Proactive care management of AI-identified at-risk patients decreases preventable admissions.

Objectives: We assessed whether proactive care management for artificial intelligence (AI)-identified at-risk patients reduced preventable emergency department (ED) visits and hospital admissions (HAs).

Study Design: Stepped-wedge cluster randomized design.

Methods: Adults receiving primary care at 48 UCLA Health clinics and determined to be at risk based on a homegrown AI model were included.

Developing an electronic health record measure of low-value esophagogastroduodenoscopy for GERD at a large academic health system.

Objectives: Low-value esophagogastroduodenoscopies (EGDs) for uncomplicated gastro-oesophageal reflux disease (GERD) can harm patients and raise patient and payer costs. We developed an electronic health record (EHR) 'eMeasure' to detect low-value EGDs.

Design: Retrospective cohort of 518 adult patients diagnosed with GERD who underwent initial EGD between 1 January 2019 and 31 December 2019.

Exploring the Relationship Between Medication Adherence and Diabetes Disparities among Hispanic Patients in a Large Health System.

Background: Sub-optimal HbA1c control is a driver of disparities in diabetes outcomes among Hispanic patients. Differences in medication adherence may underlie racial/ethnic differences in HbA1c level.

Objective: To examine the relationship between medication adherence and disparities in HbA1c level among Hispanic patients, relative to other racial/ethnic groups, obtaining care in the University of California Health System (UC Health).

A Multisite Electronic Health Record Integrated Remote Monitoring Intervention for Hypertension Improvement: Protocol for a Randomized Pragmatic Comparative Effectiveness Trial.

Background: Hypertension is a major contributor to various adverse health outcomes. Although previous studies have shown the benefits of home blood pressure (BP) monitoring over office-based measurements, there is limited evidence comparing the effectiveness of whether a BP monitor integrated into the electronic health record is superior to a nonintegrated BP monitor.

Objective: In this paper, we describe the protocol for a pragmatic multisite implementation of a quality improvement initiative directly comparing integrated to nonintegrated BP monitors for hypertension improvement.

Pharmacist-Led Diabetes Control Intervention and Health Outcomes in Hispanic Patients With Diabetes.

Importance: Among patients with type 2 diabetes (T2D), Hispanic individuals are more likely than non-Hispanic White individuals to develop diabetes-related complications.

Objective: To examine the association of a pharmacist-led intervention (UCMyRx) with hemoglobin A1c (HbA1c) and systolic blood pressure (SBP) among Hispanic patients with T2D.

Design, Setting, And Participants: This quality improvement study used electronic health record data and a difference-in-differences study design to evaluate the association of UCMyRx exposure with changes in HbA1c concentration and SBP among Hispanic patients with T2D, relative to usual care, at University of California, Los Angeles primary care clinics between February and April of 2023.

Patient Experience with In-Person and Telehealth Visits Before and During the COVID-19 Pandemic at a Large Integrated Health System in the United States.

Background: Information about telehealth versus in-office visits and how patient experience before compared to during the COVID-19 pandemic is important for healthcare planning.

Objective: To compare patient experience by visit type and before and during the pandemic.

Design: Survey of patients assessing ambulatory care before and during the pandemic.

Protocol for pragmatic randomised trial: integrating electronic health record-based behavioural economic 'nudges' into the electronic health record to reduce preoperative testing for patients undergoing cataract surgery.

Introduction: Robust randomised trial data have shown that routine preoperative (pre-op) testing for cataract surgery patients is inappropriate. While guidelines have discouraged testing since 2002, cataract pre-op testing rates have remained unchanged since the 1990s. Given the challenges of reducing low-value care despite strong consensus around the evidence, innovative approaches are needed to promote high-value care.

Reducing Emergency Department Visits Among Patients With Diabetes by Embedding Clinical Pharmacists in the Primary Care Teams.

Background: Pharmacists are effective at improving control of cardiovascular risk factors, but it less clear whether these improvements translate into less emergency department (ED) use and fewer hospitalizations. The UCMyRx program embed pharmacists in primary care.

Objective: The objective of this study was to examine if the integration of pharmacists into primary care was associated with lower ED and hospital use for patients with diabetes.

The Population Health Value Framework: Creating Value by Reducing Costs of Care for Patient Subpopulations With Chronic Conditions.

Problem: With the growth in risk-based and accountable care organization contracts, creating value by redesigning care to reduce costs and improve outcomes and the patient experience has become an urgent priority for health care systems.

Approach: In 2016, UCLA (University of California, Los Angeles) Health implemented a system-wide population health approach to identify patient populations with high expenses and promote proactive, value-based care. The authors created the Patient Health Value framework to guide value creation: (1) identify patient populations with high expenses and reasons for spending, (2) create design teams to understand the patient story, (3) create custom analytics and spending-based risk stratification, and (4) develop care pathways based on spending risk tiers.

Differences in Consumer Assessment of Healthcare Providers and Systems Clinician and Group Survey Scores by Recency of the Last Visit: Implications for Comparability of Periodic and Continuous Sampling.

Background: Patient experience data can be collected by sampling patients periodically (eg, patients with any visits over a 1-year period) or sampling visits continuously (eg, sampling any visit in a monthly interval). Continuous sampling likely yields a sample with more frequent and more recent visits, possibly affecting the comparability of data collected under the 2 approaches.

