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Developing primary care teams prepared to improve quality: a mixed-methods evaluation Learning Health System, PATH, Quality and Safety
The UW PATH collaborative describes the implementation, mixed-methods evaluation results, and lessons learned from instituting a Microsystems approach across 6 years with 58 primary care teams at a large academic health system.
Content validity of the PROMIS® family relationships measure for children with chronic illness Children and Young Adults, Chronic Conditions
Dr. Elizabeth D. Cox et al. conducted a qualitative study of patients and their parents and found the Patient-Reported Outcomes Measurement Information System® Family Relationships measure reflects the experiences of children with chronic illness.
A simple framework for weighting panels across primary care disciplines Learning Health System, PATH
The UW PATH collaborative describes the development and application of a utilization-based weighting system that accounts for patient complexity to help health systems understand patient panels and population characteristics
Medicare shared savings programs: Higher cost ACOs more likely to achieve savings Learning Health System, Quality and Safety
In a recent study, the PATH collaborative examined results for 220 ACOs from the Medicare Shared Savings Program and found that ACOs with higher baseline expenditures were significantly more likely to generate savings than lower cost ACOs.
Sociodemographics and hypertension control among young adults Children and Young Adults, Chronic Conditions, Health Equity, HIP Data, Quality and Safety
Dr. Heather Johnson et al. evaluated the role of sociodemographics in hypertension control among young adults with primary care access and found that young men, non-English primary language speakers, & unmarried people had lower control rates.
Variability in care management programs in Medicare ACOs Chronic Conditions, Quality and Safety
In this study co-authored by Dr. Maureen Smith and Peter Nordby, investigators surveyed leaders in 15 care management programs and found high variability across programs and that most programs use cost & utilization measures to determine outcomes.
Connecting rheumatology patients to primary care for high blood pressure Chronic Conditions, Dissemination and Implementation, HIPxChange
Dr. Christie Bartels et al. developed a staff protocol to improve primary care follow-up after high blood pressures were documented in specialty care, and the protocol decreased follow-up time and reduced visits with high blood pressure by 9%.
Frequency and predictors of communication about high blood pressure in RA visits Chronic Conditions, HIP Data, Quality and Safety
Dr. Christie Bartels et al. conducted a study of patients with rheumatoid arthritis and found that although there is heightened cardiovascular disease risk among patients with RA, most RA clinic visits lacked documented communication about blood pressure.
Assessing unwanted variations in rheumatology clinic previsit rooming Chronic Conditions, Quality and Safety
Edmond Ramly et al. conducted a cross-sectional time-study and work-system analysis to measure rooming workflows in rheumatology clinics and found significant variations across clinics, prompting clinic leaders to modify their policies.
Primary care colorectal cancer screening correlates with breast cancer screening Cancer, HIP Data, Older Adults
Dr. Jennifer Weiss et al. examined whether PCPs' colorectal cancer screening practices correlate with several other preventive & chronic care metrics and found that PCP CRC screening rates strongly correlate with breast cancer screening rates.
Hypertension control after an initial cardiac event among Medicare patients with diabetes Chronic Conditions, HIP Data, Older Adults
In this study co-authored by Drs. Heather Johnson and Maureen Smith, investigators examined EHR and Medicare data to determine rates & predictors of achieving hypertension control among patients with diabetes after hospital discharge for a cardiac event.
Visit patterns for severe mental illness with implementation of integrated care Chronic Conditions, Dissemination and Implementation, HIP Data, Mental Health
This pilot study using EHR data found a sharp increase in the number of patients with severe mental illness seeking care after the integration of behavioral health into primary clinics in two federally qualified health centers.
Primary care colorectal cancer screening correlates with breast cancer screening Cancer, Chronic Conditions, Quality and Safety
In this study, Dr. Jennifer Weiss et al. examined whether primary care provider practices for breast cancer screening, cervical cancer screening, HgbA1c, and LDL testing were correlated with colorectal cancer screening rates.
Using the Hendrich II inpatient fall risk screen to predict outpatient falls after ED visits Health IT, Older Adults, Quality and Safety, Transitions in Care
Dr. Brian Patterson et al. found that using a fall risk screening instrument during ED visits can predict future ED visits for falls, but is most useful when combined with routinely collected data on other fall risk factors.
Can claims data algorithms identify the physician of record? Health Equity, Health IT, HIP Data, Older Adults
Using HIP's claims and EHR data, this study found that algorithms based on claims data are less likely to identify a patient's PCP among vulnerable populations and those experiencing fragmented care.
