Julie A. Schmittdiel

Is patient activation associated with outcomes of care for adults with chronic conditions

We examined the patient activation measures (PAMs) association with process and health outcomes among adults with chronic conditions. Patients with high PAM scores were significantly more likely to perform self-management behaviors, use self-management services, and report high medication adherence, compared to patients with the lowest PAM scores. This population was 10 times more likely to report high patient-satisfaction scores, 5 times more likely to report high quality-of-life scores, and reported significantly higher physical and mental functional status scores, compared to those with the lowest scores. These results suggest that PAM scores are associated with key process and health outcome measures.

Cost-effectiveness of a Multicondition Collaborative Care Intervention: A Randomized Controlled Trial

CONTEXT Patients with depression and poorly controlled diabetes mellitus, coronary heart disease (CHD), or both have higher medical complication rates and higher health care costs, suggesting that more effective care management of psychiatric and medical disease control might also reduce medical service use and enhance quality of life. OBJECTIVE To evaluate the cost-effectiveness of a multicondition collaborative treatment program (TEAMcare) compared with usual primary care (UC) in outpatients with depression and poorly controlled diabetes or CHD. DESIGN Randomized controlled trial of a systematic care management program aimed at improving depression scores and hemoglobin A(1c) (HbA(1c)), systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDL-C) levels. SETTING Fourteen primary care clinics of an integrated health care system. PATIENTS Population-based screening identified 214 adults with depressive disorder and poorly controlled diabetes or CHD. INTERVENTION Physician-supervised nurses collaborated with primary care physicians to provide treatment of multiple disease risk factors. MAIN OUTCOME MEASURES Blinded assessments evaluated depressive symptoms, SBP, and HbA(1c) at baseline and at 6, 12, 18, and 24 months. Fasting LDL-C concentration was assessed at baseline and at 12 and 24 months. Health plan accounting records were used to assess medical service costs. Quality-adjusted life-years (QALYs) were assessed using a previously developed regression model based on intervention vs UC differences in HbA(1c), LDL-C, and SBP levels over 24 months. RESULTS Over 24 months, compared with UC controls, intervention patients had a mean of 114 (95% CI, 79 to 149) additional depression-free days and an estimated 0.335 (95% CI, -0.18 to 0.85) additional QALYs. Intervention patients also had lower mean outpatient health costs of

As good as it gets? Chronic care management in nine leading US physician organisations.

594 per patient (95% CI, -

Effect of Physician and Patient Gender Concordance on Patient Satisfaction and Preventive Care Practices

3241 to

When More Is Not Better Treatment Intensification Among Hypertensive Patients With Poor Medication Adherence

2053) relative to UC patients. CONCLUSIONS For adults with depression and poorly controlled diabetes, CHD, or both, a systematic intervention program aimed at improving depression scores and HbA(1c), SBP, and LDL-C levels seemed to be a high-value program that for no or modest additional cost markedly improved QALYs. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00468676

An Empirical Assessment of High-Performing Medical Groups: Results from a National Study:

Innovations in care management processes have improved the care of patients with chronic illnesses, but many patients still do not receive these benefits. The authors have studied the barriers and facilitators to implementing these improvements in leading US physician practices About 125 million of the 276 million people living in the United States have some type of chronic illness (table 1).1 Four chronic conditions affect nearly half of Americans with a chronic disease: asthma, depression, and diabetes each affect about 15 million,2–4 while five million have congestive heart failure.5 In 1999 these four chronic diseases were directly responsible for 140 000 deaths in the United States6 and generated at least

Adherence to cardiovascular disease medications: does patient-provider race/ethnicity and language concordance matter?

173bn (£108bn, €170bn) in medical and other costs. 5 7–9 Over the past decade the effectiveness of care for patients with these and other major chronic illnesses has been improved by innovations in care management processes such as the use of guidelines, disease management techniques, case management, and patient education to improve self management of chronic disease.10 However, many patients are not benefiting from these advances. Recent studies indicate that fewer than half of US patients with asthma, depression, and diabetes receive appropriate treatment.11–13 Organisational characteristics of physician practices associated with effective chronic disease care include the use of patient care teams, supportive information systems, and a high volume of patients.14 Hence, we expect that in the United States moderate and large sized, well organised, multispecialty practices are likely to offer chronic disease care that is as good as it gets and provide other physician organisations with benchmarks against which performance can be measured. #### Summary points

