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Awtry JA, Abernathy JH, Wu X, Yang J, Zhang M, Hou H, Kaneko T, de la Cruz KI, Stakich-Alpirez K, Yule S, Cleveland JC, Shook DC, Fitzsimons MG, Harrington SD, Pagani FD, Likosky DS. Evaluating the Impact of Operative Team Familiarity on Cardiac Surgery Outcomes: A Retrospective Cohort Study of Medicare Beneficiaries. Ann Surg 2024; 279:891-899. [PMID: 37753657 PMCID: PMC10965508 DOI: 10.1097/sla.0000000000006100] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
OBJECTIVE To associate surgeon-anesthesiologist team familiarity (TF) with cardiac surgery outcomes. BACKGROUND TF, a measure of repeated team member collaborations, has been associated with improved operative efficiency; however, examination of its relationship to clinical outcomes has been limited. METHODS This retrospective cohort study included Medicare beneficiaries undergoing coronary artery bypass grafting (CABG), surgical aortic valve replacement (SAVR), or both (CABG+SAVR) between January 1, 2017, and September 30, 2018. TF was defined as the number of shared procedures between the cardiac surgeon and anesthesiologist within 6 months of each operation. Primary outcomes were 30- and 90-day mortality, composite morbidity, and 30-day mortality or composite morbidity, assessed before and after risk adjustment using multivariable logistic regression. RESULTS The cohort included 113,020 patients (84,397 CABG; 15,939 SAVR; 12,684 CABG+SAVR). Surgeon-anesthesiologist dyads in the highest [31631 patients, TF median (interquartile range)=8 (6, 11)] and lowest [44,307 patients, TF=0 (0, 1)] TF terciles were termed familiar and unfamiliar, respectively. The rates of observed outcomes were lower among familiar versus unfamiliar teams: 30-day mortality (2.8% vs 3.1%, P =0.001), 90-day mortality (4.2% vs 4.5%, P =0.023), composite morbidity (57.4% vs 60.6%, P <0.001), and 30-day mortality or composite morbidity (57.9% vs 61.1%, P <0.001). Familiar teams had lower overall risk-adjusted odds of 30-day mortality or composite morbidity [adjusted odds ratio (aOR) 0.894 (0.868, 0.922), P <0.001], and for SAVR significantly lower 30-day mortality [aOR 0.724 (0.547, 0.959), P =0.024], 90-day mortality [aOR 0.779 (0.620, 0.978), P =0.031], and 30-day mortality or composite morbidity [aOR 0.856 (0.791, 0.927), P <0.001]. CONCLUSIONS Given its relationship with improved 30-day cardiac surgical outcomes, increasing TF should be considered among strategies to advance patient outcomes.
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Affiliation(s)
- Jake A. Awtry
- Division of Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
- Center for Surgery and Public Health, Boston, MA
| | - James H. Abernathy
- Division of Cardiac Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Xiaoting Wu
- Department of Cardiac Surgery, Section of Health Services Research and Quality, Michigan Medicine, Ann Arbor, MI
| | - Jie Yang
- Department of Cardiac Surgery, Section of Health Services Research and Quality, Michigan Medicine, Ann Arbor, MI
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Hechuan Hou
- Department of Cardiac Surgery, Section of Health Services Research and Quality, Michigan Medicine, Ann Arbor, MI
| | - Tsuyoshi Kaneko
- Division of Cardiothoracic Surgery, Washington University in St Louis/Barnes-Jewish Hospital, St. Louis, MO
| | - Kim I. de la Cruz
- Division of Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Korana Stakich-Alpirez
- Department of Cardiac Surgery, Section of Health Services Research and Quality, Michigan Medicine, Ann Arbor, MI
| | - Steven Yule
- School of Surgery, University of Edinburgh, Scotland, UK
| | - Joseph C. Cleveland
- Division of Cardiothoracic Surgery, University of Colorado Anschutz Medical Center, Aurora, CO
| | - Douglas C. Shook
- Department of Anesthesiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Michael G. Fitzsimons
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | | | - Francis D. Pagani
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI
| | - Donald S. Likosky
- Department of Cardiac Surgery, Section of Health Services Research and Quality, Michigan Medicine, Ann Arbor, MI
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2
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Patel TA, Ettyreddy A, Cheng T, Smith K, Sridharan SS, McCall AA. Cost-Effectiveness of Diffusion Weighted MRI Versus Planned Second-Look Surgery for Cholesteatoma. Ann Otol Rhinol Laryngol 2024:34894241250253. [PMID: 38676449 DOI: 10.1177/00034894241250253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
OBJECTIVE To compare the cost-effectiveness of serial non-echo planar diffusion weighted MRI (non-EP DW MRI) versus planned second look surgery following initial canal wall up tympanomastoidectomy for the treatment of cholesteatoma. METHODS A decision-analytic model was developed. Model inputs including residual cholesteatoma rates, rates of non-EP DW MRI positivity after surgery, and health utility scores were abstracted from published literature. Cost data were derived from the 2022 Centers for Medicare and Medicaid Services fee rates. Efficacy was defined as increase in quality-adjusted life year (QALY). One- and 2-way sensitivity analyses were performed on variables of interest to probe the model. Total time horizon was 50 years with a willingness to pay (WTP) threshold set at $50 000/QALY. RESULTS Base case analysis revealed that planned second-look surgery ($11 537, 17.30 QALY) and imaging surveillance with non-EP DWMRI ($10 439, 17.26 QALY) were both cost effective options. Incremental cost effectiveness ratio was $27 298/QALY, which is below the WTP threhshold. One-way sensitivity analyses showed that non-EP DW MRI was more cost effective than planned second-look surgery if the rate of residual disease after surgery increased to 48.3% or if the rate of positive MRI was below 45.9%. A probabilistic sensitivity analysis at WTP of $50 000/QALY found that second-look surgery was more cost-effective in 56.7% of iterations. CONCLUSION Non-EP DW MRI surveillance is a cost-effect alternative to planned second-look surgery following primary canal wall up tympanomastoidectomy for cholesteatoma. Cholesteatoma surveillance decisions after initial canal wall up tympanomastoidectomy should be individualized. LEVEL OF EVIDENCE V.
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Affiliation(s)
- Terral A Patel
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Abhinav Ettyreddy
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Tracy Cheng
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kenneth Smith
- Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Shaum S Sridharan
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Andrew A McCall
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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3
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Valdes K, Naughton N, Rider JV. Hand therapist use of patient-reported outcomes. J Hand Ther 2024; 37:110-117. [PMID: 37586992 DOI: 10.1016/j.jht.2023.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 05/18/2023] [Accepted: 06/01/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND The use of standardized outcome measures is essential for best clinical practice by hand therapists to determine patient status, progress, and the outcome of interventions. A better understanding of current patient-reported outcome (PRO) use in hand and upper extremity practice is warranted. PURPOSE This study sought to understand what outcome measures are being used in clinical practice, how they are being used, and the perceived usefulness of PROs by active members of the American Society of Hand Therapists (ASHT). STUDY DESIGN This study employed a cross-sectional design. METHODS The web-based survey was distributed through Qualtrics (Qualtrics, Salt Lake City, Utah) to active members of ASHT with an email address on file. The survey consisted of multiple choice and open-ended questions. RESULTS A total of 348 members responded to the survey. Seven hundred thirty-two different outcome measures were reported to be used by the hand therapist respondents. The most used outcome measure was QuickDASH by 38% of the respondents. Two hundred seventy-five (88%) indicated that their workplace advocated the use of PROs. Most respondents indicated that there were not constraints preventing the use of a PRO. Few therapists respondents use a psychosocial PRO in clinical practice. CONCLUSIONS Most of the hand therapist respondents to our survey use a PRO and discuss the results with their clients. The QuickDASH was the PRO used most often by hand therapists. Only a few hand therapists use a psychosocial tool to measure patient status in clinical practice.
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Affiliation(s)
- Kristin Valdes
- Touro University, School of Occupational Therapy, Henderson, NV, USA.
| | | | - John V Rider
- Touro University, School of Occupational Therapy, Henderson, NV, USA
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4
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Iott BE, Adler-Milstein J, Gottlieb LM, Pantell MS. Characterizing the relative frequency of clinician engagement with structured social determinants of health data. J Am Med Inform Assoc 2023; 30:503-510. [PMID: 36545752 PMCID: PMC9933071 DOI: 10.1093/jamia/ocac251] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 11/19/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE Electronic health records (EHRs) are increasingly used to capture social determinants of health (SDH) data, though there are few published studies of clinicians' engagement with captured data and whether engagement influences health and healthcare utilization. We compared the relative frequency of clinician engagement with discrete SDH data to the frequency of engagement with other common types of medical history information using data from inpatient hospitalizations. MATERIALS AND METHODS We created measures of data engagement capturing instances of data documentation (data added/updated) or review (review of data that were previously documented) during a hospitalization. We applied these measures to four domains of EHR data, (medical, family, behavioral, and SDH) and explored associations between data engagement and hospital readmission risk. RESULTS SDH data engagement was associated with lower readmission risk. Yet, there were lower levels of SDH data engagement (8.37% of hospitalizations) than medical (12.48%), behavioral (17.77%), and family (14.42%) history data engagement. In hospitalizations where data were available from prior hospitalizations/outpatient encounters, a larger proportion of hospitalizations had SDH data engagement than other domains (72.60%). DISCUSSION The goal of SDH data collection is to drive interventions to reduce social risk. Data on when and how clinical teams engage with SDH data should be used to inform informatics initiatives to address health and healthcare disparities. CONCLUSION Overall levels of SDH data engagement were lower than those of common medical, behavioral, and family history data, suggesting opportunities to enhance clinician SDH data engagement to support social services referrals and quality measurement efforts.
