Achieving Large-Scale Quality Improvement in Primary Care Annual Wellness Visits and Hierarchical Condition Coding.

BACKGROUND: Completion of Medicare Annual Wellness Visits (AWV) and documentation of Hierarchical Condition Categories (HCC) are important metrics in accountable care organizations (ACO) with quality and financial implications. To improve performance in large healthcare organizations, quality improvement (QI) efforts need to be scaled up in a way that is feasible within available system-wide resources. OBJECTIVE: We describe a 3-year effort using a multifaceted QI framework called the fractal management system for AWV and HCC performance. DESIGN: Pre-post evaluation of a multi-level, health system-wide QI management system intervention between 2018 and 2020. The system provided project management, coaching, communications, feedback of performance, and health informatics. PARTICIPANTS: The intervention was delivered to all 97 primary care practices within an Ohio-based accountable care organization, comprising 72,603 attributed Medicare and Medicare Advantage patients as of 2018. Eighty-nine of these practices were included in the analysis. APPROACH: AWV completion was defined as percent of eligible patients with a documented AWV during the calendar year. HCC completion was defined as documented reassessment of all prior-year HCC conditions. KEY RESULTS: AWV completion at the practice level increased from 23.7% (SD .14) in 2018 to 34.9% (SD .18) in 2019, and 59.8% (SD .17) in 2020. This was a statistically significant effect of time on AWV completion rates overall (F[2, 87] = 164.43, p < .000). More than half (56.2%) of practices met or exceeded the 60% goal in 2020. Practice-level HCC completion tracking started in 2019 (M = 75.9%, SD 7.4%) and increased in 2020 (M = 79.7%, SD 7.1%); t(172) = 2.0, p < .001. CONCLUSIONS: AWV and HCC performance goals were met in 2020, despite service disruptions due to COVID-19. The QI approach we used is applicable to other problems and other large healthcare systems.

Redesigning Kidney Disease Care to Improve Value Delivery.

This article describes the articulation, development, and deployment of a machine learning (ML) model-driven value solution for chronic kidney disease (CKD) in a health system. The ML model activated an electronic medical record (EMR) trigger that alerted CKD patients to seek primary care. Simultaneously, primary care physicians (PCPs) received an alert that a CKD patient needed an appointment. Using structured checklists, PCPs addressed and controlled comorbid conditions, reconciled drug dosing and choice to CKD stage, and ordered prespecified laboratory and imaging tests pertinent to CKD. After completion of checklist prescribed tasks, PCPs referred patients to nephrology. CKD patients had multiple comorbidities and ML recognition of CKD provided a facile insight into comorbid burden. Operational results of this program have exceeded expectations and the program is being expanded to the entire health system. This paradigm of ML-driven, checklist-enabled care can be used agnostic of EMR platform to deliver value in CKD through structured engagement of complexity in health systems.

Chatbot-Assisted Care Management.

PURPOSE/OBJECTIVES: Chatbots are automated conversation pathways that users can access through text message or email on smartphones or other connected devices. In care management, they can be used to monitor patients' health conditions or recovery from procedures. This article describes nurse care managers' experiences using chatbots in patient care, illustrated through two patient case reviews. Considerations for planning and implementing chatbot technology in care management settings are discussed. PRIMARY PRACTICE SETTING: This care management service is part of an accountable care organization that serves 582,000 patients in University Hospitals of Cleveland, Ohio. Care management focuses on patients with chronic conditions, recent hospital discharges, and other needs. Care managers comprise a centralized team as well as embedded staff in select primary care practices. FINDINGS/CONCLUSIONS: The two patient cases are exemplars from the care management program serving patients recently discharged from the hospital with ongoing chronic conditions that increase risk for readmission. Use of chatbots helped overcome obstacles to conventional care management outreach and resulted in improved outcomes and strong trusting relationships with the care managers. IMPLICATIONS FOR CARE MANAGEMENT PRACTICE: Patients who typically do not respond to other types of care manager outreach may respond to text message-based, asynchronous chatbot communication. Interpersonal relationships between care managers and patients can be strengthened by chatbot support. Chatbot technology tracks patients' progress and offers insights to patients and clinicians to facilitate earlier interventions when problems occur. Chatbots make frequent patient contact to collect and provide routine information, allowing care managers to spend more time on high-value interactions that require clinical judgment. Potential concerns about chatbots include effect on labor force, information security, health equity, and oversight of content.

Factors Influencing the Sugar-Sweetened Beverage Intake of Caregivers of Adolescents in Appalachia.

OBJECTIVE: To identify factors that influence the sugar-sweetened beverage (SSB) intake of caregivers of middle school-aged adolescents. DESIGN: Cross-sectional. SETTING: Southwestern Virginia, US, part of Central Appalachia. PARTICIPANTS: Caregivers (n = 362) of adolescents enrolled in the Kids SIPsmartER trial. Participants were mostly female (91%) and non-Hispanic White (96%), and 21% received Supplemental Nutrition Assistance Program (SNAP) benefits. MAIN OUTCOME MEASURES: Caregiver daily SSB intake and demographics, personal-level, interpersonal-level, and environmental-level determinants. ANALYSIS: Descriptive statistics, 1-way ANOVA, and stepwise regression. RESULTS: On average, caregivers consumed 25.7 (SD, 33.2) fluid ounces of SSB per day. In the final model, which included all variables, age (ß = -0.41; P < 0.05), receiving SNAP benefits (ß = 14.19; P ≤ 0.01), behavioral intentions (ß = -5.48; P ≤ 0.001), affective attitudes (ß = -2.15, P < 0.05), perceptions of whether their adolescent frequently consumes high amounts of SSB (ß = 1.92; P ≤ 0.001), and home availability (ß = 7.43; P ≤ 0.01) were significantly associated with SSB intake. CONCLUSIONS AND IMPLICATIONS: Caregivers of Appalachian middle school students are high SSB consumers. Findings highlight the importance of implementing behavioral interventions for caregivers of adolescents that target multiple levels of influence, including demographic, personal-level, interpersonal-level, and environmental-level factors. Interventions may be particularly important for communities and groups with higher SSB intakes, such as those in Appalachia and who receive SNAP benefits.

