1475-6773.14376","url":null,"abstract":"<p><strong>Objective: </strong>To compare theoretical strengths and limitations of common immortal time adjustment methods, propose a new approach using multiple imputation (MI), and provide practical guidance for using MI in precision medicine evaluations centered on a real-world case study.</p><p><strong>Study setting and design: </strong>Methods comparison, guidance, and real-world case study based on previous literature. We compared landmark analysis, time-distribution matching, time-dependent analysis, and our proposed MI application. Guidance for MI spanned (1) selecting the imputation method; (2) specifying and applying the imputation model; and (3) conducting comparative analysis and pooling estimates. Our case study used a matched cohort design to evaluate overall survival benefits of whole-genome and transcriptome analysis, a precision medicine technology, compared to usual care for advanced cancers, and applied both time-distribution matching and MI. Bootstrap simulation characterized imputation sensitivity to varying data missingness and sample sizes.</p><p><strong>Data sources and analytic sample: </strong>Case study used population-based administrative data and single-arm precision medicine program data from British Columbia, Canada for the study period 2012 to 2015.</p><p><strong>Principal findings: </strong>While each method described can reduce immortal time bias, MI offers theoretical advantages. Compared to alternative approaches, MI minimizes information loss and better characterizes statistical uncertainty about the true length of the immortal time period, avoiding false precision. Additionally, MI explicitly considers the impacts of patient characteristics on immortal time distributions, with inclusion criteria and follow-up period definitions that do not inadvertently risk biasing evaluations. In the real-world case study, survival analysis results did not substantively differ across MI and time distribution matching, but standard errors based on MI were higher for all point estimates. Mean imputed immortal time was stable across simulations.</p><p><strong>Conclusions: </strong>Precision medicine evaluations must employ immortal time adjustment methods for unbiased, decision-grade real-world evidence generation. MI is a promising solution to the challenge of immortal time bias.</p>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":null,"pages":null},"PeriodicalIF":3.1,"publicationDate":"2024-09-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142121213","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Jason Brian Gibbons, Manuel Hermosilla, Antonio Trujillo
Objective: To generate evidence regarding the offensive (customer acquisition) versus defensive (customer retention) motivation for pharmaceutical manufacturer coupons.
Data sources and study setting: Retail prescriptions from IQVIA's Formulary Impact Analyzer data between 2017 and 2019.
Study design: Ordinary least squares regression models with person, therapeutic class, drug, and time-fixed effects to measure the association between switching medications and coupon usage as well as the association between patient out-of-pocket spending and switching to a drug and using a coupon. To study switching type heterogeneity, reanalysis of associations for any type of switch, generic-brand switches, and brand-brand switches. Reestimation of baseline analyses for sodium-glucose cotransporter-2 inhibitors, anticoagulants, and inhaled corticosteroids/long-acting beta2-agonists to assess heterogeneity by drug class and market maturity.
Data collection: 1,167,132 privately insured patients that utilized at least one coupon between 2017 and 2019 for one or more prescriptions.
Principal findings: Coupon usage was associated with a 1.0 percentage point reduction in any kind of drug switch in the full sample and by 0.65-2.9 percentage points for the drug class subgroups. However, these estimates are governed by market dynamics; the probability of switching increased by 40% on the first coupon usage before declining by more than 50% on subsequent coupons. Switching after the first coupon use may be explained by systematic savings implied by coupon use; we find coupons reduced patient out-of-pocket spending by $45.00 (i.e., the majority of patient out-of-pocket costs). In subgroup analyses, coupon savings were $6.43 larger than average for anticoagulants, characterized by the highest levels of brand and generic competition among the considered therapeutic classes.
Conclusions: Pharmaceutical manufacturers may be using coupons to acquire customers and then build brand loyalty, especially in markets with more generic competition. Antitrust authorities and other regulators should scrutinize the impact of coupons on market competitiveness and drug spending.
