Comparative safety and costs of stepping down asthma medications in patients with controlled asthma.

BACKGROUND: Limited data exist regarding outcomes after stepping down asthma medication. OBJECTIVE: We sought to compare the safety and costs of stepping down asthma controller medications with maintaining current treatment levels in patients with controlled asthma. METHODS: Patients with persistent asthma were identified from the US Medical Expenditure Panel Survey years 2000-2010. Each patient had Medical Expenditure Panel Survey data for 2 years, and measurement was divided into 5 periods of 4 to 5 months each. Eligibility for stepping down asthma controller medications included no hospitalizations or emergency department visits for asthma in periods 1 to 3 and no systemic corticosteroid and 3 or less rescue inhalers dispensed in periods 2 and 3. Steps were defined by type and dose of chronic asthma medication based on current guidelines when comparing period 4 with period 3. The primary outcome of complete asthma control in period 5 was defined as no asthma hospitalizations, emergency department visits, and dispensed systemic corticosteroids and 2 or fewer dispensed rescue inhalers. Multivariable analyses were conducted to assess safety and costs after step down compared with those who maintained the treatment level. RESULTS: Overall, 29.9% of patients meeting the inclusion criteria (n = 4235) were eligible for step down; 89.4% (95% CI, 86.4% to 92.4%) of those who stepped down had preserved asthma control compared with 83.5% (95% CI, 79.9% to 87.0%) of those who were similarly eligible for step down but maintained their treatment level. The average monthly asthma-related cost savings was $34.02/mo (95% CI, $5.42/mo to $61.24/mo) with step down compared with maintenance of the treatment level. CONCLUSION: Stepping down asthma medications in those whose symptoms were controlled led to similar clinical outcomes at reduced cost compared with those who maintained their current treatment level.

Improvements in Health Behaviors, Eating Self-Efficacy, and Goal-Setting Skills Following Participation in Wellness Coaching.

Purpose . This project examined potential changes in health behaviors following wellness coaching. Design . In a single cohort study design, wellness coaching participants were recruited in 2011, data were collected through July 2012, and were analyzed through December 2013. Items in the study questionnaire used requested information about 11 health behaviors, self-efficacy for eating, and goal-setting skills. Setting . Worksite wellness center. Participants . One-hundred employee wellness center members with an average age of 42 years; 90% were female and most were overweight or obese. Intervention . Twelve weeks of in-person, one-on-one wellness coaching. Method . Participants completed study questionnaires when they started wellness coaching (baseline), after 12 weeks of wellness coaching, and at a 3-month follow-up. Results . From baseline to week 12, these 100 wellness coaching participants improved their self-reported health behaviors (11 domains, 0- to 10-point scale) from an average of 6.4 to 7.7 (p < .001), eating self-efficacy from an average of 112 to 142 (on a 0- to 180-point scale; p < .001), and goal-setting skills from an average of 49 to 55 (on a 16- to 80-point scale; p < .001). Conclusion . These results suggest that participants improved their current health behaviors and learned skills for continued healthy living. Future studies that use randomized controlled trials are needed to establish causality for wellness coaching.

Inclusion of short-term care patients affects the perceived performance of specialists: a retrospective cohort study.

BACKGROUND: Current publicly reported quality performance measures directly compare primary care to specialty care. Specialists see short-term patients referred due to poor control of their disease who then return to their local provider. Our study looked to determine if outcomes measured in short-term care patients differed from those in long-term care patients and what impact those differences may have on quality performance profiles for specialists. METHODS: Retrospective cohort from a large academic medical Center. Performance was measured as "Optimal Care"--all or none attainment of goals. Patients with short-term care (<90 days contact) versus long-term care (>90 days contact) were evaluated for both specialty and primary care practices during the year 2008. RESULTS: Patients with short-term care had significantly lower "Optimal Care": 7.2% vs. 19.7% for optimal diabetes care in endocrinology and 41.3% vs. 53.1% for optimal ischemic vascular disease care in cardiology (p < 0.001). Combining short and long term care patients lowered overall perceived performance for the specialty practice. CONCLUSIONS: Factors other than quality affect the perceived performance of the specialty practice. Extending current primary care quality measurement to short-term specialty care patients without adjustment produces misleading results.

