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Ozcan BB, Dogan BE, Mootz AR, Hayes JC, Seiler SJ, Schopp J, Kitchen DL, Porembka JH. Breast Cancer Disparity and Outcomes in Underserved Women. Radiographics 2024; 44:e230090. [PMID: 38127658 DOI: 10.1148/rg.230090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Women in the United States who continue to face obstacles accessing health care are frequently termed an underserved population. Safety-net health care systems play a crucial role in mitigating health disparities and reducing burdens of disease, such as breast cancer, for underserved women. Disparities in health care are driven by various factors, including race and ethnicity, as well as socioeconomic factors that affect education, employment, housing, insurance status, and access to health care. Underserved women are more likely to be uninsured or underinsured throughout their lifetimes. Hence they have greater difficulty gaining access to breast cancer screening and are less likely to undergo supplemental imaging when needed. Therefore, underserved women often experience significant delays in the diagnosis and treatment of breast cancer, leading to higher mortality rates. Addressing disparities requires a multifaceted approach, with formal care coordination to help at-risk women navigate through screening, diagnosis, and treatment. Mobile mammography units and community outreach programs can be leveraged to increase community access and engagement, as well as improve health literacy with educational initiatives. Radiology-community partnerships, comprised of imaging practices partnered with local businesses, faith-based organizations, homeless shelters, and public service departments, are essential to establish culturally competent breast imaging care, with the goal of equitable access to early diagnosis and contemporary treatment. Published under a CC BY 4.0 license. Test Your Knowledge questions are available in the Online Learning Center. See the invited commentary by Leung in this issue.
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Affiliation(s)
- B Bersu Ozcan
- From the Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, MC 8896, Dallas, TX 75390-8896
| | - Başak E Dogan
- From the Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, MC 8896, Dallas, TX 75390-8896
| | - Ann R Mootz
- From the Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, MC 8896, Dallas, TX 75390-8896
| | - Jody C Hayes
- From the Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, MC 8896, Dallas, TX 75390-8896
| | - Stephen J Seiler
- From the Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, MC 8896, Dallas, TX 75390-8896
| | - Jennifer Schopp
- From the Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, MC 8896, Dallas, TX 75390-8896
| | - Deanna L Kitchen
- From the Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, MC 8896, Dallas, TX 75390-8896
| | - Jessica H Porembka
- From the Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, MC 8896, Dallas, TX 75390-8896
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Song Z, Kannan S, Gambrel RJ, Marino M, Vaduganathan M, Clapp MA, Seiglie JA, Bloom PP, Malik AN, Resnick MJ. Physician Practice Pattern Variations in Common Clinical Scenarios Within 5 US Metropolitan Areas. JAMA HEALTH FORUM 2022; 3:e214698. [PMID: 35977237 PMCID: PMC8903123 DOI: 10.1001/jamahealthforum.2021.4698] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 11/19/2021] [Indexed: 11/29/2022] Open
Abstract
Question To what extent do physician-level variations in the appropriateness or quality of care exist within metropolitan areas, notably among specialists? Findings In this cross-sectional study of 8788 physicians across 7 specialties in 5 US metropolitan areas, sizeable physician-level practice pattern variations were evident across 14 common clinical scenarios where practice guidelines and clinical evidence can help discern, on average, the appropriateness or quality of clinical decisions. Variations were robust to adjustment for patient and area-level characteristics, and measure reliability was generally high. Meaning Within-area physician-level variations in practice patterns were qualitatively similar across clinical scenarios, despite practice guidelines designed to reduce variation. Importance While variations in quality of care have been described between US regions, physician-level practice pattern variations within regions remain poorly understood, notably among specialists. Objective To examine within-area physician-level variations in decision-making in common clinical scenarios where guidelines specifying appropriateness or quality of care exist. Design, Setting, and Participants This cross-sectional study used 2016 through 2019 data from a large nationwide network of commercial insurers, provided by Health Intelligence Company, LLC, within 5 metropolitan statistical areas (MSAs). Physician-level variations in appropriateness and quality of care were measured using 14 common clinical scenarios involving 7 specialties. The measures were constructed using public quality measure definitions, clinical guidelines, and appropriateness criteria from the clinical literature. Physician performance was calculated using a multilevel model adjusted for patient age, sex, risk score, and socioeconomic status with physician random effects. Measure reliability for each physician was calculated using the signal-to-noise approach. Within-MSA variation was calculated between physician quintiles adjusted for patient attributes, with the first quintile denoting highest quality or appropriateness and the fifth quintile reflecting the opposite. Data were analyzed March through October 2021. Main Outcomes and Measures Fourteen measures of quality or appropriateness of care, with 2 measures each in the domains of cardiology, endocrinology, gastroenterology, pulmonology, obstetrics, orthopedics, and neurosurgery. Results A total of 8788 physicians were included across the 5 MSAs, and about 2.5 million unique patient-physician pairs were included in the measures. Within the 5 MSAs, on average, patients in the measures were 34.7 to 40.7 years old, 49.1% to 52.3% female, had a mean risk score of 0.8 to 1.0, and more likely to have an employer-sponsored insurance plan that was either self-insured or fully insured (59.8% to 97.6%). Within MSAs, physician-level variations were qualitatively similar across measures. For example, statin therapy in patients with coronary artery disease ranged from 54.3% to 70.9% in the first quintile of cardiologists to 30.5% to 42.6% in the fifth quintile. Upper endoscopy in patients with gastroesophageal reflux disease without alarm symptoms spanned 14.6% to 16.9% in the first quintile of gastroenterologists to 28.2% to 33.8% in the fifth quintile. Among patients with new knee or hip osteoarthritis, 2.1% to 3.4% received arthroscopy in the first quintile of orthopedic surgeons, whereas 25.5% to 30.7% did in the fifth quintile. Appropriate prenatal screening among pregnant patients ranged from 82.6% to 93.6% in the first quintile of obstetricians to 30.9% to 65.7% in the fifth quintile. Within MSAs, adjusted differences between quintiles approximated unadjusted differences. Measure reliability, which can reflect consistency and reproducibility, exceeded 70.0% across nearly all measures in all MSAs. Conclusions and Relevance In this cross-sectional study of 5 US metropolitan areas, sizeable physician-level practice variations were found across common clinical scenarios and specialties. Understanding the sources of these variations may inform efforts to improve the value of care.
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Affiliation(s)
- Zirui Song
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston
| | - Sneha Kannan
- Department of Medicine, Massachusetts General Hospital, Boston
| | | | | | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Mark A. Clapp
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston
| | - Jacqueline A. Seiglie
- Department of Medicine, Massachusetts General Hospital, Boston
- Diabetes Unit, Massachusetts General Hospital, Boston
| | | | - Athar N. Malik
- Department of Neurosurgery, Massachusetts General Hospital, Boston
| | - Matthew J. Resnick
- Embold Health, Nashville, Tennessee
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee
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Abstract
It may seem unlikely that the field of radiology perpetuates disparities in health care, as most radiologists never interact directly with patients, and racial bias is not an obvious factor when interpreting images. However, a closer look reveals that imaging plays an important role in the propagation of disparities. For example, many advanced and resource-intensive imaging modalities, such as MRI and PET/CT, are generally less available in the hospitals frequented by people of color, and when they are available, access is impeded due to longer travel and wait times. Furthermore, their images may be of lower quality, and their interpretations may be more error prone. The aggregate effect of these imaging acquisition and interpretation disparities in conjunction with social factors is insufficiently recognized as part of the wide variation in disease outcomes seen between races in America. Understanding the nature of disparities in radiology is important to effectively deploy the resources and expertise necessary to mitigate disparities through diversity and inclusion efforts, research, and advocacy. In this article, the authors discuss disparities in access to imaging, examine their causes, and propose solutions aimed at addressing these disparities.
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Affiliation(s)
- Stephen Waite
- From the Department of Radiology, SUNY Downstate Medical Center, 450 Clarkson Ave, Brooklyn, NY 11203 (S.W., J.M.S.); and Department of Psychiatry, Weill Cornell Medical College, New York, NY (D.C.)
| | - Jinel Scott
- From the Department of Radiology, SUNY Downstate Medical Center, 450 Clarkson Ave, Brooklyn, NY 11203 (S.W., J.M.S.); and Department of Psychiatry, Weill Cornell Medical College, New York, NY (D.C.)
| | - Daria Colombo
- From the Department of Radiology, SUNY Downstate Medical Center, 450 Clarkson Ave, Brooklyn, NY 11203 (S.W., J.M.S.); and Department of Psychiatry, Weill Cornell Medical College, New York, NY (D.C.)
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Hung YC, Westfal ML, Chang DC, Kelleher CM. Lack of Data-driven Treatment Guidelines and Wide Variation in Management of Chronic Pelvic Pain in Adolescents and Young Adults. J Pediatr Adolesc Gynecol 2020; 33:349-353.e1. [PMID: 32259629 DOI: 10.1016/j.jpag.2020.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 03/20/2020] [Accepted: 03/27/2020] [Indexed: 01/28/2023]
Abstract
STUDY OBJECTIVE Current literature lacks data-driven guidelines for surgical treatment of adolescent and young adult (AYA) patients with chronic pelvic pain. We hypothesized that there is a significant variation in treatment of these patients, which might be an indicator of over- or undertreatment by some providers. DESIGN AND SETTING We completed a retrospective population-based analysis of the Nationwide Inpatient Sample from 1998 to 2016. PARTICIPANTS We included AYA patients aged 9-25 years whose primary diagnosis was adenomyosis, endometriosis, or chronic pelvic pain. Patients who might have undergone pelvic or abdominal procedures for other primary diagnoses were excluded. INTERVENTIONS AND MAIN OUTCOME MEASURES Trends of inpatient surgical intervention were calculated. Logistic regression was performed to determine the likelihood of undergoing an intervention, adjusted for patient demographic characteristics. RESULTS A total of 13,111 AYA patients were analyzed. Median age at diagnosis was 22 (interquartile range, 20-24) years. The overall inpatient intervention rate was 5879/13111 (45.0%) (2445/5897 (18.6%) for excision/ablation, 2057/5897 (15.7%) for hysterectomy, 1239/5897 (9.5%) for diagnostic laparoscopy, and 156/5897 (1.2%) for biopsy). Rate of hysterectomy increased in the late 2000s while rates of all other interventions decreased. Patients in the northeast were less likely to undergo an intervention than patients in the rest of the country. Rates of intervention also differed according to race, insurance status, and type of hospital. CONCLUSION There is wide variation in the use of surgical treatment for chronic pelvic pain in AYA patients across the country and between types of institutions. Of concern, the rate of hysterectomy has increased over time. There is a need for data-directed treatment guidelines for the management of AYA patients with chronic pelvic pain to ensure appropriate application of surgical treatments and expand high-value surgical care.
