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1.  The Oregon Experiment — Effects of Medicaid on Clinical Outcomes 
The New England journal of medicine  2013;368(18):1713-1722.
BACKGROUND
Despite the imminent expansion of Medicaid coverage for low-income adults, the effects of expanding coverage are unclear. The 2008 Medicaid expansion in Oregon based on lottery drawings from a waiting list provided an opportunity to evaluate these effects.
METHODS
Approximately 2 years after the lottery, we obtained data from 6387 adults who were randomly selected to be able to apply for Medicaid coverage and 5842 adults who were not selected. Measures included blood-pressure, cholesterol, and glycated hemoglobin levels; screening for depression; medication inventories; and self-reported diagnoses, health status, health care utilization, and out-of-pocket spending for such services. We used the random assignment in the lottery to calculate the effect of Medicaid coverage.
RESULTS
We found no significant effect of Medicaid coverage on the prevalence or diagnosis of hypertension or high cholesterol levels or on the use of medication for these conditions. Medicaid coverage significantly increased the probability of a diagnosis of diabetes and the use of diabetes medication, but we observed no significant effect on average glycated hemoglobin levels or on the percentage of participants with levels of 6.5% or higher. Medicaid coverage decreased the probability of a positive screening for depression (−9.15 percentage points; 95% confidence interval, −16.70 to −1.60; P = 0.02), increased the use of many preventive services, and nearly eliminated catastrophic out-of-pocket medical expenditures.
CONCLUSIONS
This randomized, controlled study showed that Medicaid coverage generated no significant improvements in measured physical health outcomes in the first 2 years, but it did increase use of health care services, raise rates of diabetes detection and management, lower rates of depression, and reduce financial strain.
doi:10.1056/NEJMsa1212321
PMCID: PMC3701298  PMID: 23635051
2.  Simulation Suggests That Medical Group Mergers Won’t Undermine The Potential Utility Of Health Information Exchanges 
Health affairs (Project Hope)  2012;31(3):548-559.
Substantial resources are being invested in health information exchanges (HIE), community-based consortia that enable independent health-care organizations to exchange clinical data. However, under pressure to form accountable care organizations, medical groups may merge and support private HIE, reducing the potential utility of community HIEs. Simulations of “care transitions” based on data from 10 Massachusetts communities suggest that mergers would have to be considerable to substantially reduce the potential utility of an HIE. Nonetheless, simulations also suggest that HIEs will need to recruit a large proportion of the medical groups in a community, as hospitals and the largest groups account for only 10 to 20% of care transitions in communities.
doi:10.1377/hlthaff.2011.0799
PMCID: PMC3759523  PMID: 22392665
3.  Improving the Quality of Cancer Care: Crossroads or Convergence? 
Journal of Oncology Practice  2009;5(6):284-286.
Insurers and payers are demanding performance measurement, whereas professional boards are urging practice-based quality improvement projects. Will these two streams improve day-to-day practice or add administrative burden?
doi:10.1200/JOP.091051
PMCID: PMC2869189  PMID: 21479075
4.  Addressing Racial and Ethnic Disparities in Health Care: Using Federal Data to Support Local Programs to Eliminate Disparities 
Health Services Research  2006;41(4 Pt 1):1451-1468.
To reduce racial and ethnic disparities in health care, managers, policy makers, and researchers need valid and reliable data on the race and ethnicity of individuals and populations. The federal government is one of the most important sources of such data. In this paper we review the strengths and weaknesses of federal data that pertain to racial and ethnic disparities in health care. We describe recent developments that are likely to influence how these data can be used in the future and discuss how local programs could make use of these data.
doi:10.1111/j.1475-6773.2006.00549.x
PMCID: PMC1797089  PMID: 16899018
Federal government; health disparities; racial disparities; databases
5.  A conceptual framework and protocol for defining clinical decision support objectives applicable to medical specialties 
Background
The U.S. Centers for Medicare and Medicaid Services established the Electronic Health Record (EHR) Incentive Program in 2009 to stimulate the adoption of EHRs. One component of the program requires eligible providers to implement clinical decision support (CDS) interventions that can improve performance on one or more quality measures pre-selected for each specialty. Because the unique decision-making challenges and existing HIT capabilities vary widely across specialties, the development of meaningful objectives for CDS within such programs must be supported by deliberative analysis.