{"title":"On the motivation for pharmaceutical manufacturer coupons: Brand loyalty or customer acquisition?","authors":"Jason Brian Gibbons, Manuel Hermosilla, Antonio Trujillo","doi":"10.1111/1475-6773.14379","DOIUrl":"https://doi.org/10.1111/1475-6773.14379","url":null,"abstract":"<p><strong>Objective: </strong>To generate evidence regarding the offensive (customer acquisition) versus defensive (customer retention) motivation for pharmaceutical manufacturer coupons.</p><p><strong>Data sources and study setting: </strong>Retail prescriptions from IQVIA's Formulary Impact Analyzer data between 2017 and 2019.</p><p><strong>Study design: </strong>Ordinary least squares regression models with person, therapeutic class, drug, and time-fixed effects to measure the association between switching medications and coupon usage as well as the association between patient out-of-pocket spending and switching to a drug and using a coupon. To study switching type heterogeneity, reanalysis of associations for any type of switch, generic-brand switches, and brand-brand switches. Reestimation of baseline analyses for sodium-glucose cotransporter-2 inhibitors, anticoagulants, and inhaled corticosteroids/long-acting beta2-agonists to assess heterogeneity by drug class and market maturity.</p><p><strong>Data collection: </strong>1,167,132 privately insured patients that utilized at least one coupon between 2017 and 2019 for one or more prescriptions.</p><p><strong>Principal findings: </strong>Coupon usage was associated with a 1.0 percentage point reduction in any kind of drug switch in the full sample and by 0.65-2.9 percentage points for the drug class subgroups. However, these estimates are governed by market dynamics; the probability of switching increased by 40% on the first coupon usage before declining by more than 50% on subsequent coupons. Switching after the first coupon use may be explained by systematic savings implied by coupon use; we find coupons reduced patient out-of-pocket spending by $45.00 (i.e., the majority of patient out-of-pocket costs). In subgroup analyses, coupon savings were $6.43 larger than average for anticoagulants, characterized by the highest levels of brand and generic competition among the considered therapeutic classes.</p><p><strong>Conclusions: </strong>Pharmaceutical manufacturers may be using coupons to acquire customers and then build brand loyalty, especially in markets with more generic competition. Antitrust authorities and other regulators should scrutinize the impact of coupons on market competitiveness and drug spending.</p>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":null,"pages":null},"PeriodicalIF":3.1,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142114946","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Suparna M Navale, Siran Koroukian, Nicole Cook, Anna Templeton, Brenda M McGrath, Laura Crocker, Wyatt P Bensken, Ana R Quiñones, Nicholas K Schiltz, Melissa Y Wei, Kurt C Stange
Objective: To compare morbidity burden captured from multimorbidity indices and aggregated measures of clinically meaningful categories captured in primary care community-based health center (CBHC) patients.
Data sources and study setting: Electronic health records of patients seen in 2019 in OCHIN's national network of CBHCs serving patients in rural and underserved communities.
Study design: Age-stratified analyses comparing the most common conditions captured by the Charlson, Elixhauser, and Multimorbidity Weighted (MWI) indices, and Classification Software Refined (CCSR) and Chronic Condition Indicator (CCI) algorithms.
Data collection/extraction methods: Active ICD-10 conditions on patients' problem list in 2019.
Principal findings: Approximately 35%-56% of patients with at least one condition are not captured by the Charlson, Elixhauser, and MWI indices. When stratified by age, this range broadens to 9%-90% with higher percentages in younger patients. The CCSR and CCI reflect a broader range of acute and chronic conditions prevalent among CBHC patients.
Conclusion: Three commonly used indices to capture morbidity burden reflect conditions most prevalent among older adults, but do not capture those on problem lists for younger CBHC patients. An index with an expanded range of care conditions is needed to understand the complex care provided to primary care populations across the lifespan.
