Managing total knee replacement under value-based payments.

OBJECTIVES: To evaluate opportunity gaps and set outcome goals in knee replacement (KR) between a primary care group taking financial risk for managing its patients and 6 fee-for-service (FFS) orthopedic groups that serve their patients. STUDY DESIGN: The opportunity gap analysis was a cross-sectional evaluation of the outcomes of interest on a risk-adjusted basis using orthopedic groups, the primary care group's patients, and regional comparisons. The impact evaluation was a historical cohort comparison tracking outcomes of interest over the time frame of the intervention. METHODS: Using risk-adjusted Medicare data, we defined opportunity gaps in the following outcomes: density of KR surgery, site of KR surgery, postacute care placement, and complications. RESULTS: Opportunity gap analysis demonstrated the following variation on a regional basis: a 2-fold difference in density of KR, a 3-fold difference in outpatient surgery, and a 2.5-fold difference in institutional postacute care placement. In the impact evaluation comparing 2019 with 2021, the primary care group's patients had reduced density of KR surgeries from 15.5 per 1000 to 13.0 per 1000, an increase in outpatient surgery from 31.0% to 81.6%, and a reduction in institutional postacute care utilization from 16.0% to 6.1%. Less pronounced trends were seen in the region for all Medicare FFS patients. These results were achieved with stable complication rates, which had an observed/expected ratio of 0.61 in 2019 and 0.63 in 2021. CONCLUSIONS: We achieved alignment of incentives through use of performance information with specific goals and promise of referrals to value-based partners. This approach resulted in improved value to patients with no evidence of harm and is translatable to other specialty care and markets.

An Evaluation of Reach for a Work Site Implementation of the National Diabetes Prevention Program Focusing on Diet and Exercise.

PURPOSE: Our objective is to evaluate the "reach" component of the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework by comparing prediabetics who were and were not interested in enrolling in a free work site diabetes prevention program (DPP) during the first year of the program. Reach is defined as the proportion of eligible participants who enroll in a health program. DESIGN: A cross-sectional study design was used. SETTING: The setting was a large health system in the Midwest. PARTICIPANTS: Prediabetic health plan enrollees and spouses (N = 2158). MEASURES: An online health survey, annual voluntary biometric screenings delivered by a trained health-care professional using standardized protocols via point-of-care testing, and records from the DPP office were the sources of data for this study. ANALYSIS: Health behaviors and biometric screening results were simultaneously compared using multivariable logistic regression. RESULTS: The study population was 63% female, 79% white, and 16% black, and the mean age was 50.2 years (SD = 10.2). The reach of this program was 10%. Prediabetics were more likely to express interest in the DPP, if they were female (adjusted odds ratio [AOR]: 2.4; 95% confidence interval [95% CI]: 1.55-3.72; P < .001), black (AOR = 2.23; 95% CI: 1.43-3.47; P < .001), older in age (AOR: 1.08; 95% CI: 0.99-1.17; P = .05), or had a high-risk waist circumference (AOR = 1.44; 95% CI: 0.98-2.13; P = .07), lower self-efficacy to make healthy changes (AOR = 0.48; 95% CI: 0.26-0.91; P = .03), and 5 or more doctor visits in the last year (AOR = 2.13; 95% CI: 0.99-4.57; P = .05), after controlling for other covariates. CONCLUSION: Current recruitment and implementation strategies are reaching only a small group of individuals who are not representative of the larger prediabetic population. These findings inform future engagement strategies, and we recommend that public health practitioners evaluate reach to ensure that health promotion programs are of high value.

The GDAHA hospital performance reports project: a successful community-based quality improvement initiative.

During the past decade there has been increasing distribution of hospital performance information but few examples of how this information is affecting the quality of health care delivery. This article describes the methods of implementation and factors influencing a successful community-based quality improvement initiative in Dayton, Ohio, involving a collaborative of five competing hospitals in partnership with the business community and local and state hospital associations. The initiative contributed to a 36% reduction in acute myocardial infarction mortality over a 3-year period by changing reperfusion patterns in patients with ST segment elevated myocardial infarction. Identification of an opportunity gap, root cause analysis, and development of process measures used to facilitate health care provider change are summarized. The driving and restraining forces that have shaped this initiative from a report card to a quality improvement program are outlined and a list of five contributors to success are presented. These factors can serve as a basis for how other communities can benefit from this collaborative model.

