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1.
Med Care ; 2020 Jan 07.
Artigo em Inglês | MEDLINE | ID: mdl-31914103

RESUMO

BACKGROUND: Despite the importance of the hospital discharge destination field ("discharge code" hereafter) for research and payment reform, its accuracy is not well established. OBJECTIVES: The aim of this study was to examine the accuracy of discharge codes in Medicare claims. DATA SOURCES: 2012-2015 Medicare claims of knee and hip replacement patients. RESEARCH DESIGN: We identified patients' discharge location in claims and compared it with the discharge code. We also used a mixed-effects logistic regression to examine the association of patient and hospital characteristics with discharge code accuracy. RESULTS: Approximately 9% of discharge codes were inaccurate. Long-term care hospital discharge codes had the lowest accuracy rate (41%), followed by acute care transfers (72%), inpatient rehabilitation facility (80%), and home discharges (83%). Most misclassifications occurred within 2 broad groups of postacute care settings: home-based and institutional care. The odds of inaccurate discharge codes were higher for Medicaid-enrolled patients and safety-net and low-volume hospitals. CONCLUSIONS: Inaccurate hospital discharge coding may have introduced bias in studies relying on these codes (eg, evaluations of Medicare bundled payment models). Inaccuracy was more common among Medicaid-enrolled patients and safety-net and low-volume hospitals, suggesting more potential bias in existing study findings pertaining to these patients and hospitals.

2.
J Gen Intern Med ; 35(1): 247-254, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31659659

RESUMO

OBJECTIVE: To describe how access to primary and specialty care differs for Medicaid patients relative to commercially insured patients, and how these differences vary across rural and urban counties, using comprehensive claims data from Oregon. DESIGN: Cross-sectional study of risk-adjusted access rates for two types of primary care providers (physicians; nurse practitioners (NPs) and physician assistants (PAs)); four types of mental health providers (psychiatrists, psychologists, advanced practice NPs or PAs specializing in mental health care, behavioral specialists); and four physician specialties (obstetrics and gynecology, general surgery, gastroenterology, dermatology). PARTICIPANTS: 420,947 Medicaid and 638,980 commercially insured adults in Oregon, October 2014-September 2015. OUTCOME: Presence of any visit with each provider type, risk-adjusted for sex, age, and health conditions. RESULTS: Relative to commercially insured individuals, Medicaid enrollees had lower rates of access to primary care physicians (- 11.82%; CI - 12.01 to - 11.63%) and to some specialists (e.g., obstetrics and gynecology, dermatology), but had equivalent or higher rates of access to NPs and PAs providing primary care (4.33%; CI 4.15 to 4.52%) and a variety of mental health providers (including psychiatrists, NPs and PAs, and other behavioral specialists). Across all providers, the largest gaps in Medicaid-commercial access rates were observed in rural counties. The Medicaid-commercial patient mix was evenly distributed across primary care physicians, suggesting that access for Medicaid patients was not limited to a small subset of primary care providers. CONCLUSIONS: This cross-sectional study found lower rates of access to primary care physicians for Medicaid enrollees, but Medicaid-commercial differences in access rates were not present across all provider types and displayed substantial variability across counties. Policies that address rural-urban differences as well as Medicaid-commercial differences-such as expansions of telemedicine or changes in the workforce mix-may have the largest impact on improving access to care across a wide range of populations.

3.
Diabetes Care ; 43(3): 572-579, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31857442

RESUMO

OBJECTIVE: To compare trends in Medicaid expenditures among adults with diabetes who were newly eligible due to the Affordable Care Act (ACA) Medicaid expansion to trends among those previously eligible. RESEARCH DESIGN AND METHODS: Using Oregon Medicaid administrative data from 1 January 2014 to 30 September 2016, a retrospective cohort study was conducted with propensity score-matched Medicaid eligibility groups (newly and previously eligible). Outcome measures included total per-member per-month (PMPM) Medicaid expenditures and PMPM expenditures in the following 12 categories: inpatient visits, emergency department visits, primary care physician visits, specialist visits, prescription drugs, transportation services, tests, imaging and echography, procedures, durable medical equipment, evaluation and management, and other or unknown services. RESULTS: Total PMPM Medicaid expenditures for newly eligible enrollees with diabetes were initially considerably lower compared with PMPM expenditures for matched previously eligible enrollees during the first postexpansion quarter (mean values $561 vs. $793 PMPM, P = 0.018). Within the first three postexpansion quarters, PMPM expenditures of the newly eligible increased to a similar but slightly lower level. Afterward, PMPM expenditures of both groups continued to increase steadily. Most of the overall PMPM expenditure increase among the newly eligible was due to rapidly increasing prescription drug expenditures. CONCLUSIONS: Newly eligible Medicaid enrollees with diabetes had slightly lower PMPM expenditures than previously eligible Medicaid enrollees. The increase in PMPM prescription drug expenditures suggests greater access to treatment over time.

