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Leif I Solberg

Publications and source records attributed to Leif I Solberg.

At least 19 recordsLinked to original sources
PubMed2005

Predictors of health care costs in adults with diabetes.

OBJECTIVE: The purpose of this study was to assess the impact of baseline A1c, cardiovascular disease, and depression on subsequent health care costs among adults with diabetes. RESEARCH DESIGN AND METHODS: A prospective analysis was performed of data from a patient survey and medical record review merged with 3 years of medical claims. Costs were estimated using detailed data on resource use and Medicare payment methodologies. Generalized linear models were used to analyze costs related to clinical predictors after adjusting for demographic and socioeconomic factors. RESULTS: In multivariate analysis of 1,694 adults with diabetes, 3-year costs in those with coronary heart disease (CHD) and hypertension were over 300% of those with diabetes only (46,879 dollars vs. 14,233 dollars; P < 0.05). Depression was associated with a 50% increase in costs (31,967 dollars vs. 21,609 dollars; P < 0.05). Relative to those with a baseline A1c of 6%, those with an A1c of 10% had 3-year costs that were 11% higher (26,408 dollars vs. 23,873 dollars; P < 0.05). Higher A1c predicted higher costs only for those with baseline A1c >7.5% (P = 0.015). CONCLUSIONS: In adults with diabetes, CHD, hypertension, and depression spectrum disorders more strongly predicted future costs than the A1c level. Concurrent with aggressive efforts to control glucose, greater efforts to prevent or control CHD, hypertension, and depression are necessary to control health care costs in adults with diabetes.

Coronary Disease↗
PubMed2004

Smoking-related attitudes and clinical practices of medical personnel in Minnesota.

CONTEXT: Effective clinic-based, smoking-cessation activities are not widely implemented. OBJECTIVE: To compare and contrast the smoking-cessation attitudes and clinical practices of five types of primary healthcare team members. DESIGN AND SETTING: From July to October 2002, a cross-sectional survey was mailed to randomly selected primary care physicians (MDs), advanced practice nurses (APRNs), registered nurses (RNs), licensed practical nurses (LPNs), and medical assistants (MAs). MAIN OUTCOME MEASURES: Factors associated with limited smoking-cessation service delivery. RESULTS: The overall response rate was 68% (n =3021). Most respondents reported that patients' smoking status was consistently documented at their clinic (79%); other system prompts were less common (30%). Many respondents reported documenting smoking status or recommending quitting; few reported consistently assessing, assisting, or arranging follow-up. The mean rank of smoking cessation as an important preventive service among nine preventive services declined from MDs (1.9) to APRNs (2.5), RNs (3.4), LPNs (4.2), and MAs (4.6). Smoking prevalence increased from 1% in MDs to 3% APRNs, 9% RNs, 17% LPNs, and 22% MAs. Those who reported no consistent smoking-cessation service delivery were more likely to be RNs, LPNs, or MAs, currently smoke, and work more hours. They were less likely to consider patients receptive to cessation messages, to consider themselves qualified to counsel on smoking, or to work in clinics that had smoking-cessation guidelines or system prompts such as chart reminders. CONCLUSIONS: Smoking-cessation service delivery may be enhanced if educational offerings, system changes, and training include all clinical staff members.

Adult↗
PubMed2004

Key issues in transforming health care organizations for quality: the case of advanced access.

BACKGROUND: The 2001 Institute of Medicine (IOM) report highlighted the need for transformation of the U.S. health care system. This rigorous qualitative evaluation of transformational change for patient access in one large multispecialty group practice identifies the major issues facing organizations addressing the IOM challenge. METHODS: Semistructured depth interviews were conducted with the medical and administrative leaders at all levels, physicians, and nurses from 17 primary care clinics in one integrated medical group two years after they began to transform their approach to primary care patient appointment access. RESULTS: The mean time to third-next-available appointment was reduced by 76% during one year, from 17.8 days to 4.2 days. Nine important issues related to the change process were identified from clinic interviews. When combined with issues identified by central leaders, 13 themes stood out as lessons in transformational change. A major issue is the tension between physician autonomy and both effective organizational function and putting patients first. Physician autonomy is also diminished by the need to standardize and systematize care. CONCLUSIONS: Transformational change in care delivery is possible in large and complex group practices. Changes that directly affect care delivery and physician autonomy present particular challenges to physicians that need to be attended to if the changes are to be successful.

Ambulatory Care Information Systems↗
PubMed2004

Do all components of the chronic care model contribute equally to quality improvement?