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Affiliation(s)
- Ya-Ching Hung
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts; Department of Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Maggie L Westfal
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Cassandra M Kelleher
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts; Department of Pediatric Surgery, MassGeneral Hospital for Children, Boston, Massachusetts.
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Asemota AO, Ishii M, Brem H, Gallia GL. Geographic Variation in Costs of Transsphenoidal Pituitary Surgery in the United States. World Neurosurg 2020; 149:e1180-e1198. [PMID: 32145414 DOI: 10.1016/j.wneu.2020.02.145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 02/22/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND Geographic variations in health care costs have been reported for many surgical specialties. OBJECTIVE In this study, we sought to describe national and regional costs associated with transsphenoidal pituitary surgery (TPS). METHODS Data from the Truven-MarketScan 2010-2014 were analyzed. We examined overall total, hospital/facility, physician, and out-of-pocket payments in patients undergoing TPS including technique-specific costs. Mean payments were obtained after risk adjustment for patient-level and system-level confounders and estimated differences across regions. RESULTS The estimated overall annual burden was $43 million/year in our cohort. The average overall total payment associated with TPS was $35,602.30, hospital/facility payment was $26,980.45, physician payment was $4685.95, and out-of-pocket payment was $2330.78. Overall total and hospital/facility costs were highest in the West and lowest in the South (both P < 0.001), whereas physician reimbursements were highest in the North-east and lowest in the South (P < 0.001). There were no differences in out-of-pocket expenses across regions. On a national level, there were significantly higher overall total and hospital/facility payments associated with endoscopic compared with microscopic procedures (both P < 0.001); there were no significant differences in physician payments or out-of-pocket expenses between techniques. There were also significant within-region cost differences in overall total, hospital/facility, and physician payments in both techniques as well as in out-of-pocket expenses associated with microsurgery. There were no significant regional differences in out-of-pocket expenses associated with endoscopic surgery. CONCLUSIONS Our results show significant geographic cost disparities associated with TPS. Understanding factors behind disparate costs is important for developing cost containment strategies.
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Affiliation(s)
- Anthony O Asemota
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Masaru Ishii
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Henry Brem
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Gary L Gallia
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA.
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Lin D, Liu S, Ruhm CJ. Opioid Deaths and Local Healthcare Intensity: A Longitudinal Analysis of the U.S. Population, 2003-2014. Am J Prev Med 2020; 58:50-58. [PMID: 31862102 DOI: 10.1016/j.amepre.2019.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 09/08/2019] [Accepted: 09/09/2019] [Indexed: 12/28/2022]
Abstract
INTRODUCTION This study examines the association between local healthcare intensity and drug death rates. METHODS County-level drug death rates were computed for 2003-2014 using vital statistics data adjusted for incomplete reporting of drug involvement. A county-level healthcare intensity index was constructed using Dartmouth Atlas of Health Care data. Linear regression and dose-response models were estimated for all residents and for population subgroups to analyze the relationship between healthcare intensity and drug death rates, as well as for 7 indicators of healthcare quality. Data collection and analysis were conducted in 2018 and 2019. RESULTS Linear estimates indicated a positive correlation between healthcare intensity and opioid-involved drug death rates. Dose-response models revealed that the association was especially pronounced for the 2 highest healthcare intensity quintiles. Moving from the lowest to the highest healthcare intensity quintile was associated with a 2.14 (95% CI=1.56, 2.72) per 100,000 rise in opioid-involved drug death rates and a 25.1% (95% CI=18.3%, 31.9%) increase from the base rate of 8.54 per 100,000. Corresponding associations were larger in absolute terms for individuals who were male, white, aged 20-44 years, and not college educated than for their counterparts, but similar in percentages, except for 2 minority racial groups and seniors. Non-opioid drug death rates were unrelated to healthcare intensity. High healthcare intensity was associated with worse healthcare quality for 6 of 7 indicators. CONCLUSIONS In the U.S., between 2003 and 2014, high medical care intensity was associated with elevated opioid death rates and lower healthcare quality.
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Affiliation(s)
- Dajun Lin
- American Institutes for Research, Arlington, Virginia
| | - Siying Liu
- Department of Economics and the Eudaimonia Institute, Wake Forest University, Winston-Salem, North Carolina
| | - Christopher J Ruhm
- Frank Batten School of Leadership and Public Policy, University of Virginia, Charlottesville, Virginia.
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Westert GP, Groenewoud S, Wennberg JE, Gerard C, DaSilva P, Atsma F, Goodman DC. Medical practice variation: public reporting a first necessary step to spark change. Int J Qual Health Care 2018; 30:731-735. [PMID: 29718369 PMCID: PMC6307331 DOI: 10.1093/intqhc/mzy092] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 03/02/2018] [Accepted: 04/14/2018] [Indexed: 01/15/2023] Open
Abstract
From previous work, we know that medical practice varies widely, and that unwarranted variation signals low value for patients and society. We also know that public reporting helps to create awareness of the need for quality improvement. Despite the availability of rich data, most Western countries have no routine surveillance of the geographic distribution of utilization, costs, and outcomes of healthcare, including trends in variation over time. This paper highlights the role of transparent public reporting as a necessary first step to spark change and reduce unwarranted variation. Two recent examples of public reporting are presented to illustrate possible ways to reduce unwarranted variation and improve care. We conclude by introducing the Value Improvement Cycle, which underscores that reporting is only a necessary first step, and suggests a path toward developing a multi-stakeholder approach to change.
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Affiliation(s)
- Gert P Westert
- Radboud University Medical Center/Radboud Institute for Health Sciences/Scientific Center for Quality of Healthcare (IQ healthcare), 114 IQ healthcare, 6500 HB Nijmegen Geert Grooteplein 21, Nijmegen, The Netherlands
| | - Stef Groenewoud
- Radboud University Medical Center/Radboud Institute for Health Sciences/Scientific Center for Quality of Healthcare (IQ healthcare), 114 IQ healthcare, 6500 HB Nijmegen Geert Grooteplein 21, Nijmegen, The Netherlands
| | - John E Wennberg
- The Dartmouth Institute for Health Policy and Clinical Practice, 1 Medical Center Drive; WTRB Level 5 Lebanon, NH, USA
| | - Catherine Gerard
- Health Quality & Safety Commission New Zealand, Wellington, Wellington, New Zealand
| | - Phil DaSilva
- NHS RightCare, 5th Floor Stephenson House, 75 Hampstead Road, London, UK
| | - Femke Atsma
- Radboud University Medical Center/Radboud Institute for Health Sciences/Scientific Center for Quality of Healthcare (IQ healthcare), 114 IQ healthcare, 6500 HB Nijmegen Geert Grooteplein 21, Nijmegen, The Netherlands
| | - David C Goodman
- The Dartmouth Institute for Health Policy and Clinical Practice, 1 Medical Center Drive; WTRB Level 5 Lebanon, NH, USA
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Wang SY, Hsu SH, Huang S, Doan KC, Gross CP, Ma X. Regional Practice Patterns and Racial/Ethnic Differences in Intensity of End-of-Life Care. Health Serv Res 2018; 53:4291-4309. [PMID: 29951996 DOI: 10.1111/1475-6773.12998] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To examine whether regional practice patterns impact racial/ethnic differences in intensity of end-of-life care for cancer decedents. DATA SOURCES The linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database. STUDY DESIGN We classified hospital referral regions (HRRs) based on mean 6-month end-of-life care expenditures, which represented regional practice patterns. Using hierarchical generalized linear models, we examined racial/ethnic differences in the intensity of end-of-life care across levels of HRR expenditures. PRINCIPAL FINDINGS There was greater variation in intensity of end-of-life care among Hispanics, Asians, and whites in high-expenditure HRRs than in low-expenditure HRRs. CONCLUSIONS Local practice patterns may influence racial/ethnic differences in end-of-life care.
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Affiliation(s)
- Shi-Yi Wang
- Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, CT.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT
| | - Sylvia H Hsu
- Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, CT.,Schulich School of Business, York University, Toronto, ON, Canada
| | - Siwan Huang
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT.,Beijing PricewaterhouseCoopers Management Consulting (Shanghai) Limited, Beijing, China
| | - Kathy C Doan
- Department of Social and Behavioral Sciences, Yale School of Public Health, Yale University, New Haven, CT
| | - Cary P Gross
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT.,Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Xiaomei Ma
- Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, CT.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT
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Abstract
The economic burden of cancer on the national health expenditure is billions of dollars. The economic cost is measured on direct and indirect medical costs, which vary depending on stage at diagnosis, patient age, type of medical services, and site of service. Costs vary by region, physician behavior, and patient preferences. When analyzing the economic burden of survivors of colon cancer, we cannot forget the societal burden. Post-acute care and readmissions are major economic burdens. People with colon cancer have to be followed for their lifetime. Economic models are being studied to give cost-effective solutions to this problem.
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Affiliation(s)
- Guy R Orangio
- LSU Department of Surgery, 1542 Tulane Avenue, Suite 758, New Orleans, LA 70112, USA.
