Integrated Care Delivery System Research Articles

Accurately identifying incident cases of venous thromboembolism in the electronic health record: Performance of a novel phenotyping algorithm

BackgroundAccurate identification of incident venous thromboembolism (VTE) for quality improvement and health services research is challenging. The purpose of this study was to evaluate the performance of a novel incident VTE phenotyping algorithm defined using standard terminologies, requiring three key indicators documented in the electronic health record (EHR): VTE diagnostic code, VTE-related imaging procedure code, and anticoagulant medication code. MethodsRetrospective chart reviews were conducted to assess the performance of the algorithm using a random sample of phenotype(+) and phenotype(−) diagnostic encounters from primary care practices and acute care sites affiliated with five hospitals across a large integrated care delivery system in Massachusetts. The performance of the algorithm was evaluated by calculating the positive predictive value (PPV), negative predictive value (NPV), sensitivity, and specificity, using the phenotype(+) and phenotype(−) diagnostic encounters sample and target population data. ResultsBased on gold-standard manual chart review, the algorithm had a PPV of 95.2 % (95 % CI: 93.1–96.8 %), NPV of 97.1 % (95 % CI: 95.3–98.4 %), sensitivity of 91.7 % (95 % CI: 90.8–92.6 %), and specificity of 98.4 % (95 % CI: 98.1–98.6 %). The algorithm systematically misclassified a low number of specific types of encounters, highlighting potential areas for improvement. ConclusionsThis novel phenotyping algorithm offers an accurate approach for identifying incident VTE in general populations using EHR data and standard terminologies, and accurately identifies the specific encounter and date of diagnosis of the incident VTE. This approach can be used for measurement of incident VTE to drive quality improvement, research to expand the evidence, and development of quality metrics and clinical decision support to improve the diagnostic process.

Improving routine use of clinical pathway decision support through integration of an EHR with a clinical library resource designed to provide evidence-based guidance within oncology workflows

BackgroundThe rapid evolution, complexity, and specialization of oncology treatment makes it challenging for physicians to provide care based on the latest and best evidence. We hypothesized that physicians would use evidence-based trusted care pathways if they were easy to use and integrated into clinical workflow at the point of care.MethodsWithin a large integrated care delivery system, we assembled clinical experts to define and update drug treatment pathways, encoded them as flowcharts in an online library integrated with the electronic medical record, communicated expectations that clinicians would use these pathways for every eligible patient, and combined data from multiple sources to understand usage over time.ResultsWe were able to achieve > 75% utilization of eligible protocols ordered through these pathways within two years, with > 90% of individual oncologists having consulted the pathway at least once, despite no requirements or external incentives associated with pathway usage. Feedback from users contributed to improvements and updates to the guidance.ConclusionsBy making our clinical decision support easily accessible and actionable, we find that we have made considerable progress toward our goal of having physicians consult the latest evidence in their treatment decisions.

Designing systems for the care we need: A transformation journey in Southwestern Ontario.

Primary care is considered the foundation of any health system. In Ontario, Canada Bills 41 and 74 introduced in 2016 and 2019, respectively, aimed to move towards a primary care-focused and sustainable integrated care approach designed around the needs of local populations. These bills collectively set the stage for integrated care and population health management in Ontario, with Ontario Health Teams (OHTs) introduced as a model of integrated care delivery systems. OHTs aim to streamline patient connectivity through the healthcare system and improve outcomes aligned with the Quadruple Aim. When Ontario released a call for health system partners to apply to become an OHT, providers, administrators, and patient/caregiver partners from the Middlesex-London area were quick to respond. We highlight the critical elements and journey of the Middlesex-London Ontario Health Team since its start.

Abigail Geisinger Primary Care Scholars: An Innovative Educational Program Addressing Critical Workforce Needs.

