Mobile Health Apps, Family Caregivers, and Care Planning: Scoping Review.

BACKGROUND: People living with multiple chronic conditions (MCCs) face substantial challenges in planning and coordinating increasingly complex care. Family caregivers provide important assistance for people with MCCs but lack sufficient support. Caregiver apps have the potential to help by enhancing care coordination and planning among the health care team, including patients, caregivers, and clinicians. OBJECTIVE: We aim to conduct a scoping review to assess the evidence on the development and use of caregiver apps that support care planning and coordination, as well as to identify key factors (ie, needs, barriers, and facilitators) related to their use and desired caregiver app functionalities. METHODS: Papers intersecting 2 major domains, mobile health (mHealth) apps and caregivers, that were in English and published from 2015 to 2021 were included in the initial search from 6 databases and gray literature and ancestry searches. As per JBI (Joanna Briggs Institute) Scoping Review guidelines and PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews), 2 authors independently screened full texts with disagreements resolved by a third author. Working in pairs, the authors extracted data using a pilot-tested JBI extraction table and compared results for consensus. RESULTS: We identified 34 papers representing 25 individual studies, including 18 (53%) pilot and feasibility studies, 13 (38%) qualitative studies, and 2 experimental or quasi-experimental studies. None of the identified studies assessed an intervention of a caregiver app for care planning and coordination for people with MCCs. We identified important caregiver needs in terms of information, support, and care coordination related to both caregiving and self-care. We compiled desired functionalities and features enabling apps to meet the care planning and care coordination needs of caregivers, in particular, the integration of caregiver roles into the electronic health record. CONCLUSIONS: Caregiver needs identified through this study can inform developers and researchers in the design and implementation of mHealth apps that integrate with the electronic health record to link caregivers, patients, and clinicians to support coordinated care for people with MCCs. In addition, this study highlights the need for more rigorous research on the use of mHealth apps to support caregivers in care planning and coordination.

Assessing Progress Toward the Vision of a Comprehensive, Shared Electronic Care Plan: Scoping Review.

BACKGROUND: Care plans are central to effective care delivery for people with multiple chronic conditions. But existing care plans-which typically are difficult to share across care settings and care team members-poorly serve people with multiple chronic conditions, who often receive care from numerous clinicians in multiple care settings. Comprehensive, shared electronic care (e-care) plans are dynamic electronic tools that facilitate care coordination and address the totality of health and social needs across care contexts. They have emerged as a potential way to improve care for individuals with multiple chronic conditions. OBJECTIVE: To review the landscape of e-care plans and care plan-related initiatives that could allow the creation of a comprehensive, shared e-care plan and inform a joint initiative by the National Institutes of Health and the Agency for Healthcare Research and Quality to develop e-care planning tools for people with multiple chronic conditions. METHODS: We conducted a scoping review, searching literature from 2015 to June 2020 using Scopus, Clinical Key, and PubMed; we also searched the gray literature. To identify initiatives potentially missing from this search, we interviewed expert informants. Relevant data were then identified and extracted in a structured format for data synthesis and analysis using an expanded typology of care plans adapted to our study context. The extracted data included (1) the perspective of the initiatives; (2) their scope, (3) network, and (4) context; (5) their use of open syntax standards; and (6) their use of open semantic standards. RESULTS: We identified 7 projects for e-care plans and 3 projects for health care data standards. Each project provided critical infrastructure that could be leveraged to promote the vision of a comprehensive, shared e-care plan. All the e-care plan projects supported both broad goals and specific behaviors; 1 project supported a network of professionals across clinical, community, and home-based networks; 4 projects included social determinants of health. Most projects specified an open syntax standard, but only 3 specified open semantic standards. CONCLUSIONS: A comprehensive, shared, interoperable e-care plan has the potential to greatly improve the coordination of care for individuals with multiple chronic conditions across multiple care settings. The need for such a plan is heightened in the wake of the ongoing COVID-19 pandemic. While none of the existing care plan projects meet all the criteria for an optimal e-care plan, they all provide critical infrastructure that can be leveraged as we advance toward the vision of a comprehensive, shared e-care plan. However, critical gaps must be addressed in order to achieve this vision.

