Christopher G. Wise

Context Matters: The Experience of 14 Research Teams in Systematically Reporting Contextual Factors Important for Practice Change

PURPOSE We aimed to advance the internal and external validity of research by sharing our empirical experience and recommendations for systematically reporting contextual factors. METHODS Fourteen teams conducting research on primary care practice transformation retrospectively considered contextual factors important to interpreting their findings (internal validity) and transporting or reinventing their findings in other settings/situations (external validity). Each team provided a table or list of important contextual factors and interpretive text included as appendices to the articles in this supplement. Team members identified the most important contextual factors for their studies. We grouped the findings thematically and developed recommendations for reporting context. RESULTS The most important contextual factors sorted into 5 domains: (1) the practice setting, (2) the larger organization, (3) the external environment, (4) implementation pathway, and (5) the motivation for implementation. To understand context, investigators recommend (1) engaging diverse perspectives and data sources, (2) considering multiple levels, (3) evaluating history and evolution over time, (4) looking at formal and informal systems and culture, and (5) assessing the (often nonlinear) interactions between contextual factors and both the process and outcome of studies. We include a template with tabular and interpretive elements to help study teams engage research participants in reporting relevant context. CONCLUSIONS These findings demonstrate the feasibility and potential utility of identifying and reporting contextual factors. Involving diverse stakeholders in assessing context at multiple stages of the research process, examining their association with outcomes, and consistently reporting critical contextual factors are important challenges for a field interested in improving the internal and external validity and impact of health care research.

Evaluation of patient centered medical home practice transformation initiatives.

Background:The patient-centered medical home (PCMH) has become a widely cited solution to the deficiencies in primary care delivery in the United States. To achieve the magnitude of change being called for in primary care, quality improvement interventions must focus on whole-system redesign, and not just isolated parts of medical practices. Methods:Investigators participating in 9 different evaluations of Patient Centered Medical Home implementation shared experiences, methodological strategies, and evaluation challenges for evaluating primary care practice redesign. Results:A year-long iterative process of sharing and reflecting on experiences produced consensus on 7 recommendations for future PCMH evaluations: (1) look critically at models being implemented and identify aspects requiring modification; (2) include embedded qualitative and quantitative data collection to detail the implementation process; (3) capture details concerning how different PCMH components interact with one another over time; (4) understand and describe how and why physician and staff roles do, or do not evolve; (5) identify the effectiveness of individual PCMH components and how they are used; (6) capture how primary care practices interface with other entities such as specialists, hospitals, and referral services; and (7) measure resources required for initiating and sustaining innovations. Conclusions:Broad-based longitudinal, mixed-methods designs that provide for shared learning among practice participants, program implementers, and evaluators are necessary to evaluate the novelty and promise of the PCMH model. All PCMH evaluations should as comprehensive as possible, and at a minimum should include a combination of brief observations and targeted qualitative interviews along with quantitative measures.

Potential Effects of Managed Care on Specialty Practice at a University Medical Center

BACKGROUND The growth of managed care presents a challenge to academic medical centers, because the demand for the services of specialists is likely to continue decreasing. We estimated the number of enrollees the University of Michigan Medical Center would need in its health maintenance organization (HMO) system in order to provide revenue equivalent to the total revenue it received for professional specialty care in 1992. METHODS Rates of utilization and payment were based on the medical centers experience with managed care in 1992 in its independent practice association HMO, in which 25,000 members had capitated coverage and received primary and all specialty care from university physicians, and 15,000 members received primary care and most specialty care from physicians outside the university. We assumed that persons not enrolled in Medicare were all enrolled in managed-care plans. Primary care activity was excluded from the calculations of expense, revenue, and numbers of faculty members. RESULTS If all specialty services were provided by the university to HMO members, all the 21 specialties examined except obstetrics and gynecology and emergency services would require an enrollment of more than 250,000 to support the 1992 level of professional revenue and maintain the number of faculty members. If university services were provided only for referrals from a loosely affiliated network of community physicians in the HMO system, all the 19 specialties examined except plastic surgery would require an HMO enrollment of more than 1 million. In a combined model in which all specialty services were provided to 100,000 HMO members and network referrals were provided to 500,000 members, substantial changes in faculty composition would be needed in all the departments studied. CONCLUSIONS Because of the large number of HMO members required, unless other changes occur, it is unrealistic to expect that the University of Michigan Medical Center could create an HMO or network large enough to support the specialty practice of the current number of faculty members at the 1992 level of financing.