The effectiveness of wellness coaching for improving quality of life.

OBJECTIVE: To learn more about the potential psychosocial benefits of wellness coaching. Although wellness coaching is increasing in popularity, there are few published outcome studies. PATIENTS AND METHODS: In a single-cohort study design, 100 employees who completed the 12-week wellness coaching program were of a mean age of 42 years, 90% were women, and most were overweight or obese. Three areas of psychosocial functioning were assessed: quality of life (QOL; 5 domains and overall), depressive symptoms (Patient Health Questionnaire-9), and perceived stress level (Perceived Stress Scale-10). Participants were recruited from January 1, 2011, through December 31, 2011; data were collected up to July 31, 2012, and were analyzed from August 1, 2012, through October 31, 2013. RESULTS: These 100 wellness coaching completers exhibited significant improvements in all 5 domains of QOL and overall QOL (P<.0001), reduced their level of depressive symptoms (P<.0001), and reduced their perceived stress level (P<.001) after 12 weeks of in-person wellness coaching, and they maintained these improvements at the 24-week follow-up. CONCLUSION: In this single-arm cohort study (level 2b evidence), participating in wellness coaching was associated with improvement in 3 key areas of psychosocial functioning: QOL, mood, and perceived stress level. The results from this single prospective cohort study suggest that these areas of functioning improve after participating in wellness coaching; however, randomized clinical trials involving large samples of diverse individuals are needed to establish level 1 evidence for wellness coaching.

Putting diabetes on the map: what does population health really look like at the local level?

Population health data are used to profile local conditions, call attention to areas of need, and evaluate health-related programs. Demand for data to inform health care decision making has spurred development of data sources and online systems, but these are often poorly integrated or limited in scope. Our objective was to identify existing data about diabetes mellitus-related conditions in Minnesota, build an online data resource, and identify what data are currently missing that, if available, would better inform assessment of health conditions in the state. A Web site was developed and populated with existing data and data not available elsewhere. It features functionality identified as most important by users, such as maps and county profiles. The site could serve as a flexible tool for stakeholder engagement, but issues were identified during development, including concerns about interpreting map data and open questions about sustainability, that need to be addressed.

'They leave at least believing they had a part in the discussion': understanding decision aid use and patient-clinician decision-making through qualitative research.

OBJECTIVE: This study explores how patient decision aids (DAs) for antihyperglycemic agents and statins, designed for use during clinical consultations, are embedded into practice, examining how patients and clinicians understand and experience DAs in primary care visits. METHODS: We conducted semistructured in-depth interviews with patients (n=22) and primary care clinicians (n=19), and videorecorded consultations (n=44). Two researchers coded all transcripts. Inductive analyses guided by grounded theory led to the identification of themes. Video and interview data were compared and organized by themes. RESULTS: DAs used during consultations became flexible artifacts, incorporated into existing decision making roles for clinicians (experts, authority figures, persuaders, advisors) and patients (drivers of healthcare, learners, partners). DAs were applied to different decision making steps (deliberation, bargaining, convincing, case assessment), and introduced into an existing knowledge context (participants' literacy regarding shared decision-making (SDM) and DAs). CONCLUSION: DAs' flexible use during consultations effectively provided space for discussion, even when SDM was not achieved. DAs can be used within any decision-making model. PRACTICE IMPLICATIONS: Clinician training in DA use and SDM practice may be needed to facilitate DA implementation and promote more ideal-type forms of sharing in decision making.

Asthma expenditures in the United States comparing 2004 to 2006 and 1996 to 1998.

