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Rapid CommunicationSpecial Communications

Managing Patient Populations in Primary Care: Points of Leverage

Robert Eidus, Wilson D. Pace and Elizabeth W. Staton
The Journal of the American Board of Family Medicine March 2012, 25 (2) 238-244; DOI: https://doi.org/10.3122/jabfm.2012.02.100224
Robert Eidus
MD, MBA
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Wilson D. Pace
MD
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Elizabeth W. Staton
MSTC
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References

  1. 1.↵
    1. Heath I,
    2. Rubinstein A,
    3. Stange KC,
    4. van Driel ML
    . Quality in primary health care: a multidimensional approach to complexity. BMJ 2009;338:b1242.
    OpenUrlFREE Full Text
  2. 2.↵
    1. Nyweide DJ,
    2. Weeks WB,
    3. Gottlieb DJ,
    4. Casalino LP,
    5. Fisher ES
    . Relationship of primary care physicians' patient caseload with measurement of quality and cost performance. JAMA 2009;302:2444–50.
    OpenUrlCrossRefPubMedWeb of Science
  3. 3.↵
    1. Berwick DM
    . Measuring physicians' quality and performance: adrift on Lake Wobegon. JAMA 2009;302:2485–6.
    OpenUrlCrossRefPubMedWeb of Science
  4. 4.↵
    1. Dluhy RG,
    2. McMahon GT
    . Intensive Glycemic Control in the ACCORD and ADVANCE Trials. N Engl J Med 2008;358:2630–3.
    OpenUrlCrossRefPubMedWeb of Science
  5. 5.↵
    1. Gerstein HC,
    2. Miller ME,
    3. Byington RP,
    4. et al
    . Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med 2008;358:2545–59.
    OpenUrlCrossRefPubMedWeb of Science
  6. 6.↵
    1. Patel A,
    2. MacMahon S,
    3. et al
    ADVANCE Collaborative Group, Patel A, MacMahon S, et al. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 2008;358:2560–72.
    OpenUrlCrossRefPubMedWeb of Science
  7. 7.↵
    1. Campbell SM,
    2. Reeves D,
    3. Kontopantelis E,
    4. Sibbald B,
    5. Roland M
    . Effects of pay for performance on the quality of primary care in England. N Engl J Med 2009;361:368–78.
    OpenUrlCrossRefPubMedWeb of Science
  8. 8.↵
    1. Fleetcroft R,
    2. Cookson R
    . Do the incentive payments in the new NHS contract for primary care reflect likely population health gains? J Health Serv Res Policy 2006;11:27–31.
    OpenUrlAbstract/FREE Full Text
  9. 9.↵
    1. Holmboe E,
    2. Kim N,
    3. Cohen S,
    4. et al
    . Primary care physicians, office-based practice, and the meaning of quality improvement. Am J Med 2005;118:917–22.
    OpenUrlCrossRefPubMedWeb of Science
  10. 10.↵
    World Health Organization, SabatéE. Adherence to long-term therapies: evidence for action. Geneva: World Health Organization; 2003.
  11. 11.↵
    1. Piette JD,
    2. Richardson C,
    3. Valenstein M
    . Addressing the needs of patients with multiple chronic illnesses: the case of diabetes and depression. Am J Manag Care 2004;10(2 Pt 2):152–62.
    OpenUrlPubMedWeb of Science
  12. 12.↵
    1. Golden SH,
    2. Lazo M,
    3. Carnethon M,
    4. et al
    . Examining a bidirectional association between depressive symptoms and diabetes. JAMA 2008;299:2751–9.
    OpenUrlCrossRefPubMedWeb of Science
  13. 13.↵
    1. Noel PH,
    2. Williams JW Jr.,
    3. Unutzer J,
    4. et al
    . Depression and comorbid illness in elderly primary care patients: impact on multiple domains of health status and well-being. Ann Fam Med 2004;2:555–62.
    OpenUrlAbstract/FREE Full Text
  14. 14.↵
    1. Unutzer J,
    2. Schoenbaum M,
    3. Katon WJ,
    4. et al
    . Healthcare costs associated with depression in medically Ill fee-for-service medicare participants. J Am Geriatr Soc 2009;57:506–10.
    OpenUrlCrossRefPubMedWeb of Science
  15. 15.↵
    1. Kalsekar ID,
    2. Madhavan SM,
    3. Amonkar MM,
    4. et al
    . The effect of depression on health care utilization and costs in patients with type 2 diabetes. Manag Care Interface 2006;19:39–46.
    OpenUrlPubMed
  16. 16.↵
    Screening for depression in adults: U.S. preventive services task force recommendation statement. Ann Intern Med 2009;151:784–92.
    OpenUrlCrossRefPubMedWeb of Science
  17. 17.↵
    1. Corson K,
    2. Gerrity MS,
    3. Dobscha SK
    . Screening for depression and suicidality in a VA primary care setting: 2 items are better than 1 item. Am J Manag Care2004 2004;10(11 Pt 2):839–45.