A socio-technical systems approach to the use of health IT for patient reported outcomes: Patient and healthcare provider perspectives.

BACKGROUND: Patient-Reported Outcomes (PROs) can be used to inform the clinical management of individuals, including patient self-management, care planning, and goal setting. Despite a rapid proliferation of technology to collect and integrate PROs in clinical care, uptake by patients and healthcare providers remains sub optimal. A consideration of systems factors to understand these challenges is needed. OBJECTIVES: To apply the socio-technical systems (STS) model as a framework for understanding the usability and functional requirements of patients collecting PRO data using applications (apps), and of healthcare providers using these data at the point of care in ambulatory settings. METHODS: With questions guided by the STS model, semi-structured interviews were conducted with eighteen patients and nine healthcare providers to elicit feedback about facilitators and barriers to successful use of PRO apps and PRO data in ambulatory settings. Patient participants were selected to fit into two categories: older, low utilizers of technology with less than a bachelor's degree, and younger higher utilizers of technology with at least a bachelor's degree. Participants were from primary and specialty care practices. Data were analyzed inductively to identify emergent themes. RESULTS: Younger patients were only interested in using a PRO app if they had an active health issue to track. The nine older patients preferred passive means of data collection if they were to track a health issue, and preferred direct contact with their healthcare provider and using office visits to share information. All patients desired optimal usability and emphasized bidirectional communication in an app that is transparent about privacy. All nine healthcare providers agreed that PRO data would be most useful and relevant if key patient populations were targeted based on the specific measure. In this case the healthcare providers noted potentially optimal utility of collecting physical function PRO data for patients 65 and older. Access to the data was highlighted by each healthcare provider stating that these data would be most useful if they were seamlessly integrated into the electronic health record. DISCUSSION: Several emergent themes were identified under the five selected dimensions of the STS model (clinical content, human computer interface, hardware and software computing infrastructure, people, and workflow and communication). Findings highlighted the continued need for innovative methods to obtain more rapid cycle, continuous feedback to identify system factors impacting use of these technologies. CONCLUSION: The STS model provides a comprehensive framework that can be applied to collect patient and healthcare provider feedback to better guide the design and implementation of new health information technology.

Advancing the use of patient-reported outcomes in practice: understanding challenges, opportunities, and the potential of health information technology.

PURPOSE: The effective use of patient-reported outcomes (PROs) can play a critical role in improving health care delivery and patient experience with care. However, PROs are not widely collected and used in clinical practice. This study aims to understand current opportunities and challenges with the use of PROs and the potential for health information technology (IT) to advance their use. METHODS: The Agency for Healthcare Research and Quality held two technical expert panel (TEP) meetings to discuss the current use of PROs, challenges, and opportunities in implementation, and how health IT can be leveraged to support effective PRO use in clinical practice. Results were synthesized to identify major themes and takeaways based on different stages of PRO data utilization. RESULTS: Findings from the TEP meetings indicated varying degrees of PRO usage in ambulatory care settings. Practices often lack a business case to collect PROs. Primary care physicians face more challenges than specialists in selecting appropriate PRO measures due to extensive variation in their patient populations. Providers also need training to use PRO data for shared decision making and population health management. Potential research areas to address PRO implementation challenges include measures harmonization, implementation process and workflow, electronic data collection and integration, and user-friendly data displays. CONCLUSIONS: Opportunities exist during different stages of PRO implementation to advance the use of PROs in clinical practice. Health IT can be utilized to address challenges in data collection, integration, and visualization to make PRO data accessible and understandable to patients and providers.

The role of health information technology in care coordination in the United States.

