Identifying Homogeneous Patient Clusters in Swiss University Hospital Through Latent Class Analysis.

In hospitalized populations, there is significant heterogeneity in patients' characteristics, disease severity, and treatment responses, which translates into different related outcomes and costs. Identifying inpatient clusters with similar clinical profiles could lead to better quality and personalized care while improving clinical resources used. Super-utilizers (SUs) are one such a group, who contribute a substantial proportion of health care costs and utilize a disproportionately high share of health care resources. This study uses cost, utilization metrics and clinical information to segment the population of patients (N=32,759) admitted to the University Hospitals of Geneva per year in 2017 - 2019. Using Latent Class Analysis it identifies 8 subgroups with highly similar patients demographics, medical conditions, types of service and costs within groups and which are highly different between groups. As such 82% of all SU patients, 99% of all patients less than 20 years old and 78% of all orthopedics patients are clustered into only 3 separate groups while one group contain only adult women 90% of them 20 to 40 years of age.

How to improve hospital admission screening for patients at risk of multidrug-resistant organism carriage: a before-and-after interventional study and cost-effectiveness analysis.

BACKGROUND: Infection prevention and control (IPC) is a prioritised task for healthcare workers in emergency department (ED). Here, we examined compliance with admission screening (AS) and additional precautions (AP) measures for patients at risk of infection with multidrug-resistant organisms (MDROs) by using a two-stage, multifaceted educational intervention, also comparing the cost of a developed automated indicator for AS and AP compliance and clinical audits to sustain observed findings. METHODS: In the first stage, staff in the ED of the University Hospitals of Geneva, Switzerland, were briefed on IPC measures (AS and AP). A cross-sectional survey was then conducted to assess barriers to IPC measures. In the second stage, healthcare workers underwent training sessions, and an electronic patient record 'order-set' including AS and AP compliance indicators was designed. We compared the cost-benefit of the audits and the automated indicators for AS and AP compliance. RESULTS: Compliance significantly improved after training, from 36.2% (95% CI 23.6% to 48.8%) to 78.8% (95% CI 67.1% to 90.3%) for AS (n=100, p=0.0050) and from 50.2% (95% CI 45.3% to 55.1%) to 68.5% (95% CI 60.1% to 76.9%) for AP (n=125, p=0.0092). Healthcare workers recognised MDRO screening as an ED task (70.2%), with greater acknowledgment of risk factors at AS considered an ED duty. The monthly cost was higher for clinical audits than the automated indicator, with a reported yearly cost of US$120 203. The initial cost of developing the automated indicator was US$18 290 and its return on investment US$3.44 per US$1 invested. CONCLUSION: Training ED staff increased compliance with IPC measures when accompanied by team discussions for optimal effectiveness. An automated indicator of compliance is cheaper and closer to real-time than a clinical audit.

[Benefits of integrated care delivery system for heart failure: A case study of Intermountain Healthcare (USA)]. / Bénéfices de la prise en charge intégrée de l'insuffisance cardiaque : l'exemple d'Intermountain Healthcare (États-Unis).

BACKGROUND: Among chronic diseases, heart failure is a top public health priority both in France and in the United States. If progress is possible in France, the experience from Intermountain Healthcare (IH), in the United States can be a source of significant experimentations. AIM: To identify the teaching of the clinical integration of the specialists in the field of heart failure with the primary care sector which could be useful in France. METHODS: This research is based on the qualitative analysis of data resulting from the work between experts, of bibliographical research, and of some groupings by item corresponding to the objectives of the Triple Aim from the Institute for Healthcare Improvement (IHI). RESULTS: The program of the integrated care delivery system for heart failure of Intermountain Healthcare reaches the objectives of the Triple Aim from the IHI, that is to say, the enhancement of the health of the population, improving quality of care and the satisfaction of the user, and the reduction of the cost of care. This program also enhances the Chronic Care Model by integrating a team of specialists in the field of heart failure, building up a pluridisciplinary team focused on the need of both the patients and their families. This creates a multidisciplinary care delivery system for heart failure which is global, protocolized, stratified, planned and followed. The prevention and the ambulatory care integrating the specialized care of second stage to the care of first stage are developed. The users and their families are co-responsible for their health. The systematic evaluation is based on the specific indicators. DISCUSSION: This program improves the effectiveness of care while improving organizational efficiency resulting in savings for IH Health Plan (SelectHealth). It also enhances the equality of access to better healthcare and health for the entire population.

Association of Integrated Team-Based Care With Health Care Quality, Utilization, and Cost.

