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Discharge handoff communication and pediatric readmissions Children and Young Adults, Quality and Safety, Transitions in Care
In this article, Dr. Ryan Coller et al. characterize common handoff practices between hospitals & PCPs after pediatric hospitalizations and test the hypothesis that common handoff practices are associated with fewer unplanned readmissions.
MyHEART: A non-randomized feasibility study of a young adult hypertension intervention Children and Young Adults, Chronic Conditions, Dissemination and Implementation, Stakeholder Engagement
Dr. Heather Johnson et al. discuss the feasibililty and acceptability of the MyHEART program, a telephone-based health coach self-management intervention for young adults with high blood pressure.
The role of intraoperative assessment in the surgical management of ductal carcinoma in situ Cancer, HIP Data, Surgery
Using HIP's SEER-Medicare data, investigators found that intraoperative frozen section or touch preparation during partial mastectomy did not result in a reduction in subsequent breast operations in women with DCIS.
Difference in receipt of preventive services by race/ethnicity in Medicare Advantage plans: tracking the impact of P4P HIP Data, Learning Health System, Older Adults, Quality and Safety
In this study, the authors found similar racial/ethnic differences in the receipt of preventive health care before and after the introduction of the CMS Quality Bonus Payment Demonstration, a pay-for-performance program.
Across the divide: primary care departments working together to redesign care to achieve the Triple Aim Learning Health System, Primary Care Transformation (PATH), Quality and Safety
This article by the UW PATH collaborative describes a collaboration between internal medicine, general pediatrics and adolescent medicine, and family medicine to redesign primary care in the pursuit of the Triple Aim.
Medical complexity among children with special health care needs Children and Young Adults, Chronic Conditions, Quality and Safety
Dr. Ryan Coller et al. sought to identify subgroups of US children with special health care needs and characterized key outcomes such as ED visit and hospitalization rates, medical home attributes, quality of life issues, and cost by subgroup.
Trajectories and prognosis of patients who have prolonged mechanical ventilation after high-risk surgery HIP Data, Quality and Safety, Surgery
This study, which used HIP's Chronic Conditions Warehouse data, found that older patients who received prolonged mechanical ventilation following surgery had a higher 1-year mortality and were less likely to be discharged home.
Does first-contact access to primary care differentially benefit those with certain personalities to receive preventive services? Chronic Conditions, HIP Data, Learning Health System
In a cross-sectional study using Wisconsin Longitudinal Study data, investigators found that certain personality characteristics predicted patients receiving fewer preventive care services.
Examining systemic steroid use in older inflammatory bowel disease patients using hurdle models Chronic Conditions, HIP Data, Quality and Safety
Using HIP's Chronic Conditions Warehouse data, authors examined the use of systemic steroids in patients with IBD and found that younger patients and those who lived in rural areas were more likely to receive them.
The medical home and hospital readmissions Children and Young Adults, Chronic Conditions, Quality and Safety
In this article, Dr. Ryan Coller et al. examined whether patients with medical homes were less likely to have early post-discharge hospital or emergency department encounters and found that lacking a usual source for care was associated with readmissions.
Association of anxiety and depression with hypertension control Chronic Conditions, HIP Data, Mental Health
This multidisciplinary group practice observational study by Dr. Heather Johnson's team found that greater healthcare utilization among patients with anxiety and/or depression may contribute to faster hypertension control.
Strange bedfellows: A local insurer/physician practice partnership to fund innovation Learning Health System, Primary Care Transformation (PATH)
This article by UW PATH discusses a novel partnership between an academic health system and an insurance firm that funds ambulatory care quality improvement projects that jointly benefit both the healthcare organization and the payer.
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.
Establishing chronic condition concordance and discordance with diabetes Chronic Conditions, HIP Data, Public Reporting
This study used HIP data to examine goals of 62 ambulatory-relevant condition categories. Using the Delphi method, investigators found that 12 conditions were concordant with diabetes care and 50 were discordant.
The impact of a patient's concordant and discordant chronic conditions on diabetes care quality measures Chronic Conditions, HIP Data, Public Reporting
This study used EHR data and found that among patients with diabetes, those with more conditions that were concordant with diabetes care were more likely to achieve diabetes care goals.
Are waiting rooms passé: A pilot study of patient self-rooming Learning Health System, Primary Care Transformation (PATH), Stakeholder Engagement
In a study by UW PATH, an intervention in family medicine clinics that allowed patients to room themselves was preferred by 95% of patients and resulted in staff time and cost savings.
