Lower comorbidity scores and severity levels in Veterans Health Administration hospitals: a cross-sectional study.

BACKGROUND: Previous studies found that documentation of comorbidities differed when Veterans received care within versus outside Veterans Health Administration (VHA). Changes to medical center funding, increased attention to performance reporting, and expansion of Clinical Documentation Improvement programs, however, may have caused coding in VHA to change. METHODS: Using repeated cross-sectional data, we compared Elixhauser-van Walraven scores and Medicare Severity Diagnosis Related Group (DRG) severity levels for Veterans' admissions across settings and payers over time, utilizing a linkage of VHA and all-payer discharge data for 2012-2017 in seven US states. To minimize selection bias, we analyzed records for Veterans admitted to both VHA and non-VHA hospitals in the same year. Using generalized linear models, we adjusted for patient and hospital characteristics. RESULTS: Following adjustment, VHA admissions consistently had the lowest predicted mean comorbidity scores (4.44 (95% CI 4.34-4.55)) and lowest probability of using the most severe DRG (22.1% (95% CI 21.4%-22.8%)). In contrast, Medicare-covered admissions had the highest predicted mean comorbidity score (5.71 (95% CI 5.56-5.85)) and highest probability of using the top DRG (35.3% (95% CI 34.2%-36.4%)). CONCLUSIONS: More effective strategies may be needed to improve VHA documentation, and current risk-adjusted comparisons should account for differences in coding intensity.

Evaluation of behavioral economic strategies to raise influenza vaccination rates across a health system: Results from a randomized clinical trial.

Influenza vaccination rates are low. Working with a large US health system, we evaluated three health system-wide interventions using the electronic health record's patient portal to improve influenza vaccination rates. We performed a two-arm RCT with a nested factorial design within the treatment arm, randomizing patients to usual-care control (no portal interventions) or to one or more portal interventions. We included all patients within this health system during the 2020-2021 influenza vaccination season, which overlapped with the COVID-19 pandemic. Through the patient portal, we simultaneously tested: pre-commitment messages (sent September 2020, asking patients to commit to a vaccination); monthly portal reminders (October - December 2020), direct appointment scheduling (patients could self-schedule influenza vaccination at multiple sites); and pre-appointment reminder messages (sent before scheduled primary care appointments, reminding patients about influenza vaccination). The main outcome measure was receipt of influenza vaccine (10/01/2020-03/31/2021). We randomized 213,773 patients (196,070 adults ≥18 years, 17,703 children). Influenza vaccination rates overall were low (39.0%). Vaccination rates for study arms did not differ: Control (38.9%), pre-commitment vs no pre-commitment (39.2%/38.9%), direct appointment scheduling yes/no (39.1%/39.1%), pre-appointment reminders yes/no (39.1%/39.1%); p > 0.017 for all comparisons (p value cut-off adjusted for multiple comparisons). After adjusting for age, gender, insurance, race, ethnicity, and prior influenza vaccination, none of the interventions increased vaccination rates. We conclude that patient portal interventions to remind patients to receive influenza vaccine during the COVID-19 pandemic did not raise influenza immunization rates. More intensive or tailored interventions are needed beyond portal innovations to increase influenza vaccination.

Assessment of the epidemiological trends for prostate cancer using administrative data in Ontario.

INTRODUCTION: Studies have shown fluctuations in prostate cancer (PCa) incidence and prevalence over time and by region. Less is known about the most recent epidemiological trends by PCa disease stage. METHODS: This study was a population-based, sequential, cross-sectional analysis that used administrative health data from Ontario, Canada. After inclusion, patients were classified into non-metastatic (nm) PCa and metastatic (m) PCa. The primary study outcome was a description of temporal trends in the incidence and prevalence of PCa over the study period (2010-2019), stratified by disease state. Crude incidence and prevalence rates were estimated for each year in the study period. RESULTS: Overall, there were 131 718 men living with PCa in 2019. The incident cohort contained 86 123 patients with nmPCa (n=65 691, 76.3%), mPCa (n=8431, 9.8%), or unknown stage (n=12 001, 13.9%). The prevalence increased from 216 to 253 per 10 000 men between 2010 and 2019, respectively. Between 2011 and 2014, overall PCa incidence decreased from 20.9 to 15.4 per 10 000 men, followed by an increase to 18.8 per 10 000 in 2018. The nmPCa incidence rate was considerably higher compared with mPCa and followed a trend similar to the overall incidence. In contrast, the incidence rate for mPCa demonstrated a continuous increase from 1.5 per 10 000 in 2010 to 2.4 per 10 000 in 2018. CONCLUSIONS: The overall prevalence of PCa has risen steadily over the last decade, despite fluctuations in nmPCa incidence. The concurrent rise in mPCa and nmPCa requires further study regarding the burden of localized and systemic treatment.

