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A commentary on "comparative health systems research among Kaiser Permanente and other integrated delivery systems: a systematic literature review".

In this issue of The Permanente Journal, Maeda et al enumerate the relative frequency at which articles on comparative health systems research are published about Kaiser Permanente (KP) and other integrated delivery systems. Searching PubMed and the KP Publications Library, they found that a mere 4% of publications met their criteria. This is unfortunate because well-organized systems are the foundation of effective health services delivery, and comparative health systems research to create these systems can greatly increase the value that Americans receive from their health care. After observing that the physicians he studied tended to practice very much like their colleagues despite differences in training and upbringing, Eliot Freidson concluded that “occupational organization ... constitutes a dimension quite as distinct and fully as important as its knowledge ... .” Having practiced medicine at many different sites over our careers, we have found that the organization of care in a particular location determined the services that we could offer the patient, the efficiency with which we provided those services, and the patient’s experience with the care that s/he received from us. Therefore, we would have to agree with Freidson—organizational context is a powerful determinant of clinical performance. The paucity of comparative health systems research relative to the overall investment in research represents a missed opportunity for research to contribute to the Triple Aim. Despite contributing nearly one-third of the international investment in biomedical research and spending more on health care than any other country, Americans receive a poor return on their investment. Americans die sooner and experience more illness than do residents of many other countries. In 2007, life expectancy at birth for US males was 17th of 17 peer countries; life expectancy for US females was 16th of 17 countries. We believe that these poor results are due, in part, to the paucity of comparative organizational research aimed at improving outcomes for individual patients and entire populations. This paucity also contributes to the persistence of inequitable care in America. Colorectal cancer screening rates are markedly lower for individuals of low economic and educational status. Additionally, in a large cohort of whites and African Americans, follow-up of colorectal abnormalities was significantly lower among the African Americans. Inequalities of care like these contribute to large differences in life expectancy, even in single metropolitan areas. In the Twin Cities, MN, for example, agestandardized mortality rates for American Indians are six times as high as they are for Asians. Life expectancy in some Twin Cities zip codes is equal to that of Armenia, Estonia, and Jordan, and it is exceeded by life expectancy in the Gaza Strip in the Middle East, in Romania, and in China. However, poor health outcomes and disparities do not need to be a part of American life. In a recent issue of The Permanente Journal, Tuso et al reported their analysis of the care processes that reduced the risk of readmission because of heart failure. They found that a complex case conference, along with a visit from a home health nurse and a follow-up visit with the patient’s physician reduced the risk of readmission by about 45%. Among the 21 patients for whom complete data were available and who were treated around the time of the study, there were 81 admissions in the 6 months before and 22 admissions in the 6 months after the complex case management conference was implemented, a reduction of 68%. HealthPartners in St Paul, MN, has used comparative health systems research to significantly reduce disparities in care while addressing screening targets for all patients. The tools that we have used include collecting language preference and racial identification from our patients, identifying and reporting the levels of care disparities, diagnosing the sources of the disparities, developing initiatives that address the particular causes of the disparities, and continuously monitoring the results with monthly report cards to assure ourselves that the new system is outperforming the prior system. For example, the gap in mammography rates between white women and women of color was 12.3 percentage points in 2007, and appointment no-show rates for women of color were high. We met with women in the community and learned that returning to the clinic for a second visit was a major barrier to mammography. We instituted a same-day mammography program and were able to decrease the disparity rate to 6.1 points by 2010 and 3.2 points by the fourth quarter of 2013 (unpublished written data available on request). Likewise, by offering multiple options for colorectal cancer screening (eg, fecal immunochemical test or colonoscopy) and actively promoting screening to patients of color, we have been able to reduce the