Hospitalizations for ambulatory care-sensitive conditions among children with chronic and complex diseases Children and Young Adults, Chronic Conditions, Quality and Safety
In this article, Dr. Ryan Coller et al. evaluated the predictors of ambulatory-care sensitive hospitalizations for children, as well as the influence of medical complexity and ambulatory care characteristics on hospitalization rates.
Stratifying patients with diabetes into clinically relevant groups by combination of chronic conditions Chronic Conditions, HIP Data, Public Reporting
Using HIP data, investigators evaluated the relationship between diabetes quality metrics and patients' combinations of chronic conditions and found that patients in less severe chronic condition classes were less likely to achieve diabetes metrics.
Bridging clinical researcher perceptions and health IT realities: A case study of stakeholder creep Health IT, Stakeholder Engagement
In an article co-authored by Edmond Ramly and Christie Bartels, investigators describe the cause and effects of stakeholder creep in a health information technology implementation project and present a stakeholder planning tool to plan for engagement.
Implementing a mobile health system to integrate the treatment of addiction into primary care Chronic Conditions, Dissemination and Implementation, Health IT, Quality and Safety
In this study, Dr. Andrew Quanbeck et al. describe the implementation of a mobile health system to treat addiction in primary care and discuss the effect of the mHealth system on patients and clinicians.
30-day readmission & mortality among Medicare beneficiaries discharged to SNFs after vascular surgery Older Adults, Surgery, Transitions in Care
Using Chronic Conditions Warehouse data, investigators identified several predictors of readmission or death at 30 days for vascular surgery patients discharged to SNFs.
Survival of sepsis survivors admitted to skilled nursing facilities Older Adults, Quality and Safety, Transitions in Care
Using HIP's Chronic Conditions Warehouse data, investigators found that discharge to a SNF, cognitive impairment, and activities of daily living dependence were each strongly associated with shortened survival for sepsis survivors.
The importance of frequent return visits and hypertension control among young adults Children and Young Adults, Chronic Conditions, Quality and Safety
In a recent study, HIP investigators found that frequent visits are associated with increased hypertension control in young adults with hypertension.
Risk prediction for heterogeneous populations with application to hospital admission prediction Chronic Conditions, HIP Data, Quality and Safety
This article co-authored by Menggang Yu and Maureen Smith discusses risk prediction for hospital admission in heterogeneous populations for diverse and complex patients with chronic conditions.
Validation of an instrument to assess barriers to care-seeking for accidental bowel leakage Chronic Conditions, Older Adults
Dr. Heidi Brown et al. developed and validated a survey instrument to assess barriers to seeking care for accidental bowel leakage in women. The instrument had excellent criterion validity and test-retest reliability.
Insurance coverage for CT colonography screening: Impact on overall colorectal cancer screening rates Cancer, HIP Data, Older Adults, Quality and Safety
Dr. Maureen Smith et al. found that insurance coverage of CT colonography for colorectal cancer screening was associated with a greater likelihood of a patient being screened using CT colonography or colonoscopy.
Using chief complaint in addition to diagnosis codes to identify falls in the ED Health IT, Older Adults, Quality and Safety, Transitions in Care
A study by Dr. Brian Patterson et al. found that some fall-related ED visits that were missed when using the ICD-9 definition alone could be captured using an expanded definition that includes chief complaint.
MyHEART: Development & dissemination of a patient-centered website for young adults with hypertension Children and Young Adults, Chronic Conditions, Dissemination and Implementation, Health IT, Stakeholder Engagement
This article by Dr. Heather Johnson et al. discusses the development and dissemination of the MyHEART website, which provides educational information to young adults with high blood pressure.
Diabetic eye screening: knowledge and perspectives from providers and patients Chronic Conditions
In this review, Dr. Yao Liu summarizes current knowledge and perspectives on screening for diabetic retinopahty to better understand why diabetic eye screening rates remain low, and discusses future directions towards preventing blindness from diabetes.
PCOR: Brave new world meets old institutional policies Children and Young Adults, Patient-Centered Outcomes Research, Stakeholder Engagement
Patient engagement during research has become increasingly common. A recent article by PROKids discusses the tensions between engagement of patient stakeholders in research and the institutional and legal framework governing engagement.
A family-centered rounds checklist, family engagement, and patient safety Children and Young Adults, Dissemination and Implementation, HIPxChange, Patient-Centered Outcomes Research, Quality and Safety, Stakeholder Engagement
In a recent randomized clinical trial led by Dr. Elizabeth Cox, implementing a checklist during family-centered rounds increased family engagement and the safety of hospitalized children from the perspective of the families.

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