Design
We developed a conceptual framework and protocol that combines evidence review with expert opinion to elicit clinically meaningful objectives for CDS directly from specialists. The framework links objectives for CDS to specialty-specific performance gaps while ensuring that a workable set of CDS opportunities are available to providers to address each performance gap. Performance gaps may include those with well-established quality measures but also priorities identified by specialists based on their clinical experience. Moreover, objectives are not constrained to performance gaps with existing CDS technologies, but rather may include those for which CDS tools might reasonably be expected to be developed in the near term, for example, by the beginning of Stage 3 of the EHR Incentive program. The protocol uses a modified Delphi expert panel process to elicit and prioritize CDS meaningful use objectives. Experts first rate the importance of performance gaps, beginning with a candidate list generated through an environmental scan and supplemented through nominations by panelists. For the highest priority performance gaps, panelists then rate the extent to which existing or future CDS interventions, characterized jointly as “CDS opportunities,” might impact each performance gap and the extent to which each CDS opportunity is compatible with specialists’ clinical workflows. The protocol was tested by expert panels representing four clinical specialties: oncology, orthopedic surgery, interventional cardiology, and pediatrics.
doi:10.1186/1472-6947-12-93
PMCID: PMC3536635  PMID: 22943497
6.  Hospitalized patients’ participation and its impact on quality of care and patient safety 
Objective
To understand the extent to which hospitalized patients participate in their care, and the association of patient participation with quality of care and patient safety.
Design
Random sample telephone survey and medical record review.
Setting
US acute care hospitals in 2003.
Participants
A total of 2025 recently hospitalized adults.
Main Outcome Measures
Hospitalized patients reported participation in their own care, assessments of overall quality of care and the presence of adverse events (AEs) in telephone interviews. Physician reviewers rated the severity and preventability of AEs identified by interview and chart review among 788 surveyed patients who also consented to medical record review.
Results
Of the 2025 patients surveyed, 99.9% of patients reported positive responses to at least one of seven measures of participation. High participation (use of >4 activities) was strongly associated with patients’ favorable ratings of the hospital quality of care (adjusted OR: 5.46, 95% CI: 4.15–7.19). Among the 788 patients with both patient survey and chart review data, there was an inverse relationship between participation and adverse events. In multivariable logistic regression analyses, patients with high participation were half as likely to have at least one adverse event during the admission (adjusted OR = 0.49, 0.31–0.78).
Conclusions
Most hospitalized patients participated in some aspects of their care. Participation was strongly associated with favorable judgments about hospital quality and reduced the risk of experiencing an adverse event.
doi:10.1093/intqhc/mzr002
PMCID: PMC3140261  PMID: 21307118
medical error; adverse events; patient participation
7.  Physician Groups’ Use of Data from Patient Experience Surveys 
Background
In Massachusetts, physician groups’ performance on validated surveys of patient experience has been publicly reported since 2006. Groups also receive detailed reports of their own performance, but little is known about how physician groups have responded to these reports.
Objective
To examine whether and how physician groups are using patient experience data to improve patient care.
Design and Participants
During 2008, we conducted semi-structured interviews with the leaders of 72 participating physician groups (out of 117 groups receiving patient experience reports). Based on leaders’ responses, we identified three levels of engagement with patient experience reporting: no efforts to improve (level 1), efforts to improve only the performance of low-scoring physicians or practice sites (level 2), and efforts to improve group-wide performance (level 3).
Main Measures
Groups’ level of engagement and specific efforts to improve patient care.
