Proxy use of patient portals on behalf of children: Federally Qualified Health Centers as a case study.

Objective: This study examined the proxy use of patient portals for children in a large Federally Qualified Health Centers (FQHC) network in Texas. Methods: We used de-identified individual-level data of patients, 0-18 years, who had 1+ visits between December 2018 and November 2020. Logistic regression was used to examine patient-, clinic-, and geographic-level factors associated with portal usage by an assumed proxy (i.e. parent or guardian). Results: The proxy portal usage rate increased from 28% in the pre-pandemic months (November 2018-February 2020) to 34% in the pandemic months (March-Nov 2020). Compared to patients 0-5 years, patients aged 6 to 18 years had lower odds of portal usage (6-10 OR: 0.77, p < 0.001; 11-14 OR: 0.62, p < 0.001; 15-18 OR: 0.51, p < 0.001). Minoritized groups had significantly lower odds of portal usage when compared to their non-Hispanic White counterparts (non-Hispanic Black OR: 0.78, p < 0.001; Hispanic OR 0.63, p < 0.001; Asian OR: 0.69, p < 0.001). Having one chronic condition was associated with portal usage (OR: 1.57, p < 0.001); however, there were no significant differences in portal usage between those with none or multiple chronic conditions. Portal usage also varied by service lines, with obstetrics and gynecology (OR: 1.84, p < 0.001) and behavioral health (OR 1.82, p < 0.001) having the highest odds of usage when compared to pediatrics. Having a telemedicine visit was the strongest predictor of portal usage (OR: 2.30, p < 0.001), while residence in zip codes with poor broadband internet access was associated with lower odds of portal usage (OR: 0.97, p < 0.001). Conclusion: While others have reported portal usage rates as high as 64% in pediatric settings, our analysis suggests proxy portal usage rates of 30% in pediatric FQHC settings, with race/ethnicity, age group, and chronic disease status being significant drivers of portal non-usage. These findings highlight the need for appropriate and responsive health information technology approaches for vulnerable populations receiving care in low-resource settings.

Examining longitudinal disparities in COVID-19 prevalence in the U.S.: a county level growth rate perspective.

Background: The objectives of the present study are to understand the longitudinal variability in COVID-19 reported cases at the county level and to associate the observed rates of infection with the adoption and lifting of stay-home orders.Materials and Methods: The study uses the trajectory of the pandemic in a county and controls for social and economic risk factors, physical environment, and health behaviors to elucidate the social determinants contributing to the observed rates of infection.Results and conclusion: Results indicated that counties with higher percentages of young individuals, racial and ethnic minorities and, higher population densities experienced greater difficulty suppressing transmission.Except for Education and the Gini Index, all factors were influential on the rate of COVID-19 spread before and after stay-home orders. However, after lifting the orders, six of the factors were not influential on the rate of spread; these included: African-Americans, Population Density, Single Parent Households, Average Daily PM2.5, HIV Prevalence Rate, and Home Ownership. It was concluded that different factors from the ones controlling the initial spread of COVID-19 are at play after stay-home orders are lifted.KEY MESSAGESObserved rates of COVID-19 infection at the County level in the U.S. are not directly associated with adoption and lifting of stay-home orders.Disadvantages in sociodemographic determinants negatively influence the rate of COVID-19 spread.Counties with more young individuals, racial and ethnic minorities, and higher population densities have greater difficulty suppressing transmission.

Overcoming COVID-19 Vaccine Hesitancy: Insights from an Online Population-Based Survey in the United States.

This study sought to identify individual-level determinants of COVID-19 vaccine hesitancy based on the Health Belief Model (HBM) and Theory of Planned Behavior (TPB). An online population-based survey was distributed in English and Spanish. Data were derived from 1208 U.S. adults (52% female; 38.7% minorities), 43.5% of whom reported vaccine hesitancy. Multivariable analysis revealed that unemployed individuals were more likely (OR = 1.78, 95% CI: 1.16-2.73, p = 0.009) and married (OR = 0.57, 95% CI: 0.39-0.81, p = 0.002) and higher income individuals (OR = 0.52, 95% CI 0.32-0.84, p = 0.008) were less likely to be hesitant. Individuals with greater perceived susceptibility to COVID-19 (OR = 0.82, 95% CI: 0.71-0.94, p = 0.006), who perceived vaccination as being convenient (OR = 0.86, 95% CI: 0.74-1.00, p = 0.047), and who afforded greater importance to cues to action from government (OR = 0.84, 95% CI: 0.74-0.95, p = 0.005), public health (OR = 0.70, 95% CI: 0.59-0.82, p < 0.001), and healthcare experts (OR = 0.59, 95% CI: 0.50-0.69, p < 0.001) were also less likely to be hesitant. Findings suggest that HBM and TPB constructs may be useful in informing strategies to improve COVID-19 vaccine uptake. Specifically, framing appeals based on perceptions of COVID-19 susceptibility, making vaccination convenient, and rebuilding trust through unified cues to action may help to overcome vaccine hesitancy.

