Practice context affects efforts to improve diabetes care for primary care patients: a pragmatic cluster randomized trial.

BACKGROUND: Efforts to improve primary care diabetes management have assessed strategies across heterogeneous groups of patients and practices. However, there is substantial variability in how well practices implement interventions and achieve desired outcomes. OBJECTIVE: To examine practice contextual features that moderate intervention effectiveness. DESIGN: Secondary analysis of data from a cluster randomized trial of three approaches for implementing the Chronic Care Model to improve diabetes care. PARTICIPANTS: Forty small to mid-sized primary care practices participated, with 522 clinician and staff member surveys. Outcomes were assessed for 822 established patients with a diagnosis of type 2 diabetes who had at least one visit to the practice in the 18 months following enrollment. MAIN MEASURES: The primary outcome was a composite measure of diabetes process of care, ascertained by chart audit, regarding nine quality measures from the American Diabetes Association Physician Recognition Program: HgA1c, foot exam, blood pressure, dilated eye exam, cholesterol, nephropathy screen, flu shot, nutrition counseling, and self-management support. Data from practices included structural and demographic characteristics and Practice Culture Assessment survey subscales (Change Culture, Work Culture, Chaos). KEY RESULTS: Across the three implementation approaches, demographic/structural characteristics (rural vs. urban + .70(p = .006), +2.44(p < .001), -.75(p = .004)); Medicaid: < 20 % vs. ≥ 20 % (-.20(p = .48), +.75 (p = .08), +.60(p = .02)); practice size: < 4 clinicians vs. ≥ 4 clinicians (+.56(p = .02), +1.96(p < .001), +.02(p = .91)); practice Change Culture (high vs. low: -.86(p = .048), +1.71(p = .005), +.34(p = .22)), Work Culture (high vs. low: -.67(p = .18), +2.41(p < .001), +.67(p = .005)) and variability in practice Change Culture (high vs. low: -.24(p = .006), -.20(p = .0771), -.44(p = .0019) and Work Culture (high vs. low: +.56(p = .3160), -1.0(p = .008), -.25 (p = .0216) were associated with trajectories of change in diabetes process of care, either directly or differentially by study arm. CONCLUSIONS: This study supports the need for broader use of methodological approaches to better examine contextual effects on implementation and effectiveness of quality improvement interventions in primary care settings.

Using the Health Literacy Universal Precautions Toolkit to Improve the Quality of Patient Materials.

Patient materials are often written above the reading level of most adults. Tool 11 of the Health Literacy Universal Precautions Toolkit ("Design Easy-to-Read Material") provides guidance on ensuring that written patient materials are easy to understand. As part of a pragmatic demonstration of the Toolkit, we examined how four primary care practices implemented Tool 11 and whether written materials improved as a result. We conducted interviews to learn about practices' implementation activities and assessed the readability, understandability, and actionability of patient education materials collected during pre- and postimplementation site visits. Interview data indicated that practices followed many action steps recommended in Tool 11, including training staff, assessing readability, and developing or revising materials, typically focusing on brief documents such as patient letters and information sheets. Many of the revised and newly developed documents had reading levels appropriate for most patients and--in the case of revised documents--better readability than the original materials. In contrast, the readability, understandability, and actionability of lengthier patient education materials were poor and did not improve over the 6-month implementation period. Findings guided revisions to Tool 11 and highlighted the importance of engaging multiple stakeholders in improving the quality of patient materials.

Characteristics of Medicaid-Covered Emergency Department Visits Made by Nonelderly Adults: A National Study.

BACKGROUND: The Affordable Care Act has added millions of new Medicaid enrollees to the health care system. These patients account for a large proportion of emergency department (ED) utilization. OBJECTIVE: Our aim was to characterize this population and their ED use at a national level. METHODS: We used the 2010 National Hospital Ambulatory Medical Care Survey (NHAMCS) to describe demographics and clinical characteristics of nonelderly adults (≥18 years old and ≤64 years old) with Medicaid-covered ED visits. We defined frequent ED users as individuals who make ≥4 ED visits/year and business hours as 8 am to 5 pm. We used descriptive statistics to describe the epidemiology of Medicaid-covered ED visits. RESULTS: NHAMCS included 21,800 ED visits by nonelderly adults in 2010, of which 5,659 (24.09%) were covered by Medicaid insurance. Most ED visits covered by Medicaid were made by patients who are young (25 and 44 years old) and female (67.95%; 95% confidence interval [CI] 66.00-69.89). A large proportion of the ED visits covered by Medicaid were revisits within 72 h (14.66%; 95% CI 9.13-20.19) and from frequent ED users (32.32%; 95% CI 24.29-40.35). Almost half of all ED visits covered by Medicaid occurred during business hours (45.44%; 95% CI 43.45-47.43). CONCLUSIONS: The vast majority of Medicaid enrollees who used the ED were young females, with a large proportion of visits occurring during business hours. Almost one-third of all visits were from frequent ED users.