Key Results
Forty-four group leaders (61%) reported group-wide improvement efforts (level 3), 16 (22%) reported efforts to improve only the performance of low-scoring physicians or practice sites (level 2), and 12 (17%) reported no performance improvement efforts (level 1). Level 3 groups were more likely than others to have an integrated medical group organizational model (84% vs. 31% at level 2 and 33% at level 1; P < 0.005) and to employ the majority of their physicians (69% vs. 25% and 20%; P < 0.05). Among level 3 groups, the most common targets for improvement were access, communication with patients, and customer service. The most commonly reported improvement initiatives were changing office workflow, providing additional training for nonclinical staff, and adopting or enhancing an electronic health record.
Conclusions
Despite statewide public reporting, physician groups’ use of patient experience data varied widely. Integrated organizational models were associated with greater engagement, and efforts to enhance clinicians’ interpersonal skills were uncommon, with groups predominantly focusing on office workflow and support staff.
doi:10.1007/s11606-010-1597-1
PMCID: PMC3077475  PMID: 21161419
patient experience; quality of care; quality improvement; physician groups; public reporting
8.  Current Guidelines Have Limited Applicability to Patients with Comorbid Conditions: A Systematic Analysis of Evidence-Based Guidelines 
PLoS ONE  2011;6(10):e25987.
Background
Guidelines traditionally focus on the diagnosis and treatment of single diseases. As almost half of the patients with a chronic disease have more than one disease, the applicability of guidelines may be limited. The aim of this study was to assess the extent that guidelines address comorbidity and to assess the supporting evidence of recommendations related to comorbidity.
Methodology/Principal Findings
We conducted a systematic analysis of evidence-based guidelines focusing on four highly prevalent chronic conditions with a high impact on quality of life: chronic obstructive pulmonary disease, depressive disorder, diabetes mellitus type 2, and osteoarthritis. Data were abstracted from each guideline on the extent that comorbidity was addressed (general comments, specific recommendations), the type of comorbidity discussed (concordant, discordant), and the supporting evidence of the comorbidity-related recommendations (level of evidence, translation of evidence). Of the 20 guidelines, 17 (85%) addressed the issue of comorbidity and 14 (70%) provided specific recommendations on comorbidity. In general, the guidelines included few recommendations on patients with comorbidity (mean 3 recommendations per guideline, range 0 to 26). Of the 59 comorbidity-related recommendations provided, 46 (78%) addressed concordant comorbidities, 8 (14%) discordant comorbidities, and for 5 (8%) the type of comorbidity was not specified. The strength of the supporting evidence was moderate for 25% (15/59) and low for 37% (22/59) of the recommendations. In addition, for 73% (43/59) of the recommendations the evidence was not adequately translated into the guidelines.
Conclusions/Significance
Our study showed that the applicability of current evidence-based guidelines to patients with comorbid conditions is limited. Most guidelines do not provide explicit guidance on treatment of patients with comorbidity, particularly for discordant combinations. Guidelines should be more explicit about the applicability of their recommendations to patients with comorbidity. Future clinical trials should also include patients with the most prevalent combinations of chronic conditions.
doi:10.1371/journal.pone.0025987
PMCID: PMC3197602  PMID: 22028802
9.  Quality of Care for Breast Cancer for Uninsured Women in California Under the Breast and Cervical Cancer Prevention Treatment Act  
Journal of Clinical Oncology  2010;28(21):3479-3484.
Purpose
The objective of this study was to evaluate the quality of care provided to uninsured women with breast cancer who received treatment through the Breast and Cervical Cancer Prevention Treatment Program (BCCTP).
Methods
Participants included women with stage I to III breast cancer (n = 658) from a consecutive sample of women 18 years or older who received coverage through the California BCCTP between February 2003 and September 2005 who consented to a survey and medical record review (61% response rate). Quality of breast cancer care was evaluated using 29 evidence-based quality measures developed for the National Initiative for Cancer Care Quality (NICCQ). NICCQ, a largely insured cohort of women diagnosed with stage I to III breast cancer in 1998, was used to benchmark the results.
