Integrated Care Delivery System Research Articles

Abstract 105: Normal Coronary Rates for Elective Angiography in the VA Health Care System: Insights from the VA CART Program

Background. Prior studies have shown that rates of normal coronary arteries with elective coronary angiography vary considerably among U.S. community hospitals. It has been suggested that this variation may in part reflect incentives in fee-for-service care. The rates of normal coronaries within an integrated healthcare system are unknown. Methods. Using national data from the VA Clinical Assessment Reporting and Tracking (CART) Program, we evaluated all VA patients who had elective coronary angiography from October 2007-September 2010 at the 76 VA cardiac catheterization labs. Normal coronary angiography was defined as <20% stenosis in all vessels. We assessed patients’ demographics, risk factors, noninvasive preprocedural testing, and angiographic findings. To assess hospital-level variation in normal coronary rates, we categorized hospitals by quartiles as defined by their proportion of normal coronaries. Results. Overall, 5,108 of 22,001 patients (22.8%) had normal coronary angiography. Hospital proportions of normal coronaries varied modestly (median hospital proportion 21.2%, interquartile range, 17.3% to 26.1% range, 7.9% to 56.6; Figure 1). Patients with normal coronaries were more likely to have low Framingham risk scores (36.6% versus 16.5%, p<0.001), less likely to undergo a preprocedural stress test (70.3% versus 77.8%, p<0.001), and among those with stress testing, less likely to have results positive for ischemia (42.6% versus 47.2%, p<0.001). By hospital quartile of normal coronary rates, patients at hospitals with lower normal coronary rates were more likely to undergo stress testing prior to angiography (79.8% vs. 78.6% vs. 77.4% vs. 64.4%, p<0.001). Conclusions. About 1 in 5 patients undergoing elective coronary angiography in the VA had normal coronaries. This rate is lower than prior published studies in other systems. However, the observed hospital-level variation in normal coronary rates suggests barriers to consistent patient selection for diagnostic coronary angiography despite an integrated care delivery system.

Inpatient statin use predicts improved ischemic stroke discharge disposition

To determine whether statin use is associated with improved discharge disposition after ischemic stroke. We used generalized ordinal logistic regression to analyze discharge disposition among 12,689 patients with ischemic stroke over a 7-year period at 17 hospitals in an integrated care delivery system. We also analyzed treatment patterns by hospital to control for the possibility of confounding at the individual patient level. Statin users before and during stroke hospitalization were more likely to have a good discharge outcome (odds ratio [OR] for discharge to home = 1.38, 95% confidence interval [CI] 1.25-1.52, p < 0.001; OR for discharge to home or institution = 2.08, 95% CI 1.72-2.51, p < 0.001). Patients who underwent statin withdrawal were less likely to have a good discharge outcome (OR for discharge to home = 0.77, 95% CI 0.63-0.94, p = 0.012; OR for discharge to home or institution = 0.43, 95% CI 0.33-0.55, p < 0.001). In grouped-treatment analysis, an instrumental variable method using treatment patterns by hospital, higher probability of inpatient statin use predicted a higher likelihood of discharge to home (OR = 2.56, 95% CI 1.71-3.85, p < 0.001). In last prior treatment analysis, a novel instrumental variable method, patients with a higher probability of statin use were more likely to have a good discharge outcome (OR for each better level of ordinal discharge outcome = 1.19, 95% CI 1.09-1.30, p = 0.001). Statin use is strongly associated with improved discharge disposition after ischemic stroke.

