Most recent papers:

• Instruments Measuring Integrated Care: A Systematic Review of Measurement Properties.
  Mary Ann C. Bautista, Milawaty Nurjono, Yee Wei Lim, Ezra Dessers, Hubertus Jm Vrijhoef.
  Milbank Quarterly. December 19, 2016
  Policy Points: Investigations on systematic methodologies for measuring integrated care should coincide with the growing interest in this field of research. A systematic review of instruments provides insights into integrated care measurement, including setting the research agenda for validating available instruments and informing the decision to develop new ones. This study is the first systematic review of instruments measuring integrated care with an evidence synthesis of the measurement properties. We found 209 index instruments measuring different constructs related to integrated care; the strength of evidence on the adequacy of the majority of their measurement properties remained largely unassessed. Context Integrated care is an important strategy for increasing health system performance. Despite its growing significance, detailed evidence on the measurement properties of integrated care instruments remains vague and limited. Our systematic review aims to provide evidence on the state of the art in measuring integrated care. Methods Our comprehensive systematic review framework builds on the Rainbow Model for Integrated Care (RMIC). We searched MEDLINE/PubMed for published articles on the measurement properties of instruments measuring integrated care and identified eligible articles using a standard set of selection criteria. We assessed the methodological quality of every validation study reported using the COSMIN checklist and extracted data on study and instrument characteristics. We also evaluated the measurement properties of each examined instrument per validation study and provided a best evidence synthesis on the adequacy of measurement properties of the index instruments. Findings From the 300 eligible articles, we assessed the methodological quality of 379 validation studies from which we identified 209 index instruments measuring integrated care constructs. The majority of studies reported on instruments measuring constructs related to care integration (33%) and patient‐centered care (49%); fewer studies measured care continuity/comprehensive care (15%) and care coordination/case management (3%). We mapped 84% of the measured constructs to the clinical integration domain of the RMIC, with fewer constructs related to the domains of professional (3.7%), organizational (3.4%), and functional (0.5%) integration. Only 8% of the instruments were mapped to a combination of domains; none were mapped exclusively to the system or normative integration domains. The majority of instruments were administered to either patients (60%) or health care providers (20%). Of the measurement properties, responsiveness (4%), measurement error (7%), and criterion (12%) and cross‐cultural validity (14%) were less commonly reported. We found <50% of the validation studies to be of good or excellent quality for any of the measurement properties. Only a minority of index instruments showed strong evidence of positive findings for internal consistency (15%), content validity (19%), and structural validity (7%); with moderate evidence of positive findings for internal consistency (14%) and construct validity (14%). Conclusions Our results suggest that the quality of measurement properties of instruments measuring integrated care is in need of improvement with the less‐studied constructs and domains to become part of newly developed instruments.

  December 19, 2016   doi: 10.1111/1468-0009.12233   open full text
• Community‐Academic Partnerships: A Systematic Review of the State of the Literature and Recommendations for Future Research.
  Amy Drahota, Rosemary D. Meza, Brigitte Brikho, Meghan Naaf, Jasper A. Estabillo, Emily D. Gomez, Sarah F. Vejnoska, Sarah Dufek, Aubyn C. Stahmer, Gregory A. Aarons.
  Milbank Quarterly. March 14, 2016
  Policy Points: Communities, funding agencies, and institutions are increasingly involving community stakeholders as partners in research, to provide firsthand knowledge and insight. Based on our systematic review of major literature databases, we recommend using a single term, community‐academic partnership (CAP), and a conceptual definition to unite multiple research disciplines and strengthen the field. Interpersonal and operational factors that facilitate or hinder the collaborative process have been consistently identified, including “trust among partners” and “respect among partners” (facilitating interpersonal factors) and “excessive time commitment” (hindering operational factor). Once CAP processes and characteristics are better understood, the effectiveness of collaborative partner involvement can be tested. Context Communities, funding agencies, and institutions are increasingly involving community stakeholders as partners in research. Community stakeholders can provide firsthand knowledge and insight, thereby increasing research relevance and feasibility. Despite the greater emphasis and use of community‐academic partnerships (CAP) across multiple disciplines, definitions of partnerships and methodologies vary greatly, and no systematic reviews consolidating this literature have been published. The purpose of this article, then, is to facilitate the continued growth of this field by examining the characteristics of CAPs and the current state of the science, identifying the facilitating and hindering influences on the collaborative process, and developing a common term and conceptual definition for use across disciplines. Methods Our systematic search of 6 major literature databases generated 1,332 unique articles, 50 of which met our criteria for inclusion and provided data on 54 unique CAPs. We then analyzed studies to describe CAP characteristics and to identify the terms and methods used, as well as the common influences on the CAP process and distal outcomes. Findings CAP research spans disciplines, involves a variety of community stakeholders, and focuses on a large range of study topics. CAP research articles, however, rarely report characteristics such as membership numbers or duration. Most studies involved case studies using qualitative methods to collect data on the collaborative process. Although various terms were used to describe collaborative partnerships, few studies provided conceptual definitions. Twenty‐three facilitating and hindering factors influencing the CAP collaboration process emerged from the literature. Outcomes from the CAPs most often included developing or refining tangible products. Conclusions Based on our systematic review, we recommend using a single term, community‐academic partnership, as well as a conceptual definition to unite multiple research disciplines. In addition, CAP characteristics and methods should be reported more systematically to advance the field (eg, to develop CAP evaluation tools). We have identified the most common influences that facilitate and hinder CAPs, which in turn should guide their development and sustainment.

