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Recent value-based payment reforms in the U.S. called for empirical data on how primary care practices of varying characteristics fund their integrated behavioral health services. To describe payment strategies used by U.S. primary care practices to fund behavioral health integration and compare strategies between practices with and without hospital affiliation.Baseline data were used and collected from 44 practices participating in a cluster-randomized, pragmatic trial of behavioral health integration. Data included practice characteristics and payment strategies-fee-for-service payment, pay-for-performance incentives, grants, and graduate medical education funds. Descriptive and comparative analyses using Fisher's exact tests and independent T-tests were conducted. The sample had 26 (59.1%) hospital-affiliated (hospital/health system-owned, academic medical centers and hospital-affiliated practices) and 18 (40.9%) non-hospital-affiliated practices (community health centers/federally qualified health centers and privately-owned practices). Most practices (88.6%) received payments through fee-for-service; 63.6% received pay-for-performance incentives; 31.8% received grant funds. Collaborative Care Management billing (CPT) codes were used in six (13.6%) practices. Over half (53.8%) of hospital-affiliated practices funded their behavioral health services through fee-for-service and pay-for-performance incentives only, as opposed to two-thirds (66.7%) of non-hospital-affiliated practices required additional support from grants and/or general medical education funds. Primary care practices support behavioral health integration through diverse payment strategies. More hospital-affiliated practices compared to non-hospital-affiliated practices funded integrated behavioral health services through fee-for-service and pay-for-performance incentives. Practices without hospital affiliation relied on multiple funding streams including grants and/or general medical education funds, suggesting their approach to financial sustainment may be more precarious or challenging, compared to hospital-affiliated practices.
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Planos de Pagamento por Serviço Prestado , Reembolso de Incentivo , Centros Comunitários de Saúde , Serviços de Saúde , Humanos , Atenção Primária à SaúdeRESUMO
BACKGROUND: Assess the feasibility of using goal attainment scaling (GAS) in care planning for older adults with complex needs. GAS is an individualized approach to goal setting and follow up using a quantified scale. To date, little is known about the feasibility of GAS among this population. METHODS: We conducted a qualitative study with a sample of 28 older adults and 23 providers from diverse settings to evaluate the value and challenges of this approach. We conducted semi-structured interviews and iteratively coded and analyzed interview transcripts for themes related to value, challenges, and implementation. RESULTS: Most older adults and providers reported that the GAS approach added value to the care encounter. GAS supported collaboration and patient accountability for their goals, though it could be demotivating to some patients. Some older adults and providers noted that GAS could be confusing and that it was uncomfortable to talk about negative outcomes (i.e., the - 2 and - 1 boxes of the scale). Factors that facilitated implementation included using visual copies of the GAS forms, having an established patient-provider relationship, practicing the approach, and having previous goal-related clinical training. CONCLUSIONS: GAS was feasible to implement across diverse settings, and, despite challenges, both older adults and providers reported that it added value to care planning encounters with the potential to improve delivery of person-centered care. Further efforts to demonstrate the applicability and benefit of this method for older adults are warranted, particularly to address implementation of the approach.
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Although most health care occurs in the ambulatory setting, limited research examines how providers and patients think about and enact ambulatory patient safety. This multimethod qualitative study seeks to identify perceived challenges and strategies to improve ambulatory safety from the perspectives of clinicians, staff, and patients. Data included interviews (N = 101), focus groups (N = 65), and observations of safety processes (N = 79) collected from 10 patient-centered medical homes. Key safety issues included the lack of interoperability among health information systems, clinician-patient communication failures, and challenges with medication reconciliation. Commonly cited safety strategies leveraged health information systems or involved dedicated resources (eg, providing access to social workers). Patients also identified strategies not mentioned by clinicians, emphasizing the need for their involvement in developing safety solutions. This work provides insight into safety issues of greatest concern to clinicians, staff, and patients and strategies to improve safety in the ambulatory setting.