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Discretionary decisions and disparities in receiving drug-eluting stents under a universal healthcare system: A population-based study. PLoS One 2017; 12:e0179127. [PMID: 28594876 PMCID: PMC5464647 DOI: 10.1371/journal.pone.0179127] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 05/24/2017] [Indexed: 11/19/2022] Open
Abstract
Objectives One of the main objectives behind the expansion of insurance coverage is to eliminate disparities in health and healthcare. However, researchers have not yet fully elucidated the reasons for disparities in the use of high-cost treatments among patients of different occupations. Furthermore, it remains unknown whether discretionary decisions made at the hospital level have an impact on the administration of high-cost interventions in a universal healthcare system. This study investigated the adoption of drug-eluting stents (DES) versus bare metal-stents (BMS) among patients in different occupations and income levels, with the aim of gauging the degree to which the inclination of health providers toward treatment options could affect treatment choices at the patient-level within a universal healthcare system. Design and participants We adopted a cross-sectional observational study design using hierarchical modeling in conjunction with the population-based National Health Insurance database of Taiwan. Patients who received either a BMS or a DES between 2007 and 2010 were included in the study. Results During the period of study, 42,124 patients received a BMS (65.3%) and 22,376 received DES (34.7%). Patients who were physicians or the family members of physicians were far more likely to receive DES (OR: 3.18, CI: 2.38–4.23) than were patients who were neither physicians nor in other high-status jobs (employers, other medical professions, or public service). Similarly, patients in the top 5% income bracket had a higher probability of receiving a DES (OR: 2.23, CI: 2.06–2.47, p < .001), than were patients in the lowest income bracket. After controlling for patient-level factors, the inclination of hospitals (proportion of DES>50% or between 25% and 50%) was shown to be strongly associated with the selection of DESs (OR: 3.64 CI: 3.24–4.09 and OR: 2.16, CI: 2.01–2.33, respectively). Conclusions Even under the universal healthcare system in Taiwan, socioeconomic disparities in the use of high-cost services remain widespread. Differences in the care received by patients of lower socioeconomic status may be due to the discretionary decisions of healthcare providers.
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11
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Wang S, Hsu SH, Huang S, Soulos PR, Gross CP. Longer Periods Of Hospice Service Associated With Lower End-Of-Life Spending In Regions With High Expenditures. Health Aff (Millwood) 2017; 36:328-336. [PMID: 28167723 PMCID: PMC5972542 DOI: 10.1377/hlthaff.2016.0683] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Hospice use is expected to decrease end-of-life expenditures, yet evidence for its financial impact remains inconclusive. One potential explanation is that the use of hospice may produce differential cost-savings effects by region because of geographic variation in end-of-life spending patterns. We examined 103,745 elderly Medicare fee-for-service beneficiaries in the Surveillance, Epidemiology, and End Results Program Medicare database who died from cancer in 2004-11. We created quintiles by the adjusted mean end-of-life expenditures per hospital referral region (HRR), and we examined HRR-level variation in the association between length of hospice service and expenditures across quintiles. Longer periods of hospice service were associated with decreased end-of-life expenditures for patients residing in regions with high average expenditures but not for those in regions with low average expenditures. Hospice use accounted for 8 percent of the expenditure variation between the highest and the lowest spending quintiles, which demonstrates the powers and limitations of hospice use for saving on costs.
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Affiliation(s)
- Shiyi Wang
- Shiyi Wang is an assistant professor of epidemiology in the Department of Chronic Disease Epidemiology, Yale University School of Public Health, in New Haven, Connecticut
| | - Sylvia H Hsu
- Sylvia H. Hsu is an associate professor of accounting at the Schulich School of Business, York University, in Toronto, Ontario, Canada
| | - Siwan Huang
- Siwan Huang is a master's graduate in the Department of Biostatistics at the Yale University School of Public Health
| | - Pamela R Soulos
- Pamela R. Soulos is a program manager and data analyst at the Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University School of Medicine and Yale Cancer Center
| | - Cary P Gross
- Cary P. Gross is a professor of medicine and epidemiology in the Department of Internal Medicine, Yale University School of Medicine
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Charlesworth CJ, Meath THA, Schwartz AL, McConnell KJ. Comparison of Low-Value Care in Medicaid vs Commercially Insured Populations. JAMA Intern Med 2016; 176:998-1004. [PMID: 27244044 PMCID: PMC4942278 DOI: 10.1001/jamainternmed.2016.2086] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
IMPORTANCE Reducing unnecessary tests and treatments is a potentially promising approach for improving the value of health care. However, relatively little is known about whether insurance type or local practice patterns are associated with delivery of low-value care. OBJECTIVES To compare low-value care in the Medicaid and commercially insured populations, test whether provision of low-value care is associated with insurance type, and assess whether local practice patterns are associated with the provision of low-value care. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study of claims data from the Oregon Division of Medical Assistance Programs and the Oregon All-Payer All-Claims database included Medicaid and commercially insured adults aged 18 to 64 years. The study period was January 1, 2013, through December 31, 2013. MAIN OUTCOMES AND MEASURES Low-value care was assessed using 16 claims-based measures. Logistic regression was used to test the association between Medicaid vs commercial insurance coverage and low-value care and the association between Medicaid and commercial low-value care rates within primary care service areas (PCSAs). RESULTS This study included 286 769 Medicaid and 1 376 308 commercial enrollees in 2013. Medicaid enrollees were younger (167 847 [58.5%] of Medicaid enrollees were aged 18-34 years vs 505 628 [36.7%] of those with commercial insurance) but generally had worse health status compared with those with commercial insurance. Medicaid enrollees were also more likely to be female (180 363 [62.9%] vs 702 165 [51.0%]) and live in a rural area (120 232 [41.9%] vs 389 964 [28.3%]). A total of 10 304 of 69 338 qualifying Medicaid patients (14.9%; 95% CI, 14.6%-15.1%) received at least 1 low-value service during 2013; the corresponding rate for commercially insured patients was 35 739 of 314 023 (11.4%; 95% CI, 11.3%-11.5%). No consistent association was found between insurance type and low-value care. Compared with commercial patients, Medicaid patients were more likely to receive low-value care for 10 measures and less likely to receive low-value care for 5 others. For 7 of 11 low-value care measures, Medicaid patients were significantly more likely to receive low-value care if they resided in a PCSA with a higher rate of low-value care for commercial patients. CONCLUSIONS AND RELEVANCE Oregon Medicaid and commercially insured patients received moderate amounts of low-value care in 2013. No consistent association was found between insurance type and low-value care. However, Medicaid and commercial rates of low-value care were associated with one another within PCSAs. Low-value care may be more closely related to local practice patterns than to reimbursement generosity or insurance benefit structures.
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Affiliation(s)
| | - Thomas H A Meath
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| | - Aaron L Schwartz
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - K John McConnell
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland3Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
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Abstract
Background Randomized trials evaluating new cancer screening technologies may underestimate the efficacy of screening to reduce cancer mortality if study participants are noncompliant. Participants may fail to comply with the screening itself or fail to obtain appropriate diagnostic follow-up and treatment. Noncompliance with screening has drawn wide attention, but little attention has been paid to noncompliance with diagnostic follow-up and treatment. Purpose To examine the importance of noncompliance with screening, follow-up, and treatment in cancer screening trials. Methods The unique problems associated with noncompliance in screening trials are described and provide an example illustrating the potential impact of noncompliance in a screening trial. I discuss issues that arise with measurement of follow-up and therapeutic noncompliance, and the benefit of collecting information on health system and participant characteristics associated with noncompliance. Results The estimate of the efficacy of a screening program on cancer mortality can be adjusted for screening, follow-up, and treatment noncompliance. Noncompliance needs to be measured in a rigorous, systematic manner across all arms of the trial. Information on health system and participant characteristics associated with compliance may also be incorporated into statistical models to estimate screening effects with full compliance, plan interventions to increase compliance, and extrapolate results of screening trials from one population to another. Limitations Measuring compliance with follow-up and treatment can be difficult when these occur outside the trial, and when there is variation among providers in follow-up and treatment practices. Conclusions Noncompliance may alter the estimate of a screening effect on cancer mortality in clinical trials. It is possible to adjust screening efficacy estimates for noncompliance using existing statistical techniques. It is important that data describing compliance with screening, follow-up, and treatment are collected as part of standard data collection in cancer screening trials. Clinical Trials 2007; 4: 341—349. http://ctj.sagepub.com
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Affiliation(s)
- Ilana F Gareen
- Center for Statistical Sciences and the Department of Community Health, Brown University School of Medicine, Providence, RI 02912, USA.
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Weeks WB, Ventelou B, Paraponaris A. Rates of admission for ambulatory care sensitive conditions in France in 2009-2010: trends, geographic variation, costs, and an international comparison. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2016; 17:453-70. [PMID: 25951924 DOI: 10.1007/s10198-015-0692-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 04/15/2015] [Indexed: 05/27/2023]
Abstract
BACKGROUND Admissions for ambulatory care sensitive conditions (ACSCs) are considered preventable and indicators of poor access to primary care. We wondered whether per-capita rates of admission for ACSCs in France demonstrated geographic variation, were changing, were related to other independent variables, or were comparable to those in other countries; further, we wanted to quantify the resources such admissions consume. METHODS We calculated per-capita rates of admission for five categories (chronic, acute, vaccination preventable, alcohol-related, and other) of ACSCs in 94 departments in mainland France in 2009 and 2010, examined measures and causes of geographic variation in those rates, computed the costs of those admissions, and compared rates of admission for ACSCs in France to those in several other countries. RESULTS The highest ACSC admission rates generally occurred in the young and the old, but rates varied across French regions. Over the 2-year period, rates of most categories of ACSCs increased; higher ACSC admission rates were associated with lower incomes and a higher supply of hospital beds. We found that the local supply of general practitioners was inversely associated with rates of chronic and total ACSC admission rates, but that this relationship disappeared if we accounted for patients' use of general practitioners in neighboring departments. ACSC admissions cost 4.755 billion euros in 2009 and 5.066 billion euros in 2010; they consumed 7.86 and 8.74 million bed days of care, respectively. France had higher rates of ACSC admissions than most other countries examined. CONCLUSIONS Because admissions for ACSCs are generally considered a failure of outpatient care, cost French taxpayers substantial monetary and hospital resources, and appear to occur more frequently in France than in other countries, policymakers should prioritize targeted efforts to reduce them.