The number of primary care physicians in the United States is inadequate to meet current or projected needs. This is likely exacerbated by continuing increases in the cost of medical education and student debt. The Geisinger Commonwealth School of Medicine is part of an integrated care delivery system in which primary care is central to managing health, improving access, and advancing value-based care. The need for primary care providers and psychiatrists is difficult to meet despite generous recruiting incentives. To address this, the Abigail Geisinger Scholars Program (AGSP) represents a novel curricular approach linked with the provision of full tuition and fees and a living stipend to students who commit to work at Geisinger in primary care or psychiatry following residency. The support is provided as a forgivable loan. The program features preferential clinical placements, curricular enhancements, and celebration of the dedicated cohort. Fair and nonpunitive provisions allow students to opt-out. The AGSP supports 45 students in each class of 115. Outcomes monitored include withdrawals from the AGSP; academic performance of participants and their satisfaction with the program; the number who choose to repay the loan rather than fulfill the service obligation; the percentage who remain at Geisinger and in primary care following the period of obligation; and other measures. This model offers an attractive opportunity for students to experience a curriculum enhanced in primary care while receiving generous financing for their medical education. It bolsters the primary care physician workforce and aligns care delivery with new financing models.

The Health Plan Environment In California Contributed To Differential Use Of Telehealth During The COVID-19 Pandemic.

The COVID-19 pandemic has led to substantial increases in the use of telehealth and virtual care in the US. Differential patient and provider access to technology and resources has raised concerns that existing health disparities may be extenuated by shifts to virtual care. We used data from one of the largest providers of employer-sponsored insurance, the California Public Employees' Retirement System, to examine potential disparities in the use of telehealth. We found that lower-income, non-White, and non-English-speaking people were more likely to use telehealth during the period we studied. These differences were driven by enrollment in a clinically and financially integrated care delivery system, Kaiser Permanente. Kaiser's use of telehealth was higher before and during the pandemic than that of other delivery models. Access to integrated care may be more important to the adoption of health technology than patient-level differences.

Patient and Clinician Perspectives of a Standardized Question About Firearm Access to Support Suicide Prevention

US residents report broad access to firearms, which are the most common means of suicide death in the US. Standardized firearm access questions during routine health care encounters are uncommon despite potential benefits for suicide prevention. To explore patient and clinician experiences with a standard question about firearm access on a self-administered mental health questionnaire routinely used prior to primary care and mental health specialty encounters. Qualitative semistructured interviews were conducted from November 18, 2019, to October 8, 2020, at Kaiser Permanente Washington, a large integrated care delivery system and insurance provider. Electronic health record data identified adult patients with a documented mental health diagnosis who had received a standard question about firearm access ("Do you have access to guns? yes/no") within the prior 2 weeks. A stratified sampling distribution selected 30% who answered "yes," 30% who answered "no," and 40% who left the question blank. Two groups of clinicians responsible for safety planning with patients at risk of suicide were also sampled: (1) licensed clinical social workers (LICSWs) in primary and urgent care settings and (2) consulting nurses (RNs). Participants completed semistructured telephone interviews, which were recorded and transcribed. Directive (deductive) and conventional (inductive) content analyses were used to apply knowledge from prior research and describe new information. Thematic analysis was used to organize key content, and triangulation was used to describe the intersections between patient and clinician perspectives. Thirty-six patients were interviewed (of 76 sampled; mean [SD] age, 47.3 [17.9] years; 19 [53%] were male; 27 [75%] were White; 3 [8%] were Black; and 1 [3%] was Latinx or Hispanic. Sixteen participants had reported firearm access and 15 had reported thoughts of self-harm on the questionnaire used for sampling. Thirty clinicians were interviewed (of 51 sampled) (mean [SD] age, 44.3 [12.1] years; 24 [80%] were female; 18 [60%] were White; 5 [17%] were Asian or Pacific Islander; and 4 [13%] were Latinx or Hispanic) including 25 LICSWs and 5 RNs. Key organizing themes included perceived value of standardized questions about firearm access, challenges of asking and answering, and considerations for practice improvement. Clinician interview themes largely converged and/or complemented patient interviews. In this qualitative study using semistructured interviews with patients and clinicians, a standardized question about firearm access was found to encourage dialogue about firearm access. Respondents underscored the importance of nonjudgmental acknowledgment of patients' reasons for firearm access as key to patient-centered practice improvement.