Morbidity Due to Disparity in Pediatric Electroconvulsive Therapy.

Dr. Miller and colleagues recently submitted a Letter to the Editor discussing current state laws that result in disparity of electroconvulsive therapy (ECT) availability.1 In this current letter, we present a case of treatment-resistant childhood-onset schizophrenia (COS), with morbidity due to limited access to ECT. The patient and his family presented from Kentucky to Tennessee, despite less legislative regulation in the former. The patient's family provided informed consent for this report to be published.

Outcomes and risk factors for delayed-onset postoperative respiratory failure: a multi-center case-control study by the University of California Critical Care Research Collaborative (UC3RC).

BACKGROUND: Few interventions are known to reduce the incidence of respiratory failure that occurs following elective surgery (postoperative respiratory failure; PRF). We previously reported risk factors associated with PRF that occurs within the first 5 days after elective surgery (early PRF; E-PRF); however, PRF that occurs six or more days after elective surgery (late PRF; L-PRF) likely represents a different entity. We hypothesized that L-PRF would be associated with worse outcomes and different risk factors than E-PRF. METHODS: This was a retrospective matched case-control study of 59,073 consecutive adult patients admitted for elective non-cardiac and non-pulmonary surgical procedures at one of five University of California academic medical centers between October 2012 and September 2015. We identified patients with L-PRF, confirmed by surgeon and intensivist subject matter expert review, and matched them 1:1 to patients who did not develop PRF (No-PRF) based on hospital, age, and surgical procedure. We then analyzed risk factors and outcomes associated with L-PRF compared to E-PRF and No-PRF. RESULTS: Among 95 patients with L-PRF, 50.5% were female, 71.6% white, 27.4% Hispanic, and 53.7% Medicare recipients; the median age was 63 years (IQR 56, 70). Compared to 95 matched patients with No-PRF and 319 patients who developed E-PRF, L-PRF was associated with higher morbidity and mortality, longer hospital and intensive care unit length of stay, and increased costs. Compared to No-PRF, factors associated with L-PRF included: preexisiting neurologic disease (OR 4.36, 95% CI 1.81-10.46), anesthesia duration per hour (OR 1.22, 95% CI 1.04-1.44), and maximum intraoperative peak inspiratory pressure per cm H20 (OR 1.14, 95% CI 1.06-1.22). CONCLUSIONS: We identified that pre-existing neurologic disease, longer duration of anesthesia, and greater maximum intraoperative peak inspiratory pressures were associated with respiratory failure that developed six or more days after elective surgery in adult patients (L-PRF). Interventions targeting these factors may be worthy of future evaluation.

Implementation of a Community-Partnered Research Suicide-Risk Management Protocol: Case Study From Community Partners in Care.