  March 14, 2016   doi: 10.1111/1468-0009.12184   open full text
• How Successful Is Medicare Advantage?
  JOSEPH P. NEWHOUSE, THOMAS G. McGUIRE.
  Milbank Quarterly. June 03, 2014
  Context Medicare Part C, or Medicare Advantage (MA), now almost 30 years old, has generally been viewed as a policy disappointment. Enrollment has vacillated but has never come close to the penetration of managed care plans in the commercial insurance market or in Medicaid, and because of payment policy decisions and selection, the MA program is viewed as having added to cost rather than saving funds for the Medicare program. Recent changes in Medicare policy, including improved risk adjustment, however, may have changed this picture. Methods This article summarizes findings from our group's work evaluating MA's recent performance and investigating payment options for improving its performance even more. We studied the behavior of both beneficiaries and plans, as well as the effects of Medicare policy. Findings Beneficiaries make “mistakes” in their choice of MA plan options that can be explained by behavioral economics. Few beneficiaries make an active choice after they enroll in Medicare. The high prevalence of “zero‐premium” plans signals inefficiency in plan design and in the market's functioning. That is, Medicare premium policies interfere with economically efficient choices. The adverse selection problem, in which healthier, lower‐cost beneficiaries tend to join MA, appears much diminished. The available measures, while limited, suggest that, on average, MA plans offer care of equal or higher quality and for less cost than traditional Medicare (TM). In counties, greater MA penetration appears to improve TM's performance. Conclusions Medicare policies regarding lock‐in provisions and risk adjustment that were adopted in the mid‐2000s have mitigated the adverse selection problem previously plaguing MA. On average, MA plans appear to offer higher value than TM, and positive spillovers from MA into TM imply that reimbursement should not necessarily be neutral. Policy changes in Medicare that reform the way that beneficiaries are charged for MA plan membership are warranted to move more beneficiaries into MA.