IMPORTANCE: The value of integrated team delivery models is not firmly established. OBJECTIVE: To evaluate the association of receiving primary care in integrated team-based care (TBC) practices vs traditional practice management (TPM) practices (usual care) with patient outcomes, health care utilization, and costs. DESIGN: A retrospective, longitudinal, cohort study to assess the association of integrating physical and mental health over time in TBC practices with patient outcomes and costs. SETTING AND PARTICIPANTS: Adult patients (aged ≥18 years) who received primary care at 113 unique Intermountain Healthcare Medical Group primary care practices from 2003 through 2005 and had yearly encounters with Intermountain Healthcare through 2013, including some patients who received care in both TBC and TPM practices. EXPOSURES: Receipt of primary care in TBC practices compared with TPM practices for patients treated in internal medicine, family practice, and geriatrics practices. MAIN OUTCOMES AND MEASURES: Outcomes included 7 quality measures, 6 health care utilization measures, payments to the delivery system, and program investment costs. RESULTS: During the study period (January 2010-December 2013), 113,452 unique patients (mean age, 56.1 years; women, 58.9%) accounted for 163,226 person-years of exposure in 27 TBC practices and 171,915 person-years in 75 TPM practices. Patients treated in TBC practices compared with those treated in TPM practices had higher rates of active depression screening (46.1% for TBC vs 24.1% for TPM; odds ratio [OR], 1.91 [95% CI, 1.75 to 2.08), adherence to a diabetes care bundle (24.6% for TBC vs 19.5% for TPM; OR, 1.26 [95% CI, 1.11 to 1.42]), and documentation of self-care plans (48.4% for TBC vs 8.7% for TPM; OR, 5.59 [95% CI, 4.27 to 7.33]), lower proportion of patients with controlled hypertension (<140/90 mm Hg) (85.0% for TBC vs 97.7% for TPM; OR, 0.87 [95% CI, 0.80 to 0.95]), and no significant differences in documentation of advanced directives (9.6% for TBC vs 9.9% for TPM; OR, 0.97 [95% CI, 0.91 to 1.03]). Per 100 person-years, rates of health care utilization were lower for TBC patients compared with TPM patients for emergency department visits (18.1 for TBC vs 23.5 for TPM; incidence rate ratio [IRR], 0.77 [95% CI, 0.74 to 0.80]), hospital admissions (9.5 for TBC vs 10.6 for TPM; IRR, 0.89 [95% CI, 0.85 to 0.94]), ambulatory care sensitive visits and admissions (3.3 for TBC vs 4.3 for TPM; IRR, 0.77 [95% CI, 0.70 to 0.85]), and primary care physician encounters (232.8 for TBC vs 250.4 for TPM; IRR, 0.93 [95% CI, 0.92 to 0.94]), with no significant difference in visits to urgent care facilities (55.7 for TBC vs 56.2 for TPM; IRR, 0.99 [95% CI, 0.97 to 1.02]) and visits to specialty care physicians (213.5 for TBC vs 217.9 for TPM; IRR, 0.98 [95% CI, 0.97 to 0.99], P > .008). Payments to the delivery system were lower in the TBC group vs the TPM group ($3400.62 for TBC vs $3515.71 for TPM; ß, -$115.09 [95% CI, -$199.64 to -$30.54]) and were less than investment costs of the TBC program. CONCLUSIONS AND RELEVANCE: Among adults enrolled in an integrated health care system, receipt of primary care at TBC practices compared with TPM practices was associated with higher rates of some measures of quality of care, lower rates for some measures of acute care utilization, and lower actual payments received by the delivery system.

[Integrated care delivery system for mental illness: A case study of Intermountain Healthcare (USA)]. / Prise en charge intégrée des maladies mentales: l'exemple d'Intermountain Healthcare (USA).

BACKGROUND: Mental health is a public health priority among chronic diseases in France and the United States. Although there is room for progress in France, the experience of Intermountain Healthcare (IH), Utah, in the United States can provide convincing experimental data. AIM: To identify the lessons learned from IH clinical integration of mental health specialists in primary care practices called "Mental Health Integration" (MHI) which might be useful in France. METHODS: This research is based on qualitative analysis of data derived from collaborative work with IH experts, literature searches, and item queries on the 3 objectives of the Triple Aim of the Institute for Healthcare Improvement (IHI). RESULTS: The MHI programme was developed to achieve IHI T riple AIM: improving user satisfaction; improving access of care and the health of the population; reducing health care costs per capita. By integrating mental health specialists within a multidisciplinary team headed by primary care physicians and working under the same roof with care managers and support staff, the MHI model enhances the process of the Chronic Care Model. Furthermore MHI has become the foundation for team-based care centered on the patient and theirfamily over the continuum of care by offering a global and structured evidenced-based care process. Prevention and integration of specialized care have been developed. Users and their families are co-responsible for their health. Discussion: Evaluation is systematic and based on specific indicators. The efficiency and clinical and organizational effectiveness created generate savings for health insurance as well as improved access to care and health equality.