OBJECTIVE: Suicidality is common among participants in clinical trials and health services research, but approaches to suicide risk assessment and mitigation vary widely. Studies involving vulnerable populations with limited access to care raise additional ethical concerns. The authors applied a community-partnered approach to develop and implement a suicide-risk management protocol (SRMP) in a depression study in an underresourced setting in Los Angeles. METHODS: Using a community-partnered participatory research framework, the authors designed and adapted the SRMP. Qualitative data regarding SRMP implementation included notes from SRMP development meetings and from study clinicians conducting outreach calls to study participants. Analyses included baseline and 6- and 12-month telephone survey data from 1,018 enrolled adults with moderate to severe depressive symptoms (8-item Patient Health Questionnaire score ≥10), of whom 48% were Black and 40% Latino. RESULTS: Community stakeholders prioritized a robust SRMP to ensure participant safety. Features included rapid telephone outreach by study clinicians in all cases of reported recent suicidality and expedited treatment access. Using a suicidality timeframe prompt of "in the past 2 weeks," endorsement of suicidality was common (15% at baseline, 32% cumulative). Midway through the study, the SRMP was modified to assess for present suicidality, which reduced the frequency of clinician involvement. Overall, 318 outreach calls were placed, with none requiring an emergency response. Treatment referrals were provided in 157 calls, and outreach was well received. CONCLUSIONS: SRMP implementation in research involving underresourced and vulnerable communities merits additional considerations. Partnering with community stakeholders can facilitate the development of acceptable and feasible SRMP procedures.

Differences Between Current and Desired Physician Hypertension Management Roles Among Chinese American Seniors: a Qualitative Study.

BACKGROUND: Though patient-physician racial concordance correlates with better perceived shared decision-making, Chinese immigrants report low quality of care and have undertreated hypertension regardless of concordance. OBJECTIVE: To inform efforts to change physician behavior and improve quality of hypertension care, we used role theory to explore differences between Chinese American seniors' descriptions of current and desired physician roles in hypertension management. DESIGN: Qualitative interviews. PARTICIPANTS: Immigrant Chinese Americans with hypertension age ≥ 65 years in Los Angeles County. APPROACH: We recruited 15 participants from a senior wellness center for language-matched interviews and blood pressure (BP) checks. Participants described current and desired physician activities for hypertension management. Bilingual research assistants translated audio recordings. Using thematic analysis, a three-member team independently reviewed and coded transcripts to identify themes regarding physician roles in hypertension management; discrepancies were discussed to achieve consensus. Themes were checked for validity in four subsequent focus groups. RESULTS: We completed interviews in 2014. Interviewees' mean age was 70.6 years; seven were female and five had a systolic BP over 150 mmHg. All interviewees reported having race- and language-concordant primary care providers, were prescribed at least one BP medication, and had Medicare. Three major themes encompassed current and desired physician roles in hypertension management: technical expert, empathetic health steward, and health educator. Descriptions of current and desired physician roles differed for all themes, most prominently for empathetic health steward and health educator. Participants desired but did not consistently experience interpersonal engagement or receive hypertension lifestyle counseling, citing visit time pressures. CONCLUSIONS: Among these Chinese American seniors, there remains a gap between current and desired physician roles in hypertension management, particularly interpersonal behaviors and education. Seniors deprioritized these roles in response to perceived physician role strain. Increased attention to the impact of perceived physician role strain might improve shared decision-making and hypertension management.

Potential insights from population kinetic assessment of progression-free survival curves.

Progression-free survival (PFS) curves follow first order kinetics on exponential decay nonlinear regression analysis (EDNLRA). Some exhibit 1-phase-decay, some have 2-phase-decay, some are convex. We digitized, performed EDNLRA and generated log-linear plots for 887 published PFS curves for incurable solid tumors treated with various systemic therapies. Proportion of curves fitting 2-phase-decay varied by therapy (p < 0.0001). For 13 therapies, >64 % of PFS curves had 2-phase-decay. This included epidermal growth factor receptor inhibitors in unselected lung cancer patients (some with, some without mutations), immune checkpoint inhibitors, interferon, breast cancer hormonal therapies, and selected others, suggesting 2 distinct, potentially identifiable subpopulations with differing progression rates. For 22 other therapies, <25 % of PFS curves had 2-phase-decay. Only 1 therapy was in the mid-range. Small cell lung and colon carcinomas were particularly likely to yield highly convex curves (p < 0.006), probably from discontinuation of effective therapies. PFS curve shape may yield biological and clinical insights.

Readmission Rates for Chronic Obstructive Pulmonary Disease Under the Hospital Readmissions Reduction Program: an Interrupted Time Series Analysis.