Community Experience with Pediatric Inspired Treatment of Acute Lymphoblastic Leukemia in the Adolescent and Young Adult Population in Kaiser Permanente Northern and Southern California Regions

Background:Pediatric inspired treatment for Acute Lymphoblastic Leukemia has been increasingly used for treatment of adolescents and young adults in the United States and Europe. In 2019 Dr. Stock published results of CALGB 10403 which showed that a pediatric inspired regimen was tolerable and efficacious in a population of ALL patients up to the age 40. Prior to that publication the use of pediatric inspired treatment was quite variable and mostly used in academic hospital systems. There was concern about tolerability, utilization and efficacy of pediatric inspired protocols. Kaiser Permanente is a vertically integrated care delivery system. The Northern and Southern California regions are the two largest regions each caring for approximately 4.5 million members and cared for in a network of medical offices and hospitals.Methods:We reviewed the Cancer Registries of the Kaiser Permanente Northern and Southern California regions for patients aged 15-39 diagnosed with acute lymphoblastic leukemia between 2010 - 2018. In our patient cohort, 60% of patients were under 26 and 40% were older than 26. We examined the initial induction plan selected and determined if the induction used steroids, vincristine, an anthracycline and asparaginase and if so was classified as pediatric inspired. If not induction was classified as an adult protocol. Patients were characterized as pediatric inspired or adult then followed based on the initial induction plan selected. Neither the sub type of ALL, the molecular characteristics or the MRD status at the end of induction was reviewed. The selection of chemotherapy agents after the initial induction plan was not reviewed. The use of pediatric inspired induction over the time of the study was reviewed. The patients clinical course was reviewed for the next 6 months and utilization including hospital days, ICU days was reviewed. Patients were followed for toxicities of treatments including sepsis, lab abnormalities, and documented side effects of chemotherapy. The pattern of BMT referral was reviewed. The vital status known at the end of the evaluation was also reviewed.ResultsA total of 222 patients were evaluated. In our patient cohort, 60% of patients were under 26 and 40% were older than 26. Over the study period 66.7 % of the patients received a pediatric inspired induction. The use of pediatric inspired treatments increased over the study period with 38% use in 2010 to 90% in 2018. For patients over age 21 in 2010 the use was 10% in 2018 84%. There was a significantly greater number of inpt days for patients initiated on adult protocols at months, 1, 3 and 6. There was no difference in ICU days. For outpatient utilization there was a significantly higher use of the ED at months 1,3,6 for patients initiated on adult treatments. For patients over 21 there was a significantly increased number of BMT consults during the first 6 months after diagnosis. There was no statistical difference in documented bacteremia, mucositis, pancreatitis, neuropathy or sepsis between the 2 groups. For patients over 26 there was a significant increase in peripheral neuropathy in the adult treated group. There was a significantly elevated risk of mortality at 2 years after diagnosis for the adult treated group. For patients over the age 26 the risk of mortality was similar at 2 years.ConclusionWe saw a rapid increase of utilization of pediatric inspired inductions over the study period within the Kaiser Permanente California regions. Patients who initiated treatment on adult protocols had over the first 6 months more inpatient days, were more likely to utilize the ED, were more likely to have a BMT consult. Patients who received adult protocol treatments had higher mortality at 2 years after diagnosis. We conclude that adult oncologists now favor pediatric inspired treatment approaches and there do not seem to be any safety concerns with this approach and in fact pediatric inspired treatments may lead to lower utilization and decreased mortality. DisclosuresNo relevant conflicts of interest to declare.