  June 03, 2014   doi: 10.1111/1468-0009.12061   open full text
• Social Media and Internet‐Based Data in Global Systems for Public Health Surveillance: A Systematic Review.
  Edward Velasco, Tumacha Agheneza, Kerstin Denecke, Göran Kirchner, Tim Eckmanns.
  Milbank Quarterly. March 06, 2014
  Context The exchange of health information on the Internet has been heralded as an opportunity to improve public health surveillance. In a field that has traditionally relied on an established system of mandatory and voluntary reporting of known infectious diseases by doctors and laboratories to governmental agencies, innovations in social media and so‐called user‐generated information could lead to faster recognition of cases of infectious disease. More direct access to such data could enable surveillance epidemiologists to detect potential public health threats such as rare, new diseases or early‐level warnings for epidemics. But how useful are data from social media and the Internet, and what is the potential to enhance surveillance? The challenges of using these emerging surveillance systems for infectious disease epidemiology, including the specific resources needed, technical requirements, and acceptability to public health practitioners and policymakers, have wide‐reaching implications for public health surveillance in the 21st century. Methods This article divides public health surveillance into indicator‐based surveillance and event‐based surveillance and provides an overview of each. We did an exhaustive review of published articles indexed in the databases PubMed, Scopus, and Scirus between 1990 and 2011 covering contemporary event‐based systems for infectious disease surveillance. Findings Our literature review uncovered no event‐based surveillance systems currently used in national surveillance programs. While much has been done to develop event‐based surveillance, the existing systems have limitations. Accordingly, there is a need for further development of automated technologies that monitor health‐related information on the Internet, especially to handle large amounts of data and to prevent information overload. The dissemination to health authorities of new information about health events is not always efficient and could be improved. No comprehensive evaluations show whether event‐based surveillance systems have been integrated into actual epidemiological work during real‐time health events. Conclusions The acceptability of data from the Internet and social media as a regular part of public health surveillance programs varies and is related to a circular challenge: the willingness to integrate is rooted in a lack of effectiveness studies, yet such effectiveness can be proved only through a structured evaluation of integrated systems. Issues related to changing technical and social paradigms in both individual perceptions of and interactions with personal health data, as well as social media and other data from the Internet, must be further addressed before such information can be integrated into official surveillance systems.

  March 06, 2014   doi: 10.1111/1468-0009.12038   open full text
• Shifting the Paradigm: Using HIV Surveillance Data as a Foundation for Improving HIV Care and Preventing HIV Infection.
  Patricia Sweeney, Lytt I. Gardner, Kate Buchacz, Pamela Morse Garland, Michael J. Mugavero, Jeffrey T. Bosshart, R. Luke Shouse, Jeanne Bertolli.
  Milbank Quarterly. July 08, 2013
  Context Reducing HIV incidence in the United States and improving health outcomes for people living with HIV hinge on improving access to highly effective treatment and overcoming barriers to continuous treatment. Using laboratory tests routinely reported for HIV surveillance to monitor individuals’ receipt of HIV care and contacting them to facilitate optimal care could help achieve these objectives. Historically, surveillance‐based public health intervention with individuals for HIV control has been controversial because of concerns that risks to privacy and autonomy could outweigh benefits. But with the availability of lifesaving, transmission‐interrupting treatment for HIV infection, some health departments have begun surveillance‐based outreach to facilitate HIV medical care. Methods Guided by ethics frameworks, we explored the ethical arguments for changing the uses of HIV surveillance data. To identify ethical, procedural, and strategic considerations, we reviewed the activities of health departments that are using HIV surveillance data to contact persons identified as needing assistance with initiating or returning to care. Findings Although privacy concerns surrounding the uses of HIV surveillance data still exist, there are ethical concerns associated with not using HIV surveillance to maximize the benefits from HIV medical care and treatment. Early efforts to use surveillance data to facilitate optimal HIV medical care illustrate how the ethical burdens may vary depending on the local context and the specifics of implementation. Health departments laid the foundation for these activities by engaging stakeholders to gain their trust in sharing sensitive information; establishing or strengthening legal, policy and governance infrastructure; and developing communication and follow‐up protocols that protect privacy. Conclusions We describe a shift toward using HIV surveillance to facilitate optimal HIV care. Health departments should review the considerations outlined before implementing new uses of HIV surveillance data, and they should commit to an ongoing review of activities with the objective of balancing beneficence, respect for persons, and justice.