OBJECTIVES: To describe how the types of healthcare expenditures for patients with asthma have changed over the past decade. STUDY DESIGN: Cross-sectional comparison between individuals from 1996 to 1998 and 2004 to 2006. METHODS: Expenditures among US individuals (aged 5 to 56 years) with asthma were compared using the 1996 to 1998 and the 2004 to 2006 Medical Expenditure Panel Surveys. Direct expenditures (medications, inpatient, outpatient, and emergency services) and changes in productivity (missed school and work days) were compared over this time frame. The adjusted analyses controlled for age, education level, race/ethnicity, gender, poverty, region, metropolitan statistical area, self-reported health, and Charlson Comorbidity Index. RESULTS: Mean annual per capita healthcare expenditures increased between 1996 to 1998 and 2004 to 2006 ($3802 vs $5322 inflated to 2010 US dollars, P <.0001). Annual medication expenditures doubled from $974 to $2010 per person (P <.0001) and outpatient visit expenditures increased from $861 to $1174 (P <.0001) while hospitalization and emergency department (ED) visit expenditures were similar over the same time period. Missed school and work days decreased between the 2 periods (9.23 days in 1996-1998 vs 6.39 days in 2004-2006, P = .001). CONCLUSIONS: An increase in total direct expenditures in individuals with asthma was largely driven by an increase in spending on medications comparing 2004 to 2006 and 1996 to 1998 data. However, this increase was not offset by lower spending on hospitalization and ED visits.

Incidence of antibiotic-resistant Escherichia coli bacteriuria according to age and location of onset: a population-based study from Olmsted County, Minnesota.

OBJECTIVE: To better understand the epidemiology of drug-resistant Escherichia coli across health care and community settings. PATIENTS AND METHODS: We conducted a population-based cohort study of the incidence of antibiotic-resistant E coli bacteriuria among different patient groups. All urine cultures with monomicrobial growth of E coli obtained from Olmsted County, Minnesota, residents from January 1, 2005, through December 31, 2009, were identified. The initial isolate per patient per year was included. Analyses were stratified by patient age and location of infection onset (ie, nosocomial, health care associated, and community associated). RESULTS: We evaluated 5619 E coli isolates and the associated patients. During the study period, the incidence of drug-resistant bacteriuria did not change among children but increased significantly among adults of all ages, most markedly among elderly patients older than 80 years. In elderly patients, the incidence of bacteriuria with isolates resistant to fluoroquinolones increased from 464 to 1116 per 100,000 person-years (P<.001), and the incidence of bacteriuria with isolates resistant to fluoroquinolones plus trimethoprim-sulfamethoxazole increased from 274 to 512 per 100,000 person-years (P<.05). When analyzed by location of infection onset, incidence of bacteriuria with isolates resistant to trimethoprim-sulfamethoxazole, fluoroquinolones, trimethoprim-sulfamethoxazole plus fluoroquinolones, extended-spectrum cephalosporins, and more than 3 drug classes increased significantly among community-associated but not among nosocomial or health care-associated cases. CONCLUSION: In this population-based study, the incidence of antibiotic-resistant E coli bacteriuria nearly doubled during the 5-year study period among elderly patients and those with community-associated isolates. These patient groups should be targets of interventions to slow the emergence and spread of antibiotic-resistant E coli.

The impact of asthma medication guidelines on asthma controller use and on asthma exacerbation rates comparing 1997-1998 and 2004-2005.

