Effective teamwork and quality of care.
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Humans↗
Biomedical subjects
Edward H Wagner
Publications and source records attributed to Edward H Wagner.
Quality of care for patients with type 2 diabetes mellitus in the Netherlands and the United States: a comparison of two quality improvement programs.
OBJECTIVE: To assess differences in diabetes care and patient outcomes by comparing two multifaceted quality improvement programs in two different countries, and to increase knowledge of effective elements of such programs. STUDY SETTING: Primary care in the ExtraMural Clinic (EMC) of the Department of General Practice of the Vrije Universiteit in Amsterdam, the Netherlands, and the Group Health Cooperative (GHC), a group-model health maintenance organization (HMO) in western Washington State in the United States. Data were collected from 1992 to 1997. STUDY DESIGN: In this observational study two diabetes cohorts in which a quality improvement program was implemented were compared. Both programs included a medical record system, clinical practice guidelines, physician educational meetings, audit, and feedback. Only the Dutch program (EMC) included guidelines on the structure of diabetes care and a recall system. Only the GHC program included educational outreach visits, formation of multidisciplinary teams, and patient self-management support. DATA COLLECTION: Included were 379 EMC patients, and 2,119 GHC patients with type 2 diabetes mellitus. Main process outcomes were: annual number of diabetes visits, and number of HbA1c and blood lipid measurements. Main patient outcomes were HbA1c and blood lipid levels. Multilevel analysis was used to adjust for dependency between repeated observations within one patient and for clustering of patients within general practices. PRINCIPAL FINDINGS: In the EMC process outcomes and glycemic control improved more than at GHC, however, GHC had better baseline measures. There were no differences between programs on blood lipid control. During follow-up, intensification of pharmacotherapy was noted at both sites. Differences noted between programs were in line with differences in diabetes guidelines. CONCLUSIONS: Following implementation of guidelines and organizational improvement efforts, change occurred primarily in the process outcomes, rather than in the patient outcomes. Although much effort was put into improving process and patient outcomes, both complex programs still showed only moderate effects.
Aged↗
Effects of provider practice on functional independence in older adults.
OBJECTIVES: To examine provider determinants of new-onset disability in basic activities of daily living (ADLs) in community-dwelling elderly. DESIGN: Observational study. SETTING: King County, Washington. PARTICIPANTS: A random sample of 800 health maintenance organization (HMO) enrollees aged 65 and older participating in a prospective longitudinal cohort study of dementia and normal aging and their 56 primary care providers formed the study population. MEASUREMENTS: Incident ADL disability, defined as any new onset of difficulty performing any of the basic ADLs at follow-up assessments, was examined in relation to provider characteristics and practice style using logistic regression and adjusting for case-mix, patient and provider factors associated with ADL disability, and clustering by provider. RESULTS: Neither provider experience taking care of large numbers of elderly patients nor having a certificate of added qualifications in geriatrics was associated with patient ADL disability at 2 or 4 years of follow-up (adjusted odds ratio (AOR) for experience=1.29, 95% confidence interval (CI)=0.81-2.05; AOR for added qualifications=0.72, 95% CI=0.38-1.39; results at 4 years analogous). A practice style embodying traditional geriatric principles of care was not associated with a reduced likelihood of ADL disability over 4 years of follow-up (AOR for prescribing no high-risk medications=0.56, 95% CI=0.16-1.94; AOR for managing geriatric syndromes=0.94, 95% CI=0.40-2.19; AOR for a team care approach=1.35, 95% CI=0.66-2.75). CONCLUSION: Taking care of a large number of elderly patients, obtaining a certificate of added qualifications in geriatrics, and practicing with a traditional geriatric orientation do not appear to influence the development of ADL disability in elder, community dwelling HMO enrollees.
Activities of Daily Living↗
Improving diabetes treatment quality in managed care organizations: some progress, many challenges.
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Diabetes Mellitus↗
Chronic illness management: what is the role of primary care?.