4.
JAMA Netw Open ; 2(11): e1914696, 2019 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-31693127

RESUMO

Importance: Medicare's Comprehensive Care for Joint Replacement (CJR) model rewards or penalizes hospitals on the basis of meeting spending benchmarks that do not account for patients' preexisting social and medical complexity or high expenses associated with serving disadvantaged populations such as dual-eligible patients (ie, those enrolled in both Medicare and Medicaid). The CJR model may have different implications for hospitals serving a high percentage of dual-eligible patients (termed high-dual) and hospitals serving a low percentage of dual-eligible patients (termed low-dual). Objective: To examine changes associated with the CJR model among high-dual or low-dual hospitals in 2016 to 2017. Design, Setting, and Participants: This cohort study comprised 3 analyses of high-dual or low-dual hospitals (n = 1165) serving patients with hip or knee joint replacements (n = 768 224) in 67 treatment metropolitan statistical areas (MSAs) selected for CJR participation and 103 control MSAs. The study used Medicare claims data and public reports from 2012 to 2017. Data analysis was conducted from February 1, 2019, to August 31, 2019. Exposures: The CJR model holds participating hospitals accountable for the spending and quality of care during care episodes for patients with hip or knee joint replacement, including hospitalization and 90 days after discharge. Main Outcomes and Measures: The primary outcomes were total episode spending, discharge to institutional postacute care facility, and readmission within the 90-day postdischarge period; bonus and penalty payments for each hospital; and reductions in per-episode spending required to receive a bonus for each hospital. Results: In total, 1165 hospitals (291 high-dual and 874 low-dual) and 768 224 patients with joint replacement (494 013 women [64.3%]; mean [SD] age, 76 [7] years) were included. An episode-level triple-difference analysis indicated that total spending under the CJR model decreased at high-dual hospitals (by $851; 95% CI, -$1556 to -$146; P = .02) and low-dual hospitals (by $567; 95% CI, -$933 to -$202; P = .003). The size of decreases did not differ between the 2 groups (difference, -$284; 95% CI, -$981 to $413; P = .42). Discharge to institutional postacute care settings and readmission did not change among both hospital groups. High-dual hospitals were less likely to receive a bonus compared with low-dual hospitals (40.3% vs 59.1% in 2016; 56.9% vs 76.0% in 2017). To receive a bonus, high-dual hospitals would be required to reduce spending by $887 to $2231 per episode, compared with only $89 to $215 for low-dual hospitals. Conclusions and Relevance: The study found that high- and low-dual hospitals made changes in care after CJR implementation, and the magnitude of these changes did not differ between the 2 groups. However, high-dual hospitals were less likely to receive a bonus for spending cuts. Spending benchmarks for CJR would require high-dual hospitals to reduce spending more substantially to receive a financial incentive.

5.
Health Serv Res ; 54(6): 1273-1282, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31602641

RESUMO

OBJECTIVE: To demonstrate the performance of methodologies that include machine learning (ML) algorithms to estimate average treatment effects under the assumption of exogeneity (selection on observables). DATA SOURCES: Simulated data and observational data on hospitalized adults. STUDY DESIGN: We assessed the performance of several ML-based estimators, including Targeted Maximum Likelihood Estimation, Bayesian Additive Regression Trees, Causal Random Forests, Double Machine Learning, and Bayesian Causal Forests, applying these methods to simulated data as well as data on the effects of right heart catheterization. PRINCIPAL FINDINGS: In Monte Carlo studies, ML-based estimators generated estimates with smaller bias than traditional regression approaches, demonstrating substantial (69 percent-98 percent) bias reduction in some scenarios. Bayesian Causal Forests and Double Machine Learning were top performers, although all were sensitive to high dimensional (>150) sets of covariates. CONCLUSIONS: ML-based methods are promising methods for estimating treatment effects, allowing for the inclusion of many covariates and automating the search for nonlinearities and interactions among variables. We provide guidance and sample code for researchers interested in implementing these tools in their own empirical work.