BACKGROUND: The relationship between asthma controller medication use and exacerbation rates over time is unclear at the population level. OBJECTIVE: To estimate the change in asthma controller medication use between 2 time periods as measured by the controller-to-total asthma medication ratio and its association with changes in asthma exacerbation rates between 1997-1998 and 2004-2005. METHODS: The study design was a cross-sectional population-level comparison between individuals from 1997-1998 and 2004-2005. Study participants were individuals aged 5 to 56 years identified as having asthma in the Medical Expenditure Panel Survey (MEPS). The main outcome measures were a controller-to-total asthma medication ratio greater than 0.5 and asthma exacerbation rates (dispensing of systemic corticosteroid or emergency department visit/hospitalization for asthma) in 1997-1998 compared with 2004-2005. RESULTS: The proportion of individuals with a controller-to-total asthma medication ratio greater than 0.5, when adjusted for other demographic factors, has improved by 16.1% (95% CI: 10.8%, 21.3%) for all individuals from 1997-1998 to 2004-2005. Annual asthma exacerbation rates did not change significantly in any group from 1997-1998 to 2004-2005 (0.27/year to 0.23/year). African American and Hispanic individuals with asthma had higher asthma exacerbation rates and a lower proportion with a controller-to-total asthma medication ratio greater than 0.5 than whites in both 1997-1998 and 2004-2005; however, these differences were not statistically significant. CONCLUSIONS: An increase in asthma controller-to-total medication ratio in a sample reflective of the US population was not associated with a decreased asthma exacerbation rate comparing 1997-1998 and 2004-2005.

Effectiveness of a quality improvement training course: Mayo Clinic Quality Academy.

This study assessed the effectiveness of Quality Academy Teams Training, a team-based process improvement program at Mayo Clinic. The study population consisted of employees who attended the course in 2008 (n = 103). A pretest-posttest design was used to assess learning by participants of the course, and gain score analysis was conducted using paired t test procedures. Electronic surveys were sent to participants 90 days following completion of the course to assess self-reported application of skills and process improvement tools in the work setting. The mean overall score (n = 99) for the posttest was 68%, which was a significant improvement from the pretest mean of 48% (P < .001). Survey results showed that respondents (n = 58) increased their use of 36 specific process improvement tools on the job after attending the training (P < .001). Other health care institutions may benefit from the implementation of quality-related training programs that teach employees to use process improvement tools and methods.

Clinical and economic outcomes after introduction of drug-eluting stents.

BACKGROUND: In clinical trials, drug-eluting stents (DES) improve clinical outcomes but are more expensive than bare-metal stents (BMS). OBJECTIVE: To assess clinical and economic outcomes of all percutaneous coronary intervention (PCI) procedures in a general interventional cardiology practice before and after DES introduction in 2003. METHODS: We identified all patients undergoing PCI in 2000-2002 (early cohort, pre-DES era) and from 2004 through April 31, 2006 (late cohort, DES era) in a large PCI registry. Logistic and Cox proportional hazard models estimated the risk of adverse events; generalized linear modeling predicted economic outcomes. RESULTS: We compared 4303 early-cohort patients with 3422 late-cohort patients. Most early-cohort patients (90%) had BMS implanted; the rest had atherectomy or balloon angioplasty only. Among late-cohort patients, 83% had DES, 14% BMS, and 6% balloon angioplasty or atherectomy only. In-hospital adverse-event rates and incidence of death or myocardial infarction (during a median follow-up of 22 months) were similar. Follow-up procedures were significantly fewer in the later era (hazard ratio for target lesion revascularization: 0.58; 95% confidence interval [CI], 0.50-0.68). Although catheterization lab supply costs were higher in the DES era, length of stay following index PCI and overall practice costs were reduced, on average, 0.40 days and $2053 in the late cohort (95% bootstrapped CI of adjusted mean difference, -$2937 to -$1197). Follow-up cardiac hospitalization costs were similar at 1 year. CONCLUSIONS: Patients undergoing PCI following DES introduction experienced improved clinical outcomes during follow-up and reduced overall procedural costs, despite higher stent acquisition costs.

Effect of hospital follow-up appointment on clinical event outcomes and mortality.