An estimated 99 million Americans live with a chronic illness. Meeting the needs of this population is one of the major challenges facing the U.S. health care system today and in the future. Dozens of studies, surveys, and audits have revealed that sizable proportions of chronically ill patients have not received effective therapy and do not have optimal disease control. The consistent findings of generally substandard care for many chronic conditions have spurred proposals that care be shifted to specialists or disease management programs. Published evidence to date does not indicate any clear superiority of these alternatives to primary care. The defining features of primary care (that is, continuity, coordination, and comprehensiveness) are well suited to care of chronic illness. A rapidly growing body of health services research points to the design of the care system, not the specialty of the physician, as the primary determinant of chronic care quality. The future of primary care in the United States may depend on its ability to successfully redesign care systems that can meet the needs of a growing population of chronically ill patients.
Chronic Disease↗
Community exercise program use and changes in healthcare costs for older adults.
BACKGROUND: Regular exercise is associated with many health benefits. Community-based exercise programs may increase exercise participation, but little is known about cost implications. METHOD: A retrospective, matched cohort study was conducted to determine if changes in healthcare costs for Medicare-eligible adults who choose to participate in a community-based exercise program were different from similar individuals who did not participate. Exercise program participants included 1114 adults aged > or = 65 years, who were continuously enrolled in Group Health Cooperative of Puget Sound (GHC) between October 1, 1997 and December 31, 2000 and who participated in the Lifetime Fitness (exercise) Program Copyright (LFP) at least once; three GHC enrollees who never attended LFP were randomly selected as controls for each participant by matching on age and gender. Cost and utilization estimates from GHC administrative data for the time from LFP enrollment to December 31, 2000 were compared using multivariable regression models. RESULTS: The average increase in annual total healthcare costs was less in participants compared to controls (+642 dollars vs +1175 dollars; p=0.05). After adjusting for differences in age, gender, enrollment date, comorbidity index, and pre-exposure cost and utilization levels, total healthcare costs for participants were 94.1% (95% confidence interval [CI], 85.6%-103.5%) of control costs. However, for participants who attended the exercise program at an average rate of > or = 1 visit weekly, total adjusted follow-up costs were 79.3% (95% CI, 71.3%-88.2%) of controls. CONCLUSIONS: Including a community exercise program as a health insurance benefit shows promise as a strategy for helping some Medicare-eligible adults to improve their health through exercise.
Aged↗
Glucose screening and the risk of complications in Type 2 diabetes mellitus.
It is unknown whether glucose screening for Type 2 diabetes mellitus (DM2) reduces the risk of diabetic complications. We conducted a case-control study using 303 cases with DM2 and at least one symptomatic microvascular diabetic complication, matched 1:1 to control subjects. All subjects' blood glucose tests for the decade before the first clinical suspicion of DM2 were categorized as screening or not based on the presence of symptoms suggestive of DM2. Approximately 90% of case subjects and control subjects had been screened for diabetes. After adjusting for multiple covariates in a logistic regression model, the odds ratio of developing a complication associated with screening was 0.87 (95% confidence interval 0.38-1.98), suggesting that screening may be associated with a modest reduction in the risk of certain diabetic complications. However, the confidence limits were wide and consistent with no true benefit. Further studies are needed to establish whether the small reduction we observed is genuine.
Blood Glucose↗
Primary care delivery is associated with greater physician experience and improved survival among persons with AIDS.
OBJECTIVE: It has been shown that greater physician experience in the care of persons with AIDS prolongs survival, but how more experienced primary care physicians achieve better outcomes is not known. DESIGN/SETTING/PATIENTS: Retrospective cohort study of HIV-infected patients enrolled in a large staff-model health maintenance organization from 1990 through 1999. MEASUREMENTS: Adjusted odds of medical service delivery and adjusted hazard ratio of death by physician experience level (least, moderate, most) and service utilization. MAIN RESULTS: Primary care delivery by physicians with greater AIDS experience was associated with improved survival. After controlling for disease severity, patients cared for by the most experienced physicians were twice as likely to receive a primary care visit in a given month compared with patients of the least and moderately experienced physicians (P <.01). Patients of the least experienced physicians received the lowest level of outpatient pharmacy and laboratory services (P <.001) and were half as likely to have a specialty care visit compared with patients of the most and moderately experienced physicians (P <.05). Patients who received infrequent primary care visits by the least experienced physicians were 15.3 times more likely to die than patients of the most experienced physicians (P =.02). There was a significant increase in primary care services delivered to the population of HIV-infected patients receiving care in 1999, when highly active antiretroviral therapy (HAART) was in general use, compared with the time period prior to the introduction of HAART. CONCLUSIONS: Primary care delivery by physicians with greater HIV experience contributes to improved patient outcomes.
