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Background: A team approach is one of the most effective ways to lower blood pressure (BP) in uncontrolled hypertension, but different models for organizing team-based care have not been compared directly. Methods: A pragmatic, cluster-randomized trial compared 2 interventions in adult patients with moderately severe hypertension (BP≥150/95 mm Hg): (1) clinic-based care using best practices and face-to-face visits with physicians and medical assistants; and (2) telehealth care using best practices and adding home BP telemonitoring with home-based care coordinated by a clinical pharmacist or nurse practitioner. The primary outcome was change in systolic BP over 12 months. Secondary outcomes were change in patient-reported outcomes over 6 months. Results: Participants (N=3071 in 21 primary care clinics) were on average 60 years old, 47% male, and 19% Black. Protocol-specified follow-up within 6 weeks was 32% in clinic-based care and 27% in telehealth care. BP decreased significantly during 12 months of follow-up in both groups, from 157/92 to 139/82 mm Hg in clinic-based care patients (adjusted mean difference −18/−10 mm Hg) and 157/91 to 139/81 mm Hg in telehealth care patients (adjusted mean difference −19/−10 mm Hg), with no significant difference in systolic BP change between groups (−0.8 mm Hg [95% CI, −2.84 to 1.32]). Telehealth care patients were significantly more likely than clinic-based care patients to report frequent home BP measurement, rate their BP care highly, and report that BP care visits were convenient. Conclusions: Telehealth care that includes extended team care is an effective and safe alternative to clinic-based care for improving patient-centered care for hypertension. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02996565.

Background Explanatory trials are designed to assess intervention efficacy under ideal conditions, while pragmatic trials are designed to assess whether research-proven interventions are effective in “real-world” settings without substantial research support. Methods We compared two trials (Hyperlink 1 and 3) that tested a pharmacist-led telehealth intervention in adults with uncontrolled hypertension. We applied PRagmatic Explanatory Continuum Indicator Summary-2 (PRECIS-2) scores to describe differences in the way these studies were designed and enrolled study-eligible participants, and the effect of these differences on participant characteristics and adherence to study interventions. Results PRECIS-2 scores demonstrated that Hyperlink 1 was more explanatory and Hyperlink 3 more pragmatic. Recruitment for Hyperlink 1 was conducted by study staff, and 2.9% of potentially eligible patients enrolled. Enrollees were older, and more likely to be male and White than non-enrollees. Study staff scheduled the initial pharmacist visit and adherence to attending this visit was 98%. Conversely for Hyperlink 3, recruitment was conducted by clinic staff at routine encounters and 81% of eligible patients enrolled. Enrollees were younger, and less likely to be male and White than non-enrollees. Study staff did not assist with scheduling the initial pharmacist visit and adherence to attending this visit was only 27%. Compared to Hyperlink 1, patients in Hyperlink 3 were more likely to be female, and Asian or Black, had lower socioeconomic indicators, and were more likely to have comorbidities. Owing to a lower BP for eligibility in Hyperlink 1 (>140/90 mm Hg) than in Hyperlink 3 (>150/95 mm Hg), mean baseline BP was 148/85 mm Hg in Hyperlink 1 and 158/92 mm Hg in Hyperlink 3. Conclusion The pragmatic design features of Hyperlink 3 substantially increased enrollment of study-eligible patients and of those traditionally under-represented in clinical trials (women, minorities, and patients with less education and lower income), and demonstrated that identification and enrollment of a high proportion of study-eligible subjects could be done by usual primary care clinic staff. However, the trade-off was much lower adherence to the telehealth intervention than in Hyperlink 1, which is likely to reflect uptake under real-word conditions and substantially dilute intervention effect on BP. Trial registration The Hyperlink 1 study (NCT00781365) and the Hyperlink 3 study (NCT02996565) are registered at ClinicalTrials.gov.

OBJECTIVE: To identify the impact of changes surrounding certification as a patient‐centered medical home (PCMH) on outcomes for patients with diabetes. STUDY SETTING: Minnesota legislation established mandatory quality reporting for patients with diabetes and statewide standards for certification as a PCMH. Patient‐level quality reporting data (2008‐2018) were used to study the impact of transition to a PCMH. STUDY DESIGN: Achievement of Minnesota's optimal diabetes care standard—in aggregate and by component—was modeled for adult patients with Type 1 or Type 2 diabetes as a function of time relative to the year the patient's primary care practice achieved PCMH certification. Patients from uncertified practices were used to control for general trend. Practice‐level random effects captured time‐invariant characteristics of practices and the practices’ average patient. DATA COLLECTION: Electronic health record data were submitted by 695 Minnesota practices capturing components of the quality standard: blood sugar control, cholesterol control, blood pressure control, nonsmoking status, and use of aspirin. PRINCIPAL FINDINGS: The first cohort of practices achieving PCMH certification (July 2010‐June 2014) showed statistically insignificant changes in optimal care. The next cohort of practices (July 2014‐June 2018) achieved larger, clinically meaningful increases in quality of care during the time prior to and following certification. Specifically, this second cohort of practices was estimated to achieve a 12.8 percentage‐point improvement (P

ImportanceComputed tomography (CT) radiation doses vary across institutions and are often higher than needed.ObjectiveTo assess the effectiveness of 2 interventions to reduce radiation doses in patients undergoing CT.Design, Setting, and ParticipantsThis randomized clinical trial included 864 080 adults older than 18 years who underwent CT of the abdomen, chest, combined abdomen and chest, or head at 100 facilities in 6 countries from November 1, 2015, to September 21, 2017. Data analysis was performed from October 4, 2017, to December 14, 2018.InterventionsImaging facilities received audit feedback alone comparing radiation-dose metrics with those of other facilities followed by the multicomponent intervention, including audit feedback with targeted suggestions, a 7-week quality improvement collaborative, and best-practice sharing. Facilities were randomly allocated to the time crossing from usual care to the intervention.Main Outcomes and MeasuresPrimary outcomes were the proportion of high-dose CT scans and mean effective dose at the facility level. Secondary outcomes were organ doses. Outcomes after interventions were compared with those before interventions using hierarchical generalized linear models adjusting for temporal trends and patient characteristics.ResultsAcross 100 facilities, 864 080 adults underwent 1 156 657 CT scans. The multicomponent intervention significantly reduced proportions of high-dose CT scans, measured using effective dose. Absolute changes in proportions of high-dose scans were 1.1% to 7.9%, with percentage reductions in the proportion of high-dose scans of 4% to 30% (abdomen: odds ratio [OR], 0.82; 95% CI, 0.77-0.88; P P = .03; combined abdomen and chest: OR, 0.49; 95% CI, 0.41-0.59; P P P P P Conclusions and RelevanceFor imaging facilities, detailed feedback on CT radiation dose combined with actionable suggestions and quality improvement education significantly reduced doses, particularly organ doses. Effects of audit feedback alone were modest.Trial RegistrationClinicalTrials.gov Identifier: NCT03000751

BACKGROUND: Patient-reported outcome measures (PROMs) are increasingly promoted for use in routine orthopaedic care with the expectation that if they are made available during encounters, they will be incorporated into clinical practice. We investigated an initiative in which PROMs were systematically collected and provided via the electronic health record but were infrequently used. QUESTIONS/PURPOSES: In a qualitative study, we asked: (1) Why are PROM results not being used in clinical care when they are available to surgeons? (2) What aspects of PROMs are seen as useful for clinical care? (3) How are PROMs generally perceived by surgeons and orthopaedic leaders? METHODS: A cross-sectional qualitative study was conducted in a single health system in an urban setting using semistructured interviews with a purposive sample of orthopaedic surgeons and leaders who would have substantial knowledge of and experience with the organization’s PROM system, which was embedded in the electronic health record and developed for use in clinical care but was not being used. We included surgeons whose practices consisted of at least 90% patients with osteoarthritis, including surgical and nonsurgical management, and thus their patients would be completing PROMs surveys, or surgeons who were leaders in one of the three orthopaedic divisions in the health plan. The senior research manager for orthopaedics identified 14 potential participants meeting these criteria, 11 of whom agreed to study participation. Participants included nine surgeons and two orthopaedic leaders; the majority were men, with a median of 13 years of clinical practice. Study interviews were conducted by an experienced interviewer not known to participants, in private conference rooms in the healthcare setting, and a median (range) of 27 minutes (16 to 40) in length. A content analysis approach was employed for data analysis, with thematic inductive saturation reached in the analysis and attention to trustworthiness and rigor during the analytic process. RESULTS: Interviewees reported that PROM scores are not being used in patient clinical care because of logistical barriers, such as access and display issues and the time required, and perceptual barriers, such as concerns about patient understanding and the validity and reliability of measures. Surgeons preferred talking with patients about the personal outcomes patients had identified as important; most patients preferred to assess progress toward their own goals than PROMs scores for other people. Surgeons also identified changes that could facilitate PROM use and reduce barriers in clinical care, including pushing PROM scores to physicians’ inboxes, developing inserts for physician notes, using easy-to-understand graphical displays, and engaging patients about PROMs earlier in the care process. Participants all agreed that PROMs in aggregate use are valuable for the organization, department, and individual surgeons, but individual patient scores are not. CONCLUSION: Despite the availability of PROMs, there are important barriers to incorporating and using PROMs in clinical care. Providing access to PROM scores without clearly understanding how and why surgeons may consider using or incorporating them into their clinical practice can result in expensive and underused systems that add little value for the clinician, patient, or organization. CLINICAL RELEVANCE: Involving front-line orthopaedic surgeons and leaders in shaping the design and structure of PROM systems is important for use in clinical care, but these interviewees seemed to see aggregate data as more valuable than individual patient scores.

