RESUMO
CD4(+) follicular helper T cells (T(FH) cells) are essential for germinal center (GC) responses and long-lived antibody responses. Here we report that naive CD4(+) T cells deficient in the transcription factor Foxp1 'preferentially' differentiated into T(FH) cells, which resulted in substantially enhanced GC and antibody responses. We found that Foxp1 used both constitutive Foxp1A and Foxp1D induced by stimulation of the T cell antigen receptor (TCR) to inhibit the generation of T(FH) cells. Mechanistically, Foxp1 directly and negatively regulated interleukin 21 (IL-21); Foxp1 also dampened expression of the costimulatory molecule ICOS and its downstream signaling at early stages of T cell activation, which rendered Foxp1-deficient CD4(+) T cells partially resistant to blockade of the ICOS ligand (ICOSL) during T(FH) cell development. Our findings demonstrate that Foxp1 is a critical negative regulator of T(FH) cell differentiation.
Assuntos
Diferenciação Celular , Fatores de Transcrição Forkhead/fisiologia , Proteínas Repressoras/fisiologia , Linfócitos T Auxiliares-Indutores/citologia , Animais , Linfócitos T CD4-Positivos/imunologia , Proteína Coestimuladora de Linfócitos T Induzíveis/genética , Interleucinas/genética , Camundongos , Camundongos Endogâmicos C57BL , Receptores de Antígenos de Linfócitos T/fisiologiaRESUMO
Importance: Implemented in 18 regions, Comprehensive Primary Care Plus (CPC+) was the largest US primary care delivery model ever tested. Understanding its association with health outcomes is critical in designing future transformation models. Objective: To test whether CPC+ was associated with lower health care spending and utilization and improved quality of care. Design, Setting, and Participants: Difference-in-differences regression models compared changes in outcomes between the year before CPC+ and 5 intervention years for Medicare fee-for-service beneficiaries attributed to CPC+ and comparison practices. Participants included 1373 track 1 (1â¯549â¯585 beneficiaries) and 1515 track 2 (5â¯347â¯499 beneficiaries) primary care practices that applied to start CPC+ in 2017 and met minimum care delivery and other eligibility requirements. Comparison groups included 5243 track 1 (5â¯347â¯499 beneficiaries) and 3783 track 2 (4â¯507â¯499 beneficiaries) practices, matched, and weighted to have similar beneficiary-, practice-, and market-level characteristics as CPC+ practices. Interventions: Two-track design involving enhanced (higher for track 2) and alternative payments (track 2 only), care delivery requirements (greater for track 2), data feedback, learning, and health information technology support. Main Outcomes and Measures: The prespecified primary outcome was annualized Medicare Part A and B expenditures per beneficiary per month (PBPM). Secondary outcomes included expenditure categories, utilization (eg, hospitalizations), and claims-based quality-of-care process and outcome measures (eg, recommended tests for patients with diabetes and unplanned readmissions). Results: Among the CPC+ patients, 5% were Black, 3% were Hispanic, 87% were White, and 5% were of other races (including Asian/Other Pacific Islander and American Indian); 85% of CPC+ patients were older than 65 years and 58% were female. CPC+ was associated with no discernible changes in the total expenditures (track 1: $1.1 PBPM [90% CI, -$4.3 to $6.6], P = .74; track 2: $1.3 [90% CI, -$5 to $7.7], P = .73), and with increases in expenditures including enhanced payments (track 1: $13 [90% CI, $7 to $18], P < .001; track 2: $24 [90% CI, $18 to $31], P < .001). Among secondary outcomes, CPC+ was associated with decreases in emergency department visits starting in year 1, and in acute hospitalizations and acute inpatient expenditures in later years. Associations were more favorable for practices also participating in the Medicare Shared Savings Program and independent practices. CPC+ was not associated with meaningful changes in claims-based quality-of-care measures. Conclusions and Relevance: Although the timing of the associations of CPC+ with reduced utilization and acute inpatient expenditures was consistent with the theory of change and early focus on episodic care management of CPC+, CPC+ was not associated with a reduction in total expenditures over 5 years. Positive interaction between CPC+ and the Shared Savings Program suggests transformation models might be more successful when provider cost-reduction incentives are aligned across specialties. Further adaptations and testing of primary care transformation models, as well as consideration of the larger context in which they operate, are needed.