Assuntos
Cateterismo Cardíaco/estatística & dados numéricos , Simulação por Computador , Interpretação Estatística de Dados , Pacientes Internados/estatística & dados numéricos , Aprendizado de Máquina , Resultado do Tratamento , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Teorema de Bayes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos
6.
J Health Polit Policy Law ; 44(6): 919-935, 2019 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-31408877

RESUMO

States and policy makers have expressed a strong interest in using Medicaid to address social determinants of health (SDOH). While this approach holds promise for improving outcomes and reducing costs, using Medicaid to pay for services outside the medical system creates challenges. This article examines efforts to address SDOH in Oregon, which, as part of its 2012 Medicaid waiver, incorporated health-related services that lacked billing or encounter codes and were not included in Oregon's Medicaid state plan as a strategy to improve outcomes and control costs. We examine the varieties of health-related services that were used and describe the specific challenges in deploying and paying for these services. We conclude with lessons from Oregon that can help states and the federal government as they work to address SDOH.

7.
JAMA Surg ; : e192279, 2019 Jul 10.
Artigo em Inglês | MEDLINE | ID: mdl-31290955

RESUMO

Importance: Trauma registries are the primary data mechanism in trauma systems to evaluate and improve the care of injured patients. Research has suggested that trauma registries may miss high-risk older adults, who commonly experience morbidity and mortality after injury. Objective: To compare injured older adults who were included in with those excluded from trauma registries, with a focus on patients with serious injuries, requiring major surgery, or dying after injury. Design, Setting, and Participants: This cohort study included all injured adults 65 years and older transported by 44 emergency medical services agencies to 51 trauma and nontrauma centers in 7 counties in Oregon and Washington from January 1, 2011, to December 31, 2011, with follow-up through December 31, 2012. Record linkage was used to match emergency medical services records with state trauma registries, state discharge databases, state death registries, and Medicare claims. Data were analyzed from August to November 2018. Exposures: Inclusion in vs exclusion from a trauma registry. Main Outcomes and Measures: Mortality up to 12 months, including time to death and causes of death. Results: Of 8161 included patients, 5579 (68.4%) were women, and the mean (SE) age was 82.2 (0.10) years. A total of 1720 older adults (21.1%) were matched to a trauma registry record. Seriously injured patients not captured by trauma registries ranged from 18% (7 of 38 patients with abdominal-pelvic Abbreviated Injury Scale score of 3 or greater) to 80.0% (1792 of 2241 patients with extremity Abbreviated Injury Scale score of 3 or greater), while 68 of 186 patients requiring major nonorthopedic surgery (36.6%) and 1809 of 2325 patients requiring orthopedic surgery (77.8%) were not included in trauma registries. Of patients with serious injuries or undergoing major surgery missed by trauma registries (range by injury and procedure type, 36.0% to 57.1%), 36.4% (39.3% when excluding serious extremity injuries and orthopedic procedures) were treated at trauma centers, particularly level III through V hospitals. When registry and nonregistry groups were tracked over 12 months, 93 of 188 in-hospital deaths (49.5%) and 1531 of 1887 total deaths (81.1%) occurred in the nonregistry cohort. Conclusions and Relevance: In their current form, trauma registries are ineffective in capturing, tracking, and evaluating injured older adults, although mortality following injury is frequently due to noninjury causes. High-risk injured older adults are not included in registries because of care in nontrauma hospitals, restrictive registry inclusion criteria, and being missed by registries in trauma centers.