PURPOSE: The purpose of this study was to assess whether primary care practices certified as medical homes differ in having the practice systems required for that designation and in attaining favorable outcomes for their patients with diabetes, and whether those systems are associated with better diabetes outcomes. METHODS: We undertook a cross-sectional observational study, Understanding Infrastructure Transformation Effects on Diabetes (UNITED), of 586 Minnesota adult primary care practices, comparing those that were certified vs uncertified as medical homes in 2017, with analyses supplemented by previously published studies of these practices. We collected survey information about the presence of medical home practice systems for diabetes care and obtained 6 standardized measures of diabetes care collected yearly from all Minnesota practices. RESULTS: Of 416 practices completing questionnaires (71% of all practices, 92% of participating practices), 394 had data on diabetes care measures. Uncertified practices (39%) were more likely than certified practices to be rural, but their patient populations were similar. Certified practices had more medical home practice systems (79.2% vs 74.9%, P =.01) and were more likely to meet a composite measure of optimal diabetes care (46.8% vs 43.2%, P

Objective The spread of evidence-based care is an important challenge in healthcare. We evaluated spread of an evidence-based large-scale multisite collaborative care model for patients with depression and diabetes and/or cardiovascular disease (COMPASS). Methods Primary care patients with depression and comorbid diabetes or cardiovascular disease were recruited. Collaborative care teams used care management tracking systems and systematic case reviews to track and intensify treatment for patients not improving. Targeted outcomes were depression remission and response (assessed with the Patient Health Questionnaire-9) and control of diabetes (assessed by HbA1c) and blood pressure. Patients and clinicians were surveyed about satisfaction with care. Results Eighteen care systems and 172 clinics enrolled 3609 patients across the US. Of those with uncontrolled disease at enrollment, 40% achieved depression remission or response, 23% glucose control and 58% blood pressure control during a mean follow-up of 11 months. There were large variations in outcomes across medical groups. Patients and clinicians were satisfied with COMPASS care. Conclusions COMPASS was successfully spread across diverse care systems and demonstrated improved outcomes for complex patients with previously uncontrolled chronic disease. Future large-scale implementation projects should create robust processes to identify and reduce expected variation in implementation to consistently provide improved care.

Importance The American College of Radiology (ACR) has recognized the importance of minimizing radiation doses used for lung cancer screening (LCS) computed tomography (CT). However, without standard protocols, doses could still be unnecessarily high, reducing screening margin of benefit. Objective To characterize LCS CT radiation doses and identify factors explaining variation. Design, Setting, and Participants We prospectively collected LCS examination dose metrics, from 2016 to 2017, at US institutions in the University of California, San Francisco International Dose Registry. Institution-level factors were collected through baseline survey. Mixed-effects linear and logistic regression models were estimated using forward variable selection. Results are presented as percentage excess dose and odds ratios (ORs) with 95% confidence intervals (CIs). The analysis was conducted between 2018 and 2019. Main Outcomes and Measures Log-transformed measures of (1) mean volume CT dose index (CTDIvol, mGy), reflecting the average radiation dose per slice; (2) mean effective dose (ED, mSv), reflecting the total dose received and estimated future cancer risk; (3) proportion of CT scans using radiation doses above ACR benchmarks (CTDIvol >3 mGy, ED >1 mSv); and (4) proportion of CT scans using radiation doses above 75th percentile of registry doses (CTDIvol >2.7 mGy, ED >1.4 mSv). Results Data were collected for 12 529 patients undergoing LCS CT scans performed at 72 institutions. Overall, 7232 participants (58%) were men, and the median age was 65 years (interquartile range [IQR], 60-70). Of 72 institutions, 15 (21%) had median CTDIvol and 47 (65%) had median ED above ACR guidelines. Institutions allowing any radiologists to establish protocols had 44% higher mean CTDIvol (mean dose difference [MDD], 44%; 95% CI, 19%-69%) and 27% higher mean ED (MDD, 27%; 95% CI, 5%-50%) vs those limiting who established protocols. Institutions allowing any radiologist to establish protocols had higher odds of examinations exceeding ACR CTDIvol guidelines (OR, 12.0; 95% CI, 2.0-71.4), and 75th percentile of registry CTDIvol (OR, 19.0; 95% CI, 1.9-186.7) or ED (OR, 8.5; 95% CI, 1.7-42.9). Having lead radiologists establish protocols resulted in lower odds of doses exceeding ACR ED guidelines (OR, 0.01; 95% CI, 0.001-0.1). Employing external vs internal medical physicists was associated with increased odds of exceeding ACR CTDIvol guidelines (OR, 6.1; 95% CI, 1.8-20.8). Having medical physicists establish protocols was associated with decreased odds of exceeding 75th percentile of registry CTDIvol (OR, 0.09; 95% CI, 0.01-0.59). Institutions reporting protocol updates as needed had 27% higher mean CTDIvol (MDD, 27%; 95% CI, 8%-45%). Conclusions and Relevance Facilities varied in LCS CT radiation dose distributions. Institutions limiting protocol creation to lead radiologists and having internal medical physicists had lower doses.

OBJECTIVE The effective redesign of primary care delivery systems to improve diabetes care requires an understanding of which particular components of delivery consistently lead to better clinical outcomes. We identified associations between common systems of care management (SysCMs) and the frequency of meeting standardized performance targets for Optimal Diabetes Care (NQF#0729) in primary care practices. RESEARCH DESIGN AND METHODS A validated survey of 585 eligible family or general internal medicine practices seeing ≥30 adult patients with diabetes in or near Minnesota during 2017 evaluated the presence of 62 SysCMs. From 419 (72%) practices completing the survey, NQF#0729 was determined in 396 (95%) from electronic health records, including 215,842 patients with type 1 or type 2 diabetes. RESULTS Three SysCMs were associated with higher rates of meeting performance targets across all practices: 1) a systematic process for shared decision making with patients (P = 0.001), 2) checklists of tests or interventions needed for prevention or monitoring of diabetes (P = 0.002), and 3) physician reminders of guideline-based age-appropriate risk assessments due at the patient visit (P = 0.002). When all three were in place, an additional 10.8% of the population achieved recommended performance measures. In subgroup analysis, 15 additional SysCMs were associated with better care in particular types of practices. CONCLUSIONS Diabetes care outcomes are better in primary care settings that use a patient-centered approach to systematically engage patients in decision making, remind physicians of age-appropriate risk assessments, and provide checklists for recommended diabetes interventions. Practice size and location are important considerations when redesigning delivery systems to improve performance.

To describe primary care clinicians' self-reported satisfaction, burnout and barriers for treating complex patients.We conducted a survey of 1554 primary care clinicians in 172 primary care clinics in 18 health care systems across 8 states prior to the implementation of a collaborative model of care for patients with depression and diabetes and/or cardiovascular disease.Of the clinicians who responded to the survey (n=709; 46%), we found that a substantial minority (31%) were experiencing burnout that was associated with lower career satisfaction (P.0001) and lower satisfaction with resources to treat complex patients (P.0001). Less than 50% of clinicians rated their ability to treat complex patients as very good to excellent with 21% rating their ability as fair to poor. The majority of clinicians (72%) thought that a collaborative model of care would be very helpful for treating complex patients.Burnout remains a problem for primary care clinicians and is associated with low job satisfaction and low satisfaction with resources to treat complex patients. A collaborative care model for patients with mental and physical health problems may provide the resources needed to improve the quality of care for these patients.