How Are the Costs of Care for Medical Falls Distributed? The Costs of Medical Falls by Component of Cost, Timing, and Injury Severity

To examine the components of cost that drive increased total costs after a medical fall over time, stratified by injury severity. We used 2004-2007 cost and utilization data for persons enrolled in an integrated care delivery system. We used a longitudinal cohort study design, where each individual provides 2-3 years of administrative data grouped into 3-month intervals relative to an index date. We identified 8,969 medical fallers through International Classification of Diseases, 9th Revision, codes and E-Codes and used 8,956 nonfaller controls, identified through age and gender frequency matching. Total costs were partitioned into 7 components: inpatient, outpatient, emergency, radiology, pharmacy, postacute care, and "other." The large increase in costs after a hospitalized fall is mainly associated with inpatient and postacute care components. The spike in costs after a nonhospitalized fall is attributable to outpatient and "other" (e.g., ambulatory surgery or community health services) components. Hospitalized fallers' inpatient, emergency, postacute care, outpatient, and radiology costs are not always greater than those for nonhospitalized fallers. Components associated with increased costs after a medical fall vary over time and by injury severity. Future studies should compare if delivering certain acute and postacute health services improve health and reduce cost trajectories after a medical fall more than others. Additionally, since the older adult population and the problem of falls are growing, health care delivery systems should develop standardized methodology to monitor medical fall rates.

True Patriotism: A Generation of Commitment to Quality in the Veterans Health Administration

Americans owe their freedom and prosperity to the millions of men and women who have served in our armed forces. We show our commitment and support for veterans in part by providing lifetime medical care. The system to provide this care, the Veterans Health Administration (VHA), is the largest integrated care delivery system in the United States. However, there has historically been concern that the system did not adequately address the needs of veterans and that the quality of care provided was compromised, leaving those who deserve the best with lower quality care than those they served.

Adolescents With Suicidal Ideation: Health Care Use and Functioning

Objective To improve our understanding of the clinical needs among youth with suicidal ideation (SI), we examined health care utilization patterns, functional impairment, and comorbidity among youth who endorsed SI, compared with a control group of youth without SI. Method This study included 99 youth with SI in the past year and 99 matched controls. Participants were 13- to 17-year-old youth who were enrolled in a large integrated care delivery system who had seen a provider at least one time in the past year. The 2 groups were compared with regard to health care utilization, functional impairment, and comorbid mental health symptoms, while adjusting for depression severity, lifetime diagnosis of depression or anxiety, and medical comorbidity. Results Youth with SI had a significantly higher mean functional impairment compared with youth without SI, both at baseline (84% vs 60% “definitely impaired”) and 6-month follow-up (57% vs 39% “definitely impaired”). Less than 15% in either group attended a mental health specialty visit in the 12 months before or after baseline, and under 10% received antidepressant or anxiolytic medication. Family-report data suggested that a higher proportion of youth with SI received mental health care from sources outside their health care system compared with youth without SI. Conclusions The presence of SI is associated with more severe functional impairment, comorbidity, and depression severity. Yet, only a minority of adolescents with SI receive mental health services, and clinical detection is low. This study suggests that better screening, recognition, and treatment of SI is needed to address the clinical impairment of youth with SI.

Gastroenterologistsʼ attitudes and self-reported practices regarding inflammatory bowel disease

The purpose was to assess organization-, physician-, and patient-based aspects of inflammatory bowel disease (IBD) practice variation within an integrated care delivery system and the extent to which physicians are interested in adopting a chronic care model and/or nurse assistance to manage IBD patients. As part of an observational cohort study to understand variation in IBD care and outcomes, we conducted semistructured, open-ended interviews with 17 gastroenterologists and 1 gastroenterology registered nurse at 6 clinics in an integrated care delivery system. Interviews were taperecorded and transcribed. We coded and analyzed transcripts using standard qualitative methods. Physicians reported a range of attitudes and practices regarding IBD. Analysis showed differences in 3 domains and 8 subdomains: 1) patient education and choices, including health education and patient use of complementary and alternative medicine; 2) decisions about diagnosis and treatment, including practice guidelines, conferring with colleagues, using infliximab, and medical hospitalization; and 3) organizational aspects of care, including primary care involvement with IBD and MD attitudes toward ancillary support. Standardized algorithms on care for IBD patients do not exist, but opportunities may exist to improve IBD care by: having initial work-ups and management of patients in remission in primary care; creating and maintaining opportunities for gastroenterologists to confer with colleagues and acknowledged local experts; and having nurse coordination for medications and labs and/or some type of specialty IBD clinic for high-need patients. This research highlights the need for more directed comparative efficacy and effectiveness trials that will serve to define preferred treatment strategies.