Insights into a regional collaboration for improving heart care across the complete care chain

Abstract Background The Netherlands Heart Network is a joint-effort of all relevant healthcare providers in primary, secondary, and tertiary care across the complete care chain in a region with an adherence of approximately 1,000,000 inhabitants. This regional collaboration features four non-academic hospitals, over 450 general practitioners and various other healthcare professionals who cooperate for the continuous improvement of cardiac patient care using Value Based Healthcare principles. Purpose Due to predicted demographic changes and the expected rise of cardiovascular diseases, novel initiatives are needed to optimize present-day healthcare systems. Therefore, the NHN has focused on the implementation of transmural integrated care delivery systems and impactful innovations for four major cardiovascular diseases: atrial fibrillation (AF), heart failure (HF), coronary artery disease and valvular diseases. Methods Various new health care initiatives and innovations have been implemented and evaluated in the region. For example, dedicated outpatient clinics and transmural care standards have been implemented for AF and HF across the full care cycle. The effect of the implementation of these care standards on patient-relevant outcomes and healthcare costs has been evaluated using large scale prospective and retrospective quality registries. Furthermore, new health care innovations include, among others, the opportunistic screening for AF within general practices and an optimized pre-hospital triage protocol for NSTEMI patients. Results Patient-relevant outcomes in 446 AF patients who visited dedicated outpatient clinics improved within 6 months of follow-up (EHRA score (1.93 to 1.36; p<0.01), hypertension (55.4% to 52.7%; p<0.01) and persistent AF (30.1% to 12.5%; p<0.01)). The introduction of transmural care standards for HF led to significant improvements in patient-relevant outcomes when comparing data before and after implementation (NYHA class (X2=9.1; p=0,03) and LVEF (41.7% vs. 38.4%; p<0.01)) and a reduction of mean healthcare costs by 25%. Moreover, the results of various innovations, including the AF screening protocol and potential benefits of pre-hospital triage of NSTEMI patients, are currently being evaluated. Conclusion(s) This regional collaboration by health professionals is unique in its approach and highlights that healthcare improvements are not exclusively reserved to large academic centers or referral hospitals. The present approach may serve as a blueprint for the organization of healthcare in other regions. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): ZonMWHealth insurance CZ/VGZ

Disparities in clinical trials participation in a vertically integrated care delivery system.

128 Background: Sparse data exists on the diversity clinical trial enrollment in community settings. This information is important to ensure equity of care and generalizability of results. Methods: We conducted a retrospective cohort study of members of an integrated healthcare system diagnosed with invasive malignancies (excluding non-melanoma skin cancers) between 2013-2017 to examine demographics of the oncology population compared to those who enrolled in a clinical trial. Logistic regression was used to assess correlates of clinical trial participation, comparing general and screened samples to enrolled sample. Odds ratios were adjusted for gender, geocoded median household income, cancer type, and stage. Results: Of the 84,977 patients with a cancer diagnosis, N = 2606 were screened for clinical trial participation and consented, and of those N = 1372 enrolled. The percent of Latinx (25.8% vs 24.0%; OR 0.9? CI 0.72-1.05) and African American/Black (10.9% vs 11.1%; OR 0.92 CI 0.75-1.11) clinical trial participation mirrored that of the general oncology population, respectively using Non-Hispanic Whites as reference. Asian/Pacific Islander had equal odds of clinical trial enrollment (OR 1.08 CI 0.92-1.27). The enrolled population was younger than the general oncology population. Conclusions: This study suggests that in an integrated healthcare system with equal access to care, the clinical trials population is well representative of its general oncology population.[Table: see text]

Optimizing Health Outcomes Among Newly Dual Eligibility Beneficiaries in Managed Care: Patient‐Provider Language, Race and Technology Discordance