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Reconciliação de Medicamentos , Segurança do Paciente , Comunicação , Humanos , Assistência Centrada no Paciente , Pesquisa QualitativaRESUMO
Initiatives that support and incentivize the integration of behavioral health and general medical care have become a focus of government strategies to achieve the triple aim of improved health, better patient experience, and reduced costs. The authors describe the components of four large-scale national initiatives aimed at integrating care for a wide range of behavioral health needs. Commonalities across these national initiatives highlight health care and social services needs that must be addressed to improve care for people with co-occurring behavioral health and general medical conditions. These findings can inform how to design, test, select, and align the most promising strategies for integrated care in a variety of settings.
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Prestação Integrada de Cuidados de Saúde , Psiquiatria , Atenção à Saúde , Humanos , Atenção Primária à Saúde , Serviço SocialRESUMO
BACKGROUND: Most patients living with serious illness value spending time at home. Emerging data suggest that days alive and at home (DAH) may be a useful metric, however more research is needed. We aimed to assess the concurrent validity of DAH with respect to clinically significant changes in patient- and caregiver-reported outcomes (PROs). METHODS: We drew data from a study that compared two models of home-based palliative care among seriously ill patients and their caregivers in two Kaiser Permanente regions (Southern California and Northwest). We included participants aged 18 years or older (n = 3533) and corresponding caregivers (n = 463). We categorized patients and caregivers into three groups based on whether symptom burden (Edmonton Symptom Assessment System, ESAS) or caregiving preparedness (Preparedness for Caregiving Scale, CPS) showed improvements, deterioration, or no change from baseline to 1 month later. We measured DAH across four time windows: 30, 60, 90, and 180 days, after admission to home palliative care. We used two-way ANOVA to compare DAH across the PRO groups. RESULTS: Adjusted pairwise comparisons showed that DAH was highest for patients whose ESAS scores improved or did not change compared with those with worsening symptoms. Although the mean differences ranged from less than a day to about 3 weeks, none exceeded 0.3 standard deviations. ESAS change scores had weak negative correlations (r = -0.11 to -0.21) with DAH measures. CPS change scores also showed weak, positive correlations (r = 0.23-0.24) with DAH measures. CONCLUSION: DAH measures are associated, albeit weakly, with clinically important improvement or maintenance of patient symptom burden in a diverse, seriously ill population.
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Serviços de Assistência Domiciliar , Cuidados Paliativos , Cuidadores , Hospitalização , Humanos , Cuidados Paliativos/métodos , Inquéritos e QuestionáriosRESUMO
Importance: Nearly all initiatives to improve care for individuals with opioid use disorder (OUD) have focused on improving OUD identification and treatment. Whether individuals with OUD have lower quality of care than individuals without OUD remains unclear. Objective: To measure quality of non-OUD preventive and chronic illness care and care coordination for individuals with OUD compared with individuals without OUD. Design, Setting, and Participants: A cross-sectional study of deidentified data on outpatients throughout the US was conducted. Claims for 79â¯372 commercially insured and Medicare Advantage enrollees aged 18 years or older with diagnosis codes for OUD between January 1, 2018, and December 31, 2019, and 46â¯601 individuals without OUD were included in the analysis. Exposure: Diagnosis of OUD. Main Outcomes and Measures: Quality indicator performance was calculated, using claims for individuals with OUD and matched comparators without OUD. Within 3 domains of outpatient care quality (preventive care, chronic illness care, and care coordination), 6 indicators used in accountability programs were selected. Performance for individuals with and without OUD was compared, and logistic regression was used to analyze sociodemographic and comorbidity characteristics associated with higher quality of health care. Results: The study included 125â¯973 individuals, including 69â¯466 (55.1%) women and 78â¯225 (62.1%) White individuals, with a mean (SD) age of 59.0 (16.1) years. For the preventive care measure examining breast cancer screening, performance for the OUD cohort was 55.4% (95% CI, 54.7%-56.0%) compared with 65.6% (95% CI, 64.4%-66.7%) for individuals without OUD (P < .001). Quality of care for adherence to statin therapy was lower for individuals with OUD (70.4%; 95% CI, 68.7%-72.1%) compared with individuals without OUD (76.7%; 95% CI, 74.4%-78.7%) (P < .001) and for the hemoglobin A1c testing indicator (OUD: 80.9%; 95% CI, 80.4%-81.5%; comparator: 85.8%; 95% CI, 84.9%-86.8%; P < .001). Care coordination quality also was lower for individuals with OUD compared with those without OUD for mental health follow-up (OUD: 45.3%; 95% CI, 44.6%-46.0%; comparator: 52.5%; 95% CI, 50.0%-55.0%; P < .001) and for potentially avoidable hospitalizations for chronic conditions (OUD: 11.4%; 95% CI, 11.2%-11.7%; comparator: 8.8%; 95% CI, 8.3%-9.2%; P < .001) and diabetes, where a lower score indicates higher quality (OUD: 2.4%; 95% CI, 2.3%-2.5%; comparator: 1.9%; 95% CI, 1.7%-2.1%; P = .001). Conclusions and Relevance: These findings suggest that individuals with OUD have moderately lower quality of care across preventive and chronic illness care and care coordination for non-OUD care compared with individuals without OUD. More attention to measurement and improvement of non-OUD care for these individuals is needed.
