Clinical comparative effectiveness research through the lens of healthcare decisionmakers

Background: Healthcare expenditures in the United States exceed the healthcare expenditures of other countries, yet relatively unfavorable health outcomes persist. Despite the emergence of numerous evidence-based interventions, wide variations in clinical care have caused disparities in quality of care and cost. Comparative effectiveness and cost effectiveness research may better guide healthcare decisionmakers in determining which interventions work best, for which populations, under which conditions, and at what cost. Methods: This article reviews national health policies that promote comparative effectiveness research (CER), healthcare decisionmaker roles in CER, methodological approaches to CER, and future implications of CER. Results: This article provides a brief summary of CER health policy up to the Patient Protection and Affordable Care Act and its establishment of the Patient-Centered Outcomes Research Institute (PCORI). Through PCORI, participatory methods for engaging healthcare decisionmakers in the entire CER process have gained momentum as a strategy for improving the relevance of research and expediting the translation of research into practice. Well-designed, methodologically rigorous observational studies and randomized trials conducted in real-world settings have the potential to improve the quality, generalizability, and transferability of study findings. Conclusion: Learning health systems and practice-based research networks provide the infrastructure for advancing CER methods, generating local solutions to high-quality cost-effective care, and transitioning research into implementation and dissemination science—all of which will ultimately guide health policy on clinical care, payment for care, and population health

Primary Care Practice Reengineering and Associations With Patient Portal Use, Service Utilization, and Disease Control Among Patients With Hypertension and/or Diabetes

Background: We describe the role of primary care reengineering in the Ochsner Health System (OHS) patient portal implementation strategy and compare subsequent trends in service utilization and disease control among portal users vs nonusers within this context. Methods: This retrospective cohort study includes 101,019 patients with hypertension or diabetes who saw an OHS primary care provider (PCP) between 2012 and 2014. Inverse probability treatment weighting was used to reduce case-mix differences between study groups. We used generalized estimating equation modeling to compare changes in encounter rates (PCP, telephone, specialty services, emergency department [ED], inpatient hospitalization), blood pressure (BP), and hemoglobin A1c (HbA1c). Results: Age, sex, race, comorbidities, insurance, preindex utilization, and portal use were associated with changes in utilization, BP, and HbA1C; however, the strength and direction of these differences varied. An adjusted analysis comparing portal users to nonusers showed an increase in PCP (rate ratio per patient per year of 1.18, 95% confidence interval [CI] 1.14-1.22) and telephone encounter rates (1.15, 95% CI 1.08-1.22; both

Dose effect of patient-care team communication via secure portal messaging on glucose and blood pressure control

Organizational strategies for implementing eHealth tools influence patient and provider use of portal technology. This study examines whether the intensity of bidirectional secure portal messaging is associated with improved clinical outcomes.This is a retrospective cohort analysis of 101 019 patients with diabetes or hypertension (11 138 active portal users) who received primary care within the Ochsner Health System between 2012 and 2014. Propensity score-adjusted multivariable fixed effects regression panel analysis was used to examine associations between intensity of "medical advice" portal messaging and glucose/blood pressure control.Most portal users rarely used medical advice messaging. A higher proportion of patients who were age 50 years and older, female, white non-Hispanic, and with co-morbid diabetes and hypertension had higher frequency and intensity of medical advice messaging. Study findings revealed a dose-response effect of the intensity of messaging on glucose control, whereby, compared to nonportal users, each level of messaging among portal users was associated with greater decreases in HbA1c (β estimate [95% CI]: none -0.28 (-0.34 to -0.22); low -0.28 (-0.32 to -0.24); medium -0.41 (-0.52 to -0.31); high -0.43 (-0.60 to -0.27), all P ≤ .001). There was no observed effect on blood pressure.The digital divide exists not only between portal users and nonusers but also among portal users. Research exploring the relationship between intensity of bidirectional secure messaging and health outcomes for a broader scope of chronic conditions is needed. Future implementation research must also elucidate best practices that enhance not only the use of portals by patients and providers, but how they use portals

Hospitalization and Mortality among Black Patients and White Patients with Covid-19