Patient Assessment of Chronic Illness Care (PACIC) and Improved Patient-centered Outcomes for Chronic Conditions

AbstractOBJECTIVE: To explore the role of the gender of the patient and the gender of the physician in explaining differences in patient satisfaction and patient-reported primary care practice. DESIGN: Cross-sectional mailed survey [response rate of 71%]. SETTING: A large group-model Health Maintenance Organization (HMO) in northern California. PATIENTS/PARTICIPANTS: Random sample of HMO members aged 35 to 85 years with a primary care physician. The respondents (N=10,205) were divided into four dyads: female patients of female doctors; male patients of female doctors; female patients of male doctors; and male patients of male doctors. Patients were also stratified on the basis of whether they had chosen their physician or had been assigned. MEASUREMENTS AND MAIN RESULTS: Among patients who chose their physician, females who chose female doctors were the least satisfied of the four groups of patients for four of five measures of satisfaction. Male patients of female physicians were the most satisfied. Preventive care and health promotion practices were comparable for male and female physicians. Female patients were more likely to have chosen their physician than males, and were much more likely to have chosen female physicians. These differences were not seen among patients who had been assigned to their physicians and were not due to differences in any of the measured aspects of health values or beliefs. CONCLUSIONS: Our study revealed differences in patient satisfaction related to the gender of the patient and of the physician. While our study cannot determine the reasons for these differences, the results suggest that patients who choose their physician may have different expectations, and the difficulty of fulfilling these expectations may present particular challenges for female physicians.

New Prescription Medication Gaps: A Comprehensive Measure of Adherence to New Prescriptions

Background— Hypertension may be poorly controlled because patients do not take their medications (poor adherence) or because providers do not increase medication when appropriate (lack of medication intensification, or “clinical inertia”). We examined the prevalence of and relationship between patient adherence and provider treatment intensification. Methods and Results— We used a retrospective cohort study of hypertensive patients who had filled prescriptions for 1 or more blood pressure (BP) medications at Veterans’ Affairs (VA) healthcare facilities in a Midwestern VA administrative region. Our sample included all patients who received at least 2 outpatient BP medication refills during 2004 and had 1 or more outpatient primary care visits with an elevated systolic BP >140 but <200 mm Hg or diastolic BP >90 mm Hg during 2005 (n=38 327). For each episode of elevated BP during 2005 (68 610 events), we used electronic pharmacy refill data to examine patients’ BP medication adherence over the prior 12 months and whether providers increased doses or added BP medications (“intensification”). Multivariate analyses accounted for the clustering of elevated BP events within patients and adjusted for patient age, comorbidities, number of BP medications, encounter systolic BP, and average systolic BP over the prior year. Providers intensified medications in 30% of the 68 610 elevated BP events, with almost no variation in intensification regardless of whether patients had good or poor BP medication adherence. After adjustment, intensification rates were 31% among patients who had “gaps” of <20% (days on which patients should have had medication but no medication was available because medications had not been refilled), 34% among patients with refill gaps of 20% to 59%, and 32% among patients with gaps of 60% or more. Conclusions— Intensification of medications occurred in fewer than one third of visits in which patients had an elevated BP. Patients’ prior medication adherence had little impact on providers’ decisions about intensifying medications, even at very high levels of poor adherence. Addressing both patient adherence and provider intensification simultaneously would most likely result in better BP control.

The impact of removing financial incentives from clinical quality indicators: Longitudinal analysis of four Kaiser Permanente indicators

The performance of medical groups is receiving increased attention. Relatively little conceptual or empirical work exists that examines the various dimensions of medical group performance. Using a national database of 693 medical groups, this article develops a scorecard approach to assessing group performance and presents a theory-driven framework for differentiating between high-performing versus low-performingmedical groups. The clinical quality of care, financial performance, and organizational learning capability of medical groups are assessed in relation to environmental forces, resource acquisition and resource deployment factors, and a quality-centered culture. Findings support the utility of the performance scorecard approach and identification of a number of key factors differentiating high-performing from low-performing groups including, in particular, the importance of a quality-centered culture and the requirement of outside reporting from third party organizations. The findings hold a number of important implications for policy and practice, and the framework presented provides a foundation for future research.