OBJECTIVES: Examine the extent to which office-based physicians in the United States receive patient health information necessary to coordinate care across settings and determine whether receipt of information needed to coordinate care is associated with use of health information technology (HIT) (defined by presence or absence of electronic health record system and electronic sharing of information). RESEARCH DESIGN: Cross-sectional study using the 2012 National Electronic Health Records Survey (65% weighted response rate). SUBJECTS: Office-based physicians. MEASURES: Use of HIT and 3 types of patient health information needed to coordinate care. RESULTS: In 2012, 64% of physicians routinely received the results of a patient's consultation with a provider outside of their practice, whereas 46% routinely received a patient's history and reason for a referred consultation from a provider outside of their practice. About 54% of physicians reported routinely receiving a patient's hospital discharge information. In adjusted analysis, significant differences in receiving necessary information were observed by use of HIT. Compared with those not using HIT, a lower percentage of physicians who used an electronic health record system and shared patient health information electronically failed to receive the results of outside consultations or patient's history and reason for a referred consultation. No significant differences were observed for the receipt of hospital discharge information by use of HIT. Among physicians routinely receiving information needed for care coordination, at least 54% of them did not receive the information electronically. CONCLUSIONS: Although a higher percentage of physicians using HIT received patient information necessary for care coordination than those who did not use HIT, more than one third did not routinely receive the needed patient information at all.

In which states are physician assistants or nurse practitioners more likely to work in primary care?

OBJECTIVE: Examine availability of physician assistants (PAs) or nurse practitioners (NPs) in primary care physician practices by state and by state PA and NP scope-of-practice laws. METHODS: Availability of PAs and NPs in primary care practices was examined in multivariate analysis using a 2012 state-based, nationally representative survey of office-based physicians. Covariates included practice characteristics, state, and in a separate model, PA and NP scope-of-practice variables. RESULTS: After controlling for practice characteristics, higher use of PAs and NPs was found in three states (Minnesota, Montana, and South Dakota). In a separate model, higher use of PAs or NPs was associated with favorable PA scope-of-practice laws, but not with NP scope-of-practice laws. CONCLUSIONS: Higher availability of PAs or NPs was associated with favorable PA scope-of-practice laws. Lack of association between PA or NP availability and NP scope-of-practice laws requires further investigation.

Variation in electronic health record adoption and readiness for meaningful use: 2008-2011.

BACKGROUND: Federal initiatives are underway that provide physicians with financial incentives for meaningful use (MU) of electronic health records (EHRs) and assistance to purchase and implement EHRs. OBJECTIVE: We sought to examine readiness and interest in MU among primary care physicians and specialists, and identify factors that may affect their readiness to obtain MU incentives. DESIGN/PARTICIPANTS: We analyzed 4 years of data (2008-2011) from the National Ambulatory Medical Care Survey (NAMCS) Electronic Medical Record (EMR) Supplement, an annual cross-sectional nationally representative survey of non-federally employed office-based physicians. MAIN MEASURES: Survey-weighted EHR adoption rates, potential to meet selected MU criteria, and self-reported intention to apply for MU incentives. We also examined the association between physician and practice characteristics and readiness for MU. KEY RESULTS: The overall sample consisted of 10,889 respondents, with weighted response rates of 62 % (2008); 74 % (2009); 66 % (2010); and 61 % (2011). Primary care physicians' adoption of EHRs with the potential to meet MU nearly doubled from 2009 to 2011 (18 % to 38 %, p<0.01), and was significantly higher than specialists (19 %) in 2011 (p<0.01). In 2011, half of physicians (52 %) expressed their intention to apply for MU incentives; this did not vary by specialty. Multivariate analyses report that EHR adoption was significantly higher in both 2010 and 2011 compared to 2009, and primary care physicians and physicians working in larger or multi-specialty practices or for HMOs were more likely to adopt EHRs with the potential to meet MU. CONCLUSIONS: Physician EHR adoption rates increased in advance of MU incentive payments. Although interest in MU incentives did not vary by specialty, primary care physicians had significantly higher rates of adopting EHRs with the potential to meet MU. Addressing barriers to EHR adoption, which may vary by specialty, will be important to enhancing coordination of care.

The rise of electronic health record adoption among family physicians.