BACKGROUND: The Chronic Care Model (CCM) is a widely used conceptual model for improving chronic illness care, but there is limited evidence to support the validity of this model. Seventeen clinics in a single medical group used the CCM in a diabetes improvement initiative, and the study tested which CCM components at the clinic level were associated with improved glycohemoglobin (A1C) and low-density (LDL) outcomes for patients with diabetes. DESIGN: Three leaders from each of 17 clinics completed a survey in 2002 that assessed the presence of CCM components in their clinics. Clinic scores from this survey were correlated with change in clinic-level measures of the quality of care for their diabetes patients (A1C and LDL outcomes) during the preceding year. RESULTS: Delivery system design (DSD) scores were positively correlated with improvements in A1C and lipid test rates and levels at these clinics (r = 0.49-0.57, p < .05). Self-management support and clinical information systems demonstrated associations that may have substantive significance but did not reach p < 05. CONCLUSIONS: These data suggest that delivery system design is associated with improved A1C and LDL outcomes for people with diabetes. Additional studies are necessary to determine the association of other CCM components with improved outcomes.

Cholesterol, LDL↗
PubMed2004

Is patient readiness to change a predictor of improved glycemic control?

OBJECTIVE: To test the hypothesis that patient readiness to change (RTC) predicts future changes in glycemic control in adults with diabetes. RESEARCH DESIGN AND METHODS: We linked survey data with HbA1c data for a stratified random sample of consenting adults with diabetes. Change in HbA1c from baseline to the 1-year follow-up was computed and used as a dependent variable. Linear regression models assessed RTC and other patient variables as predictors of HbA1c change. RESULTS: Among 617 patients with baseline HbA1c > or = 7% and complete data for analysis, RTC predicted subsequent improvement in HbA1c for those with higher physical functioning (interaction t = -2.45, P < 0.05). Other factors that predicted HbA1c improvement in multivariate linear regression models included higher self-reported medication adherence (t = -4.41, P < 0.01), higher baseline HbA1c (t = -15.08, P < 0.01), and older age (t = -2.61, P < 0.01). CONCLUSIONS: Diabetes RTC independently predicts change in HbA1c for patients with high but not for patients with low functional health status. Customized use of RTC assessment may have potential to improve care.

Adult↗
PubMed2004

Tobacco control efforts in managed care: what do the doctors think?

OBJECTIVES: To use physician reports to evaluate their awareness of health plan tobacco control guidelines and cessation support coverage and to validate the extent to which health plan cessation support material had been disseminated and implemented in clinical settings. STUDY DESIGN: Comparison of survey responses of physicians with tobacco control activities reported by key informants in the health plans with which those physicians were associated. METHODS: A total of 100 primary care physicians in the care delivery organizations associated with 9 nonprofit health plans were randomly selected to receive a survey asking about their health plan's tobacco cessation guidelines, coverage, and support for clinician action. Their responses were compared to data reported by the plan with which they were associated. RESULTS: Responses were obtained from 91%. Although 88% were aware of their health plan's tobacco cessation guidelines, considerably fewer were correctly aware of whether the health plan covered medications and cessation classes or counseling. Physician reports of cessation supports during care bore little relationship to health plan reports of those supports. CONCLUSIONS: Physician reports may be a useful way to verify health plan dissemination and implementation of tobacco control activities. Even these relatively high-performing plans have ample room for further improvement.

Attitude of Health Personnel↗
PubMed2004

Does improved access to care affect utilization and costs for patients with chronic conditions?

OBJECTIVE: To determine whether a major improvement in access (ie, implementing an open access system) in a large multispecialty medical group during 2000 was associated with changes in utilization or costs for patients with diabetes, coronary heart disease (CHD), or depression. STUDY DESIGN: Multilevel regression analysis of health plan administrative data. PATIENTS AND METHODS: Approximately 7000 patients with diabetes, 3800 with CHD, and 6000 with depression who received all of their care in this care system served as the subjects for this study. Utilization and costs between 1999 and 2001 (before and after implementation of open access) were compared for these patients. The main outcome measures were rates of inpatient admissions and various types of outpatient encounters as well as associated costs for these subjects. RESULTS: Between 1999 and 2001, total office visit changes were small and varied with condition, but the proportion of these visits made to primary care physicians increased significantly by an absolute 5% to 9% and primary care physician continuity increased for each condition. Urgent care visits also decreased significantly by an absolute 5% to 9%, but there was no change in emergency department visits or hospital admissions. Total costs of care for these patients were much larger than those for the overall population of the medical group, but increased at a similar rate. CONCLUSION: A major improvement in patient access to primary care clinics was associated with increased use and continuity of primary care for patients with 3 chronic conditions, but did not affect overall resource use.

