Do health systems respond to the quality of their competitors?

Objectives: Some large employers and healthcare analysts have advocated for retail competition that relies on providers competing on performance metrics to improve care quality. Using publicly available performance measures, we determined whether health systems increased the quality of diabetes care provided by their clinics based on performance relative to competitors.

Study Design: Our analysis examined publicly reported performance measures of diabetes care from 2006 to 2013 for clinics in Minnesota health systems.

From rhetoric to reality: consumer engagement in 16 multi-stakeholder alliances.

Objective: A key component of the Aligning Forces for Quality (AF4Q) program was engaging consumers in their health and healthcare. We examined the extent to which the alliances embraced 4 areas of consumer engagement: self-management, consumer friendliness of reports of healthcare provider quality, involvement of consumers in alliance governance, and the integration of consumers into quality improvement teams.

Methods: We used a largely qualitative approach.

Reporting provider performance: what can be learned from the experience of multi-stakeholder community coalitions?

Objectives: This analysis assessed the evolution of public reporting of provider performance in Aligning Forces for Quality (AF4Q) alliances, contrasted alliances that stopped reporting with those that plan to continue, and drew insights from alliance public reporting efforts for the national transparency movement.

Methods: Combined with document review, qualitative research methods were used to analyze interview data collected, over a nearly 10-year period, from the 16 participating alliances.

Results: AF4Q alliances made their greatest contributions to provider transparency in reporting ambulatory quality and patient experience measures.

The longitudinal impact of Aligning Forces for Quality on measures of population health, quality and experience of care, and cost of care.

Objective: To summarize the results from the quantitative analyses conducted during the summative evaluation of the Aligning Forces for Quality (AF4Q) initiative.

Study Design: Longitudinal design using linear difference-in-difference (DD) regression models with fixed effects. Outcomes were selected based on the AF4Q program logic model and organized according to the categories of the Triple Aim: improving population health, improving quality and experience of care, and reducing the cost of care.

Summative evaluation results and lessons learned from the Aligning Forces for Quality program.

Objective: To report summative evaluation results from the Aligning Forces for Quality (AF4Q) initiative, the Robert Wood Johnson Foundation's (RWJF's) signature effort to improve quality of care from 2005 to 2015.

Methods: This was a longitudinal mixed methods program evaluation (ie, multiphase triangulated evaluation) of 16 grantee "alliances" from across the country, funded by RWJF as part of the AF4Q initiative. Grantees were selected in a nonexperimental manner and were charged with deploying interventions in 5 main programmatic areas to improve health and healthcare in their communities.

The Aligning Forces for Quality initiative: background and evolution from 2005 to 2015.

Objective: The Robert Wood Johnson Foundation's (RWJF's) Aligning Forces for Quality (AF4Q) program was the largest privately funded, community-based quality improvement initiative to date, providing funds and technical assistance (TA) to 16 multi-stakeholder alliances located throughout the United States. This article describes the AF4Q initiative's underlying theory of change, its evolution over time, and the key activities undertaken by alliances.

Study Design: Descriptive overview of a multi-site, community-based quality improvement initiative.

Evaluating a complex, multi-site, community-based program to improve healthcare quality: the summative research design for the Aligning Forces for Quality initiative.

Objective: The Aligning Forces for Quality (AF4Q) initiative was the Robert Wood Johnson Foundation's (RWJF's) signature effort to increase the overall quality of healthcare in targeted communities throughout the country. In addition to sponsoring this 16-site complex program, RWJF funded an independent scientific evaluation to support objective research on the initiative's effectiveness and contributions to basic knowledge in 5 core programmatic areas. The research design, data, and challenges faced during the summative evaluation phase of this near decade-long program are discussed.

Is Anyone Paying Attention to Physician Report Cards? The Impact of Increased Availability on Consumers' Awareness and Use of Physician Quality Information.

Objective: To determine if the release of health care report cards focused on physician practice quality measures leads to changes in consumers' awareness and use of this information.

Primary Data Sources: Data from two rounds of a survey of the chronically ill adult population conducted in 14 regions across the United States, combined with longitudinal information from a public reporting tracking database. Both data were collected as part of the evaluation for Aligning Forces for Quality, a nationwide quality improvement initiative funded by the Robert Wood Johnson Foundation.

Referrals to integrative medicine in a tertiary hospital: findings from electronic health record data and qualitative interviews.

Objective: To examine patterns of, and decision-making processes, informing referrals for inpatient access to integrative medicine (IM) services at a large, acute care hospital.

Design: Retrospective electronic health record review and structured qualitative interviews.

Setting: A 630-bed tertiary care hospital with an IM service available to inpatients.

Do Health Systems Have Consistent Performance Across Locations and Is Consistency Associated With Higher Performance?

This study addresses whether health systems have consistent diabetes care performance across their ambulatory clinics and whether increasing consistency is associated with improvements in clinic performance. Study data included 2007 to 2013 diabetes care intermediate outcome measures for 661 ambulatory clinics in Minnesota and bordering states. Health systems provided more consistent performance, as measured by the standard deviation of performance for clinics in a system, relative to propensity score-matched proxy systems created for comparison purposes.

Health System Consolidation and Diabetes Care Performance at Ambulatory Clinics.

Objective: We addressed two questions regarding health system consolidation through the acquisition of ambulatory clinics: (1) Was increasing health system size associated with improved diabetes care performance and (2) Did the diabetes care performance of acquired clinics improve postacquisition?

Data Sources/study Setting: Six hundred sixty-one ambulatory clinics in Minnesota and bordering states that reported performance data from 2007 to 2013.

