Bruce E. Landon

Leaving medicine: the consequences of physician dissatisfaction.

Background:During the past decade, a confluence of forces has changed the practice of medicine in unprecedented ways. Anecdotal reports suggest that, in response, some physicians are leaving the practice of medicine or retiring earlier than they otherwise would have. Objective:We sought to examine how physician demographic characteristics, practice characteristics, and career satisfaction are related to physician decisions to leave the practice of medicine or substantially cut back their practice hours. Design:Data for this study are from the first 2 rounds of the Community Tracking Study (CTS) Physician Survey, a series of nationally representative telephone surveys of physicians first conducted in 1996. Subsequent rounds of the survey included physicians sampled in the previous round, which allowed us to ascertain their career status 2 years after their initial interviews. Subjects:Primary care and specialist physicians initially spending at least 20 hours per week in direct patient care activities were studied. Main Outcomes Measures:Physicians cutting back their practice hours to less than 20 hours per week or leaving the practice of medicine altogether. Results:Of the 16,681 physicians interviewed for whom we also had information about their career status 2 years later, 462 (2.8%) had retired and 499 (3.0%) had reduced time spent in patient care to less than 20 hours per week. In multinomial logistic analyses that examined both outcomes, full- or part-owners of practices were both less likely to retire and to cut back hours. Internal medicine specialists and psychiatrists were less likely to retire (odds ratio [OR] 0.69, 95% confidence interval [CI] 0.48–0.99 and OR 0.33, 95% CI 0.18–0.60 respectively) whereas surgical specialists were more likely to retire (OR 1.6, 95% CI 1.1–2.2). Physician satisfaction was strongly related to both outcomes. For instance, very dissatisfied physicians were both more likely to retire (OR 2.34, 95% CI 1.6–3.5) and cut back on their hours (OR 3.6, 95% CI 2.32–5.6). Conclusions:Our findings demonstrate that dissatisfied physicians were 2 to 3 times more likely to leave medicine than satisfied physicians. These findings have implications for physician manpower projections and quality of care.

A Nationwide Survey of Patient Centered Medical Home Demonstration Projects

BackgroundThe patient centered medical home has received considerable attention as a potential way to improve primary care quality and limit cost growth. Little information exists that systematically compares PCMH pilot projects across the country.DesignCross-sectional key-informant interviews.ParticipantsLeaders from existing PCMH demonstration projects with external payment reform.MeasurementsWe used a semi-structured interview tool with the following domains: project history, organization and participants, practice requirements and selection process, medical home recognition, payment structure, practice transformation, and evaluation design.ResultsA total of 26 demonstrations in 18 states were interviewed. Current demonstrations include over 14,000 physicians caring for nearly 5 million patients. A majority of demonstrations are single payer, and most utilize a three component payment model (traditional fee for service, per person per month fixed payments, and bonus performance payments). The median incremental revenue per physician per year was

The relationship between patients' perception of care and measures of hospital quality and safety.

22,834 (range

Effects of a Quality Improvement Collaborative on the Outcome of Care of Patients with HIV Infection: The EQHIV Study

720 to

The ‘Alternative Quality Contract,’ Based On A Global Budget, Lowered Medical Spending And Improved Quality

91,146). Two major practice transformation models were identified—consultative and implementation of the chronic care model. A majority of demonstrations did not have well-developed evaluation plans.ConclusionCurrent PCMH demonstration projects with external payment reform include large numbers of patients and physicians as well as a wide spectrum of implementation models. Key questions exist around the adequacy of current payment mechanisms and evaluation plans as public and policy interest in the PCMH model grows.

Early Performance of Accountable Care Organizations in Medicare

BACKGROUND The extent to which patient experiences with hospital care are related to other measures of hospital quality and safety is unknown. METHODS; We examined the relationship between Hospital Consumer Assessment of Healthcare Providers and Systems scores and technical measures of quality and safety using service-line specific data in 927 hospitals. We used data from the Hospital Quality Alliance to assess technical performance in medical and surgical processes of care and calculated Patient Safety Indicators to measure medical and surgical complication rates. RESULTS The overall rating of the hospital and willingness to recommend the hospital had strong relationships with technical performance in all medical conditions and surgical care (correlation coefficients ranging from 0.15 to 0.63; p<.05 for all). Better patient experiences for each measure domain were associated with lower decubitus ulcer rates (correlations -0.17 to -0.35; p<.05 for all), and for at least some domains with each of the other assessed complications, such as infections due to medical care. CONCLUSIONS Patient experiences of care were related to measures of technical quality of care, supporting their validity as summary measures of hospital quality. Further study may elucidate implications of these relationships for improving hospital care.

