Measuring quality in health care and its implications for pay-for-performance initiatives

Textbook outcomes in DIEP flap breast reconstruction: a Delphi study to establish consensus

PURPOSE

Composite measures, like textbook outcomes, may be superior to individual metrics when assessing hospital performance and quality of care. This study utilized a Delphi process to define a textbook outcome in DIEP flap breast reconstruction.

METHODS

A two-round Delphi survey defined: (1) A textbook outcome, (2) Exclusion criteria for a study population, and (3) Respondent opinion regarding textbook outcomes. An a priori threshold of ≥ 70% agreement among respondents established consensus among the tested statements.

RESULTS

Out of 85 invitees, 48 responded in the first round and 41 in the second. A textbook outcome was defined as one that meets the following within 90 days: (1) No intraoperative complications, (2) Operative duration ≤ 12 h for bilateral and ≤ 10 h for unilateral/stacked reconstruction, (3) No post-surgical complications requiring re-operation, (4) No surgical site infection requiring IV antibiotics, (5) No readmission, (6) No mortality, (7) No systemic complications, and (8) Length of stay < 5 days. Exclusion criteria for medical and surgical characteristics (e.g., BMI > 40, HgbA1c > 7) and case-volume cut-offs for providers (≥ 21) and institutions (≥ 44) were defined. Most agreed that textbook outcomes should be defined for complex plastic surgery procedures (75%) and utilized to gauge hospital performance for microsurgical breast reconstruction (77%).

CONCLUSION

This Delphi study identified (1) Key elements of a textbook outcome for DIEP flap breast reconstruction, (2) Exclusion criteria for future studies, and (3) Characterized surgeon opinions regarding the utility of textbook outcomes in serving as quality metric for breast reconstruction care.

Outcome Measurement for Distal Radius Fractures

Distal radius fractures (DRFs) are among the most common upper extremity injuries. Multiple medical conditions now are evaluated by standardized outcome sets that enable comparability. Recent international working groups have provided consensus statements for outcomes measurement after DRFs. These statements emphasized the growing importance of patient-reported outcome measures as well as traditional measures, including pain assessment, radiographic alignment, performance, and assessment of complications. A standardized instrument and timeline for measuring outcomes following DRFs offers clinicians, researchers, and health care economists a powerful tool. This article reviews the current evidence and provides recommendations for a DRF standardized outcome set.

Navigating the Intersection of Evidence and Policy in Hand Surgery Practice

Collaboration with organizations beyond the clinical setting is necessary to identify safety hazards that contribute to the high incidence and severity of hand conditions. Hand surgeons are acutely aware of obstacles patients face while navigating the health care system. Advocacy efforts encourage the development of equitable insurance policies and improve health resource allocation so that hand surgeons can treat a larger patient population. Participation in quality initiatives supports the development of evidence-based clinical guidelines. Further evidence must be generated to ensure that surgeons remain proficient in the latest techniques and uphold high standards of care as hand surgery procedures evolve.

Establishing a National Registry for Hand Surgery

Hand surgery leadership in the United States must identify and define what quality care means for its patients. To achieve this, the surgical team needs a standardized framework to track and improve quality. This is necessary not only in our value-based health care system but also in light of considerable provider variation in the management of common hand conditions and the ongoing need for evidence-based guidelines to inform decision-making. Building a national registry for the field of hand surgery could be the solution and warrants serious consideration. A registry designed by hand surgery experts can collect data on process and outcome measures that are meaningful and specific to patients with hand conditions. These data inform the surgical team regarding where to focus their efforts for improvement. Existing methods of quality measurement are not compatible with hand surgery, a field with an ambulatory setting and rare incidence of mortality. Patient-reported outcomes, such as health-related quality of life, represent a more useful measure of quality for hand surgery and are just one example of the type of data that could be tracked using a national registry. An investment in a large-scale registry could seamlessly integrate patient preferences, values, and expectations into clinical practice so that desired outcomes can be delivered consistently across the nation.

Performance Measures in Dermatologic Surgery: A Review of the Literature and Future Directions

BACKGROUND

In recent years, health care reform initiatives have aimed to assess quality of care through the use of performance measures. Multiple specialties, including dermatology, have implemented registries to track and report health care quality.

OBJECTIVE

The authors review the history and rationale for assessing quality in dermatologic surgery. The authors also discuss the different types of performance measures and the current efforts to develop clinically relevant dermatologic surgery-specific measures.

MATERIALS AND METHODS

An extensive literature review was conducted using OVID, MEDLINE, PubMed, and government and health care-related websites to identify articles related to surgical performance measures.