Research ObjectiveOver one‐third of individuals dually eligible for Medicaid and Medicare coverage (“dual eligibles”) receive care in managed care settings. Despite improvements in care processes, access and overall satisfaction, suboptimal outcomes persist. We investigated whether lack of patient portal use and/or language/race discordance were associated with potentially avoidable hospital and emergency room admissions.Study DesignLeveraging electronic health record data in a large integrated care delivery system, we applied a retrospective observational cohort design and Cox proportional hazards models to estimate the risk of potentially avoidable hospital and emergency room admissions during the first two years following dual eligibility. We examined three factors previously identified as important to patient‐provider interactions: patient engagement with providers via a patient portal, race concordance, and language concordance. Models controlled for potential patient (e.g., age, sex, race, ethnicity, comorbidity, distance to the nearest clinic, behavioral risk factors, coverage type), and health system (e.g., neighborhood deprivation index, hospital) confounders.Population StudiedWe identified 36,961 adults enrolled in Kaiser Permanente Northern California health plans who became newly eligible for dual enrollment in Medicaid and Medicaid between 2016 and 2019. We excluded individuals with any hospice services and long‐ term skilled nursing facility residents. The final model included 36,689 individuals.Principal FindingsAt time of new dual eligibility, patients were 64.7 years old on average and 59% were female. The cohort was racially and ethnically diverse: 37.4% white; 22.1% Asian; 13.5% Black or African American; 21.2% Latinx; 1.7% other; and 4.1% unknown. 4.8% had the outcome of interest within two years of new dual eligibility. Consistent with our hypothesis, individuals who did not use the patient portal were at significantly increased risk for potentially avoidable admissions [HR: 1.32; 95% CI: (1.17, 1.49)]. Race discordance was also associated with increased [HR: 1.13; 95% CI: (1.00, 1.27)]. In contrast with our hypothesis, language discordance was associated with a lower risk of avoidable hospital and ED admissions [HR: 0.72 CI: (0.61, 0.85)]. In addition, multi‐morbidity, new enrollment into the Kaiser Permanente health system, lack of exercise and living in a lower socioeconomic status neighborhood was associated with elevated risk. Younger age, enrollment in both Dual Eligible Special Needs Plans (D‐SNP) and Medicaid or in Medicare alone (versus D‐SNP only), and Asian race was associated with lower risk.ConclusionsAmong individuals newly eligible for dual coverage from Medicare and Medicaid, both race discordance and non‐use of the patient portal, was associated with increased risk of potentially avoidable hospital events. Limitations of this study include potential lack of generalizability to individuals transitioning from fee‐for‐service to managed care and reliance on indirect measures of cultural and linguistic discordance.Implications for Policy or PracticeIncreasing the use of telehealth services among dual eligibles may be critical to close the gap between potential and realized access to manage care services.Primary Funding SourceKaiser Permanente.

Smoking cessation treatment for individuals with comorbid diabetes and serious mental illness in an integrated health care delivery system

IntroductionSmoking is a significant modifiable risk factor for mortality for persons with serious mental illness (SMI), who have a life expectancy 15–20 years shorter than the general population. Individuals with SMI and comorbid diabetes who are smokers face an even higher risk of cardiovascular complications and early death. Yet despite high rates of smoking among people with SMI, tobacco cessation interventions have not been broadly offered to this population. MethodsWe conducted a retrospective cohort study using electronic health records from 2014 in a large integrated care delivery system to examine whether use of smoking cessation pharmacotherapy among smokers with type 2 diabetes varies by serious mental illness (SMI) diagnosis. We analyzed smoking cessation medication prescription fills among adult smokers with diabetes, comparing those with SMI (N = 634) and without SMI (N = 18,021). Risk ratios were adjusted for age, gender, race, urban area type, and medical facility. ResultsOf the SMI group, 19.09% filled at least one smoking cessation prescription compared to 9.73% of the non-SMI group (adjusted risk ratio 1.80 [95% CI 1.52–2.13]; p < .001). For the SMI group, primary care providers wrote 80.24% of prescriptions, while psychiatrists wrote 8.81% of prescriptions. ConclusionsThese findings offer an example of a delivery system with higher uptake of smoking cessation pharmacotherapy among people with SMI than without SMI, and highlight the opportunity to provide more smoking cessation interventions in mental health care settings.