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Affiliation(s)
- Bradley E Iott
- Center for Clinical Informatics and Improvement Research, University of California, San Francisco (UCSF), San Francisco, California, USA
- Social Interventions Research and Evaluation Network, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Julia Adler-Milstein
- Center for Clinical Informatics and Improvement Research, University of California, San Francisco (UCSF), San Francisco, California, USA
- Department of Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Laura M Gottlieb
- Social Interventions Research and Evaluation Network, University of California, San Francisco (UCSF), San Francisco, California, USA
- Center for Health and Community, University of California, San Francisco (UCSF), San Francisco, California, USA
- Department of Family and Community Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Matthew S Pantell
- Center for Health and Community, University of California, San Francisco (UCSF), San Francisco, California, USA
- Department of Pediatrics, University of California, San Francisco (UCSF), San Francisco, California, USA
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5
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Iott BE, Pantell MS, Adler-Milstein J, Gottlieb LM. Physician awareness of social determinants of health documentation capability in the electronic health record. J Am Med Inform Assoc 2022; 29:2110-2116. [PMID: 36069887 PMCID: PMC9667172 DOI: 10.1093/jamia/ocac154] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 07/26/2022] [Accepted: 08/18/2022] [Indexed: 11/13/2022] Open
Abstract
Healthcare organizations are increasing social determinants of health (SDH) screening and documentation in the electronic health record (EHR). Physicians may use SDH data for medical decision-making and to provide referrals to social care resources. Physicians must be aware of these data to use them, however, and little is known about physicians' awareness of EHR-based SDH documentation or documentation capabilities. We therefore leveraged national physician survey data to measure level of awareness and variation by physician, practice, and EHR characteristics to inform practice- and policy-based efforts to drive medical-social care integration. We identify higher levels of social needs documentation awareness among physicians practicing in community health centers, those participating in payment models with social care initiatives, and those aware of other advanced EHR functionalities. Findings indicate that there are opportunities to improve physician education and training around new EHR-based SDH functionalities.
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Affiliation(s)
- Bradley E Iott
- Center for Clinical Informatics and Improvement Research, University of California, San Francisco (UCSF), San Francisco, California, USA
- Social Interventions Research and Evaluation Network, UCSF, San Francisco, California, USA
| | - Matthew S Pantell
- Department of Pediatrics, UCSF, San Francisco, California, USA
- Center for Health and Community, UCSF, San Francisco, California, USA
| | - Julia Adler-Milstein
- Center for Clinical Informatics and Improvement Research, University of California, San Francisco (UCSF), San Francisco, California, USA
- Department of Medicine, UCSF, San Francisco, California, USA
| | - Laura M Gottlieb
- Social Interventions Research and Evaluation Network, UCSF, San Francisco, California, USA
- Center for Health and Community, UCSF, San Francisco, California, USA
- Department of Family and Community Medicine, UCSF, San Francisco, California, USA
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6
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Transforming Clinical Practice Initiative Boosted Participation in Medicare Alternative Payment Models. J Ambul Care Manage 2022; 45:150-160. [PMID: 35612386 DOI: 10.1097/jac.0000000000000419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The Centers for Medicare & Medicaid Services' (CMS's) Transforming Clinical Practice Initiative (TCPi) was the largest national-scale practice transformation model. We analyzed the effect of TCPi on new enrollment into Medicare Alternative Payment Models (APMs) through January 2020 (3 months after program end), using 6958 physician practices enrolled in TCPi and a closely matched comparison group of 6958 practices. More TCPi practices enrolled in Medicare APMs and Medicare Advanced APMs relative to comparison practices overall and in subgroups, including rural, small, and specialty practices. Results suggest that large-scale technical assistance can boost participation in Medicare APMs for a diverse set of practices.
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7
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Wang X, Zhu Y, Wang F, Liang Y. Association of organizational and patient behaviors with physician well-being: A national survey in China. PLoS One 2022; 17:e0268274. [PMID: 35639674 PMCID: PMC9154115 DOI: 10.1371/journal.pone.0268274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 04/26/2022] [Indexed: 11/19/2022] Open
Abstract
This study aims to investigate the association of organizational and patient behaviors (reflecting the internal and external environment of hospital, respectively) with physician well-being. A national cross-sectional survey was conducted in 77 hospitals across seven provinces in China between July 2014 and April 2015. Physician well-being was assessed with job satisfaction, career regret and happiness. Organizational behaviors were assessed with organizational fairness, leadership attention and team interaction; patient behaviors were assessed with patient trust and unreasonable requests from patients. Of a study sample of 3,159 physicians, 1,788 were men (56.6%) and 1,371 were women (43.4%). Overall, positive organizational and patient behaviors reported by physicians were relatively low. Negative organizational behaviors and patient behaviors including lower organizational fairness, lower leadership attention, lower team interaction and lower patient trust were associated with lower job satisfaction and lower life satisfaction, and higher career regret. The association between organizational behaviors and physician well-being exhibited some gender differences, while no clear gender difference was found for the relationship between patient behaviors and physician well-being. Given the importance of physician well-being for the healthcare system, interventions for improving internal and external hospital environments (e.g., organizational fairness, leadership attention, team interaction and patient trust) may benefit physician well-being.
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Affiliation(s)
- Xiaoyu Wang
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yimei Zhu
- School of Media, Communication and Sociology, University of Leicester, Leicester, United Kingdom
| | - Fang Wang
- Department of Epidemiology and Health Statistics, School of Health, Wuhan University, Wuhan, China
| | - Yuan Liang
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- * E-mail: ,
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8
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Bu DD, Schwam ZG, Kaul VF, Wong K, Fan C, Wanna GB, Cosetti MK, Perez E. Cost-effectiveness of Canal Wall-Up vs Canal Wall-Down Mastoidectomy: A Modeling Study. Otolaryngol Head Neck Surg 2022; 167:552-559. [PMID: 35133895 DOI: 10.1177/01945998221076051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To assess the relative lifetime costs, benefits, and cost-effectiveness between the 2 approaches, canal wall-up (CWU) and canal wall-down (CWD) tympanomastoidectomy, used in the treatment of cholesteatomas. STUDY DESIGN Markov state transition model. SETTING Tertiary academic health system. METHODS A Markov state transition model was used to simulate outcomes across the patient lifetime. Outcome and complication probabilities were obtained from the existing literature. Costs were calculated from the payer perspective, with procedure, hospital, clinic, and physician cost derived from Medicare reimbursement. Quality-adjusted life years (QALYs) were used to represent effectiveness and utility. One-way and probability sensitivity analyses (PSAs) were conducted. RESULTS The base case analysis, assuming a 40-year-old patient, yielded a lifetime cost of $14,214 for a patient treated with the CWU approach assuming second-look surgery and $22,290 with a CWD approach. CWU and CWD generated a benefit of 17.11 and 17.30 QALYs, respectively. The incremental cost-effectiveness ratio for CWU was $43,237 per QALY. The Monte Carlo PSA validated the base case scenario. Using a standard $50,000 willingness-to-pay threshold, CWD was the more cost-effective approach and was selected 54.8% of the time by the simulation. CONCLUSION Both CWU and CWD were found to be cost-effective, with CWD being cost-effective 54.8% of the time at a WTP threshold of $50,000. The assumptions used in the analysis were validated by the results of 1-way and PSA.