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Continuidade da Assistência ao Paciente/normas , Transtornos Relacionados ao Uso de Opioides/terapia , Indicadores de Qualidade em Assistência à Saúde , Adulto , Idoso , Estudos de Casos e Controles , Doença Crônica/prevenção & controle , Doença Crônica/terapia , Estudos Transversais , Bases de Dados Factuais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Estados Unidos/epidemiologiaRESUMO
AIM: The aim of this study was to characterize quality of buprenorphine care for opioid use disorder (OUD) by quantifying buprenorphine initiation, engagement, and maintenance for individuals in a large, diverse, real-world cohort in the United States. DESIGN: This was a retrospective cohort analysis. SETTING: OUD treatment in the outpatient setting. PARTICIPANTS: A total of 45,210 commercially insured and Medicare Advantage (MA) enrollees 18 years or older in the OptumLabs Data Warehouse with an index diagnosis of OUD between January 1, 2018 and December 31, 2018. INTERVENTIONS: Treatment with buprenorphine. MEASUREMENTS: We calculated 6 measures of buprenorphine treatment quality. We conducted survival analyses to characterize treatment duration and logistic regressions to evaluate the association between clinical and sociodemographic characteristics and quality. FINDINGS: Of 45,210 eligible individuals with OUD, â¼1 in 10 (n=4600, 10.2%) initiated buprenorphine within 365 days following diagnosis (Measure #1) and 2850 individuals (6.3%) initiated buprenorphine within 14 days of diagnosis (Measure #2). Of individuals initiating treatment within 14 days of diagnosis, 1769 (62.1%) had 2 or more buprenorphine claims within 34 days of initiation (Measure #3). Of the 4600 individuals who received buprenorphine, 2300 (50.0%) were maintained in care with 180 days or more of covered buprenorphine treatment during 365 days after diagnosis (Measure #4). Finally, of the 4600 individuals who received buprenorphine, 2543 (55.3%) did not fill any other concurrent opioid analgesic (Measure #5) and 2951 (64.2%) did not fill any concurrent benzodiazepine (Measure #6). Quality was generally lower for individuals with MA compared with commercial coverage and among Hispanic and Black adults compared with White adults. CONCLUSION: Widespread gaps exist in quality of buprenorphine treatment initiation, engagement, and maintenance among commercially insured and MA enrollees with OUD.
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Analgésicos Opioides/uso terapêutico , Buprenorfina/uso terapêutico , Seguro Saúde/estatística & dados numéricos , Medicare Part C/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides , Setor Privado , Qualidade da Assistência à Saúde , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/etnologia , Estudos Retrospectivos , Estados UnidosRESUMO
BACKGROUND: The patient-centered medical home (PCMH) model has been widely adopted, but the evidence on its effectiveness remains mixed. One potential explanation for these mixed findings is variation in how the model is implemented by practices. OBJECTIVE: To identify the impact of different approaches to PCMH adoption on health care utilization in a long-term, geographically diverse sample of patients. DESIGN: Difference-in-differences evaluation of PCMH impact on cost and utilization. SUBJECTS: A total of 5,314,284 patient-year observations from the HealthCore Integrated Research Database, and 5943 practices which adopted the PCMH model in 14 states between 2011 and 2015. INTERVENTION: PCMH adoption, as defined by the National Committee for Quality Assurance. MEASUREMENTS: Six claims-based utilization measures, plus total health care expenditures. We employ hierarchical clustering to organize practices into groups based on their PCMH capabilities, then use generalized difference-in-differences models with practice or patient fixed effects to estimate the effect of PCMH recognition (overall and separately by the groups identified by the clustering algorithm) on utilization. RESULTS: PCMH adoption was associated with a >8% reduction in total expenditures. We find significant reductions in emergency department utilization and outpatient care, and both lab and imaging services. In our by-group results we find that while the reduction in outpatient care is significant across all 3 groups, the reduction in emergency department utilization is driven entirely by 1 group with enhanced electronic communications. CONCLUSION: The PCMH model has significant impact on patterns of health care utilization, especially when heterogeneity in implementation is accounted for in program evaluation.