Practice facilitation to improve diabetes care in primary care: a report from the EPIC randomized clinical trial.

PURPOSE: We investigated 3 approaches for implementing the Chronic Care Model to improve diabetes care: (1) practice facilitation over 6 months using a reflective adaptive process (RAP) approach; (2) practice facilitation for up to 18 months using a continuous quality improvement (CQI) approach; and (3) providing self-directed (SD) practices with model information and resources, without facilitation. METHODS: We conducted a cluster-randomized trial, called Enhancing Practice, Improving Care (EPIC), that compared these approaches among 40 small to midsized primary care practices. At baseline and 9 months and 18 months after enrollment, we assessed practice diabetes quality measures from chart audits and Practice Culture Assessment scores from clinician and staff surveys. RESULTS: Although measures of the quality of diabetes care improved in all 3 groups (all P <.05), improvement was greater in CQI practices compared with both SD practices (P <.0001) and RAP practices (P <.0001); additionally, improvement was greater in SD practices compared with RAP practices (P <.05). In RAP practices, Change Culture scores showed a trend toward improvement at 9 months (P = .07) but decreased below baseline at 18 months (P <.05), while Work Culture scores decreased from 9 to 18 months (P <.05). Both scores were stable over time in SD and CQI practices. CONCLUSIONS: Traditional CQI interventions are effective at improving measures of the quality of diabetes care, but may not improve practice change and work culture. Short-term practice facilitation based on RAP principles produced less improvement in quality measures than CQI or SD interventions and also did not produce sustained improvements in practice culture.

A qualitative comparison of primary care clinicians' and their patients' perspectives on achieving depression care: implications for improving outcomes.

BACKGROUND: Improving the patient experience of primary care is a stated focus of efforts to transform primary care practices into "Patient-centered Medical Homes" (PCMH) in the United States, yet understanding and promoting what defines a positive experience from the patient's perspective has been de-emphasized relative to the development of technological and communication infrastructure at the PCMH. The objective of this qualitative study was to compare primary care clinicians' and their patients' perceptions of the patients' experiences, expectations and preferences as they try to achieve care for depression. METHODS: We interviewed 6 primary care clinicians along with 30 of their patients with a history of depressive disorder attending 4 small to medium-sized primary care practices from rural and urban settings. RESULTS: Three processes on the way to satisfactory depression care emerged: 1. a journey, often from fractured to connected care; 2. a search for a personal understanding of their depression; 3. creation of unique therapeutic spaces for treating current depression and preventing future episodes. Relative to patients' observations regarding stigma's effects on accepting a depression diagnosis and seeking treatment, clinicians tended to underestimate the presence and effects of stigma. Patients preferred clinicians who were empathetic listeners, while clinicians worried that discussing depression could open "Pandora's box" of lengthy discussions and set them irrecoverably behind in their clinic schedules. Clinicians and patients agreed that somatic manifestations of mental distress impeded the patients' ability to understand their suffering as depression. Clinicians reported supporting several treatment modalities beyond guideline-based approaches for depression, yet also displayed surface-level understanding of the often multifaceted support webs their patient described. CONCLUSIONS: Improving processes and outcomes in primary care may demand heightened ability to understand and measure the patients' experiences, expectations and preferences as they receive primary care. Future research would investigate a potential mismatch between clinicians' and patients' perceptions of the effects of stigma on achieving care for depression, and on whether time spent discussing depression during the clinical visit improves outcomes. Improving care and outcomes for chronic disorders such as depression may require primary care clinicians to understand and support their patients' unique 'therapeutic spaces.'

Evaluation of a seven state criminal history screening pilot program for long-term care workers.