Medication Non-adherence: a Major Cause of Resistant Hypertension.

As the global burden of hypertension continues to rise, it remains suboptimally controlled despite increased awareness. Poor medication adherence is a well-recognized although underestimated contributing factor of uncontrolled hypertension. This review focuses on medication non-adherence as an important cause of apparent treatment-resistant hypertension and its impact on patient's well-being. In addition to biochemical screening, electronic technology-including electronic medication packaging devices such as medication event monitoring system, device integrated care delivery systems like digital medicine, and blood pressure telemonitoring-provides reliable objective data that enables healthcare providers to make decisions that enhance adherence and improve blood pressure control. Consistent medication adherence is a key factor to sustained blood pressure control. Evaluation and correct assessment for adherence should be an integral part of management of patients with apparent treatment-resistant hypertension. Clinicians need to recognize key clues linked to suboptimal adherence or non-adherence that can result in poor outcomes.

Association of Azithromycin Use With Cardiovascular Mortality

Azithromycin is one of the most commonly prescribed antibiotics in the US. It has been associated with an increased risk of cardiovascular death in some observational studies. To estimate the relative and absolute risks of cardiovascular and sudden cardiac death after an outpatient azithromycin prescription compared with amoxicillin, an antibiotic not known to increase cardiovascular events. This retrospective cohort study included 2 large, diverse, community-based integrated care delivery systems with comprehensive capture of encounters and prescriptions from January 1, 1998, to December 31, 2014. The cohort included patients aged 30 to 74 years who had at least 12 months of health-plan enrollment prior to antibiotic exposure. The exclusion criteria were absence of prescription benefits, prescription for more than 1 type of study antibiotic within 10 days, hospitalization or nursing home residence, and serious medical conditions. Risk of cardiovascular death associated with azithromycin vs amoxicillin exposure was calculated after controlling for confounding factors using a propensity score. Data were analyzed from December 1, 2016, to March 30, 2020. Outpatient prescription of azithromycin or amoxicillin. The primary outcomes were cardiovascular death and sudden cardiac death. An a priori subgroup analysis quantified the effects of azithromycin exposure among patients with increased baseline cardiovascular risk. The secondary outcomes were noncardiovascular death and all-cause mortality. The study included 7 824 681 antibiotic exposures, including 1 736 976 azithromycin exposures (22.2%) and 6 087 705 amoxicillin exposures (77.8%), among 2 929 008 unique individuals (mean [SD] age, 50.7 [12.3] years; 1 810 127 [61.8%] women). Azithromycin was associated with a significantly increased hazard of cardiovascular death (hazard ratio [HR], 1.82; 95% CI, 1.23-2.67) but not sudden cardiac death (HR, 1.59; 95% CI, 0.90-2.81) within 5 days of exposure. No increases in risk were found 6 to 10 days after exposure. Similar results were observed in patients within the top decile of cardiovascular risk (HR, 1.71; 95% CI, 1.06-2.76). Azithromycin was also associated with an increased risk of noncardiovascular death (HR, 2.17; 95% CI, 1.44-3.26) and all-cause mortality (HR, 2.00; 95% CI, 1.51-2.63) within 5 days of exposure. These findings suggest that outpatient azithromycin use was associated with an increased risk of cardiovascular death and noncardiovascular death. Causality cannot be established, particularly for noncardiovascular death, owing to the likelihood of residual confounding.