Assuntos
Gastos em Saúde , Medicare , Idoso , Humanos , Feminino , Estados Unidos , Masculino , Atenção à Saúde , Assistência Integral à Saúde , Planos de Pagamento por Serviço Prestado , Atenção Primária à Saúde/organização & administraçãoRESUMO
The molecular mechanisms that underlie T cell quiescence are poorly understood. Here we report that mature naive CD8(+) T cells lacking the transcription factor Foxp1 gained effector phenotype and function and proliferated directly in response to interleukin 7 (IL-7) in vitro. Foxp1 repressed expression of the IL-7 receptor α-chain (IL-7Rα) by antagonizing Foxo1 and negatively regulated signaling by the kinases MEK and Erk. Acute deletion of Foxp1 induced naive T cells to gain an effector phenotype and proliferate in lympho-replete mice. Foxp1-deficient naive CD8(+) T cells proliferated even in lymphopenic mice deficient in major histocompatibility complex class I. Our results demonstrate that Foxp1 exerts essential cell-intrinsic regulation of naive T cell quiescence, providing direct evidence that lymphocyte quiescence is achieved through actively maintained mechanisms that include transcriptional regulation.
Assuntos
Proliferação de Células , Fatores de Transcrição Forkhead/imunologia , Proteínas Repressoras/imunologia , Linfócitos T/imunologia , Animais , Butadienos/farmacologia , Linfócitos T CD8-Positivos/efeitos dos fármacos , Linfócitos T CD8-Positivos/imunologia , Linfócitos T CD8-Positivos/metabolismo , Células Cultivadas , Inibidores Enzimáticos/farmacologia , MAP Quinases Reguladas por Sinal Extracelular/antagonistas & inibidores , MAP Quinases Reguladas por Sinal Extracelular/imunologia , MAP Quinases Reguladas por Sinal Extracelular/metabolismo , Feminino , Citometria de Fluxo , Proteína Forkhead Box O1 , Fatores de Transcrição Forkhead/genética , Fatores de Transcrição Forkhead/metabolismo , Regulação da Expressão Gênica/efeitos dos fármacos , Imidazóis/farmacologia , Immunoblotting , Interleucina-7/farmacologia , MAP Quinase Quinase Quinases/antagonistas & inibidores , MAP Quinase Quinase Quinases/imunologia , MAP Quinase Quinase Quinases/metabolismo , Masculino , Camundongos , Camundongos Endogâmicos C57BL , Camundongos Knockout , Camundongos Transgênicos , Nitrilas/farmacologia , Ligação Proteica , Piridinas/farmacologia , Receptores de Interleucina-7/genética , Receptores de Interleucina-7/imunologia , Receptores de Interleucina-7/metabolismo , Proteínas Repressoras/genética , Proteínas Repressoras/metabolismo , Reação em Cadeia da Polimerase Via Transcriptase Reversa , Linfócitos T/efeitos dos fármacos , Linfócitos T/metabolismoRESUMO
BACKGROUND: The Centers for Medicare & Medicaid Services launched the 4-year Comprehensive Primary Care Initiative (CPC Classic) in 2012 and its 5-year successor, CPC Plus (CPC+), in 2017 to test whether improving primary care delivery in five areas-and providing practices with financial and technical support-reduced spending and improved quality. This is the first study to examine long-term effects of a primary care practice transformation model. OBJECTIVE: To test whether long-term primary care transformation-the 4-year CPC Classic and the first 2 years of its successor, CPC+-reduced hospitalizations, emergency department (ED) visits, and spending over 6 years. DESIGN: We used a difference-in-differences analysis to compare outcomes for beneficiaries attributed to CPC Classic practices with outcomes for beneficiaries attributed to comparison practices during the year before and 6 years after CPC Classic began. PARTICIPANTS: The study involved 565,674 Medicare fee-for-service beneficiaries attributed to 502 CPC Classic practices and 1,165,284 beneficiaries attributed to 908 comparison practices, with similar beneficiary-, practice-, and market-level characteristics as the CPC Classic practices. INTERVENTIONS: The interventions required primary care practices to improve 5 care areas and supported their transformation with substantially enhanced payment, data feedback, and learning support and, for CPC+, added health information technology support. MAIN MEASURES: Hospitalizations (all-cause), ED visits (outpatient and total), and Medicare Part A and B expenditures. KEY RESULTS: Relative to comparison practices, beneficiaries in intervention practices experienced slower growth in hospitalizations-3.1% less in year 5 and 3.5% less in year 6 (P < 0.01) and roughly 2% (P < 0.1) slower growth each year in total ED visits during years 3 through 6. Medicare Part A and B expenditures (excluding care management fees) did not change appreciably. CONCLUSIONS: The emergence of favorable effects on hospitalizations in years 5 and 6 suggests primary care transformation takes time to translate into lower hospitalizations. Longer tests of models are needed.
