Improving Access to Improve Quality in an HMO

描述（由申请人提供）：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，美国的医疗保健受到低质量的困扰，并建议通过创建“以患者为中心”的交付系统，提供“持续的”医疗保健服务，可以在一定程度上提高质量。集团健康合作社（GHC）发起了一项获取倡议，通过以下系统改革增加注册者获得医生和信息的机会，从而提高质量：“我的集团健康”（MyGroupHealth）注册者门户网站上的健康促进信息；通过MyGH实现患者与提供者之间的安全信息传递，并为信息传递提供医生经济奖励；提前获得初级保健；重新设计初级保健系统以控制费用；直接接触专科医生（取消门卫）；初级医师和专科医师薪酬的变化；以及为注册者提供互联网访问他们的电子医疗记录。根据IOM的建议，GHC改革可能会使患有多种慢性疾病的患者受益。目标。对1997-2006年连续纳入组健康的2型糖尿病患者，目的是：1)估计1997-2006年期间其他慢性疾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)评估基于web的患者-提供者安全信息、电子病历和健康促进信息的利用率；3)比较计划实施前后的提供者访问量、医院使用情况和费用；4)比较“倡议”前后护理的连续性和质量。

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.