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Affiliation(s)
- Daniel D Bu
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Otolaryngology, New York Eye and Ear Infirmary of Mount Sinai, New York, New York, USA
| | - Zachary G Schwam
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Otolaryngology, New York Eye and Ear Infirmary of Mount Sinai, New York, New York, USA
| | - Vivian F Kaul
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Otolaryngology, New York Eye and Ear Infirmary of Mount Sinai, New York, New York, USA
| | - Kevin Wong
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Otolaryngology, New York Eye and Ear Infirmary of Mount Sinai, New York, New York, USA
| | - Caleb Fan
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Otolaryngology, New York Eye and Ear Infirmary of Mount Sinai, New York, New York, USA
| | - George B Wanna
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Otolaryngology, New York Eye and Ear Infirmary of Mount Sinai, New York, New York, USA
| | - Maura K Cosetti
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Otolaryngology, New York Eye and Ear Infirmary of Mount Sinai, New York, New York, USA
| | - Enrique Perez
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Otolaryngology, New York Eye and Ear Infirmary of Mount Sinai, New York, New York, USA
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Ke X, Zhang L, Tang W. Cost-Utility Analysis of the Integrated Care Models for the Management of Hypertension Patients: A Quasi-Experiment in Southwest Rural China. Front Public Health 2021; 9:727829. [PMID: 34966712 PMCID: PMC8710505 DOI: 10.3389/fpubh.2021.727829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 11/10/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Hypertension has become the second-leading risk factor for death worldwide. However, the fragmented three-level “county–township–village” medical and healthcare system in rural China cannot provide continuous, coordinated, and comprehensive health care for patients with hypertension, as a result of which rural China has a low rate of hypertension control. This study aimed to explore the costs and benefits of an integrated care model using three intervention modes—multidisciplinary teams (MDT), multi-institutional pathway (MIP), and system global budget and performance-based payments (SGB-P4P)—for hypertension management in rural China. Methods: A Markov model with 1-year per cycle was adopted to simulate the lifetime medical costs and quality-adjusted life-years (QALYs) for patients. The interventions included Option 1 (MDT + MIP), Option 2 (MDT + MIP + SGB–P4P), and the Usual practice (usual care). We used the incremental cost-effectiveness ratio (ICER), net monetary benefit (NMB), and net health benefit (NHB) to make economic decisions and a 5% discount rate. One-way and probability sensitivity analyses were performed to test model robustness. Data on the blood pressure control rate, transition probability, utility, annual treatment costs, and project costs were from the community intervention trial (CMB-OC) project. Results: Compared with the Usual practice, Option 1 yielded an additional 0.068 QALYs and an additional cost of $229.99, resulting in an ICER of $3,373.75/QALY, the NMB was –$120.97, and the NHB was −0.076 QALYs. Compared with the Usual practice, Option 2 yielded an additional 0.545 QALYs, and the cost decreased by $2,007.31, yielding an ICER of –$3,680.72/QALY. The NMB was $2,879.42, and the NHB was 1.801 QALYs. Compared with Option 1, Option 2 yielded an additional 0.477 QALYs, and the cost decreased by $2,237.30, so the ICER was –$4,688.50/QALY, the NMB was $3,000.40, and the NHB was 1.876 QALYs. The one-way sensitivity analysis showed that the most sensitive factors in the model were treatment cost of ESRD, human cost, and discount rate. The probability sensitivity analysis showed that when willingness to pay was $1,599.16/QALY, the cost-effectiveness probability of Option 1, Option 2, and the Usual practice was 0.008, 0.813, and 0.179, respectively. Conclusions: The integrated care model with performance-based prepaid payments was the most beneficial intervention, whereas the general integrated care model (MDT + MIP) was not cost-effective. The integrated care model (MDT + MIP + SGB-P4P) was suggested for use in the community management of hypertension in rural China as a continuous, patient-centered care system to improve the efficiency of hypertension management.
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Affiliation(s)
- Xiatong Ke
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China.,Center for Pharmacoeconomics and Outcomes Research of China Pharmaceutical University, Nanjing, China
| | - Liang Zhang
- School of Medical and Health Management, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China.,Research Center for Rural Health Services, Hubei Province Key Research Institute of Humanities and Social Sciences, Wuhan, China
| | - Wenxi Tang
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China.,Center for Pharmacoeconomics and Outcomes Research of China Pharmaceutical University, Nanjing, China
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10
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Senteio C, Adler-Milstein J, Richardson C, Veinot T. Psychosocial information use for clinical decisions in diabetes care. J Am Med Inform Assoc 2021; 26:813-824. [PMID: 31329894 DOI: 10.1093/jamia/ocz053] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/26/2019] [Accepted: 03/31/2019] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE There are increasing efforts to capture psychosocial information in outpatient care in order to enhance health equity. To advance clinical decision support systems (CDSS), this study investigated which psychosocial information clinicians value, who values it, and when and how clinicians use this information for clinical decision-making in outpatient type 2 diabetes care. MATERIALS AND METHODS This mixed methods study involved physician interviews (n = 17) and a survey of physicians, nurse practitioners (NPs), and diabetes educators (n = 198). We used the grounded theory approach to analyze interview data and descriptive statistics and tests of difference by clinician type for survey data. RESULTS Participants viewed financial strain, mental health status, and life stressors as most important. NPs and diabetes educators perceived psychosocial information to be more important, and used it significantly more often for 1 decision, than did physicians. While some clinicians always used psychosocial information, others did so when patients were not doing well. Physicians used psychosocial information to judge patient capabilities, understanding, and needs; this informed assessment of the risks and the feasibility of options and patient needs. These assessments influenced 4 key clinical decisions. DISCUSSION Triggers for psychosocially informed CDSS should include psychosocial screening results, new or newly diagnosed patients, and changes in patient status. CDSS should support cost-sensitive medication prescribing, and psychosocially based assessment of hypoglycemia risk. Electronic health records should capture rationales for care that do not conform to guidelines for panel management. NPs and diabetes educators are key stakeholders in psychosocially informed CDSS. CONCLUSION Findings highlight opportunities for psychosocially informed CDSS-a vital next step for improving health equity.
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Affiliation(s)
- Charles Senteio
- Department of Library and Information Science, Rutgers School of Communication and Information, New Brunswick, New Jersey, USA
| | - Julia Adler-Milstein
- Department of Medicine, University of California San Francisco, San Francisco, California USA
| | - Caroline Richardson
- Department of Family Medicine, University of Michigan Medical School, Ann Arbor, Michigan USA
| | - Tiffany Veinot
- School of Information, School of Public Health, University of Michigan, Ann Arbor, Michigan USA
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11
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Schuttner L, Reddy A, White AA, Wong ES, Liao JM. Quality in the Context of Value. Am J Med Qual 2020; 35:465-473. [DOI: 10.1177/1062860620917205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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12
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Connors EH, Douglas S, Jensen-Doss A, Landes SJ, Lewis CC, McLeod BD, Stanick C, Lyon AR. What Gets Measured Gets Done: How Mental Health Agencies can Leverage Measurement-Based Care for Better Patient Care, Clinician Supports, and Organizational Goals. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2020; 48:250-265. [PMID: 32656631 DOI: 10.1007/s10488-020-01063-w] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Mental health clinicians and administrators are increasingly asked to collect and report treatment outcome data despite numerous challenges to select and use instruments in routine practice. Measurement-based care (MBC) is an evidence-based practice for improving patient care. We propose that data collected from MBC processes with patients can be strategically leveraged by agencies to also support clinicians and respond to accountability requirements. MBC data elements are outlined using the Precision Mental Health Framework (Bickman et al. in Adm Policy Mental Health Mental Health Serv Res 43:271-276, 2016), practical guidance is provided for agency administrators, and conceptual examples illustrate strategic applications of one or more instruments to meet various needs throughout the organization.
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Affiliation(s)
- Elizabeth H Connors
- Department of Psychiatry, Yale University, 389 Whitney Avenue, Office 106, New Haven, CT, 06511, USA.
| | - Susan Douglas
- Department of Leadership, Policy and Organizations, Vanderbilt University, 230 Appleton Place, Nashville, TN, 37203, USA
| | - Amanda Jensen-Doss
- Department of Psychology, University of Miami, P.O. Box 248185, Coral Gables, FL, 33124, USA
| | - Sara J Landes
- VISN 16 Mental Illness Research, Education, and Clinical Center (MIRECC), Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR, 72114, USA
- Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W. Markham St, Little Rock, AR, 72205, USA
| | - Cara C Lewis
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101-1466, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington, School of Medicine, 6200 NE 74th Street, Suite 100, Seattle, WA, 98115, USA
| | - Bryce D McLeod
- Department of Psychology, Virginia Commonwealth University, 806 W. Franklin Street, PO Box 842018, Richmond, VA, 23284, USA
| | - Cameo Stanick
- Clinical Practice, Training, and Research and Evaluation, Hathaway-Sycamores Child and Family Services, 100 W. Walnut Street, Ste #375, Pasadena, CA, 91124, USA
| | - Aaron R Lyon
- Department of Psychiatry and Behavioral Sciences, University of Washington, School of Medicine, 6200 NE 74th Street, Suite 100, Seattle, WA, 98115, USA
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Marcotte LM, Moriates C, Wolfson DB, Frankel RM. Professionalism as the Bedrock of High-Value Care. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2020; 95:864-867. [PMID: 31274519 DOI: 10.1097/acm.0000000000002858] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
"High-value care" has become a popular mantra and a call to action among health system leaders, policymakers, and educators who are advocating widespread practice changes to reduce costs, minimize overuse, and optimize outcomes in the United States. Regrettably, current research does not demonstrate significant progress in improving high-value care. Many investigators have looked to payment models, benefit design, and policy changes as the main levers to reduce low-value care delivery; thus, the prevailing approach to ensuring high-value care has been to identify and limit low-value services. This approach has a clear limitation: The number of identified low-value services has become too high for individual physicians to track. Using professionalism as a key driver of practice change presents an important opportunity to shift from a deficit-based reactive model to one that is proactive and uses the concepts of intrinsic motivation and medical stewardship to effect high-value care. Transforming aspirational values such as professionalism into actions that engage all physician stakeholders regardless of their position or influence, and regardless of system agility or payment structure, has the potential for bringing about real change. These concepts can be integrated into medical education, introduced early in training, and modeled by educators to drive long-term sustainable change. Physicians can, and should, embrace professionalism as the motivation for redesigning care. Payment reform incentives that align with their professional values should follow and encourage these efforts; that is, payment reform should not be the impetus for redesigning care.