Assuntos
Gastos em Saúde , Medicare , Idoso , Assistência Integral à Saúde , Planos de Pagamento por Serviço Prestado , Humanos , Atenção Primária à Saúde , Estados UnidosRESUMO
BACKGROUND: Several E2 (reference electrode) positions are described for fibular (peroneal) nerve conduction studies to tibialis anterior (TA). METHODS: This study compared the contribution of different E2 sites to the TA motor response, using remote referential recordings and different bipolar montages. RESULTS: The medial knee contributes minimal electrical activity to the bipolar TA recordings, whereas tibial, ankle, and toe references resulted in very similar, moderate amplitude contributions consistent with far field potentials. These observations were very similar in controls and in patients with lower leg symptoms and signs. CONCLUSIONS: Standard montages using distal leg or foot E2 sites result in lower amplitudes with distortion arising from the E2 electrode, compared with the TA-Knee montage. Optimal measurement of the TA motor response is achieved using a medial knee reference, without compromising measures of fibular nerve conduction across the knee.
Assuntos
Eletrodos , Eletrodiagnóstico/métodos , Músculo Esquelético/fisiopatologia , Condução Nervosa , Nervo Fibular/fisiopatologia , Neuropatias Fibulares/fisiopatologia , Radiculopatia/fisiopatologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Feminino , Voluntários Saudáveis , Humanos , Vértebras Lombares , Masculino , Pessoa de Meia-Idade , Neuropatias Fibulares/diagnóstico , Radiculopatia/diagnóstico , Padrões de Referência , Adulto JovemRESUMO
BACKGROUND: Various techniques are described for proximal motor nerve conduction studies (NCSs). We investigated alternative reference electrode (E2) locations for accessory and axillary NCSs. METHODS: Multi-channel recordings were made from trapezius or deltoid referred to different sites, and from those sites referred to a remote electrode. Responses were compared using grouped statistics, and correlation analysis. RESULTS: For accessory NCSs, all belly:E2 montages showed comparable responses but axillary NCSs were more variable. Low amplitude contamination was seen at the sternum and contralateral acromion but greater distortion using other potential E2 sites. In both accessory and axillary studies, the ipsilateral acromion showed moderate activity, which correlated with the belly:remote response. CONCLUSIONS: Variation in E2 electrode sites may significantly distort the measured compound muscle action potential (CMAP). For accessory and axillary NCS, a sternal reference has favorable characteristics. Other sites, such as ipsilateral acromion or deltoid insertion, may not yield a representative CMAP.
Assuntos
Nervo Acessório/fisiopatologia , Potenciais de Ação/fisiologia , Plexo Braquial/fisiopatologia , Músculo Deltoide/inervação , Eletrodos , Eletrodiagnóstico/métodos , Condução Nervosa/fisiologia , Músculos Superficiais do Dorso/inervação , Nervo Acessório/fisiologia , Acrômio , Adulto , Idoso , Idoso de 80 Anos ou mais , Pontos de Referência Anatômicos , Axila , Plexo Braquial/fisiologia , Cotovelo , Feminino , Mãos , Humanos , Masculino , Pessoa de Meia-Idade , Esterno , Adulto JovemRESUMO
PURPOSE: Practices in the 4-year Comprehensive Primary Care (CPC) initiative changed staffing patterns during 2012-2016 to improve care delivery. We sought to characterize these changes and to compare practice patterns with those in similar non-CPC practices in 2016. METHODS: We conducted an online survey among selected US primary care practices. We statistically tested 2012-2016 changes in practice-reported staff composition among 461 CPC practices using 2-tailed t tests. Using logistic regression analysis, we compared differences in staff types between the CPC practices and 358 comparison practices that participated in the survey in 2016. RESULTS: In 2012, most CPC practices reported having physicians (100%), administrative staff (99%), and medical assistants (90%). By 2016, 84% reported having care managers/care coordinators (up from 24% in 2012), and 29% reported having behavioral health professionals, clinical psychologists, or social workers (up from 19% in 2014). There were also smaller increases (of less than 10 percentage points) in the share of practices having pharmacists, nutritionists, registered nurses, quality improvement specialists, and health educators. Larger and system-affiliated practices were more likely to report having care managers/care coordinators and behavioral health professionals. In 2016, relative to comparison practices, CPC practices were more likely to report having various staff types-notably, care managers/care coordinators (84% of CPC vs 36% of comparison practices), behavioral health professionals (29% vs 12%), and pharmacists (18% vs 4%). CONCLUSIONS: During the CPC initiative, CPC practices added different staff types to a fairly traditional staffing model of physicians with medical assistants. They most commonly added care managers/care coordinators and behavioral health staff to support the CPC model and, at the end of CPC, were more likely to have these staff members than comparison practices.