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Affiliation(s)
- William B Weeks
- , 35 Centerra Parkway, Lebanon, NH, 03766, USA.
- The Geisel School of Medicine at Dartmouth, Hanover, USA.
- The Aix-Marseille School of Economics, Marseille, France.
| | - Bruno Ventelou
- SESSTIM, UMR 912, INSERM-IRD-Aix-Marseille Université, Marseille, France
- The Aix-Marseille School of Economics, Marseille, France
| | - Alain Paraponaris
- SESSTIM, UMR 912, INSERM-IRD-Aix-Marseille Université, Marseille, France
- The Aix-Marseille School of Economics, Marseille, France
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Ryskina KL, Smith CD, Weissman A, Post J, Dine CJ, Bollmann K, Korenstein D. U.S. Internal Medicine Residents' Knowledge and Practice of High-Value Care: A National Survey. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2015; 90:1373-1379. [PMID: 26083399 DOI: 10.1097/acm.0000000000000791] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
PURPOSE To determine U.S. internal medicine (IM) residents' knowledge of, attitudes toward, and self-reported practice of high-value care (HVC), or care that balances the benefits, harms, and costs of tests and treatments. METHOD The authors conducted a cross-sectional survey of U.S. IM residents who took the Internal Medicine In-Training Examination in October 2012. They used multivariable mixed-effects models to examine the relationships between self-reported knowledge and practice of HVC and both exposure to HVC teaching and the care intensity of the training hospital (based on a composite age-sex-race-illness standardized measure of hospital days and inpatient physician visits by Medicare recipients). RESULTS Of 21,617 residents who received the survey, 18,102 (83.7%) completed it. Self-reported HVC practices varied: 4,187 of 17,633 respondents (23.7%) agreed that they "share estimated costs of tests and treatments with patients"; 15,549 of 17,626 (88.2%) agreed that they "incorporate patients' values and concerns into clinical decisions." Discussions about balancing the benefits, harms, and costs of treatments with faculty during patient care at least a few times a week were reported by 7,103 of 17,704 respondents (40.1%) and were associated with all self-reported HVC practices. The training hospital's care intensity was inversely associated with self-reported incorporation of costs and patient values into clinical decisions but not with other self-reported behaviors. CONCLUSIONS U.S. IM residents reported varying HVC knowledge and practice. Faculty discussions of HVC during patient care correlated with such knowledge and practice and may represent an opportunity to improve residents' competency in providing value-based care.
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Affiliation(s)
- Kira L Ryskina
- K.L. Ryskina is general internal medicine fellow, Division of General Internal Medicine, and fellow, Leonard Davis Institute of Health Economics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.C.D. Smith is director of clinical programs development and senior physician educator, American College of Physicians, Philadelphia, Pennsylvania.A. Weissman is research center director, American College of Physicians, Philadelphia, Pennsylvania.J. Post is assistant professor, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota.C.J. Dine is assistant professor, Division of Pulmonary and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.K. Bollmann is assistant professor, Department of Medicine, Banner Good Samaritan Medical Center, Phoenix, Arizona.D. Korenstein is clinical member, Memorial Hospital at Memorial Sloan Kettering Cancer Center, New York, New York
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Yu MK, O'Hare AM, Batten A, Sulc CA, Neely EL, Liu CF, Hebert PL. Trends in Timing of Dialysis Initiation within Versus Outside the Department of Veterans Affairs. Clin J Am Soc Nephrol 2015. [PMID: 26206891 DOI: 10.2215/cjn.12731214] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The secular trend toward dialysis initiation at progressively higher levels of eGFR is not well understood. This study compared temporal trends in eGFR at dialysis initiation within versus outside the Department of Veterans Affairs (VA)-the largest non-fee-for-service health system in the United States. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The study used linked data from the US Renal Data System, VA, and Medicare to compare temporal trends in eGFR at dialysis initiation between 2000 and 2009 (n=971,543). Veterans who initiated dialysis within the VA were compared with three groups who initiated dialysis outside the VA: (1) veterans whose dialysis was paid for by the VA, (2) veterans whose dialysis was not paid for by the VA, and (3) nonveterans. Logistic regression was used to estimate average predicted probabilities of dialysis initiation at an eGFR≥10 ml/min per 1.73 m(2). RESULTS The adjusted probability of starting dialysis at an eGFR≥10 ml/min per 1.73 m(2) increased over time for all groups but was lower for veterans who started dialysis within the VA (0.31; 95% confidence interval [95% CI], 0.30 to 0.32) than for those starting outside the VA, including veterans whose dialysis was (0.36; 95% CI, 0.35 to 0.38) and was not (0.40; 95% CI, 0.40 to 0.40) paid for by the VA and nonveterans (0.39; 95% CI, 0.39 to 0.39). Differences in eGFR at initiation within versus outside the VA were most pronounced among older patients (P for interaction <0.001) and those with a higher risk of 1-year mortality (P for interaction <0.001). CONCLUSIONS Temporal trends in eGFR at dialysis initiation within the VA mirrored those in the wider United States dialysis population, but eGFR at initiation was consistently lowest among those who initiated within the VA. Differences in eGFR at initiation within versus outside the VA were especially pronounced in older patients and those with higher 1-year mortality risk.
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Affiliation(s)
- Margaret K Yu
- Veterans Affairs Health Services Research and Development Center of Excellence, Veterans Affairs Puget Sound Health Care System, Seattle, Washington; Division of Nephrology, Department of Medicine, and Kidney Research Institute, Seattle, Washington
| | - Ann M O'Hare
- Veterans Affairs Health Services Research and Development Center of Excellence, Veterans Affairs Puget Sound Health Care System, Seattle, Washington; Division of Nephrology, Department of Medicine, and Kidney Research Institute, Seattle, Washington
| | - Adam Batten
- Veterans Affairs Health Services Research and Development Center of Excellence, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Christine A Sulc
- Veterans Affairs Health Services Research and Development Center of Excellence, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Emily L Neely
- Veterans Affairs Health Services Research and Development Center of Excellence, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Chuan-Fen Liu
- Veterans Affairs Health Services Research and Development Center of Excellence, Veterans Affairs Puget Sound Health Care System, Seattle, Washington; Department of Health Services, University of Washington School of Public Health, Seattle, Washington; and
| | - Paul L Hebert
- Veterans Affairs Health Services Research and Development Center of Excellence, Veterans Affairs Puget Sound Health Care System, Seattle, Washington; Department of Health Services, University of Washington School of Public Health, Seattle, Washington; and
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Ryskina KL, Halpern SD, Minyanou NS, Goold SD, Tilburt JC. The role of training environment care intensity in US physician cost consciousness. Mayo Clin Proc 2015; 90:313-20. [PMID: 25633153 PMCID: PMC5298854 DOI: 10.1016/j.mayocp.2014.12.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 11/19/2014] [Accepted: 12/03/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To examine a potential relationship between training environment and physician views about cost consciousness. PARTICIPANTS AND METHODS This was a cross-sectional study of US physicians who responded to the Physicians, Health Care Costs, and Society survey conducted between May 30, 2012, and September 30, 2012, for whom information was available about the care intensity environment of their residency training hospital. The exposure of interest was a measure of the health care utilization environment during residency from the Dartmouth Atlas of Health Care Hospital Care Intensity (HCI) index of primary training hospitals. The main outcome measure was agreement with an 11-point cost-consciousness scale. The generalized estimating equations method was used to measure the association between exposure and outcome. RESULTS Of the 2556 physicians who responded to the survey, 2424 had a valid HCI index (95%), representing 649 residency programs. The mean ± SD cost-consciousness score among physicians trained at hospitals in the lowest quartile of care intensity (31.8±5.0) was higher than that for physicians trained at hospitals in the top quartile of care intensity (30.7±5.1; P<.001). Adjusting for other physician and practice characteristics, a population of physicians trained in hospitals with a 1.0-point higher HCI index would score approximately 0.83 points lower on the cost-consciousness scale (beta coefficient = -0.83; 95% CI, -1.60 to -0.05; P=.04). CONCLUSION The intensity of the health care utilization environment during training may play a role in shaping physician cost consciousness later in their careers.
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Affiliation(s)
- Kira L Ryskina
- Division of General Internal Medicine, University of Pennsylvania, Philadelphia.
| | - Scott D Halpern
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Biostatistics and Epidemiology, and Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
| | - Nancy S Minyanou
- School of Arts and Sciences, University of Pennsylvania, Philadelphia
| | - Susan D Goold
- Department of General Internal Medicine, University of Michigan, Ann Arbor
| | - Jon C Tilburt
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
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Affiliation(s)
- Laura G Burke
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, USA Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Ashish K Jha
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, USA Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Sirovich BE, Lipner RS, Johnston M, Holmboe ES. The association between residency training and internists' ability to practice conservatively. JAMA Intern Med 2014; 174:1640-8. [PMID: 25179515 PMCID: PMC4445367 DOI: 10.1001/jamainternmed.2014.3337] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Growing concern about rising costs and potential harms of medical care has stimulated interest in assessing physicians' ability to minimize the provision of unnecessary care. OBJECTIVE To assess whether graduates of residency programs characterized by low-intensity practice patterns are more capable of managing patients' care conservatively, when appropriate, and whether graduates of these programs are less capable of providing appropriately aggressive care. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional comparison of 6639 first-time takers of the 2007 American Board of Internal Medicine certifying examination, aggregated by residency program (n = 357). EXPOSURES Intensity of practice, measured using the End-of-Life Visit Index, which is the mean number of physician visits within the last 6 months of life among Medicare beneficiaries 65 years and older in the residency program's hospital referral region. MAIN OUTCOMES AND MEASURES The mean score by program on the Appropriately Conservative Management (ACM) (and Appropriately Aggressive Management [AAM]) subscales, comprising all American Board of Internal Medicine certifying examination questions for which the correct response represented the least (or most, respectively) aggressive management strategy. Mean scores on the remainder of the examination were used to stratify programs into 4 knowledge tiers. Data were analyzed by linear regression of ACM (or AAM) scores on the End-of-Life Visit Index, stratified by knowledge tier. RESULTS Within each knowledge tier, the lower the intensity of health care practice in the hospital referral region, the better residency program graduates scored on the ACM subscale (P < .001 for the linear trend in each tier). In knowledge tier 4 (poorest), for example, graduates of programs in the lowest-intensity regions had a mean ACM score in the 38th percentile compared with the 22nd percentile for programs in the highest-intensity regions; in tier 2, ACM scores ranged from the 75th to the 48th percentile in regions from lowest to highest intensity. Graduates of programs in low-intensity regions tended, more weakly, to score better on the AAM subscale (in 3 of 4 knowledge tiers). CONCLUSIONS AND RELEVANCE Regardless of overall medical knowledge, internists trained at programs in hospital referral regions with lower-intensity medical practice are more likely to recognize when conservative management is appropriate. These internists remain capable of choosing an aggressive approach when indicated.