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Affiliation(s)
- Leah M Marcotte
- L.M. Marcotte is associate medical director for population health, UW Medicine, and clinical assistant professor, Department of Medicine, University of Washington School of Medicine, Seattle, Washington. C. Moriates is assistant dean for health care value, Department of Medical Education, associate chair for quality, safety and value, and associate professor of internal medicine, Department of Internal Medicine, Dell Medical School, University of Texas at Austin, Austin, Texas. D.B. Wolfson is executive vice president and chief operating officer, American Board of Internal Medicine (ABIM) Foundation, Philadelphia, Pennsylvania. R.M. Frankel is professor of medicine and geriatrics, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
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Dalkin BH, Sampson LR, Novicoff WM, Browne JA. Zip Codes May Not Be an Adequate Method to Risk Adjust for Socioeconomic Status Following Total Joint Arthroplasty at the Individual Surgeon Level. J Arthroplasty 2020; 35:309-312. [PMID: 31668695 DOI: 10.1016/j.arth.2019.09.047] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 09/26/2019] [Accepted: 09/30/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Increasing consumerism in healthcare has included a push toward the ranking of individual surgeons. These rankings rely on the adjustment of patient outcomes based on individual patient risk. Socioeconomic status (SES) has been identified as an important variable impacting patient outcomes following total joint arthroplasty, and patient zip code has been proposed as a proxy. Our study attempts to determine if zip code is an acceptable proxy for SES within a single surgeon's practice. METHODS Using public zip code and Geographic Information Systems (GIS) tax map data, we compared the real estate holdings of 244 patients undergoing total joint arthroplasty from an individual hip and knee arthroplasty surgeon's practice within an academic medical center over a 14-month period. An independent t-test was used to compare GIS data with the average home value within a given zip code. A Pearson correlation coefficient was calculated between GIS values and average home value per zip code. RESULTS In a sample of 244 patients, mean home value calculated from GIS data was $335,993 (standard deviation [SD] $246,549), and $243,663 with zip code data (SD $84,731). The Pearson correlation coefficient was 0.411 (P < .001). There was a significant difference between mean home values calculated from zip code data and GIS data (P < .001). Using zip code estimates would have mischaracterized home value, as defined as greater than or less than 1 SD, in 15% of patients. CONCLUSION Although there was some relationship between zip code and real estate holdings, the correlation is only moderate in strength and a substantial number of outliers were present. Given the sample size at the individual surgeon level, we question whether zip code can be used as a proxy for SES risk adjustment for the purposes of surgeon ranking.
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Affiliation(s)
- Benjamin H Dalkin
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - Luke R Sampson
- University of Virginia School of Medicine, Charlottesville, VA
| | - Wendy M Novicoff
- Departments of Public Health Sciences and Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - James A Browne
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
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Boden WE, Redberg RF. Evolving from volume to value, or to a bolder vision of reimbursement reform? Am Heart J 2018; 204:174-177. [PMID: 30146116 DOI: 10.1016/j.ahj.2018.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 07/07/2018] [Indexed: 06/08/2023]
Affiliation(s)
- William E Boden
- VA New England Healthcare System, Boston University School of Medicine, Boston, MA; University of California, San Francisco, San Francisco, CA.
| | - Rita F Redberg
- VA New England Healthcare System, Boston University School of Medicine, Boston, MA; University of California, San Francisco, San Francisco, CA
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Braun Y, Mellema JJ, Peters RM, Curley S, Burchill G, Ring D. The relationship between therapist-rated function and patient-reported outcome measures. J Hand Ther 2018; 30:516-521. [PMID: 27912920 DOI: 10.1016/j.jht.2016.02.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 12/12/2015] [Accepted: 02/18/2016] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Prospective cohort study. INTRODUCTION Some third-party payers require hand therapists to rate patient's functional disability based on patient self-rating using patient-reported outcome measures (PROMs), objective measurements of impairment, and observation of functional tasks-hand therapist-rated function (HTRF). PURPOSE OF THE STUDY To test the correlation between HTRF and PROMs (upper limb functional index [ULFI] and Patient-Reported Outcomes Measurement Information System upper extremity [PROMIS UE]) and its association with psychological factors. METHODS In 2014, 100 new patients with upper extremity illness presenting to hand therapists were asked to participate in an observational cross-sectional study. Demographic-, condition-related, and psychological factors were obtained in addition to PROMs and HTRF. RESULTS HTRF correlated moderately with PROMIS UE (r = -0.49, P < .001) and ULFI (r = -0.56, P < .001). Correlation between PROMIS UE and ULFI was strong (r = 0.78, P < .001). Psychological factors explained most of the variations in both HTRF and PROMs. CONCLUSIONS Hand therapists' ratings of patient function correlate less strongly with PROMs than PROMs correlate with one other. The discrepancy between HTRF and PROMs may offer an opportunity to address stress, distress, or ineffective coping strategies that can interfere with recovery-an opportunity for therapists and patients to collaborate and develop goals and for future research to develop effective and feasible strategies for hand therapists. LEVEL OF EVIDENCE Level II, diagnostic study.
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Affiliation(s)
- Yvonne Braun
- Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital - Harvard Medical School, Boston, MA, USA
| | - Jos J Mellema
- Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital - Harvard Medical School, Boston, MA, USA
| | - Rinne M Peters
- Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital - Harvard Medical School, Boston, MA, USA
| | - Suzanne Curley
- Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital - Harvard Medical School, Boston, MA, USA
| | - Gae Burchill
- Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital - Harvard Medical School, Boston, MA, USA
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX.
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Quality Reporting by Payers: A Mixed-Methods Study of Provider Perspectives and Practices. Qual Manag Health Care 2018; 27:157-164. [DOI: 10.1097/qmh.0000000000000179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Roberts ET, Zaslavsky AM, McWilliams JM. The Value-Based Payment Modifier: Program Outcomes and Implications for Disparities. Ann Intern Med 2018; 168:255-265. [PMID: 29181511 PMCID: PMC5820192 DOI: 10.7326/m17-1740] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND When risk adjustment is inadequate and incentives are weak, pay-for-performance programs, such as the Value-Based Payment Modifier (Value Modifier [VM]) implemented by the Centers for Medicare & Medicaid Services, may contribute to health care disparities without improving performance on average. OBJECTIVE To estimate the association between VM exposure and performance on quality and spending measures and to assess the effects of adjusting for additional patient characteristics on performance differences between practices serving higher-risk and those serving lower-risk patients. DESIGN Exploiting the phase-in of the VM on the basis of practice size, regression discontinuity analysis and 2014 Medicare claims were used to estimate differences in practice performance associated with exposure of practices with 100 or more clinicians to full VM incentives (bonuses and penalties) and exposure of practices with 10 or more clinicians to partial incentives (bonuses only). Analyses were repeated with 2015 claims to estimate performance differences associated with a second year of exposure above the threshold of 100 or more clinicians. Performance differences were assessed between practices serving higher- and those serving lower-risk patients after standard Medicare adjustments versus adjustment for additional patient characteristics. SETTING Fee-for-service Medicare. PATIENTS Random 20% sample of beneficiaries. MEASUREMENTS Hospitalization for ambulatory care-sensitive conditions, all-cause 30-day readmissions, Medicare spending, and mortality. RESULTS No statistically significant discontinuities were found at the threshold of 10 or more or 100 or more clinicians in the relationship between practice size and performance on quality or spending measures in either year. Adjustment for additional patient characteristics narrowed performance differences by 9.2% to 67.9% between practices in the highest and those in the lowest quartile of Medicaid patients and Hierarchical Condition Category scores. LIMITATION Observational design and administrative data. CONCLUSION The VM was not associated with differences in performance on program measures. Performance differences between practices serving higher- and those serving lower-risk patients were affected considerably by additional adjustments, suggesting a potential for Medicare's pay-for-performance programs to exacerbate health care disparities. PRIMARY FUNDING SOURCE The Laura and John Arnold Foundation and National Institute on Aging.
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Affiliation(s)
- Eric T Roberts
- University of Pittsburgh, Pittsburgh, Pennsylvania, and Harvard Medical School, Boston, Massachusetts (E.T.R.)
| | | | - J Michael McWilliams
- Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts (J.M.M.)