Results
Twenty-three percent of women presented with stage III disease compared with fewer than 10% nationally. Patients received 93% of recommended care (95% CI, 92% to 93%). Adherence to recommended care within domains ranged from 87% for post-treatment surveillance (95% CI, 84% to 90%) to 97% for diagnostic evaluation (95% CI, 96% to 97%). Compared to the NICCQ cohort, adherence to quality measures was as good or better for the BCCPT cohort in all domains except post-treatment surveillance.
Conclusion
The BCCTP has made important inroads in providing poor, uninsured women with access to high quality care when faced with the diagnosis of breast cancer; however, many present at an advanced stage, which is associated with worse outcomes.
doi:10.1200/JCO.2009.27.7491
PMCID: PMC2917212  PMID: 20530279
10.  Health Information Exchange, Health Information Technology Use, and Hospital Readmission Rates 
The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 offers significant financial incentives to hospitals that can demonstrate “meaningful use” of EHRs. Reduced hospital readmissions are an expected outcome of improved care coordination. Increased use of HIT, and in particular participation in HIE are touted as ways to improve coordination of care. In a 2007 national sample of US hospitals, we evaluated the association between hospitals’ HIE and HIT use and 30-day risk adjusted readmission rates for acute myocardial infarction (AMI), heart failure, and pneumonia. We found that hospital participation in HIE was not associated with lower hospital readmission rates; however, high levels of electronic documentation (an aspect of HIT use) were associated with modest reductions in readmission for heart failure (24.6% vs. 24.1%, P=.02) and pneumonia (18.4% vs. 17.9%, P=.003). More detailed data on participation in HIE are necessary to conduct more robust assessment of the relationship between HIE and hospital readmission rates.
PMCID: PMC3243133  PMID: 22195120
11.  Readiness for the Patient-Centered Medical Home: Structural Capabilities of Massachusetts Primary Care Practices 
Background
The Patient-Centered Medical Home (PCMH), a popular model for primary care reorganization, includes several structural capabilities intended to enhance quality of care. The extent to which different types of primary care practices have adopted these capabilities has not been previously studied.
Objective
To measure the prevalence of recommended structural capabilities among primary care practices and to determine whether prevalence varies among practices of different size (number of physicians) and administrative affiliation with networks of practices.
Design
Cross-sectional analysis.
Participants
One physician chosen at random from each of 412 primary care practices in Massachusetts was surveyed about practice capabilities during 2007. Practice size and network affiliation were obtained from an existing database.
Measurements
Presence of 13 structural capabilities representing 4 domains relevant to quality: patient assistance and reminders, culture of quality, enhanced access, and electronic health records (EHRs).
Main Results
Three hundred eight (75%) physicians responded, representing practices with a median size of 4 physicians (range 2–74). Among these practices, 64% were affiliated with 1 of 9 networks. The prevalence of surveyed capabilities ranged from 24% to 88%. Larger practice size was associated with higher prevalence for 9 of the 13 capabilities spanning all 4 domains (P < 0.05). Network affiliation was associated with higher prevalence of 5 capabilities (P < 0.05) in 3 domains. Associations were not substantively altered by statistical adjustment for other practice characteristics.
Conclusions
Larger and network-affiliated primary care practices are more likely than smaller, non-affiliated practices to have adopted several recommended capabilities. In order to achieve PCMH designation, smaller non-affiliated practices may require the greatest investments.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-008-0856-x) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-008-0856-x
PMCID: PMC2629002  PMID: 19050977
primary care; quality improvement; health policy; patient centered care
12.  Quality Monitoring of Physicians: Linking Patients’ Experiences of Care to Clinical Quality and Outcomes 
Journal of General Internal Medicine  2008;23(11):1784-1790.
Background
Physicians are increasingly asked to improve the delivery of clinical services and patient experiences of care.
Objective
We evaluated the association between clinical performance and patient experiences in a statewide sample of physician practice sites and a sample of physicians within a large physician group.
Design, Setting, Participants
We separately identified 373 practice sites and 119 individual primary care physicians in Massachusetts.