{"title":"Capturing the care of complex community-based health center patients: A comparison of multimorbidity indices and clinical classification software.","authors":"Suparna M Navale, Siran Koroukian, Nicole Cook, Anna Templeton, Brenda M McGrath, Laura Crocker, Wyatt P Bensken, Ana R Quiñones, Nicholas K Schiltz, Melissa Y Wei, Kurt C Stange","doi":"10.1111/1475-6773.14378","DOIUrl":"10.1111/1475-6773.14378","url":null,"abstract":"<p><strong>Objective: </strong>To compare morbidity burden captured from multimorbidity indices and aggregated measures of clinically meaningful categories captured in primary care community-based health center (CBHC) patients.</p><p><strong>Data sources and study setting: </strong>Electronic health records of patients seen in 2019 in OCHIN's national network of CBHCs serving patients in rural and underserved communities.</p><p><strong>Study design: </strong>Age-stratified analyses comparing the most common conditions captured by the Charlson, Elixhauser, and Multimorbidity Weighted (MWI) indices, and Classification Software Refined (CCSR) and Chronic Condition Indicator (CCI) algorithms.</p><p><strong>Data collection/extraction methods: </strong>Active ICD-10 conditions on patients' problem list in 2019.</p><p><strong>Principal findings: </strong>Approximately 35%-56% of patients with at least one condition are not captured by the Charlson, Elixhauser, and MWI indices. When stratified by age, this range broadens to 9%-90% with higher percentages in younger patients. The CCSR and CCI reflect a broader range of acute and chronic conditions prevalent among CBHC patients.</p><p><strong>Conclusion: </strong>Three commonly used indices to capture morbidity burden reflect conditions most prevalent among older adults, but do not capture those on problem lists for younger CBHC patients. An index with an expanded range of care conditions is needed to understand the complex care provided to primary care populations across the lifespan.</p>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":null,"pages":null},"PeriodicalIF":3.1,"publicationDate":"2024-08-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142114945","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Dharma E Cortés, Ana M Progovac, Frederick Lu, Esther Lee, Nathaniel M Tran, Margo A Moyer, Varshini Odayar, Caryn R R Rodgers, Leslie Adams, Valeria Chambers, Jonathan Delman, Deborah Delman, Selma de Castro, María José Sánchez Román, Natasha A Kaushal, Timothy B Creedon, Rajan A Sonik, Catherine Rodriguez Quinerly, Ora Nakash, Afsaneh Moradi, Heba Abolaban, Tali Flomenhoft, Ruth Nabisere, Ziva Mann, Sherry Shu-Yeu Hou, Farah N Shaikh, Michael W Flores, Dierdre Jordan, Nicholas Carson, Adam C Carle, Benjamin Lé Cook, Danny McCormick
Objective: To understand whether and how primary care providers and staff elicit patients' past experiences of healthcare discrimination when providing care.
Data sources/study setting: Twenty qualitative semi-structured interviews were conducted with healthcare staff in primary care roles to inform future interventions to integrate data about past experiences of healthcare discrimination into clinical care.
Study design: Qualitative study.
Data collection/extraction methods: Data were collected via semi-structured qualitative interviews between December 2018 and January 2019, with health care staff in primary care roles at a hospital-based clinic within an urban safety-net health system that serves a patient population with significant racial, ethnic, and linguistic diversity.
Principal findings: Providers did not routinely, or in a structured way, elicit information about past experiences of healthcare discrimination. Some providers believed that information about healthcare discrimination experiences could allow them to be more aware of and responsive to their patients' needs and to establish more trusting relationships. Others did not deem it appropriate or useful to elicit such information and were concerned about challenges in collecting and effectively using such data.
Conclusions: While providers see value in eliciting past experiences of discrimination, directly and systematically discussing such experiences with patients during a primary care encounter is challenging for them. Collecting this information in primary care settings will likely require implementation of multilevel systematic data collection strategies. Findings presented here can help identify clinic-level opportunities to do so.
