Browsing by Subject "Chronic disease management"

Now showing 1 - 3 of 3
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    Examining the Impact of State-Mandated Insurance Benefits and Reimbursement Provisions on Access to Diabetes Self-Management Education and Training (DSME/T)
    (2019-09) Brown-Podgorski, Brittany L.; Vest, Joshua R.; deGroot, Mary K.; Holmes, Ann M.; Shi, Yunfeng; Simon, Kosali I.
    With an estimated 30.2 million diagnosed and undiagnosed cases among adults (and another 84 million at risk), diabetes mellitus is one of the most prevalent chronic conditions and a leading cause of mortality in the US. Diabetes self-management education and training (DSME/T) is a recognized standard of care and provides patients with the requisite knowledge and skills to properly manage the condition, improve long-term health outcomes, and reduce health care expenditures. Yet, DSME/T is greatly underutilized. Health insurance coverage that does not include benefits for DSME/T effectively imposes barriers to access for patients in need of the service. Many states have adopted laws and regulations requiring public and/or private insurers in their market to provide benefits for DSME/T; however, these requirements vary by state. It is unclear if these policies effectively improve access to DSME/T services. This dissertation seeks to rigorously assess the impact of state-mandated benefits and reimbursement provisions on access to DSME/T among adult patients with diabetes. The first analysis utilizes a unique combination of legal and programmatic data to quantify changes in the supply of DSME/T resources after the adoption of state-mandated benefits (potential access). The second analysis merges legal data with the Medical Expenditure Panel Survey (MEPS) from 2008 to 2016 to examine the impact of state mandates and reimbursement provisions on patient utilization of DSME/T (realized access). Lastly, the final analysis utilizes electronic health record data (2010-2016) from a safety net population to determine if patients’ evaluated need for DSME/T predicts the likelihood of receiving a DSME/T referral during a provider encounter (equitable access). Using novel data sources and a sophisticated policy analysis technique, this study provides a rigorous assessment of the impact of decades of state policies designed to improve access to care.
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    Modelling care quality for patients after a transient ischaemic attack within the US Veterans Health Administration
    (2019-11) Arling, Greg; Sico, Jason J.; Reeves, Mathew J.; Myers, Laura; Baye, Fitsum; Bravata, Dawn M.; Biostatistics, School of Public Health
    Objective Timely preventive care can substantially reduce risk of recurrent vascular events or death after a transient ischaemic attack (TIA). Our objective was to understand patient and facility factors influencing preventive care quality for patients with TIA in the US Veterans Health Administration (VHA). Methods We analysed administrative data from a retrospective cohort of 3052 patients with TIA cared for in the emergency department (ED) or inpatient setting in 110 VHA facilities from October 2010 to September 2011. A composite quality indicator (QI score) pass rate was constructed from four process-related quality measures—carotid imaging, brain imaging, high or moderate potency statin and antithrombotic medication, associated with the ED visit or inpatient admission after the TIA. We tested a multilevel structural equation model where facility and patient characteristics, inpatient admission, and neurological consultation were predictors of the resident’s composite QI score. Results Presenting with a speech deficit and higher Charlson Comorbidity Index (CCI) were positively related to inpatient admission. Being admitted increased the likelihood of neurology consultation, whereas history of dementia, weekend arrival and a higher CCI score made neurological consultation less likely. Speech deficit, higher CCI, inpatient admission and neurological consultation had direct positive effects on the composite quality score. Patients in facilities with fewer full-time equivalent neurology staff were less likely to be admitted or to have a neurology consultation. Facilities having greater organisational complexity and with a VHA stroke centre designation were more likely to provide a neurology consultation. Conclusions Better TIA preventive care could be achieved through increased inpatient admissions, or through enhanced neurology and other care resources in the ED and during follow-up care.
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    Pharmacy program to improve care for veterans with transient ischaemic attack: a pilot implementation evaluation
    (BMJ, 2022-09-08) Rattray, Nicholas; Damush, Teresa M.; Myers, Laura; Perkins, Anthony J.; Homoya, Barbara; Knefelkamp, Christopher; Fleming, Breanne; Kingsolver, Andrea; Boldt, Amy; Ferguson, Jared; Zillich, Alan; Bravata, Dawn M.; Biostatistics, School of Public Health
    Background: Early evaluation and effective communication to manage transient ischaemic attacks (TIA) may lead to a reduction of up to 70% in recurrent events for patients with TIA/minor stroke, along with reduced costs and lengths of hospital stay. Methods: We conducted a single site pilot evaluation of a clinical pharmacy programme to improve medication management among TIA patients. The programme included a structured protocol, online identification tool, and a templated discharge checklist. Primary effectiveness measures were change in systolic blood pressure (SBP) 90 days post discharge and prescription of high/moderate potency statins. Contextual aspects and clinical perspectives on the implementation process were evaluated through prospective semistructured interviews with key informants. Results: The analysis included 75 patients in the preimplementation group and 61 in the postimplementation group. The mean SBP at 90 days post discharge was significantly lower in the post implementation period (pre implementation, 133.3 mm Hg (SD 17.8) vs post implementation, 126.8 mm Hg (16.6); p=0.045). The change in SBP from discharge to 90 days post discharge was greater in the postimplementation period (15.8 mm Hg (20.5) vs 24.8 mm Hg (23.2); p=0.029). The prescription of high/moderate potency statins were similar across groups (pre implementation, 66.7% vs post implementation, 77.4%; p=0.229). Front-line clinicians involved in the pilot study reported positively on the acceptability, appropriateness and feasibility of implementing the protocol without additional cost and within current scope of practice. Conclusions: Implementation of a clinical protocol outlining medication management and provider communication to ensure rapid postdischarge treatment of TIA patients was associated with SBP improvements. The pilot evaluation demonstrates how clinical pharmacists may play a role in treating low frequency, high stakes cerebrovascular events where early treatment and follow-up are critical.