Potential barriers to control of blood pressure.

Numerous studies, including the National Health and Nutrition Examination Survey, have suggested inadequate control in patients with hypertension. Few studies have investigated the factors that may contribute to inadequate blood pressure control. This study assesses adequacy of blood pressure control in patients treated at two osteopathic resident-training family practice centers and investigates potential barriers to adequate blood pressure control in this setting. The care of 127 hypertensive patients was studied for 9 months. The charts of these patients were examined for blood pressure readings, gender, number of missed visits, comorbid conditions, and changes in medications. The adequacy of blood pressure control was assessed by the standards promulgated by the sixth report of the Joint National Committee guidelines. Barriers to adequate control, including missed visits and changes in medications, were assessed. With the standard of control as a mean blood pressure of less than or equal to 140/80 mm Hg, 51.2% of the sample had controlled blood pressure. Factors that were associated with a significant reduction in the control of blood pressure were (1) patients new to the practice, (2) patients who missed follow-up visits for treatment of hypertension, and (3) patients who were undergoing changes in their medication profiles. Although rates of blood pressure control in this population are higher than those previously reported in the general population, they demonstrate room for improvement. Factors that are less under the control of physicians may be responsible for a large percentage of patients with uncontrolled hypertension. An understanding of the factors associated with poor blood pressure control is important in developing interventions to improve adequacy of blood pressure control.

OMT associated with reduced analgesic prescribing and fewer missed work days in patients with low back pain: an observational study.

CONTEXT: Randomized controlled trials (RCTs) are considered the standard for establishing practice guidelines; however, they are expensive and time-consuming, and often the generalizability of the results is limited. OBJECTIVES: To conduct an observational study using the findings of the American Osteopathic Association's Clinical Assessment Program (AOA-CAP) low back pain module, and to compare these findings with those of a major back pain-related RCT to determine the validity and generalizability of this pseudoexperimental model. METHODS: Data were abstracted from the AOA-CAP for Residencies platform from April 1, 2006, through October 5, 2007, with a diagnosis code consistent with low back pain. Process and outcome measures were compared after segregating a similar patient population to an RCT that compared "osteopathic spinal manipulation" with standard care. RESULTS: A total of 1013 medical records were abstracted and entered into the AOA-CAP low back pain module. Mean (standard deviation [SD]) age was 44.7 (15.9) years, and body mass index was 29.6 (8.1). The eligible patients comprised 415 men (41.0%) and 598 women (59.0%), and common comorbid disease was found in 69 patients (6.8%). Activities of daily living were limited in 402 patients (42.4%), whereas 546 (57.6%) had no limitations. Previous exacerbations of low back pain occurred in 653 patients (65.9%). Most patients had no sensory or proprioception deficit (729 [87.7%]), and motor function was normal in 636 patients (74.5%). Normal ankle and knee reflexes were found in 744 of 814 (91.4%) and 755 of 829 (89.0%) patients, respectively. Osteopathic manipulative treatment (OMT) was performed on the lumbar spine (576 patients [56.9%]), thoracic spine (411 [40.6%]), sacrum/pelvis (440 [43.4%]), rib (261 [25.8%]), and lower extremity (256 [25.3%]). A segregated patient cohort (n=539) showed statistically significant differences between patients who received OMT and those who did not with the use of analgesics, steroids, spinal injections, straight-leg raising, and days off or limited work duties. CONCLUSION: The observational findings of the present study, which suggest that analgesic medication use is lower in patients who receive OMT, align with previous findings of RCTs and support the generalizability of these findings.

Effects of repeated use of the American Osteopathic Association's Clinical Assessment Program on measures of care for patients with diabetes mellitus.