Acquired Immunodeficiency Syndrome↗
Effect of part-time practice on patient outcomes.
BACKGROUND: Primary care physicians are spending fewer hours in direct patient care, yet it is not known whether reduced hours are associated with differences in patient outcomes. OBJECTIVE: To determine whether patient outcomes vary with physicians' clinic hours. DESIGN: Cross-sectional retrospective design assessing primary care practices in 1998. SETTING: All 25 outpatient-clinics of a single medical group in western Washington. PARTICIPANTS: One hundred ninety-four family practitioners and general internists, 80% of whom were part-time, who provided ambulatory primary care services to specified HMO patient panels. Physician appointment hours ranged from 10 to 35 per week (30% to 100% of full time). MEASUREMENTS: Twenty-three measures of individual primary care physician performance collected in an administrative database were aggregated into 4 outcome measures: cancer screening, diabetic management, patient satisfaction, and ambulatory costs. Multivariate regression on each of the 4 outcomes controlled for characteristics of physicians (administrative role, gender, seniority) and patient panels (size, case mix, age, gender). MAIN RESULTS: While the effects were small, part-time physicians had significantly higher rates for cancer screening (4% higher, P =.001), diabetic management (3% higher, P =.033), and for patient satisfaction (3% higher, P =.035). After controlling for potential confounders, there was no significant association with patient satisfaction (P =.212) or ambulatory costs (P =.323). CONCLUSIONS: Primary care physicians working fewer clinical hours were associated with higher quality performance than were physicians working longer hours, but with patient satisfaction and ambulatory costs similar to those of physicians working longer hours. The trend toward part-time clinical practice by primary care physicians may occur without harm to patient outcomes.
Adult↗
Care for chronic diseases.
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Chronic Disease↗
Comprehensive health care for people infected with HIV in developing countries.
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Anti-HIV Agents↗
Improving primary care for patients with chronic illness: the chronic care model, Part 2.
This article reviews research evidence showing to what extent the chronic care model can improve the management of chronic conditions (using diabetes as an example) and reduce health care costs. Thirty-two of 39 studies found that interventions based on chronic care model components improved at least 1 process or outcome measure for diabetic patients. Regarding whether chronic care model interventions can reduce costs, 18 of 27 studies concerned with 3 examples of chronic conditions (congestive heart failure, asthma, and diabetes) demonstrated reduced health care costs or lower use of health care services. Even though the chronic care model has the potential to improve care and reduce costs, several obstacles hinder its widespread adoption.
Ambulatory Care↗
Improving primary care for patients with chronic illness.
The chronic care model is a guide to higher-quality chronic illness management within primary care. The model predicts that improvement in its 6 interrelated components-self-management support, clinical information systems, delivery system redesign, decision support, health care organization, and community resources-can produce system reform in which informed, activated patients interact with prepared, proactive practice teams. Case studies are provided describing how components of the chronic care model have been implemented in the primary care practices of 4 health care organizations.
Chronic Disease↗
Is the use of benzodiazepines associated with incident disability?