Toward the Development of the Perfect Medical Team: Critical Components for Adaptation.

OBJECTIVE: Medical teams play a vital role in the delivery of safe and effective patient care. Toward the goal of becoming a high-reliability health system, the authors posit that the "perfect" medical team is one that develops their attitudes, behaviors, and cognitions (ABCs) to facilitate adaptation. METHODS: The authors synthesized the literature (frameworks, measures, and conceptual models) on teamwork in healthcare (k = 161) to develop an evidence-based model of ABCs, which current evidence suggests, are requisite for medical team adaptation. Clinical vignettes were garnered from the media and other sources to illustrate how these ABCs-or failure in using these ABCs-can lead to positive or negative events in healthcare. RESULTS: The resulting model contains the most frequently included ABCs in healthcare teamwork models, measures, and frameworks: psychological safety (41, 25.5%), situation assessment (66, 41.0%), shared mental models (56, 34.8%), team leadership behaviors (78, 48.4%), role awareness (64, 39.7%), team decision-making (61, 37.9%) and planning (41, 25.5%), conflict management (51, 31.7%), task coordination (71, 44.1%), adaptation (46, 28.6%), and backup behavior (54, 33.5%). The authors posit that communication and organizational conditions-other highly cited components-(141, 87.6%, and 90, 55.9%, respectively) serve as moderators of these relationships. CONCLUSIONS: The authors argue that each of these ABCs is critical for enhancing team adaptation and subsequently increasing patient safety. A list of practical tools and educational strategies that teams and organizations can use to improve their performance on each of these ABCs is provided.

Development of a Hybrid, Interprofessional, Interactive Quality Improvement Curriculum as a Model for Continuing Professional Development.

Over the past 20 years, there has been an increased focus on quality improvement (QI) in health care, which is critical in achieving care that is patient-centered, safer, timelier, and more effective, efficient, and equitable. At the center of this movement is QI education, which is known to lead to learning, behavior change, and improved outcomes. However, there is a need for the development and provision of long-duration, interactive, interprofessional training in QI, to allow for in-depth learning and application of learned skills. To this end, we designed a curriculum for an established interprofessional, interactive, web-based QI fellowship for doctorally prepared clinicians. Curricular content is delivered virtually to geographically dispersed learners over a 2-year time span. The didactic curriculum and experiential learning opportunities provide learners with the foundational knowledge and practical skills to engage in-and eventually, lead-QI initiatives around the country. Evaluation of learner satisfaction and cognitive, affective, and skills-based learning has found that this model is an effective method to train geographically distributed learners. A hybrid training structure is used, where learners interact with the material through 3 distinct delivery modes: (1) virtual instruction in QI topics; (2) face-to-face training, mentorship, and the opportunity for practical application of applied knowledge and skills through the completion of QI projects; and (3) opportunities for other types of training, tailored to each learner's Individual Development Plan. This training program model holds value for QI learning in various health care settings, which are interprofessional by nature. These foundational concepts of hybrid learning to distributed learners-wherein an instructor delivers curriculum in small, face-to-face batches, interprofessional learning is supplemented in a virtual, longitudinal manner, and learners are allowed the opportunity to put skills into action for real-world problems in interdisciplinary clinical teams-can be applied in a multitude of settings, with comparatively lower time and cost expenditure than traditional training programs.

Impact of Patient-Centered Medical Home Implementation on Diabetes Control in the Veterans Health Administration.