BACKGROUND: Decreasing hospital readmission and patient mortality after hospital dismissal is important when providing quality health care. Interventions recently proposed by the Centers for Medicare and Medicaid Services to reduce avoidable hospital readmissions include providing patients with clear discharge instructions and appointments for timely follow-up visits. Although research has demonstrated a correlation between follow-up arrangements and reduced hospital readmission in specific patient populations, the effect of hospital follow-up in general medicine patients has not been assessed. METHODS: For this study, we reviewed hospital dismissal instructions for general medicine patients dismissed in 2006 from Mayo Clinic hospitals in Rochester, Minnesota (n = 4989), and determined whether specific appointment details for follow-up were documented. Survival analysis and propensity score-adjusted proportional hazards regression models were developed to investigate the association of follow-up appointment arrangements with hospital readmission, emergency department visits, and mortality at 30 and 180 days after discharge. RESULTS: Of the 4989 dismissal summaries, 3037 (60.9%) contained instructions for a follow-up appointment. No difference was found between those with a documented follow-up appointment vs those without regarding hospital readmission, emergency department visits, or mortality 30 days after dismissal. However, those with a documented follow-up appointment were slightly more likely to have an adverse event (hospital readmission, emergency department visit, or death) within 180 days after dismissal. CONCLUSIONS: Improved discharge processes, including arrangement of hospital follow-up appointments, do not appear to improve readmission rates or survival in general medicine patients. Therefore, national efforts to ensure follow-up for all patients after hospital dismissal may not be beneficial or cost-effective.

Automated detection of follow-up appointments using text mining of discharge records.

OBJECTIVE: To determine whether text mining can accurately detect specific follow-up appointment criteria in free-text hospital discharge records. DESIGN: Cross-sectional study. SETTING: Mayo Clinic Rochester hospitals. PARTICIPANTS: Inpatients discharged from general medicine services in 2006 (n = 6481). INTERVENTIONS: Textual hospital dismissal summaries were manually reviewed to determine whether the records contained specific follow-up appointment arrangement elements: date, time and either physician or location for an appointment. The data set was evaluated for the same criteria using SAS Text Miner software. The two assessments were compared to determine the accuracy of text mining for detecting records containing follow-up appointment arrangements. MAIN OUTCOME MEASURES: Agreement of text-mined appointment findings with gold standard (manual abstraction) including sensitivity, specificity, positive predictive and negative predictive values (PPV and NPV). RESULTS: About 55.2% (3576) of discharge records contained all criteria for follow-up appointment arrangements according to the manual review, 3.2% (113) of which were missed through text mining. Text mining incorrectly identified 3.7% (107) follow-up appointments that were not considered valid through manual review. Therefore, the text mining analysis concurred with the manual review in 96.6% of the appointment findings. Overall sensitivity and specificity were 96.8 and 96.3%, respectively; and PPV and NPV were 97.0 and 96.1%, respectively. ANALYSIS: of individual appointment criteria resulted in accuracy rates of 93.5% for date, 97.4% for time, 97.5% for physician and 82.9% for location. CONCLUSION: Text mining of unstructured hospital dismissal summaries can accurately detect documentation of follow-up appointment arrangement elements, thus saving considerable resources for performance assessment and quality-related research.

Clinical informatics to improve quality of care: a population-based system for patients with diabetes mellitus.

BACKGROUND: The prevalence of diabetes mellitus is increasing in the USA. However, control of intermediate outcome measures remains substandard. Recently, significant emphasis has been placed on the value of electronic medical records and informatics systems to improve the delivery of health care. OBJECTIVE: To determine whether a clinical informatics system improves care of patients with diabetes mellitus. METHODS: In this quality improvement pilot initiative, we identified 48 patients with diabetes mellitus who were due for their annual haemoglobin A1c (HbA1c), low-density lipoprotein (LDL) and microalbumin tests. Through our newly developed clinical informatics initiative, patients were reminded to schedule tests and a physician appointment. Seventy-five patients without reminders served as controls. RESULTS: A significant improvement in LDL control was achieved in the intervention group (35.4% vs 13.3%; P=0.004). The intervention group had a greater percentage of patients who underwent the three tests, and members of this group also showed greater control of haemoglobin A1c, but these differences were not statistically significant. CONCLUSIONS: A clinical informatics system, used to deliver proactive, co-ordinated care to a population of patients with diabetes mellitus, can improve process and also quality outcome measures. Larger studies are needed to confirm these early findings.