Measurements
Using Health Plan Employer Data and Information Set data, we produced two composites addressing processes of care (prevention, disease management) and one composite addressing outcomes. Using Ambulatory Care Experiences Survey data, we produced seven composite measures summarizing the quality of clinical interactions and organizational features of care. For each sample (practice site and individual physician), we calculated adjusted Spearman correlation coefficients to assess the relationship between the composites summarizing patient experiences of care and those summarizing clinical performance.
Results
Among 42 possible correlations (21 correlations involving practice sites and 21 involving individual physicians), the majority were positive in site level (71%) and physician level (67%) analyses. For the 28 possible correlations involving patient experiences and clinical process composites, 8 (29%) were significant and positive, and only 2 (7%) were significant and negative. The magnitude of the significant positive correlations ranged from 0.13 to 0.19 at the site level and from 0.28 to 0.51 at the physician level. There were no significant correlations between patient experiences and the clinical outcome composite.
Conclusions
The modest correlations suggest that clinical quality and patient experience are distinct, but related domains that may require separate measurement and improvement initiatives.
doi:10.1007/s11606-008-0760-4
PMCID: PMC2585686  PMID: 18752026
quality of care; patient centered care; primary care; quality measurement; quality improvement
13.  Does Affiliation of Physician Groups with One Another Produce Higher Quality Primary Care? 
Journal of General Internal Medicine  2007;22(10):1385-1392.
Purpose
Recent reports have emphasized the importance of delivery systems in improving health care quality. However, few prior studies have assessed differences in primary care quality between physician groups that differ in size and organizational configuration. We examined whether larger physician group size and affiliation with networks of multiple groups are associated with higher quality of care.
Methods
We conducted a cross-sectional observational analysis of 132 physician groups (including 4,358 physicians) who delivered primary care services in Massachusetts in 2002. We compared physician groups on performance scores for 12 Health Plan Employer Data and Information Set (HEDIS) measures reflecting processes of adult primary care.
Results
Network-affiliated physician groups had higher performance scores than non-affiliated groups for 10 of the 12 HEDIS measures (p < 0.05). There was no consistent relationship between group size and performance scores. Multivariable models including group size, network affiliation, and health plan showed that network-affiliated groups had higher performance scores than non-affiliated groups on 8 of the 12 HEDIS measures (p < 0.05), and larger group size was not associated with higher performance scores. Adjusted differences in the performance scores of network-affiliated and non-affiliated groups ranged from 2% to 15%. For 4 HEDIS measures related to diabetes care, performance score differences between network-affiliated and non-affiliated groups were most apparent among the smallest groups.
Conclusions
Physician group affiliation with networks of multiple groups was associated with higher quality, and for measures of diabetes care the quality advantage of network-affiliation was most evident among smaller physician groups.
doi:10.1007/s11606-007-0234-0
PMCID: PMC2305845  PMID: 17594130
quality of care; primary care; HEDIS measures; health care organization
14.  Use of Angiotensin-converting Enzyme Inhibitors and Angiotensin Receptor Blockers in High-risk Clinical and Ethnic Groups with Diabetes 
BACKGROUND
Diabetes causes 45% of incident end-stage renal disease (ESRD). Risk of progression is higher in those with clinical risk factors (albuminuria and hypertension), and in ethnic minorities (including blacks, Asians, and Latinos). Angiotensin-converting enzyme inhibitors (ACE) and angiotensin receptor blockers (ARB) slow the progression of diabetic nephropathy, yet little is known about their use among patients at high risk for progression to ESRD.
OBJECTIVES
To examine the prevalence of ACE or ARB (ACE/ARB) use overall and within patients with high-risk clinical indications, and to assess for ethnic disparities in ACE/ARB use.
DESIGN
Observational cohort study.
SETTING
Kaiser Permanente Northern California (KPNC) Diabetes Registry, a longitudinal registry that monitors quality and outcomes of care for all KPNC patients with diabetes.
