Background

Red blood cell (RBC) transfusion is a common medical procedure. While it offers clinical benefits for many, hemodynamically stable patients are often subjected to unwarranted transfusions, with the potential to lead to adverse consequences. We created a real-time clinical decision support (CDS) tool in the electronic health record system to address this problem and optimize transfusion practice as part of an institutional multidisciplinary, team-based patient blood management program.

Methods

The real-time CDS tool incorporated the transfusion guidelines published by the AABB. The tool was deployed as a dynamic order set within the computerized provider order entry interface. Prior to implementation, extensive education and outreach to increase provider engagement were provided. The CDS tool was launched in September 2015.

Results

The percentage of guideline-indicated RBC transfusions increased from a baseline of 43.6 to 54.2% while the percentage of multiunit (≥ 2 units) RBC transfusions decreased from 31.3 to 22.7% between September 2014 and July 2019. The estimated minimum cost saving over the entire study period was $36,519.36.

Conclusion

Our intervention increased guideline-indicated transfusions by 10.6% and reduced multiunit transfusions by 8.6%. The adoption of a dynamic order set for the CDS tool, as opposed to an interruptive alert that displays static alert messages, allowed for more customized and tighter control of RBC orders, leading to a sustained improvement in our transfusion practice.

Importance

Patients treated outside of their Medicare Shared Savings Program (MSSP) accountable care organization (ACO) likely benefit less from the ACO's integration of care. Consequently, the MSSP's open-network design may preclude ACOs from improving value in care.

Objectives

Quantify out-of-ACO care in a single urban ACO and examine associations between patient-level predictors and out-of-ACO expenditures.

Research design

Secondary data analysis using Centers for Medicare and Medicaid ACO Program Claim and Claim Line Feed dataset (dates of service January 1, 2013-December 31, 2013). Two-part modeling was used to examine associations between patient-level predictors and likelihood and level of out-of-ACO expenditures.

Subjects

Patients were included if they were prospectively assigned to the MSSP in 2013. Patients were excluded if they declined to share data with the ACO, were not retrospectively confirmed to be in the ACO, or had missing data on covariates. Analytic sample included 11,922 patients.

Measures

Total out-of-ACO expenditures and out-of-ACO expenditures by place of service.

Results

Of total expenditures, 32.9% were paid to out-of-ACO providers, and 89.8% of beneficiaries had out-of-ACO expenditures. The presence of almost all medical comorbidities increased out-of-ACO expenditures ($800-$3000 per comorbidity) across the study population. Racial/ethnic minority groups spent between $1076 and $1422 less outside of the ACO than white patients, which was driven by less out-of-ACO outpatient office expenditures ($417-$517 less for each racial/ethnic minority group).

Conclusions

Out-of-ACO expenditures represented a significant portion of expenditures for the study population. Medically complex patients spent more outside of the ACO and represent an important population to study further.

Patients with behavioral health disorders often have worse health outcomes and have higher health care utilization than patients with medical diseases alone. As such, people with behavioral health conditions are important populations for accountable care organizations (ACOs) seeking to improve the efficiency of their delivery systems. However, ACOs have historically faced numerous barriers in implementing behavioral health population-based programs, including acquiring reimbursement, recruiting providers, and integrating new services. We developed an evidence-based, all-payer collaborative care program called Behavioral Health Associates (BHA), operated as part of UCLA Health, an integrated academic medical center. Building BHA required several innovations, which included using our enterprise electronic medical record for behavioral health referrals and documentation; registering BHA providers with insurance plans' mental health carve-out products; and embedding BHA providers in primary care practices throughout the UCLA Health system. Since 2012 BHA has more than tripled the number of patients receiving behavioral health services through UCLA Health. After receiving BHA treatment, patients had a 13 percent reduction in emergency department use. Our efforts can serve as a model for other ACOs seeking to integrate behavioral health care into routine practice.

Objectives

Although care coordination is an essential component of the patient-centered medical home structure, current case manager models have limited usefulness to population health because they typically serve a small group of patients defined based on disease or utilization. Our objective was to support our health system's population health by implementing and evaluating a program that embedded nonlicensed coordinators within our primary care practices to support physicians in executing care plans and communicating with patients.

Study design

Matched case-control differences-in-differences.

Methods

Comprehensive care coordinators (CCC) were introduced into 14 of the system's 28 practice sites in 2 waves. After a structured training program, CCCs identified, engaged, and intervened among patients within the practice in conjunction with practice primary care providers. We counted and broadly coded CCC activities that were documented in the intervention database. We examined the impact of CCC intervention on emergency department (ED) utilization at the practice level using a negative binomial multivariate regression model controlling for age, gender, and medical complexity.

Results

CCCs touched 10,500 unique patients over a 1-year period. CCC interventions included execution of care (38%), coordination of transitions (32%), self-management support/link to community resources (15%), monitor and follow-up (10%), and patient assessment (1%). The CCC intervention group had a 20% greater reduction in its prepost ED visit rate compared with the control group (P < .0001).

Conclusions

Our CCC intervention demonstrated a significant reduction in ED visits by focusing on the centrality of the primary care provider and practice. Our model may serve as a cost-effective and scalable alternative for care coordination in primary care.

Background

Organisational culture affects physician behaviours. Patient safety culture surveys have previously been used to drive care improvements, but no comparable survey of high-value care culture currently exists. We aimed to develop a High-Value Care Culture Survey (HVCCS) for use by healthcare leaders and training programmes to target future improvements in value-based care.

Methods

We conducted a two-phase national modified Delphi process among 28 physicians and nurse experts with diverse backgrounds. We then administered a cross-sectional survey at two large academic medical centres in 2015 among 162 internal medicine residents and 91 hospitalists for psychometric evaluation.

Results

Twenty-six (93%) experts completed the first phase and 22 (85%) experts completed the second phase of the modified Delphi process. Thirty-eight items achieved ≥70% consensus and were included in the survey. One hundred and forty-one residents (83%) and 73 (73%) hospitalists completed the survey. From exploratory factor analyses, four factors emerged with strong reliability: (1) leadership and health system messaging (α=0.94); (2) data transparency and access (α=0.80); (3) comfort with cost conversations (α=0.70); and (4) blame-free environment (α=0.70). In confirmatory factor analysis, this four-factor model fit the data well (Bentler-Bonett Normed Fit Index 0.976 and root mean square residual 0.056). The leadership and health system messaging (r=0.56, p<0.001), data transparency and access (r=0.15, p<0.001) and blame-free environment (r=0.37, p<0.001) domains differed significantly between institutions and positively correlated with Value-Based Purchasing Scores.

Conclusions

Our results provide support for the reliability and validity of the HVCCS to assess high-value care culture among front-line clinicians. HVCCS may be used by healthcare groups to identify target areas for improvements and to monitor the effects of high-value care initiatives.