BACKGROUND: Many reports on coronavirus disease 2019 (Covid-19) have highlighted age- and sex-related differences in health outcomes. More information is needed about racial and ethnic differences in outcomes from Covid-19. METHODS: In this retrospective cohort study, we analyzed data from patients seen within an integrated-delivery health system (Ochsner Health) in Louisiana between March 1 and April 11, 2020, who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, the virus that causes Covid-19) on qualitative polymerase-chain-reaction assay. The Ochsner Health population is 31% black non-Hispanic and 65% white non-Hispanic. The primary outcomes were hospitalization and in-hospital death. RESULTS: A total of 3626 patients tested positive, of whom 145 were excluded (84 had missing data on race or ethnic group, 9 were Hispanic, and 52 were Asian or of another race or ethnic group). Of the 3481 Covid-19-positive patients included in our analyses, 60.0% were female, 70.4% were black non-Hispanic, and 29.6% were white non-Hispanic. Black patients had higher prevalences of obesity, diabetes, hypertension, and chronic kidney disease than white patients. A total of 39.7% of Covid-19-positive patients (1382 patients) were hospitalized, 76.9% of whom were black. In multivariable analyses, black race, increasing age, a higher score on the Charlson Comorbidity Index (indicating a greater burden of illness), public insurance (Medicare or Medicaid), residence in a low-income area, and obesity were associated with increased odds of hospital admission. Among the 326 patients who died from Covid-19, 70.6% were black. In adjusted time-to-event analyses, variables that were associated with higher in-hospital mortality were increasing age and presentation with an elevated respiratory rate; elevated levels of venous lactate, creatinine, or procalcitonin; or low platelet or lymphocyte counts. However, black race was not independently associated with higher mortality (hazard ratio for death vs. white race, 0.89; 95% confidence interval, 0.68 to 1.17). CONCLUSIONS: In a large cohort in Louisiana, 76.9% of the patients who were hospitalized with Covid-19 and 70.6% of those who died were black, whereas blacks comprise only 31% of the Ochsner Health population. Black race was not associated with higher in-hospital mortality than white race, after adjustment for differences in sociodemographic and clinical characteristics on admission

Clinical pharmacist team-based care in a safety net medical home: facilitators and barriers to chronic care management

Collaborative care models incorporating pharmacists have been shown to improve quality of care for patients with hypertension and/or diabetes. Little is known about how to integrate such services outside of clinical trials. The authors implemented a 22-month observational study to evaluate pharmacy collaborative care for hypertension and diabetes in a safety net medical home that incorporated population risk stratification, clinical decision support, and medication dose adjustment protocols. Patients in the pharmacy group saw their primary care provider (PCP) more often and had higher baseline systolic blood pressure (SBP) and diastolic blood pressure (DBP) and A1c levels compared to patients who only received care from their PCPs. There were no significant differences in the proportion of patients achieving treatment goals (SB

eHealth Literacy: Patient Engagement in Identifying Strategies to Encourage Use of Patient Portals Among Older Adults

Innovations in chronic disease management are growing rapidly as advancements in technology broaden the scope of tools. Older adults are less likely to be willing or able to use patient portals or smartphone apps for health-related tasks. The authors conducted a cross-sectional survey of older adults (ages 50) with hypertension or diabetes to examine relationships between portal usage, interest in health-tracking tools, and eHealth literacy, and to solicit practical solutions to encourage technology adoption. Among 247 patients surveyed in a large integrated delivery health system between August 2015 and January 2016, eHealth literacy was positively associated with portal usage (OR [95% CI]: 1.3 [1.2-1.5]) and interest in health-tracking tools (1.2 [1.1-1.3]). Portal users compared to nonusers (N=137 vs.110) had higher rates of interest in using websites/smartphone apps to track blood pressure (55% vs. 36%), weight (53% vs. 35%), exercise (53% vs. 32%), or medication (46% vs 33%, all

Intelligent clinical decision support to improve safe opioid management of chronic noncancer pain in primary care