Depression is pervasive and costly, and the majority of depression is treated in primary care. The objective of this study was to identify patient characteristics predictive of poor depression outcomes in primary care clinics.This observational study followed 792 patients receiving usual care for depression in 83 clinics across Minnesota for at least six months between 2008 and 2010. The primary outcome was an ordinal outcome of remission or response without remission ("response") six months after the start of treatment. The outcome was assessed via telephone administration of the Patient Health Questionnaire-9. Associations of patient characteristics with the primary outcome were assessed by using ordinal logistic regression.The majority of patients were female, Caucasian, and employed, and most had some college education and good, very good, or excellent self-rated health. At baseline, 32% had mild depression, 40% moderate depression, 20% moderately severe depression, and 8% severe depression. One-third of patients had psychotherapy or psychiatric care in addition to antidepressant medications. At six months, only 47% of patients obtained depression remission or response. Patients were significantly less likely to experience remission or response if they rated their health as poor or fair or if they were unemployed and were more likely to achieve remission or response if they were younger or had mild depression.Patients with poor or fair health or who were unemployed were less likely to respond to usual depression care and may be good candidates for limited, but potentially more effective, intensive treatment resources for depression.

Background Research connecting patient-centered medical homes (PCMHs) with improved quality and reduced utilization is inconsistent, possibly because individual domains of change, and the stage of change, are not incorporated in the research design. The objective of this study was to examine the association between stage and domain of change and patterns of health care utilization. Methods This was a cross-sectional observational study that including 87 Minnesota clinics certified as medical homes. Patients included those receiving management for diabetes or cardiovascular disease with insurance coverage by payers participating in the study. PCMH transformation stage was defined by practice systems in place, with measurements summarized in 5 domains. Health care utilization was measured by total utilization, frequency of outpatient visits and prescriptions, and occurrence of inpatient and emergency department visits. Results PCMH transformation was associated with few changes in utilization, but there were important differences by the underlying domains of change. We demonstrate meaningful differences in the impact of PCMH transformation by diagnosis cohort and comorbidity status of the patient. Conclusions Because the association of health care utilization with PCMH transformation varied by transformation domain and patient diagnosis, practice leaders need to be supported by research incorporating detailed measures of PCMH transformation.

Background Uncontrolled hypertension is the largest single contributor to all-cause and cardiovascular mortality in the U.S. population. Nurse- and pharmacist-led team-based care and telehealth care interventions have been shown to result in large and lasting improvements in blood pressure (BP); however, it is unclear how successfully these can be implemented at scale in real-world settings. It is also uncertain how telehealth interventions impact patient experience compared to traditional clinic-based care. Aims/objectives To compare the effects of two evidence-based blood pressure care strategies in the primary care setting: (1) best-practice clinic-based care and (2) telehealth care with home BP telemonitoring and management by a clinical pharmacist. To evaluate implementation using mixed-methods supported by the RE-AIM framework and Consolidated Framework for Implementation Research. Methods The design is a cluster-randomized comparative effectiveness pragmatic trial in 21 primary care clinics (9 clinic-based care, 12 telehealth care). Adult patients (age 18–85) with hypertension are enrolled via automated electronic health record (EHR) tools during primary care encounters if BP is elevated to ≥150/95 mmHg at two consecutive visits. The primary outcome is change in systolic BP over 12 months as extracted from the EHR. Secondary outcomes are change in key patient-reported outcomes over 6 months as measured by surveys. Qualitative data are collected at various time points to investigate implementation barriers and help explain intervention effects. Conclusion This pragmatic trial aims to inform health systems about the benefits, strengths, and limitations of implementing home BP telemonitoring with pharmacist management for uncontrolled hypertension in real-world primary care settings.

Introduction There are few proven strategies to reduce the frequency of potentially preventable hospitalizations and Emergency Department (ED) visits. To facilitate strategy development, we documented these events among complex patients and the factors that contribute to them in a large care-improvement initiative. Methods Observational study with retrospective audits and selective interviews by the patients' care managers among 12 diverse medical groups in California, Minnesota, Pennsylvania, and Washington that participated in an initiative to implement collaborative care for patients with both depression and either uncontrolled diabetes, uncontrolled hypertension, or both. We reviewed information about 373 adult patients with the required conditions who belonged to these medical groups and had experienced 389 hospitalizations or ED visits during the 12-month study period from March 30, 2014, through March 29, 2015. The main outcome measures were potentially preventable hospitalizations or ED visit events. Results Of the studied events, 28% were considered to be potentially preventable (39% of ED visits and 14% of hospitalizations) and 4.6% of patients had 40% of events. Only type of insurance coverage; patient lack of resources, caretakers, or understanding of care; and inability to access clinic care were more frequent in those with potentially preventable events. Neither disease control nor ambulatory care-sensitive conditions were associated with potentially preventable events. Conclusion Among these complex patients, patient characteristics, disease control, and the presence of ambulatory care-sensitive conditions were not associated with likelihood of ED visits or hospital admissions, including those considered to be potentially preventable. The current focus on using ambulatory care-sensitive conditions as a proxy for potentially preventable events needs further evaluation.

Purpose: To test the association between repeated clinical smoking cessation support and long-term cessation. Design: Retrospective, observational cohort study using structured and free-text data from electronic health records. Setting: Six diverse health systems in the United States. Participants: Patients aged ≥18 years who were smokers in 2007 and had ≥1 primary care visit in each of the following 4 years (N = 33 691). Measures: Primary exposure was a composite categorical variable (comprised of documentation of smoking cessation medication, counseling, or referral) classifying the proportions of visits for which patients received any cessation assistance (Analysis: Mixed effects logistic regression analysis adjusted for age, sex, race, and comorbidities, with robust standard error estimation to account for within site correlation. Results: Overall, 20% of the cohort achieved LTQ status. Patients with ≥75% of visits with any assistance had almost 3 times the odds of achieving LTQ status compared to those with Conclusions: These findings provide support for the importance of repeated assistance at primary care visits to increase long-term smoking cessation.

BACKGROUND: Burnout among primary care physicians, advanced practice clinicians (nurse practitioners and physician assistants [APCs]), and staff is common and associated with negative consequences for patient care, but the association of burnout with characteristics of primary care practices is unknown. OBJECTIVE: To examine the association between physician-, APC- and staff-reported burnout and specific structural, organizational, and contextual characteristics of smaller primary care practices. DESIGN: Cross-sectional analysis of survey data collected from 9/22/2015–6/19/2017. SETTING: Sample of smaller primary care practices in the USA participating in a national initiative focused on improving the delivery of cardiovascular preventive services. PARTICIPANTS: 10,284 physicians, APCs and staff from 1380 primary care practices. MAIN MEASURE: Burnout was assessed with a validated single-item measure. KEY RESULTS: Burnout was reported by 20.4% of respondents overall. In a multivariable analysis, burnout was slightly more common among physicians and APCs (physician vs. non-clinical staff, adjusted odds ratio [aOR] = 1.26; 95% confidence interval [CI], 1.05–1.49, APC vs. non-clinical staff, aOR = 1.34, 95% CI, 1.10–1.62). Other multivariable correlates of burnout included non-solo practice (2–5 physician/APCs vs. solo practice, aOR = 1.71; 95% CI, 1.35–2.16), health system affiliation (vs. physician/APC-owned practice, aOR = 1.42; 95%CI, 1.16–1.73), and Federally Qualified Health Center status (vs. physician/APC-owned practice, aOR = 1.36; 95%CI, 1.03–1.78). Neither the proportion of patients on Medicare or Medicaid, nor practice-level patient volume (patient visits per physician/APC per day) were significantly associated with burnout. In analyses stratified by professional category, practice size was not associated with burnout for APCs, and participation in an accountable care organization was associated with burnout for clinical and non-clinical staff. CONCLUSIONS: Burnout is prevalent among physicians, APCs, and staff in smaller primary care practices. Members of solo practices less commonly report burnout, while members of health system-owned practices and Federally Qualified Health Centers more commonly report burnout, suggesting that practice level autonomy may be a critical determinant of burnout. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-018-4679-0) contains supplementary material, which is available to authorized users.