{"title":"Eliciting patient past experiences of healthcare discrimination as a potential pathway to reduce health disparities: A qualitative study of primary care staff.","authors":"Dharma E Cortés, Ana M Progovac, Frederick Lu, Esther Lee, Nathaniel M Tran, Margo A Moyer, Varshini Odayar, Caryn R R Rodgers, Leslie Adams, Valeria Chambers, Jonathan Delman, Deborah Delman, Selma de Castro, María José Sánchez Román, Natasha A Kaushal, Timothy B Creedon, Rajan A Sonik, Catherine Rodriguez Quinerly, Ora Nakash, Afsaneh Moradi, Heba Abolaban, Tali Flomenhoft, Ruth Nabisere, Ziva Mann, Sherry Shu-Yeu Hou, Farah N Shaikh, Michael W Flores, Dierdre Jordan, Nicholas Carson, Adam C Carle, Benjamin Lé Cook, Danny McCormick","doi":"10.1111/1475-6773.14373","DOIUrl":"https://doi.org/10.1111/1475-6773.14373","url":null,"abstract":"<p><strong>Objective: </strong>To understand whether and how primary care providers and staff elicit patients' past experiences of healthcare discrimination when providing care.</p><p><strong>Data sources/study setting: </strong>Twenty qualitative semi-structured interviews were conducted with healthcare staff in primary care roles to inform future interventions to integrate data about past experiences of healthcare discrimination into clinical care.</p><p><strong>Study design: </strong>Qualitative study.</p><p><strong>Data collection/extraction methods: </strong>Data were collected via semi-structured qualitative interviews between December 2018 and January 2019, with health care staff in primary care roles at a hospital-based clinic within an urban safety-net health system that serves a patient population with significant racial, ethnic, and linguistic diversity.</p><p><strong>Principal findings: </strong>Providers did not routinely, or in a structured way, elicit information about past experiences of healthcare discrimination. Some providers believed that information about healthcare discrimination experiences could allow them to be more aware of and responsive to their patients' needs and to establish more trusting relationships. Others did not deem it appropriate or useful to elicit such information and were concerned about challenges in collecting and effectively using such data.</p><p><strong>Conclusions: </strong>While providers see value in eliciting past experiences of discrimination, directly and systematically discussing such experiences with patients during a primary care encounter is challenging for them. Collecting this information in primary care settings will likely require implementation of multilevel systematic data collection strategies. Findings presented here can help identify clinic-level opportunities to do so.</p>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":null,"pages":null},"PeriodicalIF":3.1,"publicationDate":"2024-08-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142082665","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Lucinda B Leung, Karen Chu, Danielle E Rose, Susan E Stockdale, Edward P Post, Jennifer S Funderburk, Lisa V Rubenstein
Objective: To examine the relationship between the penetration (or reach) of a national program aiming to integrate mental health clinicians into all primary care clinics (PC-MHI) and rates of guideline-concordant follow-up and treatment among clinic patients newly identified with depression in the Veterans Health Administration (VA).
Data sources/study setting: 15,155 screen-positive patients 607,730 patients with 2-item Patient Health Questionnaire scores in 82 primary care clinics, 2015-2019.
Study design: In this retrospective cohort study, we used established depression care quality measures to assess primary care patients who (a) newly screened positive (score ≥3) and (b) were identified with depression by clinicians via diagnosis and/or medication (n = 15,155; 15,650 patient-years). Timely follow-up included ≥3 mental health, ≥3 psychotherapy, or ≥3 primary care visits for depression. Minimally appropriate treatment included ≥4 mental health visits, ≥3 psychotherapy, or ≥60 days of medication. In multivariate regressions, we examined whether higher rates of PC-MHI penetration in clinic (proportion of total primary care patients in a clinic who saw any PC-MHI clinician) were associated with greater depression care quality among cohort patients, adjusting for year, healthcare system, and patient and clinic characteristics.
Data collection/extraction methods: Electronic health record data from 82 VA clinics across three states.
