Improving Access to Improve Quality in an HMO

简介(申请人提供)：背景和意义。在《跨越质量鸿沟》一书中，美国医学研究所得出结论，美国的医疗保健服务存在低质量的问题，并建议部分可以通过创建以患者为中心的提供系统来提高质量，为人们提供持续的医疗保健服务。团体健康合作社(GHC)发起了一项接入计划，通过以下制度改革增加参保者接触医生和信息的机会，从而提高质量：MyGH(MyGH)参保者网络门户网站上的健康促进信息；患者-提供者通过MyGH进行安全报文传递，提供医生对报文的经济奖励；高级获得初级保健；初级保健系统重新设计，以控制成本；直接接触专科医生(取消把关)；改变初级和专科医生薪酬；以及参保者访问其电子医疗记录的互联网接入。根据国际移民组织的建议，GHC改革可能会使患有多种慢性病的患者受益。目标。对于在1997-2006年间持续参加团体健康计划的2型糖尿病患者，其目标是：1)估计1997-2006年间其他慢性病的基线患病率和发病率，重点是心脏病、高血压、充血性心力衰竭和抑郁症；2)估计基于网络的患者-提供者安全消息传递、电子病历和健康促进信息的利用；3)比较计划实施前后的提供者访问、医院使用和费用；以及4)比较计划实施前后的连续性和护理质量。 研究设计。在目标1和目标2中，将使用纵向队列设计来估计II型糖尿病的基线、患病率和发病率，并估计GHC连续登记的16,561名18岁糖尿病成人中三个相互排斥的队列中参与者对该计划组成部分的利用：1)1997年患有糖尿病和一种或多种其他慢性病的参与者的患病率队列；2)1998-2006年发展为一种或多种其他慢性病的参与者的发病率队列；以及3)1997-2006年没有其他慢性病的仅患有糖尿病的队列。在目标3-4中，将使用单一中断时间序列设计来比较倡议实施前后的利用率、成本和质量。 人口。1997-2006年在华盛顿州西部连续登记患有糖尿病的团体健康参与者(约N=16,561人)。措施。参与者使用安全消息传递和MyGH、门诊和医院使用、急诊室使用、成本和护理质量。 数据源。集团健康自动化数据库。 分析。将进行描述性、双变量、回归和时间序列分析。

DESCRIPTION (Provided by applicant): Background and Significance. In Crossing the Quality Chasm, the Institute of Medicine concludes that U.S. health care is plagued by low quality, and recommends that quality can be improved partly by creating "patient-centered" delivery systems offering "continuous access" to healthcare. Group Health Cooperative (GHC) has launched an Access Initiative to improve quality by increasing enrollee access to physicians and information through the following system reforms: health promotion information on the MyGroupHealth (MyGH) enrollee Web portal; patient-provider secure messaging through MyGH with physician financial incentives for messaging; advanced access to primary care; primary care system redesign to control costs; direct access to specialist physicians (removal of gatekeeping); changes in primary and specialty physician compensation; and Internet access for enrollees to their electronic medical records. The GHC reforms may benefit patients with multiple chronic conditions, based on the IOM recommendations. Aims. For the population of enrollees with type 2 diabetes mellitus continuously enrolled in Group Health between 1997-2006, aims are to: 1) Estimate the baseline prevalence and incidence of other chronic conditions between 1997-2006, emphasizing heart disease, hypertension, congestive heart failure and depression; 2) Estimate utilization of Web-based patient-provider secure messaging, electronic medical records, and health promotion information; 3) Compare provider visits, hospital use, and costs before vs. after the Initiative; and 4) Compare continuity and quality of care before vs. after the Initiative. Study Design. In Aims 1 and 2, a longitudinal cohort design will be used to estimate baseline, prevalence and incidence of type 2 diabetes, and to estimate enrollee utilization of the Initiative's components for three mutually-exclusive cohorts in GHC's population of 16,561 continuously enrolled adults > age 18 with diabetes: 1) Prevalence cohort of enrollees who had diabetes and one or more other chronic conditions in 1997; 2) Incidence cohort of enrollees who developed one or more other chronic conditions in 1998-2006; and 3) a Diabetes only cohort with no other chronic conditions 1997-2006. In Aims 3-4, single interrupted time series design will be used to compare utilization, cost and quality before vs. after the Initiative. Population. Group Health enrollees who are continuously enrolled 1997-2006 with diabetes in western Washington state (approximately N= 16,561). Measures. Enrollee use of secure messaging and MyGH, outpatient and hospital use, ER use, costs and quality of care. Data Sources. Group Health automated data bases. Analyses. Descriptive, bivariate, regression, and time series analyses will be performed.