The multidisciplinary melanoma clinic: A cost outcomes analysis of specialty care

The traditional process of melanoma care delivery can differ substantially among providers regarding screening laboratories, staging work-ups, surgical margins, and outpatient versus inpatient surgical management. It has been suggested that multidisciplinary care may provide a more cost-effective management approach. We sought to evaluate whether coordinated multidisciplinary melanoma care that follows evidence-based, consensus-approved clinical practice guidelines at a large academic medical center can provide a more efficient alternative to traditional community-based strategies with clinical outcomes that are at least equivalent. The University of Michigan Multidisciplinary Melanoma Clinic (MDMC) possesses a database of demographic, clinical, and treatment information for all patients seen since its inception. A consecutive sample of 104 patients with local disease who were treated in the Michigan community were compared with 104 blindly selected subjects treated at the MDMC during an identical time period, matched for Breslow depth and melanoma body site. Patients treated in the MDMC would save a third party payer roughly

A Model for Practice Guideline Adaptation and Implementation: Empowerment of the Physician

1600 per patient when compared with a similar group treated in the Michigan community. Surgical morbidity, length of hospitalization, and long-term survival of MDMC patients were similar to those reported in the literature. The cost discrepancy is explained by the fundamental differences in the usage pattern of health care resources exhibited by the MDMC compared with the community setting.

Downsizing and financial performance in rural hospitals.

The Medical Center model of practice guideline adaptation and implementation uses local clinical leaders to evaluate nationally endorsed guidelines, adapt those guidelines for use in the local setting, work with support staff to develop and apply methods for guideline implementation, and assist the evaluation of clinical practice and outcomes data. The model described here combines the guideline dissemination techniques of clinical leadership, implementation, and data support and feedback. This model overcomes the failures of previous models by incorporating local physician involvement during every step of practice guideline selection, adaptation, implementation, and evaluation, and by supporting the physician leaders with quality data, resources to support guideline implementation, and outcomes assessment and feedback.

The logic of transaction cost economics in health care organization theory.

This article examines the association between downsizing and financial performance in a national sample of 797 U.S. rural hospitals from 1983-1988. The results indicate that downsizing occurred in about 15 percent of all rural hospitals and that a positive association between downsizing and financial performance was unconfirmed.

Assessment and Measurement of Patient-Centered Medical Home Implementation: The BCBSM Experience

Health care is, at its core, comprised of complex sequences of transactions among patients, providers, and other stakeholders; these transactions occur in markets as well as within systems and organizations. Health care transactions serve one of two functions: the production of care (i.e., the laying on of hands) or the coordination of that care (i.e., scheduling, logistics). Because coordinating transactions is integral to care delivery, it is imperative that they are executed smoothly and efficiently. Transaction cost economics (TCE) is a conceptual framework for analyzing health care transactions and quantifying their impact on health care structures (organizational forms), processes, and outcomes.

The effects of a low-cost intervention program on hospital costs

PURPOSE Our goal was to describe an approach to patient-centered medical home (PCMH) measurement based on delineating the desired properties of the measurement relative to assumptions about the PCMH and the uses of the measure by Blue Cross Blue Shield of Michigan (BCBSM) and health services researchers. METHODS We developed and validated an approach to assess 13 functional domains of PCMHs and 128 capabilities within those domains. A measure of PCMH implementation was constructed using data from the validated self-assessment and then tested on a large sample of primary care practices in Michigan. RESULTS Our results suggest that the measure adequately addresses the specific requirements and assumptions underlying the BCBSM PCMH program—ability to assess change in level of implementation; ability to compare across practices regardless of size, affiliation, or payer mix; and ability to assess implementation of the PCMH through different sequencing of capabilities and domains. CONCLUSIONS Our experience illustrates that approaches to measuring PCMH should be driven by the measures’ intended use(s) and users, and that a one-size-fits-all approach may not be appropriate. Rather than promoting the BCBSM PCMH measure as the gold standard, our study highlights the challenges, strengths, and limitations of developing a standardized approach to PCMH measurement.

Implementation of patient-centered medical homes in adult primary care practices

Objective:To assess the impact of a low-cost education and feedback intervention designed to change physicians’ utilization behavior on general medicine services.Design:Prospective, nonequivalent control group study of 1,432 admissions on four general medicine services over 12 months. Two services were randomly selected to receive the intervention. The other two served as controls. Admissions alternated between control and intervention services each day. Results were casemix-adjusted using diagnosis-related groups (DRGs). Three internists blinded to patient study group assignment assessed quality of care using a structured implicit instrument.Setting:Four general medicine services at a university hospital.Interventions:A brief orientation, a pamphlet of cost strategies and common charges, detailed interim bills, and information about projected length of stay and usual hospital reimbursement for each patient.Patients/participants:Each service was staffed by a full-time internal medicine faculty member, one third-year and two first-year internal medicine houseofficers, three medical students, and a clinical pharmacist. Physicians were assigned to services for one-month periods by a physician unaware of the study design. To prevent crossover, houseofficers assigned to a service returned to the same service for all subsequent general medical inpatient assignments.Measurements and main results:Geometric mean length of stay was 0.44 days (7.8%) shorter for the intervention services than for the control services (p<0.01), and geometric mean charges were