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Overley SC, McAnany SJ, Brochin RL, Kim JS, Merrill RK, Qureshi SA. The 5-year cost-effectiveness of two-level anterior cervical discectomy and fusion or cervical disc replacement: a Markov analysis. Spine J 2018; 18:63-71. [PMID: 28673826 DOI: 10.1016/j.spinee.2017.06.036] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 05/23/2017] [Accepted: 06/26/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Anterior cervical discectomy and fusion (ACDF) and cervical disc replacement (CDR) are both acceptable surgical options for the treatment of cervical myelopathy and radiculopathy. To date, there are limited economic analyses assessing the relative cost-effectiveness of two-level ACDF versus CDR. PURPOSE The purpose of this study was to determine the 5-year cost-effectiveness of two-level ACDF versus CDR. STUDY DESIGN The study design is a secondary analysis of prospectively collected data. PATIENT SAMPLE Patients in the Prestige cervical disc investigational device exemption (IDE) study who underwent either a two-level CDR or a two-level ACDF were included in the study. OUTCOME MEASURES The outcome measures were cost and quality-adjusted life years (QALYs). MATERIALS AND METHODS A Markov state-transition model was used to evaluate data from the two-level Prestige cervical disc IDE study. Data from the 36-item Short Form Health Survey were converted into utilities using the short form (SF)-6D algorithm. Costs were calculated from the payer perspective. QALYs were used to represent effectiveness. A probabilistic sensitivity analysis (PSA) was performed using a Monte Carlo simulation. RESULTS The base-case analysis, assuming a 40-year-old person who failed appropriate conservative care, generated a 5-year cost of $130,417 for CDR and $116,717 for ACDF. Cervical disc replacement and ACDF generated 3.45 and 3.23 QALYs, respectively. The incremental cost-effectiveness ratio (ICER) was calculated to be $62,337/QALY for CDR. The Monte Carlo simulation validated the base-case scenario. Cervical disc replacement had an average cost of $130,445 (confidence interval [CI]: $108,395-$152,761) with an average effectiveness of 3.46 (CI: 3.05-3.83). Anterior cervical discectomy and fusion had an average cost of $116,595 (CI: $95,439-$137,937) and an average effectiveness of 3.23 (CI: 2.84-3.59). The ICER was calculated at $62,133/QALY with respect to CDR. Using a $100,000/QALY willingness to pay (WTP), CDR is the more cost-effective strategy and would be selected 61.5% of the time by the simulation. CONCLUSIONS Two-level CDR and ACDF are both cost-effective strategies at 5 years. Neither strategy was found to be more cost-effective with an ICER greater than the $50,000/QALY WTP threshold. The assumptions used in the analysis were strongly validated with the results of the PSA.
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Affiliation(s)
- Samuel C Overley
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, New York City, NY, USA
| | - Steven J McAnany
- Department of Orthopedic Surgery, Washington University Orthopedics, 660 Euclid Avenue, St. Louis, MO, USA
| | - Robert L Brochin
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, New York City, NY, USA
| | - Jun S Kim
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, New York City, NY, USA
| | - Robert K Merrill
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, New York City, NY, USA
| | - Sheeraz A Qureshi
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, New York City, NY, USA.
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Sielatycki JA, Chotai S, Kay H, Stonko D, McGirt M, Devin CJ. Does Obesity Correlate With Worse Patient-Reported Outcomes Following Elective Anterior Cervical Discectomy and Fusion? Neurosurgery 2017; 79:69-74. [PMID: 27166659 DOI: 10.1227/neu.0000000000001252] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Studies have investigated the impact of obesity in thoracolumbar surgery; however, the effect of obesity on patient-reported outcomes (PROs) following anterior cervical discectomy and fusion (ACDF) is unknown. OBJECTIVE To examine the relationship between obesity and PROs following elective ACDF. METHODS Consecutive patients undergoing ACDF for degenerative conditions were evaluated. Patients were divided into groups with a body mass index ≥35. The EuroQol-5D, Short-Form 12 (SF-12), modified Japanese Orthopaedic Association score, and Neck Disability Index were used. Correlations between PROs and obesity were calculated at baseline and 1 year. RESULTS A total of 299 patients were included, with 80 obese (27%) and 219 nonobese (73%). patients At baseline, obesity was associated with worse myelopathy (modified Japanese Orthopaedic Association score: 10.7 vs 12.2, P = .01), general physical health (SF-12 physical component scale score: 28.7 vs 31.8, P = .02), and general mental health (SF-12 mental component scale score: 38.9 vs 42.3, P = .04). All PROs improved significantly following surgery in both groups. There was no difference in absolute scores and change scores for any PRO at 12 months following surgery. Furthermore, there was no difference in the percentage of patients achieving a minimal clinically important difference for the Neck Disability Index (52% vs 56%, P = .51) and no difference in patient satisfaction (85% vs 85%, P = .85) between groups. CONCLUSION Obesity was not associated with less improvement in PROs following ACDF. There was no difference in the proportion of patients satisfied with surgery and those achieving a minimal clinically important difference across all PROs. Obese patients may therefore achieve meaningful improvement following elective ACDF. ABBREVIATIONS ACDF, anterior cervical discectomy and fusionBMI, body mass indexEQ-5D, EuroQol-5DMCID, minimal clinically important differenceMCS, mental component scalemJOA, modified Japanese Orthopaedic AssociationNDI, Neck Disability IndexNRS, Numerical Rating ScalePCS, physical component scalePROs, patient-reported outcomesSF-12, Short Form 12.
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Affiliation(s)
- John A Sielatycki
- *Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; ‡Vanderbilt University School of Medicine, Nashville, Tennessee; §Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina
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Pocket change: a simple educational intervention increases hospitalist documentation of comorbidities and improves hospital quality performance measures. Qual Manag Health Care 2016; 24:74-8. [PMID: 25830615 DOI: 10.1097/qmh.0000000000000052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Complete documentation of patient comorbidities in the medical record is important for clinical care, hospital reimbursement, and quality performance measures. We designed a pocket card reminder and brief educational intervention aimed at hospitalists with the goal of improving documentation of 6 common comorbidities present on admission: coagulation abnormalities, metastatic cancer, anemia, fluid and electrolyte abnormalities, malnutrition, and obesity. METHODS Two internal medicine inpatient teams led by 10 hospitalist physicians at an academic medical center received the educational intervention and pocket card reminder (n = 520 admissions). Two internal medicine teams led by nonhospitalist physicians served as a control group (n = 590 admissions). Levels of documentation of 6 common comorbidities, expected length of stay, and expected mortality were measured at baseline and during the 9-month study period. RESULTS The intervention was associated with increased documentation of anemia, fluid and electrolyte abnormalities, malnutrition, and obesity in the intervention group, both compared to baseline and compared to the control group during the study period. The expected length of stay increased in the intervention group during the study period. CONCLUSIONS A simple educational intervention and pocket card reminder were associated with improved documentation and hospital quality measures at an academic medical center.
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22
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Trauma patients: I can't get no (patient) satisfaction? Am J Surg 2016; 212:1256-1260. [DOI: 10.1016/j.amjsurg.2016.09.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 09/13/2016] [Accepted: 09/14/2016] [Indexed: 11/19/2022]
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Chakrabarti A, Sheetz K, Katariya N, Singer A, Hewitt W, Heilman R, Khamash H, Reddy K, Moss A, Mathur A. Do Patient Assessments of Hospital Quality Correlate With Kidney Transplantation Surgical Outcomes? Transplant Proc 2016; 48:1986-92. [DOI: 10.1016/j.transproceed.2016.03.038] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 03/21/2016] [Indexed: 10/21/2022]
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Wisco OJ, Adelson D. Basal cell carcinoma screening drives a comprehensive approach to skin cancer. Br J Dermatol 2016; 174:1182-3. [PMID: 27317277 DOI: 10.1111/bjd.14707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- O J Wisco
- Bend Memorial Clinic, Bend, OR, U.S.A.. .,Department of Dermatology, Oregon Health Sciences University, Portland, OR, U.S.A..
| | - D Adelson
- Department of Dermatology, Oregon Health Sciences University, Portland, OR, U.S.A
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Ryan AM, Tompkins CP, Markovitz AA, Burstin HR. Linking Spending and Quality Indicators to Measure Value and Efficiency in Health Care. Med Care Res Rev 2016; 74:452-485. [DOI: 10.1177/1077558716650089] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Policy makers and stakeholders have reached a consensus that both quality and spending or resource use indicators should be jointly measured and prioritized to meet the objectives of our health system. However, the relative merits of alternative approaches that combine quality and spending indicators are not well understood. We conducted a literature review to identify different approaches that combine indicators of quality and spending measures to profile provider efficiency in the context of specific applications in health care. Our investigation identified seven alternative models that are either in use or have been proposed to evaluate provider efficiency. We then used publicly available data to profile hospitals using these approaches. Profiles of hospital efficiency using alternative models yielded wide variation in performance, underscoring the importance of model selection. By identifying the current efficiency models and evaluating their trade-offs within specific programmatic contexts, our analysis informs stakeholder and policy maker decisions about how to link quality and spending indicators when measuring efficiency in health care.