Principal findings: A median of 9% of all primary care patients were seen by any PC-MHI clinician annually. In fully adjusted models, greater PC-MHI penetration was associated with timely depression follow-up within 84 days (∆P = 0.5; SE = 0.1; p < 0.001) and 180 days (∆P = 0.3; SE = 0.1; p = 0.01) of a positive depression screen. Completion of at least minimal treatment within 12 months was high (77%), on average, and not associated with PC-MHI penetration.
Conclusions: Greater PC-MHI program penetration was associated with early depression treatment engagement at 84-/180-days among clinic patients newly identified with depression, with no effect on already high rates of completion of minimally sufficient treatment within the year.
目的研究旨在将心理健康临床医生纳入所有初级保健诊所(PC-MHI)的国家计划的渗透率(或覆盖率)与退伍军人健康管理局(VA)新发现的抑郁症患者的指南一致性随访和治疗率之间的关系:2015-2019年,82家初级保健诊所的15155名筛查阳性患者607730名患者的2项患者健康问卷得分:在这项回顾性队列研究中,我们使用已建立的抑郁症护理质量测量方法来评估(a)新筛查阳性(得分≥3)和(b)临床医生通过诊断和/或药物治疗确定为抑郁症的初级保健患者(n = 15,155; 15,650 患者年)。及时随访包括≥3 次心理健康随访、≥3 次心理治疗随访或≥3 次抑郁症初级保健随访。最低限度的适当治疗包括≥4次精神健康检查、≥3次心理治疗或≥60天的药物治疗。在多变量回归中,我们考察了诊所中PC-MHI渗透率越高(诊所中看过任何PC-MHI临床医生的全科患者比例)是否与队列患者中抑郁症护理质量越高有关,并对年份、医疗保健系统、患者和诊所特征进行了调整:数据收集/提取方法:来自三个州 82 家退伍军人诊所的电子健康记录数据:在所有初级保健患者中,每年接受 PC-MHI 诊疗的患者中位数为 9%。在完全调整模型中,PC-MHI 普及率越高,84 天内抑郁症的及时随访率就越高(∆P = 0.5; SE = 0.1; p 结论:PC-MHI 计划普及率越高,抑郁症的随访率就越高(∆P = 0.5; SE = 0.1; pPC-MHI项目的普及率越高,新发现的抑郁症门诊患者在84天/180天内尽早接受抑郁症治疗的可能性就越大,而对一年内完成最低限度治疗的高比率则没有影响。
{"title":"Primary care mental health integration to improve early treatment engagement for veterans who screen positive for depression.","authors":"Lucinda B Leung, Karen Chu, Danielle E Rose, Susan E Stockdale, Edward P Post, Jennifer S Funderburk, Lisa V Rubenstein","doi":"10.1111/1475-6773.14354","DOIUrl":"10.1111/1475-6773.14354","url":null,"abstract":"<p><strong>Objective: </strong>To examine the relationship between the penetration (or reach) of a national program aiming to integrate mental health clinicians into all primary care clinics (PC-MHI) and rates of guideline-concordant follow-up and treatment among clinic patients newly identified with depression in the Veterans Health Administration (VA).</p><p><strong>Data sources/study setting: </strong>15,155 screen-positive patients 607,730 patients with 2-item Patient Health Questionnaire scores in 82 primary care clinics, 2015-2019.</p><p><strong>Study design: </strong>In this retrospective cohort study, we used established depression care quality measures to assess primary care patients who (a) newly screened positive (score ≥3) and (b) were identified with depression by clinicians via diagnosis and/or medication (n = 15,155; 15,650 patient-years). Timely follow-up included ≥3 mental health, ≥3 psychotherapy, or ≥3 primary care visits for depression. Minimally appropriate treatment included ≥4 mental health visits, ≥3 psychotherapy, or ≥60 days of medication. In multivariate regressions, we examined whether higher rates of PC-MHI penetration in clinic (proportion of total primary care patients in a clinic who saw any PC-MHI clinician) were associated with greater depression care quality among cohort patients, adjusting for year, healthcare system, and patient and clinic characteristics.</p><p><strong>Data collection/extraction methods: </strong>Electronic health record data from 82 VA clinics across three states.</p><p><strong>Principal findings: </strong>A median of 9% of all primary care patients were seen by any PC-MHI clinician annually. In fully adjusted models, greater PC-MHI penetration was associated with timely depression follow-up within 84 days (∆P = 0.5; SE = 0.1; p < 0.001) and 180 days (∆P = 0.3; SE = 0.1; p = 0.01) of a positive depression screen. Completion of at least minimal treatment within 12 months was high (77%), on average, and not associated with PC-MHI penetration.