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Countywide Physician Organization Learning Collaborative and Changes in Hospitalization Rates

Brent D. Fulton, PhD, MBA; Susan L. Ivey, MD, MHSA; Hector P. Rodriguez, PhD, MPH; and Stephen M. Shortell, PhD, MPH, MBA
The University of Best Practices physician organization learning collaborative in San Diego County was associated with lower hospitalization rates for heart attacks.
Although a quasi-experimental research design using DID models is a strong design, results could be biased if another intervention or phenomenon occurred contemporaneously with the UBP that was also associated with hospitalization rates in San Diego County and/or the rest of California. Kaiser Permanente has started a number of statewide initiatives in California to improve cardiovascular and cerebrovascular care, such as the Prevent Heart Attacks and Strokes Everyday (“PHASE”) program and the Aspirin, Lisinopril and Lipid-Lowering Medication (“ALL”) initiative; however, we do not think these would bias our results because they began well before UBP’s start in 2011.35-38 Changes in the share of patients who experienced a heart attack, but did not survive to be admitted into the hospital, could also bias our results, but there is no reason to think this change would have occurred disproportionately in San Diego County. Also, stroke hospitalizations were more difficult to analyze because San Diego County’s 2010 age-adjusted hospitalization rate for strokes was a high outlier: its rate increased by 5.1% that year, just before the start of UBP, whereas the rest of California’s rate decreased by 0.3%. This could be one reason why the stroke findings were not significant and sensitive to different model specifications. Finally, we do not think hospital closures significantly contributed to lower hospitalization rates in San Diego County, because among the 16 hospitals in the county in 2007, only Fallbrook Hospital, a small, 47-bed hospital, closed during the study period, but not until November 2014. On the other hand, Palomar Medical Center, a 288-bed hospital, opened in August 2012.


Our study results suggest California RCI’s UBP physician organization learning collaborative in San Diego County was significantly associated with—and likely at least a partial cause of—a marked decline in the number of hospitalizations for heart attacks. No robust relationship was found for hospitalizations for strokes. Although our findings are not explicitly generalizable to other physician organization learning collaboratives, they could inform similar existing or new learning collaboratives, whose numbers are increasing.16-20 As the Medicare Access and CHIP Reauthorization Act expands value-based payment arrangements, physicians and their affiliated hospitals will have greater incentives to test different learning collaborative models to reduce hospitalizations via prevention and disease management strategies. Thus, efforts to extend learning collaborative models to other counties in California and elsewhere in the United States become especially important.

Author Affiliations: School of Public Health (BDF, SLI, HPR, SMS), and Haas School of Business (SMS), University of California, Berkeley, CA.

Source of Funding: This study was funded by the California Right Care Initiative (RCI). 

Author Disclosures: RCI is a collaborative of organizations that receives funds from donors and RCI partners that include multiple University of California campuses and other universities, the regional Medicare Quality Improvement Organization, California physician organizations, state and local public health professionals, health plans, grocery/pharmacy chains, consumer advocates, and pharmaceutical companies ( None of the donors nor any of the RCI partners participated in the study itself, except to review the manuscript for factual corrections. They had no input on the research design, methods, analysis, interpretation of the results, or writing the manuscript. The California Right Care Initiative hosts an annual meeting in which the authors regularly attend and present research findings. The authors received no honoraria or payment to attend these meetings. The authors report no other relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. 

Authorship Information: Concept and design (BDF, SLI, HPR, SMS); acquisition of data (BDF); analysis and interpretation of data (BDF, SLI, HPR, SMS); drafting of the manuscript (BDF, SLI); critical revision of the manuscript for important intellectual content (BDF, SLI, HPR, SMS); statistical analysis (BDF); obtaining funding (SLI). 

Address Correspondence to: Brent D. Fulton, PhD, MBA, University of California, Berkeley, 50 University Hall, MC7360, Berkeley, CA 94720. E-mail:  

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