Improving Access to Improve Quality in an HMO

说明（申请人提供）：背景和意义。在《跨越质量鸿沟》一书中，医学研究所得出结论，美国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”的提供医疗保健“持续访问”的交付系统来部分提高质量。团体保健合作社发起了一项获取倡议，通过以下系统改革，增加参加者接触医生和获得信息的机会，以提高质量：MyGroupHealth参加者门户网站上的健康促进信息;通过MyGH向患者提供安全的信息，并对医生提供信息给予财政奖励;促进初级保健的获取;重新设计初级保健系统，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的薪酬;以及让登记者通过互联网查阅其电子病历。根据IOM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1997-2006年期间连续参加团体健康的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）估计基于Web的患者-提供者安全消息传递、电子医疗记录和健康促进信息的利用率; 3）比较提供者访问、医院使用和倡议前后的费用;和4）比较倡议前后的连续性和护理质量。 研究设计.在目标1和2中，将使用纵向队列设计来估计2型糖尿病的基线、患病率和发病率，并估计GHC的16，561名连续入组的18岁以上糖尿病成年人中三个互斥队列的倡议组成部分的入组者利用率：1）1997年患有糖尿病和一种或多种其他慢性疾病的登记者的患病率队列; 2）1998-2006年患有一种或多种其他慢性疾病的登记者的发病率队列;和3）1997-2006年仅糖尿病队列，没有其他慢性疾病。在目标3-4中，将采用单一间断时间序列设计，比较倡议前后的利用率、成本和质量。 人口1997-2006年在西部华盛顿州连续入组的糖尿病组健康登记者（约N= 16，561）。措施入组者使用安全消息和MyGH、门诊和医院使用、ER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.