BACKGROUND: Given its widespread dissemination across primary care, the Veterans Health Administration (VA) is an ideal setting to examine the impact of the patient-centered medical home (PCMH) on diabetes outcomes. OBJECTIVE: To assess the impact of PCMH implementation on diabetes outcomes among patients receiving care in the Veterans Health Administration. DESIGN: Retrospective cohort analysis and multilevel logistic regression. PATIENTS: Twenty thousand eight hundred fifty-eight patients in one Midwest VA network who had a diabetes diagnosis in both 2009 and 2012 and who received primary care between October 1, 2008 and September 30, 2009. MAIN MEASURES: Glycemic and lipid control using VA quality indicators [hemoglobin (Hb) A1c < 9%, low-density lipoprotein cholesterol (LDL-C) < 100 mg/dL]. KEY RESULTS: Odds of glycemic control were lower in 2012 than 2009 (OR = 0.72, 95% CI = 0.67-0.77, p < 0.001), and this change in control over time varied by race (OR of the interaction between time and race = 1.18, 95% CI = 1.02-1.36, p = 0.028). While the disparity in glycemic control between white and black patients persisted post-PCMH, the magnitude of the disparity was smaller in 2012 compared to 2009 (2012: OR = 1.32, 95% CI = 1.18-1.47, p < 0.0001 and 2009: OR = 1.59, 95% CI = 1.39-1.82, p < 0.0001). Odds of lipid control did not significantly change between 2009 and 2012 and change did not vary by race and/or gender. CONCLUSIONS: Although there were no significant improvements in odds of lipid control, and odds of glycemic control decreased following PCMH implementation, there was evidence of reduced racial disparities in glycemic control post-PCMH implementation.

Evaluation of a Distance Learning Curriculum for Interprofessional Quality Improvement Leaders.

As health care systems move toward value-based care, training future leaders in quality improvement (QI) is essential. Web-based training allows for broad dissemination of QI knowledge to geographically distributed learners. The authors conducted a longitudinal evaluation of a structured, synchronous web-based, advanced QI curriculum that facilitated engagement and real-time feedback. Learners (n = 54) were satisfied (overall satisfaction; M = 3.31/4.00), and there were improvements in cognitive (immediate QI knowledge tests; P = .02), affective (self-efficacy of QI skills; P < .001), and skill-based learning (Quality Improvement Knowledge Application Tool; P < .001). There was significant improvement in affective transfer (interprofessional attitudes on the job; p < .01) but no significant change on cognitive (distal QI knowledge test; P = .91), or skill-based transfer (self-reported interprofessional collaboration job skills; P = .23). The findings suggest that this model can be effective to train geographically distributed future QI leaders.

Qualitative findings on building a partnered approach to implementation of a group-based diabetes intervention in VA primary care.

OBJECTIVE: Conduct a formative evaluation to inform the implementation of 'Empowering Patients in Chronic Care' (EPIC), an evidence-based interdisciplinary group medical appointment intervention to improve collaborative goal-setting in patients with treated but uncontrolled diabetes. DESIGN: The formative evaluation involved qualitative, in-depth interviews with clinicians, structured according to the Promoting Action on Research in Health Services framework. Interviews elicited (1) participants' knowledge regarding interdisciplinary group self-management and goal-setting programmes and how well clinicians embrace these interventions (evidence), (2) physical and social climate at each target facility and how the intervention can best be embedded into routine primary care (context) and (3) site-specific needs to be addressed by our implementation team and clinicians' preparedness and intentions to participate in the intervention (facilitation). SETTING: Clinicians were part of a primary care setting at one of five participating medical facilities within one Veterans Health Administration Veterans Affairs regional network. PARTICIPANTS: We interviewed a snowball sample of 35 interdisciplinary clinicians engaged in diabetes management, practising leadership and administrators at target sites. RESULTS: Most participants had previous experience with diabetes group self-management programmes and viewed group appointments as an effective approach to enhancing care. Discussions about existing group appointments provided a context for evaluating potential barriers and facilitators to implementing EPIC into target sites. Interviews revealed clinicians' expectations about the roles they would play in the intervention, their assessments of the roles and strategies to facilitate their performance in those roles. CONCLUSIONS: Successful implementation of evidence-based practices into routine care requires a partnered approach with engaged local staff. The intervention should address local goals and research objectives to encourage bidirectional engagement. Robust partnerships are nurtured further by sustained, open communication and must consider the context, target population and local experience to address barriers and facilitators to implementation.

Impact of a Pay-for-Performance Program on Care for Black Patients with Hypertension: Important Answers in the Era of the Affordable Care Act.