BACKGROUND: Hospital readmission rates decreased for myocardial infarction (AMI), heart failure (CHF), and pneumonia with implementation of the first phase of the Hospital Readmissions Reduction Program (HRRP). It is not established whether readmissions fell for chronic obstructive pulmonary disease (COPD), an HRRP condition added in 2014. OBJECTIVE: We sought to determine whether HRRP penalties influenced COPD readmissions among Medicare, Medicaid, or privately insured patients. DESIGN: We analyzed a retrospective cohort, evaluating readmissions across implementation periods for HRRP penalties ("pre-HRRP" January 2010-April 2011, "implementation" May 2011-September 2012, "partial penalty" October 2012-September 2014, and "full penalty" October 2014-December 2016). PATIENTS: We assessed discharged patients ≥ 40 years old with COPD versus those with HRRP Phase 1 conditions (AMI, CHF, and pneumonia) or non-HRRP residual diagnoses in the Nationwide Readmissions Database. INTERVENTIONS: HRRP was announced and implemented during this period, forming a natural experiment. MEASUREMENTS: We calculated differences-in-differences (DID) for 30-day COPD versus HRRP Phase 1 and non-HRRP readmissions. KEY RESULTS: COPD discharges for 1.2 million Medicare enrollees were compared with 22 million non-HRRP and 3.4 million HRRP Phase 1 discharges. COPD readmissions decreased from 19 to 17% over the study. This reduction was significantly greater than non-HRRP conditions (DID - 0.41%), but not HRRP Phase 1 (DID + 0.02%). A parallel trend was observed in the privately insured, with significant reduction compared with non-HRRP (DID - 0.83%), but not HRRP Phase 1 conditions (DID - 0.45%). Non-significant reductions occurred in Medicaid (DID - 0.52% vs. non-HRRP and - 0.21% vs. Phase 1 conditions). CONCLUSIONS: In Medicare, HRRP implementation was associated with reductions in COPD readmissions compared with non-HRRP controls but not versus other HRRP conditions. Parallel findings were observed in commercial insurance, but not in Medicaid. Condition-specific penalties may not reduce readmissions further than existing HRRP trends.

Operational Strategies to Prevent Coronavirus Disease 2019 (COVID-19) Spread in Radiology: Experience From a Singapore Radiology Department After Severe Acute Respiratory Syndrome.

As coronavirus disease 2019 (COVID-19) infection spreads globally, the demand for chest imaging will inevitably rise with an accompanying increase in risk of disease transmission to frontline radiology staff. Radiology departments should implement strict infection control measures and robust operational plans to minimize disease transmission and mitigate potential impact of possible staff infection. In this article, the authors share several operational guidelines and strategies implemented in our practice to reduce spread of COVID-19 and maintain clinical and educational needs of a teaching hospital.

Factors Associated with Differential Readmission Diagnoses Following Acute Exacerbations of Chronic Obstructive Pulmonary Disease.

BACKGROUND: Readmissions after exacerbations of chronic obstructive pulmonary disease (COPD) are penalized under the Hospital Readmissions Reduction Program (HRRP). Understanding attributable diagnoses at readmission would improve readmission reduction strategies. OBJECTIVES: Determine factors that portend 30-day readmissions attributable to COPD versus non-COPD diagnoses among patients discharged following COPD exacerbations. DESIGN, SETTING, AND PARTICIPANTS: We analyzed COPD discharges in the Nationwide Readmissions Database from 2010 to 2016 using inclusion and readmission definitions in HRRP. MAIN OUTCOMES AND MEASURES: We evaluated readmission odds for COPD versus non-COPD returns using a multilevel, multinomial logistic regression model. Patient-level covariates included age, sex, community characteristics, payer, discharge disposition, and Elixhauser Comorbidity Index. Hospital-level covariates included hospital ownership, teaching status, volume of annual discharges, and proportion of Medicaid patients. RESULTS: Of 1,622,983 (a weighted effective sample of 3,743,164) eligible COPD hospitalizations, 17.25% were readmitted within 30 days (7.69% for COPD and 9.56% for other diagnoses). Sepsis, heart failure, and respiratory infections were the most common non-COPD return diagnoses. Patients readmitted for COPD were younger with fewer comorbidities than patients readmitted for non-COPD. COPD returns were more prevalent the first two days after discharge than non-COPD returns. Comorbidity was a stronger driver for non-COPD (odds ratio [OR] 1.19) than COPD (OR 1.04) readmissions. CONCLUSION: Thirty-day readmissions following COPD exacerbations are common, and 55% of them are attributable to non-COPD diagnoses at the time of return. Higher burden of comorbidity is observed among non-COPD than COPD rehospitalizations. Readmission reduction efforts should focus intensively on factors beyond COPD disease management to reduce readmissions considerably by aggressively attempting to mitigate comorbid conditions.