    OpenUrlPubMedWeb of Science
  18. 18.↵
    1. Kroenke K,
    2. Spitzer RL,
    3. Williams JBW
    . The patient health questionnaire-2: Validity of a two-item depression screener. Med Care 2003;41:1284–92.
    OpenUrlCrossRefPubMedWeb of Science
  19. 19.↵
    Task Force on Community Preventive Services, Guide to Community Preventive Services. Mental health & mental illness: collaborative care for the management of depressive disorders. Atlanta, GA: Centers for Disease Control and Prevention; 2003. Available at: www.thecommunityguide.org/mentalhealth/collab-care.html. Accessed May 3, 2011.
  20. 20.↵
    1. Peters AL,
    2. Davidson MB
    . Application of a diabetes managed care program. The feasibility of using nurses and a computer system to provide effective care. Diabetes Care 1998;21:1037–43.
    OpenUrlAbstract/FREE Full Text
  21. 21.↵
    1. Bordley WC,
    2. Margolis PA,
    3. Stuart J,
    4. Lannon C,
    5. Keyes L
    . Improving preventive service delivery through office systems. Pediatrics 2001;108:E41.
    OpenUrlCrossRefPubMed
  22. 22.↵
    1. Renders CM,
    2. Valk GD,
    3. Griffin S,
    4. Wagner EH,
    5. Eijk JT,
    6. Assendelft WJ
    . Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings. Cochrane Database Syst Rev 2001;(1):CD001481.
  23. 23.↵
    Institute for Clinical Systems Improvement. The DIAMOND Initiative: depression improvement across Minnesota, offering a new direction. Bloomington, MN: Institute for Clinical Systems Improvement; 2008.
  24. 24.↵
    1. Nagpal K,
    2. Arora S,
    3. Abboudi M,
    4. et al
    . Postoperative handover: problems, pitfalls, and prevention of error. Ann Surg 2010;252:171–6.
    OpenUrlCrossRefPubMed
  25. 25.↵
    1. Petersen LA,
    2. Brennan TA,
    3. O'Neil AC,
    4. Cook EF,
    5. Lee TH
    . Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med 1994;121:866–72.
    OpenUrlCrossRefPubMedWeb of Science
  26. 26.↵
    1. Forster AJ,
    2. Murff HJ,
    3. Peterson JF,
    4. Gandhi TK,
    5. Bates DW
    . The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med 2003;138:161–7.
    OpenUrlCrossRefPubMedWeb of Science
  27. 27.↵
    1. Boult C,
    2. Reider L,
    3. Frey K,
    4. et al
    . Early effects of “Guided Care” on the quality of health care for multimorbid older persons: a cluster-randomized controlled trial. J Gerontol A Biol Sci Med Sci 2008;63:321–7.
    OpenUrlAbstract/FREE Full Text
  28. 28.↵
    1. West D,
    2. Pace WD,
    3. Dickinson LM,
    4. et al
    . Relationship between patient harm and reported medical errors in primary care: a report from the ASIPS Collaborative. Advances in Patient Safety 2. Rockville, MD: Agency for Healthcare Research and Quality; 2008.
  29. 29.↵
    1. Fernald DH,
    2. Pace WD,
    3. Harris DM,
    4. West DR,
    5. Main DS,
    6. Westfall JM
    . Event reporting to a primary care patient safety reporting system: a report from the ASIPS collaborative [see comment]. Ann Fam Med 2004;2:327–32.
    OpenUrlAbstract/FREE Full Text
  30. 30.↵
    1. Kripalani S,
    2. LeFevre F,
    3. Phillips CO,
    4. Williams MV,
    5. Basaviah P,
    6. Baker DW
    . Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA 2007;297:831–41.
    OpenUrlCrossRefPubMedWeb of Science
  31. 31.↵
    1. Liu CW,
    2. Einstadter D,
    3. Cebul RD
    . Care fragmentation and emergency department use among complex patients with diabetes. Am J Manag Care 2010;16(6):413–20.
    OpenUrlPubMed
  32. 32.↵
    1. Zweifler J
    . The missing link: improving quality with a chronic disease management intervention for the primary care office. Ann Fam Med 2007;5:453–6.
    OpenUrlAbstract/FREE Full Text
  33. 33.↵
    Kaiser Commission on Medicaid and the Uninsured. Community care of North Carolina: putting health reform ideas into practice in Medicaid (Publication 7899). Updated May 12, 2009. Available at: http://www.kff.org/medicaid/7899.cfm. Accessed May 3, 2011.
  34. 34.↵
    1. Paulus RA,
    2. Davis K,
    3. Steele GD
    . Continuous innovation in health care: implications of the Geisinger experience. Health Aff (Millwood) 2008;27:1235–45.
    OpenUrlAbstract/FREE Full Text
  35. 35.↵
    1. Wagner EH,
    2. Austin BT,
    3. Von Korff M
    . Organizing care for patients with chronic illness. Milbank Quarterly 1996;74:511–44.