</p><p><strong>Conclusions: </strong>Greater PC-MHI program penetration was associated with early depression treatment engagement at 84-/180-days among clinic patients newly identified with depression, with no effect on already high rates of completion of minimally sufficient treatment within the year.</p>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":null,"pages":null},"PeriodicalIF":3.1,"publicationDate":"2024-08-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142019635","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Evolution of the Veterans Health Administration Learning Health System: 25 years of QUERI.","authors":"Melissa M Garrido, Amy M Kilbourne","doi":"10.1111/1475-6773.14372","DOIUrl":"https://doi.org/10.1111/1475-6773.14372","url":null,"abstract":"","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":null,"pages":null},"PeriodicalIF":3.1,"publicationDate":"2024-08-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142019634","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Amy M Kilbourne, Amanda E Borsky, Robert W O'Brien, Melissa Z Braganza, Melissa M Garrido
{"title":"The foundational science of learning health systems.","authors":"Amy M Kilbourne, Amanda E Borsky, Robert W O'Brien, Melissa Z Braganza, Melissa M Garrido","doi":"10.1111/1475-6773.14374","DOIUrl":"https://doi.org/10.1111/1475-6773.14374","url":null,"abstract":"","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":null,"pages":null},"PeriodicalIF":3.1,"publicationDate":"2024-08-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142009969","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Courtney Harold Van Houtven, Cynthia J Coffman, Kasey Decosimo, Janet M Grubber, Joshua Dadolf, Caitlin Sullivan, Matthew Tucker, Rebecca Bruening, Nina R Sperber, Karen M Stechuchak, Megan Shepherd-Banigan, Nathan Boucher, Jessica E Ma, Brystana G Kaufman, Cathleen S Colón-Emeric, George L Jackson, Teresa M Damush, Leah Christensen, Virginia Wang, Kelli D Allen, Susan N Hastings
Objective: To assess the effects of an evidence-based family caregiver training program (implementation of Helping Invested Families Improve Veteran Experiences Study [iHI-FIVES]) in the Veterans Affairs healthcare system on Veteran days not at home and family caregiver well-being.
Data sources and study setting: Participants included Veterans referred to home- and community-based services with an identified caregiver across 8 medical centers and confirmed family caregivers of eligible Veterans.
Study design: In a stepped wedge cluster randomized trial, sites were randomized to a 6-month time interval for starting iHI-FIVES and received standardized implementation support. The primary outcome, number of Veteran "days not at home," and secondary outcomes, changes over 3 months in measures of caregiver well-being, were compared between pre- and post-iHI-FIVES intervals using generalized linear models including covariates.
Data collection/extraction methods: Patient data were extracted from the electronic health record. Caregiver data were collected from 2 telephone-based surveys.
Principal findings: Overall, n = 898 eligible Veterans were identified across pre-iHI-FIVES (n = 327) and post-iHI-FIVES intervals (n = 571). Just under one fifth (17%) of Veterans in post-iHI-FIVES intervals had a caregiver enroll in iHI-FIVES. Veteran and caregiver demographics in pre-iHI-FIVES intervals were similar to those in post-iHI-FIVES intervals. In adjusted models, the estimated rate of days not at home over 6-months was 42% lower (rate ratio = 0.58 [95% confidence interval: 0.31-1.09; p = 0.09]) post-iHI-FIVES compared with pre-iHI-FIVES. The estimated mean days not at home over a 6-month period was 13.0 days pre-iHI-FIVES and 7.5 post-iHI-FIVES. There were no differences between pre- and post-iHI-FIVES in change over 3 months in caregiver well-being measures.
