Visit Entropy Associated with Diabetic Control Outcomes

Abstract

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.

Measures of care fragmentation: Mathematical insights from population genetics

“…We also note that the approach we have used has potential applications for other fragmentation measures. For example, recent studies have examined “visit entropy” using a measure closely related to entropy statistics from population genetics that have been studied in a similar way to the analogues of UPC and COCI . Examining the mathematical relationship between UPC and visit entropy could further shed light on the distinct contributions of different measures and combinations of measures.…”

Quantifying organization of care in a complex healthcare environment

“…Put another way, disorganized care is as important as the history of myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, or diabetes without end‐organ damage to hospital readmission risk. Likewise, Dilger et al showed, higher VE is associated with reduced odds of meeting diabetic quality metrics (OR = 0.88) 21 . Their study showed that a single unit increase in disorganized care (equivalent to seeing three different physicians vs seeing the same primary physician three times) as measured by VE produces a 47% lower probability of a controlled D5 metric (a1c < 8.0, blood pressure < 140/90, on statin, non‐smoker, on anti‐platelet agent).…”

“…In fact, almost half of primary care patients do not visit their primary care physician's office in a given year 19 . This results in a division by zero error making the calculation of these indexes undefined, often resulting in the elimination of significant number of patients from studies 15,20,21 . The problem is worse for COC and SECON which require at least two visits.…”

“…Likewise, visit pattern H where the patient sees their primary physician four times has more continuity than visit pattern B or E where they only see their primary physician once or twice. COC is undefined for pattern B and does not distinguish between pattern H and pattern E. Thus, in a Patient‐centred medical home (PCMH) operating under the team‐based care recommended for chronic disease management by Brodenheimer et al, traditional continuity measures will be indistinguishable from situations with little organization of care and may be erroneously reduced 21‐23 …”

Practice-Based Research Today: A Changing Primary Care Landscape Requires Changes in Practice-Based Research Network (PBRN) Research

“…The other original research articles in this issue remind us that not all practice-based research takes place in PBRNs. Using EHR data from 5 practices, Dilger et al 16 posit that visit entropy is a better measure of care organization and is associated with better diabetic quality scores. And reporting on just a single practice, Morcos 17 presents compelling evidence for the importance of taking the blood pressure the right way in daily office practice, an oftenoverlooked component of quality care.…”