Ashok Reddy

Impact of Prior HAART Use on Clinical Outcomes in a Large Kenyan HIV Treatment Program

BACKGROUND HIV treatment programs in Africa typically approach all enrolling patients uniformly. Growing numbers of patients are antiretroviral experienced. Defining patients on the basis of antiretroviral experience may inform enrollment practices, particularly if medical outcomes differ. METHODS Baseline and follow-up measures (CD4, weight change, and survival) were compared in a retrospective analysis between antiretroviral-naïve (ARV-N) and antiretroviral experience (ARV-E) patients enrolled at the Coptic Hope Center for Infectious Diseases in Nairobi, Kenya and followed between January 2004 and August 2006. RESULTS 1,307 ARV-N and 962 ARV-E patients receiving highly active antiretroviral therapy (HAART) were followed for median of 9 months (interquartile range: 4-16 months). Compared to ARV-N, ARV-E had substantially higher CD4 count (median cells/mm(3), 193 versus 95, P < 0.001) and weight (median kg, 62 versus 57, P < 0.001) at baseline, and lower rates of change in CD4 (-9.2 cells/mm(3)/month; 95% CI, -11.4 -7.0) and weight (-0.24 kg/month; 95% CI, -0.35 - -0.14) over 12 months. Mortality was significantly higher in ARV-N than ARV-E (P = 0.001). CONCLUSIONS ARV-E patients form a growing group that differs significantly from ARV-N patients and requires a distinct approach from ARV-N clients. Systematic approaches to streamline care of ARV-E patients may allow focused attention on early ARV-N clients whose mortality risks are substantially higher.

Patient portals and personal health information online: perception, access, and use by US adults

Background: Access to online patient portals is key to improving care, but we have limited understanding of patient perceptions of online portals and the characteristics of people who use them. Methods: Using a national survey of 3677 respondents, we describe perceptions and utilization of online personal health information (PHI) portals. Results: Most respondents (92%) considered online PHI access important, yet only 34% were offered access to online PHI by a health care provider, and just 28% accessed online PHI in the past year. While there were no differences across race or ethnicity in importance of access, black and Hispanic respondents were significantly less likely to be offered access (P = .006 and <.001, respectively) and less likely to access their online PHI (P = .041 and <.001, respectively) compared to white and non-Hispanic respondents. Conclusion: Health care providers are crucial to the adoption and use of online patient portals and should be encouraged to offer consistent access regardless of patient race and ethnicity.

Behavioral Health and the Comprehensive Primary Care (CPC) Initiative: Findings from the 2014 CPC behavioral health survey

BackgroundIncorporating behavioral health care into patient centered medical homes is critical for improving patient health and care quality while reducing costs. Despite documented effectiveness of behavioral health integration (BHI) in primary care settings, implementation is limited outside of large health systems. We conducted a survey of BHI in primary care practices participating in the Comprehensive Primary Care (CPC) initiative, a four-year multi-payer initiative of the Centers for Medicare and Medicaid Services (CMS). We sought to explore associations between practice characteristics and the extent of BHI to illuminate possible factors influencing successful implementation.MethodWe fielded a survey that addressed six substantive domains (integrated space, training, access, communication and coordination, treatment planning, and available resources) and five behavioral health conditions (depression, anxiety, pain, alcohol use disorder, and cognitive function). Descriptive statistics compared BHI survey respondents to all CPC practices, documented the availability of behavioral health providers, and primary care and behavioral health provider communication. Bivariate relationships compared provider and practice characteristics and domain scores.ResultsOne hundred sixty-one of 188 eligible primary care practices completed the survey (86% response rate). Scores indicated basic to good baseline implementation of BHI in all domains, with lowest scores on communication and coordination and highest scores for depression. Higher scores were associated with: having any behavioral health provider, multispecialty practice, patient-centered medical home designation, and having any communication between behavioral health and primary care providers.ConclusionsThis study provides useful data on opportunities and challenges of scaling BHI integration linked to primary care transformation. Payment reform models such as CPC can assist in BHI promotion and development.