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Equipe de Assistência ao Paciente/organização & administração , Assistência Centrada no Paciente/organização & administração , Atenção Primária à Saúde/organização & administração , Qualidade da Assistência à Saúde/organização & administração , Feminino , Humanos , Masculino , Inovação Organizacional , Avaliação de Programas e Projetos de Saúde , Estados UnidosRESUMO
BACKGROUND: Older adults with complex care needs face trade-offs in determining the right course of treatment. The Centers for Medicare and Medicaid Services identified 'Care is personalized and aligned with patient's goals' as a key meaningful measures category, yet existing quality measures typically assess disease-specific care and may not effectively evaluate what is most important to older adults and family members. Measures based on individualised goals and goal-based outcomes have been proposed as an alternative but are not routinely assessed or implemented. OBJECTIVES: We tested two approaches to assessing goal-based outcomes that allow individuals to set goals based on their own priorities and measure progress-(1) goal attainment scaling and (2) existing, validated patient-reported outcome measures (PROM). METHODS: A prospective cohort study of feasibility in seven sites (33 clinicians) of the two approaches with 229 individuals. We calculated performance on a measure of achievement of individually identified goals. RESULTS: Both approaches were successfully implemented in a non-randomly selected population, and a goal-based outcome could be calculated for 189 (82%) of participants. Most individuals met their goal-based outcome (73%) with no statistical difference between the goal attainment scaling approach (74%) and the patient-reported outcomes approach (70%). Goals were heterogeneous ranging from participating in activities, health management, independence and physical health. Clinicians chose to use goal attainment scaling (n=184, 80%) more often than PROMs (n=49, 20%) and rated the goal attainment scaling approach as useful for providing patient care. CONCLUSION: Goal-based outcomes have the potential to both improve the way healthcare is provided and fill a critical gap in value-based payment.
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Objetivos , Avaliação de Resultados em Cuidados de Saúde , Idoso , Família , Humanos , Medicare , Estudos Prospectivos , Estados UnidosRESUMO
OBJECTIVE: The authors evaluated available evidence to determine whether telemedicine services should be allowed in seven nationally reported behavioral health quality measures in the Healthcare Effectiveness Data and Information Set. METHODS: The authors searched PubMed, Google Scholar, and the Cochrane Database of Systematic Reviews for articles that met several inclusion criteria (relevant diagnosis and age, as specified in the quality measures). They also consulted expert panels on whether, and how, to include telemedicine in behavioral health measure specifications. RESULTS: Thirty-two studies met the inclusion criteria. Their findings suggested that video conferencing, telephone calls, and web-based telemedicine modalities are as effective as in-person visits for diagnosis and management of most mental health and substance use disorders. Expert panels supported including telemedicine modalities in specific behavioral health measures. CONCLUSIONS: Specific telemedicine modalities are effective, convenient ways to deliver behavioral health care. Revising quality measures to allow telemedicine services will support new methods for providing care.