Assuntos
Atenção à Saúde/organização & administração , Pessoal de Saúde/organização & administração , Admissão e Escalonamento de Pessoal/tendências , Padrões de Prática Médica/tendências , Atenção Primária à Saúde/organização & administração , Atenção à Saúde/normas , Pesquisas sobre Atenção à Saúde , Pessoal de Saúde/normas , Humanos , Modelos Logísticos , Admissão e Escalonamento de Pessoal/normas , Atenção Primária à Saúde/normas , Papel Profissional , Melhoria de Qualidade , Estados UnidosRESUMO
BACKGROUND: The 4-year, multipayer Comprehensive Primary Care Initiative was started in October 2012 to determine whether several forms of support would produce changes in care delivery that would improve the quality and reduce the costs of care at 497 primary care practices in seven regions across the United States. Support included the provision of care-management fees, the opportunity to earn shared savings, and the provision of data feedback and learning support. METHODS: We tracked changes in the delivery of care by practices participating in the initiative and used difference-in-differences regressions to compare changes over the first 2 years of the initiative in Medicare expenditures, health care utilization, claims-based measures of quality, and patient experience for Medicare fee-for-service beneficiaries attributed to initiative practices and a group of matched comparison practices. RESULTS: During the first 2 years, initiative practices received a median of $115,000 per clinician in care-management fees. The practices reported improvements in approaches to the delivery of primary care in areas such as management of the care of high-risk patients and enhanced access to care. Changes in average monthly Medicare expenditures per beneficiary did not differ significantly between initiative and comparison practices when care-management fees were not taken into account (-$11; 95% confidence interval [CI], -$23 to $1; P=0.07; negative values indicate less growth in spending at initiative practices) or when these fees were taken into account ($7; 95% CI, -$5 to $19; P=0.27). The only significant differences in other measures were a 3% reduction in primary care visits for initiative practices relative to comparison practices (P<0.001) and changes in two of the six domains of patient experience--discussion of decisions regarding medication with patients and the provision of support for patients taking care of their own health--both of which showed a small improvement in initiative practices relative to comparison practices (P=0.006 and P<0.001, respectively). CONCLUSIONS: Midway through this 4-year intervention, practices participating in the initiative have reported progress in transforming the delivery of primary care. However, at this point these practices have not yet shown savings in expenditures for Medicare Parts A and B after accounting for care-management fees, nor have they shown an appreciable improvement in the quality of care or patient experience. (Funded by the Department of Health and Human Services, Centers for Medicare and Medicaid Services; ClinicalTrials.gov number, NCT02320591.).
Assuntos
Planos de Pagamento por Serviço Prestado/economia , Custos de Cuidados de Saúde , Medicare/economia , Atenção Primária à Saúde/organização & administração , Qualidade da Assistência à Saúde , Centers for Medicare and Medicaid Services, U.S. , Assistência Integral à Saúde , Humanos , Medicare/normas , Atenção Primária à Saúde/economia , Atenção Primária à Saúde/normas , Estados UnidosRESUMO
BACKGROUND: Physician burnout is associated with deleterious effects for physicians and their patients and might be exacerbated by practice transformation. OBJECTIVE: Assess the effect of the Comprehensive Primary Care (CPC) initiative on primary care physician experience. DESIGN: Prospective cohort study conducted with about 500 CPC and 900 matched comparison practices. Mail surveys of primary care physicians, selected using cross-sectional stratified random selection 11 months into CPC, and a longitudinal design with sample replacement 44 months into CPC. PARTICIPANTS: Primary care physicians in study practices. INTERVENTION: A multipayer primary care transformation initiative (October 2012-December 2016) that required care delivery changes and provided enhanced payment, data feedback, and learning support. MAIN MEASURES: Burnout, control over work, job satisfaction, likelihood of leaving current practice within 2 years. KEY RESULTS: More than 1000 physicians responded (over 630 of these in CPC practices) in each round (response rates 70-81%, depending on round and research group). Physician experience outcomes were similar for physicians in CPC and comparison practices. About one third of physician respondents in CPC and comparison practices reported high levels of burnout in each round (32 and 29% in 2013 [P = 0.59], and 34 and 36% in 2016 [P = 0.63]). Physicians in CPC and comparison practices reported some to moderate control over work, with an average score from 0.50 to 0.55 out of 1 in 2013 and 2016 (CPC-comparison differences of - 0.04 in 2013 [95% CI - 0.08-0.00, P = 0.07], and - 0.03 in 2016 [95% CI - 0.03-0.02, P = 0.19]). In 2016, roughly three quarters of CPC and comparison physicians were satisfied with their current job (77 and 74%, P = 0.77) and about 15% planned to leave their practice within 2 years (14 and 15%, P = 0.17). CONCLUSIONS: Despite requiring substantial practice transformation, CPC did not affect physician experience. Research should track effects of other transformation initiatives on physicians and test new ways to address burnout. TRIAL REGISTRATION: ClinicalTrials.gov number, NCT02320591.