Effects of Cigarette Prices on Intention to Quit, Quit Attempts, and Successful Cessation Among African American Smokers.

INTRODUCTION: This study examined the effects of cigarette price on intention to quit, quit attempts, and successful cessation among African American smokers in the United States and explored whether price effects differed by income level and menthol use status. Price effects were further compared to White counterparts. METHODS: We used pooled cross-sectional data from 2006 to 2007 and 2010 to 2011 Tobacco Use Supplements to the Current Population Survey to analyze 4213 African American recent active smokers. Three dependent variables were examined: any quit attempts in the past 12 months, successful cessation for at least 3 months, and intention to quit in the next 6 months. For each dependent variable, separate multiple logistic regression models were estimated to determine the impact of cigarette prices. RESULTS: There was no indication that price was associated with quit attempts or successful cessation, but price was positively associated with increased odds of intending to quit among African American smokers (p < .001). In contrast, prices were positively associated with intention to quit and quit attempts for White smokers. The association between price and intention to quit was significantly positive for African American low-income and menthol smokers but was not statistically significant for African American high-income and non-menthol smokers. There was no evidence of a price effect on quit attempts and successful cessation for each subgroup of African Americans. CONCLUSIONS: Tobacco tax policy alone may not be enough to increase quit attempts or successful cessation among African Americans. Community-based cessation programs tailored toward African American smokers, especially low-income menthol smokers, are needed. IMPLICATIONS: The results revealed that, among African American smokers, particularly among low-income and menthol smoking African American smokers, price appears to be positively associated with intention to quit; nevertheless, this deterrent effect does not appear to translate to actualized quit attempts or successful cessation. Increasing cigarette prices as a standalone policy may not be independently effective in increasing quit attempts and successful cessation within the African American community. Community-based cessation interventions tailored for African Americans are needed to help further translate desired cessation into actualized quit attempts.

Assessment of Heart Failure Patients' Interest in Mobile Health Apps for Self-Care: Survey Study.

BACKGROUND: Heart failure is a serious public health concern that afflicts millions of individuals in the United States. Development of behaviors that promote heart failure self-care may be imperative to reduce complications and avoid hospital re-admissions. Mobile health solutions, such as activity trackers and smartphone apps, could potentially help to promote self-care through remote tracking and issuing reminders. OBJECTIVE: The objective of this study was to ascertain heart failure patients' interest in a smartphone app to assist them in managing their treatment and symptoms and to determine factors that influence their interest in such an app. METHODS: In the clinic waiting room on the day of their outpatient clinic appointments, 50 heart failure patients participated in a self-administered survey. The survey comprised 139 questions from previously published, institutional review board-approved questionnaires. The survey measured patients' interest in and experience using technology as well as their function, heart failure symptoms, and heart failure self-care behaviors. The Minnesota Living with Heart Failure Questionnaire (MLHFQ) was among the 11 questionnaires and was used to measure the heart failure patients' health-related quality of life through patient-reported outcomes. RESULTS: Participants were aged 64.5 years on average, 32% (16/50) of the participants were women, and 91% (41/45) of the participants were determined to be New York Heart Association Class II or higher. More than 60% (30/50) of the survey participants expressed interest in several potential features of a smartphone app designed for heart failure patients. Participant age correlated negatively with interest in tracking, tips, and reminders in multivariate regression analysis (P<.05). In contrast, MLHFQ scores (worse health status) produced positive correlations with these interests (P<.05). CONCLUSIONS: The majority of heart failure patients showed interest in activity tracking, heart failure symptom management tips, and reminder features of a smartphone app. Desirable features and an understanding of factors that influence patient interest in a smartphone app for heart failure self-care may allow researchers to address common concerns and to develop apps that demonstrate the potential benefits of mobile technology.