OBJECTIVE: Evaluate the effect of a pay-for-performance intervention on the quality of hypertension care provided to black patients and determine whether it produced risk selection. DATA SOURCE/STUDY SETTING: Primary data collected between 2007 and 2009 from Veterans Affairs physicians and their primary care panels. STUDY DESIGN: Nested study within a cluster randomized controlled trial of three types of financial incentives and no incentives (control). We compared the proportion of physicians' black patients meeting hypertension performance measures for baseline and final performance periods. We measured risk selection by comparing the proportion of patients who switched providers, patient visit frequency, and panel turnover. Due to limited power, we prespecified in the analysis plan combining the three incentive groups and oversampling black patients. DATA COLLECTION/EXTRACTION METHOD: Data collected electronically and by chart review. PRINCIPAL FINDINGS: The proportion of black patients who achieved blood pressure control or received an appropriate response to uncontrolled blood pressure in the final period was 6.3 percent (95 percent confidence interval, 0.8-11.7 percent) greater for physicians who received an incentive than for controls. There was no difference between intervention and controls in the proportion of patients who switched providers, visit frequency, or panel turnover. CONCLUSIONS AND RELEVANCE: A pay-for-performance intervention improved blood pressure control or appropriate response to uncontrolled blood pressure in black patients and did not produce risk selection.

Statin Use and Its Facility-Level Variation in Patients With Diabetes: Insight From the Veterans Affairs National Database.

We sought to determine use of any and at least moderate-intensity statin therapy in a national sample of patients with diabetes mellitus (DM), with the hypothesis that nationwide frequency and facility-level variation in statin therapy are suboptimal. We sampled patients with DM age 40 to 75 years receiving primary care between October 1, 2012, and September 30, 2013, at 130 parent facilities and associated community-based outpatient clinics in the Veterans Affairs Health Care System. We examined frequency and facility-level variation in use of any or at least moderate-intensity statin therapy (mean daily dose associated with ≥30% low-density lipoprotein cholesterol lowering). In 911 444 patients with DM, 68.3% and 58.4% were receiving any and moderate- to high-intensity statin therapy, respectively. Patients receiving statin had higher burden of cardiovascular disease, were more likely to be on nonstatin lipid-lowering therapy and to receive care at a teaching facility, and had more frequent primary-care visits. Median facility-level uses of any and at least moderate-intensity statin therapy were 68.7% (interquartile range, 65.9%-70.8%) and 58.6% (interquartile range, 55.8%-61.4%), respectively. After adjusting for several patient-related and some facility-related characteristics, the median rate ratios for any and moderate- to high-intensity statin therapy were 1.20 (95% confidence interval: 1.18-1.22) and 1.29 (95% confidence interval: 1.24-1.33) respectively, indicating 20% to 29% variation in statin use between 2 identical patients receiving care at 2 random facilities. Statin use was suboptimal in a national sample of patients with DM with modest facility-level variation, likely indicating differences in statin-prescribing patterns.

Calculations of Financial Incentives for Providers in a Pay-for-Performance Program: Manual Review Versus Data From Structured Fields in Electronic Health Records.

BACKGROUND: Hospital report cards and financial incentives linked to performance require clinical data that are reliable, appropriate, timely, and cost-effective to process. Pay-for-performance plans are transitioning to automated electronic health record (EHR) data as an efficient method to generate data needed for these programs. OBJECTIVE: To determine how well data from automated processing of structured fields in the electronic health record (AP-EHR) reflect data from manual chart review and the impact of these data on performance rewards. RESEARCH DESIGN: Cross-sectional analysis of performance measures used in a cluster randomized trial assessing the impact of financial incentives on guideline-recommended care for hypertension. SUBJECTS: A total of 2840 patients with hypertension assigned to participating physicians at 12 Veterans Affairs hospital-based outpatient clinics. Fifty-two physicians and 33 primary care personnel received incentive payments. MEASURES: Overall, positive and negative agreement indices and Cohen's kappa were calculated for assessments of guideline-recommended antihypertensive medication use, blood pressure (BP) control, and appropriate response to uncontrolled BP. Pearson's correlation coefficient was used to assess how similar participants' calculated earnings were between the data sources. RESULTS: By manual chart review data, 72.3% of patients were considered to have received guideline-recommended antihypertensive medications compared with 65.0% by AP-EHR review (κ=0.51). Manual review indicated 69.5% of patients had controlled BP compared with 66.8% by AP-EHR review (κ=0.87). Compared with 52.2% of patients per the manual review, 39.8% received an appropriate response by AP-EHR review (κ=0.28). Participants' incentive payments calculated using the 2 methods were highly correlated (r≥0.98). Using the AP-EHR data to calculate earnings, participants' payment changes ranged from a decrease of $91.00 (-30.3%) to an increase of $18.20 (+7.4%) for medication use (interquartile range, -14.4% to 0%) and a decrease of $100.10 (-31.4%) to an increase of $36.40 (+15.4%) for BP control or appropriate response to uncontrolled BP (interquartile range, -11.9% to -6.1%). CONCLUSIONS: Pay-for-performance plans that use only EHR data should carefully consider the measures and the structure of the EHR before data collection and financial incentive disbursement. For this study, we feel that a 10% difference in the total amount of incentive earnings disbursed based on AP-EHR data compared with manual review is acceptable given the time and resources required to abstract data from medical records.