Assuntos
Esgotamento Profissional/epidemiologia , Atenção à Saúde/organização & administração , Satisfação no Emprego , Médicos de Atenção Primária/organização & administração , Atenção Primária à Saúde/tendências , Local de Trabalho/organização & administração , Adulto , Estudos Transversais , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Inquéritos e Questionários , Estados Unidos/epidemiologia , Adulto JovemRESUMO
BACKGROUND: Incorporating behavioral health care into patient centered medical homes is critical for improving patient health and care quality while reducing costs. Despite documented effectiveness of behavioral health integration (BHI) in primary care settings, implementation is limited outside of large health systems. We conducted a survey of BHI in primary care practices participating in the Comprehensive Primary Care (CPC) initiative, a four-year multi-payer initiative of the Centers for Medicare and Medicaid Services (CMS). We sought to explore associations between practice characteristics and the extent of BHI to illuminate possible factors influencing successful implementation. METHOD: We fielded a survey that addressed six substantive domains (integrated space, training, access, communication and coordination, treatment planning, and available resources) and five behavioral health conditions (depression, anxiety, pain, alcohol use disorder, and cognitive function). Descriptive statistics compared BHI survey respondents to all CPC practices, documented the availability of behavioral health providers, and primary care and behavioral health provider communication. Bivariate relationships compared provider and practice characteristics and domain scores. RESULTS: One hundred sixty-one of 188 eligible primary care practices completed the survey (86% response rate). Scores indicated basic to good baseline implementation of BHI in all domains, with lowest scores on communication and coordination and highest scores for depression. Higher scores were associated with: having any behavioral health provider, multispecialty practice, patient-centered medical home designation, and having any communication between behavioral health and primary care providers. CONCLUSIONS: This study provides useful data on opportunities and challenges of scaling BHI integration linked to primary care transformation. Payment reform models such as CPC can assist in BHI promotion and development.
Assuntos
Assistência Integral à Saúde , Comportamentos Relacionados com a Saúde , Atenção Primária à Saúde , Centers for Medicare and Medicaid Services, U.S. , Inquéritos Epidemiológicos , Humanos , Saúde Mental , Assistência Centrada no Paciente , Atenção Primária à Saúde/organização & administração , Atenção Primária à Saúde/estatística & dados numéricos , Qualidade da Assistência à Saúde , Estados UnidosRESUMO
PURPOSE: Despite growing calls for team-based care, the current staff composition of primary care practices is unknown. We describe staffing patterns for primary care practices in the Centers for Medicare and Medicaid Services (CMS) Comprehensive Primary Care (CPC) initiative. METHODS: We undertook a descriptive analysis of CPC initiative practices' baseline staffing using data from initial applications and a practice survey. CMS selected 502 primary care practices (from 987 applicants) in 7 regions based on their health information technology, number of patients covered by participating payers, and other factors; 496 practices were included in this analysis. RESULTS: Consistent with the national distribution, most of the CPC initiative practices included in this study were small: 44% reported 2 or fewer full-time equivalent (FTE) physicians; 27% reported more than 4. Nearly all reported administrative staff (98%) and medical assistants (89%). Fifty-three percent reported having nurse practitioners or physician assistants; 47%, licensed practical or vocational nurses; 36%, registered nurses; and 24%, care managers/coordinators-all of these positions are more common in larger practices. Other clinical staff were reported infrequently regardless of practice size. Compared with other CPC initiative practices, designated patient-centered medical homes were more likely to have care managers/coordinators but otherwise had similar staff types. Larger practices had fewer FTE staff per physician. CONCLUSIONS: At baseline, most CPC initiative practices used traditional staffing models and did not report having dedicated staff who may be integral to new primary care models, such as care coordinators, health educators, behavioral health specialists, and pharmacists. Without such staff and payment for their services, practices are unlikely to deliver comprehensive, coordinated, and accessible care to patients at a sustainable cost.