8.
J Am Board Fam Med ; 32(3): 398-407, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31068404

RESUMO

PURPOSE: We assessed differences in structural characteristics, quality improvement processes, and cardiovascular preventive care by ownership type among 989 small to medium primary care practices. METHODS: This cross-sectional analysis used electronic health record and survey data collected between September 2015 and April 2017 as part of an evaluation of the EvidenceNOW: Advancing Heart Health in Primary Care Initiative by the Agency for Health Care Research and Quality. We compared physician-owned practices, health system or medical group practices, and Federally Qualified Health Centers (FQHC) by using 15 survey-based practice characteristic measures, 9 survey-based quality improvement process measures, and 4 electronic health record-based cardiovascular disease prevention quality measures, namely, aspirin prescription, blood pressure control, cholesterol management, and smoking cessation support (ABCS). RESULTS: Physician-owned practices were more likely to be solo (45.0% compared with 8.1%, P < .001 for health system practices and 12.8%, P = .009 for FQHCs) and less likely to have experienced a major change (eg, moved to a new location) in the last year (43.1% vs 65.4%, P = .01 and 72.1%, P = .001, respectively). FQHCs reported the highest use of quality improvement processes, followed by health system practices. ABCS performance was similar across ownership type, with the exception of smoking cessation support (51.0% for physician-owned practices vs 67.3%, P = .004 for health system practices and 69.3%, P = .004 for FQHCs). CONCLUSIONS: Primary care practice ownership was associated with differences in quality improvement process measures, with FQHCs reporting the highest use of such quality-improvement strategies. ABCS were mostly unrelated to ownership, suggesting a complex path between quality improvement strategies and outcomes.

9.
Injury ; 50(6): 1175-1185, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31101411

RESUMO

INTRODUCTION/OBJECTIVE: Little is known about the long-term outcomes of injured older adults cared for in trauma systems. We sought to describe mortality and causes of death over time, and the independent association of injury severity, comorbidities, and other factors on 12-month mortality among injured older adults transported by emergency medical services (EMS). MATERIALS AND METHODS: This was a population-based cohort study of injured adults ≥ 65 years in the United States transported by 44 EMS agencies to 51 hospitals from January 1, 2011 to December 31, 2011, with 12-month follow-up through December 31, 2012. The primary outcomes were time to death and causes of death. We used descriptive statistics and Cox proportional hazards models to generate adjusted hazard ratios (HR). RESULTS: 15,649 injured older adults were transported by EMS, frequently after a fall (84.5%). Serious injuries (Injury Severity Score [ISS] ≥ 16) occurred in 3.5%, with serious extremity injury (Abbreviated Injury Scale score ≥ 3) being most common (17.8%). Mortality rates were: 1.6% in-hospital, 5.1% at 30 days, 9.4% at 90 days and 20.3% at 1 year. The adjusted HR for patients in the highest comorbidity quartile was 2.20 (versus lowest quartile, 95% CI 1.97-2.46, p < .001), while the HR for ISS ≥ 25 was 2.69 (versus ISS 0-8, 95% CI 1.60-4.51, p = .001). Cardiovascular etiologies (53.3%) and dementia (32.7%) were the most common causes of death, with injury listed in 12.8% of death certificates. CONCLUSIONS: Injury requiring EMS transport is a sentinel event among older adults, with death typically occurring months later, often due to cardiovascular causes and dementia. A heavy comorbidity burden had an adjusted mortality risk comparable to severe injury.

10.
Milbank Q ; 97(3): 636-640, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31134690
11.
BMC Health Serv Res ; 19(1): 207, 2019 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-30935394

RESUMO

BACKGROUND: In 2016, Oregon became the first of eight states to allow pharmacists to directly prescribe hormonal contraception (HC), including the pill, patch, or ring, without a clinic visit. In the two years following this policy change, the majority of ZIP codes across the state of Oregon had a pharmacist certified to prescribe HC. METHODS: We will utilize complementary methodologies to evaluate the effect of this policy change on convenient access to contraception (cost, supply dispensed), safety, contraceptive continuation and unintended pregnancy rates. We will conduct a prospective clinical cohort study to directly measure the impact of provider type on contraceptive continuation and to understand who is accessing hormonal contraception directly from pharmacists. We will concurrently conduct a retrospective analysis using medical claims data to evaluate the state-level effect of the policy. We will examine contraceptive continuation rates, incident pregnancy, and safety measures. The combination of these methodologies allows us to examine key woman-level factors, such as pregnancy intention and usual place of care, while also estimating the impact of the pharmacist prescription policy at the state level. DISCUSSION: Pharmacist prescription of HC is emerging nationally as a strategy to reduce unintended pregnancy. This study will provide data on the effect of this practice on convenient access to care, contraceptive safety and continuation rates.