Diabetes self-management education improves quality of care and clinical outcomes determined by a diabetes bundle measure.

PURPOSE: The purpose of this study was to determine the impact of diabetes self-management education (DSME) in improving processes and outcomes of diabetes care as measured by a five component diabetes bundle and HbA1c, in individuals with type 2 diabetes mellitus (T2DM). METHODS: A retrospective analysis was performed for adult T2DM patients who received DSME training in 2011-2012 from an accredited American Diabetes Association center at Intermountain Healthcare (IH) and had an HbA1c measurement within the prior 3 months and 2-6 months after completing their first DSME visit. Control patients were selected from the same clinics as case-patients using random number generator to achieve a 1 to 4 ratio. Case and control patients were included if 1) pre-education HbA1c was between 6.0%-14.0%; 2) their main provider was a primary care physician; 3) they met the national Healthcare Effectiveness Data and Information Set criteria for inclusion in the IH diabetes registry. The IH diabetes bundle includes retinal eye exam, nephropathy screening or prescription of angiotensin converting enzyme or angiotensin receptor blocker; blood pressure <140/90 mmHg, LDL <100 mg/dL, HbA1c <8.0%. RESULTS: DSME patients had a significant difference in achievement of the five element IH diabetes bundle and in HbA1c % compared to those without DSME. After adjusting for possible confounders in a multivariate logistic regression model, DSME patients had a 1.5 fold difference in improvement in their diabetes bundle and almost a 3 fold decline in HbA1c compared to the control group. CONCLUSION: Standardized DSME taught within an IH American Diabetes Association center is strongly associated with a substantial improvement in patients meeting all five elements of a diabetes bundle and a decline in HbA1c beyond usual care. Given the low operating cost of the DSME program, these results strongly support the value adding benefit of this program in treating T2DM patients.

Impact of the healthcare payment system on patient access to oral anticancer drugs: an illustration from the French and United States contexts.

BACKGROUND: Oral anticancer drugs (OADs) allow treating a growing range of cancers. Despite their convenience, their acceptance by healthcare professionals and patients may be affected by medical, economical and organizational factors. The way the healthcare payment system (HPS) reimburses OADs or finances hospital activities may impact patients' access to such drugs. We discuss how the HPS in France and USA may generate disincentives to the use of OADs in certain circumstances. DISCUSSION: French public and private hospitals are financed by National Health Insurance (NHI) according to the nature and volume of medical services provided annually. Patients receiving intravenous anticancer drugs (IADs) in a hospital setting generate services, while those receiving OADs shift a part of service provision from the hospital to the community. In 2013, two million outpatient IADs sessions were performed, representing a cost of €815 million to the NHI, but positive contribution margin of €86 million to hospitals. Substitution of IADs by OADs mechanically induces a shortfall in hospital income related to hospitalizations. Such economic constraints may partially contribute to making physicians reluctant to prescribe OADs. In the US healthcare system, coverage for OADs is less favorable than coverage for injectable anticancer drugs. In 2006, a Cancer Drug Coverage Parity Act was adopted by several states in order to provide patients with better coverage for OADs. Nonetheless, the complexity of reimbursement systems and multiple reimbursement channels from private insurance represent real economic barriers which may prevent patients with low income being treated with OADs. From an organizational perspective, in both countries the use of OADs generates additional activities related to physician consultations, therapeutic education and healthcare coordination between hospitals and community settings, which are not considered in the funding of hospitals activities so far. SUMMARY: Funding of healthcare services is a critical factor influencing in part the choice of cancer treatments and this is expected to become increasingly important as economic constraints grow. Drug reimbursement systems and hospital financing changes, coupled with other accompanying measures, should contribute to improve equal and safe patient access to appropriate anticancer drugs and improve the management and care pathway of cancer patients.

Computerization of Mental Health Integration complexity scores at Intermountain Healthcare.

Intermountain Healthcare's Mental Health Integration (MHI) Care Process Model (CPM) contains formal scoring criteria for assessing a patient's mental health complexity as "mild," "medium," or "high" based on patient data. The complexity score attempts to assist Primary Care Physicians in assessing the mental health needs of their patients and what resources will need to be brought to bear. We describe an effort to computerize the scoring. Informatics and MHI personnel collaboratively and iteratively refined the criteria to make them adequately explicit and reflective of MHI objectives. When tested on retrospective data of 540 patients, the clinician agreed with the computer's conclusion in 52.8% of the cases (285/540). We considered the analysis sufficiently successful to begin piloting the computerized score in prospective clinical care. So far in the pilot, clinicians have agreed with the computer in 70.6% of the cases (24/34).

Obesity leads to higher risk of sperm DNA damage in infertile patients.