Scale-up and spread of evidence-based practices is one of the most important challenges facing health care. We tested whether a statewide initiative, Depression Improvement Across Minnesota-Offering a New Direction (DIAMOND), to implement the collaborative care model for depression in 75 primary care clinics resulted in patient outcome improvements corresponding to those reported in randomized controlled trials.Health plans provided a new monthly payment to participating clinics after a 6-month intensive training program with ongoing data submission, networking, and consultation. Implementation was staggered, with 5 sequences of 10 to 40 clinics every 6 months. Payers provided weekly contact information for members from participating clinics who were filling antidepressant prescriptions, and we conducted baseline and 6-month surveys of 1,578 patients about their care and outcomes.There were 466 patients in DIAMOND clinics who received usual care before implementation (UCB), 559 who received usual care in DIAMOND clinics after implementation (UCA), 245 who received DIAMOND care after implementation (DCA), and 308 who received usual care in comparison clinics (UC). Patients who received DIAMOND care after implementation reported more collaborative care depression services than the 3 comparison groups (10.9 vs 6.4-6.7, on a scale of 0 of 14, where higher numbers indicate more services; P.001) and more satisfaction with their care (4.0 vs 3.4 on a scale 1 to 5, in which higher scores indicate higher satisfaction; P ≤.001). Depression remission rates, however, were not significantly different among the 4 groups (36.4% DCA vs 35.8% UCB, 35.0% UCA, 33.9% UC; P = .94).Despite the incentive of a supporting payment change and intensive training and support for clinics volunteering to participate, no difference in depression outcomes was documented. Specific unmeasured actions present in trials but not present in these clinics may be critical for successful outcome improvement.

Suicide is a public health concern, but little is known about the patterns of health care visits made before a suicide attempt, and whether those patterns differ by race/ethnicity.To examine racial/ethnic variation in the types of health care visits made before a suicide attempt, when those visits occur, and whether mental health or substance use diagnoses were documented.Retrospective, longitudinal study, 2009-2011.22,387 individuals who attempted suicide and were enrolled in the health plan across 10 health systems in the Mental Health Research Network.Cumulative percentage of different types of health care visits made in the 52 weeks before a suicide attempt, by self-reported racial/ethnicity and diagnosis. Data were from the Virtual Data Warehouse at each site.Over 38% of the individuals made any health care visit within the week before their suicide attempt and ∼95% within the preceding year; these percentages varied across racial/ethnic groups (P0.001). White individuals had the highest percentage of visits (41%) within 1 week of suicide attempt. Asian Americans were the least likely to make visits within 52 weeks. Hawaiian/Pacific Islanders had proportionally the most inpatient and emergency visits before an attempt, but were least likely to have a recorded mental health or substance use diagnosis. Overall, visits were most common in primary care and outpatient general medical settings.This study provides temporal evidence of racial/ethnic differences in health care visits made before suicide attempt. Health care systems can use this information to help focus the design and implementation of their suicide prevention initiatives.

Evidence is evolving about the impact of patient-centered medical homes (PCMHs) on important outcomes in primary care. Minnesota has developed its own PCMH certification process, envisioned as an all-payer initiative with an emphasis on patient-centeredness, which may add unique experiences and outcomes to the national discussion.We aimed to identify the facilitators and barriers encountered by nine diverse primary care practices selected from the first 80 to achieve PCMH certification in Minnesota.This was a qualitative analysis of semi-structured, in-person interviews.Thirty-one administrative and clinical leaders, including clinic managers, physician champions, medical directors, nursing supervisors, and care coordinators participated in the study.Six factors emerged as most important to the efforts to become PMCHs: leadership support, organizational culture, finances, quality improvement (QI) experience, information technology (IT) resources, and patient involvement. Facilitators included committed leadership at local and higher levels, prior experience and ongoing support for QI initiatives, and adequate financial and IT resources. Reimbursement was a significant barrier due to perceived inadequacy and inconsistent participation by health plans. The unsuitability of electronic medical records (EMRs) to PCMH documentation requirements likewise presented ongoing challenges. Many interviewees described patient input as helpful to their clinics' PCMH-related changes and were enthusiastic about their "patient partners." The majority of interviewees felt that becoming a PCMH was right for patients and was personally worthwhile, even while acknowledging the tremendous effort involved and voicing skepticism about reimbursement over the short term.The experience of participants in Minnesota's state-wide initiative to legislate PCMH transformation provides a broad view of facilitators and barriers. Unique facilitators included a requirement for patient involvement, which pushed practices to create patient-centered innovations, and new reimbursement models based on quality indicators for a population. Among barriers were the costs to practices and patients, and EMRs that failed to accommodate PCMH requirements.

Shared decision making (SDM) is an important component of patient-centered care, but there is little information about its use in the primary care of depression, so we sought to study its frequency in usual care as reported by patients.Telephone interview of 1168 depressed patients taking antidepressants in 88 Minnesota primary care clinics who were identified from pharmacy claims data soon after a prescription for an antidepressant. We measured depression severity with the 9-item Patient Health Questionnaire and used a composite measure of SDM that reflected patient involvement in treatment decisions.These patients reported an average score for SDM of 50.7 (standard deviation, 32.8) on a scale of 0 to 100, where higher scores equate with greater SDM. In univariate analyses, the largest differences among scores were for age (scores of 58, 53, 45, and 33 for those aged 18-34, 35-49, 50-64, and64 years, respectively; P.0001); duration of treatment (a score of 56.6 on treatment6 weeks vs 45.5 if longer; P.001); and other treatments in the past 6 months (60.5 if yes vs. 46.0 if no; P = .001). SDM was not associated with any clinic characteristics, but it was correlated with patient-reported quality of care (r = 0.48; P.001). Multivariate analyses confirmed some of these findings while showing a more complex set of relationships.Older patients with depression and those who have been in treatment longer report much less SDM in their care. Improving SDM, especially for these groups, may be an important target for improving patient experience and perceived quality.

Using clinical trials, researchers have demonstrated effective methods for treating depression in primary care, but improvements based on these trials are not being implemented. This might be because these improvements require more systematic organizational changes than can be made by individual physicians. We interviewed 82 physicians and administrative leaders of 41 medical groups to learn what is preventing those organizational changes. The identified barriers to improving care included external contextual problems (reimbursement, scarce resources, and access to/communication with specialty mental health), individual attitudes (physician and patient resistance), and internal care process barriers (organizational and condition complexity, difficulty standardizing and measuring care). Although many of these barriers are challenging, we can overcome them by setting clear priorities for change and allocating adequate resources. We must improve primary care of depression if we are to reduce its enormous adverse social and economic impacts.

PURPOSE The Patient Protection and Affordable Care Act’s provisions for first-dollar coverage of evidence-based preventive services have reduced an important barrier to receipt of preventive care. Safety-net providers, however, still serve a substantial uninsured population, and clinician and patient time remain limited in all primary care settings. As a consequence, decision makers continue to set priorities to help focus their efforts. This report updates estimates of relative health impact and cost-effectiveness for evidence-based preventive services. METHODS We assessed the potential impact of 28 evidence-based clinical preventive services in terms of their cost-effectiveness and clinically preventable burden, as measured by quality-adjusted life years (QALYs) saved. Each service received 1 to 5 points on each of the 2 measures—cost-effectiveness and clinically preventable burden—for a total score ranging from 2 to 10. New microsimulation models were used to provide updated estimates of 12 of these services. Priorities for improving delivery rates were established by comparing the ranking with what is known of current delivery rates nationally. RESULTS The 3 highest-ranking services, each with a total score of 10, are immunizing children, counseling to prevent tobacco initiation among youth, and tobacco-use screening and brief intervention to encourage cessation among adults. Greatest population health improvement could be obtained from increasing utilization of clinical preventive services that address tobacco use, obesity-related behaviors, and alcohol misuse, as well as colorectal cancer screening and influenza vaccinations. CONCLUSIONS This study identifies high-priority preventive services and should help decision makers select which services to emphasize in quality-improvement initiatives.

Recent interest in the concept of the “medical home” arises from the hypothesis that this care delivery model will revive primary care practices and help the health care system achieve the “triple aim” of higher quality clinical care, affordability, and improved patient experience (Rittenhouse and Shortell 2009). While there is reasonable empiric evidence related to concepts included in the patient-centered medical home (PCMH), evidence is lacking as to whether medical homes will produce the expected results. Moreover, the definition of PCMH is still controversial. The National Committee on Quality Assurance (NCQA) has a program for evaluating the capacity of a primary care practice to function as a PCMH, the Physician Practice Connections—Patient-Centered Medical Home (PPC-PCMH) (Road to Recognition: Your Guide to the NCQA Medical Home 2009). This program assesses the degree to which a medical practice has adopted processes that are consistent with the PCMH principles defined by the four primary care specialty groups in 2007 (Joint Principles of the Patient-Centered Medical Home 2007). Previously we studied the association between scores on the PPC-RS (a research survey based on the 2006 NCQA PPC program, and addressing much of the content of the PP-CPCMH program) and three measures of quality in a set of 21 clinics that are recognized as Level III NCQA Medical Homes using the PPC-PCMH 2008 (Solberg et al. 2011). Using standard statistical analysis, we found no association between PPC-RS scores and clinic quality performance after controlling for other factors like patient demographics. However, the small sample size may have limited our ability to detect associations. To address this sample size limitation, and to further explore possible connections between “medical home-ness”, patient characteristics, and quality outcomes, we now report an exploratory study using a set-theoretical analytic method, fuzzy set qualitative comparative analysis (fs/QCA). fs/QCA is an accepted analytic method in the social sciences, but it has seen only limited use in health services and organizational research (Ragin 1987, 1999, 2008; Dy et al. 2005; Britt 2006; Britt and Evans 2007; Fiss 2007; Shanahan et al. 2008; Schensul et al. 2010). There are several reasons why fs/QCA may reveal relationships between clinic characteristics and quality scores that were not evident in the prior analysis. fs/QCA is designed for small-N qualitative case studies. Also, fs/QCA identifies “necessary but not sufficient,” or “sufficient but not necessary,” set relationships, not just “necessary and sufficient” correlations. Finally, fs/QCA is well suited for exploring complex causality, such as when more than one combination of conditions is associated with the same outcome (equifinality). Health services research often involves studying complex social phenomena and interventions using small-N, qualitative data sets—conditions that are challenging for conventional statistical analysis and for which fs/QCA was specifically designed. The purpose of this study is to use fs/QCA to evaluate the connection between medical home system capabilities and quality outcomes.