Objective: To explore differences in Consumer Assessment of Healthcare Providers and Systems Clinician and Group survey (CG-CAHPS) scores using periodic and continuous sampling.

Improving Communication About Resuscitation Preference for Patients Discharged from Hospital to Nursing Home: A Quality Improvement Project.

Physician Orders for Life-Sustaining Treatment (POLST) can help ensure continuity of do-not-resuscitate (DNR) decisions and other care preferences after discharge from the hospital. We aimed to improve POLST completion rates for patients with DNR orders who were being discharged to a nursing home (NH) after an acute hospitalization at our institution. We implemented an interprofessional quality improvement intervention involving education, communication skills, and nursing and case manager cues regarding POLST use.

A Multi-Level Fit-Based Quality Improvement Initiative to Improve Colorectal Cancer Screening in a Managed Care Population.

Introduction: Colorectal cancer (CRC) is a common but largely preventable disease with suboptimal screening rates despite national guidelines to screen individuals age 50-75. Single-component interventions aimed to improve screening uptake only modestly improve rates; data suggest that multi-modal approaches may be more effective.

Methods: We designed, implemented, and evaluated the impact of a multi-modal intervention on CRC screening uptake among unscreened patients in a large managed care population.

The effect of implementing a care coordination program on team dynamics and the patient experience.

Objectives: Care coordination programs are frequently implemented in the redesign of primary care systems, focused on improving patient outcomes and reducing utilization. However, redesign can be disruptive, affect patient experiences, and undermine elements in the patient-centered medical home, such as team-based care.

Study Design: Case-controlled study with difference-in-differences (DID) and cross-sectional analyses.

Effect and Efficiency of an Embedded Palliative Care Nurse Practitioner in an Oncology Clinic.

Purpose: To test a simultaneous care model for palliative care for patients with advanced cancer by embedding a palliative care nurse practitioner (NP) in an oncology clinic.

Methods: We evaluated the effect of the intervention in two oncologists' clinics beginning March 2014 by using implementation strategies, including use of a structured referral mechanism, routine symptom screening, integration of a psychology-based cancer supportive care center, implementation team meetings, team training, and a metrics dashboard for continuous quality improvement. After 1 year of implementation, we evaluated key process and outcome measures for supportive oncology and efficiency of the model by documenting tasks completed by the NP during a subset of patient visits and time-motion studies.

Physician experiences with clinical pharmacists in primary care teams.

Background: Improving medication management is an important component of comprehensive care coordination for health systems. The Managing Your Medication for Education and Daily Support (MyMeds) medication management program at the University of California Los Angeles addresses medication management issues by embedding trained clinical pharmacists in primary care practice teams.

Objectives: The aim of this work was to examine and explore physician opinions about the clinical pharmacist program and identify common themes among physician experiences as well as barriers to integration of clinical pharmacists into primary care practice teams.

Delivering On Accountable Care: Lessons From A Behavioral Health Program To Improve Access And Outcomes.

Patients with behavioral health disorders often have worse health outcomes and have higher health care utilization than patients with medical diseases alone. As such, people with behavioral health conditions are important populations for accountable care organizations (ACOs) seeking to improve the efficiency of their delivery systems. However, ACOs have historically faced numerous barriers in implementing behavioral health population-based programs, including acquiring reimbursement, recruiting providers, and integrating new services.

Innovative approach to patient-centered care coordination in primary care practices.

Objectives: Although care coordination is an essential component of the patient-centered medical home structure, current case manager models have limited usefulness to population health because they typically serve a small group of patients defined based on disease or utilization. Our objective was to support our health system's population health by implementing and evaluating a program that embedded nonlicensed coordinators within our primary care practices to support physicians in executing care plans and communicating with patients.

Study Design: Matched case-control differences-in-differences.

Building the Infrastructure for Value at UCLA: Engaging Clinicians and Developing Patient-Centric Measurement.

Problem: Evolving payer and patient expectations have challenged academic health centers (AHCs) to improve the value of clinical care. Traditional quality approaches may be unable to meet this challenge.

Approach: One AHC, UCLA Health, has implemented a systematic approach to delivery system redesign that emphasizes clinician engagement, a patient-centric scope, and condition-specific, clinician-guided measurement.

Specialties differ in which aspects of doctor communication predict overall physician ratings.

Background: Effective doctor communication is critical to positive doctor-patient relationships and predicts better health outcomes. Doctor communication is the strongest predictor of patient ratings of doctors, but the most important aspects of communication may vary by specialty.

Objective: To determine the importance of five aspects of doctor communication to overall physician ratings by specialty.

Cervical cancer screening overuse and underuse: patient and physician factors.

Objectives: Despite recommendations for triennial cervical cancer screening for low-risk women 30 years and older, annual screening remains common. We studied how often women receiving care from an academically affiliated medical group were screened, and patient and provider factors associated with overuse and underuse. We also explored the impact of changing measurement intervals on computed screening frequency.

Differences in CAHPS reports and ratings of health care provided to adults and children.

Background: Consumer assessment of health care is an important metric for evaluating quality of care. These assessments can help purchasers, health plans, and providers deliver care that fits patients' needs.

Objective: To examine differences in reports and ratings of care delivered to adults and children and whether they vary by site.