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Affiliation(s)
- Brenda E Sirovich
- Outcomes Group, Veterans Affairs Medical Center, White River Junction, Vermont2The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
| | - Rebecca S Lipner
- The American Board of Internal Medicine, Philadelphia, Pennsylvania
| | - Mary Johnston
- Center for Assessment and Research Studies, James Madison University, Harrisonburg, Virginia
| | - Eric S Holmboe
- The Accreditation Council for Graduate Medical Education, Philadelphia, Pennsylvania
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Tritter JQ, Lutfey K, McKinlay J. What are tests for? The implications of stuttering steps along the US patient pathway. Soc Sci Med 2014; 107:37-43. [PMID: 24602969 DOI: 10.1016/j.socscimed.2014.02.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Revised: 02/02/2014] [Accepted: 02/07/2014] [Indexed: 11/29/2022]
Abstract
This article explores the implications of how US family physicians make decisions about ordering diagnostic tests for their patients. Data is based on a study of 256 physicians interviewed after viewing a video vignette of a presenting patient. The qualitative analysis of 778 statements relating to trustworthiness of evidence for their decision making, the use of any kind of technology and diagnostic testing suggests a range of internal and external constraints on physician decision making. Test-ordering for family physicians in the United States is significantly influenced by both hidden cognitive processes related to the physician's calculation of patient resources and a health insurance system that requires certain types of evidence in order to permit further tests or particular interventions. The consequence of the need for physicians to meet multiple forms of proof that may not always relate to relevant treatment delays a diagnosis and treatment plan agreed not only by the physician and patient but also the insurance company. This results in a patient journey that is made up of stuttering steps to a confirmed diagnosis and treatment undermining patient-centred practice, compromising patient care, constraining physician autonomy and creating additional expense.
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Affiliation(s)
- Jonathan Q Tritter
- Department of Sociology and Public Policy, Aston University, Birmingham B4 7ET, United Kingdom.
| | - Karen Lutfey
- Department of Health and Behavioral Sciences, University of Colorado, Denver, United States
| | - John McKinlay
- New England Research Institute, Boston, United States
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Physicians' beliefs about breast cancer surveillance testing are consistent with test overuse. Med Care 2013; 51:315-23. [PMID: 23269111 DOI: 10.1097/mlr.0b013e31827da908] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Overuse of surveillance testing for breast cancer survivors is an important problem but its extent and determinants are incompletely understood. The objectives of this study were to determine the extent to which physicians' breast cancer surveillance testing beliefs are consistent with test overuse, and to identify factors associated with these beliefs. METHODS During 2009-2010, a cross-sectional survey of US medical oncologists and primary care physicians (PCPs) was carried out. Physicians responded to a clinical vignette ascertaining beliefs about appropriate breast cancer surveillance testing. Multivariable analyses examined the extent to which test beliefs were consistent with overuse and associated with physician and practice characteristics and physician perceptions, attitudes, and practices. RESULTS A total of 1098 medical oncologists and 980 PCPs completed the survey (response rate 57.5%). Eighty-four percent of PCPs [95% confidence interval (CI), 81.4%-86.5%] and 72% of oncologists (95% CI, 69.8%-74.7%) reported beliefs consistent with blood test overuse, whereas 50% of PCPs (95% CI, 47.3%-53.8%) and 27% of oncologists (95% CI, 23.9%-29.3%) reported beliefs consistent with imaging test overuse. Among PCPs, factors associated with these beliefs included smaller practice size, lower patient volume, and practice ownership. Among oncologists, factors included older age, international medical graduate status, lower self-efficacy (confidence in knowledge), and greater perceptions of ambiguity (conflicting expert recommendations) regarding survivorship care. CONCLUSIONS Beliefs consistent with breast cancer surveillance test overuse are common, greater for PCPs and blood tests than for oncologists and imaging tests, and associated with practice characteristics and perceived self-efficacy and ambiguity about testing. These results suggest modifiable targets for efforts to reduce surveillance test overuse.
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Abstract
BACKGROUND Our aim is to assess state variation in renal trauma outcomes. We hypothesize that states with more hospitals participating in a trauma system will have lower nephrectomy and mortality rates. METHODS The Healthcare Cost and Utilization Project State Inpatient Database was used to conduct a retrospective cohort study of all patients hospitalized with renal injury from partnering states during 2001, 2004, and 2007. State trauma systems were categorized based on the proportion of all acute care hospitals designated as a trauma center (Levels I-V) with higher proportions correlating to a more inclusive system. Poisson regression for relative risks (RRs) of inpatient nephrectomy and case fatality were performed adjusting for patient and state level factors. RESULTS Patients in states with the "most inclusive" trauma systems had a 30% lower risk of nephrectomy (RR, 0.70; 95% confidence interval [CI], 0.56-0.88) and a 2.06% lower unadjusted inpatient case fatality rate compared with states with "exclusive" trauma systems. Inpatient case fatality risk varied significantly by trauma system inclusiveness. Patients treated in states with either a "more inclusive" (RR, 0.85; 95% CI, 0.74-0.97) or "most inclusive" (RR, 0.74; 95% CI, 0.64-0.85) trauma system were independently associated with a lower inpatient case fatality risk compared with states with "exclusive" systems. CONCLUSIONS A reduced risk of nephrectomy and inpatient case fatality are more common among states that have a higher proportion of acute care hospitals participating as a trauma center (Levels I-V). Standardization of care may correlate with improved patient outcomes after renal trauma. LEVEL OF EVIDENCE II, exploratory cohort analysis.
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Barnett ML, Keating NL, Christakis NA, O'Malley AJ, Landon BE. Reasons for choice of referral physician among primary care and specialist physicians. J Gen Intern Med 2012; 27:506-12. [PMID: 21922159 PMCID: PMC3326096 DOI: 10.1007/s11606-011-1861-z] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Revised: 07/25/2011] [Accepted: 08/16/2011] [Indexed: 11/24/2022]
Abstract
BACKGROUND Specialty referral patterns can affect health care costs as well as clinical outcomes. For a given clinical problem, referring physicians usually have a choice of several physicians to whom they can refer. Once the decision to refer is made, the choice of individual physician may have important downstream effects. OBJECTIVE To examine the reasons why primary care and specialist physicians choose certain specific colleagues to refer to and how those reasons differ by specialty. DESIGN Cross-sectional Web-based survey supplemented with analysis of administrative claims data. PARTICIPANTS A total of 616 physicians in office-based patient care specialties who were members of an academic physicians' organization and treated Medicare patients in 2006. MAIN MEASURES A total of 386 respondents (63% response rate) were presented with a "roster" of other physicians' names with whom we predicted they had a relationship based on sharing Medicare patients. Among physicians in their "professional network" (consisting of any listed physician with whom respondents acknowledged a professional relationship), respondents reported if they referred to those physicians, and if so, provided up to two reasons why they referred to that particular colleague. Using logistic regression, we examined the likelihood that different specialists would endorse specific reasons for referring to chosen colleagues. KEY RESULTS Primary care physicians (PCPs) initiated referrals to 66% of their "professional network" colleagues, while medical and surgical specialists initiated referrals to 49% and 52%, respectively (p < 0.001 for both versus PCPs). After adjustment, medical specialists were less likely than PCPs to cite ease of communication with colleagues (RR = 0.69, 95% CI = 0.49-0.91), and medical and surgical specialists were less likely than PCPs to cite "shares my medical record system" as a reason to refer (medical specialist RR = 0.13, 95% CI 0.03-0.40, surgical specialist RR = 0.26, 95% CI = 0.05-0.78). CONCLUSIONS Specialists frequently initiate referrals, bypassing PCPs. In choosing specific physicians to refer to, PCPs are more often concerned with between-physician communication and patient access. Modifying referral practices among doctors may need to account for such patterns of behavior.
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Affiliation(s)
- Michael L Barnett
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02215, USA
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National variation in outcomes and costs for splenic injury and the impact of trauma systems: a population-based cohort study. Ann Surg 2012; 255:165-70. [PMID: 22156925 DOI: 10.1097/sla.0b013e31823840ca] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To measure national variation in splenectomy rates, mortality, and costs for hospitalized patients with splenic injury and the impact of state trauma systems on these outcomes. METHODS Using the HCUP State Inpatient Database for 2001, 2004, and 2007, all patients hospitalized with splenic injury were identified from 19 participating states. Multivariate regression was performed to compare splenectomy rates, inpatient mortality, and costs between states. Inclusiveness of statewide trauma systems was categorized based on the proportion of hospitals designated as a trauma center. RESULTS Of 33,131 patients, 26.2% underwent splenectomy, 6.1% died, and median hospital costs were $14,317. After adjusting for patient, injury, and hospital characteristics, there was a 1.7-fold variation (RR 1.67; 95% CI, 1.39-2.01) among the 19 states in rates of splenectomy. Adjusted inpatient mortality varied more than 2-fold between the highest and lowest states (RR 2.43; 95% CI, 1.76-3.37). Adjusted hospital costs varied over 60% between the highest and lowest states (cost ratio 1.61; 95% CI, 1.41-1.83). States with the most inclusive trauma systems had significantly lower splenectomy rate (RR 0.79; 95% CI, 0.68-0.92) and lower mortality (RR 0.71; 95% CI, 0.58-0.87), but similar hospital costs (CR 1.05; 95% CI, 0.95-1.16) compared to states with exclusive or no trauma systems. CONCLUSIONS Significant geographic variation in the management, outcome, and costs for splenic injury exists in the United States, and may reflect differences in quality of care. Inclusive trauma systems seem to improve outcomes without increasing hospital costs.