Conclusions: Reducing days not at home is consistent with effectiveness because more time at home increases quality of life. In this study, after adjusting for Veteran characteristics, we did not find evidence that implementation of a caregiver training program yielded a reduction in Veteran's days not at home.
{"title":"A stepped wedge cluster randomized trial to evaluate the effectiveness of a multisite family caregiver skills training program.","authors":"Courtney Harold Van Houtven, Cynthia J Coffman, Kasey Decosimo, Janet M Grubber, Joshua Dadolf, Caitlin Sullivan, Matthew Tucker, Rebecca Bruening, Nina R Sperber, Karen M Stechuchak, Megan Shepherd-Banigan, Nathan Boucher, Jessica E Ma, Brystana G Kaufman, Cathleen S Colón-Emeric, George L Jackson, Teresa M Damush, Leah Christensen, Virginia Wang, Kelli D Allen, Susan N Hastings","doi":"10.1111/1475-6773.14326","DOIUrl":"https://doi.org/10.1111/1475-6773.14326","url":null,"abstract":"<p><strong>Objective: </strong>To assess the effects of an evidence-based family caregiver training program (implementation of Helping Invested Families Improve Veteran Experiences Study [iHI-FIVES]) in the Veterans Affairs healthcare system on Veteran days not at home and family caregiver well-being.</p><p><strong>Data sources and study setting: </strong>Participants included Veterans referred to home- and community-based services with an identified caregiver across 8 medical centers and confirmed family caregivers of eligible Veterans.</p><p><strong>Study design: </strong>In a stepped wedge cluster randomized trial, sites were randomized to a 6-month time interval for starting iHI-FIVES and received standardized implementation support. The primary outcome, number of Veteran \"days not at home,\" and secondary outcomes, changes over 3 months in measures of caregiver well-being, were compared between pre- and post-iHI-FIVES intervals using generalized linear models including covariates.</p><p><strong>Data collection/extraction methods: </strong>Patient data were extracted from the electronic health record. Caregiver data were collected from 2 telephone-based surveys.</p><p><strong>Principal findings: </strong>Overall, n = 898 eligible Veterans were identified across pre-iHI-FIVES (n = 327) and post-iHI-FIVES intervals (n = 571). Just under one fifth (17%) of Veterans in post-iHI-FIVES intervals had a caregiver enroll in iHI-FIVES. Veteran and caregiver demographics in pre-iHI-FIVES intervals were similar to those in post-iHI-FIVES intervals. In adjusted models, the estimated rate of days not at home over 6-months was 42% lower (rate ratio = 0.58 [95% confidence interval: 0.31-1.09; p = 0.09]) post-iHI-FIVES compared with pre-iHI-FIVES. The estimated mean days not at home over a 6-month period was 13.0 days pre-iHI-FIVES and 7.5 post-iHI-FIVES. There were no differences between pre- and post-iHI-FIVES in change over 3 months in caregiver well-being measures.</p><p><strong>Conclusions: </strong>Reducing days not at home is consistent with effectiveness because more time at home increases quality of life. In this study, after adjusting for Veteran characteristics, we did not find evidence that implementation of a caregiver training program yielded a reduction in Veteran's days not at home.</p>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":null,"pages":null},"PeriodicalIF":3.1,"publicationDate":"2024-08-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141977306","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Risha Gidwani, Veronica Yank, Lane Burgette, Aaron Kofner, Steven M Asch, Zachary Wagner
Objective: Evaluate whether cost-sharing decreases led high-deductible health plans (HDHP) enrollees to increase their use of healthcare.
Data sources, study setting: National sample of chronically-ill patients age 18-64 from 2018 to 2020 (n = 1,318,178).