This article summarizes results from an evaluation of a federally sponsored criminal history screening (CHS) pilot program to improve screening for workers in long-term care settings. The evaluation addressed eight key issues specified through enabling legislation, including efficiency, costs, and outcomes of screening procedures. Of the 204,339 completed screenings, 3.7% were disqualified due to criminal history, and 18.8% were withdrawn prior to completion for reasons that may include relevant criminal history. Lessons learned from the pilot program experiences may inform a new national background check demonstration program.

An electronic practice-based network for observational comparative effectiveness research.

The Distributed Ambulatory Research in Therapeutics Network (DARTNet) is a federated network of electronic health data from 8 organizations representing more than 500 clinicians and more than 400 000 patients. DARTNet was designed to increase knowledge of the comparative effectiveness of prescription medications and medical devices. Traditional observational comparative effectiveness research is conducted using large data sets, such as claims databases. Such databases do not provide important clinical information that is critical to understanding comparative effectiveness. By linking electronic health records, laboratory and imaging data, and administrative data from diverse and geographically disparate patients, DARTNet provides important new insight into the comparative effectiveness of oral diabetes medications, and it is ready for expansion to further enable effectiveness research.

Predictors of colorectal screening in rural Colorado: testing to prevent colon cancer in the high plains research network.

CONTEXT: Colorectal cancer is the second leading cause of cancer death in the United States, yet screening rates are well below target levels. Rural communities may face common and unique barriers to health care, particularly preventive health care. PURPOSE: To establish baseline attitudinal, knowledge, belief, and behavior measures on colorectal cancer screening and to identify barriers to or predictors of colorectal cancer screening. METHODS: As part of a controlled trial using a quasi-experimental, pretest, post-test design, we conducted a baseline telephone survey of 1,050 rural eastern Colorado residents aged 50 years and older. Smaller counties were over-sampled to ensure a minimum of 30 completed interviews per county. FINDINGS: Seventy-seven percent reported they ever had a colorectal cancer screening test and 59% were up-to-date on at least 1 test. The most important independent predictors of being up-to-date were having visited a doctor or other health care practitioner for a checkup in the past year, having personal or family history of colon polyps or cancer, and having asked for a colorectal cancer screening test. Financial concerns were reported reasons for not obtaining fecal occult blood testing by 18% and colonoscopy by 21%. CONCLUSIONS: This study suggests that health care providers should be vigilant in counseling their patients 50 and older to have a colorectal cancer test. Community programs designed to promote colon cancer screening should encourage residents to have regular contact with their primary care physician and ask their doctor for a screening test. Additionally, programs should provide financial assistance for testing for low-income and uninsured patients.

Improving the Effectiveness of Medication Review: Guidance from the Health Literacy Universal Precautions Toolkit.

BACKGROUND: Although routine medication reviews in primary care practice are recommended to identify drug therapy problems, it is often difficult to get patients to bring all their medications to office visits. The objective of this study was to determine whether the medication review tool in the Agency for Healthcare Research and Quality Health Literacy Universal Precautions Toolkit can help to improve medication reviews in primary care practices. METHODS: The toolkit's "Brown Bag Medication Review" was implemented in a rural private practice in Missouri and an urban teaching practice in California. Practices recorded outcomes of medication reviews with 45 patients before toolkit implementation and then changed their medication review processes based on guidance in the toolkit. Six months later we conducted interviews with practice staff to identify changes made as a result of implementing the tool, and practices recorded outcomes of medication reviews with 41 additional patients. Data analyses compared differences in whether all medications were brought to visits, the number of medications reviewed, drug therapy problems identified, and changes in medication regimens before and after implementation. RESULTS: Interviews revealed that practices made the changes recommended in the toolkit to encourage patients to bring medications to office visits. Evaluation before and after implementation revealed a 3-fold increase in the percentage of patients who brought all their prescription medications and a 6-fold increase in the number of prescription medications brought to office visits. The percentage of reviews in which drug therapy problems were identified doubled, as did the percentage of medication regimens revised. CONCLUSIONS: Use of the Health Literacy Universal Precautions Toolkit can help to identify drug therapy problems.

Monitoring suicidal patients in primary care using electronic health records.