OBJECTIVES: This study examined the association between benzodiazepine use and incident disability with an emphasis on elucidating whether the underlying health conditions that result in benzodiazepine use (confounding factors) or intrinsic adverse effects of benzodiazepine use were responsible for functional decline. DESIGN: Cohort study with follow-up of 4 to 5 years. SETTING: A health maintenance organization (HMO) in western Washington. PARTICIPANTS: Individuals aged 65 and older from a random sample of HMO enrollees who participated in a health promotion intervention trial (n = 1,519). MEASUREMENTS: Benzodiazepine use was ascertained from computerized pharmacy records. Self-reported functional status was assessed using a six-item physical function scale ranging from vigorous activity to self-care activities of daily living (ADLs). Two outcomes were examined: decline in overall physical function and limitations in self-care ADLs. Multivariate models were examined that included demographic characteristics, health status, and health behaviors that were likely to be confounders. Several analyses were conducted to examine whether benzodiazepine use or confounding factors were responsible for functional decline. RESULTS: Benzodiazepine use was significantly associated with incident loss of physical function (hazard ratio (HR) = 1.51, 95% confidence interval (CI) = 1.02-2.24) in the fully adjusted model. Although use of benzodiazepines was associated with limitations in ADLs, it was not significant when adjusting for other factors (HR = 1.71, 95% CI = 0.87-3.34). Several of our findings suggest that the health conditions leading to benzodiazepine use may partly or fully explain these associations: (1) use of anxiolytic benzodiazepines (HR = 1.95, 95% CI = 1.24-3.07), but not hypnotic agents (HR = 1.21, 95% CI = 0.73-2.00), was associated with functional decline; (2) adjustment for health status variables minimized these associations; and (3) there was little evidence of dose response. CONCLUSIONS: A modestly increased risk for decline in physical function was associated with benzodiazepine use, especially of anxiolytic agents. The health conditions that result in benzodiazepine use may be more important in the pathogenesis of disability than benzodiazepine use itself. Although there are many reasons for avoiding benzodiazepines in older adults, it is still unclear whether use contributes independently to functional decline.
Activities of Daily Living↗
Outcomes of a community-based dissemination of the health enhancement program.
OBJECTIVES: We previously found in an efficacy trial that a health promotion program prevented functional decline and reduced hospitalizations in community-dwelling older people with chronic conditions. We sought to evaluate the effectiveness of the program in its dissemination phase. DESIGN: Outcome evaluation using a within-group, pretest-posttest design. SETTING: Fourteen senior centers located throughout western Washington. PARTICIPANTS: Three hundred four community-dwelling men and women aged 65 and older. INTERVENTION: A disability-prevention, chronic disease-self-management program. MEASUREMENTS: Participant characteristics, risk factors for disability, change in health and functional status, and healthcare use over 1 year of enrollment; participant satisfaction. RESULTS: Participants were 71% female, had a mean age of 76, and reported three chronic health conditions on average. The percentage of participants found to be depressed decreased (28% at time of enrollment vs 17% at 1-year follow-up, P =.005). The percentage of physically inactive participants decreased (56% vs 38%, P =.001). Physical activity level and exercise readiness improved (Physician-based Assessment and Counseling for Exercise mean score 4.3 vs 5.1, P =.001). At follow-up, 83% rated their health the same as or better than a year ago, compared with 73% at time of enrollment. The proportion with impaired functional status, as measured by bed days and restricted activity days, stayed the same. The proportion hospitalized remained stable (23% at enrollment and follow-up, P = 1.0). CONCLUSIONS: Under real world conditions, the Health Enhancement Program reaches older people at risk of functional decline. Those enrolled for 1 year experience a reduction in disability risk factors, improvement in health status, no decrements in functional status, and no increase in self-reported healthcare use.
Aged↗
Clinical effectiveness research in managed-care systems: lessons from the Pediatric Asthma Care PORT. Patient Outcomes Research Team.