PURPOSE Depression is associated with lowered work functioning, including absences, impaired productivity, and decreased job retention. Few studies have examined depression symptoms across a continuum of severity in relationship to the magnitude of work impairment in a large and heterogeneous patient population, however. We assessed the relationship between depression symptom severity and productivity loss among patients initiating treatment for depression. METHODS Data were obtained from patients participating in the DIAMOND (Depression Improvement Across Minnesota: Offering a New Direction) initiative, a statewide quality improvement collaborative to provide enhanced depression care. Patients newly started on antidepressants were surveyed with the Patient Health Questionnaire 9-item screen (PHQ-9), a measure of depression symptom severity; the Work Productivity and Activity Impairment (WPAI) questionnaire, a measure of loss in productivity; and items on health status and demographics. RESULTS We analyzed data from the 771 patients who reported being currently employed. General linear models adjusting for demographics and health status showed a significant linear, monotonic relationship between depression symptom severity and productivity loss: with every 1-point increase in PHQ-9 score, patients experienced an additional mean productivity loss of 1.65% (P

Multilevel, multivariate models examined the relationship between Primary Care Medical Home (PCMH) practice systems as measured by the Physician Practice Connections®-Readiness Survey™ (PPC®-RS™) and costs (total, outpatient, and inpatient) using 2008 patient data from 21 primary care clinics. Overall, PPC-RS scores were associated with insignificant changes in total (-$75/person, 1.1%) outpatient (-$67/person, 1.2%), and inpatient ($68/person, 0.5%) costs. However, improved PPC-RS scores were associated with significant decreases in total ($2378, 4.4%) and outpatient ($1282/person, 3.5%) costs among patients with 11 or more prescriptions suggesting higher functioning PCMHs may lead to reduced costs among the most complex and costly patients.

We tested the association between medical home characteristics and measures of technical quality and patient experience of care in the 21 clinics of a large medical group that had all achieved level III recognition from the National Committee for Quality Assurance. There was substantial variation among them in both scores on the recognition instrument and in clinic performance measures. However, the few statistically significant associations that were identified disappeared when correction for multiple analyses was applied. We conclude that among primary care clinics recognized as high-level medical homes, the instrument used to assess medical home characteristics cannot differentiate their quality.

PURPOSE Many clinical preventive care services are recommended for adolescents. Little is known about whether most adolescents have a sufficient number of preventive care services visits over time to receive those services. We wanted to measure how frequently adolescents who are insured either through private insurance or government programs have preventive vs nonpreventive care visits. METHODS We conducted a retrospective descriptive analysis based on claims data from a large health plan in Minnesota with about 700,000 members. All study patients were aged 11 to 18 years between January 1, 1998, and December 31, 2007. Our outcome measure was rates of preventive and nonpreventive care visits. RESULTS One-third of adolescents with 4 or more years of continuous enrollment had no preventive care visits from age 13 through 17 years, and another 40% had only a single such visit. Nonpreventive care visits were more frequent in all age-groups, averaging about 1 per year at age 11 years, climbing to about 1.5 per year at age 17 years. Differences in rates between government insurance and commercial insurance were small. In older adolescence, girls had more preventive care visits and more nonpreventive care visits than did boys. CONCLUSIONS Most adolescents come in infrequently for preventive care visits but more often for nonpreventive care visits. We recommend using the same approach in adolescence for preventive care that is being used in adults: the no-missed-opportunities paradigm. All visits by adolescents should be viewed as an opportunity to provide preventive care services, and systems should be set up to make that possible, even in busy practices with short encounters with a clinician.

INTRODUCTION: Tobacco use disproportionately affects some ethnic minority populations. Important gains in understanding the relationship between acculturation and tobacco use have been hindered by the lack of available data, large samples of specific immigrant groups. This study is among the first to use electronic medical record (EMR) data to examine differences in tobacco use associated with acculturation among various population groups. METHODS: Relevant variables for all medical group patients aged 18 years and older with clinician visits were extracted from the EMR of one large medical group from March 2006 to February 2007. Preferred language and country of origin data from the EMR were used to create distinct cultural groupings. Adjusted prevalences were computed. RESULTS: One hundred thousand [corrected] three hundred [corrected] twenty nine patients reported [corrected] languages as English, Hmong, Vietnamese, Oromo, Amharic, Somali, and Spanish and were categorized as U.S. born or non-U.S. born. After adjusting for age, utilization, and insurance status, more acculturated Mexican and Hmong women were more likely to be tobacco users compared with less acculturated women. Among non-English speaking, current tobacco use was more prevalent among men compared with women. DISCUSSION: Interpreted language and country of origin data collected in a clinical setting were useful for describing tobacco use differences between and within cultural groups. Using preferred language and country of origin as a proxy for acculturation status may help understand some of the within and between cultural differences in tobacco use. These novel data sources have potential usefulness for tobacco surveillance of relatively small cultural groups.

Most of the many clinical preventive services (CPS) recommended for adolescents by various national organizations lack good evidence of effectiveness. Improving adolescent preventive care will require focusing on those CPS for which there is such evidence and on developing better delivery strategies. The objective of the current study was to identify those CPS for adolescents that do have a strong evidence base, to update the literature review and summarize evidence gaps where research is needed, and to summarize current delivery prevalence and opportunities.A summary was conducted of the recommendations for adolescents of the U.S. Preventive Services Task Force (USPSTF) and the CDC's Advisory Committee on Immunization Practices (ACIP). An update is provided of the literature review for services with an inadequate evidence base to support a recommendation. A summary was prepared of the types of evidence still needed. A literature search was also conducted for current delivery prevalence of recommended services for those aged 11-17 years, and common gaps in the evidence were identified.Although 24 CPS for adolescents have been reviewed by the USPSTF, only ten received definite recommendations and only seven of these favored delivery of the service. In addition, the ACIP recommends four immunizations for all adolescents, and two additional ones for those at high risk. There are many gaps in the evidence supporting most of the other services as well as in the information about current delivery prevalence.There are too many CPS recommended for adolescents with insufficient evidence of effectiveness, and there is low delivery prevalence for the few services with good evidence of effectiveness. Both more research and more attention to the practice changes that might improve delivery prevalence are needed.

Although a considerable body of evidence supports telephone quit lines for smoking cessation, much less is known about the effectiveness of proactive Telephone Counseling with smokeless tobacco (ST) users. We conducted a randomized controlled trial comparing Telephone Counseling with the distribution of a self-help manual for ST cessation. We recruited 406 adult ST users throughout the state of Minnesota and randomized them to receive either: (a) a self-help manual (Manual only) or (b) a self-help manual plus proactive telephone-based cessation counseling (Telephone Counseling). The telephone-based treatment included up to four calls in support of quitting, and personalized various cognitive and behavioral strategies that are generally considered effective in tobacco cessation (such as setting a quit date, examining patterns of use, developing stress reduction skills, avoiding known triggers to use). Participants were surveyed by phone at 3 and 6 months to assess both point prevalence and continued abstinence. Prolonged abstinence from all tobacco was 6.8% and 30.9% (p < .001) at 3 months and 9.8% and 30.9% (p < .001) at 6 months in Manual only and Telephone Counseling, respectively. We found older age, lower dependency, and increased readiness predicted quitting success. Proactive telephone-based counseling is an effective strategy for improving cessation rates among ST users. Future research should determine the components contributing to the intervention success.