RESULTS

Few performance measures are established to assess quality in dermatologic surgery. The authors propose specific candidate measures and discuss how clinical registries can capture measures that meet federal reporting requirements.

CONCLUSION

Assessment of health care quality will become increasingly important in health care reform. Physicians need to take an active role in selecting appropriate, clinically relevant performance measures that will help improve patient care while containing health care costs and meeting government-mandated reporting requirements.

A survey-based design of a pricing system for psychotherapy

For admission to statutory health insurance, it is common in Switzerland that health care providers negotiate prices for health care services directly with health insurers. Once they agree upon a price, they must submit the resulting price to the Federal Office of Public Health (FOPH), which can then authorize it. Swiss law requires the prices in health care to be based on empirical data. There has been little research on how to derive such a price for health care from empirical data and which data should be used. Based on a collaboration with psychological psychotherapists in Switzerland, we have designed a pricing system. The empirical basis were two representative surveys: a survey about costs and earnings of psychotherapists, as well as a time-use survey for psychotherapy. This paper shows the methodology followed to establish an empirically based pricing system. The paper may serve as a practical guide for health service providers who want to develop a pricing system. Our approach offers a high degree of freedom because it involves the collection of the data and an explicit modelling phase. At the same time, it might be more resource intensive than other approaches that are based on existing data sources.

Quality Measurement: A Primer for Hand Surgeons

As the government and payers place increasing emphasis on measuring and reporting quality and meeting-specific benchmarks, physicians and health care systems will continue to adapt to meet regulatory requirements. Hand surgeons' involvement in quality measure development will help ensure that our services are appropriately assessed. Moreover, by embracing a culture of quality assessment and improvement, we will improve patient care while demonstrating the importance of our services in a health care system that is transitioning from a fee-for-service model to a fee-for-value model. Understanding quality and the tools for its measurement, and the application of quality assessment and improvement methods can help hand surgeons continue to deliver high-quality care that aligns with national priorities.

Cost-effectiveness of diabetes pay-for-performance incentive designs

BACKGROUND

Taiwan's National Health Insurance (NHI) Program implemented a diabetes pay-for-performance program (P4P) based on process-of-care measures in 2001. In late 2006, that P4P program was revised to also include achievement of intermediate health outcomes.

OBJECTIVES

This study examined to what extent these 2 P4P incentive designs have been cost-effective and what the difference in effect may have been.

RESEARCH DESIGN AND METHOD

Analyzing data using 3 population-based longitudinal databases (NHI's P4P dataset, NHI's claims database, and Taiwan's death registry), we compared costs and effectiveness between P4P and non-P4P diabetes patient groups in each phase. Propensity score matching was used to match comparable control groups for intervention groups. Outcomes included life-years, quality-adjusted life-years (QALYs), program intervention costs, cost-savings, and incremental cost-effectiveness ratios.

RESULTS

QALYs for P4P patients and non-P4P patients were 2.08 and 1.99 in phase 1 and 2.08 and 2.02 in phase 2. The average incremental intervention costs per QALYs was TWD$335,546 in phase 1 and TWD$298,606 in phase 2. The average incremental all-cause medical costs saved by the P4P program per QALYs were TWD$602,167 in phase 1 and TWD$661,163 in phase 2. The findings indicated that both P4P programs were cost-effective and the resulting return on investment was 1.8:1 in phase 1 and 2.0:1 in phase 2.

CONCLUSIONS

We conclude that the diabetes P4P program in both phases enabled the long-term cost-effective use of resources and cost-savings regardless of whether a bonus for intermediate outcome improvement was added to a process-based P4P incentive design.

Quality assessment in hand surgery

Measuring quality assessment in hand surgery remains an underexplored area. However, measuring quality is becoming increasingly transparent and important. Patients now have direct access to hospital and physician metrics and large payers have linked financial incentives to quality metrics. It is critical for hand surgeons to understand the essential elements of quality and its assessment. This article reviews several areas of hand surgery quality assessments including safety, outcomes, satisfaction, and cost.

Development of a brief, 12-item version of the Michigan Hand Questionnaire

BACKGROUND

The Michigan Hand Questionnaire is one of the most widely used hand-specific surveys that measure health status relevant to patients with acute and chronic hand disorders. However, item redundancy exists in the original version, and an abbreviated survey could minimize responder burden and offer broader applicability.

