Background: Chronic diseases such as type 2 diabetes place a large burden on the health care system and are associated with increased morbidity and mortality. A team-based multidisciplinary approach that organizes care to improve chronic disease management may actually decrease traditional continuity of care metrics. Visit entropy (VE) provides a novel measure of care organization produced by teambased approaches. Higher VE, reflecting more disorganized care, has been associated with more hospital readmissions. We hypothesized that higher VE was also associated with reduced adherence to the D5 quality criteria. Methods: A retrospective study of 6590 adult diabetic patients in 5 established medical home practices was conducted. Multivariate logistic regression was used to determine if VE was associated with the dependent variable of D5 control. Separate models for usual provider continuity, continuity of care index, and sequence continuity were also constructed. Results: Less organized care with a higher VE was associated with decreased odds of D5 control (odds ratio ؍ 0.88; 95% confidence interval, 0.80 to 0.97). The other continuity measures were not significant. Age, education level, and initial HgA1c were significant covariates, but sex, race, endocrine consults, and Charlson comorbidity were not significant. The Number Needed to be Exposed to more organized care to produce 1 more controlled diabetic was 32.5. Conclusions: More organized care reflected by a lower VE is associated with improved odds of D5 diabetic control. VE represents a better measure of care organization in team-based medical home environments than traditional continuity of care metrics.
Introduction True penicillin allergy is rare and is commonly incorrectly reported. In fact, less than five percent of patients who report a penicillin allergy will have a currently active clinically-significant IgE- or T-cell-mediated hypersensitivity when appropriately tested. Penicillin is the agent of choice for intrapartum antibiotic prophylaxis to reduce the risk of group B streptococcus early-onset disease in the newborn. Inaccurate penicillin allergy status may lead to inappropriate antibiotic use, as most alternative drugs are more expensive and broader spectrum than penicillin. Penicillin allergy testing has been found to be safe in pregnancy and cost-effective in other patient populations. Objective To evaluate the cost-effectiveness of penicillin allergy testing and appropriate antibiotic treatment (test then treat strategy) compared to usual care among pregnant women. Methods We developed a decision tree to evaluate the cost of providing appropriate care via a test then treat strategy for pregnant women who report a penicillin allergy, compared to usual care. Results Using the test then treat strategy the additional cost to ensure appropriate care for all pregnant women who report a penicillin allergy, was $1122.38 per person. Adopting a test then treat strategy increased the number of appropriate antibiotic use from 7,843/10,000 to 10,000/10,000 simulations. Conclusion Our results show that a test then treat strategy for pregnant women who report a penicillin allergy is a good-value intervention.
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