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Affiliation(s)
- Andrew M. Ryan
- University of Michigan School of Public Health, Ann Arbor, MI, USA
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Hernandez-Boussard T, Tamang S, Blayney D, Brooks J, Shah N. New Paradigms for Patient-Centered Outcomes Research in Electronic Medical Records: An Example of Detecting Urinary Incontinence Following Prostatectomy. EGEMS 2016; 4:1231. [PMID: 27347492 PMCID: PMC4899050 DOI: 10.13063/2327-9214.1231] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction: National initiatives to develop quality metrics emphasize the need to include patient-centered outcomes. Patient-centered outcomes are complex, require documentation of patient communications, and have not been routinely collected by healthcare providers. The widespread implementation of electronic medical records (EHR) offers opportunities to assess patient-centered outcomes within the routine healthcare delivery system. The objective of this study was to test the feasibility and accuracy of identifying patient centered outcomes within the EHR. Methods: Data from patients with localized prostate cancer undergoing prostatectomy were used to develop and test algorithms to accurately identify patient-centered outcomes in post-operative EHRs – we used urinary incontinence as the use case. Standard data mining techniques were used to extract and annotate free text and structured data to assess urinary incontinence recorded within the EHRs. Results A total 5,349 prostate cancer patients were identified in our EHR-system between 1998–2013. Among these EHRs, 30.3% had a text mention of urinary incontinence within 90 days post-operative compared to less than 1.0% with a structured data field for urinary incontinence (i.e. ICD-9 code). Our workflow had good precision and recall for urinary incontinence (positive predictive value: 0.73 and sensitivity: 0.84). Discussion. Our data indicate that important patient-centered outcomes, such as urinary incontinence, are being captured in EHRs as free text and highlight the long-standing importance of accurate clinician documentation. Standard data mining algorithms can accurately and efficiently identify these outcomes in existing EHRs; the complete assessment of these outcomes is essential to move practice into the patient-centered realm of healthcare.
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McLaughlin N, Martin NA, Upadhyaya P, Bari AA, Buxey F, Wang MB, Heaney AP, Bergsneider M. Assessing the cost of contemporary pituitary care. Neurosurg Focus 2016. [PMID: 26223274 DOI: 10.3171/2014.8.focus14445] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Knowledge of the costs incurred through the delivery of neurosurgical care has been lagging, making it challenging to design impactful cost-containment initiatives. In this report, the authors describe a detailed cost analysis for pituitary surgery episodes of care and demonstrate the importance of such analyses in helping to identify high-impact cost activities and drive value-based care. METHODS This was a retrospective study of consecutively treated patients undergoing an endoscopic endonasal procedure for the resection of a pituitary adenoma after implementation and maturation of quality-improvement initiatives and the implementation of cost-containment initiatives. RESULTS The cost data pertaining to 27 patients were reviewed. The 2 most expensive cost activities during the index hospitalization were the total operating room (OR) and total bed-assignment costs. Together, these activities represented more than 60% of the cost of hospitalization. Although value-improvement initiatives contributed to the reduction of variation in the total cost of hospitalization, specific cost activities remained relatively variable, namely the following: 1) OR charged supplies, 2) postoperative imaging, and 3) use of intraoperative neuromonitoring. These activities, however, each contributed to less than 10% of the cost of hospitalization. Bed assignment was the fourth most variable cost activity. Cost related to readmission/reoperation represented less than 5% of the total cost of the surgical episode of care. CONCLUSIONS After completing a detailed assessment of costs incurred throughout the management of patients undergoing pituitary surgery, high-yield opportunities for cost containment should be identified among the most expensive activities and/or those with the highest variation. Strategies for safely reducing the use of the targeted resources, and related costs incurred, should be developed by the multidisciplinary team providing care for this patient population.
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Affiliation(s)
| | | | | | | | | | | | - Anthony P Heaney
- Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
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Bekelis K, McGirt MJ, Parker SL, Holland CM, Davies J, Devin CJ, Atkins T, Knightly J, Groman R, Zyung I, Asher AL. The present and future of quality measures and public reporting in neurosurgery. Neurosurg Focus 2015; 39:E3. [DOI: 10.3171/2015.8.focus15354] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Quality measurement and public reporting are intended to facilitate targeted outcome improvement, practice-based learning, shared decision making, and effective resource utilization. However, regulatory implementation has created a complex network of reporting requirements for physicians and medical practices. These include Medicare’s Physician Quality Reporting System, Electronic Health Records Meaningful Use, and Value-Based Payment Modifier programs. The common denominator of all these initiatives is that to avoid penalties, physicians must meet “generic” quality standards that, in the case of neurosurgery and many other specialties, are not pertinent to everyday clinical practice and hold specialists accountable for care decisions outside of their direct control.
The Centers for Medicare and Medicaid Services has recently authorized alternative quality reporting mechanisms for the Physician Quality Reporting System, which allow registries to become subspecialty-reporting mechanisms under the Qualified Clinical Data Registry (QCDR) program. These programs further give subspecialties latitude to develop measures of health care quality that are relevant to the care provided. As such, these programs amplify the power of clinical registries by allowing more accurate assessment of practice patterns, patient experiences, and overall health care value. Neurosurgery has been at the forefront of these developments, leveraging the experience of the National Neurosurgery Quality and Outcomes Database to create one of the first specialty-specific QCDRs.
Recent legislative reform has continued to change this landscape and has fueled optimism that registries (including QCDRs) and other specialty-driven quality measures will be a prominent feature of federal and private sector quality improvement initiatives. These physician- and patient-driven methods will allow neurosurgery to underscore the value of interventions, contribute to the development of sustainable health care solutions, and actively participate in meaningful quality initiatives for the benefit of the patients served.
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Affiliation(s)
- Kimon Bekelis
- 1Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Matthew J. McGirt
- 2Department of Neurosurgery, Carolina Neurosurgery & Spine Associates and Neuroscience Institute, Carolinas Healthcare System, Charlotte, North Carolina
| | | | | | - Jason Davies
- 5Department of Neurological Surgery, State University of New York at Buffalo, New York
| | - Clinton J. Devin
- 6Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tyler Atkins
- 2Department of Neurosurgery, Carolina Neurosurgery & Spine Associates and Neuroscience Institute, Carolinas Healthcare System, Charlotte, North Carolina
| | - Jack Knightly
- 7Department of Neurological Surgery, Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Rachel Groman
- 8Clinical Affairs and Quality Improvement, Hart Health Strategies, Inc., Washington, DC; and
| | - Irene Zyung
- 9American Association of Neurological Surgeons, Rolling Meadows, Illinois
| | - Anthony L. Asher
- 2Department of Neurosurgery, Carolina Neurosurgery & Spine Associates and Neuroscience Institute, Carolinas Healthcare System, Charlotte, North Carolina
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Do Patient Demographics and Patient-Reported Outcomes Predict 12-Month Loss to Follow-Up After Spine Surgery? Spine (Phila Pa 1976) 2015; 40:1934-40. [PMID: 26595443 DOI: 10.1097/brs.0000000000001101] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Analysis of patients in a prospective registry. OBJECTIVE To determine the association between patient demographics, outcomes, and loss to follow-up 12 months after spine surgery. SUMMARY OF BACKGROUND DATA Obtaining outcomes 12 months after spine surgery remains a challenge. Loss to follow-up is believed to introduce biases and portend poor outcomes. Associations between follow-up, patient demographics, and outcomes in the degenerative spine population have not been studied. METHODS Patients undergoing surgery for degenerative spine disease at a single institution over a 2-year period were enrolled in a prospective registry. Patient demographics, comorbidities, treatment variables, readmissions/reoperations, and all 90-day surgical morbidity were collected. Patient-reported outcomes were recorded at baseline, 3-months, and 12-months after surgery. Multivariate logistic regression analysis was done to identify predictors of loss to follow-up. RESULTS A total of 1484 patients with baseline and 3-month outcomes were included. Two hundred thirty-three (15.7%) patients were lost to follow-up at 12 months. There was no difference in the baseline demographics (Sex: P = 0.46) and comorbidities (American Society of Anesthesiologists Grade: P = 0.06) of patients who had follow-up at 12-months versus those who did not, except age and employment status. Patients lost to follow-up at 12 months were younger (51.0 vs. 57.1 years; P < 0.001) and a higher proportion were employed preoperatively (45.9% vs. 41.7%, P = 0.24). Preoperative pain, disability, and quality of life was similar between the two groups (P > 0.05). There was no difference in 90-day morbidity (17.2% vs. 16.2%; P = 0.70) and 3-month pain, disability, quality of life, and patient satisfaction (85.0% vs. 88.3%; P = 0.63) (P > 0.05). In multivariate model, only younger age (P < 0.001) was an independent predictor of loss to follow-up at 12 months. CONCLUSION In our prospective spine registry the 12-month loss to follow-up rate is approximately 15%. The only independent predictor of loss to follow-up is younger age and preoperative employment. LEVEL OF EVIDENCE 3.