METHODS

Patients (n = 422) with four specific hand conditions--rheumatoid arthritis (n = 162), thumb carpometacarpal osteoarthritis (n = 31), carpal tunnel syndrome (n = 97), and distal radius fracture (n = 132)--completed the Michigan Hand Questionnaire at two time points. Correlation analysis identified two items from each of six domains (i.e., function, activities of daily living, work, pain, aesthetics, and satisfaction). The Brief Michigan Hand Questionnaire score was calculated as the sum of the responses to the 12 items. Psychometric analysis was performed to describe the reliability, validity, and responsiveness of the Brief Michigan Hand Questionnaire.

RESULTS

The Brief Michigan Hand Questionnaire includes 12 items that were highly correlated with the summary Michigan Hand Questionnaire score (r = 0.99, p < 0.001). The Brief Michigan Hand Questionnaire scores were highly correlated between the two time periods (r = 0.78, p < 0.001) and by disease type. Responsiveness of the Brief Michigan Hand Questionnaire was high for all diseases and similar to that of the original Michigan Hand Questionnaire.

CONCLUSIONS

The 12-item Brief Michigan Hand Questionnaire is an efficient and versatile outcomes instrument specific to hand disability that retains the psychometric properties of the original Michigan Hand Questionnaire. The Brief Michigan Hand Questionnaire is an important tool with which to measure patient outcomes and the quality of care in hand surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, I.(Figure is included in full-text article.).

Maintenance of Certification, maintenance of public trust

The Maintenance of Certification program has been well received by many physicians but has faced significant opposition from others who complain that it is overly tedious, costly, and irrelevant to their practice. This article offers a consolidated and concise history of the program and a summary of what plastic surgeons need to know to successfully complete the American Board of Plastic Surgery's own Maintenance of Certification requirements. The authors have justified each step of the board's Maintenance of Certification process in terms of how it improves the quality of care delivered to plastic surgery patients. Finally, a summary of research is presented that demonstrates both that the public supports the maintenance of certification process for all physicians and that continuing education and formal assessment and improvement initiatives have been linked in multiple studies to a better and more evidence-based medical practice.

Archie Cochrane and his vision for evidence-based medicine

Archibald (Archie) Cochrane's most influential mark on health care was his 1971 publication, Effectiveness and Efficiency. This book strongly criticized the lack of reliable evidence behind many of the commonly accepted health care interventions at the time. His criticisms spurred rigorous evaluations of health care interventions and highlighted the need for evidence in medicine. His call for a collection of systematic reviews led to the creation of The Cochrane Collaboration. Archie Cochrane was a visionary person who helped lay down much of the foundation for evidence-based medicine. This article introduces evidence-based medicine to plastic surgery by tracing its history to the seminal efforts by Archie Cochrane.

Future of the US healthcare system and the effects on the practice of hand surgery

The multitier healthcare system of the USA has several major flaws. High costs and uncertain quality of care indicate that this system is no longer practical. Several improvement initiatives, such as the Oregon Health Plan, Leapfrog, Lean Manufacturing, and Pay-for-Performance have been implemented into the current system. All of these quality improvement models are being experimented in a limited fashion and do not address the biggest problem in the US healthcare, inequality of care. There is now increasing support for a universal health coverage model as an ethically sound and just way to decrease health disparities in the USA. The current quality initiatives as well as an adoption of universal coverage appear to be the best way to improve quality of care, reduce cost, and increase equality in healthcare. These initiatives may have considerable effects on the practice of hand surgery in the near future, and thus, it is important for the field of hand surgery to become more engaged in advocacy and public policy arena. The purpose of this paper is to examine the current problems in the US healthcare system and to evaluate potential solutions that will enhance quality while simultaneously curbing the unchecked increase in healthcare expenditure.

Introducing evidence-based medicine to plastic and reconstructive surgery

An effective healthcare system is one in which healthcare spending provides acceptable returns in terms of health outcomes and broad coverage for its citizens. By this measure, the United States healthcare system unfortunately falls short. Tremendous pressure for improvement has given rise to several initiatives designed to decrease healthcare expenditure and improve outcomes, access, and quality of care. The outcomes movement, which is revolutionary in American medicine, has heightened awareness about the need to critically examine our treatment outcomes. However, the early euphoria surrounding the outcomes movement was met with restraint at the realization of its limitations. Although the outcomes movement has verified the effectiveness of many existing treatments in plastic surgery, most of the investments in these projects unfortunately have resulted in few, if any, positive changes for the patient, physician or healthcare system (1 ). US healthcare is now moving towards the adoption of evidence-based medicine (EBM), which may potentially be another revolution in American healthcare (2 ).