Article-at-a-Glance Background A study was conducted to test whether patient reports of medical errors via surveys could produce sufficiently accurate information to be used as a measure of patient safety. Methods A survey mailed regularly by a large multispecialty medical group to recent patients to assess their satisfaction and error experiences was expanded to collect more details about the patient-perceived errors. Following an initial mailing to 3,109 patients and parents of child patients soon after they had office visits in June 2005, usable mailed or phone follow-up responses were obtained from 1,998 respondents (65.1% adjusted). Responses were reviewed through a two-stage process that included chart audits and implicit physician reviewer judgments. The analysis categorized the review results and compared patient-reported errors with satisfaction. Results Of the 1,998 respondents, 219 (11.0%) reported 247 separate incidents, for a rate of 12.4 errors per 100 patients. After complete review, only 5 (2.0%) of these incidents were judged to be real clinician errors. Most appeared to represent misunderstandings or behavior/communication problems, but 15.4% lacked sufficient information to categorize. Women, Hispanics, and those aged 41–60 years were most likely to report errors. Those respondents making error reports were much more likely to report visit dissatisfaction than those not reporting them (odds ratio [OR] = 13.8, p Discussion Although patient reports of perceived errors might be useful to improve the patient experience of care, they cannot be used to measure technical medical errors and patient safety reliably without added evaluation. This study's findings need to be replicated elsewhere before generalizing from one metropolitan region and a patient population that is about two-thirds members of one health plan.

Objective: To determine how frequently patients with advanced imaging for back or abdominal pain achieve outcomes that are identified by patients as important and whether those achieving those outcomes are more satisfied. Methods: Cross-sectional analysis of survey responses from patients of an 800-physician multi-specialty group in Minnesota in 2013. A total of 201 patients with abdominal pain and 167 patients with back pain 1 year earlier that was serious enough for a computed tomography or magnetic resonance imaging scan (67% of those contacted). The main outcomes were the frequency of occurrence of 19 outcomes previously identified by patients as important, plus satisfaction with the results of care. Results: The majority of patients surveyed had achieved most of the desired outcomes. For abdominal pain, 17 of 19 of the desired outcomes were achieved by >50% of patients, while 11 of 19 desired outcomes were achieved by >50% of patients with back pain. Seven of the desired outcomes were significantly associated with satisfaction. Conclusion: Achieving outcomes important to patients is associated with greater patient satisfaction. Such measures are potentially valuable measures of quality.

INTRODUCTION This study examined change in tobacco use over 4 years among the general population of patients in six diverse health care organizations using electronic medical record data. METHODS The study cohort (N = 34 393) included all patients age 18 years or older who were identified as smokers in 2007, and who then had at least one primary care visit in each of the following 4 years. RESULTS In the 4 years following 2007, this patient cohort had a median of 13 primary care visits, and 38.6% of the patients quit smoking at least once. At the end of the fourth follow-up year, 15.4% had stopped smoking for 1 year or more. Smokers were more likely to become long-term quitters if they were 65 or older (OR = 1.32, 95% CI = [1.16, 1.49]), or had a diagnoses of cancer (1.26 [1.12, 1.41]), cardiovascular disease (1.22 [1.09, 1.37]), asthma (1.15 [1.06, 1.25]), or diabetes (1.17 [1.09, 1.27]). Characteristics associated with lower likelihood of becoming a long-term quitter were female gender (0.90 [0.84, 0.95]), black race (0.84 [0.75, 0.94]) and those identified as non-Hispanic (0.50 [0.43, 0.59]). CONCLUSIONS Among smokers who regularly used these care systems, one in seven had achieved long-term cessation after 4 years. This study shows the practicality of using electronic medical records for monitoring patient smoking status over time. Similar methods could be used to assess tobacco use in any health care organization to evaluate the impact of environmental and organizational programs.

Background The U.S. Public Health Service clinical practice guideline calls for clinicians and healthcare organizations to identify and treat every tobacco user seen in a healthcare setting. There is little information on the extent of compliance with the guideline's treatment model described by the "5A's" (Ask, Advise, Assess, Assist, Arrange). Methods In 1999–2000 a survey was mailed to 64,764 members aged 25 to 75 years, of nine nonprofit HMOs participating in the National Cancer Institute-funded Cancer Research Network. These plans provide medical care to more than 8 million Americans including a minority enrollment of 30%. Smokers were asked about tobacco-cessation treatments received during primary care visits in the past year. Results A 70% response rate identified a smoking prevalence of 10% ( n =4207). Results indicated that 90% of smokers were asked about smoking, 71% were advised to quit, 56% were assessed for their willingness to quit, 49% received assistance interventions, and 9% had follow-up arranged. Treatment was provided more often to smokers who asked for help and/or intended to quit. Few and only modest associations were found between other patient characteristics and receipt of 5A's cessation services. In contrast to widely reported concerns about smokers' resistance to tobacco interventions, smokers who received treatment were more satisfied with health plan services. Conclusions Results demonstrate substantial clinician compliance with the first two steps—Ask and Advise. Greater efforts are needed in providing the more effective tobacco treatments—Assist and Arrange. Compliance with the guideline is associated with greater patient satisfaction.

OBJECTIVE—To assess the impact of a quality improvement (QI) intervention on the quality of diabetes care at primary care clinics. RESEARCH DESIGN AND METHODS—Twelve primary care medical practices were matched by size and location and randomized to intervention or control conditions. Intervention clinic staff were trained in a seven-step QI change process to improve diabetes care. Surveys and medical record reviews of 754 patients, surveys of 329 clinic staff, interviews with clinic leaders, and analysis of training session videotapes evaluated compliance with and impact of the intervention. Mixed-model nested analyses compared differences in the quality of diabetes care before and after intervention. RESULTS—All intervention clinics completed at least six steps of the seven-step QI change process in an 18-month period and, compared with control clinics, had broader staff participation in QI activities (P = 0.04), used patient registries more often (P = 0.03), and had better test rates for HbA1c (A1C), LDL, and blood pressure (P = 0.02). Other processes of diabetes care were unchanged. The intervention did not improve A1C (P = 0.54), LDL (P = 0.46), or blood pressure (P = 0.69) levels or a composite of these outcomes (P = 0.35). CONCLUSIONS—This QI change process was successfully implemented but failed to improve A1C, LDL, or blood pressure levels. Data suggest that to be successful, such a QI change process should direct more attention to specific clinical actions, such as drug intensification and patient activation.

OBJECTIVE—The purpose of this study was to assess the impact of baseline A1c, cardiovascular disease, and depression on subsequent health care costs among adults with diabetes. RESEARCH DESIGN AND METHODS—A prospective analysis was performed of data from a patient survey and medical record review merged with 3 years of medical claims. Costs were estimated using detailed data on resource use and Medicare payment methodologies. Generalized linear models were used to analyze costs related to clinical predictors after adjusting for demographic and socioeconomic factors. RESULTS—In multivariate analysis of 1,694 adults with diabetes, 3-year costs in those with coronary heart disease (CHD) and hypertension were over 300% of those with diabetes only ($46,879 vs. $14,233; P < 0.05). Depression was associated with a 50% increase in costs ($31,967 vs. $21,609; P < 0.05). Relative to those with a baseline A1c of 6%, those with an A1c of 10% had 3-year costs that were 11% higher ($26,408 vs. $23,873; P < 0.05). Higher A1c predicted higher costs only for those with baseline A1c >7.5% (P = 0.015). CONCLUSIONS—In adults with diabetes, CHD, hypertension, and depression spectrum disorders more strongly predicted future costs than the A1c level. Concurrent with aggressive efforts to control glucose, greater efforts to prevent or control CHD, hypertension, and depression are necessary to control health care costs in adults with diabetes.

Background. Previous studies of nonresponders have not assessed the effects of nonresponse on the accuracy of clinician behavior measurements. Knowledge of these effects is critical to both research and quality improvement. Objective. To evaluate the hypothesis that nonresponders to a survey would not adversely affect the ability to measure rates of preventive services. Research Design. Four primary-care medical practices participating in a randomized clinical trial provided an unusual opportunity to compare the medical record-documented care of both responders and nonresponders to a survey of their patients. Subjects. Three hundred forty-five nonresponders and 321 responders to a questionnaire requesting participation in the study. Measures. Differences in patient characteristics and diseases and documentation of screening and management of tobacco use, hypertension, and hypercholesterolemia. Results. Although the survey process resulted in a response rate of only 52.5% and some statistically significant differences in responder and nonresponder characteristics, there were no differences in management behavior regarding cardiovascular risk factors. Responders were more likely to have adjusted documentation of tobacco use (OR = 1.4), blood pressure measurement (OR = 9.8), and cholesterol testing (OR = 2.0), but not family history of cardiovascular disease. The most striking difference in subject characteristics was that 22.0% of nonresponders and only 12.1% of responders were tobacco users (P = 0.002). Conclusions. This study confirms that survey nonresponders may have some different characteristics and risk factor screening rates than responders. However, if confirmed by others, nonresponders who have risk factors identified may not be managed differently than responders.