Study Design: We employed fixed effects regression to determine if increased health system size and being acquired improved clinics' performance. Using our regression results, we estimated the average effect of consolidation on the performance of clinics that were acquired during our study.

Practitioner Perspectives on Delivering Integrative Medicine in a Large, Acute Care Hospital.

Background. We describe the process and challenges of delivering integrative medicine (IM) at a large, acute care hospital, from the perspectives of IM practitioners. To date, minimal literature that addresses the delivery of IM care in an inpatient setting from this perspective exists.

Are healthcare quality "report cards" reaching consumers? Awareness in the chronically ill population.

Background: Significant investments have been made to provide comparative healthcare quality information (CQI) to the public, but whether these efforts are increasing awareness of CQI is unknown.

Objectives: To provide regional estimates of change in awareness of CQI among the chronically ill population residing in 14 geographic regions of the United States between 2008 and 2012. Additionally, to examine its correlation with the changes in the availability of quality reports.

Public reporting and the evolution of diabetes quality.

We address three questions related to public reports of diabetes quality. First, does clinic quality evolve over time? Second, does the quality of reporting clinics converge to a common standard? Third, how persistent are provider quality rankings across time? Since current methods of public reporting rely on historic data, measures of clinic quality are most informative if relative clinic performance is persistent across time. We use data from the Minnesota Community Measurement spanning 2007-2012.

What is the cost of quality for diabetes care?

Increasing the quality of care and reducing cost growth are core objectives of numerous private- and public-sector performance improvement initiatives. Using a unique panel data set for a commercially insured population and multivariate regression analysis, this study examines the relationship between medical care spending and diabetes-related quality measures, including provider-initiated processes of care and patient-dependent quality activities. Empirical evidence generated from this analysis of the relationship between a comprehensive set of diabetes quality measures and diabetes-related spending does not lend support for the assumption that high-quality preventive and primary care combined with effective patient self-management can lead to lower costs in the near term.

The dynamics of community health care consolidation: acquisition of physician practices.

Context: Health care delivery systems are becoming increasingly consolidated in urban areas of the United States. While this consolidation could increase efficiency and improve quality, it also could raise the cost of health care for payers. This article traces the consolidation trajectory in a single community, focusing on factors influencing recent acquisitions of physician practices by integrated delivery systems.

What influences the awareness of physician quality information? Implications for Medicare.

Objective: Examine the factors that are associated with awareness of physician quality information (PQI) among older people with one or more chronic illnesses and the implications for Medicare.

Data Sources/study Setting: Random digit-dial survey of adults with one or more chronic illnesses.

Research Design: Structural equation modeling to examine factors related to awareness of PQI.

Multistakeholder perspectives on composite measures of ambulatory care quality: a qualitative descriptive study.

The development of composite measures of ambulatory care quality is an area of growing practice and policy interest. Using 29 semistructured interviews, this study describes the opinions of stakeholders related to the use and development of composite measures in a multistakeholder setting. Research experts working in multistakeholder settings need to understand the perspective of various stakeholders, many of whom have varying levels of research expertise, in order to develop useful and acceptable composite measures.

Do electronic medical records improve diabetes quality in physician practices?

Objectives: To measure the effect of electronic medical records (EMRs) on a publicly reported composite measure indicating optimal diabetes care (ODC) rates in ambulatory settings.

Study Design: Data from Minnesota Community Measurement on 557 clinics were used, including information on ODC, EMR adoption, and clinic characteristics.

Methods: A difference-in-differences strategy was used to estimate the impact of EMR adoption on patient outcomes while controlling for observed and unobserved clinic characteristics.

Using websites to engage consumers in managing their health and healthcare.

Objective: This study provides insight into the potential of local community health information websites to cultivate and support consumer engagement through website positioning and content choices.

Study Design: This descriptive study compared health-related websites maintained by 16 multi-stakeholder community alliances charged with improving consumer engagement and public reporting of provider performance data.

Methods: We systematically assessed website messaging, content, and the presence of explicit connections among information and tools related to consumer engagement behaviors for 32 websites maintained by alliances as of November 2011.

Evaluating a community-based program to improve healthcare quality: research design for the Aligning Forces for Quality initiative.

Objective: The Aligning Forces for Quality (AF4Q) initiative is the Robert Wood Johnson Foundation's (RWJF's) signature effort to increase the overall quality of healthcare in targeted communities throughout the country. In addition to sponsoring this 16-site, complex program, the RWJF funds an independent scientific evaluation to support objective research on the initiative's effectiveness and contributions to basic knowledge in 5 core programmatic areas. The research design, data, and challenges faced in the evaluation of this 10-year initiative are discussed.

Producing public reports of physician quality at the community level: the Aligning Forces for Quality initiative experience.

Objectives: To describe the approaches used by the Aligning Forces for Quality (AF4Q) alliances in producing community-based reports of physician quality and to assess the contribution of these reports to existing physician performance information.

Study Design: The study included semi-structured interviews with alliance stakeholders and tracking of the number and content of physician performance reports in 14 AF4Q initiative communities and 7 comparison communities.

Methods: The study used qualitative analysis of interview data and systematic tracking of the number and content of physician performance reports over time.

Midterm observations and recommendations from the evaluation of the AF4Q initiative.

Objective: To offer midterm observations and recommendations based on how Aligning Forces for Quality (AF4Q) alliances are faring in their journey toward improving healthcare quality at the community level.

Study Design: This study used a mixed method design.

Methods: Longitudinal evaluation data to date were analyzed, including results from multiple surveys, qualitative analysis of key informant interviews, review of secondary documents and analysis of secondary data, and ongoing tracking of the activities of the 16 participating alliances.