Comparative Health System Performance Initiative: Dartmouth College Center of Excellence

Principal Investigator

Ellen Meara, Ph.D.

Partners

• University of California at Berkeley.
• Harvard University.
• High Value Healthcare Collaborative.

Overview

The Dartmouth College Center of Excellence is studying the use of evidence-based innovations in health systems and their impact on healthcare quality, delivery, and costs. They are exploring how market and organizational factors influence the implementation of biomedical, care delivery, and patient engagement innovations.

In addition, the Dartmouth Center of Excellence has conducted the National Survey of Healthcare Organizations and Systems, which included responses from more than 3,300 healthcare leaders in practices, hospitals, and health systems. The survey asks leaders about the external environment, organizational characteristics, operational factors, and characteristics of healthcare innovations.

Aims

The aims of the Dartmouth Center of Excellence are to:

1. Identify, track, and characterize health systems by developing a taxonomy that will define the various types of health systems, hospitals, and physician organizations and their relationships with one another.
2. Develop measures of integration and identify how environmental factors influence the adoption of new payment models, levels of integration, and systematic use of evidence.
3. Identify mechanisms health systems use to influence adoption of evidence-based practices, reasons for and ways that different systems adopt these approaches, and effects of these approaches on performance.
4. Identify factors that influence the successful deployment of effective biomedical innovations, factors that help target innovations to those most likely to benefit from them, and approaches to eliminating outmoded or low-value care.
5. Evaluate factors that influence decisions to adopt healthcare delivery innovations and identify ways to improve the use of evidence-based care.
6. Identify factors that influence the adoption of innovations that enhance patient engagement or promote shared decision making and identify the impact of adoption on utilization, health outcomes, and cost.

The Dartmouth Center of Excellence is studying important clinical conditions to advance the understanding of factors that influence the implementation of healthcare innovations. It will identify potentially high-impact policy and organizational levers by:

• Examining factors that influence the use of specific innovations: (1) external environment, (2) characteristics of organizations that adopt the innovation, (3) mechanisms used to implement the innovation, and (4) characteristics of the innovation itself.
• Studying how the influence of these factors varies across different types of organizations.
• Distinguishing three major classes of innovation: (1) biomedical innovations that target specific diseases and are generally ordered or delivered by physicians, (2) care delivery innovations that target patient groups defined on the basis of function or illness severity and that are implemented largely by managers and teams, and (3) patient engagement innovations that focus on new ways patients and their caregivers interact with providers.

Research Projects

Dartmouth's Center of Excellence is conducting five research projects that focus on understanding characteristics of health systems, external environments in which they operate, and factors that affect their adoption of a wide range of healthcare innovations. The first two projects focus on understanding internal and external factors that drive the use of evidence within health systems:

1. External Influences on the Emergence of Integrated Systems seeks to evaluate how external environmental factors, such as payment and regulatory policies, influence clinical integration, adoption of new payment models, and ways organizations use evidence. This work includes developing measures of system integration and external environmental factors, identifying external factors that lead health systems to transition toward value-based payment, and testing whether adoption of value-based payment mechanisms is associated with the degree of system integration and integrated approaches to using evidence.
2. Deployment and Success of Internal Management and Incentive Mechanisms is identifying internal mechanisms physician organizations use to increase evidence-based practices, to better understand how certain characteristics of health systems encourage or discourage the use of evidence. This work involves measuring performance improvement mechanisms across different environmental and organizational contexts; and testing the association between incentive and management mechanisms and performance.

The remaining three projects identify factors that influence health systems' use of biomedical, care delivery, and patient engagement innovations and the impact on cost and quality of care:

3. Adoption and Use of Biomedical Innovations in Diverse Healthcare Systems is studying the environmental, organizational, and operational factors that influence the use of biomedical innovations, such as effective prescribing, which may or may not be well supported by evidence-based research. The study examines the links between these factors, use of biomedical innovations, and performance on outcomes and costs.
4. Adoption and Use of Care Delivery Innovations in Diverse Health Systems is studying the environmental, organizational, and operational factors that influence the use of care delivery innovations that target patients with multiple chronic conditions. The care delivery innovations of interest aim to reduce hospital readmissions and integrate behavioral health into primary care. The study also examines the links between the above factors, use of care delivery innovations, and performance on outcomes and costs for complex patients.
5. Adoption and Use of Patient Engagement Innovations in Diverse Healthcare Systems is studying the environmental, organizational, and operational factors that influence the use of innovations to enhance patient engagement. Examples of patient engagement innovations of interest include shared decision making, motivational interviewing, health coaching, and group visits. The study also examines the links between the above factors, use of patient engagement innovations, and performance on outcomes and costs.

Data Core

Dartmouth's Center of Excellence collected data from multiple sources to create a central repository for comprehensive data sources, robust statistical analyses, taxonomies of health systems, network measures, and performance measures. The five research projects described above draw on a range of data sources, including claims data, survey data, and qualitative interview data.

The Dartmouth-led team created claims databases using Medicare claims. To assess relationships between organizational characteristics, types of healthcare innovations, and patient outcomes, the team linked claims data with data from surveys. These surveys include the National Survey of Accountable Care Organizations, the National Study of Physician Organizations, the American Hospital Association Annual Hospital Survey, and the National Survey of Healthcare Organizations and Systems.

The Data Core also includes data from the High Value Healthcare Collaborative, Leavitt Partners, and IQVIA's OneKey database. Finally, qualitative data from interviews with health system leaders will provide further insight into why and how health system organizations adopt and implement innovations.

The Dartmouth Center of Excellence projects have a national focus and will use national claims and survey data. Analyses examine health system characteristics, integration, and performance, as well as data on healthcare innovations. In addition, some of the projects will focus on patients with specific conditions, as well as some of AHRQ's other priority populations, such as people with chronic care needs and people with multiple chronic conditions.