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Barnett ML, Christakis NA, O’Malley AJ, Onnela JP, Keating NL, Landon BE. Physician patient-sharing networks and the cost and intensity of care in US hospitals. Med Care 2012; 50:152-60. [PMID: 22249922 PMCID: PMC3260449 DOI: 10.1097/mlr.0b013e31822dcef7] [Citation(s) in RCA: 121] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is substantial variation in the cost and intensity of care delivered by US hospitals. We assessed how the structure of patient-sharing networks of physicians affiliated with hospitals might contribute to this variation. METHODS We constructed hospital-based professional networks based on patient-sharing ties among 61,461 physicians affiliated with 528 hospitals in 51 hospital referral regions in the US using Medicare data on clinical encounters during 2006. We estimated linear regression models to assess the relationship between measures of hospital network structure and hospital measures of spending and care intensity in the last 2 years of life. RESULTS The typical physician in an average-sized urban hospital was connected to 187 other doctors for every 100 Medicare patients shared with other doctors. For the average-sized urban hospital an increase of 1 standard deviation (SD) in the median number of connections per physician was associated with a 17.8% increase in total spending, in addition to 17.4% more hospital days, and 23.8% more physician visits (all P<0.001). In addition, higher "centrality" of primary care providers within these hospital networks was associated with 14.7% fewer medical specialist visits (P<0.001) and lower spending on imaging and tests (-9.2% and -12.9% for 1 SD increase in centrality, P<0.001). CONCLUSIONS Hospital-based physician network structure has a significant relationship with an institution's care patterns for their patients. Hospitals with doctors who have higher numbers of connections have higher costs and more intensive care, and hospitals with primary care-centered networks have lower costs and care intensity.
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Affiliation(s)
- Michael L. Barnett
- Department of Health Care Policy, Harvard Medical School, Boston, MA
- Division of General Internal Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Nicholas A. Christakis
- Department of Health Care Policy, Harvard Medical School, Boston, MA
- Division of Primary Care and General Internal Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Department of Sociology, Harvard University, Cambridge, MA
| | - A. James O’Malley
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | | | - Nancy L. Keating
- Department of Health Care Policy, Harvard Medical School, Boston, MA
- Division of General Internal Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Bruce E. Landon
- Department of Health Care Policy, Harvard Medical School, Boston, MA
- Division of Primary Care and General Internal Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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Matlock DD, Kutner JS, Emsermann CB, Al-Khatib SM, Sanders GD, Dickinson LM, Rumsfeld JS, Davidson AJ, Crane LA, Masoudi FA. Regional variations in physicians' attitudes and recommendations surrounding implantable cardioverter-defibrillators. J Card Fail 2011; 17:318-24. [PMID: 21440870 DOI: 10.1016/j.cardfail.2010.11.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Revised: 11/26/2010] [Accepted: 11/30/2010] [Indexed: 02/04/2023]
Abstract
INTRODUCTION This study was designed to determine if physicians' attitudes and recommendations surrounding implantable cardioverter-defibrillators (ICDs) are regionally associated with ICD use. METHODS AND RESULTS A national sample of 9969 members of the American College of Cardiology was surveyed electronically. Responses were merged with rates of ICD implantation from the National Cardiovascular Data Registry. Multivariable regression was used to assess trends between regional use and responses. We received 1210 responses (12%) and used 1124 after exclusions. Across regions, physicians were equally likely to recommend ICDs to males or females with ischemic (∼99% for both; P = NS) or nonischemic cardiomyopathy (85 vs. 88% P = 0.85). Significant increasing trends in the probability recommending ICD therapy were found when the patient was "frail" (21% to 32%; P = .03) or had a life expectancy <1 year (5% to 10%; P = .05). These differences were not associated with attitudes toward ICDs. CONCLUSIONS Independent of variations in physicians' attitudes towards ICDs, physicians in regions of low ICD use are not less likely to recommend ICDs in situations clearly supported by guidelines while those in regions of high ICD use are more likely to recommend ICDs to patients who might have limited benefit.
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Affiliation(s)
- Dan D Matlock
- Division of General InternalMedicine, University of Colorado, Denver School of Medicine, 12631 E. 17th Ave., Aurora, CO 80045, USA.
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Abstract
BACKGROUND Although there is considerable interest in underutilization of lipid testing, little is known about the prevalence and factors associated with overtesting of serum lipids. METHODS We assessed the number of different days in which outpatient lipid testing was performed in a 5% national sample of patients with parts A and B Medicare in 2006. Covariates included patient characteristics (age, race, prior diagnosis of lipid disorder, and other indications for lipid testing), number of usual care physicians (UCP), type of UCP, total outpatient physician encounters, and health referral region (HRR) characteristics (average per-patient Medicare expenditures and percent of patients seeing multiple UCPs). RESULTS Among the 1,151,891 patients, 11.9% underwent 3 or more outpatient measurements of serum lipids. In multivariable analyses, the total number of UCPs providing care for the patient was associated with multiple lipid testing, independent of patient characteristics, indications for lipid testing, and total outpatient encounters. There was a strong association among HRRs between the rate of multiple lipid testing and average Medicare expenditures (r = 0.56). This was reduced after including the percentage of patients with more than 2 medical subspecialist UCPs in the HRR in a partial correlation (r = 0.31). CONCLUSIONS Multiple lipid testing is associated with the presence of multiple providers, independent of indications for testing, comorbidity, and total physician visits. Much of the association of multiple lipid testing with medical expenditures at the level of HRR appears to be explained by differences in exposure to multiple providers.
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Delgado A, López-Fernández LA, Luna JDD, Saletti-Cuesta L, Gil N, Jiménez M. The role of expectations in preferences of patients for a female or male general practitioner. PATIENT EDUCATION AND COUNSELING 2011; 82:49-57. [PMID: 20371157 DOI: 10.1016/j.pec.2010.02.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2009] [Revised: 02/23/2010] [Accepted: 02/27/2010] [Indexed: 05/29/2023]
Abstract
OBJECTIVE to determine, for five health problems, whether preference for a male or female general practitioner (GP) is related to patient gender, GP gender and/or patient expectations of GP behaviour. METHODS cross-sectional study in 14 health centres in Spain, administering a questionnaire to 360 patients. Outcome variables were: preference for male GP, female GP or no preference in consultations for five hypothetical health problems. RESULTS mean age was 47.3 ± 16.5 years, 51% were female. Preference was more frequently expressed by females. Odds ratios (ORs) for a woman preferring a female to male GP ranged from 3 to 508, according to the hypothetical problem, and ORs for a patient with female GP preferring a female GP ranged from 2.8 to 9.1. Patient gender and GP gender had no interactive effect on preferences. Expectations of GP behaviour were related to preferences, except for chest pain. Higher expectations of communication or technical care were associated with greater preference for female or male GP, respectively. CONCLUSIONS patient gender and current GP gender are related to preferences in five hypothetical clinical situations and expectations of GP behaviour to preferences in four of them. PRACTICE IMPLICATIONS educational strategies are needed to adjust clinical encounters to patients' preferences.
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Affiliation(s)
- Ana Delgado
- Andalusian School of Public Health, Granada, Spain.
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Causes and Consequences of Regional Variations in Health Care11This chapter was written for the Handbook of Health Economics (Vol. 2). My greatest debt is to John E. Wennberg for introducing me to the study of regional variations. I am also grateful to Handbook authors Elliott Fisher, Joseph Newhouse, Douglas Staiger, Amitabh Chandra, and especially Mark Pauly for insightful comments, and to the National Institute on Aging (PO1 AG19783) for financial support. HANDBOOK OF HEALTH ECONOMICS 2011. [DOI: 10.1016/b978-0-444-53592-4.00002-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
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Matlock DD, Peterson PN, Sirovich BE, Wennberg DE, Gallagher PM, Lucas FL. Regional variations in palliative care: do cardiologists follow guidelines? J Palliat Med 2010; 13:1315-9. [PMID: 20954826 DOI: 10.1089/jpm.2010.0163] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Regional variation in health care use in the last 6 months of life is well documented. Our objective was to examine whether an association exists between cardiologists' tendencies to discuss palliative care for patients with advanced heart failure and the regional use of health care in the last 6 months of life. METHODS We performed a national mail survey of a random sample of 994 eligible Cardiologists from the American Medical Association Masterfile. Hypothetical patient scenarios were used to explore physician management of patient scenarios. RESULTS We received 614 responses (response rate: 62%). In a 75-year-old with symptomatic chronic heart failure and asymptomatic nonsustained ventricular tachycardia, cardiologists in regions with high use in the last 6 months of life were less likely to have discussions about palliative care (23% versus 32% for comparisons between the highest and lowest quintiles, p = 0.04). Similarly, in an 85 year-old with symptomatic chronic heart failure and an acute exacerbation, cardiologists in high use regions were less likely to have discussions about palliative care (35% versus 47%, p = 0.0008). CONCLUSIONS Despite professional guidelines suggesting that cardiologists discuss palliative care with patients with late stage heart failure, less than half of cardiologists would discuss palliative care in two elderly patients with late-stage heart failure and this guideline discordance was worse in the regions with more health care use in the last 6 months of life.
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Affiliation(s)
- Dan D Matlock
- Department of Medicine, University of Colorado, Denver, Colorado, USA.