INTRODUCTION: Patients at risk for suicide often come into contact with primary care providers, many of whom use electronic health records (EHRs) for charting. It is not known, however, how often suicide ideation or attempts are documented in EHRs. METHODS: We used retrospective analyses of de-identified EHR data from a distributed health network of primary care organizations to estimate the frequency of using diagnostic codes to record suicidal ideation and attempts. Data came from 3 sources: a clinician notes field processed using natural language processing; a suicidal ideation item on a patient-reported depression severity instrument (9-item Patient Health Questionnaire [PHQ-9]); and diagnostic codes from the EHR. RESULTS: Only 3% of patients with an indication of suicidal ideation in the notes field had a corresponding International Classification of Diseases, 9th Revision (ICD-9), code (κ = 0.036). Agreement between an indication of suicidal ideation from item 9 of the PHQ-9 and an ICD-9 code was slightly higher (κ = 0.068). Suicide attempt indicated in the notes field was more likely to be recorded using an ICD-9 code (19%; κ = 0.18). CONCLUSIONS: Few cases of suicidal ideation and attempt were documented in patients' EHRs using diagnostic codes. Increased documentation of suicidal ideation and behaviors in patients' EHRs may improve their monitoring in the health care system.

Database design to ensure anonymous study of medical errors: a report from the ASIPS Collaborative.

Medical error reporting systems are important information sources for designing strategies to improve the safety of health care. Applied Strategies for Improving Patient Safety (ASIPS) is a multi-institutional, practice-based research project that collects and analyzes data on primary care medical errors and develops interventions to reduce error. The voluntary ASIPS Patient Safety Reporting System captures anonymous and confidential reports of medical errors. Confidential reports, which are quickly de-identified, provide better detail than do anonymous reports; however, concerns exist about the confidentiality of those reports should the database be subject to legal discovery or other security breaches. Standard database elements, for example, serial ID numbers, date/time stamps, and backups, could enable an outsider to link an ASIPS report to a specific medical error. The authors present the design and implementation of a database and administrative system that reduce this risk, facilitate research, and maintain near anonymity of the events, practices, and clinicians.

The DARTNet Institute: Seeking a Sustainable Support Mechanism for Electronic Data Enabled Research Networks.

CONTEXT: Clinical data research networks require large investments in infrastructure support to maintain their abilities to extract, transform, and load data from varied data sources, expand electronic data sources and develop learning communities. CASE DESCRIPTION: This paper outlines a sustainable business model of ongoing infrastructure support for clinical data research activities. The DARTNet Institute is a not-for-profit 501(c)(3) organization that serves as a support entity for multiple practice-based research networks. Several clinical data research networks working closely with a professional society began collaborating to support shared goals in 2008. This loose affiliation called itself the "DARTNet Collaborative." In 2011, the DARTNet Institute incorporated as an independent, not-for-profit entity. The business structure allows DARTNet to advocate for all partners without operating its own practice-based research network, serve as a legal voice for activities that overlap multiple partners, share personnel resources through service contracts between partners, and purchase low-cost (nonprofit rate) software. MAJOR THEMES: DARTNet's business model relies upon four diverse sources of revenue: (1) DARTNet licenses and provides access to a propriety software system that extracts, transforms, and loads data from all major electronic health records (EHRs) utilized in the United States, and which also provides clinical decision support for research studies; (2) DARTNet operates a recognized, national professional-society-quality improvement registry that enables organizations to fulfill Meaningful Use 2 criteria; (3) DARTNet provides access to data for research activities that are funded by direct research dollars, provided at prices that generate excess revenue; and (4) DARTNet provides access to large primary care datasets for observational studies and pregrant analyses such as for sample size development. The ability of the system to support pragmatic trials will be described. CONCLUSION: The DARTNet model facilitates the use of direct grant dollars to generate revenue to support the overall enterprise through a purchased services arrangement. Other services provided through subcontracting provide facilities and administration fees as well as direct dollars to support the system. The flexibility of the business model overcomes the complicated financial arrangements and governance requirements of many professional associations and academic medical centers.

Laboratory medicine handoff gaps experienced by primary care practices: A report from the shared networks of collaborative ambulatory practices and partners (SNOCAP).