High-Value Care Culture Among the Future Physician Workforce in Internal Medicine.

PURPOSE: Training in high-spending regions correlates with higher spending patterns among practicing physicians. This study aimed to evaluate whether trainees' exposure to a high-value care culture differed based on type of health system in which they trained. METHOD: In 2016, 517 internal medicine residents at 12 California graduate medical education programs (university, community, and safety-net medical centers) completed a cross-sectional survey assessing perceptions of high-value care culture within their respective training program. The authors used multilevel linear regression to assess the relationship between type of medical center and High-Value Care Culture Survey (HVCCS) scores. The correlation between mean institutional HVCCS and Centers for Medicare and Medicaid Services' Value-Based Purchasing (VBP) scores was calculated using Spearman rank coefficients. RESULTS: Of 517 residents, 306 (59.2%), 83 (16.1%), and 128 (24.8%) trained in university, community, and safety-net programs, respectively. Across all sites, the mean HVCCS score was 51.2 (standard deviation [SD] 11.8) on a 0-100 scale. Residents reported lower mean HVCCS scores if they were from safety-net-based training programs (ß = -4.4; 95% confidence interval: -8.2, -0.6) with lower performance in the leadership and health system messaging domain (P < .001). Mean institutional HVCCS scores among university and community sites positively correlated with institutional VBP scores (Spearman r = 0.71; P < .05). CONCLUSIONS: Safety-net trainees reported less exposure to aspects of high-value care culture within their training environments. Tactics to improve the training environment to foster high-value care culture include training, increasing access to data, and improving open communication about value.

The Effects of Three Kinds of Insurance Benefit Design Features on Specialty Mental Health Care Use in Managed Care.

BACKGROUND: Insurance benefit features play a role in determining access to specialty mental health care. Previous research, primarily examining the effects of copayments, coinsurance, and deductibles in a fee-for-service setting, has concluded that specialty mental health use is highly sensitive to changes in financial requirements. Less is known about the effects of other benefit features and the effects of all of these features in a managed care environment. AIMS OF THE STUDY: Determine whether increased generosity of three types of benefit features was associated with increases in specialty mental health use and expenditures in a managed care setting. Secondary analyses investigated whether these associations varied by income level. METHODS: A first-differences design used linked claims, enrollment, and benefit data for 1,242,949 non-elderly adults (aged 18-64) with employer-sponsored insurance, before (2009) and after (2011) national behavioral health parity implementation. The data were provided by a large national managed behavioral health organization. Benefit design features included combined cost sharing from copayment and coinsurance, deductibles, the presence of annual use limits, cost sharing penalties associated with services used without getting required prior-authorization, and provider network. Outcomes included visits/days, total expenditures and patient out-of-pocket expenditures for individual psychotherapy and inpatient use, with separate values for in-network and out-of-network (OON) service use. Ordinary least squares regression was performed on change scores (2011 minus 2009 values) of all outcomes to implement the first-differences study design and normalize distributions of otherwise heavily skewed (towards zero) variables. Regressions stratified by higher income (>=USD75,000) and net worth (>=USD100,000) and lower income/net worth were also conducted. RESULTS: For in-network individual psychotherapy, larger increases in cost sharing from copayment and coinsurance were modestly associated with larger decreases in use and total expenditures (beta_visits=--0.00008, p-value=0.030; beta_total expenditures=USD--0.00629, p-value=0.011), and elimination of treatment limits was associated with larger increases in use (beta=0.09637, p-value=0.002) and total expenditures (beta=USD6.57506, p-value=0.001). These results were observed among all enrollees of plans that covered in-network and out-of-network plans and among a sub-set of these enrollees who did not change plans between 2009 and 2011. Benefit features had fewer associations with inpatient care and OON services. DISCUSSION: Elimination of limits was associated with small average increases in in-network individual psychotherapy utilization and expenditures. Cost sharing sensitivities of individual psychotherapy visits to financial requirements reported here were small, and resembled previous findings based in a managed care setting, which were smaller than findings based on the fee-for-service settings. Cost sharing may not pose a practical barrier to specialty behavioral health for non-elderly adults with employer-sponsored managed care plans. However, the influence of cost sharing may vary by specific healthcare needs, something that should be explored in further research.