Assuntos
Anticoncepcionais Femininos , Prescrições de Medicamentos , Legislação de Medicamentos , Farmacêuticos/legislação & jurisprudência , Feminino , Acesso aos Serviços de Saúde , Humanos , Oregon , Assistência Farmacêutica/legislação & jurisprudência , Gravidez , Taxa de Gravidez , Gravidez não Planejada , Estudos Prospectivos , Projetos de Pesquisa , Estudos Retrospectivos
12.
BMC Health Serv Res ; 19(1): 54, 2019 Jan 21.
Artigo em Inglês | MEDLINE | ID: mdl-30665396

RESUMO

BACKGROUND: Health care reform is changing preventive services delivery. This study explored trajectories in colorectal cancer (CRC) testing over a 5-year period that included implementation of 16 Medicaid Accountable Care Organizations (ACOs, 2012) and Medicaid expansion (2014) - two provisions of the Affordable Care Act (ACA) - within the state of Oregon, USA. METHODS: Retrospective analysis of Oregon's Medicaid claims for enrollee's eligible for CRC screening (50-64 years) spanning January 2010 through December 2014. Our analysis was conducted and refined April 2016 through June 2018. The analysis assessed the annual probability of patients receiving CRC testing and the modality used (e.g., colonoscopy, fecal testing) relative to a baseline year (2010). We hypothesized that CRC testing would increase following Medicaid ACO formation - called Coordinated Care Organizations (CCOs). RESULTS: A total of 132,424 unique Medicaid enrollees (representing 255,192 person-years) met inclusion criteria over the 5-year study. Controlling for demographic and regional factors, the predicted probability of CRC testing was significantly higher in 2014 (+ 1.4 percentage points, p < 0.001) compared to the 2010 baseline but not in 2012 or 2013. Increased fecal testing using Fecal Occult Blood Tests (FOBT) or Fecal Immunochemical Tests (FIT) played a prominent role in 2014. The uptick in statewide fecal testing appears driven primarily by a subset of CCOs. CONCLUSIONS: Observed CRC testing did not immediately increase following the transition to CCOs in 2012. However increased testing in 2014, may reflect a delay in implementation of interventions to increase CRC screening and/or a strong desire by newly insured Medicaid CCO members to receive preventive care.


Assuntos
Organizações de Assistência Responsáveis , Neoplasias Colorretais/diagnóstico , Detecção Precoce de Câncer , Medicaid , Idoso , Feminino , Reforma dos Serviços de Saúde , Humanos , Revisão da Utilização de Seguros , Masculino , Pessoa de Meia-Idade , Oregon , Aceitação pelo Paciente de Cuidados de Saúde , Patient Protection and Affordable Care Act , Estudos Retrospectivos , Estados Unidos
13.
Med Care Res Rev ; 76(5): 661-677, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-29139330

RESUMO

Dual-eligible beneficiaries or "duals" are individuals enrolled in both the Medicare and Medicaid programs. For both Medicare and Medicaid, they may be enrolled in fee-for-service or managed care, creating a mix of possible coverage models. Understanding these different models is essential to improving care for duals. Using All-Payer All-Claims data, we empirically described health service use and quality of care for Oregon duals across five coverage models with different combinations of fee-for-service, managed care, and plan alignment status across Medicare and Medicaid. We found substantial heterogeneity in care across these five coverage models. We also found that duals in plans with aligned financial incentives for Medicare and Medicaid experienced more improvement in their care relative to those with nonaligned Medicare Advantage and Medicaid managed care plans. These results highlight the importance of developing policies that account for the heterogeneity of the dual population and their coverage options.

