Did Access to Ambulatory Care Moderate the Associations Between Visit Mode and Ancillary Services Utilization Across the COVID-19 Pandemic Period?

BACKGROUND/OBJECTIVE: In recent years, 2 circumstances changed provider-patient interactions in primary care: the substitution of virtual (eg, video) for in-person visits and the COVID-19 pandemic. We studied whether access to care might affect patient fulfillment of ancillary services orders for ambulatory diagnosis and management of incident neck or back pain (NBP) and incident urinary tract infection (UTI) for virtual versus in-person visits. METHODS: Data were extracted from the electronic health records of 3 Kaiser Permanente Regions to identify incident NBP and UTI visits from January 2016 through June 2021. Visit modes were classified as virtual (Internet-mediated synchronous chats, telephone visits, or video visits) or in-person. Periods were classified as prepandemic [before the beginning of the national emergency (April 2020)] or recovery (after June 2020). Percentages of patient fulfillment of ancillary services orders were measured for 5 service classes each for NBP and UTI. Differences in percentages of fulfillments were compared between modes within periods and between periods within the mode to assess the possible impact of 3 moderators: distance from residence to primary care clinic, high deductible health plan (HDHP) enrollment, and prior use of a mail-order pharmacy program. RESULTS: For diagnostic radiology, laboratory, and pharmacy services, percentages of fulfilled orders were generally >70-80%. Given an incident NBP or UTI visit, longer distance to the clinic and higher cost-sharing due to HDHP enrollment did not significantly suppress patients' fulfillment of ancillary services orders. Prior use of mail-order prescriptions significantly promoted medication order fulfillments on virtual NBP visits compared with in-person NBP visits in the prepandemic period (5.9% vs. 2.0%, P=0.01) and in the recovery period (5.2% vs. 1.6%, P=0.02). CONCLUSIONS: Distance to the clinic or HDHP enrollment had minimal impact on the fulfillment of diagnostic or prescribed medication services associated with incident NBP or UTI visits delivered virtually or in-person; however, prior use of mail-order pharmacy option promoted fulfillment of prescribed medication orders associated with NBP visits.

Adapting adaptive design methods to accelerate adoption of a digital asthma management intervention.

Investigators conducting translational research in real-world settings may experience changes that create challenges to the successful completion of the trial as well as post-trial adoption and implementation. Adaptive designs support translational research by systematically adapting content and methods to meet the needs of target populations, settings and contexts. This manuscript describes an adaptive implementation research model that provides strategies for changing content, delivery processes, and research methods to correct course when anticipated and unanticipated circumstances occur during a pragmatic trial. The Breathewell Program included two large pragmatic trials of the effectiveness of a digital communication technology intervention to improve symptom management and medication adherence in asthma care. The first trial targeted parents of children with asthma; the second targeted adults with asthma. Adaptations were made iteratively to adjust to dynamic conditions within the healthcare setting, informed by prospectively collected stakeholder input, and were categorized retrospectively by the authors as proactive or reactive. Study outcomes demonstrated improved treatment adherence and clinical efficiency. Kaiser Permanente Colorado, the setting for both studies, adopted the speech recognition intervention into routine care, however, both interventions required numerous adaptations, including changes to target population, intervention content, and internal workflows. Proactive and reactive adaptations assured that both trials were successfully completed. Adaptive research designs will continue to provide an important pathway to move healthcare delivery research into practice while conducting ongoing effectiveness evaluation.

Health care research often moves slowly and consequently important results may take a long time to reach the patients they are intended to help. Implementation studies conducted in routine clinical practice are intended to accelerate the process of delivering new discoveries into settings where they can be more quickly put to use. However, conducting research in real-world settings can be challenging if changes occur in those settings during the course of the study. Therefore, an adaptive implementation approach that allows researchers to make changes during the course of a study can facilitate study completion and improve likelihood of intervention adoption into routine care. This report demonstrates the use of an adaptive implementation model in two large studies of asthma in children and adults. In both studies, communication technology including computerized phone calls, texts, and email helped improve treatment consistency and efficiency.

Racial and Ethnic Equity in Care for Hypertension and Diabetes in an Urban Indian Health Organization.