CONTEXT: The American Osteopathic Association developed its Clinical Assessment Program (AOA-CAP) for Residencies to provide a mechanism for osteopathic residency programs to measure and improve their quality of patient care. OBJECTIVE: To compare program performance in processes of care and intermediate outcomes for patients with diabetes mellitus in residency programs that contributed data to the AOA-CAP for the first time vs residency programs that contributed data repeatedly. METHODS: Osteopathic family medicine residency programs that entered data into the AOA-CAP diabetes registry between July 1, 2005, and December 31, 2007, were included in the present study. Residency programs were separated into those that entered data into the registry for the first time during the 2005-2007 cycle (ie, first-time programs) and those that also entered data into the registry during the previous cycle (2003-2005) (ie, repeat programs). Measures of processes of care were annual foot examination, annual referral for ophthalmologic examination, annual microalbuminuria screening, use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) if albuminuria is present, use of ACE inhibitors or ARBs if hypertension is present, glycosylated hemoglobin (HbA(1c)) test in the previous year, and low-density lipoprotein cholesterol (LDL-C) test in the previous year. Measures of intermediate outcomes were control of blood pressure, HbA(1c), and LDL-C. Processes of care and outcome composite scores were also computed. RESULTS: Data from 52 osteopathic family medicine residency programs consisting of 2568 patient cases were analyzed. Twenty-three first-time programs with 992 cases and 29 repeat programs with 1576 cases entered data into the registry in the 2005-2007 cycle. Repeat programs had statistically significant better performance than first-time programs in the composite measure of processes of care (P=.0023)-largely the result of increased use of ACE inhibitors and ARBs in patients with albuminuria (P=.0087). The difference in the composite measure of intermediate outcomes was not statistically significant between the 2 groups. CONCLUSION: Repeated participation in the AOA-CAP registry was associated with improved residency program performance on the composite process of care measure but not on intermediate outcome measures for patients with diabetes mellitus. This finding suggests that osteopathic residency programs need to provide better training on adjusting patient care according to performance results.

"All-or-none" (bundled) process and outcome indicators of diabetes care.

OBJECTIVES: To evaluate processes and outcomes of diabetes care using bundled indicators from a primary care registry of osteopathic training programs. STUDY DESIGN: Retrospective cohort analysis. METHODS: This study examined care delivered to 7333 patients across 95 family practice and internal medicine residency programs (July 1, 2005, through September 15, 2008) to determine diabetes care performance using measures of processes of care and outcomes. Two summary (bundled) reports of care for each measure were constructed. The first used the frequency of indicated care delivered (indicator-level bundle), and the second used the frequency of patients' receiving all indicated care (patient-level bundle). RESULTS: Use of the indicator-level bundle demonstrated that outcomes goals were achieved at a rate of 44.5%. Use of the patient-level bundle demonstrated that outcomes goals were achieved at a rate of only 16.2%, a significant difference (P <.001). Eight evidence-based processes of diabetes care were then examined using the 2 bundling methods. The indicator-level analysis mean rate for the bundled processes of care was 77.3%, whereas the patient-level analysis mean rate was only 33.5%. This was also significantly different (P <.001). CONCLUSIONS: The method of bundling care measures can have a profound effect on the reporting of goals achieved. This can in turn influence the assessment of provider performance and opportunity gaps in diabetes care delivery. In this study, providers were more likely to achieve processes-of-care goals when diabetes care was bundled at the indicator level than at the patient level. Standardization of summary reporting of diabetes care should be developed to enhance consistent interpretation of performance.

Effect of a weight management program on the determinants and prevalence of metabolic syndrome.

OBJECTIVE: As prevalence of obesity and metabolic syndrome (met synd) rises, establishing effective, community-based treatments is imperative. Our investigation sought to evaluate and report the effect of a weight management program on the prevalence and determinants of met synd, and the effect of participation level. METHODS AND PROCEDURES: Between 10 July 2001 and 17 November 2005, 339 of 574 individuals enrolled in and completed our 6-month weight management program at the McConnell Heart Health Center in Columbus, Ohio. One hundred and sixty completers met our inclusion criteria for our retrospective analysis: (i) non diabetic, (ii) complete outcomes, (iii) no program participation in the previous 6 months. Met synd status was determined using AHA/NHLBI criteria. Blood pressure criterion was modified to a history of hypertension or current antihypertension medication use. Participation level was dichotomized as high participators (HP) and low participators (LP) using the number of center visits. RESULTS: The entire cohort showed significant reductions in BMI, waist circumference and met synd prevalence (51-39%). The met synd group had significant improvements in high-density lipoprotein (HDL), triglycerides, and glucose. Compared with LP, HP had a significant reduction in the prevalence of met synd and significantly greater improvement in the anthropometric, HDL and triglyceride determinants of met synd. DISCUSSION: This weight management program had a positive effect on determinants and prevalence of met synd. High participation levels were associated with significantly greater improvements in the anthropometric variables, HDL, triglycerides, met synd determinants, and reduction of met synd prevalence.