16.
J Subst Abuse Treat ; 94: 24-28, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30243413

RESUMO

The study examines impacts of delivery system reforms and Medicaid expansion on treatment for alcohol use disorders within the Oregon Health Plan (Medicaid). Diagnoses, services and pharmacy claims related to alcohol use disorders were extracted from Medicaid encounter data. Logistic regression and interrupted time series analyses assessed the percent with alcohol use disorder entering care and the percent receiving pharmacotherapy before (January 2010-June 2012) and after (January 2013-June 2015) the initiation of Oregon's Coordinated Care Organization (CCO) model (July 2012-December 2012). Analyses also examined changes in access following Medicaid expansion (January 2014). Treatment entry rates increased from 35% in 2010 to 41% in 2015 following the introduction of CCOs and Medicaid expansion. The number of Medicaid enrollees with a diagnosed alcohol use disorder increased about 150% from 10,360 (2013) to 25,454 (2014) following Medicaid expansion. Individuals with an alcohol use disorder who were prescribed a medication to support recovery increased from 2.3% (2010) to 3.8% (2015). In Oregon, Medicaid expansion and health care reforms enhanced access and improved treatment initiation for alcohol use disorders.


Assuntos
Alcoolismo/tratamento farmacológico , Reforma dos Serviços de Saúde , Acesso aos Serviços de Saúde/tendências , Medicaid/organização & administração , Adolescente , Adulto , Feminino , Humanos , Análise de Séries Temporais Interrompida , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Oregon , Padrões de Prática Médica/tendências , Estados Unidos , Adulto Jovem
17.
Med Care ; 56(7): 589-595, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29762274

RESUMO

BACKGROUND: Expansion of the Medicaid program is likely to create new budgetary pressures at the state and federal levels, creating a need for greater understanding of how program dollars are allocated and what drives spending growth. OBJECTIVE: To characterize Oregon Medicaid expenditures across diseases and medical conditions, during periods of payment reform and coverage expansion. RESEARCH DESIGN: Decomposition of changes in Medicaid expenditures using a person-based allocation of spending across 50 diseases/medical conditions. Four indices describe changes in costs per enrolled member, demographic shifts, prevalence of treated disease/condition, and costs per treated member. SUBJECTS: Oregon Medicaid beneficiaries during 2011 (N=597,422), 2013 (N=614,858), and 2014 (N=978,237). RESULTS: Expenditures on pregnancy/birth and mental conditions accounted for 24% of 2011 spending. Oregon's 2012 payment reform was associated with reduced spending attributable primarily to decreased prevalence of treated conditions. The 2014 Medicaid expansion was marked by lower pregnancy and mental health expenditures and higher spending on treatment for substance use and heart disease. CONCLUSIONS: Medicaid spending is concentrated among a small group of medical conditions, not all of which are typically associated with the program. The relative expenditure burdens for some conditions are likely to change with health system reform and enrollment expansions. Decomposition into 4 indices and reporting by disease/condition elucidate variability in drivers of cost growth.


Assuntos
Reforma dos Serviços de Saúde , Gastos em Saúde/estatística & dados numéricos , Programas de Assistência Gerenciada , Medicaid/organização & administração , Patient Protection and Affordable Care Act/legislação & jurisprudência , Adolescente , Adulto , Algoritmos , Criança , Pré-Escolar , Feminino , Gastos em Saúde/tendências , Humanos , Lactente , Masculino , Programas de Assistência Gerenciada/economia , Programas de Assistência Gerenciada/organização & administração , Medicaid/economia , Transtornos Mentais , Pessoa de Meia-Idade , Oregon , Parto , Transtornos Relacionados ao Uso de Substâncias , Estados Unidos , Adulto Jovem
18.
Health Aff (Millwood) ; 37(4): 635-643, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29608365

RESUMO

Federal value-based payment programs require primary care practices to conduct quality improvement activities, informed by the electronic reports on clinical quality measures that their electronic health records (EHRs) generate. To determine whether EHRs produce reports adequate to the task, we examined survey responses from 1,492 practices across twelve states, supplemented with qualitative data. Meaningful-use participation, which requires the use of a federally certified EHR, was associated with the ability to generate reports-but the reports did not necessarily support quality improvement initiatives. Practices reported numerous challenges in generating adequate reports, such as difficulty manipulating and aligning measurement time frames with quality improvement needs, lack of functionality for generating reports on electronic clinical quality measures at different levels, discordance between clinical guidelines and measures available in reports, questionable data quality, and vendors that were unreceptive to changing EHR configuration beyond federal requirements. The current state of EHR measurement functionality may be insufficient to support federal initiatives that tie payment to clinical quality measures.