Approximately 70% of American Indian/Alaska Native (AI/AN) individuals reside in urban areas. Urban Indian Health Organizations (UIHOs) provide culturally engaged primary care for AI/AN patients and members of other racial and ethnic groups who have experienced disparities in diabetes and hypertension care, and are commonly affected by social and economic barriers to care. We assessed whether disparities were present between the racial and ethnic groups served by the largest UIHO in the USA. We developed retrospective cohorts of patients with hypertension or diabetes receiving primary care from this UIHO, measuring differences between AI/AN, Spanish-preferring Latinx, English-preferring Latinx, Black, and White patients in mean systolic blood pressure (SBP) and mean hemoglobin A1c (A1c) as primary outcomes. To assess processes of care, we also compared visit intensity, missed visits, and medication treatment intensity in regression models adjusted for sociodemographic and clinical characteristics. For hypertension (n = 2148), adjusted mean SBP ranged from 135.8 mm Hg among Whites to 141.3 mm Hg among Blacks (p = 0.06). For diabetes (n = 1211), adjusted A1c ranged from 7.7% among English-preferring Latinx to 8.7% among Blacks (p = 0.38). Care processes for both hypertension and diabetes varied across groups. No group consistently received lower-quality care. This UIHO provided care of comparable quality for hypertension and diabetes among urban-dwelling AI/ANs and members of other racial, ethnic, and language preference groups. Systematic assessments of care quality in UIHOs may help demonstrate the importance of their role in providing care and improve the quality of care.

Can digital communication technology reduce health system personnel time? An evaluation of personnel requirements and costs in a randomized controlled trial.

Use of digital communication technologies (DCT) shows promise for enhancing outcomes and efficiencies in asthma care management. However, little is known about the impact of DCT interventions on healthcare personnel requirements and costs, thus making it difficult for providers and health systems to understand the value of these interventions. This study evaluated the differences in healthcare personnel requirements and costs between usual asthma care (UC) and a DCT intervention (Breathewell) aimed at maintaining guidelines-based asthma care while reducing health care staffing requirements. We used data from a pragmatic, randomized controlled trial conducted in a large integrated health system involving 14,978 patients diagnosed with asthma. To evaluate differences in staffing requirements and cost between Breathewell and UC needed to deliver guideline-based care we used electronic health record (EHR) events, provider time tracking surveys, and invoicing. Differences in cost were reported at the patient and health system level. The Breathewell intervention significantly reduced personnel requirements with a larger percentage of participants requiring no personnel time (45% vs. 5%, p < .001) and smaller percentage of participants requiring follow-up outreach (44% vs. 68%, p < .001). Extrapolated to the total health system, cost for the Breathewell intervention was $16,278 less than usual care. The intervention became cost savings at a sample size of at least 957 patients diagnosed with asthma. At the population level, using DCT to compliment current asthma care practice presents an opportunity to reduce healthcare personnel requirements while maintaining population-based asthma control measures.

Implementing Health Care Technology Research into Practice to Improve Adult Asthma Management.

BACKGROUND: Use of health technology has shown potential to improve asthma adherence and outcomes. Few studies have looked at the implementation of such research within larger asthma populations. OBJECTIVE: This report examines the process of translating results from a pragmatic trial using speech recognition (SR) in children with persistent asthma into the standard operating procedure within a large health maintenance organization. Medication adherence and outcomes in adults with asthma were examined. METHODS: The SR protocol was implemented for the total Kaiser Permanente Colorado (KPCO) patient population of 480,142, of whom 36,356 had asthma. Patients had persistent asthma, filled 1 or more inhaled corticosteroid prescriptions in the prior 6 months, and remained continuously enrolled with KPCO for 2 years. Documented exacerbations included the presence of a hospitalization, emergency department visit, or course of oral corticosteroid where asthma was the principal diagnosis. Adherence and exacerbation events were compared 1 year before and 1 year after intervention for 4,510 adults aged 19 to 64. RESULTS: Patient adherence demonstrated a small but significant improvement from 39.5% to 41.7% (P < .0001). Although not significant, data trends suggested greater improvement for patients with lower socioeconomic status. When an outlier month was removed from both the pre- and postintervention time periods, courses of oral corticosteroids decreased. Emergency department visits and hospitalizations were infrequent in both time periods and did not decrease over time. CONCLUSIONS: A low-cost SR intervention reminding patients to fill and take their daily controller asthma medication can improve treatment adherence and decrease the need for oral corticosteroids due to asthma exacerbations, but not decrease emergency department visits or hospitalizations.

Predicting the 6-month risk of severe hypoglycemia among adults with diabetes: Development and external validation of a prediction model.