Gender disparities in evidence-based statin therapy in patients with cardiovascular disease.

Studies have shown gender disparities in cholesterol care in patients with cardiovascular disease (CVD), with women less likely than men to have low-density lipoprotein cholesterol levels <100 mg/dl. Whether this is related to a lower evidence-based statin or high-intensity statin use is not known. We used a national cohort of 972,532 patients with CVD (coronary heart disease, peripheral artery disease, and ischemic stroke) receiving care in 130 Veterans Health Administration facilities from October 1, 2010, to September 30, 2011, to identify the proportion of male and female patients with CVD receiving any statin and high-intensity statin. Women with CVD (n = 13,371) were less likely than men to receive statins (57.6% vs 64.8%, p <0.0001) or high-intensity statins (21.1% vs 23.6%, p <0.0001). Mean low-density lipoprotein cholesterol levels (99 vs 85 mg/dl) were higher in women compared with men (p <0.0001). In adjusted models, female gender was independently associated with a lower likelihood of receiving statins (odds ratio 0.68, 95% confidence interval 0.66 to 0.71) or high-intensity statins (odds ratio 0.76, 95% confidence interval 0.73 to 0.80). The median facility-level rate of statin and high-intensity statin use among female patients (57.3% [interquartile range = 8.93%] for statin, 20% [interquartile range = 7.7%] for high-intensity statin use) showed significant variation. In conclusion, women with CVD are less likely to receive evidence-based statin and high-intensity statins compared with men, although, their use remains low in both genders. There is a significant facility-level variation in evidence-based statin or high-intensity statin use in female patients with CVD. With the "statin dose-based approach" proposed by the recent cholesterol guidelines, these results highlight areas for quality improvement.

Is high-intensity statin therapy associated with lower statin adherence compared with low- to moderate-intensity statin therapy? Implications of the 2013 American College of Cardiology/American Heart Association Cholesterol Management Guidelines.

BACKGROUND: The recent cholesterol guideline recommends high-intensity statins in cardiovascular disease (CVD) patients. High-intensity statins are associated with more frequent side effects. Therefore, it may be of concern that these recommendations might reduce statin adherence. HYPOTHESIS: High-intensity statins are associated with lower adherence compared with low- to moderate-intensity statins. METHODS: In a national database of 972,532 CVD patients from the Veterans Health Administration, we identified patients receiving statins between October 1, 2010, and September 30, 2011. We assessed statin adherence by calculating proportion of days covered (PDC) and determined whether high-intensity statin therapy was independently associated with a lower PDC. RESULTS: Statins were prescribed in 629,005 (64.7%). Of those, 229,437 (36.5%) received high-intensity statins. Mean PDC (0.87 vs 0.86, P < 0.0001) and patients with PDC ≥ 0.80 (76.3% vs 74.2%, P < 0.0001) were slightly higher for those receiving low- to moderate-intensity compared with high-intensity statins. In adjusted analyses, high-intensity statin use was associated with a significant but modest PDC reduction compared with low- to moderate-intensity statin use, whether PDC was assessed as a continuous (ß-coefficient: -0.008, P < 0.0001) or categorical (PDC ≥ 0.80 [odds ratio: 0.94, 95% confidence interval: 0.93-0.96]) measure of statin adherence. CONCLUSIONS: An approach of high-intensity statin therapy will lead to a significant practice change, as the majority of CVD patients are not on high-intensity therapy. However, this change may be associated with a very modest reduction in statin adherence compared with low- to moderate-intensity therapy that is unlikely to be of clinical significance.

Interaction between functional health literacy, patient activation, and glycemic control.