Assuntos
Assistência Integral à Saúde , Admissão e Escalonamento de Pessoal , Atenção Primária à Saúde , Assistência Integral à Saúde/organização & administração , Feminino , Humanos , Masculino , Atenção Primária à Saúde/organização & administração , Estados Unidos , Recursos HumanosRESUMO
We report a woman in her 30s with dysferlinopathy whose diagnosis was masked by superimposed hypothyroidism. Laboratory studies revealed Hashimoto's thyroiditis and markedly raised serum creatine kinase (CK of 6255 U/L; reference range 0-170 U/L). Electromyography, nerve conduction studies and MRI of the hip and thigh were consistent with a diagnosis of hypothyroid myopathy, but thyroxine failed to resolve her clinical presentation or normalise the CK level. Immunohistochemical (IHC) staining of right vastus lateralis muscle biopsy revealed the selective absence of dysferlin leading to a diagnosis of limb-girdle muscular dystrophy type IIB. Dysferlinopathy is a challenging diagnosis due to a varied clinical picture and low incidence. Misdiagnosis is common even in uncomplicated presentations, and this case outlines the need for routine inclusion of IHC and a low threshold for genetic testing, in the workup of complex myopathy.
Assuntos
Hipotireoidismo , Distrofia Muscular do Cíngulo dos Membros , Humanos , Feminino , Distrofia Muscular do Cíngulo dos Membros/diagnóstico , Distrofia Muscular do Cíngulo dos Membros/complicações , Adulto , Hipotireoidismo/complicações , Hipotireoidismo/diagnóstico , Disferlina/genética , Eletromiografia , Diagnóstico Diferencial , Imageamento por Ressonância Magnética , Tiroxina/uso terapêutico , Biópsia , Doença de Hashimoto/complicações , Doença de Hashimoto/diagnóstico , Creatina Quinase/sangueRESUMO
OBJECTIVES: To determine how the multipayer Comprehensive Primary Care (CPC) initiative that transformed primary care delivery affected patient experience of Medicare fee-for-service beneficiaries. The study examines whether patient experience changed during the 4-year initiative, whether ratings of CPC practices changed relative to ratings of comparison practices, and areas in which practices still have an opportunity to improve patient experience. STUDY DESIGN: Prospective study using 2 cross-sectional samples of more than 25,000 Medicare fee-for-service beneficiaries attributed to 490 CPC practices and more than 8000 beneficiaries attributed to 736 comparison practices. METHODS: We analyzed patient experience 8 to 12 months and 45 to 48 months after CPC began, measured using 5 domains of the Consumer Assessment of Healthcare Providers and Systems Clinician and Group survey with Patient-Centered Medical Home items, version 2.0. A regression-adjusted analysis compared differences in the proportion of beneficiaries giving the best responses (and, as a sensitivity test, mean responses) to survey questions over time and between CPC and comparison practices. RESULTS: Patient ratings of care over time were generally comparable for CPC and comparison practices. CPC had favorable effects on measures of follow-up care after hospitalizations and emergency department visits. CONCLUSIONS: Practice transformation did not alter patient experience. The lack of favorable findings raises questions about how future efforts in primary care can succeed in improving patient experience.
Assuntos
Inovação Organizacional , Atenção Primária à Saúde/organização & administração , Estudos Transversais , Serviço Hospitalar de Emergência/estatística & dados numéricos , Planos de Pagamento por Serviço Prestado , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Medicare , Satisfação do Paciente/estatística & dados numéricos , Estudos Prospectivos , Qualidade da Assistência à Saúde/estatística & dados numéricos , Estados UnidosRESUMO
BACKGROUND: Performance feedback is central to data-driven models of quality improvement, but the use of claims-based data for feedback has received little attention. PURPOSE: To examine the challenges, uses, and limitations of quarterly Medicare claims-based performance feedback reports generated for practices participating in the Comprehensive Primary Care (CPC) initiative from 2012 to 2015. METHODS: Mixed methods study of nearly 500 CPC practices in seven regions, combining pilot testing; systematic monitoring; surveys; in-depth interviews; user feedback; and input from data feedback team. RESULTS: Designing reports required addressing issues about timing, data completeness and reliability, variations in patient risk across practices, and use of benchmarks and metrics understandable to users. Practices' ability to use reports constructively depended on their experience, analytic resources, expectations, and perceptions about the role of primary care in improving reported outcomes. CONCLUSIONS: Generating claims-based feedback reports that support practices' quality improvement efforts requires a significant investment of analytic expertise, time, resources, continuous improvement, and technical assistance. IMPLICATIONS: Claims-based performance feedback can provide insight into patterns of patients' care across provider settings and opportunities for improvement, but practices need data from other sources to manage patients in real time or assess the short-term effects of specific changes in care delivery.