PURPOSE: Realizing the benefits of adopting electronic health records (EHRs) in large measure depends heavily on clinicians and providers' uptake and meaningful use of the technology. This study examines EHR adoption among family physicians using 2 different data sources, compares family physicians with other office-based medical specialists, assesses variation in EHR adoption among family physicians across states, and shows the possibility for data sharing among various medical boards and federal agencies in monitoring and guiding EHR adoption. METHOD: We undertook a secondary analysis of American Board of Family Medicine (ABFM) administrative data (2005-2011) and data from the National Ambulatory Medical Care Survey (NAMCS) (2001-2011). RESULTS: The EHR adoption rate by family physicians reached 68% nationally in 2011. NAMCS family physician adoption rates and ABFM adoption rates (2005-2011) were similar. Family physicians are adopting EHRs at a higher rate than other office-based physicians as a group; however, significant state-level variation exists, indicating geographical gaps in EHR adoption. CONCLUSION: Two independent data sets yielded convergent results, showing that adoption of EHRs by family physicians has doubled since 2005, exceeds other office-based physicians as a group, and is likely to surpass 80% by 2013. Adoption varies at a state level. Further monitoring of trends in EHR adoption and characterizing their capacities are important to achieve comprehensive data exchange necessary for better, affordable health care.

A multicenter, phased, cluster-randomized controlled trial to reduce central line-associated bloodstream infections in intensive care units*.

OBJECTIVES: To determine the causal effects of an intervention proven effective in pre-post studies in reducing central line-associated bloodstream infections in the intensive care unit. DESIGN: We conducted a multicenter, phased, cluster-randomized controlled trial in which hospitals were randomized into two groups. The intervention group started in March 2007 and the control group started in October 2007; the study period ended September 2008. Baseline data for both groups are from 2006. SETTING: Forty-five intensive care units from 35 hospitals in two Adventist healthcare systems. INTERVENTIONS: A multifaceted intervention involving evidence-based practices to prevent central line-associated bloodstream infections and the Comprehensive Unit-based Safety Program to improve safety, teamwork, and communication. MEASUREMENTS AND RESULTS: We measured central line-associated bloodstream infections per 1,000 central line days and reported quarterly rates. Baseline average central line-associated bloodstream infections per 1,000 central line days was 4.48 and 2.71, for the intervention and control groups (p = .28), respectively. By October to December 2007, the infection rate declined to 1.33 in the intervention group compared to 2.16 in the control group (adjusted incidence rate ratio 0.19; p = .003; 95% confidence interval 0.06-0.57). The intervention group sustained rates <1/1,000 central line days at 19 months (an 81% reduction). The control group also reduced infection rates to <1/1,000 central line days (a 69% reduction) at 12 months. CONCLUSIONS: This study demonstrated a causal relationship between the multifaceted intervention and the reduced central line-associated bloodstream infections. Both groups decreased infection rates after implementation and sustained these results over time, replicating the results found in previous, pre-post studies of this multifaceted intervention and providing further evidence that most central line-associated bloodstream infections are preventable.

Design of a quality and performance improvement project for small primary care practices: reflections on the Center for Practice Innovation.

BACKGROUND: Small practices often lack the human, financial and technical resources to make necessary practice improvements and infrastructure investments in order to achieve sustainable change that promotes quality and efficiency. AIMS: To report on an effort to assist small primary care practices in improving quality of care and efficiency of practice management to meet the needs of patients, improve physician satisfaction and enhance the ability of these small practices to survive. METHODS: We report on an intervention design and the reflections of the implementers on what they learned and what went well or poorly during implementation. Results of the intervention are reported separately (in Quality in Primary Care). Thirty practices underwent the entire intervention. The practices were selected on the basis of practice size, diversity in patient factors, apparent dedication to making practice improvements and geographic location. The main components of the intervention were two site visits to the participating practices by Center for Practice Innovation (CPI); now known as the Centre for Practice Improvement and Innovation, team members. The CPI team provided ongoing advice and support in focus areas selected by practices after initial site visit and assessment. RESULTS: A customised session focusing on the practice report and on helping practices to think about which areas they wished to improve was more effective in engaging practices than didactic presentation. Quality and practice management improvements were observed in information posting, patient education, staff communication and patient safety practices. Having a strong physician champion and a strong office manager determined to make quality improvement changes were important elements for successful change. In addition, practices with greater stability of staff and strong finances were more likely to meet project goals. CONCLUSIONS: Small practices today are facing a range of important challenges. The CPI sought to provide successful guidance to small practices with evidence of positive change in some clinical measures, patient satisfaction and practice motivation to implement quality of care and practice management improvements.