Private-Payer Innovation In Massachusetts: The ‘Alternative Quality Contract’

Context Multi-institutional quality improvement collaboratives are popular, but are they effective? Contribution This controlled study evaluated an HIV care Breakthrough Series program that emphasized provider teams, sessions on quality improvement theory and techniques, and report backs about implementing quality improvement. A review of the medical records of 9986 HIV-infected patients showed no important differences in quality of care (viral load suppression, pneumocystitis prophylaxis, and screening for tuberculosis and hepatitis) between the 44 intervention clinics and the 25 control clinics. Cautions Patient adherence and satisfaction were not measured, and some control clinics may have used quality improvement techniques similar to those recommended by the collaborative program. The Editors In the pastdecade, tremendous improvements have occurred in measuring and monitoring the quality of medical care in the United States. Despite these advances, striking problems with quality persist (1, 2). The quality of care for patients with HIV infection is of particular concern. Substantial evidence shows that obtaining medical services and treatment for patients with HIV infection may lead to longer survival and better quality of life (3, 4), yet serious quality-of-care problems and striking disparities in quality by race and social class have been documented (4-6). In the 1980s, continuous quality improvement techniques were introduced into health care (7, 8). These strategies emphasize that most quality problems are a result of system failings rather than problems with individual practitioners (9). In 1995, the Institute for Healthcare Improvement introduced the concept of the Breakthrough Series, which brings together health care organizations dedicated to improving the quality of care in particular clinical areas through the application of continuous quality improvement techniques (10). These techniques (known as Plan/Do/Study/Act or PDSA cycles; Figure 1) first identify deficiencies in quality, next repeatedly implement small-scale interventions and measure changes, and then refine and expand interventions to improve processes of care (11, 12). Typically, each Breakthrough Series collaborative is composed of 20 to 40 participating health care organizations and a faculty with expertise in the clinical area and quality improvement methods (13). To date, the Institute for Healthcare Improvement has conducted collaboratives with more than 700 teams working on 23 clinical conditions or treatment processes, including improving asthma care and reducing medication errors. Although some evaluations of quality before and after a collaborative support the validity of this approach, only a few limited controlled trials have been conducted (14, 15). Figure 1. Theoretical construct of continuous quality improvement. An important source of funding for HIV care is the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act, which is administered by the HIV/AIDS Bureau of the Health Resources and Services Administration. Title III of the CARE Act supports comprehensive primary health care for HIV-infected individuals and currently supports primary care services for more than 150000 patients receiving care in more than 200 community health centers, hospital-based clinics, and city or county health services (16). In 1999, the Health Resources and Services Administration required all clinical sites that were newly awarded funding under Title III of the CARE Act to participate in a quality improvement collaborative conducted by the Institute for Healthcare Improvement. Other sites already receiving Title III funding were also invited to participate. This study evaluates the impact of the collaborative by examining pre- and postimplementation quality-of-care information on samples of patients from both participating and matched nonparticipating clinics. Methods Study Site Selection and Controls Of the 200 Title III sites in the continental United States in May 2000, we excluded 16 that reported caseloads of fewer than 100 cases per year, 12 that were initially slated to participate in the Breakthrough collaborative but elected not to do so, and 1 that lost its CARE Act funding shortly before the collaborative began. Of the remaining 171 sites, 62 participated in the collaborative. Among these sites, 54 agreed to participate in the study and 44 (including 11 mandatory participants and 33 voluntary participants; 71% of collaborative participants) provided chart review data. Of the 109 nonparticipating sites eligible to be selected as control sites, 65 provided information needed for matching. The potential control sites were matched with intervention sites on the basis of the type of site (community health center, community-based organization, health department, hospital, or university medical center), location (rural or urban), number of locations delivering care, region, and number of patients with active HIV infection. When these criteria were used, 40 sites were selected as potential controls and 37 of them (93%) agreed to participate in the study. Of these, 25 (63% of potential control sites) participated in the chart review portion of the study. The Committee on Human Studies of Harvard Medical School approved the study protocol. Quality Improvement Intervention Each participating clinic selected a team, usually consisting of at least one administrator and one or more clinicians, and a population of focus on which the teams interventions would be tested. Usually, the population of focus consisted of all HIV-infected patients in a particular site, but participants sometimes chose to focus on a subset of patients, such as those under the care of a particular group of clinicians. Originally, the design of the collaborative extended for 12 months and included a kickoff meeting and 2 subsequent 2-day meetings called learning sessions. The kickoff learning session included instruction in the theory and practice of quality improvement by identifying problems in HIV care and then introducing the techniques of continuously implementing, measuring, and refining changes (the Plan/Do/Study/Act cycles) (11, 12) to improve the care of HIV-infected patients. Each learning session included additional instruction in quality improvement techniques and breakout sessions that focused on improving specific aspects of care, developing an information infrastructure to track progress, and specific aspects of quality improvement theory. In addition, teams exchanged ideas and presented storyboards of their progress to date. At each session, teams reported on activities, methods, and results. Toward the end of the 12-month period, the Health Resources and Services Administration decided to extend the collaborative by 4 months and add a third learning session. Between the sessions (action periods), team members implemented concepts and ideas. Each site had access to a collaborative listserve, participated in monthly conference calls with the collaborative faculty, and submitted monthly reports of its improvements, which included charts that tracked the sites improvements to date in the required key quality measures described in the next section. Detailed descriptions of the Breakthrough Series collaboratives are available elsewhere (10, 17-19). Quality-of-Care Monitors We selected quality-of-care measures (Table 1) to coincide with required and optional quality measures selected by the collaborative faculty as areas for improvement. These measures were selected by the faculty after reviewing the literature to identify areas of quality deficiency in the delivery of HIV care, particularly for underserved populations targeted by the CARE Act. Because of the paramount importance of antiretroviral therapy to the treatment of HIV infection, the faculty focused on measures related to antiretroviral treatment, including the percentage of patients receiving highly active antiretroviral therapy, the percentage of patients with a controlled viral load, and the percentage of patients who received adherence counseling, as required key measures for the collaborative. Measures were then developed on the basis of consensus guidelines appropriate for the period of care (20). Our primary measures were rates of highly active antiretroviral therapy use and control of HIV viral load for appropriate patients. Patients eligible for highly active antiretroviral therapy included those with CD4+cell counts less than 0.350 109 cells/L, those with CD4+counts between 0.350 and 0.500 109 cells/L and a viral load greater than 5000 copies/mL, all patients with a viral load greater than 30000 copies/mL, and patients already receiving highly active antiretroviral therapy, as per the guidelines. We also assessed the use of highly active antiretroviral therapy for those with CD4+counts less than 0.350 109 cells/L to reflect recommendations that were published after the end of the collaborative (21). Because of the variability in viral load assays available at the time, viral load was considered controlled if it was undetectable or if the total viral load was less than 400 copies/mL. We also assessed the use of screening and prophylaxis, as well as access to care. The only key measure followed by the collaborative that we could not assess was related to adherence counseling because this information is not reliably available from medical records. Table 1. Quality of Care Indicators* Quality-of-Care Data Collection To identify pre- and postintervention samples of patients, we requested lists of all HIV-infected patients in care at each of the sites during the 2 time periods (Figure 2). For the first sample, sites were asked to provide encrypted lists of all HIV-infected patients age 18 years or older as of June 2000 seen at the site between 1 January and 30 June 2000. For the second sample, sites were asked to provide a similar list of active patients age 18 years or older as of Dec