Assuntos
Registros Eletrônicos de Saúde/normas , Uso Significativo , Atenção Primária à Saúde/normas , Melhoria de Qualidade/normas , Projetos de Pesquisa , Humanos
19.
Ann Fam Med ; 16(Suppl 1): S35-S43, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29632224

RESUMO

PURPOSE: Improving primary care quality is a national priority, but little is known about the extent to which small to medium-size practices use quality improvement (QI) strategies to improve care. We examined variations in use of QI strategies among 1,181 small to medium-size primary care practices engaged in a national initiative spanning 12 US states to improve quality of care for heart health and assessed factors associated with those variations. METHODS: In this cross-sectional study, practice characteristics were assessed by surveying practice leaders. Practice use of QI strategies was measured by the validated Change Process Capability Questionnaire (CPCQ) Strategies Scale (scores range from -28 to 28, with higher scores indicating more use of QI strategies). Multivariable linear regression was used to examine the association between practice characteristics and the CPCQ strategies score. RESULTS: The mean CPCQ strategies score was 9.1 (SD = 12.2). Practices that participated in accountable care organizations and those that had someone in the practice to configure clinical quality reports from electronic health records (EHRs), had produced quality reports, or had discussed clinical quality data during meetings had higher CPCQ strategies scores. Health system-owned practices and those experiencing major disruptive changes, such as implementing a new EHR system or clinician turnover, had lower CPCQ strategies scores. CONCLUSION: There is substantial variation in the use of QI strategies among small to medium-size primary care practices across 12 US states. Findings suggest that practices may need external support to strengthen their ability to do QI and to be prepared for new payment and delivery models.


Assuntos
Atenção Primária à Saúde/normas , Melhoria de Qualidade/organização & administração , Indicadores de Qualidade em Assistência à Saúde , Estudos Transversais , Assistência à Saúde/normas , Fidelidade a Diretrizes/estatística & dados numéricos , Humanos , Atenção Primária à Saúde/estatística & dados numéricos , Inquéritos e Questionários , Estados Unidos , United States Agency for Healthcare Research and Quality
20.
Addiction ; 2018 Apr 20.
Artigo em Inglês | MEDLINE | ID: mdl-29679440

RESUMO

BACKGROUND AND AIMS: In response to the opioid overdose epidemic, US state Medicaid programs have adopted restrictive policies for opioid analgesics, yet effects on prescribing patterns and health outcomes are uncertain. This study aimed to examine effects of a prior authorization policy for extended-release/long-acting (ER/LA) opioids on opioid use in the Oklahoma, USA state Medicaid program. DESIGN: Retrospective difference-in-differences design study comparing changes in opioid use in Oklahoma Medicaid to control (Oregon Medicaid). SETTING: Oklahoma and Oregon, USA. PARTICIPANTS: Medicaid beneficiaries in the Oklahoma and Oregon fee-for-service Medicaid programs between July 2007 and June 2009 (33 724 in Oklahoma and 13 520 in Oregon) MEASUREMENTS: The primary outcome was incident opioid-naive ER/LA opioid use. Secondary outcomes included other opioid and non-opioid pain medication use. We also examined indicators of high-risk prescribing (e.g. high-dosage opioid use) and opioid-related hospitalizations or emergency department (ED) visits. FINDINGS: The prior authorization policy was associated with a 0.7 percentage point reduction in the likelihood of incident opioid-naive ER/LA opioid use [95% confidence interval (CI) = -1.16 to -0.33 percentage points; 70% pre-policy mean reduction, a 1.4 percentage point decrease in likelihood of any new ER/LA opioid prescriptions (95% CI = -2.1 to -0.7 percentage points; 33% pre-policy mean reduction) and a decline of 0.16 in total ER/LA opioid prescriptions per enrollee (PPE) (95% CI = -0.29 to -0.04 PPE)]. There was a significant increase in the number of short-acting opioids filled after the policy (0.36; 95% CI = 0.22-0.50 PPE), increases in likelihood of having overlapping opioids and benzodiazepines, but significant reductions in likelihood of having overlapping opioids. No significant changes in opioid-related hospitalizations or ED visits were observed. CONCLUSIONS: In Oklahoma, USA's July 2008 prior authorization policy for extended-release/long-acting opioids appears to have reduced the number of opioid-naive patients initiating extended-release/long-acting opioid use by more than half, but may also have increased short-acting opioid prescriptions by 7%.

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