  July 08, 2013   doi: 10.1111/milq.12018   open full text
• Rewarding Healthy Food Choices in SNAP: Behavioral Economic Applications.
  Michael R. Richards, Jody L. Sindelar.
  Milbank Quarterly. June 12, 2013
  Context American obesity rates continue to escalate, but an effective policy response remains elusive. Specific changes to the Supplemental Nutrition Assistance Program (SNAP) have been proposed as one way to improve nutrition and combat obesity among lower‐income populations. While current SNAP proposals hold promise, some important challenges still remain. Methods We discuss the four most common recommendations for changes to SNAP and their benefits and limitations. We then propose three new delivery options for SNAP that take advantage of behavioral economic insights and encourage the selection of healthy foods. Findings Although the existing proposals could help SNAP recipients, they often do not address some important behavioral impediments to buying healthy foods. We believe that behavioral economics can be used to design alternative policies with several advantages, although we recognize and discuss some of their limitations. The first proposal rewards healthy purchases with more SNAP funds and provides an additional incentive to maintain healthier shopping patterns. The second proposal uses the opportunity to win prizes to reward healthy food choices, and the prizes further support healthier habits. The final proposal simplifies healthy food purchases by allowing individuals to commit their SNAP benefits to more nutritious selections in advance. Conclusions Reforming the delivery structure of SNAP's benefits could help improve nutrition, weight, and overall health of lower‐income individuals. We advocate for more and diverse SNAP proposals, which should be tested and, possibly, combined. Their implementation, however, would require political will, administrative capacity, and funding.

  June 12, 2013   doi: 10.1111/milq.12017   open full text
• Understanding the Components of Quality Improvement Collaboratives: A Systematic Literature Review.
  ERUM NADEEM, S. SERENE OLIN, LAURA CAMPBELL HILL, KIMBERLY EATON HOAGWOOD, SARAH McCUE HORWITZ.
  Milbank Quarterly. June 12, 2013
  Context In response to national efforts to improve quality of care, policymakers and health care leaders have increasingly turned to quality improvement collaboratives (QICs) as an efficient approach to improving provider practices and patient outcomes through the dissemination of evidence‐based practices. This article presents findings from a systematic review of the literature on QICs, focusing on the identification of common components of QICs in health care and exploring, when possible, relations between QIC components and outcomes at the patient or provider level. Methods A systematic search of five major health care databases generated 294 unique articles, twenty‐four of which met our criteria for inclusion in our final analysis. These articles pertained to either randomized controlled trials or quasi‐experimental studies with comparison groups, and they reported the findings from twenty different studies of QICs in health care. We coded the articles to identify the components reported for each collaborative. Findings We found fourteen crosscutting components as common ingredients in health care QICs (e.g., in‐person learning sessions, phone meetings, data reporting, leadership involvement, and training in QI methods). The collaboratives reported included, on average, six to seven of these components. The most common were in‐person learning sessions, plan‐do‐study‐act (PDSA) cycles, multidisciplinary QI teams, and data collection for QI. The outcomes data from these studies indicate the greatest impact of QICs at the provider level; patient‐level findings were less robust. Conclusions Reporting on specific components of the collaborative was imprecise across articles, rendering it impossible to identify active QIC ingredients linked to improved care. Although QICs appear to have some promise in improving the process of care, there is great need for further controlled research examining the core components of these collaboratives related to patient‐ and provider‐level outcomes.

  June 12, 2013   doi: 10.1111/milq.12016   open full text
• The Effects of Quality of Care on Costs: A Conceptual Framework.
  Teryl K. Nuckols, José J. Escarce, Steven M. Asch.
  Milbank Quarterly. June 12, 2013
  Context The quality of health care and the financial costs affected by receiving care represent two fundamental dimensions for judging health care performance. No existing conceptual framework appears to have described how quality influences costs. Methods We developed the Quality‐Cost Framework, drawing from the work of Donabedian, the RAND/UCLA Appropriateness Method, reports by the Institute of Medicine, and other sources. Findings The Quality‐Cost Framework describes how health‐related quality of care (aspects of quality that influence health status) affects health care and other costs. Structure influences process, which, in turn, affects proximate and ultimate outcomes. Within structure, subdomains include general structural characteristics, circumstance‐specific (e.g., disease‐specific) structural characteristics, and quality‐improvement systems. Process subdomains include appropriateness of care and medical errors. Proximate outcomes consist of disease progression, disease complications, and care complications. Each of the preceding subdomains influences health care costs. For example, quality improvement systems often create costs associated with monitoring and feedback. Providing appropriate care frequently requires additional physician visits and medications. Care complications may result in costly hospitalizations or procedures. Ultimate outcomes include functional status as well as length and quality of life; the economic value of these outcomes can be measured in terms of health utility or health‐status‐related costs. We illustrate our framework using examples related to glycemic control for type 2 diabetes mellitus or the appropriateness of care for low back pain. Conclusions The Quality‐Cost Framework describes the mechanisms by which health‐related quality of care affects health care and health status–related costs. Additional work will need to validate the framework by applying it to multiple clinical conditions. Applicability could be assessed by using the framework to classify the measures of quality and cost reported in published studies. Usefulness could be demonstrated by employing the framework to identify design flaws in published cost analyses, such as omitting the costs attributable to a relevant subdomain of quality.