PATIENTS
Individuals (N= 38,887) with diabetes who were continuously enrolled with pharmacy benefits during the year 2000, and had self-reported ethnicity data on survey.
INTERVENTIONS AND MEASUREMENTS
Pharmacy dispensing of ACE/ARB.
RESULTS
Forty-one percent of the cohort had both hypertension and albuminuria, 30% had hypertension alone, and 12% had albuminuria alone. Fourteen percent were black, 11% Latino, 13% Asian, and 63% non-Latino white. Overall, 61% of the cohort received an ACE/ARB. ACE/ARB was dispensed to 74% of patients with both hypertension and albuminuria, 64% of those with hypertension alone, and 54% of those with albuminuria alone. ACE/ARB was dispensed to 61% of whites, 63% of blacks, 59% of Latinos, and 60% of Asians. Among those with albuminuria alone, blacks were significantly (P = .0002) less likely than whites to receive ACE/ARB (47% vs 56%, respectively). No other ethnic disparities were found.
CONCLUSIONS
In this cohort, the majority of eligible patients received indicated ACE/ARB therapy in 2000. However, up to 45% to 55% of high-risk clinical groups (most notably individuals with isolated albuminuria) were not receiving indicated therapy. Additional targeted efforts to increase use of ACE/ARB could improve quality of care and reduce ESRD incidence, both overall and in high-risk ethnic groups. Policymakers might consider use of ACE/ARB for inclusion in diabetes performance measurement sets.
doi:10.1111/j.1525-1497.2004.30264.x
PMCID: PMC1492381  PMID: 15209606
diabetes; renal disease; ACE inhibitors; angiotensin receptor blockers; secondary prevention
15.  Colorectal Cancer Screening Disparities Related to Obesity and Gender 
BACKGROUND
Obesity is associated with a higher incidence of colorectal cancer and increased colorectal cancer mortality. Obese women are less likely to undergo breast and cervical cancer screening than nonobese women. It is not known whether obesity is associated with a lower likelihood of colorectal cancer screening.
OBJECTIVE
To evaluate whether there is an association between body mass index (BMI) and rates of colorectal cancer screening. To examine whether BMI-related disparities in colorectal cancer screening differ between men and women.
DESIGN AND SETTING
The Behavioral Risk Factor Surveillance System, a cross-sectional random-digit telephone survey of noninstitutionalized adults conducted by the Centers for Disease Control and Prevention and state health departments in the 50 states and Washington, DC in 1999.
PATIENTS
Survey respondents (N= 52,886) between 51 and 80 years of age representing 64,563,332 U.S. adults eligible for colorectal cancer screening.
INTERVENTIONS AND MEASURMENTS
Adjusted rates of self-reported colorectal cancer screening with fecal occult blood testing within the past year or endoscopic screening (sigmoidoscopy or colonoscopy) within the past 5 years.
RESULTS
The colorectal cancer screening rate was 43.8% overall. The rate of screening by FOBT within the last year or endoscopic screening within the past 5 years was 39.5% for the morbidly obese group, 45.0% for the obese group, 44.3% for the overweight group, and 43.5% for the normal weight group. The difference in screening rates was entirely attributable to differences in BMI among women. After statistical adjustment for potential confounders, morbidly obese women were less likely than normal weight women to be screened (adjusted rate difference, −5.6%; 95% confidence interval, −8.5 to −2.6). Screening rates among normal weight, overweight, and obese women, and among men in different weight groups did not differ significantly.
CONCLUSIONS
Colorectal cancer screening rates among age-eligible persons in the U.S. are disturbingly low. Morbidly obese women, who are at higher risk than others to develop and to die from colorectal cancer, are less likely to be screened. Efforts to increase colorectal cancer screening are needed for all age-eligible groups, but should also include targeted screening of morbidly obese women since they could reap substantial clinical benefits from screening.
doi:10.1111/j.1525-1497.2004.30339.x
PMCID: PMC1492191  PMID: 15061742
colorectal cancer screening; obesity; disparities; gender; quality of care

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