Building the evidence-base to reduce electronic health record-related clinician burden.

Clinicians face competing pressures of being clinically productive while using imperfect electronic health record (EHR) systems and maximizing face-to-face time with patients. EHR use is increasingly associated with clinician burnout and underscores the need for interventions to improve clinicians' experiences. With an aim of addressing this need, we share evidence-based informatics approaches, pragmatic next steps, and future research directions to improve 3 of the highest contributors to EHR burden: (1) documentation, (2) chart review, and (3) inbox tasks. These approaches leverage speech recognition technologies, natural language processing, artificial intelligence, and redesign of EHR workflow and user interfaces. We also offer a perspective on how EHR vendors, healthcare system leaders, and policymakers all play an integral role while sharing responsibility in helping make evidence-based sociotechnical solutions available and easy to use.

A novel application of SMART on FHIR architecture for interoperable and scalable integration of patient-reported outcome data with electronic health records.

OBJECTIVE: Despite a proliferation of applications (apps) to conveniently collect patient-reported outcomes (PROs) from patients, PRO data are yet to be seamlessly integrated with electronic health records (EHRs) in a way that improves interoperability and scalability. We applied the newly created PRO standards from the Office of the National Coordinator for Health Information Technology to facilitate the collection and integration of standardized PRO data. A novel multitiered architecture was created to enable seamless integration of PRO data via Substitutable Medical Apps and Reusable Technologies on Fast Healthcare Interoperability Resources apps and scaled to different EHR platforms in multiple ambulatory settings. MATERIALS AND METHODS: We used a standards-based approach to deploy 2 apps that source and surface PRO data in real-time for provider use within the EHR and which rely on PRO assessments from an external center to streamline app and EHR integration. RESULTS: The apps were developed to enable patients to answer validated assessments (eg, a Patient-Reported Outcomes Measurement Information System including using a Computer Adaptive Test format). Both apps were developed to populate the EHR in real time using the Health Level Seven FHIR standard allowing providers to view patients' data during the clinical encounter. The process of implementing this architecture with 2 different apps across 18 ambulatory care sites and 3 different EHR platforms is described. CONCLUSION: Our approach and solution proved feasible, secure, and time- and resource-efficient. We offer actionable guidance for this technology to be scaled and adapted to promote adoption in diverse ambulatory care settings and across different EHRs.

A simple intervention promoting patient safety improvements in small internal medicine practices.

BACKGROUND: small primary care practices may face difficulties in staying abreast of patient safety recommendations and implementing them. Some safety issues, however, may be easily and inexpensively addressed, given the necessary information on what is required. AIM: to assess changes in patient safety measures in small practices and describe simple mechanisms that appear to have facilitated change. METHODS: The design uses pre-post bivariate tests to determine the effect of a quality improvement intervention provided by the Center for Practice Innovation (CPI) of the American College of Physicians (ACP) to 34 small internal medicine practices. Compliance with safety measures was reassessed in 30 practices after the intervention. The CPI intervention involved two site visits, a practice assessment, self-selection of clinical, operational and financial focus areas for improvement and ongoing 'directed guidance' of the practices in their efforts, including weekly 'Practice tips' email alerts. Data used in this study came from the practice assessment form completed by the CPI team, which included 21 safety measures. The Wilcoxon signed-rank test and McNemar's test were used to compare the practices' safety compliance before and after the intervention. RESULTS: many safety measures had high compliance rates at the first site visit; for other safety measures, fewer than half the practices followed the recommended procedures. The intervention was associated with statistically significant positive change on over 70% of the 21 safety issues. The positive effects were most profound in safety measures regarding how a practice managed sharps, hazardous materials, medications and vaccines. CONCLUSION: this study provides insights into mechanisms that assist practices to make initial steps to improve patient safety and care quality. The study also suggests that with concrete recommendations, small practices can make significant changes in a short period of time and at relatively low cost.