BACKGROUND: The majority of errors in laboratory medicine testing are thought to occur in the pre- and postanalytic testing phases, and a large proportion of these errors are secondary to failed handoffs. Because most laboratory tests originate in ambulatory primary care, understanding the gaps in handoff processes within and between laboratories and practices is imperative for patient safety. Therefore, the purpose of this study was to understand, based on information from primary care practice personnel, the perceived gaps in laboratory processes as a precursor to initiating process improvement activities. DESIGN: A survey was used to assess perceptions of clinicians, staff, and management personnel of gaps in handoffs between primary care practices and laboratories working in 21 Colorado primary care practices. Data were analyzed to determine statistically significant associations between categorical variables. In addition, qualitative analysis of responses to open-ended survey questions was conducted. RESULTS: Primary care practices consistently reported challenges and a desire/need to improve their efforts to systematically track laboratory test status, confirm receipt of laboratory results, and report results to patients. Automated tracking systems existed in roughly 61% of practices, and all but one of those had electronic health record-based tracking systems in place. One fourth of these electronic health record-enabled practices expressed sufficient mistrust in these systems to warrant the concurrent operation of an article-based tracking system as backup. Practices also reported 12 different procedures used to notify patients of test results, varying by test result type. CONCLUSION: The results highlight the lack of standardization and definition of roles in handoffs in primary care laboratory practices for test ordering, monitoring, and receiving and reporting test results. Results also identify high-priority gaps in processes and the perceptions by practice personnel that practice improvement in these areas is needed. Commonalities in these areas warrant the development and support of tools for use in primary care settings.

Evaluating the connections between primary care practice and clinical laboratory testing: a review of the literature and call for laboratory involvement in the solutions.

CONTEXT: Growing evidence has demonstrated a high frequency of quality gaps in laboratory medicine, with recent studies estimating that 15% to 54% of primary care medical errors reported by primary care physicians and staff are related to the testing process. However, there is lack of evidence-based performance metrics in the preanalytic and postanalytic phases of the testing pathway for primary care practices. OBJECTIVE: To use results of the literature review to assist in the development of quality indicators that could improve preanalytic and postanalytic processes in primary care-based laboratory medicine. DATA SOURCES: Literature in Ovid/MEDLINE from 2001 through 2011 was searched as a primary source of information. Ninety-five peer-reviewed and non-peer-reviewed publications were retrieved following title and abstract review and 10 articles were reviewed in their entirety by the authors. A systematic review of the literature was conducted regarding the connections between clinical laboratories and primary care offices and the resulting errors. Root causes of errors were categorized into 7 major themes: process failures, delays, communication gaps, errors in judgment and cognition, influence of minorities/language, practice culture, and lack of patient centeredness. Selected articles were evaluated for evidence quality using the Systematic Evidence Review and Evaluation Methods for Quality Improvement grading scale developed by the Centers for Disease Control and Prevention. CONCLUSIONS: The focused literature review documented 7 key error themes in the laboratory medicine/primary care testing process. Performance metrics related to these themes are proposed that deserve future study for evidence-based improvement.

Effects of clinical pathways for common outpatient infections on antibiotic prescribing.

BACKGROUND: Antibiotic overuse in the primary care setting is common. Our objective was to evaluate the effect of a clinical pathway-based intervention on antibiotic use. METHODS: Eight primary care clinics were randomized to receive clinical pathways for upper respiratory infection, acute bronchitis, acute rhinosinusitis, pharyngitis, acute otitis media, urinary tract infection, skin infections, and pneumonia and patient education materials (study group) versus no intervention (control group). Generalized linear mixed effects models were used to assess trends in antibiotic prescriptions for non-pneumonia acute respiratory infections and broad-spectrum antibiotic use for all 8 conditions during a 2-year baseline and 1-year intervention period. RESULTS: In the study group, antibiotic prescriptions for non-pneumonia acute respiratory infections decreased from 42.7% of cases at baseline to 37.9% during the intervention period (11.2% relative reduction) (P<.0001) and from 39.8% to 38.7%, respectively, in the control group (2.8% relative reduction) (P=.25). Overall use of broad-spectrum antibiotics in the study group decreased from 26.4% to 22.6% of cases, respectively (14.4% relative reduction) (P<.0001) and from 20.0% to 19.4%, respectively, in the control group (3.0% relative reduction) (P=.35). There were significant differences in the trends of prescriptions for acute respiratory infections (P<.0001) and broad-spectrum antibiotic use (P=.001) between the study and control groups during the intervention period, with greater declines in the study group. CONCLUSIONS: This intervention was associated with declining antibiotic prescriptions for non-pneumonia acute respiratory infections and use of broad-spectrum antibiotics over the first year. Evaluation of the impact over a longer study period is warranted.