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Psiquiatria , Telemedicina , Humanos , Indicadores de Qualidade em Assistência à Saúde , Revisões Sistemáticas como Assunto , Comunicação por VideoconferênciaRESUMO
PURPOSE: Oncology practices often serve as the "medical home" for patients but may not have systems to support all aspects of patient-centered care. We piloted a new set of oncology medical home standards that call for accessible, continuous, coordinated, and team-based care. We examined how adoption of the standards varies across a variety of practices and compared practice self-report with external evaluation of implementation. METHODS: Five medical oncology practices in southeastern Pennsylvania implemented the standards from 2014 into 2016. Implementation support included training webinars and technical assistance. External reviewers evaluated practices' implementation of the standards. We conducted site visits to interview providers and patients. RESULTS: Between baseline and follow-up, practice self-assessments and independent audits showed practices increased implementation of the patient-centered oncology standards. The largest improvement was seen in continuous quality improvement (QI). Practices were less successful in implementing care coordination: achievement on two standards (access and evidence-based decision support) declined from baseline to follow-up. Qualitative analyses revealed that practices focused QI in five areas: goals of care, engaging patients in QI, financial counseling, symptom management, and care coordination. Interviewees talked about facilitators, such as leadership support and physician buy-in, and barriers to transformation, including inadequate resources and staffing. Health information technology both supported and limited implementation. CONCLUSION: Oncology practices showed some progress in their implementation of patient-centered care processes over the course of the pilot program. Systems for tracking and documenting improvement, training for staff and clinicians, leadership support, and alignment of financial incentives are critical to transformation.
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Assistência Centrada no Paciente , Melhoria de Qualidade , Humanos , Liderança , Oncologia , PennsylvaniaRESUMO
INTRODUCTION: Patient safety in primary care is an emerging priority, and experts have highlighted medications, diagnoses, transitions, referrals, and testing as key safety domains. This study aimed to (1) describe how frontline clinicians, administrators, and staff conceptualize patient safety in primary care; and (2) compare and contrast these conceptual meanings from the patient's perspective. METHODS: We conducted interviews with 101 frontline clinicians, administrators and staff, and focus groups with 65 adult patients at 10 patient-centered medical homes. We used thematic analysis to approach coding. RESULTS: Findings indicate that frontline personnel conceptualized patient safety more in terms of work functions, which reflect the grouping of tasks or responsibilities to guide how care is being delivered. Frontline personnel and patients conceptualized patient safety in largely consistent ways. DISCUSSION: Function-based conceptualizations of patient safety in primary care may better reflect frontline personnel and patients' experiences than domain-based conceptualizations, which are favored by experts.
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Segurança do Paciente , Atenção Primária à Saúde , Adolescente , Adulto , Idoso , Atitude do Pessoal de Saúde , Feminino , Grupos Focais , Humanos , Masculino , Pessoa de Meia-Idade , Equipe de Assistência ao Paciente , Pacientes/psicologia , Pacientes/estatística & dados numéricos , Adulto JovemRESUMO
OBJECTIVES: Alcohol misuse is a leading cause of preventable death in the United States. This pilot study examined rates of screening and follow-up for unhealthy alcohol use among health plan beneficiaries. STUDY DESIGN: We analyzed medical records and claims data from 4 health plans-2 nonintegrated Medicaid plans and 2 integrated plans serving Medicaid, Medicare, and commercial product lines. The nonintegrated plans used medical records, case management, and claims data to identify alcohol screening and follow-up services using a random sample of 108 (plan 1) and 120 (plan 2) adults. The integrated plans (plans 3 and 4) used provider electronic health record data for all adults. METHODS: We adapted the Physician Consortium for Performance Improvement Foundation's measure, Unhealthy Alcohol Use Screening & Brief Counseling, and applied it to plan populations for the 2014 and 2015 calendar years. We calculated rates of screening and follow-up for unhealthy alcohol use for each plan. RESULTS: Results from the Medicaid plans showed that between 40% and 46% of members had documentation of alcohol screening, but standardized alcohol screening tools were rarely used and screening results were inconsistently documented. Results from the integrated plans with multiple product lines showed wide variation: 5% to 69% of members were screened; of those, 3% to 31% screened positive. Among members who screened positive, 1% to 46% received follow-up care. CONCLUSIONS: Rates of screening and follow-up for unhealthy alcohol use are low in plan populations. There is room for improvement in documentation and quality of care for alcohol misuse.