BACKGROUND: Functional health literacy (FHL) and patient activation can impact diabetes control through enhanced diabetes self-management. Less is known about the combined effect of these characteristics on diabetes outcomes. Using brief, validated measures, we examined the interaction between FHL and patient activation in predicting glycosylated hemoglobin (HbA1c) control among a cohort of multimorbid diabetic patients. METHODS: We administered a survey via mail to 387 diabetic patients with coexisting hypertension and ischemic heart disease who received outpatient care at one regional VA medical center between November 2010 and December 2010. We identified patients with the study conditions using the International Classification of Diseases-Ninth Revision-Clinical Modification (ICD-9-CM) diagnoses codes and Current Procedure Terminology (CPT) procedures codes. Surveys were returned by 195 (50.4%) patients. We determined patient activation levels based on participant responses to the 13-item Patient Activation Measure and FHL levels using the single-item screening question, "How confident are you filling out medical forms by yourself?" We reviewed patient medical records to assess glycemic control. We used multiple logistic regression to examine whether activation and FHL were individually or jointly related to HbA1c control. RESULTS: Neither patient activation nor FHL was independently related to glycemic control in the unadjusted main effects model; however, the interaction between the two was significantly associated with glycemic control (odds ratio 1.05 [95% confidence interval 1.01-1.09], P=0.02). Controlling for age, illness burden, and number of primary care visits, the combined effect of these measures on glycemic control remained significant (odds ratio 1.05 [95% confidence interval 1.01-1.09], P=0.02). CONCLUSION: The interaction between FHL and patient activation is associated with HbA1c control beyond the independent effects of these parameters alone. A personalized approach to diabetes management incorporating these characteristics may increase patient-centered care and improve outcomes for patients with diabetes.

Effects of individual physician-level and practice-level financial incentives on hypertension care: a randomized trial.

IMPORTANCE: Pay for performance is intended to align incentives to promote high-quality care, but results have been contradictory. OBJECTIVE: To test the effect of explicit financial incentives to reward guideline-recommended hypertension care. DESIGN, SETTING, AND PARTICIPANTS: Cluster randomized trial of 12 Veterans Affairs outpatient clinics with 5 performance periods and a 12-month washout that enrolled 83 primary care physicians and 42 nonphysician personnel (eg, nurses, pharmacists). INTERVENTIONS: Physician-level (individual) incentives, practice-level incentives, both, or none. Intervention participants received up to 5 payments every 4 months; all participants could access feedback reports. MAIN OUTCOMES AND MEASURES: Among a random sample, number of patients achieving guideline-recommended blood pressure thresholds or receiving an appropriate response to uncontrolled blood pressure, number of patients prescribed guideline-recommended medications, and number who developed hypotension. RESULTS: Mean (SD) total payments over the study were $4270 ($459), $2672 ($153), and $1648 ($248) for the combined, individual, and practice-level interventions, respectively. The unadjusted baseline and final percentages and the adjusted absolute change over the study in patients meeting the combined blood pressure/appropriate response measure were 75% to 84% and 8.84% (95% CI, 4.20% to 11.80%) for the individual group, 80% to 85% and 3.70% (95% CI, 0.24% to 7.68%) for the practice-level group, 79% to 88% and 5.54% (95% CI, 1.92% to 9.52%) for the combined group, and 86% to 86% and 0.47% (95% CI, -3.12% to 4.04%) for the control group. The adjusted absolute estimated difference in the change between the proportion of patients with blood pressure control/appropriate response for individual incentive and control groups was 8.36% (95% CI, 2.40% to 13.00%; P=.005). The other incentive groups did not show a significant change compared with controls for this outcome. For medications, the unadjusted baseline and final percentages and the adjusted absolute change were 61% to 73% and 9.07% (95% CI, 4.52% to 13.44%), 56% to 65% and 4.98% (95% CI, 0.64% to 10.08%), 65% to 80% and 7.26% (95% CI, 2.92% to 12.48%), and 63% to 72% and 4.35% (95% CI, -0.28% to 9.28%), respectively. These changes in the use of guideline-recommended medications were not significant in any of the incentive groups compared with controls, nor was the incidence of hypotension. The effect of the incentive was not sustained after a washout. CONCLUSIONS AND RELEVANCE: Individual financial incentives, but not practice-level or combined incentives, resulted in greater blood pressure control or appropriate response to uncontrolled blood pressure; none of the incentives resulted in greater use of guideline-recommended medications or increased incidence of hypotension compared with controls. Further research is needed on the factors that contributed to these findings. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00302718.