The effects of expanding public insurance to rural low-income childless adults Health Equity, Older Adults
In this study, Marguerite Burns et al. measured the change in health care use by rural, low-income childless adults after enrollment into a new public insurance program and found that it led to substantial increases in outpatient visits.
Approaches and challenges to optimising primary care teams' electronic health record usage Health IT, Learning Health System, Primary Care Transformation (PATH)
The UW PATH collaborative examined the approaches used and challenges perceived by analysts supporting the optimization of primary care teams' EHR use at a large health system.
Effects of Medicare Part D on guideline-concordant pharmacotherapy for bipolar 1 disorder among dually enrolled beneficiaries Chronic Conditions, Health Equity, Mental Health, Quality and Safety
Marguerite Burns et al. examined the effect of switching from Medicaid to Medicare Part D private drug plans on the receipt of pharmacotherapy for biopolar I disorder and found that the use of guideline-concordant pharmacotherapy increased.
The effect of Medicare Part D on the quality of pharmacotherapy for bipolar 1 disorder among dually enrolled beneficiaries Chronic Conditions, Mental Health, Quality and Safety
Marguerite Burns et al. examined whether the shift from Medicaid to Medicare Part D coverage in 2006 affected pharmacotherapy and emergency department use for individuals with bipolar I disorder.
Patient demographic and tumor characteristics influencing oncologist follow-up frequency in older breast cancer survivors Cancer, HIP Data, Older Adults
Using SEER-Medicare data, investigators studied current patterns of oncologist breast cancer follow-up to determine the association between patient and tumor characteristics and follow-up frequency.
PAs and NPs perform effective roles on teams caring for Medicare patients with diabetes Chronic Conditions, HIP Data, Learning Health System
This study used Medicare claims and EHR data to examine the roles of PAs and NPs on care teams and determine the outcomes of these patterns of care for patients with diabetes.
Division of primary care services between physicians, PAs, and NPs for older patients with diabetes Chronic Conditions, HIP Data, Older Adults
Investigators used Medicare claims and EHR data to look at the division of services between primary care panels with varying levels of PA/NP involvement and characterize their patient panels.
External Community Review Committee: A new strategy for engaging community stakeholders in research funding decisions Stakeholder Engagement
In this article, Dr. Maureen Smith et al. describe the External Community Review Committee that engages community reviewers in making funding decisions for the University of Wisconsin Institute for Clinical and Translational Research Pilot Grant Program.
Predictors of colorectal cancer screening variation among primary care providers and clinics Cancer, HIP Data, Learning Health System, Quality and Safety
Dr. Jennifer Weiss led a study investigating patient, provider, and clinic factors that predict variation in colorectal cancer screening rates and found that variation exists among primary care providers and clinics.
Publicly reported quality-of-care measures influenced Wisconsin physician groups to improve performance Chronic Conditions, HIP Data, Learning Health System, Public Reporting
This study co-authored by Dr. Maureen Smith found that public reporting of quality-of-care measures influenced physician groups to improve their performance on certain quality measures.
Low-cost transitional care with nurse managers making mostly phone contact with patients cut rehospitalization at a VA hospital Dissemination and Implementation, HIPxChange, Quality and Safety, Transitions in Care
This article introduces the Coordinated-Transitional Care (C-TraC) Program, a low-resource telephone-based program designed to reduce rehospitalizations for patients with high-risk conditions discharged to community settings.
Lipid testing in patients with rheumatoid arthritis and key cardiovascular-related comorbidities Chronic Conditions, HIP Data, Older Adults, Quality and Safety
In this study, Dr. Christie Bartels et al. examined the extent to which lipid testing was performed among patients with rheumatoid arthritis and cardiovascular-related comorbidities and the effect of annual PCP visits on lipid testing rates.
Monitoring diabetes in patients with and without rheumatoid arthritis Chronic Conditions, HIP Data, Older Adults
Dr. Christie Bartels et al. sought to determine whether having rheumatoid arthritis in addition to diabetes had an impact on receipt of guideline recommended A1c and lipid testing for diabetes.
5 year colorectal cancer outcomes in a large negative CT colonography screening cohort Cancer, Older Adults, Quality and Safety
In this study co-authored by Dr. Jennifer Weiss, the authors found that colorectal adenocarcinoma is rare in the 5 years following a negative CT colonography screening, suggesting that current strategies for CT screening are appropriate.

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