Opioid prescription drug abuse is a major public health concern. Healthcare provider prescribing patterns, especially among non-pain management specialists, are a major factor. Practice guidelines recommend what to do for safe opioid prescribing but do not provide guidance on how to implement best practices.We describe the implementation of electronic medical record clinical decision support (EMR CDS) for opioid management of chronic noncancer pain in an integrated delivery system. This prospective cohort study will examine relationships between primary care physician compliance with EMR CDS-guided care (vs usual care), delivery of guideline-concordant care, and changes in the morphine equivalent of prescribed opioids. We report baseline characteristics of patients receiving chronic opioid therapy and organizational prescribing trends.Between August and October 2016, we identified 2,759 primary care patients who received chronic opioid therapy. Of these patients, approximately 71% had chronic noncancer pain, and 62% had diagnoses of depression/anxiety. Six of 36 primary care clinics each had >100 patients receiving chronic opioid therapy. When the EMR CDS launched in October 2017, we identified 54,200 patients who had received opioid therapy for at least 14 days from various specialty and primary care providers during the prior 24 months. Of these patients, 36% had a benzodiazepine coprescription, and 13% had substance abuse diagnoses.Health system research that examines workflow-focused strategies to improve physician knowledge and skills for safely managing opioid therapy is needed. If EMR CDS proves to be effective in increasing adherence to practice guidelines, this EMR strategy can potentially be replicated and scaled up nationwide to improve population health management

Outpatient complex case management: health system-tailored risk stratification taxonomy to identify high-cost, high-need patients

Background: U.S. health systems, incentivized by financial penalties, are designing programs such as case management to reduce service utilization among high-cost, high-need populations. The major challenge is identifying patients for whom targeted programs are most effective for achieving desired outcomes. Objective: To evaluate a health system’s outpatient complex case management (OPCM) for Medicare beneficiaries for patients overall and for high-risk patients using system-tailored taxonomy, and examine whether OPCM lowers service utilization and healthcare costs. Design: Retrospective case-control study using Medicare data collected between 2012 and 2016 for Ochsner Health System. Participants: Super-utilizers defined as Medicare patients with at least two hospital/ED encounters within 180\ua0days of the index date including the index event. Intervention: Outpatient complex case management. Main Measures: Propensity score-adjusted multivariable logistic regression analysis was conducted for primary outcomes (90-day hospital readmission; 90-day ED re-visit). A difference-in-difference analysis was conducted to examine changes in per membership per month (PMPM) costs based on OPCM exposure. Key Results: Among 18,882 patients, 1197 (6.3%) were identified as “high-risk” and 470 (2.5%) were OPCM participants with median enrollment of 49\ua0days. High-risk OPCM cases compared to high-risk controls had lower odds of 90-day hospital readmissions (0.81 [0.40–1.61], non-significant) and lower odds of 90-day ED re-visits (0.50 [0.32–0.79]). Non-high-risk OPCM cases compared to non-high-risk controls had lower odds of 90-day hospital readmissions (0.20 [0.11–0.36]) and 90-day ED re-visits (0.66 [0.47–0.94]). Among OPCM cases, high-risk patients compared to non-high-risk patients had greater odds of 90-day hospital readmissions (4.44 [1.87–10.54]); however, there was no difference in 90-day ED re-visits (0.99 [0.58–1.68]). Overall, OPCM cases had lower total cost of care compared to controls (PMPM mean [SD]: − $1037.71 [188.18]). Conclusions: Use of risk stratification taxonomy for super-utilizers can identify patients most likely to benefit from case management. Future studies must further examine which OPCM components drive improvements in select outcome for specific populations

Non-face-to-face chronic care management: a qualitative study assessing the implementation of a new CMS reimbursement strategy

Diabetes and its comorbidities are leading causes of morbidity and mortality in the United States and disproportionately in Louisiana. Chronic care management (CCM) efforts, such as care coordination models, are important initiatives in mitigating the impact of diabetes, such as poorer health outcomes and increased costs. This study examined one such effort, the Centers for Medicare & Medicaid Services' non-face-to-face CCM reimbursement program, for patients with diabetes and at least 1 other chronic condition in Louisiana. This qualitative study included interviews with patients in this program and health care providers and system leaders implementing the program. Results include lessons learned from health system leadership relating to CCM design and implementation, challenges experienced, overlapping initiatives, perceived benefits, performance, billing, and health information technology. Another key finding is that co-pays seem to be a barrier to patient interest in participation in non-face-to-face CCM, especially given that the value of the program is not completely clear to patients. A common strategy to address this co-pay barrier is to target dual eligibles, as Medicaid will cover the co-pay. However, widespread use of such strategies may indirectly exclude individuals who need and may also benefit from non-face-to-face CCM