Rates of 5 common antidepressant side effects among new adult and adolescent cases of depression: a retrospective US claims study.

BACKGROUND: Antidepressants are the first-line treatment for depression, yet medication-related side effects may be associated with antidepressant discontinuation before reaching a period of exposure believed to result in effectiveness. There is a gap in knowledge of the prevalence of side effects across commonly prescribed antidepressants and the effect of the type of antidepressant on the likelihood of side effects in real-world clinical practice. OBJECTIVE: The aim of this study was to estimate and compare the prevalence of headaches, nausea or vomiting, agitation, sedation, and sexual dysfunction among patients diagnosed with depression who initiated monotherapy across different classes of antidepressants and to estimate the effect of the type of antidepressant on the likelihood of each of the 5 side effects. METHODS: A retrospective cohort of patients aged ≥13 who were newly diagnosed with depression and began antidepressant monotherapy was created using LifeLink managed care claims from 1998 to 2008. Antidepressant groups included selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), bupropion, phenylpiperazine, and tetracyclic antidepressants. Prevalence of headache, nausea or vomiting, agitation, sedation, and sexual dysfunction were compared across antidepressant groups. Propensity-adjusted Cox proportional hazards regression was used to estimate the likelihood of each of the 5 side effects for each antidepressant group compared with SSRIs, adjusted for demographic, clinical, and treatment characteristics. RESULTS: The study cohort included 40,017 patients (3617 adolescents, aged 13-18 years, and 36,400 adults, aged ≥19 years; mean age = 45 years; 67% female) with a new episode of depression who were initiated on antidepressant monotherapy within 30 days of diagnosis (SSRI [66%], bupropion [14%], SNRI [12%], other [8%]). The most common side effects were headache (up to 17/1000 person-months of therapy in adults and adolescents) and nausea (up to 7.2/1000 in adults, 9.3/1000 in adolescents). Relative to adults receiving SSRIs, adults receiving SNRIs had a higher risk of nausea (hazard ratio [HR] = 1.26; 95%CI,1.05-1.51). Adults (HR = 0.78; 95% CI, 0.62-0.96) and adolescents (HR = 0.43; 95% CI, 0.21-0.87) taking bupropion were less likely to experience headaches compared with adults and adolescents, respectively, taking an SSRI. Adolescents receiving a tetracyclic were more likely to experience headaches than adolescents receiving an SSRI (HR = 3.16; 95%CI, 1.13-8.84). CONCLUSIONS: Prevalence and risk of the 5 side effects varied across types of antidepressants for both adults and adolescents. Results from this study were consistent with prior clinical trials, suggesting that variation in side effect profiles exists in a more generalized managed care population.

The role of the champion in primary care change efforts: from the State Networks of Colorado Ambulatory Practices and Partners (SNOCAP).

BACKGROUND: Change champions are important for moving new innovations through the phases of initiation, development, and implementation. Although research attributes positive health care changes to the help of champions, little work provides details about the champion role. METHODS: Using a combination of immersion/crystallization and matrix techniques, we analyzed qualitative data, which included field notes of team meetings, interviews, and transcripts of facilitator meetings, from a sample of 8 practices. RESULTS: Our analysis yielded insights into the value of having 2 discrete types of change champions: (1) those associated with a specific project (project champions) and (2) those leading change for entire organizations (organizational change champions). Relative to other practices under study, those that had both types of champions who complemented each other were best able to implement and sustain diabetes care processes. We provide insights into the emergence and development of these champion types, as well as key qualities necessary for effective championing. CONCLUSIONS: Practice transformation requires a sustained improvement effort that is guided by a larger vision and commitment and assures that individual changes fit together into a meaningful whole. Change champions--both project and organizational change champions--are critical players in supporting both innovation-specific and transformative change efforts.

Costs associated with data collection and reporting for diabetes quality improvement in primary care practices: a report from SNOCAP-USA.