Depression is associated with lowered work functioning, including absence, productivity impairment at work, and decreased job retention. Although high-quality depression treatment provided in clinical trials has been found to reduce symptoms and improve work function, the effectiveness of routine treatment for depression in primary care has received less attention.This prospective cohort study investigated the relationship between improvements in both depression symptoms and productivity in outpatients from 77 clinics in Minnesota following routine depression treatment.Data were obtained from patients receiving usual care for depression prior to initiation of a statewide quality improvement collaborative called DIAMOND (Depression Improvement Across Minnesota: Offering a New Direction). Patients started on antidepressants were surveyed on depression symptom severity (Patient Health Questionnaire [PHQ-9]), productivity loss (Work Productivity and Activity Impairment questionnaire [WPAI]), health status, and demographics. Data were collected again 6 months later to assess changes in depression symptoms and productivity.Data from 432 employed patients with complete baseline and outcome data showed significant reductions in depression symptoms and increases in productivity (P.0001) over 6 months. Greater improvements in productivity at 6 months were associated with greater improvement in depression symptoms as well as with greater depression severity (P.0001) and poorer productivity (P.0001) at baseline.This study demonstrated a significant relationship betweenimprovement in depression symptoms and improvements in productivity following routine primary care depression treatment. These findings underscore the benefit of depression care to improve work outcomes and to yield a potential return on healthcare investment to employers.

PURPOSE Guideline implementation in primary care has proven difficult. Although external assistance through performance feedback, academic detailing, practice facilitation (PF), and learning collaboratives seems to help, the best combination of interventions has not been determined. METHODS In a cluster randomized trial, we compared the independent and combined effectiveness of PF and local learning collaboratives (LLCs), combined with performance feedback and academic detailing, with performance feedback and academic detailing alone on implementation of the National Heart, Lung and Blood Institute’s Asthma Guidelines. The study was conducted in 3 primary care practice-based research networks. Medical records of patients with asthma seen during pre- and postintervention periods were abstracted to determine adherence to 6 guideline recommendations. McNemar’s test and multivariate modeling were used to evaluate the impact of the interventions. RESULTS Across 43 practices, 1,016 patients met inclusion criteria. Overall, adherence to all 6 recommendations increased (P ≤.002). Examination of improvement by study arm in unadjusted analyses showed that practices in the control arm significantly improved adherence to 2 of 6 recommendations, whereas practices in the PF arm improved in 3, practices in the LLCs improved in 4, and practices in the PF + LLC arm improved in 5 of 6 recommendations. In multivariate modeling, PF practices significantly improved assessment of asthma severity (odds ratio [OR] = 2.5, 95% CI, 1.7–3.8) and assessment of asthma level of control (OR = 2.3, 95% CI, 1.5–3.5) compared with control practices. Practices assigned to LLCs did not improve significantly more than control practices for any recommendation. CONCLUSIONS Addition of PF to performance feedback and academic detailing was helpful to practices attempting to improve adherence to asthma guidelines.

Physicians can help patients quit smoking using the 5 As of smoking cessation. This study aimed to (1) identify the proportion of known smokers that receive smoking cessation services in the course of routine clinical practice; (2) describe demographic and comorbidity characteristics of patients receiving the 5 As in these systems; and (3) evaluate differences in performance of the 5 As across health systems, gender, and age categories.Electronic medical records of 200 current smokers from 6 unique health systems (N = 1200) were randomly selected from 2006 to 2010. Primary care encounter progress notes were hand coded for occurrences of the 5 As.Bivariate comparisons of delivery of the 3 smoking-cessation services by site, gender, and age category were analyzed using χ² tests.About 50% of smokers were advised to quit smoking, 39% were assessed for their readiness to quit, and 54% received some type of assistance to help them quit smoking. Only 2% had a documented plan for follow-up regarding their quitting efforts (arrange). Significant differences were found among sites for documentation of receiving the 5 As and between age groups receiving assistance with quitting. There was no statistically significant difference between genders in receipt of the 5 As.Documentation of adherence to the 5 As varied by site and some demographics. Adjustments to protocols for addressing cessation and readiness to quit may be warranted. Health systems could apply the methodology described in this paper to assess their own performance, and then use that as a basis to guide improvement initiatives.

Suicide prevention is a public health priority, but no data on the health care individuals receive prior to death are available from large representative United States population samples.To investigate variation in the types and timing of health services received in the year prior to suicide, and determine whether a mental health condition was diagnosed.Longitudinal study from 2000 to 2010 within eight Mental Health Research Network health care systems serving eight states.In all, 5,894 individuals who died by suicide, and were health plan members in the year before death.Health system contacts in the year before death. Medical record, insurance claim, and mortality records were linked via the Virtual Data Warehouse, a federated data system at each site.Nearly all individuals received health care in the year prior to death (83 %), but half did not have a mental health diagnosis. Only 24 % had a mental health diagnosis in the 4-week period prior to death. Medical specialty and primary care visits without a mental health diagnosis were the most common visit types. The individuals more likely to make a visit in the year prior to death (p 0.05) tended to be women, individuals of older age (65+ years), those where the neighborhood income was over $40,000 and 25 % were college graduates, and those who died by non-violent means.This study indicates that opportunities for suicide prevention exist in primary care and medical settings, where most individuals receive services prior to death. Efforts may target improved identification of mental illness and suicidal ideation, as a large proportion may remain undiagnosed at death.

Objective To determine the rates at which private primary-care clinics are recommending blood pressure and cholesterol measurement, smoking cessation, clinical breast examination, screening mammography, Papanicolaou testing, and influenza and pneumococcus immunizations. Material and Methods We conducted a mail survey of 7,997 randomly selected patients from 44 primary-care clinics in and around Minneapolis-St. Paul, Minnesota, of whom 6,830 (85.4%) completed the questionnaire on preventive services delivery rates. The responses were analyzed statistically, including stratification by reason for the clinic visit. Results On the average, about two-thirds of the patients in each clinic reported being up-to-date on preventive services before their clinic visit; an exception was pneumococcus immunization (mean rate, 33%). Except for blood pressure and smoking cessation advice, less than 30% of patients who were not up-to-date on a preventive service were offered it if the clinic visit was for a reason other than a checkup or physical examination. For patients who said that they saw their physician for a checkup or physical examination, the rate was more than 50% only for Papanicolaou smear. In contrast, nearly all responding practitioners agreed that each of the eight preventive services was very important or important. Conclusion Preventive services consensus goals are not being met, even for patients who report that their clinic visit was for a checkup or physical examination. This finding suggests that it may be necessary to develop clinical systems that support and enable the delivery of preventive services.

Objective To demonstrate a rigorous methodology that optimally balanced internal validity with generalizability to evaluate a statewide collaborative that implemented an evidence-based, collaborative care model for depression management in primary care. Study design and setting Several operational features of the DIAMOND (Depression Improvement Across Minnesota, Offering a New Direction) Initiative suggested that the DIAMOND Study use a staggered implementation design with repeated cross-sections of patients across clinical settings. A multilevel recruitment strategy elicited virtually complete study participation from the medical groups, clinics, and health plans that coordinated efforts to deliver and reimburse DIAMOND care. Patient identification capitalized on large health plan claims databases to rapidly identify the population of patients newly treated for depression in DIAMOND clinics. Results The staggered implementation design and multilevel recruitment strategy made it possible to evaluate DIAMOND by holding confounding factors constant and accurately identifying an intent-to-treat population of patients treated for depression without intruding on or requiring effort from their clinics. Conclusions Recruitment and data collection from health plans, medical groups and clinics, and patients ensured a representative, intent-to-treat sample of study-enrolled patients. Separating patient identification from care delivery reduced threats of selection bias and enabled comparisons between the treated population and study sample. A key challenge is that intent-to-treat patients may not be exposed to DIAMOND which dilutes the effect size but offers realistic expectations of the impact of quality improvement in a population of treated patients.