Hospitalization for ambulatory-care-sensitive conditions in Taiwan following the SARS outbreak: a population-based interrupted time series study.

BACKGROUND/PURPOSE: In 2003, the severe acute respiratory syndrome (SARS) outbreak resulted in 8096 probable cases and 774 deaths in 26 countries. The purpose of this study was to explore the effect of the SARS outbreak on hospitalization for chronic ambulatory-care-sensitive conditions (ACSCs) in Taiwan. METHODS: We applied a population-based interrupted time series study design and used the time series auto-regressive integrated moving-average model to compare the actual and predicted admission rates of seven selected chronic ACSCs. The analyses were based on National Health Insurance hospital inpatient claims data from 1997 to 2003. RESULTS: The impact of SARS on ACSCs after the outbreak varied among seven selected chronic conditions. Hospitalization for respiratory conditions was significantly lower than the predicted values, whereas hospitalization for diabetes was significantly higher than the predicted values after the outbreak. CONCLUSION: Admission rates for most ACSCs, except for diabetes, did not change in the post-SARS period. The reductions in outpatient utilization during the SARS outbreak did not appear to affect adversely admissions for most ACSCs.

Parent perspectives of health related quality of life in adolescents with chronic kidney disease due to underlying urological disorders: an assessment using the Child Health Questionnaire-Parent Form 50.

PURPOSE: Little is known about health related quality of life in adolescents with chronic kidney disease due to urological anomalies. We assessed generic health related quality of life in this population using a validated parent proxy instrument. MATERIALS AND METHODS: In this multicenter prospective cohort study the Child Health Questionnaire-Parent Form 50, a generic health related quality of life parent proxy instrument, was administered to 92 parents of adolescents 10 to 18 years old with chronic kidney disease. Mean summary measure and scale scores in adolescents with urological anomalies were compared to scores in those with other causes of kidney disease and in a representative American population sample. RESULTS: The cohort included 35 adolescents with an underlying diagnosis of congenital urological anomaly and 57 with another cause of kidney disease. There were no significant differences in mean scale or summary measure scores between the 2 diagnostic groups. When compared to a representative population sample, adolescents with congenital urological anomalies scored significantly worse on the questionnaire physical summary measure (44.5, 95% CI 39.9-49.1 vs 52.0, 95% CI 51.1-52.9, p = 0.002), and on the Child Health Questionnaire scales physical functioning, role physical, general health perceptions, family activities and parental emotional impact. CONCLUSIONS: As assessed by Child Health Questionnaire-Parent Form 50, parents reported that adolescents with chronic kidney disease due to urological disorders scored lower on the physical summary measure than a population based reference sample and they reported a negative effect on family activities and parental emotional well-being. These findings suggest that the Child Health Questionnaire-Parent Form 50 could provide a family based assessment of generic health related quality of life in adolescents with urological disorders.

Health related quality of life in adolescents with abnormal bladder function: an assessment using the Child Health and Illness Profile-Adolescent Edition.

PURPOSE: We studied the impact of abnormal bladder function due to congenital urological disorders on health related quality of life in children. A reliable patient based method is needed to assess the impact of these conditions in children and the interventions used to treat them. MATERIALS AND METHODS: Participants 11 to 17 years old with bladder exstrophy-epispadias complex, spina bifida or other causes of abnormal bladder function self-administered the Child Health and Illness Profile-Adolescent Edition, a generic health related quality of life instrument. They also responded to questions about incontinence, catheterization status and bother level. Mean scores on the profile were compared to population based norms. RESULTS: Mean age of the 50 participants was 14.9 years, 62% were male and 82% were white. Diagnoses included bladder exstrophy-epispadias complex in 37 patients, spina bifida in 10 and other in 3. The mean +/- SD score on the disorders domain of 14.2 +/- 6.3 was significantly worse than the population norm of 20. Mean scores on the satisfaction, discomfort, resilience, risks and achievement domains were comparable to or better than the population based norm of 20. A total of 29 participants reported incontinence and 31 performed catheterization. CONCLUSIONS: In this study of adolescents with congenital causes of abnormal bladder function Child Health and Illness Profile-Adolescent Edition generic health related quality of life scores were significantly worse in the disorders domain but largely comparable to or better than those of the general population in other domains. This suggests that the profile may discern between adolescents with structural urological disease and norms but it may not be sensitive enough to fully detect the impact of the condition. Alternatively adolescents may adapt well to the challenges of urological disease.