PURPOSE: Information about the costs and experiences of collecting and reporting quality measure data are vital for practices deciding whether to adopt new quality improvement initiatives or monitor existing initiatives. METHODS: Six primary care practices from Colorado's Improving Performance in Practice program participated. We conducted structured key informant interviews with Improving Performance in Practice coaches and practice managers, clinicians, and staff and directly observed practices. RESULTS: Practices had 3 to 7 clinicians and 75 to 300 patients with diabetes, half had electronic health records, and half were members of an independent practice association. The estimated per-practice cost of implementation for the data collection and reporting for the diabetes quality improvement program was approximately $15,552 per practice (about $6.23 per diabetic patient per month). The first-year maintenance cost for this effort was approximately $9,553 per practice ($3.83 per diabetic patient per month). CONCLUSIONS: The cost of implementing and maintaining a diabetes quality improvement effort that incorporates formal data collection, data management, and reporting is significant and quantifiable. Policymakers must become aware of the financial and cultural impact on primary care practices when considering value-based purchasing initiatives.

Enhancing electronic health record measurement of depression severity and suicide ideation: a Distributed Ambulatory Research in Therapeutics Network (DARTNet) study.

BACKGROUND: Depression is a leading cause of morbidity worldwide. The majority of treatment for depression occurs in primary care, but effective care remains elusive. Clinical decision making and comparative studies of real-world antidepressant effectiveness are limited by the absence of clinical measures of severity of illness and suicidality. METHODS: The Distributed Ambulatory Research in Therapeutics Network (DARTNet) was engaged to systematically collect data using the 9-item Patient Health Questionnaire (PHQ-9) at the point of care. We used electronic health records (EHRs) and the PHQ-9 to capture, describe, and compare data on both baseline severity of illness and suicidality and response and suicidality after diagnosis for depressed patients in participating DARTNet practices. RESULTS: EHR data were obtained for 81,028 episodes of depression (61,464 patients) from 14 clinical organizations. Over 9 months, data for 4900 PHQ-9s were collected from 2969 patients in DARTNet practices (this included 1892 PHQ-9s for 1019 adults and adolescents who had at least one depression diagnosis). Only 8.3% of episodes identified in our depression cohort had severity of illness information available in the EHR. For these episodes, considerable variation existed in both severity of illness (32.05% with no depression, 26.89% with minimal, 19.54% with mild, 12.04% with moderate, and 9.47% with severe depression) and suicidality (69.43% with a score of 0, 22.58% with a score of 1, 4.97% with a score of 2, and 3.02% with a score of 3 on item 9 of the PHQ-9). Patients with an EHR diagnosis of depression and a PHQ-9 (n = 1019) had similar severity but slightly higher suicidality levels compared with all patients for which PHQ-9 data were available. The PHQ-9 showed higher sensitivity for identifying depression response and emergent (after diagnosis) severity and suicidality; 25% to 30% of subjects had some degree of suicidal thought at some point in time according to the PHQ-9. CONCLUSIONS: This study demonstrated the value of adding PHQ-9 data and prescription fulfillment data to EHRs to improve diagnosis and management of depression in primary care and to enable more robust comparative effectiveness research on antidepressants.

The Agency for Healthcare Research and Quality (AHRQ) Practice-Based Research Network (PBRN) relationship: delivering on an opportunity, challenges, and future directions.

Practice-based research networks (PBRNs) often lack sufficient funding to develop the underlying infrastructure necessary to conduct high-quality, pragmatic, policy-relevant studies. One mechanism introduced by the Agency for Healthcare Research and Quality (AHRQ) that held the potential to address this issue was the PBRN Master Contract Program. The program allows the AHRQ to fund tightly focused "research activities" and to create a partnership through the PBRN contracts. Although PBRNs expected Master Contracts to strengthen them, several issues limit the utility of these contracts. The funding levels are lower than that provided from other sources for comparable work. Although some Task Order Officers are diligent, responsive, and supportive, too frequently their zeal for specific results and heavy handed approaches have led to significant "scope creep" and unrealistic expectations. Finally, a mechanism to allow PBRNs and network clinicians to influence the direction of the research questions has not been well developed. We see value in a new approach that supports the ability of the AHRQ to (1) garner support from other government agencies to engage PBRNs in studies relevant to policymakers and PBRNs; (2) capitalize on the collaborative nature of PBRNs by developing projects that support collaboration; (3) provide modest funding for infrastructure; (4) avoid the unnecessary and costly regulatory oversight from OMB; and (5) develop sustained "lines of research" on a scale, currently unavailable through the Master Contract, that can meaningfully contribute to the shaping of health policy.