Rodriguez Hector P, Henke Rachel Mosher, Bibi Salma, Ramsay Patricia P, Shortell Stephen M
Center for Healthcare Organizational and Innovation Research, University of California, Berkeley.
Division of Health Policy and Management, UC Berkeley School of Public Health.
Milbank Q. 2016 Sep;94(3):626-53. doi: 10.1111/1468-0009.12213.
Policy Points The rate of adoption of chronic care management processes (CMPs) by physician organizations has been fairly slow in spite of demonstrated effectiveness of CMPs in improving outcomes of chronic care. Exnovation (ie, removal of innovations) by physician organizations largely explains the slow population-level increases in practice use of CMPs over time. Expanded health information technology functions may aid practices in retaining CMPs. Low provider reimbursement by Medicaid programs, however, may contribute to disinvestment in CMPs by physician organizations.
Exnovation is the process of removal of innovations that are not effective in improving organizational performance, are too disruptive to routine operations, or do not fit well with the existing organizational strategy, incentives, structure, and/or culture. Exnovation may contribute to the low overall adoption of care management processes (CMPs) by US physician organizations over time.
Three national surveys of US physician organizations, which included common questions about organizational characteristics, use of CMPs, and health information technology (HIT) capabilities for practices of all sizes, and Truven Health Insurance Coverage Estimates were integrated to assess organizational and market influences on the exnovation of CMPs in a longitudinal cohort of 1,048 physician organizations. CMPs included 5 strategies for each of 4 chronic conditions (diabetes, asthma, congestive heart failure, and depression): registry use, nurse care management, patient reminders for preventive and care management services to prevent exacerbations of chronic illness, use of nonphysician clinicians to provide patient education, and quality of care feedback to physicians.
Over one-third (34.1%) of physician organizations exnovated CMPs on net. Quality of care data feedback to physicians and patient reminders for recommended preventive and chronic care were discontinued by over one-third of exnovators, while nurse care management and registries were largely retained. Greater proportions of baseline Medicaid practice revenue (incidence rate ratio [IRR] = 1.44, p < 0.001) and increasing proportions of revenue from Medicaid (IRR = 1.02, p < 0.05) were associated with greater CMP exnovation by physician organizations on net. Practices with greater expansion of HIT functionality exnovated fewer CMPs (IRR = 0.91, p < 0.001) compared to practices with less expansion of HIT functionality.
Exnovation of CMPs is an important reason why the population-level adoption of CMPs by physician organizations has remained low. Expanded HIT functions and changes to Medicaid reimbursement and incentives may aid the retention of CMPs by physician organizations.
政策要点 尽管慢性护理管理流程（CMPs）在改善慢性病护理结局方面已被证明有效，但医师组织采用这些流程的速度相当缓慢。医师组织的创新淘汰（即去除创新措施）在很大程度上解释了随着时间推移，CMPs在实际应用中人口层面增长缓慢的原因。扩展的健康信息技术功能可能有助于医疗机构保留CMPs。然而，医疗补助计划对医疗服务提供者的低报销额度可能导致医师组织减少对CMPs的投入。
创新淘汰是去除那些在改善组织绩效方面无效、对日常运营干扰过大或与现有组织战略、激励措施、结构和/或文化不太契合的创新措施的过程。随着时间的推移，创新淘汰可能导致美国医师组织对护理管理流程（CMPs）的总体采用率较低。
对美国医师组织进行了三项全国性调查，这些调查包括有关组织特征、CMPs的使用以及各种规模医疗机构的健康信息技术（HIT）能力的常见问题，并整合了Truven健康保险覆盖范围估计数据，以评估在一个由1048个医师组织组成的纵向队列中，组织和市场因素对CMPs创新淘汰的影响。CMPs包括针对4种慢性病（糖尿病、哮喘、充血性心力衰竭和抑郁症）各自的5种策略：使用登记册、护士护理管理、为预防和护理管理服务提供患者提醒以防止慢性病恶化、使用非医师临床人员提供患者教育以及向医师提供护理质量反馈。
超过三分之一（34.1%）的医师组织净淘汰了CMPs。超过三分之一的创新淘汰者停止了向医师提供护理质量数据反馈以及对推荐的预防和慢性病护理的患者提醒，而护士护理管理和登记册在很大程度上得以保留。更高比例 的基线医疗补助业务收入（发病率比[IRR]=1.44，p<0.001）以及不断增加的医疗补助收入比例（IRR=1.02，p<0.05）与医师组织更大比例的CMPs净创新淘汰相关。与HIT功能扩展较少的医疗机构相比，HIT功能扩展较多的医疗机构淘汰的CMPs较少（IRR=0.91，p<0.001）。
CMPs的创新淘汰是医师组织在人口层面采用CMPs率仍然较低的一个重要原因。扩展的HIT功能以及医疗补助报销和激励措施的改变可能有助于医师组织保留CMPs。