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Dowd BE, Swenson T, Parashuram S, Coulam R, Kane R. PQRS Participation, Inappropriate Utilization of Health Care Services, and Medicare Expenditures. Med Care Res Rev 2015; 73:106-23. [PMID: 26324510 DOI: 10.1177/1077558715597846] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 07/06/2015] [Indexed: 11/17/2022]
Abstract
Medicare's Physician Quality Reporting System (PQRS) is the largest quality-reporting system in the U.S. health care system and a basis for the new value-based modifier system for physician payment. The PQRS allows health care providers to report measures of quality of care that include both the process of care and physiological outcomes. Using a multivariate difference-in-differences model, we examine the relationship of PQRS participation to three claims-computable measures of inappropriate utilization of health care services and risk-adjusted per capita Medicare expenditures. The data are a national random sample of PQRS-participating providers matched to nonparticipating providers by zip code and caseload. We found few significant relationships in the overall analysis. However, the magnitude and statistical significance of the desirable associations increased in subgroups of providers and beneficiaries more prone to overutilization (e.g., males, older beneficiaries, beneficiaries treated in larger medical practices or by nonphysicians, and practices in rural areas), and among beneficiaries with heart conditions, diabetes, and eye problems.
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Affiliation(s)
| | | | | | | | - Robert Kane
- University of Minnesota, Minneapolis, MN, USA
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Evaluating the feasibility and utility of translating Choosing Wisely recommendations into e-Measures. Healthcare (Basel) 2015; 3:24-37. [DOI: 10.1016/j.hjdsi.2014.12.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2014] [Revised: 11/08/2014] [Accepted: 12/16/2014] [Indexed: 01/26/2023] Open
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Osnabrugge RL, Speir AM, Head SJ, Jones PG, Ailawadi G, Fonner CE, Fonner E, Kappetein AP, Rich JB. Cost, quality, and value in coronary artery bypass grafting. J Thorac Cardiovasc Surg 2014; 148:2729-35.e1. [DOI: 10.1016/j.jtcvs.2014.07.089] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 07/02/2014] [Accepted: 07/13/2014] [Indexed: 01/21/2023]
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The 5-year cost-effectiveness of anterior cervical discectomy and fusion and cervical disc replacement: a Markov analysis. Spine (Phila Pa 1976) 2014; 39:1924-33. [PMID: 25188602 DOI: 10.1097/brs.0000000000000562] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A Markov state-transition model was developed to evaluate the cost-effectiveness of anterior cervical discectomy and fusion (ACDF) and cervical disc replacement (CDR) at 5 years. OBJECTIVE To determine the cost-effectiveness of ACDF and CDR at 5 years. SUMMARY OF BACKGROUND DATA ACDF and CDR are surgical options for the treatment of an acute cervical disc herniation with associated myelopathy/radiculopathy. Cost-effectiveness analysis provides valuable information regarding which intervention will lead to a more efficient utilization of health care resources. METHODS Outcome and complication probabilities were obtained from existing literature. Physician costs were based on a fixed percentage of 140% of 2010 Medicare reimbursement. Hospital costs were determined from the Nationwide Inpatient Sample. Utilities were derived from responses to health state surveys (Short Form 36) at baseline and at 5 years from the treatment arms of the ProDisc-C trial. Incremental cost-effectiveness ratios were used to compare treatments. One-way sensitivity analyses were performed on all parameters within the model. RESULTS CDR generated a total 5-year cost of $102,274, whereas ACDF resulted in a 5-year cost of $119,814. CDR resulted in a generation of 2.84 quality-adjusted life years, whereas ACDF resulted in 2.81. The incremental cost-effectiveness ratio was -$557,849 per quality-adjusted life year gained. CDR remained the dominant strategy below a cost of $20,486. ACDF was found to be a cost-effective strategy below a cost of $18,607. CDR was the dominant strategy when the utility value was above 0.713. CDR remained the dominant strategy assuming an annual complication rate less than 4.37%. CONCLUSION ACDF and CDR were both shown to be cost-effective strategies at 5 years. CDR was found to be the dominant treatment strategy in our model. Further long-term studies evaluating the clinical and quality-of-life outcomes of these 2 treatments are needed to further validate the model. LEVEL OF EVIDENCE 5.
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Abstract
The Affordable Care Act has resulted in a dramatic governmental restructuring of the healthcare insurance market and delivery system. Orthopaedic traumatologists must be aware of the law's impact on their clinical practice, finances, and overall business model. This includes the effect of accountable care organizations, the Independent Payment Advisory Board, and the Physician Value-Based Payment Modifier program, as well as the impact of the Affordable Care Act's grace period provision, medical device excise tax, and cuts to funding for the Disproportionate Share Hospital program.
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Counihan T, Gary M, Lopez E, Tutela S, Ellrodt G, Glasener R. Surgical Multidisciplinary Rounds: An Effective Tool for Comprehensive Surgical Quality Improvement. Am J Med Qual 2014; 31:31-7. [PMID: 25210093 DOI: 10.1177/1062860614549761] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
An analysis of outcomes, quality, and survey data was carried out to evaluate the impact of surgical multidisciplinary rounds (SMDR) at a community teaching hospital. Surgical inpatients were reviewed over a 4-year period. Real-time changes to clinical care, documentation, and programs were enacted during the rounds. SMDR contributed to reductions in length of stay (6.1 to 5.1 days), postoperative respiratory failure (15.5% to 6.8%), deep venous thrombosis/pulmonary embolism (2.8% to 2.3%), cardiac complications (7.0% to 1.6%), and catheter-associated urinary tract infection (5.2% to 1.5%), and increased Surgical Care Improvement Program All-or-None compliance (95.6% to 98.7%). Additionally, SMDR increased awareness of Accreditation Council for Graduate Medical Education core competencies among surgical residents and was associated with enhanced job satisfaction among participants. Twice-weekly SMDR is an effective care paradigm that has changed culture, improved care coordination, and facilitated rapid, sustained process improvement along multiple patient safety indicators and core measures.
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Casalino LP, Pesko MF, Ryan AM, Mendelsohn JL, Copeland KR, Ramsay PP, Sun X, Rittenhouse DR, Shortell SM. Small primary care physician practices have low rates of preventable hospital admissions. Health Aff (Millwood) 2014; 33:1680-8. [PMID: 25122562 DOI: 10.1377/hlthaff.2014.0434] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Nearly two-thirds of US office-based physicians work in practices of fewer than seven physicians. It is often assumed that larger practices provide better care, although there is little evidence for or against this assumption. What is the relationship between practice size--and other practice characteristics, such as ownership or use of medical home processes--and the quality of care? We conducted a national survey of 1,045 primary care-based practices with nineteen or fewer physicians to determine practice characteristics. We used Medicare data to calculate practices' rate of potentially preventable hospital admissions (ambulatory care-sensitive admissions). Compared to practices with 10-19 physicians, practices with 1-2 physicians had 33 percent fewer preventable admissions, and practices with 3-9 physicians had 27 percent fewer. Physician-owned practices had fewer preventable admissions than hospital-owned practices. In an era when health care reform appears to be driving physicians into larger organizations, it is important to measure the comparative performance of practices of all sizes, to learn more about how small practices provide patient care, and to learn more about the types of organizational structures--such as independent practice associations--that may make it possible for small practices to share resources that are useful for improving the quality of care.