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Alcoolismo/diagnóstico , Seguro Saúde/estatística & dados numéricos , Programas de Rastreamento/estatística & dados numéricos , Adolescente , Adulto , Idoso , Registros Eletrônicos de Saúde , Feminino , Seguimentos , Humanos , Masculino , Medicaid/estatística & dados numéricos , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Projetos Piloto , Encaminhamento e Consulta/estatística & dados numéricos , Estados Unidos , Adulto JovemRESUMO
OBJECTIVE: To examine variation among commercial health plans in resource use and quality of care for patients with diabetes mellitus or cardiovascular disease. STUDY DESIGN: Cohort study using Healthcare Effectiveness Data and Information Set data submitted to the National Committee for Quality Assurance in 2008. METHODS: Composite measures were estimated for diabetes and cardiovascular disease resource use and quality of care. A "value" classification approach was defined. Obtained were descriptive statistics, Pearson product moment correlations between resource use and quality of care, and 90% confidence intervals around each health plan's composite measures of resource use and quality of care. Health plans were classified based on their results. RESULTS: For patients with diabetes, the correlation between combined medical care services resource use and composite quality of care is negative (-0.201, p = .008); the correlation between ambulatory pharmacy services resource use and composite quality of care is positive (0.162, p = .03). For patients with cardiovascular disease, no significant correlation was found between combined medical care services resource use and composite quality of care (-0.007, p = .94) or ambulatory pharmacy services resource use (0.170, p = .06). CONCLUSIONS: Measures of resource use and quality of care provide important information about the value of a health plan. Although our analysis did not determine causality, the statistically weak or absent correlations between resource use and quality of care suggest that health plans and practices can create higher value by improving quality of care without large increases in resource use or by maintaining the same quality of care with decreased resource use.
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Seguro Saúde/classificação , Doenças Cardiovasculares/economia , Doenças Cardiovasculares/terapia , Estudos de Coortes , Atenção à Saúde/economia , Diabetes Mellitus/economia , Diabetes Mellitus/terapia , Humanos , Seguro Saúde/economia , Seguro Saúde/normas , Qualidade da Assistência à Saúde/economia , Estados UnidosRESUMO
OBJECTIVE: To study a mental health sample to assess (1) the prevalence of physical, sexual and emotional intimate partner violence (IPV) victimization and perpetration, (2) the extent this sample reported being asked about IPV by mental health clinicians and (3) how prevalence and screening rates varied by gender. METHOD: Women and men receiving services at a large psychiatric facility completed anonymous written questionnaires. RESULTS: A total of 524 adults were approached for study participation, and 428 (158 men, 270 women) completed a survey. Over half (51%) of participants experienced some form of IPV; 63% of women and 32% of men reported IPV victimization. Experience of IPV was more likely if participants were women and had diagnoses of posttraumatic stress disorder, anxiety disorder or bipolar disorder. Both women (33%) and men (16%) reported perpetrating IPV. The reported IPV screening rate by mental health providers was 44% for the whole sample (women: 55%; men: 27%). CONCLUSION: IPV victimization and perpetration is a prevalent problem among women and men receiving mental health services. Clinicians are missing opportunities to screen for IPV as part of mental health evaluation and treatment.
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Violência Doméstica/estatística & dados numéricos , Programas de Rastreamento , Serviços de Saúde Mental , Parceiros Sexuais , Adulto , Feminino , Humanos , Masculino , Pennsylvania/epidemiologia , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Physicians report outpatient quality measures from data in electronic health records to facilitate care improvement and qualify for incentive payments. OBJECTIVE: To determine the frequency and validity of exceptions to quality measures and to test a system for classifying the reasons for these exceptions. DESIGN: Cross-sectional observational study. SETTING: 5 internal medicine or cardiology practices. PARTICIPANTS: 47,075 patients with coronary artery disease between 2006 and 2007. MEASUREMENTS: Counts of adherence with and exceptions to 4 quality measures, on the basis of automatic reports of recommended drug therapy by computer software and separate manual reviews of electronic health records. RESULTS: 3.5% of patients who had a drug recommended had an exception to the drug and were not prescribed it (95% CI, 3.4% to 3.7%). Clinicians did prescribe the recommended drug for many other patients with exceptions. In 538 randomly selected records, 92.6% (CI, 90.3% to 94.9%) of the exceptions reported automatically by computer software were also exceptions during manual review. Most medical exceptions were clinical contraindications, drug allergies, or drug intolerances. In 592 randomly selected records, an unreported exception or a drug prescription was found during manual review for 74.6% (CI, 71.1% to 78.1%) of patients for whom automatic reporting recorded a quality failure. LIMITATION: The study used a convenience sample of practices, nonstandardized data extraction methods, only drug-related quality measures, and no financial incentives. CONCLUSION: Exceptions to recommended therapy occur infrequently and are usually valid. Physicians frequently prescribed drugs even when exceptions were present. Automated reports of quality failure often miss critical information. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.