Correlates of repeat lipid testing in patients with coronary heart disease.

IMPORTANCE: Understanding the frequency and correlates of redundant lipid testing could identify areas for quality improvement initiatives aimed at improving the efficiency of cholesterol care in patients with coronary heart disease (CHD). OBJECTIVE: To determine the frequency and correlates of repeat lipid testing in patients with CHD who attained low-density lipoprotein cholesterol (LDL-C) goals and received no treatment intensification. DESIGN, SETTING, AND PARTICIPANTS: We assessed the proportion of patients with LDL-C levels of less than 100 mg/dL and no intensification of lipid-lowering therapy who underwent repeat lipid testing during an 11-month follow-up period. We performed logistic regression analyses to evaluate facility, provider, and patient characteristics associated with repeat testing. In total, we analyzed 35,191 patients with CHD in a Veterans Affairs network of 7 medical centers with associated community-based outpatient clinics. MAIN OUTCOMES AND MEASURES: Frequency and correlates of repeat lipid testing in patients having CHD with LDL-C levels of less than 100 mg/dL and no further treatment intensification with lipid-lowering therapies. RESULTS: Of 27,947 patients with LDL-C levels of less than 100 mg/dL, 9200 (32.9%) had additional lipid assessments without treatment intensification during the following 11 months (12 ,686 total additional panels; mean, 1.38 additional panel per patient). Adjusting for facility-level clustering, patients with a history of diabetes mellitus (odds ratio [OR], 1.16; 95% CI, 1.10-1.22), a history of hypertension (OR, 1.21; 95% CI, 1.13-1.30), higher illness burden (OR, 1.39; 95% CI, 1.23-1.57), and more frequent primary care visits (OR, 1.32; 95% CI, 1.25-1.39) were more likely to undergo repeat testing, whereas patients receiving care at a teaching facility (OR, 0.74; 95% CI, 0.69-0.80) or from a physician provider (OR, 0.93; 95% CI, 0.88-0.98) and those with a medication possession ratio of 0.8 or higher (OR, 0.75; 95% CI, 0.71-0.80) were less likely to undergo repeat testing. Among 13,114 patients who met the optional LDL-C target level of less than 70 mg/dL, repeat lipid testing was performed in 8177 (62.4% of those with LDL-C levels of <70 mg/dL) during 11 follow-up months. CONCLUSIONS AND RELEVANCE: One-third of patients having CHD with LDL-C levels at goal underwent repeat lipid panels. Our results highlight areas for quality improvement initiatives to reduce redundant lipid testing. These efforts would be more important if the forthcoming cholesterol guidelines adopt a medication dose-based approach in place of the current treat-to-target approach.

Impact of clinical complexity on the quality of diabetes care.

OBJECTIVES: To assess the impact of clinical complexity on 3 dimensions of diabetes care. STUDY DESIGN: We identified 35,872 diabetic patients receiving care at 7 Veterans Affairs facilities between July 2007 and June 2008 using administrative and clinical data. We examined control at index and appropriate care (among uncontrolled patients) within 90 days, for blood pressure (<130/80 mm Hg), glycated hemoglobin (<7%), and low-density lipoprotein cholesterol (<100 mg/dL). We used ordered logistic regression to examine the impact of complexity, defined by comorbidities count and illness burden, on control at index and a combined measure of quality (control at index or appropriate follow-up care) for all 3 measures. RESULTS: There were 6260 (17.5%) patients controlled at index for all 3 quality indicators. Patients with >3 comorbidities (odds ratio [OR], 1.94; 95% confidence interval [CI], 1.67-2.26) and illness burden >2.00 (OR, 1.22; 95% CI, 1.13-1.32) were more likely than the least complex patients to be controlled for all 3 measures. Patients with >3 comorbidities (OR, 2.30; 95% CI, 2.07-2.54) and illness burden >2.00 (OR, 1.25; 95% CI, 1.18-1.33) were also more likely than the least complex patients to meet the combined quality indicator for all 3 measures. CONCLUSIONS: Patients with greatest complexity received higher quality diabetes care compared with less complex patients, regardless of the definition of complexity chosen. Although providers may appropriately target complex patients for aggressive control, deficits in guideline achievement among all diabetic patients highlight the challenges of caring for chronically ill patients and the importance of structuring primary care to promote higher-quality, patient-centered care.