Incorporating Theory into Practice: Reconceptualizing Exemplary Care Coordination Initiatives from the US Veterans Health Delivery System.

This perspective paper seeks to lay out an efficient approach for health care providers, researchers, and other stakeholders involved in interventions aimed at improving care coordination to partner in locating and using applicable care coordination theory. The objective is to learn from relevant theory-based literature about fit between intervention options and coordination needs, thereby bringing insights from theory to enhance intervention design, implementation, and troubleshooting. To take this idea from an abstract notion to tangible application, our workgroup on models and measures from the Veterans Health Administration (VA) State of the Art (SOTA) conference on care coordination first summarizes our distillation of care coordination theoretical frameworks (models) into three common conceptual domains-context of an intervention, locus in which an intervention is applied, and specific design features of the intervention. Then we apply these three conceptual domains to four cases of care coordination interventions ("use cases") chosen to represent various scopes and stages of interventions to improve care coordination for veterans. Taken together, these examples make theory more accessible and practical by demonstrating how it can be applied to specific cases. Drawing from theory offers one method to anticipate which intervention options match a particular coordination situation.

Association between Hospitalist Productivity Payments and High-Value Care Culture.

BACKGROUND: Given the national emphasis on affordability, healthcare systems expect that their clinicians are motivated to provide high-value care. However, some hospitalists are reimbursed with productivity bonuses, and little is known about the effects of these reimbursements on the local culture of high-value care delivery. OBJECTIVE: To evaluate if hospitalist reimbursement models are associated with high-value culture in university, community, and safety-net hospitals. DESIGN, SETTING, PATIENTS: Internal medicine hospitalists from 12 hospitals across California completed a cross-sectional survey assessing their perceptions of high-value care culture within their institutions. Sites represented university, community, and safety-net centers with different performances as reflected by the Centers of Medicare and Medicaid Service's Value-based Purchasing (VBP) scores. MEASUREMENT: Demographic characteristics and High-Value Care Culture Survey (HVCCSTM) scores were evaluated using descriptive statistics, and associations were assessed through multilevel linear regression. RESULTS: Of the 255 hospitalists surveyed, 147 (57.6%) worked in university hospitals, 85 (33.3%) in community hospitals, and 23 (9.0%) in safety-net hospitals. Across all 12 sites, 166 (65.1%) hospitalists reported payment with salary or wages, and 77 (30.2%) with salary plus productivity adjustments. The mean HVCCS score was 50.2 (SD 13.6) on a 0-100 scale. Hospitalists reported lower mean HVCCS scores if they reported payment with salary plus productivity (ß = -6.2, 95% CI -9.9 to -2.5) than if they reported payment with salary or wages. CONCLUSIONS: Hospitalists paid with salary plus productivity reported lower high-value care culture scores for their institutions than those paid with salary or wages. High-value care culture and clinician reimbursement schemes are potential targets of strategies for improving quality outcomes at low cost.

12-Month Cost Outcomes of Community Engagement Versus Technical Assistance for Depression Quality Improvement: A Partnered, Cluster Randomized, Comparative-Effectiveness Trial.

Objective: To compare community engagement and planning (CEP) for coalition support to implement depression quality improvement (QI) to resources for services (RS) effects on service-use costs over a 12-month period. Design: Matched health and community programs (N=93) were cluster-randomized within communities to CEP or RS. Setting: Two Los Angeles communities. Participants: Adults (N=1,013) with depressive symptoms (Patient Health Questionnaire (PHQ-8) ≥10); 85% African American and Latino. Interventions: CEP and RS to support programs in depression QI. Main Outcome Measures: Intervention training and service-use costs over 12 months. Results: CEP planning and training costs were almost 3 times higher than RS, largely due to greater CEP provider training participation vs RS, with no significant differences in 12-month service-use costs. Conclusions: Compared with RS, CEP had higher planning and training costs with similar service-use costs.