There has been a growing interest over the past few years in the impact of male nutrition on fertility. Infertility has been linked to male overweight or obesity, and conventional semen parameter values seem to be altered in case of high body mass index (BMI). A few studies assessing the impact of BMI on sperm DNA integrity have been published, but they did not lead to a strong consensus. Our objective was to explore further the relationship between sperm DNA integrity and BMI, through a 3-year multicentre study. Three hundred and thirty male partners in subfertile couples were included. Using the terminal uridine nick-end labelling (TUNEL) assay, we observed an increased rate of sperm DNA damage in obese men (odds ratio (95% confidence interval): 2.5 (1.2-5.1)).

Cost and quality impact of Intermountain's mental health integration program.

Most patients with mental health (MH) conditions, such as depression, receive care for their conditions from a primary care physician (PCP) in their health/medical home. Providing MH care, however, presents many challenges for the PCP, including (1) the difficulty of getting needed consultation from an MH specialist; (2) the time constraints of a busy PCP practice; (3) the complicated nature of recognizing depression, which may be described with only somatic complaints; (4) the barriers to reimbursement and compensation; and (5) associated medical and social comorbidities. Practice managers, emergency departments, and health plans are stretched to provide care for complex patients with unmet MH needs. At the same time, payment reform linked to accountable care organizations and/or episodic bundle payments, MH parity rules, and increasing MH costs to large employers and payers all highlight the critical need to identify high-quality, efficient, integrated MH care delivery practices. Over the past ten years, Intermountain Healthcare has developed a team-based approach-known as mental health integration (MHI)-for caring for these patients and their families. The team includes the PCPs and their staff, and they, in turn, are integrated with MH professionals, community resources, care management, and the patient and his or her family. The integration model goes far beyond co-location in its team-based approach; it is operationalized at the clinic, thereby improving both physician and staff satisfaction. Patients treated in MHI clinics also show improved satisfaction, lower costs, and better quality outcomes. The MHI program is financially sustainable in routinized clinics without subsidies. MHI is a successful approach to improving care for patients with MH conditions in primary care health homes.

[Application of "disease management" to the organization and compensation of professionals in the U.S.A., Germany and England: prospects for France]. / Modatités d'application du "disease management" concernant l'organisation et la rémunération des professionnels aux U.S.A., en Allemagne et en Angleterre: perspectives pour la France.

Disease management, developed in the U.S.A. in the 1990s, is a comprehensive integrated approach that aims to incorporate all phases of chronic disease management from prevention to health education. Its main objective is to optimize patient care services by making patients more responsible for the management of their chronic disease. The specificity of its implementation in different countries is reflected by its translation into various concepts, such as: in the United States by the concept of the "Medical Home", in Germany by establishing contracts that encourage GPs and social security funds to support patients with chronic diseases, and in the United Kingdom through programs with measures that support the delegation of tasks and cooperation between primary care professionals. Disease management is accompanied by the introduction of new forms of payment for doctors and primary care facilities that ensure the effective implementation of the underpinning principles of disease management programs. In France, the development of the disease management approach is being promoted and advocated for integration into primary care, as it is gradually becoming an integral part of the French National Health Insurance Fund's strategy to enhance and improve the quality of care.

Mental health integration: rethinking practitioner roles in the treatment of depression: the specialist, primary care physicians, and the practice nurse.

Although primary care provides the majority of mental health care, lack of time and documented economic benefit make it difficult for healthcare delivery systems to proactively implement effective treatment strategies for the growing disability of depression. Current care delivery models are inadequate and inefficient, leading to provider and consumer exhaustion, as well as significant gaps in care and poor outcomes. This publication describes a quality improvement pilot demonstration called "mental health integration" (MHI) that has been successful in realigning resources, enhancing clinical decision making, measuring the impact and building a business case to determine what actually is the value added for quality. Mental health integration (MHI) promotes the rethinking and retraining of traditional solo practitioner roles to new practitioner roles that facilitate partnership and effective communication as a means to help patients and families achieve a state of successful performance. Results describe the improvements in depression detection at a neutral or lower cost to the health plan. Recommendations are identified for building the business case for MHI quality in order to sustain improved outcomes and promote diffusion of the model outside of Intermountain Health Care (IHC) setting.

Evaluation of "depression in primary care" innovations.

Key stakeholders and executive decision makers in health care system require clear and convincing data of the value of chronic illness care models for the primary care treatment of depression. Well-conceived and conducted evaluations provide this necessary information. This case study describes the experience of a large, nonprofit health care system's experience with implementing and evaluating a quality improvement program for integrating depression management into primary care. The commentary that follows discusses specific evaluation questions that are relevant to each of the stakeholder groups involved in deciding whether or not to continue supporting such programs.