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Mittler JN, Landon BE, Fisher ES, Cleary PD, Zaslavsky AM. Market variations in intensity of Medicare service use and beneficiary experiences with care. Health Serv Res 2010; 45:647-69. [PMID: 20403055 PMCID: PMC2875753 DOI: 10.1111/j.1475-6773.2010.01108.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Examine associations between patient experiences with care and service use across markets. DATA SOURCES/STUDY SETTING Medicare fee-for-service (FFS) and managed care (Medicare Advantage [MA]) beneficiaries in 306 markets from the 2003 Consumer Assessments of Healthcare Providers and Systems (CAHPS) surveys. Resource use intensity is measured by the 2003 end-of-life expenditure index. STUDY DESIGN We estimated correlations and linear regressions of eight measures of case-mix-adjusted beneficiary experiences with intensity of service use across markets. DATA COLLECTION/EXTRACTION We merged CAHPS data with service use data, excluding beneficiaries under 65 years of age or receiving Medicaid. PRINCIPAL FINDINGS Overall, higher intensity use was associated (p<.05) with worse (seven measures) or no better care experiences (two measures). In higher-intensity markets, Medicare FFS and MA beneficiaries reported more problems getting care quickly and less helpful office staff. However, Medicare FFS beneficiaries in higher-intensity markets reported higher overall ratings of their personal physician and main specialist. Medicare MA beneficiaries in higher-intensity markets also reported worse quality of communication with physicians, ability to get needed care, and overall ratings of care. CONCLUSIONS Medicare beneficiaries in markets characterized by high service use did not report better experiences with care. This trend was strongest for those in managed care.
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Affiliation(s)
- Jessica N Mittler
- Health Policy and Administration, The Pennsylvania State University, 604 Ford Building, University Park, PA 16802, USA.
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Variation in cardiologists' propensity to test and treat: is it associated with regional variation in utilization? Circ Cardiovasc Qual Outcomes 2010; 3:253-60. [PMID: 20388874 DOI: 10.1161/circoutcomes.108.840009] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Regional variation in healthcare utilization, including cardiac testing and procedures, is well documented. Some factors underlying such variation are understood, including resource supply. However, less is known about how physician behaviors and attitudes may influence variation in utilization across regions. METHODS AND RESULTS We performed a survey of a national sample of cardiologists using patients vignettes to ascertain physicians' self-reported propensity to test and treat patients with cardiovascular problems, computing a Cardiac Intensity Score for each physician based on his/her responses intended to measure the physician's propensity to recommend high-tech and/or invasive tests and treatments. In addition, we asked under what circumstances they would order a cardiac catheterization "for other than purely clinical reasons." For some survey items, there was substantial variation in physician responses. We found that the Cardiac Intensity Score was associated with 2 measures of population based healthcare utilization measured within geographic regions, with a stronger association with general healthcare spending than with delivery of cardiac services. Although nearly all physicians denied ordering a potentially unnecessary cardiac catheterization for financial reasons, some physicians acknowledged ordering the test for other reasons, including meeting patient and referring physician expectations, meeting peer expectations, and malpractice concerns. More than 27% of respondents reported ordering a cardiac catheterization if a colleague would in the same situation frequently or sometimes, and nearly 24% reported doing so out of fear of malpractice. These 2 factors were significantly associated with the propensity to test and treat, but only fear of malpractice was associated with regional utilization. CONCLUSIONS Variability in cardiologists' propensity to test and treat partly underlies regional variation in utilization of general health and cardiology services. The factor most closely associated with this propensity was fear of malpractice suits. This factor may be an appropriate target of intervention.
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Barnett R, Malcolm L. Practice and ethnic variations in avoidable hospital admission rates in Christchurch, New Zealand. Health Place 2010; 16:199-208. [DOI: 10.1016/j.healthplace.2009.09.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2009] [Revised: 08/20/2009] [Accepted: 09/23/2009] [Indexed: 10/20/2022]
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Delgado A, López-Fernández LA, de Dios Luna J, Saletti Cuesta L, Gil Garrido N, Puga González A. Expectativas de los pacientes sobre la toma de decisiones ante diferentes problemas de salud. GACETA SANITARIA 2010; 24:66-71. [DOI: 10.1016/j.gaceta.2009.09.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2009] [Revised: 07/06/2009] [Accepted: 09/04/2009] [Indexed: 10/20/2022]
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Anthony DL, Herndon MB, Gallagher PM, Barnato AE, Bynum JPW, Gottlieb DJ, Fisher ES, Skinner JS. How much do patients' preferences contribute to resource use? Health Aff (Millwood) 2009; 28:864-73. [PMID: 19414899 DOI: 10.1377/hlthaff.28.3.864] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Regional variation in health care use may stem, in part, from the fact that patients in high-utilization regions demand and receive more-intensive care. We examine the association between patients' care-seeking preferences and use of services, using a national survey of Medicare patients. Patients' preferences, in addition to health and sociodemographic characteristics, are associated with differences in individuals' use of office visits. However, we find that patients' preferences for seeking primary and specialty medical care do not play a significant role in explaining regional variation in health care use.
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Solberg LI, Asche SE, Anderson LH, Sepucha K, Thygeson NM, Madden JE, Morrissey L, Kraemer KK. Evaluating Preference-Sensitive Care for Uterine Fibroids: It's Not So Simple. J Womens Health (Larchmt) 2009; 18:1071-9. [DOI: 10.1089/jwh.2008.0948] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Leif I. Solberg
- HealthPartners, HealthPartners Medical Group, and HealthPartners Research Foundation, Minneapolis, Minnesota
| | - Stephen E. Asche
- HealthPartners, HealthPartners Medical Group, and HealthPartners Research Foundation, Minneapolis, Minnesota
| | - Louise H. Anderson
- HealthPartners, HealthPartners Medical Group, and HealthPartners Research Foundation, Minneapolis, Minnesota
| | - Karen Sepucha
- Massachusetts General Hospital, Boston, Massachusetts
| | - N. Marcus Thygeson
- HealthPartners, HealthPartners Medical Group, and HealthPartners Research Foundation, Minneapolis, Minnesota
| | - Joan E. Madden
- HealthPartners, HealthPartners Medical Group, and HealthPartners Research Foundation, Minneapolis, Minnesota
| | | | - Karen K. Kraemer
- HealthPartners, HealthPartners Medical Group, and HealthPartners Research Foundation, Minneapolis, Minnesota
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Ketcham JD, Lutfey KE, Gerstenberger E, Link CL, McKinlay JB. Physician clinical information technology and health care disparities. Med Care Res Rev 2009; 66:658-81. [PMID: 19564640 DOI: 10.1177/1077558709338485] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The authors develop a conceptual framework regarding how information technology (IT) can alter within-physician disparities, and they empirically test some of its implications in the context of coronary heart disease. Using a random experiment on 256 primary care physicians, the authors analyze the relationships between three IT functions (feedback and two types of clinical decision support) and five process-of-care measures. Endogeneity is addressed by eliminating unobserved patient characteristics with vignettes and by proxying for omitted physician characteristics. The results indicate that IT has no effects on physicians' diagnostic certainty and treatment of vignette patients overall. The authors find that treatment and certainty differ by patient age, gender, and race. Consistent with the framework, IT's effects on these disparities are complex. Feedback eliminated the gender disparities, but the relationships differed for other IT functions and process measures. Current policies to reduce disparities and increase IT adoption may be in discord.
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Abstract
BACKGROUND There is substantial hospital-level variation in end-of-life (EOL) treatment intensity. OBJECTIVE To explore the association between organizational factors and EOL treatment intensity in Pennsylvania (PA) hospitals. RESEARCH DESIGN Cross-sectional mixed-mode survey of Chief Nursing Officers of PA hospitals linked to hospital-level measures of EOL treatment intensity calculated from PA Health Care Cost Containment Council (PHC4) hospital discharge data. HOSPITALS: One hundred sixty-four hospitals, of which 124 (76%) responded to the survey. MEASURES : The dependent variable was an index of hospital EOL treatment intensity; the independent variables included administrative data-derived structural and market characteristics and 29 survey-derived hospital or ICU programs, policies, or practices. RESULTS : In models restricted to independent variables drawn from administrative sources (available for all 164 hospitals), bed size (P < 0.001), proportion of admissions among black patients (P < 0.001), and county-wide hospital market competitiveness (Herfindahl-Hirschman index) (P = 0.001) were independently associated with greater EOL treatment intensity (adjusted R = 0.5136). In models that additionally included hospital programs, policies, and practices (available for 124 hospitals), only an ICU long length of stay review committee (P = 0.03) was independently associated with greater EOL treatment intensity (adjusted R = 0.5357). CONCLUSIONS Information about hospital and ICU programs, policies, and practices believed relevant to the treatment of patients near the end of life offers little additional explanatory power in understanding hospital-level variation in EOL treatment intensity than administratively-derived variables alone. Future studies should explore the contribution of more difficult to measure social norms in shaping hospital practice patterns.
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Referral of patients with thrombocytopenia from primary care clinicians to hematologists. Blood 2009; 113:4126-7. [DOI: 10.1182/blood-2009-01-200907] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Joyce DL, Conte JV, Russell SD, Joyce LD, Chang DC. Disparities in Access to Left Ventricular Assist Device Therapy. J Surg Res 2009; 152:111-7. [DOI: 10.1016/j.jss.2008.02.065] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2007] [Revised: 02/26/2008] [Accepted: 02/28/2008] [Indexed: 11/28/2022]
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Using simulation to isolate physician variation in intensive care unit admission decision making for critically ill elders with end-stage cancer: a pilot feasibility study. Crit Care Med 2008; 36:3156-63. [PMID: 18936694 DOI: 10.1097/ccm.0b013e31818f40d2] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To determine the feasibility of high-fidelity simulation for studying variation in intensive care unit admission decision making for critically ill elders with end-stage cancer. DESIGN Mixed qualitative and quantitative analysis of physician subjects participating in a simulation scenario using hospital set, actors, medical chart, and vital signs tracings. The simulation depicted a 78-yr-old man with metastatic gastric cancer, life-threatening hypoxia most likely attributable to cancer progression, and stable preferences to avoid intensive care unit admission and intubation. Two independent raters assessed the simulations and subjects completed a postsimulation web-based survey and debriefing interview. SETTING Peter M. Winter Institute for Simulation Education and Research at the University of Pittsburgh. SUBJECTS Twenty-seven hospital-based attending physicians, including 6 emergency physicians, 13 hospitalists, and 8 intensivists. MEASUREMENTS AND MAIN RESULTS Outcomes included qualitative report of clinical verisimilitude during the debriefing interview, survey-reported diagnosis and prognosis, and observed treatment decisions. Independent variables included physician demographics, risk attitude, and reactions to uncertainty. All (100%) reported that the case and simulation were highly realistic, and their diagnostic and prognostic assessments were consistent with our intent. Eight physicians (29.6%) admitted the patient to the intensive care unit. Among the eight physicians who admitted the patient to the intensive care unit, three (37%) initiated palliation, two (25%) documented the patient's code status (do not intubate/do not resuscitate), and one intubated the patient. Among the 19 physicians who did not admit the patient to the intensive care unit, 13 (68%) initiated palliation and 5 (42%) documented code status. Intensivists and emergency physicians (p = 0.048) were more likely to admit the patient to the intensive care unit. Years since medical school graduation were inversely associated with the initiation of palliative care (p = 0.043). CONCLUSIONS Simulation can reproduce the decision context of intensive care unit triage for a critically ill patient with terminal illness. When faced with an identical patient, hospital-based physicians from the same institution vary significantly in their treatment decisions.