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Affiliation(s)
- Lawrence P Casalino
- Lawrence P. Casalino is the Livingston Farrand Professor in the Department of Healthcare Policy and Research at Weill Cornell Medical College, in New York, New York
| | - Michael F Pesko
- Michael F. Pesko is an assistant professor in the Department of Healthcare Policy and Research, Weill Cornell Medical College
| | - Andrew M Ryan
- Andrew M. Ryan is an associate professor in the Department of Healthcare Policy and Research, Weill Cornell Medical College
| | - Jayme L Mendelsohn
- Jayme L. Mendelsohn worked on this project as a research coordinator in the Department of Healthcare Policy and Research, Weill Cornell Medical College. She is currently a postbaccalaureate premedical student at Bryn Mawr
| | - Kennon R Copeland
- Kennon R. Copeland is senior vice president and director in the Department of Statistics and Methodology, NORC at the University of Chicago, in Illinois
| | - Patricia Pamela Ramsay
- Patricia Pamela Ramsay is a research specialist at the School of Public Health, University of California, Berkeley
| | - Xuming Sun
- Xuming Sun worked on this project as a research biostatistician in the Department of Healthcare Policy and Research, Weill Cornell Medical College. She is currently working as a statistician in the New York City Department of Health and Mental Hygiene
| | - Diane R Rittenhouse
- Diane R. Rittenhouse is an associate professor in the Department of Family and Community Medicine and Center for Excellence in Primary Care, University of California, San Francisco
| | - Stephen M Shortell
- Stephen M. Shortell is the Blue Cross of California Distinguished Professor of Health Policy and Management at the School of Public Health, University of California, Berkeley
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Eskander A, Irish J, Groome PA, Freeman J, Gullane P, Gilbert R, Hall SF, Urbach DR, Goldstein DP. Volume-outcome relationships for head and neck cancer surgery in a universal health care system. Laryngoscope 2014; 124:2081-8. [DOI: 10.1002/lary.24704] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Revised: 02/10/2014] [Accepted: 03/28/2014] [Indexed: 12/13/2022]
Affiliation(s)
- Antoine Eskander
- Department of Otolaryngology-Head and Neck Surgery; University of Toronto; Toronto Ontario Canada
| | - Jonathan Irish
- Department of Otolaryngology-Head and Neck Surgery; University of Toronto; Toronto Ontario Canada
- Department of Otolaryngology-Head and Neck Surgery and Department of Surgical Oncology; Princess Margaret Cancer Centre; Toronto Ontario Canada
| | - Patti A. Groome
- Cancer Care and Epidemiology Division; Queen's Cancer Research Institute; Queen's University; Kingston Ontario Canada
| | - Jeremy Freeman
- Department of Otolaryngology-Head and Neck Surgery; University of Toronto; Toronto Ontario Canada
- Department of Otolaryngology-Head and Neck Surgery; Mount Sinai Hospital; Toronto Ontario Canada
| | - Patrick Gullane
- Department of Otolaryngology-Head and Neck Surgery; University of Toronto; Toronto Ontario Canada
- Department of Otolaryngology-Head and Neck Surgery and Department of Surgical Oncology; Princess Margaret Cancer Centre; Toronto Ontario Canada
| | - Ralph Gilbert
- Department of Otolaryngology-Head and Neck Surgery; University of Toronto; Toronto Ontario Canada
- Department of Otolaryngology-Head and Neck Surgery and Department of Surgical Oncology; Princess Margaret Cancer Centre; Toronto Ontario Canada
| | - Stephen F. Hall
- Cancer Care and Epidemiology Division; Queen's Cancer Research Institute; Queen's University; Kingston Ontario Canada
- Department of Otolaryngology-Head and Neck Surgery; Queen's University; Kingston Ontario Canada
| | - David R. Urbach
- Division of General Surgery; Department of General Surgery and Surgical Oncology; University of Toronto; Toronto Ontario Canada
- Department of Otolaryngology-Head and Neck Surgery and Department of Surgical Oncology; Princess Margaret Cancer Centre; Toronto Ontario Canada
| | - David P. Goldstein
- Department of Otolaryngology-Head and Neck Surgery; University of Toronto; Toronto Ontario Canada
- Department of Otolaryngology-Head and Neck Surgery and Department of Surgical Oncology; Princess Margaret Cancer Centre; Toronto Ontario Canada
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Harewood GC. Creating a lean endoscopist: does operations management have a role in endoscopy? Gastrointest Endosc 2014; 79:646-7. [PMID: 24630085 DOI: 10.1016/j.gie.2013.11.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Accepted: 11/18/2013] [Indexed: 02/08/2023]
Affiliation(s)
- Gavin C Harewood
- Division of Gastroenterology and Hepatology, Beaumont Hospital, Dublin, Ireland
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Zulman DM, Asch SM, Martins SB, Kerr EA, Hoffman BB, Goldstein MK. Quality of care for patients with multiple chronic conditions: the role of comorbidity interrelatedness. J Gen Intern Med 2014; 29:529-37. [PMID: 24081443 PMCID: PMC3930789 DOI: 10.1007/s11606-013-2616-9] [Citation(s) in RCA: 122] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 07/30/2013] [Accepted: 08/26/2013] [Indexed: 12/21/2022]
Abstract
Multimorbidity--the presence of multiple chronic conditions in a patient--has a profound impact on health, health care utilization, and associated costs. Definitions of multimorbidity in clinical care and research have evolved over time, initially focusing on a patient's number of comorbidities and the associated magnitude of required care processes, and later recognizing the potential influence of comorbidity characteristics on patient care and outcomes. In this article, we review the relationship between multimorbidity and quality of care, and discuss how this relationship may be mediated by the degree to which conditions interact with one another to generate clinical complexity (comorbidity interrelatedness). Drawing on established theoretical frameworks from cognitive engineering and biomedical informatics, we describe how interactions among conditions result in clinical complexity and may affect quality of care. We discuss how this comorbidity interrelatedness influences the value of existing quality guidelines and performance metrics, and describe opportunities to quantify this construct using data widely available through electronic health records. Incorporating comorbidity interrelatedness into conceptualizations of multimorbidity has the potential to enhance clinical and research efforts that aim to improve care for patients with multiple chronic conditions.
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Affiliation(s)
- Donna M Zulman
- Center for Health Care Evaluation, VA Palo Alto Health Care System, Menlo Park, CA, USA,
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Dy SM, Pfoh ER, Salive ME, Boyd CM. Health-related quality of life and functional status quality indicators for older persons with multiple chronic conditions. J Am Geriatr Soc 2013; 61:2120-2127. [PMID: 24320819 PMCID: PMC4459785 DOI: 10.1111/jgs.12555] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To explore central challenges with translating self-reported measurement tools for functional status and health-related quality of life (HRQOL) into ambulatory quality indicators for older people with multiple chronic conditions (MCCs). DESIGN Review. SETTING Sources including the National Quality Measures Clearinghouse and National Quality Forum were reviewed for existing ambulatory quality indicators relevant to functional status, HRQOL, and people with MCCs. PARTICIPANTS Seven informants with expertise in indicators using functional status and HRQOL. MEASUREMENTS Informant interviews were conducted to explore knowledge about these types of indicators, particularly usability and feasibility. RESULTS Nine important existing indicators were identified in the review. For process, identified indicators addressed whether providers assessed functional status; outcome indicators addressed quality of life. In interviews, informants agreed that indicators using self-reported data were important in this population. Challenges identified included concerns about usability due to inability to discriminate quality of care adequately between organizations and feasibility concerns regarding high data collection burden, with a correspondingly low response rate. Validity was also a concern because evidence is mixed that healthcare interventions can improve HRQOL or functional status for this population. As a possible first step, a structural standard could be systematic collection of these measures in a specific setting. CONCLUSION Although functional status and HRQOL are important outcomes for older people with MCCs, few relevant ambulatory quality indicators exist, and there are concerns with usability, feasibility, and validity. Further research is needed on how best to incorporate these outcomes into quality indicators for people with MCCs.
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Affiliation(s)
- Sydney M. Dy
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Elizabeth R. Pfoh
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Marcel E. Salive
- Division of Geriatrics and Clinical Gerontology, National Institute on Aging, Bethesda, Maryland
| | - Cynthia M. Boyd
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
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Chien AT, Rosenthal MB. Medicare's physician value-based payment modifier--will the tectonic shift create waves? N Engl J Med 2013; 369:2076-8. [PMID: 24195501 DOI: 10.1056/nejmp1311957] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Alyna T Chien
- From the Division of General Pediatrics, Boston Children's Hospital (A.T.C.), Harvard Medical School (A.T.C.), and the Department of Health Policy and Management, Harvard School of Public Health (M.B.R.) - all in Boston
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McDeavitt JT. The siren song of physician incentives: avoiding the rocks. PM R 2013; 5:970-3. [PMID: 24247016 DOI: 10.1016/j.pmrj.2013.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 09/26/2013] [Indexed: 11/17/2022]
Abstract
As the United States attempts to reform its health care system, various incentive programs are playing an increasingly important role. In this review, the primary dynamics that drive the rise of incentives in health care management are discussed. Increasingly well-designed studies on the impact of incentives on outcomes continue to yield variable and, at times, unexpected results. The incorporation of incentives into the overall process of organizational cultural change is an important tool but one with significant limitations.
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Affiliation(s)
- James T McDeavitt
- Division of Education and Research, Carolinas HealthCare System, PO Box 32861, Charlotte, NC 28232(∗).
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Yu H, Mehrotra A, Adams J. Reliability of utilization measures for primary care physician profiling. Healthcare (Basel) 2013; 1:22-9. [DOI: 10.1016/j.hjdsi.2013.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 04/12/2013] [Accepted: 04/15/2013] [Indexed: 10/26/2022] Open
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45
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Blumenthal D, Jena AB. Hospital value-based purchasing. J Hosp Med 2013; 8:271-7. [PMID: 23589485 DOI: 10.1002/jhm.2045] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 03/04/2013] [Accepted: 03/08/2013] [Indexed: 11/09/2022]
Abstract
Hospital Value Based Purchasing (VBP) aims to incentivize inpatient providers to delivery high value, as opposed to high volume, health care. The formal mandate of hospitals to provide high value health care through financial incentives marks an important change in Medicare and Medicaid policy. In this opportune review of VBP, we discuss the relevant historical changes in the reimbursement environment of U.S. hospitals that have set the stage for VBP. We describe the structure of the Centers for Medicare and Medicaid Services' VBP program, with a focus on which hospitals are eligible to participate in the program, the specific outcomes measured and incentivized, how rewards and penalties are allocated, and how the program will be funded. In an effort to anticipate some of the issues that lie ahead, we then highlight a number of potential challenges to the success of VBP, and discuss how VBP will impact the delivery and reimbursement of inpatient care services. We conclude by examining how the VBP program is likely to evolve over time.
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Affiliation(s)
- Daniel Blumenthal
- Department of Medicine, Massachusetts General Hospital, Boston, MA 02115, USA.
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