OBJECTIVE: To highlight the unique challenges of evaluative research on practice behavior change in the "real world" settings of contemporary managed-care organizations, using the experience of the Pediatric Asthma Care PORT (Patient Outcomes Research Team). STUDY SETTING: The Pediatric Asthma Care PORT is a five-year initiative funded by the Agency for Healthcare Research and Quality to study strategies for asthma care improvement in three managed-care plans in Chicago, Seattle, and Boston. At its core is a randomized trial of two care improvement strategies compared with usual care: (1) a targeted physician education program using practice based Peer Leaders (PL) as change agents, (2) adding to the PL intervention a "Planned Asthma Care Intervention" incorporating joint "asthma check-tips" by nurse-physician teams. During the trial, each of the participating organizations viewed asthma care improvement as an immediate priority and had their own corporate improvement programs underway. DATA COLLECTION: Investigators at each health plan described the organizational and implementation challenges in conducting the PAC PORT randomized trial. These experiences were reviewed for common themes and "lessons" that might be useful to investigators planning interventional research in similar care-delivery settings. CONCLUSIONS: Randomized trials in "real world" settings represent the most robust design available to test care improvement strategies. In complex, rapidly changing managed-care organizations, blinding is not feasible, corporate initiatives may complicate implementation, and the assumption that a "usual care" arm will be static is highly likely to be mistaken. Investigators must be prepared to use innovative strategies to maintain the integrity of the study design, including: continuous improvement within the intervention arms, comanagement by researchers and health plan managers of condition-related quality improvement initiatives, procedures for avoiding respondent burden in health plan enrollees, and anticipation and minimization of risks from experimental arm contamination and major organizational change. With attention to these delivery system issues, as well as the usual design features of randomized trials, we believe managed-care organizations can serve as important laboratories to test care improvement strategies.
Asthma↗
Assessment of chronic illness care (ACIC): a practical tool to measure quality improvement.
OBJECTIVE: To describe initial testing of the Assessment of Chronic Illness Care (ACIC), a practical quality-improvement tool to help organizations evaluate the strengths and weaknesses of their delivery of care for chronic illness in six areas: community linkages, self-management support, decision support, delivery system design, information systems, and organization of care. DATA SOURCES: (1) Pre-post, self-report ACIC data from organizational teams enrolled in 13-month quality-improvement collaboratives focused on care for chronic illness; (2) independent faculty ratings of team progress at the end of collaborative. STUDY DESIGN: Teams completed the ACIC at the beginning and end of the collaborative using a consensus format that produced average ratings of their system's approach to delivering care for the targeted chronic condition. Average ACIC subscale scores (ranging from 0 to 11, with 11 representing optimal care) for teams across all four collaboratives were obtained to indicate how teams rated their care for chronic illness before beginning improvement work. Paired t-tests were used to evaluate the sensitivity. of the ACIC to detect system improvements for teams in two (of four) collaboratives focused on care for diabetes and congestive heart failure (CHF). Pearson correlations between the ACIC subscale scores and a faculty rating of team performance were also obtained. RESULTS: Average baseline scores across all teams enrolled at the beginning of the collaboratives ranged from 4.36 (information systems) to 6.42 (organization of care), indicating basic to good care for chronic illness. All six ACIC subscale scores were responsive to system improvements diabetes and CHF teams made over the course of the collaboratives. The most substantial improvements were seen in decision support, delivery system design, and information systems. CHF teams had particularly high scores in self-management support at the completion of the collaborative. Pearson correlations between the ACIC subscales and the faculty rating ranged from .28 to .52. CONCLUSION: These results and feedback from teams suggest that the ACIC is responsive to health care quality-improvement efforts and may be a useful tool to guide quality improvement in chronic illness care and to track progress over time.
Chronic Disease↗
Self-management aspects of the improving chronic illness care breakthrough series: implementation with diabetes and heart failure teams.
Self-management is an essential but frequently neglected component of chronic illness management that is challenging to implement. Available effectiveness data regarding self-management interventions tend to be from stand-alone programs rather than from efforts to integrate self-management into routine medical care. This article describes efforts to integrate self-management support into broader health care systems change to improve the quality of patient care in the Chronic Illness Care Breakthrough Series. We describe the general approach to system change (the Chronic Care Model) and the more specific self-management training model used. The process used in training organizations in self-management is discussed, and data are presented on teams from 21 health care systems participating in a 13-month-long Breakthrough Series to address diabetes and heart failure care. Available system-level data suggest that teams from a variety of health care organizations made improvements in support provided for self-management. Improvements were found for both diabetes and heart failure teams, suggesting that this improvement process may be broadly applicable. Lessons learned, keys to success, and directions for future research and practice are discussed.
Chronic Disease↗