Assuntos
Atenção à Saúde/normas , Revisão da Utilização de Seguros/estatística & dados numéricos , Medicare/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Atenção Primária à Saúde/normas , Melhoria de Qualidade/estatística & dados numéricos , Melhoria de Qualidade/normas , Adulto , Atenção à Saúde/estatística & dados numéricos , Retroalimentação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Estados UnidosRESUMO
The Comprehensive Primary Care Initiative (CPC), a health care delivery model developed by the Centers for Medicare and Medicaid Services (CMS), tested whether multipayer support of 502 primary care practices across the country would improve primary care delivery, improve care quality, or reduce spending. We evaluated the initiative's effects on care delivery and outcomes for fee-for-service Medicare beneficiaries attributed to initiative practices, relative to those attributed to matched comparison practices. CPC practices reported improvements in primary care delivery, including care management for high-risk patients, enhanced access, and improved coordination of care transitions. The initiative slowed growth in emergency department visits by 2 percent in CPC practices, relative to comparison practices. However, it did not reduce Medicare spending enough to cover care management fees or appreciably improve physician or beneficiary experience or practice performance on a limited set of Medicare claims-based quality measures. As CMS and other payers increasingly use alternative payment models that reward quality and value, CPC provides important lessons about supporting practices in transforming care.
Assuntos
Assistência Integral à Saúde/organização & administração , Atenção à Saúde/economia , Gastos em Saúde , Atenção Primária à Saúde/organização & administração , Qualidade da Assistência à Saúde , Centers for Medicare and Medicaid Services, U.S./organização & administração , Bases de Dados Factuais , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Assistência Centrada no Paciente/economia , Padrões de Prática Médica/economia , Avaliação de Programas e Projetos de Saúde , Análise de Regressão , Mecanismo de Reembolso , Estados UnidosRESUMO
OBJECTIVES: To evaluate impacts of a telephonic transitional care program on service use and spending for Medicare fee-for-service beneficiaries at a rural hospital. STUDY DESIGN: Observational cohort study. METHODS: Patients discharged from Atlantic General Hospital (AGH) with an AGH primary care provider were assigned a nurse care coordinator for 30 days. The nurse reviewed the patient's conditions, assessed needs for transition support, conducted weekly telephone calls (beginning 24-72 hours after discharge) to monitor adherence to treatment plans, and scheduled follow-up appointments. Using claims data, we evaluated impacts on service use and spending using a difference-in-differences design with a matched comparison group. RESULTS: The intervention reduced Medicare spending in the 6-month period after discharge by 30.8%, or $1333 per beneficiary per month (90% CI, -$2078 to -$589), which was partly driven by a 39.4% reduction in spending for inpatient claims (difference, -$729; 90% CI, -$1234 to -$225). There were no statistically significant changes in the 14-day ambulatory care follow-up rate, 30-day unplanned readmission rate, number of inpatient admissions, or number of emergency department visits, although this may be due to modest statistical power to detect effects. CONCLUSIONS: The estimated $5.4 million in savings from this intervention more than offset the costs of the $1.1 million funding for the award. Although other studies have found that care transitions programs can improve outcomes, this study was unique in the size of the impacts relative to the low-touch intervention and the location in a small rural healthcare system.