Aged↗
PubMed2004

Measuring patient safety in ambulatory care: potential for identifying medical group drug-drug interaction rates using claims data.

OBJECTIVE: To evaluate the feasibility of using health-plan administrative data to measure potential drug-drug interaction (DDI) rates in the ambulatory setting at the medical-group level and to assess the potential use of DDI rates in performance measurement, quality improvement, and research in patient safety. STUDY DESIGN: We combined administrative and pharmacy claims data from 2 large health plans to calculate the rates at which member users of selected chronic medications were potentially exposed to a second drug known to pose a risk of harmful interactions. METHODS: We divided 44 medication combinations with risk of adverse interactions into those with DDIs of moderate/severe clinical significance and those with DDIs of mild significance. We then calculated yearly rates of potential DDIs in continuously enrolled members aged 19 and older from 1998 through 2001. Rates were calculated for all members, overall base-medication users, and, individual medical groups responsible for their care. RESULTS: The analytic data set included 756 047 patient-years of data and 110 to 123 medical groups per year. During the 4-year interval, one or more unique potential DDIs occurred in 6.2% to 6.7% of base-drug users and 2.0% to 2.3% of all adult health-plan members per year. Medical-group mean user rates were slightly lower (5.33%-5.81%), with wide variance (SD = 2.6%-3.1%) and high stability over time. CONCLUSION: Potential DDI rates calculated from health-plan data have promise for measurement in patient medication safety. This readily available and inexpensive evaluation tool has potential for monitoring, improvement, and research purposes if further studies validate their relationship to actual adverse events.

Adult↗
PubMed2003

Variation in diabetes care by age: opportunities for customization of care.

BACKGROUND: The quality of diabetes care provided to older adults has usually been judged to be poor, but few data provide direct comparison to other age groups. In this study, we hypothesized that adults age 65 and over receive lower quality diabetes care than adults age 45-64 years old. METHODS: We conducted a cohort study of members of a health plan cared for by multiple medical groups in Minnesota. Study subjects were a random sample of 1109 adults age 45 and over with an established diagnosis of diabetes using a diabetes identification method with estimated sensitivity 0.91 and positive predictive value 0.94. Survey data (response rate 86.2%) and administrative databases were used to assess diabetes severity, glycemic control, quality of life, microvascular and macrovascular risks and complications, preventive care, utilization, and perceptions of diabetes. RESULTS: Compared to those aged 45-64 years (N = 627), those 65 and older (N = 482) had better glycemic control, better health-related behaviors, and perceived less adverse impacts of diabetes on their quality of life despite longer duration of diabetes and a prevalence of cardiovascular disease twice that of younger patients. Older patients did not ascribe heart disease to their diabetes. Younger adults often had explanatory models of diabetes that interfere with effective and aggressive care, and accessed care less frequently. Overall, only 37% of patients were simultaneously up-to-date on eye exams, foot exams, and glycated hemoglobin (A1c) tests within one year. CONCLUSION: These data demonstrate the need for further improvement in diabetes care for all patients, and suggest that customisation of care based on age and explanatory models of diabetes may be an improvement strategy that merits further evaluation.

Age Distribution↗
PubMed2003

Does methodology affect the ability to monitor tobacco control activities? implications for HEDIS and other performance measures.

BACKGROUND: It is unclear whether methodological differences in sample size, survey methods, and analysis approach significantly affect the ability to accurately monitor tobacco control activities and to make rate comparisons. METHODS: Questionnaires were sent to 64,764 members of nine health plans in diverse settings soon after their visit to a primary care clinician. Of these 41,677 completed responses were received. We compared responses received by mail and by telephone follow-up for the percentage of smokers, characteristics of smokers, and their rates of reporting physician cessation counseling. RESULTS: Overall, 10.2% were current cigarette smokers, but the proportion was 8.6% for mail responders and 17.2% for phone follow-up responders. Smokers identified by phone follow-up were different from mail responders in most demographic and smoking characteristics and their reports of clinical smoking cessation activities differed for six of nine clinician smoking cessation actions. Calculating advice rates as a proportion of visits produced lower rates with more dispersion among plan rates than doing so without accounting for visit variation. CONCLUSIONS: Smoking surveys using only mailed questionnaires dramatically undersample smokers, especially in some demographic groups. Comparisons of tobacco counseling among health plans can be improved by ensuring an adequate sample size and response rate and by analyzing by frequency of quit advice.