Study design: Difference-in-differences analyses using entropy-balancing weights were used to evaluate the effect of a policy shift to $0 cost-sharing for telehealth on utilization for HDHP compared with non-HDHP enrollees. Due to this shock, HDHP enrollees experienced substantial declines in cost-sharing for telehealth, while non-HDHP enrollees experienced small declines. Event study models were also used to evaluate changes over time.
Data collection/extraction methods: Outcomes included use of any outpatient care; use of $0 telehealth; use of $0 telehealth as a proportion of all outpatient care; and use of any telehealth. To test whether any differences were due to preferences for care modality versus cost-sharing, we further evaluated use of non-$0 telehealth as a placebo test.
Principal findings: There was no difference in change in overall outpatient visits (p = 0.84), with chronicall-ill HDHP enrollees using less care both before and after the policy shift. However, compared with non-HDHP enrollees, HDHP enrollees increased their use of $0 telehealth by 0.08 visits over a 9-month period, a 27% increase (95% CI 0.07-0.09, p < 0.001) and shifted 1.2 percentage points more of their care to $0 telehealth, a 15% increase (ß = 0.01, 95% CI 0.01, 0.01, p < 0.001). However, HDHP enrollees had lower uptake of non-$0 telehealth than non-HDHP enrollees (ß = -0.01, 95%CI -0.02, 0.00, p = 0.04).
Conclusions: Recent-but-expiring federal legislation exempts telehealth from HDHP deductibles for care provided in 2023 and 2024. Our results indicate that extending the protections provided by this legislation could help reduce the gap in access to care for chronically-ill persons enrolled in HDHPs.
{"title":"The impact of telehealth cost-sharing on healthcare utilization: Evidence from high-deductible health plans.","authors":"Risha Gidwani, Veronica Yank, Lane Burgette, Aaron Kofner, Steven M Asch, Zachary Wagner","doi":"10.1111/1475-6773.14343","DOIUrl":"10.1111/1475-6773.14343","url":null,"abstract":"<p><strong>Objective: </strong>Evaluate whether cost-sharing decreases led high-deductible health plans (HDHP) enrollees to increase their use of healthcare.</p><p><strong>Data sources, study setting: </strong>National sample of chronically-ill patients age 18-64 from 2018 to 2020 (n = 1,318,178).</p><p><strong>Study design: </strong>Difference-in-differences analyses using entropy-balancing weights were used to evaluate the effect of a policy shift to $0 cost-sharing for telehealth on utilization for HDHP compared with non-HDHP enrollees. Due to this shock, HDHP enrollees experienced substantial declines in cost-sharing for telehealth, while non-HDHP enrollees experienced small declines. Event study models were also used to evaluate changes over time.</p><p><strong>Data collection/extraction methods: </strong>Outcomes included use of any outpatient care; use of $0 telehealth; use of $0 telehealth as a proportion of all outpatient care; and use of any telehealth. To test whether any differences were due to preferences for care modality versus cost-sharing, we further evaluated use of non-$0 telehealth as a placebo test.</p><p><strong>Principal findings: </strong>There was no difference in change in overall outpatient visits (p = 0.84), with chronicall-ill HDHP enrollees using less care both before and after the policy shift. However, compared with non-HDHP enrollees, HDHP enrollees increased their use of $0 telehealth by 0.08 visits over a 9-month period, a 27% increase (95% CI 0.07-0.09, p < 0.001) and shifted 1.2 percentage points more of their care to $0 telehealth, a 15% increase (ß = 0.01, 95% CI 0.01, 0.01, p < 0.001). However, HDHP enrollees had lower uptake of non-$0 telehealth than non-HDHP enrollees (ß = -0.01, 95%CI -0.02, 0.00, p = 0.04).</p><p><strong>Conclusions: </strong>Recent-but-expiring federal legislation exempts telehealth from HDHP deductibles for care provided in 2023 and 2024. Our results indicate that extending the protections provided by this legislation could help reduce the gap in access to care for chronically-ill persons enrolled in HDHPs.</p>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":null,"pages":null},"PeriodicalIF":3.1,"publicationDate":"2024-08-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141972330","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}