  June 12, 2013   doi: 10.1111/milq.12015   open full text
• The Redefinition of Aging in American Surgery.
  Mark D. Neuman, Charles L. Bosk.
  Milbank Quarterly. June 12, 2013
  Context Adults aged sixty‐five and over account for a large fraction of all surgeries performed in the United States each year. While historical growth in rates of surgery in this population is commonly attributed to financial incentives and technological innovations, the shifts in thought that underpinned the spread of surgery among the U.S. elderly remain largely unexplored. We examined changing perspectives on aging over time in American surgery through two case studies: the expansion of general surgical procedures among older U.S. adults between 1945 and 1965, and the spread of coronary artery bypass grafting (CABG) among the U.S. elderly between 1975 and 1995. Methods For this article, we used close readings of historical journal articles, textbook excerpts, survey reports, and government documents related to surgery and aging. Findings Similar perspectives on aging informed the spread of both general surgical procedures among older adults after World War II and CABG in the elderly from the mid‐1970s onward. In each case, surgeons argued against earlier views that surgery was contraindicated in old age using rhetoric that negated the relevance of age to medical decisions. Furthermore, surgeons elevated other types of information—such as the presence or absence of chronic diseases—to supplant age as an explanation for the high operative mortality rates seen among older patients. By stressing the modifiability of operative risk in the elderly, surgeons’ arguments positioned old age itself as a new surgical “frontier.” Conclusions Surgeons’ arguments for the expansion of surgery among the U.S. elderly over time worked to negate the relevance of age to medical decisions and to portray the wider use of surgery in the elderly as uniformly beneficial. While potentially promoting broader access to surgical care, such perspectives may also have contributed to ongoing health policy challenges by normalizing surgery at any stage in the life‐course, with implications for current patterns of surgical utilization and medical spending.

  June 12, 2013   doi: 10.1111/milq.12014   open full text
• Supporting Well‐Being in Retirement through Meaningful Social Roles: Systematic Review of Intervention Studies.
  Ben Heaven, Laura J.E. Brown, Martin White, Linda Errington, John C. Mathers, Suzanne Moffatt.
  Milbank Quarterly. June 12, 2013
  Context The marked demographic change toward greater proportions of older people in developed nations poses significant challenges for health and social care. Several studies have demonstrated an association between social roles in later life and positive health and well‐being outcomes. After retiring from work, people may lose roles that provide purpose and social contacts. The outcomes of interventions to promote social roles in retirement have not been systematically reviewed. Methods We examined three research questions: (1) What kinds of intervention have been developed to promote social roles in retirement? (2) How much have they improved perceived roles? (3) Have these roles improved health or well‐being? We included those studies that evaluated the provision of social roles; used a control or comparison group; targeted healthy retirement‐transition adults who were living in the community; provided an abstract written in English; took place in a highly developed nation; and reported social role, health, or well‐being outcomes. We searched eight electronic databases and combined the results with hand searches. Findings Through our searches, we identified 9,062 unique publications and eleven evaluative studies of acceptable quality, which reported seven interventions that met our inclusion criteria. These interventions varied in year of inception and scope, but only two were based outside North America. The studies rarely reported the quality or meaning of roles. Only three studies used random allocation, thus limiting inferences of causality from these studies. Interventions providing explicit roles and using supportive group structures were somewhat effective in improving one or more of the following: life satisfaction, social support and activity, physical health and activity, functional health, and cognition. Conclusions Social role interventions may improve health and well‐being for people in retirement transition. Future research should improve the quality of intervention and assessment and look at which interventions are most effective and acceptable in facilitating social roles for diverse older populations.

  June 12, 2013   doi: 10.1111/milq.12013   open full text