Long-Term Outcomes of Abdominal Aortic Aneurysm in the Medicare Population

Seven provider organizations in Massachusetts entered the Blue Cross Blue Shield Alternative Quality Contract in 2009, followed by four more organizations in 2010. This contract, based on a global budget and pay-for-performance for achieving certain quality benchmarks, places providers at risk for excessive spending and rewards them for quality, similar to the new Pioneer Accountable Care Organizations in Medicare. We analyzed changes in spending and quality associated with the Alternative Quality Contract and found that the rate of increase in spending slowed compared to control groups, more so in the second year than in the first. Overall, participation in the contract over two years led to savings of 2.8 percent (1.9 percent in year 1 and 3.3 percent in year 2) compared to spending in nonparticipating groups. Savings were accounted for by lower prices achieved through shifting procedures, imaging, and tests to facilities with lower fees, as well as reduced utilization among some groups. Quality of care also improved compared to control organizations, with chronic care management, adult preventive care, and pediatric care within the contracting groups improving more in year 2 than in year 1. These results suggest that global budgets with pay-for-performance can begin to slow underlying growth in medical spending while improving quality of care.

Changes in Health Care Spending and Quality 4 Years into Global Payment

BACKGROUND In the Medicare Shared Savings Program (MSSP), accountable care organizations (ACOs) have financial incentives to lower spending and improve quality. We used quasi-experimental methods to assess the early performance of MSSP ACOs. METHODS Using Medicare claims from 2009 through 2013 and a difference-in-differences design, we compared changes in spending and in performance on quality measures from before the start of ACO contracts to after the start of the contracts between beneficiaries served by the 220 ACOs entering the MSSP in mid-2012 (2012 ACO cohort) or January 2013 (2013 ACO cohort) and those served by non-ACO providers (control group), with adjustment for geographic area and beneficiary characteristics. We analyzed the 2012 and 2013 ACO cohorts separately because entry time could reflect the capacity of an ACO to achieve savings. We compared ACO savings according to organizational structure, baseline spending, and concurrent ACO contracting with commercial insurers. RESULTS Adjusted Medicare spending and spending trends were similar in the ACO cohorts and the control group during the precontract period. In 2013, the differential change (i.e., the between-group difference in the change from the precontract period) in total adjusted annual spending was -

Does Racial Concordance Between HIV-positive Patients and Their Physicians Affect the Time to Receipt of Protease Inhibitors?

144 per beneficiary in the 2012 ACO cohort as compared with the control group (P=0.02), consistent with a 1.4% savings, but only -