Louise H. Anderson

Trends in Quality During Medical Home Transformation

PURPOSE We describe changes over time in performance on measures of technical quality and patient experience as a group of primary care clinics transformed themselves into level III patient-centered medical homes. METHODS A group of 21 Minnesota primary care clinics achieving level III recognition as medical homes by the National Committee for Quality Assurance has been tracking a variety of quality and patient satisfaction measures for years. We analyzed trends in these measures and compared them with those of other medical groups in the community to estimate what we might expect as other primary care sites gear up to achieve medical home status. RESULTS The clinics in this group achieved a 1% to 3% increase per year in patient satisfaction and a 2% to 7% increase per year in performance on quality measures for diabetes, coronary artery disease, preventive services, and generic medication use. When compared with the average for other medical groups in the region, the rates of increase were greater for satisfaction, but similar for the quality measures. CONCLUSIONS Achieving medical home recognition was associated with improvements in quality and patient satisfaction for these clinics, but the rate of improvement is slow and does not always exceed levels in the surrounding community in Minnesota (which are also improving). Expectations for large and rapid change are probably unrealistic.

Informed Choice Assistance for Women Making Uterine Fibroid Treatment Decisions: A Practical Clinical Trial

Background. There is limited evidence about how to ensure that patients are helped to make informed medical care decisions. Objective. To test a decision support intervention for uterine fibroid treatments. Design and Setting. Practical clinical trial to test informed choice assistance in 4 randomly assigned gynecology clinics compared to 5 others providing a pamphlet. Patients. Three hundred women facing a treatment decision for fibroids over a 13-month period. Intervention. Mailed DVD and brochure about fibroid treatments plus the Ottawa decision guide and an offer of counseling soon after an index visit. Measurements. Mailed survey 6 to 8 weeks later asking about knowledge, preferences, and satisfaction with decision support. Results. In total, 244 surveys were completed for an adjusted response rate of 85.4%. On a 5-point scale, intervention subjects reported more treatment options being mentioned (3.0 v. 2.4), had a higher knowledge score (3.3 v. 2.8), and were more likely to report being adequately informed (4.4 v. 4.0), and their decision was both more satisfactory (4.3 v. 4.0) and more consistent with their personal values (4.5 v. 4.2). Neither knowledge nor use of the intervention was associated with greater concordance between preferences and decisions. Limitations. Implementation of intervention may not have been well timed to the decision for some patients, limiting their use of the materials and counseling. Conclusion. It is difficult to integrate structured decision support consistently into practice. Decision support for benign uterine conditions showed effects on knowledge and satisfaction but not on concordance.

Evaluating preference-sensitive care for uterine fibroids: it's not so simple.

BACKGROUND Preference-sensitive care decisions should reflect an informed patients preferences. This retrospective survey of women with fibroids, a benign condition with multiple treatment options, sought to evaluate the extent to which this was measurable and true. METHODS All 260 women in one medical group with visit codes for uterine fibroids during a 9-month period in 2006 were mailed surveys constructed through focus groups with physicians and interviews with patients. Correlations tested associations among their preferences, knowledge, and treatment decisions. RESULTS The adjusted response rate was 82%, but only 100 respondents fit all criteria for analysis. Nearly all wanted to either share or control the decision, and 86% felt informed, satisfied, and that the decision was consistent with their values. However, only 55% of patients could answer at least five of seven fibroid questions correctly. Hysterectomy use was significantly correlated with desire to relieve symptoms, have a permanent treatment, and do something right away (r = 0.36, 0.37, and 0.30, respectively). Those deciding not to treat were significantly less likely to have these preferences (r = -0.65, -0.40, and -0.58). These relationships were not affected by patient knowledge level, but patients with high knowledge scores were significantly more likely to believe their decision was concordant with their preferences (94.9% vs. 74.4%, p < 0.01). CONCLUSIONS There were knowledge gaps but unclear associations between knowledge and decision-preference relationships for this condition, which has many different treatment alternatives. A prospective intervention trial is needed to determine if better information and counseling would produce stronger concordance between treatment selected and patient preferences.

CA7-03: Adolescent and Adult Immunizations: Health Impact and Cost-Effectiveness.

Background/Aims The scope of vaccines recommended for adolescents and adults by ACIP has grown in number of vaccines and populations covered. We estimated the relative health impact and cost-effectiveness of these vaccines to help guide quality improvement initiative decisions. Methods Markov deterministic and micro-simulation models were used to estimate the health impact and CE ratios for birth cohorts of four million using a societal perspective. All models used methods consistent with the ‘reference case’ of the Panel of Cost-Effectiveness in Health and Medicine, producing results that are comparable and suitable for ranking. The influenza model recognized the 2010 ACIP recommendation for universal vaccination. The pneumococcal model recognized the recent decline in adult incidence after introduction of the PCV7 childhood vaccine. The meningococcal model included the 2010 ACIP recommendation for a booster five years after an initial vaccination at age 11 or 12. The HPV model estimated the influence of vaccine on rates of cervical cancer with and without cancer screening. Parameter estimates were from published literature. Single- and multiple-variable sensitivity analyses were performed. Results Health impacts, measured as QALYs saved during the lifetime of the cohort, were greatest for influenza vaccine (283,300), followed by HPV vaccine with screening (221,100), pneumococcal vaccine (17,100) and meningococcal vaccine (2,900). CE ratios ranged from

CA7-02: The Extent and Impact of Consistent Primary Care

9,300 for adult pneumococcal vaccination to over

Meeting Recommendations for Multiple Healthy Lifestyle Factors Prevalence, Clustering, and Predictors Among Adolescent, Adult, and Senior Health Plan Members

640,000 for adolescent meningococcal vaccination. CE of influenza vaccination for ages 18 and older was

Health care charges associated with physical inactivity, overweight, and obesity.

6,100, but the vaccine was most cost-effective for ages 65 and older (

Patient-Centered Medical Home Cost Reductions Limited to Complex Patients

4,000) and least cost-effective for ages 18 to 49 (

Patient Medical Group Continuity and Healthcare Utilization

260,500). HPV vaccine CE was

Critical Review of Stochastic Simulation Literature and Applications for Health Actuaries

15,100 without screening and