Assuntos
Redução de Custos , Hospitais Rurais/economia , Medicare/economia , Telefone , Cuidado Transicional/economia , Idoso , Planos de Pagamento por Serviço Prestado/economia , Feminino , Humanos , Masculino , Estados UnidosRESUMO
OBJECTIVES: Risk-stratified care management is a cornerstone of patient-centered medical home models, but studies on patients' perspectives of care management are scarce. We explored patients' experiences with care management, what they found useful, and what needs improvement. STUDY DESIGN: Semi-structured qualitative telephone interviews. METHODS: We interviewed 43 high-risk patients or their caregivers who were receiving care management from 11 practices in CMS' Comprehensive Primary Care initiative, provided by nurse care managers (9 practices) or the physician (2 [solo] practices). RESULTS: Patients' perceptions of care management were mixed. Patients who had regular contact with, and a desire to work with, their care manager valued the care management services provided. These patients valued care managers who listened to them and explained their conditions and options in lay terms, helped them navigate the healthcare system and community resources, and followed up after hospitalizations. However, one-fifth of the patients in practices that used nurse care managers could not identify their care manager although we: 1) sampled patients who had recent contact with their care manager and 2) defined the care manager's roles and provided examples of typical care management activities. Patients' interactions with care managers from health plans and hospitals contributed to confusion. CONCLUSIONS: Practices can improve patient buy-in for care management through in-person introductions to care managers by their physicians, offering care management to patients who need and are interested in it, broader agreement about terminology and the role of care managers and care plans, and better coordination with care management from insurers and hospitals.
Assuntos
Atenção à Saúde/organização & administração , Administração dos Cuidados ao Paciente/organização & administração , Satisfação do Paciente , Assistência Centrada no Paciente/organização & administração , Atenção Primária à Saúde/organização & administração , Comunicação , Humanos , Entrevistas como Assunto , Papel do Profissional de Enfermagem , Percepção , Pesquisa Qualitativa , Fatores de Risco , Fatores Socioeconômicos , Estados UnidosRESUMO
Using delivery system innovations to advance health care reform continues to be of widespread interest. However, it is difficult to generalize about the success of specific types of innovations, since they have been examined in only a few studies. To gain a broader perspective, we analyzed the results of forty-three ambulatory care programs funded by the first round of the Center for Medicare and Medicaid Innovation's Health Care Innovations Awards. The innovations' impacts on total cost of care were estimated by independent evaluators using multivariable difference-in-differences models. Through the first two years, most of the innovations did not show a significant effect on total cost of care. Using meta-regression, we assessed the effects on costs of five common components of these innovations. Innovations that used health information technology or community health workers achieved the greatest cost savings. Savings were also relatively large in programs that targeted clinically fragile patients-clinically complex populations at risk for disease progression. While the magnitude of these effects was often substantial, none achieved conventional levels of significance in our analyses. Meta-analyses of a larger number of delivery system innovations are needed to more clearly establish their potential for patient care cost savings.
Assuntos
Redução de Custos , Atenção à Saúde/economia , Inovação Organizacional/economia , Assistência Ambulatorial/economia , Assistência Ambulatorial/organização & administração , Centers for Medicare and Medicaid Services, U.S. , Agentes Comunitários de Saúde , Humanos , Tecnologia da Informação , Estados UnidosRESUMO
OBJECTIVES: To determine how the multipayer Comprehensive Primary Care (CPC) initiative that transforms primary care delivery affects the patient experience of Medicare fee-for-service beneficiaries. The study examines how experience changed between the first and second years of CPC, how ratings of CPC practices have changed relative to ratings of comparison practices, and areas in which practices still have opportunities to improve patient experience. STUDY DESIGN: Prospective study using 2 serial cross-sectional samples of more than 25,000 Medicare fee-for-service beneficiaries attributed to 496 CPC practices and nearly 9000 beneficiaries attributed to 792 comparison practices. METHODS: We analyzed patient experience 8 to 12 months and 21 to 24 months after CPC began, measured using 6 domains of the Consumer Assessment of Healthcare Providers and Systems Clinician and Group 12-Month Survey with Patient-Centered Medical Home supplemental items. We compared changes over time in patients giving the best responses between CPC and comparison practices using a regression-adjusted difference-in-differences analysis. RESULTS: Patient ratings of care over time were generally comparable for CPC and comparison practices, with slightly more favorable differences-generally of small magnitude-for CPC practices than expected by chance. There were small, statistically significant, favorable effects for 2 of 6 composite measures measured using both the proportion giving the best responses and mean responses: getting timely appointments, care, and information; providers support patients in taking care of their own health; and providers discuss medication decisions. There was an additional small favorable effect on the proportion of patients giving the best response in getting timely appointments, care, and information; there was no effect on the mean. CONCLUSIONS: During the first 2 years of CPC, CPC practices showed slightly better year-to-year patient experience ratings for selected items, indicating that transformation did not negatively affect patient experience and improved some aspects slightly. Patient ratings for the 2 groups were generally comparable, and both faced substantial room for improvement.