Improving clinical outcomes and patient satisfaction among patients with coronary artery disease: an example of enhancing regional integration between a cardiac centre and a referring hospital

BackgroundValue-based healthcare (VBHC) is a promising strategy to increase patient value. For a successful implementation of VBHC, intensive collaborations between organizations and integrated care delivery systems are key conditions. Our aim was to evaluate the effects of a pilot study regarding enhancing regional integration between a cardiac centre and a referring hospital on patient-relevant clinical outcomes and patient satisfaction.MethodsThe study population consisted of a sample of patients treated for coronary artery disease by use of a coronary artery bypass graft (CABG) or a percutaneous coronary intervention between 2011 and 2016. Since 2013, the two hospitals have implemented different interventions to improve clinical outcomes and the degree of patient satisfaction, e.g. improvement of communication, increased consultant capacity, introduction of outpatient clinic for complex patients, and improved guideline adherence. To identify intervention effects, logistic regression analyses were conducted. Patients’ initial conditions, like demographics and health status, were included in the model as predictors. Clinical data extracted from the electronic health records and the hospitals’ cardiac databases as well as survey-based data were used.ResultsOur findings indicate a non-significant increase of event-free survival of patients treated for coronary artery disease between 2014 and 2016 compared to patients treated between 2011 and 2013 (97.4% vs. 96.7% respectively). This non-significant improvement over time has led to significant better outcomes for patients referred from the study referring hospital compared to patients referred from other hospitals. The level of patient satisfaction (response rate 32.2%; 216 out of 669) was improved and reached statistically significant higher scores regarding patient information and education (p = .013), quality of care (p = .007), hospital admission and stay (p = .032), personal contact with the physician (p = .024), and total impression (p = .007).ConclusionsThis study shows a promising effect of regional integration. An intensified collaboration in the care chain, organized in a structured manner between a cardiac centre and a referring hospital and aiming at high quality, resulted in successful improvement of clinical outcomes and degree of patient satisfaction. The applied method may be used as a starting point of regional integration with other referring hospitals. We encourage others to organize the whole care chain to continuously improve patient-relevant outcomes and patient satisfaction.Trial registrationISRCTN11311830. Registered 01 October 2018 (retrospectively registered).

1240-P: Differences in Initial Care and Outcomes Comparing Adults with Early vs. Usual Onset Type 2 Diabetes

The prevalence of newly diagnosed type 2 diabetes (T2D) among American adults under age 45 is increasing. Given the lasting benefits conferred by early glycemic control, we examined initial diabetes care and subsequent glycemic control at one year following diagnosis, comparing adults with early onset (21-&amp;lt;45 years old) vs. usual onset (45-&amp;lt;65 years old) T2D. Using data from a large, integrated care delivery system, we identified adults who had a first diabetes-defining Hemoglobin A1c value (≥6.5% “index A1c”) between Jan. 2010 and Dec. 2016, followed by clinical diagnosis of T2D (visit with T2D ICD code or T2D on problem list) within 3 months of the index A1c. We excluded anyone with evidence of prior T2D, gestational diabetes or T1D. We compared baseline characteristics by onset age using t- or chi-2 tests. Adjusting for index A1c and other patient characteristics, we used logistic regression to examine initial management and GEE models to examine glycemic control (goal A1c &amp;lt;7%) at one-year following diagnosis, comparing early vs. usual age onset status. We identified 32,137 adults with new T2D, including 8,496 with early onset (26.4%, age 37.6 ± 5.3 years) and 23,641 with usual onset (73.6%, age 54.4 ± 5.5 years). Adults with early onset had a higher index A1c (A1c 8.9% vs. 8.4% for usual onset, p&amp;lt;0.001). Compared to usual onset, adults with early onset were more likely to initiate metformin (adjusted odds ratio [aOR] 1.20, 95% CI [1.12-1.27]), but less likely to receive a retinal exam (aOR 0.80, 95% CI [0.76-0.85]) or diabetes-related education (aOR 0.84, 95% CI [0.80-0.89]) during the first year of care. Adults with early onset were less likely to achieve goal glycemic control at one year following diagnosis (aOR 0.85, 95% CI [0.79-0.91]). In conclusion, individuals with early onset T2D were less likely to achieve goal A1c (&amp;lt;7%) at one year following diagnosis. This suggests a need for tailored strategies to improve early T2D care for this high-risk population of adults presenting with T2D at younger ages. Disclosure M.A. Blatchins: None. P. Mishra: None. R.W. Grant: None. A. Gopalan: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases

Benefits of integrated care delivery system for heart failure: A case study of Intermountain Healthcare (USA)

Among chronic diseases, heart failure is a top public health priority both in France and in the United States. If progress is possible in France, the experience from Intermountain Healthcare (IH), in the United States can be a source of significant experimentations. To identify the teaching of the clinical integration of the specialists in the field of heart failure with the primary care sector which could be useful in France. This research is based on the qualitative analysis of data resulting from the work between experts, of bibliographical research, and of some groupings by item corresponding to the objectives of the Triple Aim from the Institute for Healthcare Improvement (IHI). The program of the integrated care delivery system for heart failure of Intermountain Healthcare reaches the objectives of the Triple Aim from the IHI, that is to say, the enhancement of the health of the population, improving quality of care and the satisfaction of the user, and the reduction of the cost of care. This program also enhances the Chronic Care Model by integrating a team of specialists in the field of heart failure, building up a pluridisciplinary team focused on the need of both the patients and their families. This creates a multidisciplinary care delivery system for heart failure which is global, protocolized, stratified, planned and followed. The prevention and the ambulatory care integrating the specialized care of second stage to the care of first stage are developed. The users and their families are co-responsible for their health. The systematic evaluation is based on the specific indicators. This program improves the effectiveness of care while improving organizational efficiency resulting in savings for IH Health Plan (SelectHealth). It also enhances the equality of access to better healthcare and health for the entire population.

Prompting Patients with Poorly Controlled Diabetes to Identify Visit Priorities Before Primary Care Visits: a Pragmatic Cluster Randomized Trial.

Most patients with diabetes do not meet all evidence-based goals of care, and many patients report poor communication and lack of involvement in decision-making during primary care visits. To test the hypothesis that a "Pre-Visit Prioritization" secure email message could improve visit communication and glycemic control among patients with type 2 diabetes. We conducted a pragmatic, provider-randomized, multi-site clinical trial from March 2015 to October 2016 across 30 primary care practices within Kaiser Permanente Northern California (KPNC), a large integrated care delivery system. Eligible patients had at least 1year of KPNC membership, type 2 diabetes with most recently measured hemoglobin A1c (HbA1c) > = 8.0%, and were registered users of the KPNC online patient portal. Patients in the intervention arm, upon booking an appointment, received a secure email through the KPNC online portal with a link to the EHR allowing them to submit their top one or two priorities prior to the visit. Control patients received usual care. Glycemic control; change in HbA1c 6 and 12months after the initial visit; patient-reported outcomes related to patient-provider communication and patient care experiences. During the study period, 1276 patients had at least one eligible visit. In post-visit surveys (n = 457), more intervention arm patients reported preparing questions for their visit (72% vs 63%, p = 0.048) and being given treatment choices to consider (81% vs 73%, p = 0.041). Patients in both arms had similar reductions in HbA1c over the 12-month study period (0.56% ± 1.45%), with no significant differences between arms. A "light touch" email-based pre-visit intervention resulted in improved measures of visit interaction but did not significantly improve glycemic control relative to usual care. Improving diabetes clinical outcomes through more effective primary care visits may require more intensive approaches to patient visit preparation. NCT02375932.

Arizona moves to managed care delivery integrated care system

Nearly a month and a half into its new integrated care delivery system for Medicaid beneficiaries, Arizona officials say the transition, in the works for two years, is moving forward smoothly.

Physicians speak: Medicine’s point of view on working with pharmacy

Physicians speak: Medicine’s point of view on working with pharmacy

Payment for Integrated Care: Challenges and Opportunities.

A multidisciplinary team approach to care and robust care coordination services are primary components of almost all integrated care delivery systems. Given that these services have limited reimbursement in fee-for-service payment arrangements, integrating care in a fee-for-service environment is almost impossible. Capitated payment models hold promise for supporting integrated behavioral and physical health services. There are multiple national examples of integrated care delivery systems supported by capitated payment arrangements.