Effects of quality on outcomes in primary care: a review of the literature.

It is widely believed that health care quality affects primary care outcomes, but the evidence is fragmented and incomplete. The authors searched MEDLINE for relevant articles published between 1950 and 2006 and reviewed the evidence to assess the relationship between the personal aspects of primary care quality and patients' health status and health services utilization. These personal aspects, which include patient-physician continuity and communication, are distinct from the technical aspects of primary care, which include ordering tests, treatments, and referrals. Fourteen articles met the inclusion criteria. Results showed that greater continuity of care is associated with less use of hospitals and emergency departments and lower health care costs; effective communication may be associated with better health status. The limited available evidence suggests that higher quality in the personal aspects of primary care is associated with some but not all outcomes of care. Additional research is needed to define these relationships more clearly.

Morbidity and older persons' perceptions of the quality of their primary care.

OBJECTIVES: To quantify the association between community-dwelling older persons' level of morbidity and their perceptions of the quality of their primary care. DESIGN: Cross-sectional study. SETTING: Urban primary care practice. PARTICIPANTS: A sample of community-dwelling members of a capitated health plan aged 65 and older who were patients of four general internists in one urban practice (N = 120). MEASUREMENTS: The Johns Hopkins Adjusted Clinical Groups case-mix system was used to designate a person's aggregate morbidity level as moderate or high depending on the number and types of chronic conditions they had. Aspects of quality of primary care (physician-patient communication, interpersonal treatment, knowledge of patient, integration of care, and trust in physician) were assessed using the Primary Care Assessment Survey. RESULTS: All participants were classified as having moderate (41%) or high morbidity (59%). Older adults with high morbidity assigned a lower rating to all aspects of quality of primary care (physician-patient communication (P = .001), interpersonal treatment (P = .002), knowledge of patient (P = .03), integration of care (P = .004), and trust in physician (P = .01)) than those with moderate morbidity. The differences in quality of primary care remained statistically significant after controlling for age, sex, race, and education level. CONCLUSION: Older persons with multiple chronic conditions report inadequate quality of primary care and dissatisfaction with their care. Those with high morbidity levels experience poorer quality of primary care than those with moderate morbidity in all five aspects measured here.

Clinical features of high-risk older persons identified by predictive modeling.

The objective of this study was to describe the clinical features of older persons identified as high risk by a predictive modeling algorithm and to determine their suitability for clinical interventions like case management or disease management. A cross-sectional survey was undertaken at a community-based general internal medicine practice with 826 older patients enrolled in a Medicare-like health plan for military retirees and their dependents. Administrative claims data provided information about all 826 enrollees' chronic conditions, their use of health services, and the cost of those services during the past year. A survey mailed to 150 identified high-risk enrollees provided information about sociodemographic characteristics, general health, bed disability days, restricted activity days, activities of daily living (ADL) limitations, and instrumental activities of daily living (IADL) limitations. Compared to the 676 low-risk enrollees, the 150 high-risk enrollees had higher prevalence of eight individual chronic conditions, higher total chronic conditions (2.93 vs. 1.48, p < 0.001), higher annual rates of hospital admission (1.1 vs. 0.1, p < 0.001), more annual hospital days (7.3 vs. 0.5, p < 0.001), and higher total health insurance expenditures ($22,815 vs. $3,726, p < 0.001). The high-risk respondents to the survey (response rate = 80.0%) had suboptimal health (42.8% "fair or poor"), impaired functional ability (36.3% with 1+ ADL limitations, 58.1% with 1+ IADL limitations), and frequent health-related disruptions in their activities during the previous six months (38.7% with 1+ bed disability day, 52.3% with 1+ restricted activity day). A claims-based predictive modeling algorithm identifies older persons whose health, functional ability, and use of health services suggest they are good candidates for clinical interventions such as case management and disease management.