Spatial analysis of colorectal cancer outcomes and socioeconomic factors in Virginia.

BACKGROUND: Colorectal cancer (CRC) disparities vary by country and population group, but often have spatial features. This study of the United States state of Virginia assessed CRC outcomes, and identified demographic, socioeconomic and healthcare access contributors to CRC disparities. METHODS: County- and city-level cross-sectional data for 2011-2015 CRC incidence, mortality, and mortality-incidence ratio (MIR) were analyzed for geographically determined clusters (hotspots and cold spots) and their correlates. Spatial regression examined predictors including proportion of African American (AA) residents, rural-urban status, socioeconomic (SES) index, CRC screening rate, and densities of primary care providers (PCP) and gastroenterologists. Stationarity, which assesses spatial equality, was examined with geographically weighted regression. RESULTS: For incidence, one CRC hotspot and two cold spots were identified, including one large hotspot for MIR in southwest Virginia. In the spatial distribution of mortality, no clusters were found. Rurality and AA population were most associated with incidence. SES index, rurality, and PCP density were associated with spatial distribution of mortality. SES index and rurality were associated with MIR. Local coefficients indicated stronger associations of predictor variables in the southwestern region. CONCLUSIONS: Rurality, low SES, and racial distribution were important predictors of CRC incidence, mortality, and MIR. Regions with concentrations of one or more factors of disparities face additional hurdles to improving CRC outcomes. A large cluster of high MIR in southwest Virginia region requires further investigation to improve early cancer detection and support survivorship. Spatial analysis can identify high-disparity populations and be used to inform targeted cancer control programming.

Applying the socio-ecological model to understand factors associated with sugar-sweetened beverage behaviours among rural Appalachian adolescents.

OBJECTIVE: The objective of the current study was to identify factors across the socio-ecological model (SEM) associated with adolescents' sugar-sweetened beverage (SSB) intake. DESIGN: This cross-sectional study surveyed adolescents using previously validated instruments. Analyses included descriptive statistics, ANOVA tests and stepwise nonlinear regression models (i.e., two-part models) adjusted to be cluster robust. Guided by SEM, a four-step model was used to identify factors associated with adolescent SSB intake - step 1: demographics (i.e., age, gender), step 2: intrapersonal (i.e., theory of planned behaviour (attitudes, subjective norms, perceived behavioural control, behavioural intentions), health literacy, media literacy, public health literacy), step 3: interpersonal (i.e., caregiver's SSB behaviours, caregiver's SSB rules) and step 4: environmental (i.e., home SSB availability) level variables. SETTING: Eight middle schools across four rural southwest Virginia counties in Appalachia. PARTICIPANTS: Seven hundred ninety seventh grade students (55·4 % female, 44·6 % males, mean age 12 (sd 0·5) years). RESULTS: Mean SSB intake was 36·3 (sd 42·5) fluid ounces or 433·4 (sd 493·6) calories per day. In the final step of the regression model, seven variables significantly explained adolescent's SSB consumption: behavioural intention (P < 0·05), affective attitude (P < 0·05), perceived behavioural control (P < 0·05), health literacy (P < 0·001), caregiver behaviours (P < 0·05), caregiver rules (P < 0·05) and home availability (P < 0·001). CONCLUSIONS: SSB intake among adolescents in rural Appalachia was nearly three times above national mean. Home environment was the strongest predictor of adolescent SSB intake, followed by caregiver rules, caregiver behaviours and health literacy. Future interventions targeting these factors may provide the greatest opportunity to improve adolescent SSB intake.

Neighborhood Food Environment and Health Outcomes in U.S. Low-Socioeconomic Status, Racial/Ethnic Minority, and Rural Populations: A Systematic Review.

INTRODUCTION: This review examined associations between the neighborhood food environment and health outcomes in populations with the highest obesity rates in the United States: people of low-socioeconomic status (SES), racial/ethnic minorities, and rural residents. METHODS: We searched multiple databases using preselected search terms through June 2017. Forty-three sources met criteria of peer-reviewed U.S. studies that tested food environment-health associations (e.g. obesity, diabetes) in the populations of interest. RESULTS: Evidence was sparse for multiple populations. For populations with multiple studies of adequate sample size, few found significant food environment-health associations. Modest evidence indicates that negative health outcomes were associated with (1) convenience store access for Black and Hispanic youth and (2) fast food access for Black and Hispanic adults and youth. Additionally, lower body weights were associated with supermarket and grocery store access in low-SES adults. CONCLUSION: Food environment interventions may have health benefits for some populations, but additional research is needed.