AIMS: To develop and externally validate a prediction model for the 6-month risk of a severe hypoglycemic event among individuals with pharmacologically treated diabetes. METHODS: The development cohort consisted of 31,674 Kaiser Permanente Colorado members with pharmacologically treated diabetes (2007-2015). The validation cohorts consisted of 38,764 Kaiser Permanente Northwest members and 12,035 HealthPartners members. Variables were chosen that would be available in electronic health records. We developed 16-variable and 6-variable models, using a Cox counting model process that allows for the inclusion of multiple 6-month observation periods per person. RESULTS: Across the three cohorts, there were 850,992 6-month observation periods, and 10,448 periods with at least one severe hypoglycemic event. The six-variable model contained age, diabetes type, HgbA1c, eGFR, history of a hypoglycemic event in the prior year, and insulin use. Both prediction models performed well, with good calibration and c-statistics of 0.84 and 0.81 for the 16-variable and 6-variable models, respectively. In the external validation cohorts, the c-statistics were 0.80-0.84. CONCLUSIONS: We developed and validated two prediction models for predicting the 6-month risk of hypoglycemia. The 16-variable model had slightly better performance than the 6-variable model, but in some practice settings, use of the simpler model may be preferred.

Racial and ethnic disparities in the outcomes of elderly home care recipients.

The purpose of this study was to examine racial/ethnic disparities in functional outcomes of elderly home health care recipients. Analyses were conducted using Outcome and Assessment Information Set (OASIS) data for a nationally representative sample of home health care episodes for patients aged 65 and older. Risk-adjusted regression analyses examined the association between race/ethnicity and functional outcomes. Fourteen outcome measures reflected improvement in specific functional areas (e.g., ambulation) and two reflected overall functional change. Non-Hispanic Whites (Whites) experienced substantially better functional outcomes than did home health care recipients of other racial/ethnic backgrounds. The disparity in outcomes was most pronounced between Whites and African Americans.

Initial home health outcomes under prospective payment.

OBJECTIVE: To assess initial changes in home health patient outcomes under Medicare's home health Prospective Payment System (PPS), implemented by the Centers for Medicare and Medicaid Services (CMS) in October 2000. DATA SOURCES/STUDY SETTING: Pre-PPS and early PPS data were obtained from CMS Outcome and Assessment Information Set (OASIS) and Medicare claims files. STUDY DESIGN: Regression analysis was applied to national random samples (n=164,810) to estimate pre-PPS/PPS outcome and visit-per-episode changes. DATA COLLECTION/EXTRACTION METHODS: Outcome episodes were constructed from OASIS data and linked with Medicare claims data on visits. PRINCIPAL FINDINGS: Outcome changes (risk adjusted) were mixed and generally modest. Favorable changes included higher improvement rates under PPS for functioning and dyspnea, higher community discharge rates, and lower hospitalization and emergent care rates. Most stabilization (nonworsening) outcome rates also increased. However, improvement rates were lower under PPS for wounds, incontinence, and cognitive and emotional/behavioral outcomes. Total visits per episode (case-mix adjusted) declined 16.6 percent although therapy visits increased by 8.4 percent. CONCLUSIONS: The outcome and visit results suggest improved system efficiency under PPS (fewer visits, similar outcomes). However, declines in several improvement rates merit ongoing monitoring, as do subsequent (posthome health) hospitalization and emergent care use. Since only the early PPS period was examined, longer-term analyses are needed.

Home health outcome patterns.

Using OASIS data collected by all Medicare-certified home health agencies, this article first presents descriptive statistics on patient outcomes for a national agency sample in 2001, soon after Medicare prospective payment implementation. Ratios of actual to predicted outcome rates, aggregated for groups of outcomes, are considered as potential summary indicators of agency outcome performance. The aggregate ratios show promise, but information on each outcome remains critical to agencies' outcome improvement efforts. Ratios for some outcomes are interrelated, suggesting that agencies focusing outcome enhancement efforts on a few target outcomes also may improve related outcomes.

Rural-urban home health care differences before the Balanced Budget Act of 1997.

This study arose from concerns that home health care may be more difficult to provide to rural than urban elderly patients (because of geographic barriers, personnel shortages, and other factors) and may therefore be less effective in terms of patient outcomes. Case mix, home health care service use, and outcomes (primarily discharge status) were analyzed for a national random sample of 3,869 rural and urban elderly home health patients. Longitudinal data covered the period from home health admission to discharge or 120 days (whichever occurred first). Primary data collection instruments were designed to obtain longitudinal patient-level health status data; agency records and Medicare data provided service use information. (The study did not address access but focused on services and outcomes after admission to home health care.) Two-group statistical tests and multivariate analyses were employed to assess rural-urban differences. The major findings were that, after adjustment for rural-urban case mix and agency differences, rural compared to urban patients received fewer home health services and attained less favorable discharge outcomes. For example, the rural patients had a higher case mix adjusted hospitalization rate. Because the study data pertain to 1995 through 1996, the results provide a baseline for future analyses of possibly different rural compared to urban effects of the Balanced Budget Act of 1997, which resulted in major changes in Medicare payment for home health care.