Risk Stratification Methods and Provision of Care Management Services in Comprehensive Primary Care Initiative Practices

PURPOSE Risk-stratified care management is essential to improving population health in primary care settings, but evidence is limited on the type of risk stratification method and its association with care management services. METHODS We describe risk stratification patterns and association with care management services for primary care practices in the Comprehensive Primary Care (CPC) initiative. We undertook a qualitative approach to categorize risk stratification methods being used by CPC practices and tested whether these stratification methods were associated with delivery of care management services. RESULTS CPC practices reported using 4 primary methods to stratify risk for their patient populations: a practice-developed algorithm (n = 215), the American Academy of Family Physicians’ clinical algorithm (n = 155), payer claims and electronic health records (n = 62), and clinical intuition (n = 52). CPC practices using practice-developed algorithm identified the most number of high-risk patients per primary care physician (282 patients, P = .006). CPC practices using clinical intuition had the most high-risk patients in care management and a greater proportion of high-risk patients receiving care management per primary care physician (91 patients and 48%, P =.036 and P =.128, respectively). CONCLUSIONS CPC practices used 4 primary methods to identify high-risk patients. Although practices that developed their own algorithm identified the greatest number of high-risk patients, practices that used clinical intuition connected the greatest proportion of patients to care management services.

US Department of Veterans Affairs Primary Care Provider Turnover and Patient Satisfaction—Reply

US Department of Veterans Affairs Primary Care Provider Turnover and Patient Satisfaction To the Editor Reddy et al1 found no clinical quality effect, but a modest reduction in patient satisfaction, associated with a US Department of Veterans Affairs (VA) patient experiencing primary care provider (PCP) turnover. On average, the PCP change occurred 1.5 years before quality and satisfaction were measured in 2010 to 2012. Relevant alternative policy explanations other than those offered by Reddy et al should be considered. First, fewer than 30% of VA enrollees are exclusively reliant on the VA for ambulatory care,2,3 and even patients who obtain primary care within the VA get more of their primary care outside of the VA, through other insurance.4 Because testing performed, cancer screening done, and effective care management provided outside of the VA all contribute to VA quality scores, it should not be surprising that changing a patient’s VA PCP did not affect quality metrics. Second, during the study’s duration, VA PCP turnover rates were about 15% per year, excluding transfers of PCPs to a different VA. Turnover rates also accelerated, in part because of implementation of a new patient-centered medical home initiative.5 Also, between 2010 and 2012, VA enrollees’ satisfaction with the VA declined. In national surveys,2,3 the proportion of respondents who agreed or completely agreed that “veterans like me are satisfied with the health care they receive” dropped from 73.7% to 67.5% and those who agreed that “VA health care providers treat their patients with respect” declined from 83.5% to 78.9%. Perhaps the new VA PCPs to whom patients are reassigned actually interact with patients less effectively than previous PCPs did. The Veterans’ Access to Care Through Choice, Accountability, and Transparency Act of 2014 seeks to improve veterans’ access to care by filling long-standing PCP shortages and improving private sector care access for some VA users. The study by Reddy et al1 suggests that VA administrators should ensure that newly hired PCPs are respectful and customer oriented. Furthermore, the study might encourage VA policy makers to consider adopting recently suggested insurer roles vis-à-vis their patient population by outsourcing more care.6 Because VA PCP changes do not appear to affect quality, their replacement with private sector PCPs might not either. Nonetheless, studies exploring how satisfaction and quality scores change among VA enrollees who obtain free, local, high-quality, private sector primary care through the 2014 Act are needed to determine the best future role for the VA from VA patients’ perspective.

The Effect of Organizational Climate on Patient-Centered Medical Home Implementation

Organizational climate is a key determinant of successful adoption of innovations; however, its relation to medical home implementation is unknown. This study examined the association between primary care providers’ (PCPs’) perception of organization climate and medical home implementation in the Veterans Health Administration. Multivariate regression was used to test the hypothesis that organizational climate predicts medical home implementation. This analysis of 191 PCPs found that higher scores in 2 domains of organizational climate (communication and cooperation, and orientation to quality improvement) were associated with a statistically significantly higher percentage (from 7 to 10 percentage points) of PCPs implementing structural changes to support the medical home model. In addition, some aspects of a better organizational climate were associated with improved organizational processes of care, including a higher percentage of patients contacted within 2 days of hospital discharge (by 2 to 3 percentage points) and appointments made within 3 days of a patient request (by 2 percentage points).