Adult↗
PubMed2003

Emergency department crowding: consensus development of potential measures.

STUDY OBJECTIVE: We identify measures of emergency department (ED) and hospital workflow that would be of value in understanding, monitoring, and managing crowding. METHODS: A national group of 74 experts developed 113 potential measures using a conceptual model of ED crowding that segmented the measures into input, throughput, and output categories. Ten investigators then used group consensus methods to revise and consolidate them into a refined set of 30 measures that were rated by all 74 experts, who used a magnitude estimation technique on a Web site. Each measure was compared with a standard to obtain numeric ratings for feasibility, affordability, early warning potential, long-term planning potential, a summary rating of operational usefulness, and research potential. After review of the comprehensiveness of the resulting measures, 8 additional measures were developed and also rated by all reviewers. RESULTS: The original set of 113 measures (46 input, 35 throughput, and 32 output) was reduced to 38 through the iterative revision and rating process (15 input, 9 throughput, and 14 output). Summary scores in each rating category showed significant variation in ratings among the various potential measures. For measures that address similar concepts, the priority ranking depended on the rating category chosen. CONCLUSION: The final 38 measures of ED and hospital workflow provide a useful pool from which EDs and policymakers can draw to improve their ability to understand and address the issue of ED crowding. These measures require rigorous testing for feasibility, reliability, and value.

Consensus↗
PubMed2003

Paying for quality improvement: compliance with tobacco cessation guidelines.

BACKGROUND: Identification and treatment of routine tobacco use in medical practice is an effective intervention but is not used consistently. A study was conducted at HealthPartners, a large network-model health plan in Minnesota, to determine the effect of an outcomes recognition strategy that involved bonus funds and the rates at which network physicians document that tobacco users are identified and advised to quit. METHODS: Audits of 14,489 ambulatory patient records from 19-20 medical groups were conducted to determine the proportion of charts from each medical group that demonstrated identification of smoking status and counseling to encourage quitting at the most recent office visit in each year. RESULTS: Overall mean tobacco use identification increased from 49% +/- 7% (95% confidence interval [CI]) in 1996 to 73% +/- 7% in 1999 (p < .001), while advice to quit increased from 32% +/- 10% in 1996 to 53% +/- 10% CI in 1999 (p < .005). The number of medical groups with tobacco status identified at > 80% of visits and > 80% of tobacco users advised to quit increased from 0 in 1996 to 8 in 1999. DISCUSSION: Data feedback combined with a financial incentive appear to be an effective way for a health plan to improve physician compliance with the tobacco treatment guideline. Other health plans might consider similar reporting and incentive approaches to effectively engage medical group leadership and to improve the health of their members who use tobacco.

Ambulatory Care↗
PubMed2003

Treatment of elderly and other adult patients for depression in primary care.

OBJECTIVES: To determine whether depression is treated differently in older and younger patients in primary care clinics. DESIGN: Administrative data were used to identify patients with a depression diagnosis code. The sources of data were baseline and 3-month follow-up surveys, the health plan electronic database, and chart audits. SETTING: Nine primary care clinics owned by a health maintenance organization in the Midwest. PARTICIPANTS: The study sample (N=1023) consisted of adult patients, aged 19 to 93, and was divided into six age groups, from young adult, under age 35, to old old, 75 or older. MEASUREMENTS: Independent variables were a series of dummy variables: age groups, baseline depression severity, sex, and incident depression. Outcomes were defined as care processes (assessment, resources) and improvement in depression symptoms (Center for Epidemiologic Studies-Depression scale short form). Univariate and multivariate logistic regression analyses were used to analyze patient characteristics, depression symptoms, and care process variables. Significance level was reported based on the chi-square test of probability, P<or=.05. RESULTS: The adjusted response rates to the baseline and follow-up surveys were 69% and 82%. Elderly depressed patients were more likely than younger depressed patients to be widowed, have low levels of education, have fair or poor health, and have three or more comorbid health problems. There were no differences, by age, in number of depressive symptoms, antidepressant treatment, or recommendation for a follow-up appointment. Younger patients were more likely than older patients to have a new diagnosis of depression and to report being depressed most of the past year. Providers were only 6% as likely to ask old-old depressed patients about suicide risk, about one-fourth as likely to referral them to a mental health therapist, about one-fifth as likely to ask if they felt depressed, and one-twentieth as likely to ask about a problem with alcohol as they were with young-adult depressed patients. The old-old were about one-third as likely to report improvement in depression symptoms after 3 months as the young-adult patients. CONCLUSION: This study suggests a possible pattern of underattention to the oldest depressed patients. Failure to ask about suicide risk is especially of concern because of the high suicide rate of depressed geriatric patients. The finding that physicians are less likely to focus on depression with old-old patients may be explained, in part, by the concept of invisibility of the ordinary.