    OpenUrlCrossRefPubMedWeb of Science
  36. 36.↵
    1. McGinnis BD,
    2. Olson KL,
    3. Delate TM,
    4. Stolcpart RS
    . Statin adherence and mortality in patients enrolled in a secondary prevention program. Am J Manag Care 2009;15:689–95.
    OpenUrlPubMedWeb of Science
  37. 37.↵
    1. Rothman RL,
    2. Malone R,
    3. Bryant B,
    4. et al
    . A randomized trial of a primary care-based disease management program to improve cardiovascular risk factors and glycated hemoglobin levels in patients with diabetes. Am J Med 2005;118:276–84.
    OpenUrlCrossRefPubMedWeb of Science
  38. 38.↵
    1. Merenich JA,
    2. Olson KL,
    3. Delate T,
    4. Rasmussen J,
    5. Helling DK,
    6. Ward DG
    . Mortality reduction benefits of a comprehensive cardiac care program for patients with occlusive coronary artery disease. Pharmacotherapy 2007;27:1370–8.
    OpenUrlCrossRefPubMedWeb of Science
  39. 39.↵
    1. Sluzki CE
    . Personal social networks and health: conceptual and clinical implications of their reciprocal impact. Fam Syst Health 2010;28:1–18.
    OpenUrlCrossRefPubMedWeb of Science
  40. 40.↵
    1. Shaw E,
    2. Levitt C,
    3. Wong S,
    4. Kaczorowski J
    . Systematic review of the literature on postpartum care: effectiveness of postpartum support to improve maternal parenting, mental health, quality of life, and physical health. Birth 2006;33:210–20.
    OpenUrlCrossRefPubMedWeb of Science
  41. 41.↵
    1. Saxena S,
    2. Misra T,
    3. Car J,
    4. Netuveli G,
    5. Smith R,
    6. Majeed A
    . Systematic review of primary healthcare interventions to improve diabetes outcomes in minority ethnic groups. J Ambul Care Manage 2007;30:218–30.
    OpenUrlPubMed
  42. 42.↵
    1. Roebuck MC,
    2. Liberman JN,
    3. Gemmill-Toyama M,
    4. Brennan TA
    . Medication adherence leads to lower health care use and costs despite increased drug spending. Health Aff (Millwood) 2011;30:91–9.
    OpenUrlAbstract/FREE Full Text
  43. 43.↵
    1. Cutler DM,
    2. Everett W
    . Thinking outside the pillbox–medication adherence as a priority for health care reform. N Engl J Med 2010;362:1553–5.
    OpenUrlCrossRefPubMedWeb of Science
  44. 44.↵
    1. Safran DG
    . Defining the future of primary care: what can we learn from patients? Ann Intern Med 2003;138:248–55.
    OpenUrlCrossRefPubMedWeb of Science
  45. 45.↵
    1. Scott JG,
    2. Cohen D,
    3. Dicicco-Bloom B,
    4. Miller WL,
    5. Stange KC,
    6. Crabtree BF
    . Understanding healing relationships in primary care. Ann Fam Med 2008;6:315–22.
    OpenUrlAbstract/FREE Full Text
  46. 46.↵
    1. Starfield B,
    2. Shi L
    . Primary care impact on health outcomes: a literature review. Milbank Q. In press.
  47. 47.↵
    1. Kerr S
    . On the folly of rewarding A, while hoping for B. Acad Manage J 1975;18:769–83.
    OpenUrlAbstract/FREE Full Text
  48. 48.↵
    1. Petersen LA,
    2. Woodard LD,
    3. Urech T,
    4. Daw C,
    5. Sookanan S
    . Does pay-for-performance improve the quality of health care? Ann Intern Med 2006;145:265–72.
    OpenUrlCrossRefPubMedWeb of Science
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The Journal of the American Board of Family     Medicine: 25 (2)
The Journal of the American Board of Family Medicine
Vol. 25, Issue 2
March-April 2012
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Managing Patient Populations in Primary Care: Points of Leverage
Robert Eidus, Wilson D. Pace, Elizabeth W. Staton
The Journal of the American Board of Family Medicine Mar 2012, 25 (2) 238-244; DOI: 10.3122/jabfm.2012.02.100224

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Managing Patient Populations in Primary Care: Points of Leverage
Robert Eidus, Wilson D. Pace, Elizabeth W. Staton
The Journal of the American Board of Family Medicine Mar 2012, 25 (2) 238-244; DOI: 10.3122/jabfm.2012.02.100224
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  • Article
    • Abstract
    • The Power of Data
    • A Better Alternative: High-Leverage Activities
    • Identification and Management of Depression
    • Management of Transitions of Care
    • Care Coordination
    • Team-based Care
    • Identification of the Socially Frail Individual
    • Pharmacologic Management
    • Establishment of the Therapeutic Environment
    • Implications of High-Leverage Activities in the Development of the Patient-Centered Medical Home Infrastructure
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