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Lutfey KE, Link CL, Grant RW, Marceau LD, McKinlay JB. Is certainty more important than diagnosis for understanding race and gender disparities?: an experiment using coronary heart disease and depression case vignettes. Health Policy 2008; 89:279-87. [PMID: 18701185 DOI: 10.1016/j.healthpol.2008.06.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2008] [Revised: 06/23/2008] [Accepted: 06/25/2008] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To (1) examine the influence of patient and provider attributes on physicians' diagnostic certainty and (2) assess the effect of diagnostic certainty on clinical therapeutic actions. METHODS Factorial experiment of 128 generalist physicians using identical clinically authentic videotaped vignettes depicting patients with coronary heart disease (CHD) or depression. RESULTS For CHD, physicians were least certain for Black patients (p=.003) and for younger female patients (p=.013). For depression, average certainty was higher than for the CHD presentation (74.0 vs. 57.9 on of scale of 0-100, p<.001) and there were no main effects of patient or provider characteristics. Increasing diagnostic certainty was a significant predictor of subsequent clinical actions, and these varied according to physician and patient characteristics across both conditions. CONCLUSIONS Physicians were least certain of their CHD diagnoses for Black patients and for younger women, but patient characteristics alone did not affect physician certainty of depression diagnoses. Physicians responded differentially to diagnostic certainty in terms of their clinical therapeutic actions such as test ordering and writing prescriptions. Physician responses to certainty may be as important as their responses to patient characteristics for understanding variation in clinical decision-making.
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Affiliation(s)
- Karen E Lutfey
- New England Research Institutes, 9 Galen Street, Watertown, MA 02472, USA.
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Sirovich B, Gallagher PM, Wennberg DE, Fisher ES. Discretionary decision making by primary care physicians and the cost of U.S. Health care. Health Aff (Millwood) 2008; 27:813-23. [PMID: 18474975 PMCID: PMC2438037 DOI: 10.1377/hlthaff.27.3.813] [Citation(s) in RCA: 187] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Efforts to improve the quality and costs of U.S. health care have focused largely on fostering physician adherence to evidence-based guidelines, ignoring the role of clinical judgment in more discretionary settings. We surveyed primary care physicians to assess variability in discretionary decision making and evaluate its relationship to the cost of health care. Physicians in high-spending regions see patients back more frequently and are more likely to recommend screening tests of unproven benefit and discretionary interventions compared with physicians in low-spending regions; however, both appear equally likely to recommend guideline-supported interventions. Greater attention should be paid to the local factors that influence physicians' clinical judgment in discretionary settings.
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Affiliation(s)
- Brenda Sirovich
- Outcomes Group, Veterans Affairs Medical Center, White River Junction, Vermont, USA.
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Fisher ES. 2007 Robert and Alma Moreton lecture: pay for performance: more than rearranging the deck chairs? J Am Coll Radiol 2008; 4:879-85. [PMID: 18047982 DOI: 10.1016/j.jacr.2007.06.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2007] [Indexed: 11/27/2022]
Abstract
Over the past 30 years, research exploring the causes and consequences of geographic variations in practice has called into question widely held assumptions about the relationship between spending and quality. Two-fold differences in spending are observed across U.S. regions that are not due to differences in illness or to the prices charged by providers. Rather, higher spending is due primarily to greater use of "supply-sensitive" services: the frequency of visits to physicians and referrals to specialists, the amount of time similar patients spend in the hospital, and the frequency of imaging, tests, and minor procedures. The paradox, however, is that greater use of these services has been shown to be associated with lower quality, no gain in survival, and worse physician and patient-reported quality of care. It may be possible, therefore, to lower spending while improving quality. But this will require addressing the underlying causes of the variations: overuse of discretionary services in a fee-for-service system that ensures that physicians stay busy and that existing capacity remains fully deployed. These findings point to 3 strategies that will be required for pay for performance to achieve its potential: fostering local organizational accountability for the overall quality and costs of care--and for the capacity of the local delivery system; adoption of comprehensive longitudinal performance measures--to reassure the public that lower spending is compatible with higher quality care; and fundamental reform of the payment system.
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Affiliation(s)
- Elliott S Fisher
- Center for the Evaluative Clinical Sciences, Dartmouth Medical School, Lebanon, New Hampshire 03766, USA.
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Barnato AE, Herndon MB, Anthony DL, Gallagher PM, Skinner JS, Bynum JPW, Fisher ES. Are regional variations in end-of-life care intensity explained by patient preferences?: A Study of the US Medicare Population. Med Care 2007; 45:386-93. [PMID: 17446824 PMCID: PMC2147061 DOI: 10.1097/01.mlr.0000255248.79308.41] [Citation(s) in RCA: 322] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We sought to test whether variations across regions in end-of-life (EOL) treatment intensity are associated with regional differences in patient preferences for EOL care. RESEARCH DESIGN Dual-language (English/Spanish) survey conducted March to October 2005, either by mail or computer-assisted telephone questionnaire, among a probability sample of 3480 Medicare part A and/or B eligible beneficiaries in the 20% denominator file, age 65 or older on July 1, 2003. Data collected included demographics, health status, and general preferences for medical care in the event the respondent had a serious illness and less than 1 year to live. EOL concerns and preferences were regressed on hospital referral region EOL spending, a validated measure of treatment intensity. RESULTS A total of 2515 Medicare beneficiaries completed the survey (65% response rate). In analyses adjusted for age, sex, race/ethnicity, education, financial strain, and health status, there were no differences by spending in concern about getting too little treatment (39.6% in lowest spending quintile, Q1; 41.2% in highest, Q5; P value for trend, 0.637) or too much treatment (44.2% Q1, 45.1% Q5; P = 0.797) at the end of life, preference for spending their last days in a hospital (8.4% Q1, 8.5% Q5; P = 0.965), for potentially life-prolonging drugs that made them feel worse all the time (14.4% Q1, 16.5% Q5; P = 0.326), for palliative drugs, even if they might be life-shortening (77.7% Q1, 73.4% Q5; P = 0.138), for mechanical ventilation if it would extend their life by 1 month (21% Q1, 21.4% Q5; P = 0.870) or by 1 week (12.1% Q1, 11.7%; P = 0.875). CONCLUSIONS Medicare beneficiaries generally prefer treatment focused on palliation rather than life-extension. Differences in preferences are unlikely to explain regional variations in EOL spending.
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Affiliation(s)
- Amber E Barnato
- Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania 15312, USA.
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Williams G, Sureshkumar P, Chan SF, Macaskill P, Craig JC. Ordering of renal tract imaging by paediatricians after urinary tract infection. J Paediatr Child Health 2007; 43:271-9. [PMID: 17444829 DOI: 10.1111/j.1440-1754.2007.01058.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM To describe paediatricians' reported ordering of renal tract imaging of children following urinary tract infection. METHODS This is a piloted self-administered survey. A total of 354 randomly sampled practising paediatricians in Australia participated in the survey. The survey included 12 clinical scenarios that varied with age, gender and fever. Respondents indicated their likelihood of ordering renal ultrasound, micturating cystourethrogram (MCU) and dimercaptosuccinic acid scan (DMSA) from 0 to 100%. RESULTS Response rate was 74.6% (264/354). For all clinical scenarios the median probability of ordering an ultrasound was 100% with little variability. For children aged 2 months, likelihood of ordering an MCU was 100%, with little variability, but was 70% for 3-year-olds with fever (45% without fever), and 5% for 6-year-olds with very large variability. Median likelihood of ordering a DMSA was 80% at 2 months, 60% at 3 years and 20% at 6 years (40%, 15%, 5% without fever, respectively). Variability was large for all scenarios and DMSA ordering. Child gender did not influence ordering practices. CONCLUSIONS Renal tract imaging practice across paediatricians shows consistent, approximately 100% use of the least invasive modality, ultrasound. In contrast, there is considerable variation in the reported ordering of the more invasive tests MCU and DMSA. Doctors order these tests more in younger children and when fever is present.
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Affiliation(s)
- Gabrielle Williams
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, and Screening and Test Evaluation Program, School of Public Health, University of Sydney, Sydney, New South Wales, Australia.
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Fisher ES, Staiger DO, Bynum JPW, Gottlieb DJ. Creating accountable care organizations: the extended hospital medical staff. Health Aff (Millwood) 2006; 26:w44-57. [PMID: 17148490 PMCID: PMC2131738 DOI: 10.1377/hlthaff.26.1.w44] [Citation(s) in RCA: 197] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Many current policies and approaches to performance measurement and payment reform focus on individual providers; they risk reinforcing the fragmented care and lack of coordination experienced by patients with serious illness. In this paper we show that Medicare beneficiaries receive most of their care from relatively coherent local delivery systems comprising physicians and the hospitals where they work or admit their patients. Efforts to create accountable care organizations at this level--the extended hospital medical staff--deserve consideration as a potential means of improving the quality and lowering the cost of care.
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Affiliation(s)
- Elliott S Fisher
- Dartmouth Medical School and the Center for the Evaluative Clinical Sciences, Hanover, New Hampshire, USA.
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