Adult↗
PubMed2003

A conceptual model of emergency department crowding.

Emergency department (ED) crowding has become a major barrier to receiving timely emergency care in the United States. Despite widespread recognition of the problem, the research and policy agendas needed to understand and address ED crowding are just beginning to unfold. We present a conceptual model of ED crowding to help researchers, administrators, and policymakers understand its causes and develop potential solutions. The conceptual model partitions ED crowding into 3 interdependent components: input, throughput, and output. These components exist within an acute care system that is characterized by the delivery of unscheduled care. The goal of the conceptual model is to provide a practical framework on which an organized research, policy, and operations management agenda can be based to alleviate ED crowding.

Acute Disease↗
PubMed2003

A framework for improving the quality of cancer care: the case of breast and cervical cancer screening.

This commentary presents a conceptual framework, Quality in the Continuum of Cancer Care (QCCC), for quality improvement studies and research. Data sources include review of relevant literature (cancer care, quality improvement, organizational behavior, health services evaluation, and research). The Detecting Early Tumors Enables Cancer Therapy (DETECT) project is used to apply the QCCC model to evaluate the quality of secondary prevention. Cancer care includes risk assessment, primary prevention, screening, detection, diagnosis, treatment, recurrence surveillance, and end-of-life care. The QCCC model represents a systematic approach for assessing factors that influence types of cancer care and the transitions between them, the factors at several levels (community, plan and practice setting) that potentially impact access and quality, and the strategies groups and organizations can consider to reduce potential failures. Focusing on the steps and transitions in care where failures can occur can facilitate more organized systems and medical practices that improve care, establish meaningful measures of quality that promote improved outcomes, and enhance interdisciplinary research.

Algorithms↗
PubMed2003

When depression is the diagnosis, what happens to patients and are they satisfied?

OBJECTIVES: To understand the process, outcomes, and patient satisfaction of usual primary care for patients given a diagnostic code for depression. STUDY DESIGN: Health plan data were used to identify patients with a diagnostic code for depression (and no such diagnosis in the preceding 6 months). Patients were surveyed by mail soon after the coded visit and again 3 months later about the care they had received; their charts were also audited. METHODS: The 274 patients in 9 primary care clinics who responded to both surveys reported on their personal characteristics, depression symptoms and history, the care received in that initial visit, and the follow-up care during the next 3 months. They also reported on their satisfaction with various aspects of that care. RESULTS: These patients were likely to be given antidepressant medications as their main or only treatment. Referral for mental health therapies was not used often, even though referral is readily available in this setting; other types of self-management recommendations and support were even less frequent. Patient outcomes and levels of satisfaction during a 3-month follow-up period were unimpressive. CONCLUSIONS: To successfully maintain a key role in the care of this important problem for their patients, primary care physicians may need to incorporate a more comprehensive and systematic approach to management that involves other team members and is more satisfying to patients.

Adult↗
PubMed2003

Implementation of systems strategies for breast and cervical cancer screening services in health maintenance organizations.

OBJECTIVE: To describe the systems strategies used to reduce failures in delivery of breast and cervical cancer screening services in HMOs with high performance rates for these services. STUDY DESIGN: Multiple case study. PARTICIPANTS AND METHODS: Seven HMOs participated in an assessment of their breast and cervical cancer screening policies and procedures. Current clinical practice guidelines were analyzed, and key informants were interviewed about organizational policies and procedures that ensure initial screening and follow-up of abnormal results. Data were analyzed across plans for several theoretically relevant domains, including leadership and policies, clinical decision support, delivery system design, clinical information systems, and patient self-management support. RESULTS: Practice guidelines were fundamentally similar across plans for both cancer screenings, although operationalization of risk and formatting of the written documents differed. These plans adopted a wide array of strategies, particularly in the clinical decision support, clinical information systems, and patient self-management support domains, but there is room for improvement. Differences among plans and between strategies for breast and cervical cancer screening provide new understanding of how to approach this problem. CONCLUSIONS: Organizations seeking to improve performance of breast and cervical cancer screening should consider multiple strategies aimed at multiple targets and should ensure that strategies used for one type of cancer are considered for others.

Breast Neoplasms↗