To examine the long-term relationships between costs, utilization, and patient-centered medical home (PCMH) clinical practice systems.Clinical practice systems were evaluated at baseline by the Physician Practice Connections-Research Survey (PPC-RS). Annual costs and utilization of a retrospectively constructed cohort of 58,391 persons receiving primary care at 1 of 22 medical groups over a 5-year period (2005-2009) were compared.Multivariate regressions adjusting for patient demographics, health status, and autoregressive errors compared PPC-RS scores and study outcomes for the entire cohort and 3 subcohorts defined by medical complexity (medication count 0-2 [n = 29,657], 2-6 [n = 19,505],7 [n = 9229]). Outcomes (adjusted to 2005 dollars) were total costs, outpatient costs, inpatient costs, inpatient days, and emergency department (ED) use.For the entire cohort, a 10% increase in PPC-RS scores was associated with 3.9 (medication count: 0-2), 6 (3-6), and 11.6 (7) fewer ED visits per 1000 in 2005; and 5.1, 7.6, and 13.6 fewer ED visits in 2009. That 10% increase was not associated with the 0-2 medication subcohort's total (-$22/person in 2005; $184/person in 2009), outpatient (-$11/person in 2005; $42/person in 2009), or inpatient ($26/person in 2005; $29/person in 2009) costs. However, it was associated with significantly decreased total (-$446/person in 2005; -$184/person in 2009) and outpatient (-$241/person in 2005; -$54/person in 2009) costs for the most medically complex subcohort (7 medications).Association of PCMH clinical practice systems with reduced costs appears limited to the most medically complex patients.

Objective To examine the relationship between primary care medical home clinical practice systems corresponding to the domains of the Chronic Care Model and annual diabetes-related health care costs incurred by members of a health plan with type-2 diabetes and receiving care at one of 27 Minnesota-based medical groups. Study design Cross-sectional analysis of the relation between patient-level costs and Patient-Centered Medical Home (PCMH) practice systems as measured by the Physician Practice Connections Readiness Survey. Methods Multivariate regressions adjusting for patient demographics, health status, and comorbidities estimated the relationship between the use of PCMH clinical practice systems and 3 annual cost outcomes: total costs of diabetes-related care, outpatient medical costs of diabetes-related care, and inpatient costs of diabetes-related care (ie, inpatient and emergency care). Results Overall PCMH scores were not significantly related to any annual cost outcome; however, 2 of 5 subdomains were related. Health Care Organization scores were related to significantly lower total (P=0.04) and inpatient costs (P=0.03). Clinical Decision Support was marginally related to a lower total cost (P=0.06) and significantly related to lower inpatient costs (P=0.02). A detailed analysis of the Health Care Organization domain showed that compared with medical groups with only quality improvement, those with performance measurement and individual provider feedback averaged $245/patient less. Medical groups with clinical reminders for counseling averaged $338/patient less. Conclusions Certain PCMH practice systems were related to lower costs, but these effects are small compared with total costs. Further research about how these and other PCMH domains affect costs over time is needed.

ContextUse of diagnostic imaging has increased significantly within fee-for-service models of care. Little is known about patterns of imaging among members of integrated health care systems.ObjectiveTo estimate trends in imaging utilization and associated radiation exposure among members of integrated health care systems.Design, setting, and participantsRetrospective analysis of electronic records of members of 6 large integrated health systems from different regions of the United States. Review of medical records allowed direct estimation of radiation exposure from selected tests. Between 1 million and 2 million member-patients were included each year from 1996 to 2010.Main outcome measureAdvanced diagnostic imaging rates and cumulative annual radiation exposure from medical imaging.ResultsDuring the 15-year study period, enrollees underwent a total of 30.9 million imaging examinations (25.8 million person-years), reflecting 1.18 tests (95% CI, 1.17-1.19) per person per year, of which 35% were for advanced diagnostic imaging (computed tomography [CT], magnetic resonance imaging [MRI], nuclear medicine, and ultrasound). Use of advanced diagnostic imaging increased from 1996 to 2010; CT examinations increased from 52 per 1000 enrollees in 1996 to 149 per 1000 in 2010, 7.8% annual increase (95% CI, 5.8%-9.8%); MRI use increased from 17 to 65 per 1000 enrollees, 10% annual growth (95% CI, 3.3%-16.5%); and ultrasound rates increased from 134 to 230 per 1000 enrollees, 3.9% annual growth (95% CI, 3.0%-4.9%). Although nuclear medicine use decreased from 32 to 21 per 1000 enrollees, 3% annual decline (95% CI, 7.7% decline to 1.3% increase), PET imaging rates increased after 2004 from 0.24 to 3.6 per 1000 enrollees, 57% annual growth. Although imaging use increased within all health systems, the adoption of different modalities for anatomic area assessment varied. Increased use of CT between 1996 and 2010 resulted in increased radiation exposure for enrollees, with a doubling in the mean per capita effective dose (1.2 mSv vs 2.3 mSv) and the proportion of enrollees who received high (>20-50 mSv) exposure (1.2% vs 2.5%) and very high (>50 mSv) annual radiation exposure (0.6% vs 1.4%). By 2010, 6.8% of enrollees who underwent imaging received high annual radiation exposure (>20-50 mSv) and 3.9% received very high annual exposure (>50 mSv).ConclusionWithin integrated health care systems, there was a large increase in the rate of advanced diagnostic imaging and associated radiation exposure between 1996 and 2010.

PURPOSE We describe changes over time in performance on measures of techni- cal quality and patient experience as a group of primary care clinics transformed themselves into level III patient-centered medical homes. METHODS A group of 21 Minnesota primary care clinics achieving level III rec- ognition as medical homes by the National Committee for Quality Assurance has been tracking a variety of quality and patient satisfaction measures for years. We analyzed trends in these measures and compared them with those of other medi- cal groups in the community to estimate what we might expect as other primary care sites gear up to achieve medical home status. RESULTS The clinics in this group achieved a 1% to 3% increase per year in patient satisfaction and a 2% to 7% increase per year in performance on quality measures for diabetes, coronary artery disease, preventive services, and generic medication use. When compared with the average for other medical groups in the region, the rates of increase were greater for satisfaction, but similar for the quality measures. CONCLUSIONS Achieving medical home recognition was associated with improve- ments in quality and patient satisfaction for these clinics, but the rate of improve- ment is slow and does not always exceed levels in the surrounding community in Minnesota (which are also improving). Expectations for large and rapid change are probably unrealistic.

To design a bundled case rate for Collaborative Care for Depression (CCD) that aligns incentives with evidence-based depression care in primary care.A clinical information system used by all care managers in a randomized controlled trial of CCD for older primary care patients.We conducted an empirical investigation of factors accounting for variation in CCD resource use over time and across patients. CCD resource use at the patient-episode and patient-month levels was measured by number of care manager contacts and direct patient contact time and analyzed with count data (Poisson or negative binomial) models.Episode-level resource use varies substantially with patient's time in the program. Monthly use declines sharply in the first 6 months regardless of treatment response or remission status, but it remains stable afterwards. An adjusted episode or monthly case rate design better matches payment with variation in resource use compared with a fixed design.Our findings lend support to an episode payment adjusted by number of months receiving CCD and a monthly payment adjusted by the ordinal month. Nonpayment tools including program certification and performance evaluation and reward systems are needed to fully align incentives.

The patient-centered medical home (PCMH) is seen as an important vehicle for providing consistent primary care and achieving cost savings through care coordination. We used health plan administrative data to evaluate utilization and cost among enrollees who attended a PCMH compared with those who fragmented their care. Controlling for demographic differences, PCMH attendees made significantly fewer primary care and specialist visits than other groups, and associated professional fees were significantly lower than for enrollees receiving less consistent primary care.

Background There is considerable interest in measuring and eliminating health care disparities among various special populations, but there is limited understanding of their extent, causes, or potential remedies. To improve this for tobacco cessation, we measured differences in the frequency of receiving and filling cessation medication prescriptions by race, ethnicity, age, language preference, health insurance, and pregnancy. Methods The relevant variables for all patients of a Minnesota medical group aged 18 years and older with clinician visits were extracted from the electronic medical records of 1 large medical group from March 2006 to February 2007. This was combined with claims data from 1 insurance plan that covered most of these individuals. Order and fill rates for cessation medications were then adjusted for each of the other variables. Results There were 32,733 current users of tobacco, 18,047 of whom had both health insurance and pharmacy claims data available. After adjustment, 15.4% overall had received an order for cessation medications during this year, but only 78% had filled it. Groups receiving fewer orders than their comparison groups were aged 18-34 years or older than 65 years, men, pregnant women, Asians and Hispanics, and those with non-English-language preference, on Medicaid, or with fewer visits. The same groups were less likely to fill that prescription, except patients with non-English preference or Medicaid. Discussion There are disparities in both the receipt of cessation medication orders and the likelihood of filling them for some special populations. The causes are likely to be complex, but this information provides a starting point for learning to improve this problem.