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Doença da Artéria Coronariana/tratamento farmacológico , Registros Eletrônicos de Saúde/normas , Qualidade da Assistência à Saúde , Idoso , Codificação Clínica/normas , Estudos Transversais , Prescrições de Medicamentos/normas , Humanos , Masculino , Observação , Pacientes Ambulatoriais , Reembolso de Incentivo , Reprodutibilidade dos TestesRESUMO
Health professionals from two different clinical settings were asked about their comfort level in dealing with intimate partner violence (IPV). Focus groups and semistructured interviews were used to gather information. Staff in an obstetrics and gynecology setting relatively rich in IPV resources described feeling capable dealing with IPV. The staff in a general medicine setting dedicated to women's health but without a focus on IPV and with fewer supports described discomfort and difficulty dealing with IPV. Presence of systemic prioritization of and resources for IPV were described as contributing to the confidence in addressing the issue. Other necessary elements identified included (a) on-site resources, (b) adequate time, (c) focused IPV training, and (d) a team or systemic approach.
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Atitude do Pessoal de Saúde , Vítimas de Crime/reabilitação , Comportamento de Ajuda , Relações Profissional-Paciente , Maus-Tratos Conjugais/reabilitação , Adulto , Mulheres Maltratadas , Vítimas de Crime/psicologia , Feminino , Grupos Focais , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação das Necessidades , Maus-Tratos Conjugais/prevenção & controleRESUMO
Quality measurement can inform and encourage improvement in child health care. Currently, most measures gauge only whether care is received (e.g., receipt of a well-child care visit), providing little information about the actual content of care. We propose a measurement framework for comprehensive well-child care to capture a richer view of children's health care and take a more efficient approach to data collection. To promote measurement development, it will be necessary to: 1) align new measures with existing reporting requirements; 2) manage the burden of data collection; 3) weigh the evidence base; 4) consider adding new types of content; 5) develop clear but flexible measure specifications; and 6) consider children's enrollment patterns in Medicaid and the Children's Health Insurance Program. It also will be important to seek opportunities for eliciting families' views on the quality of well-child care.
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Serviços de Saúde da Criança/organização & administração , Indicadores de Qualidade em Assistência à Saúde/organização & administração , Qualidade da Assistência à Saúde/organização & administração , Adolescente , Criança , Pré-Escolar , Humanos , Esquemas de Imunização , Lactente , Recém-Nascido , Programas de Rastreamento/organização & administração , Medicaid , Serviços Preventivos de Saúde/organização & administração , Governo Estadual , Estados UnidosRESUMO
OBJECTIVE: To examine how resource use varies with care quality for managed care populations with diabetes. DESIGN AND METHODS: Data from 31 commercial health plans (23 health maintenance organizations and 8 preferred provider organizations) were analyzed. Resource use was calculated using medical and pharmacy claims and enrollment data for members with diabetes. A standardized pricing methodology was applied for resource use associated with inpatient, pharmacy, evaluation and management, and procedural services. Quality of care results were calculated for 4 process quality indicators of the Healthcare Effectiveness Data and Information Set (HEDIS) comprehensive diabetes care measure set. RESULTS: Resource use varied more between organizations than quality of care results. Pharmacy resource use was significantly associated with higher quality; inpatient, procedure and surgery, and ambulatory care visit resource use were not significantly associated. CONCLUSIONS: Quality and resource use for managed care populations with diabetes may vary considerably and be largely independent factors in health care delivery. Health plans may be able to favorably impact both factors.