Integration and co-location of HIV/AIDS, tuberculosis and drug treatment services

Injection drug use (IDU) plays a critical role in the HIV epidemic in several countries throughout the world. In these countries, injection drug users are at significant risk for both HIV and tuberculosis, and active IDU negatively impacts treatment access, adherence and retention. Comprehensive strategies are therefore needed to effectively deliver preventive, diagnostic and curative services to these complex patient populations. We propose that developing co-located integrated care delivery systems should become the focus of national programmes as they continue to scale-up access to antiretroviral medications for drug users. Existing data suggest that such a programme will expand services for each of these diseases; increase detection of tuberculosis (TB) and HIV; improve medication adherence; increase entry into substance use treatment; decrease the likelihood of adverse drug events; and improve the effectiveness of prevention interventions. Key aspects of integration programmes include: co-location of services convenient to the patient; provision of effective substance use treatment, including pharmacotherapies; cross-training of generalist and specialist care providers; and provision of enhanced monitoring of drug–drug interactions and adverse side effects. Central to implementing this agenda will be fostering the political will to fund infrastructure and service delivery, expanding street-level outreach to IDUs, and training community health workers capable of cost effectively delivering these services.

Seamless care: Changing the approach to caring for children suffering from anaphylaxis

The development and implementation of a clinical practice guideline based on the seamless care model is presented. Developed at Kidz First Children's Hospital in Auckland, New Zealand, the guideline deals with the prescription of epi-pens to children who have experienced an anaphylactic reaction. Traditionally, epi-pen prescription and follow-up support have been fragmented, with responsibility spread across a range of service providers, each operating largely on its own. To address this issue, the seamless care model has been used to establish a fully integrated care delivery system that facilitates a smooth transition from acute to community-based care. This development serves to demonstrate how seamless care can facilitate practice development and organisational change, as well as enhancing child and family health outcomes. Copyright © 2006 John Wiley & Son, Ltd.

Balance Sheets: Tools to Inform Changes in Practice

Matt Handley, MD Spring 2005 - Volume 9 Number 2 Balance Sheets--Tools for Translating Evidence into Practice Integrated care delivery systems have two inherent advantages over other health care organizations. First, we integrate the financing of car

Cost Benefit of Effective Diabetes Management in the Managed Care Setting: A Case Study

A growing body of evidence suggests that people with diabetes achieve better outcomes if approached with an integrated disease management care plan consisting of clinical guidelines, patient education, access to glucose meters, and information system reporting. The diabetes management program at the Geisinger Health System in Pennsylvania provides a blueprint for success using those guidelines in an integrated care delivery system.

Improving clinical effectiveness in an integrated care delivery system.

HealthEast, an integrated care delivery system based in St. Paul, MN, established a care management program in 1993. At HealthEast, care management is defined as "an interdisciplinary process of coordinating client-centered services across the continuum of care to achieve quality and cost-effective outcomes." The program included establishing a collaborative practice model that was used to drive the organization's improvement efforts. The use of this model has been instrumental in achieving significant improvements in financial and clinical performance. As a result, HealthEast received a leadership award for "Improving Clinical Effectiveness within a Healthcare System" from VHA, Inc., a nationwide membership alliance of approximately 1,700 community healthcare organizations.

Leadership and Quality of Working Life in Home Health Care

Home health care has undergone startling changes in the past decade and, in the process, become a strategically important ingredient of health care delivery. However, the question remains whether home health care organizations can deliver the benefits anticipated for integrated care delivery systems. The answer to this question depends to a great extent on whether home health care organizations build vibrant, visionary leadership capable of transforming organizations and motivating staff to deliver high quality and low cost services. This paper examines a case study of transformational leadership as it relates to the quality of working life for nurses, homemakers, and staff. The findings indicate that leader behaviour is strongly associated with homemakers', and to a lesser extent staff members', job satisfaction, job involvement, and propensity to remain with the organization. These job attitudes have been shown to be related to higher job performance. The implications for leadership in home health agencies are discussed.