Tackling rising health care costs in Massachusetts

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Comparing the implementation of team approaches for improving diabetes care in community health centers

Contains fulltext : 139071.pdf (publisher's version ) (Open Access)BackgroundPatient panel management and community-based care management may be viable strategies for community health centers to improve the quality of diabetes care for vulnerable patient populations. The objective of our study was to clarify implementation processes and experiences of integrating office-based medical assistant (MA) panel management and community health worker (CHW) community-based management into routine care for diabetic patients.MethodsMixed methods study with interviews and surveys of clinicians and staff participating in a study comparing the effectiveness of MA and CHW health coaching for improving diabetes care. Participants included 24 key informants in five role categories and 249 clinicians and staff survey respondents from 14 participating practices. We conducted thematic analyses of key informant interview transcripts to clarify implementation processes and describe barriers to integrating the new roles into practice. We surveyed clinicians and staff to assess differences in practice culture among intervention and control groups. We triangulated findings to identify concordant and disparate results across data sources.ResultsImplementation processes and experiences varied considerably among the practices implementing CHW and MA team-based approaches, resulting in differences in the organization of health coaching and self-management support activities. Importantly, CHW and MA responsibilities converged over time to focus on health coaching of diabetic patients. MA health coaches experienced difficulty in allocating dedicated time due to other MA responsibilities that often crowded out time for diabetic patient health coaching. Time constraints also limited the personal introduction of patients to health coaches by clinicians. Participants highlighted the importance of a supportive team climate and proactive leadership as important enablers for MAs and CHWs to implement their health coaching responsibilities and also promoted professional growth.ConclusionImplementation of team-based strategies to improve diabetes care for vulnerable populations was diverse, however all practices converged in their foci on health coaching roles of CHWs and MAs. Our study suggests that a flexible approach to implementing health coaching is more important than fidelity to rigid models that do not allow for variable allocation of responsibilities across team members. Clinicians play an instrumental role in supporting health coaches to grow into their new patient care responsibilities

Integrating the use of patient-reported outcomes for both clinical practice and performance measurement: views of experts from 3 countries

Item does not contain fulltextPolicy Points: The patient-reported outcome (PRO) is a standardized method for measuring patients' views of their health status. Our international study showed that experts in clinical practice and performance measurement supported the integrated collection of PRO data for use in both clinical care and performance measurement. The measurement of PROs to support patient-provider decisions and the use of PRO performance measures to evaluate health care providers have developed both separately and in parallel. The use of PROs would benefit from a shared vision by health care providers, purchasers of care, and patients regarding the aims and purposes of the various applications; and the establishment of trust among stakeholders concerning the prudent use of PRO performance measures. CONTEXT: Patient-reported outcomes (PROs) can play an important role in patient-centered health care by focusing on the patient's health goals guiding therapeutic decisions. When aggregated, PROs also can be used for other purposes, including comparative effectiveness research, practice improvement, assessment of the performance of clinicians and organizations, and as a metric for value-based payments. The feasibility of integrating the use of PROs for these various purposes on a wide scale has not yet been demonstrated. Our study was conducted to inform policymakers of prudent next steps for implementing PROs in clinical practice and performance measurement programs in order to maximize their impact on the quality of health care. METHODS: We conducted a qualitative study, interviewing 58 experts and leaders from 37 organizations (response rate: 88%) in the United States, England, and the Netherlands. Respondents included clinical practitioners (n = 30), measure developers (n = 11), and leaders of performance measurement programs (n = 17). We used a qualitative content analysis to assess current strategies for applying PROs in clinical practice and performance measurement and to identify barriers to and facilitators of further implementation. FINDINGS: The use of PROs in clinical practice and for performance measurement has developed both separately and in parallel. Experts across the stakeholder spectrum support the collection of PRO data in an integrated manner that would enable using the data for these distinct purposes. We identified 2 main concerns about the feasibility for integrated use of PRO data: the complexity of establishing routine data collection and the tension among stakeholders when using PRO data for different purposes. These contrasting stakeholder views suggested varying interests among clinicians, measure developers, and purchasers of care. CONCLUSIONS: Data collection approaches that support the use of PROs in health care are underdeveloped, need better integration with clinical care, and must be tailored to the characteristics of the health care system. Enabling the sustainable use of PROs will require a shared vision of clinical professionals, purchasers, and patients, with a prudent selection of the steps in implementing PROs that will maximize their impact on the quality of health care

Memory and Temporal Phenomenology

In the general project of trying to reconcile the objective view of the world with the subjective view, analytic philosophy in recent years, has been almost solely focused on sensory phenomenology. But there is at least as a big a gap between the view of time presented in physics and the view of time presented in the experience of the subject. In physics, there is an almost complete assimilation of time to space. Time is just one dimension in a four-dimensional manifold of events. We experience time, however, as something dynamic. I'll be exploring prospects for understanding of the phenomenology of flow without falling into the incoherent idea that time itself moves.Centre for Consciousness, Australian National Universit

Gender bias in cardiovascular advertisements

Rationale: Women with cardiovascular disease are treated less aggressively than men. The reasons for this disparity are unclear. Pharmaceutical advertisements may influence physician practices and patient care. Aims and objective: To determine if female and male patients are equally likely to be featured in cardiovascular advertisements. Methods: We examined all cardiovascular advertisements from US editions of general medical and cardiovascular journals published between 1 January 1996 and 30 June 1998. For each unique advertisement, we recorded the total number of journal appearances and the number of appearances in journals' premium positions. We noted the gender, age, race and role of both the primary figure and the majority of people featured in the advertisement. Results: Nine hundred and nineteen unique cardiovascular advertisements were identified of which 254 depicted a patient as the primary figure. A total of 20% [95% confidence interval (CI) 15.3-25.5%] of these advertisements portrayed a female patient, while 80% (95% CI 74.5-84.7%) depicted a male patient, P < 0.0001. Female patient advertisements appeared 249 times (13.3%; 95% CI 8.6-18.9%) while male patient advertisements appeared 1618 times (86.7%; 95% CI 81.1-91.4%), P < 0.0001. Female patient advertisements also had significantly fewer mean appearances than male patient advertisements in journals' premium positions (0.82 vs. 1.99, P=0.02). Similar results were seen when the advertisements were analysed according to predominant gender. Conclusions: Despite increasing emphasis on cardiovascular disease in women, significant under-representation of female patients exists in cardiovascular advertisements. Physicians should be cognizant of this gender bias.Ontario Ministry of Health Services Research Career Scientist AwardOntario Ministry of Health Services Research Career Scientist Awar