1
|
Sage WM, Warren KD. Swimming Together Upstream: How to Align MLP Services with U.S. Healthcare Delivery. J Law Med Ethics 2024; 51:786-797. [PMID: 38477273 PMCID: PMC10937178 DOI: 10.1017/jme.2023.163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
Medical-legal partnership (MLP) embeds attorneys and paralegals into care delivery to help clinicians address root causes of health inequities. Notwithstanding decades of favorable outcomes, MLP is not as well-known as might be expected. In this essay, the authors explore ways in which strategic alignment of legal services with healthcare services in terms of professionalism, information collection and sharing, and financing might help the MLP movement become a more widespread, sustainable model for holistic care delivery.
Collapse
Affiliation(s)
- William M Sage
- TEXAS A&M UNIVERSITY SCHOOL OF LAW, FORT WORTH, TX, USA
- TEXAS A&M UNIVERSITY SCHOOL OF MEDICINE, FORT WORTH, TX, USA
| | - Keegan D Warren
- TEXAS A&M UNIVERSITY HEALTH SCIENCE CENTER, FORT WORTH, TX, USA
| |
Collapse
|
2
|
Shah ED, Salwen-Deremer JK, Gibson PR, Muir JG, Eswaran S, Chey WD. Comparing Costs and Outcomes of Treatments for Irritable Bowel Syndrome With Diarrhea: Cost-Benefit Analysis. Clin Gastroenterol Hepatol 2022; 20:136-144.e31. [PMID: 33010413 DOI: 10.1016/j.cgh.2020.09.043] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 08/28/2020] [Accepted: 09/21/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Irritable bowel syndrome (IBS) is one of the most expensive gastroenterological conditions and is an ideal target for developing a value-based care model. We assessed the comparative cost-benefit of treatments for IBS with diarrhea (IBS-D), the most common IBS subtype from insurer and patient perspectives. METHODS We constructed a decision analytic model assessing trade-offs among guideline-recommended and recently FDA-approved drugs, supplements, low FODMAP diet, cognitive behavioral therapy (CBT). Outcomes and costs were derived from systematic reviews of clinical trials and national databases. Health-gains were represented using quality-adjusted life years (QALY). RESULTS From an insurer perspective, on-label prescription drugs (rifaximin, eluxadoline, alosetron) were significantly more expensive than off-label treatments, low FODMAP, or CBT. Insurer treatment preferences were driven by average wholesale prescription drug prices and were not affected by health gains in sensitivity analysis within standard willingness-to-pay ranges up to $150,000/QALY-gained. From a patient perspective, prescription drug therapies and neuromodulators appeared preferable due to a reduction in lost wages due to IBS with effective therapy, and also considering out-of-pocket costs of low FODMAP food and out-of-pocket costs to attend CBT appointments. Comparative health outcomes exerted influence on treatment preferences from a patient perspective in cost-benefit analysis depending on a patients' willingness-to-pay threshold for additional health-gains, but health outcomes were less important than out-of-pocket costs at lower willingness-to-pay thresholds. CONCLUSIONS Costs are critical determinants of IBS treatment value to patients and insurers, but different costs drive patient and insurer treatment preferences. Divergent cost drivers appear to explain misalignment between patient and insurer IBS treatment preferences in practice.
Collapse
Affiliation(s)
- Eric D Shah
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
| | - Jessica K Salwen-Deremer
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Department of Psychiatry, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Peter R Gibson
- Department of Gastroenterology, Central Clinical School, Monash University, Melbourne, Australia
| | - Jane G Muir
- Department of Gastroenterology, Central Clinical School, Monash University, Melbourne, Australia
| | - Shanti Eswaran
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan
| | - William D Chey
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan
| |
Collapse
|
3
|
Nguyen NH, Koola J, Dulai PS, Prokop LJ, Sandborn WJ, Singh S. Rate of Risk Factors for and Interventions to Reduce Hospital Readmission in Patients With Inflammatory Bowel Diseases. Clin Gastroenterol Hepatol 2020; 18:1939-1948.e7. [PMID: 31470176 PMCID: PMC7044053 DOI: 10.1016/j.cgh.2019.08.042] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 08/15/2019] [Accepted: 08/21/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We investigated 30- and 90-day rates and causes of, risk factors for, and interventions to reduce hospital readmission in patients who received medical treatment for inflammatory bowel diseases (IBD). METHODS We performed a systematic search of publications through July 1, 2018 for studies of rates of hospital readmission and associated causes and risk factors in patients who received medical treatments for IBD. Our final analysis included 17 cohort studies (6324 patients) of hospitalized adults with IBD who had received medical treatment, along with reported readmission rates with detailed chart review. We performed random effects meta-analysis to estimate 30- and 90-day rates of readmission and identified causes and risk factors associated with readmission. We also performed qualitative analyses of studies that focused on interventions to reduce readmission. RESULTS Overall, the 30-day rate of readmission was 18.1% (95% CI, 14.4-22.4) and the 90-day rate was 26.0% (95% CI, 22.7-29.6). On meta-regression, studies with higher proportions of patients with ulcerative colitis than Crohn's disease reported higher risks for readmission. Most common reasons for readmission were IBD flare, infection, or complications from unplanned surgeries during hospitalizations. Consistent risk factors for 30-day readmission were admission for pain control (odds ratio [OR], 2.27; 95% CI, 1.69-3.03), need for total parenteral nutrition on discharge (OR, 2.13; 95% CI, 1.36-3.35), and prior or unplanned surgery during admission (OR, 3.11; 95% CI, 2.27-4.25). Only 1 study focused on interventions (specialized inpatient IBD service) to reduce risk of readmission. CONCLUSIONS Overall 30- and 90-day rates of readmission for patients who received medical treatment for IBD are 18.1% and 26.0%, respectively. IBD flares and infections are common reasons for readmission, and inadequate pain control and need for parenteral nutrition were common risk factors. Interventional studies to reduce risk of readmission are needed.
Collapse
Affiliation(s)
- Nghia H. Nguyen
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Jejo Koola
- Division of Hospital Medicine, Department of Medicine, University of California San Diego, La Jolla, California,Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, California
| | - Parambir S. Dulai
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Larry J. Prokop
- Department of Library Services, Mayo Clinic, Rochester, Minnesota
| | - William J. Sandborn
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Siddharth Singh
- Division of Gastroenterology, University of California, San Diego, La Jolla, California; Division of Biomedical Informatics, Department of Medicine, University of California, San Diego, La Jolla, California.
| |
Collapse
|
4
|
Aragon S, Khojasteh M, Boykin M, Crumpton B, McGuinn L, Gesell S. Challenging a Fundamental Proposition of Patient-Centeredness. J Best Pract Health Prof Divers 2020; 13:94-119. [PMID: 35310827 PMCID: PMC8929671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
This investigation challenged the proposition that physician patient-centeredness influences patients' experience-of-care (PEC). A theory-driven, three-factor, multigroup structural equation modeling design, using asymptotic-distribution-free and bootstrap estimation, with two national random and 5,000 bootstrap samples challenged the proposition's plausibility, measurement invariance, replicability, robustness against a competing model, and coherence with theory. The model fit [χ2(39) = 28, p =.900, RMSEA = .001, p = 1.00, CFI = 1.00], explaining 81 percent of PEC's variance; the proposition was invariant across samples, held against the competing model [χ2Δ(7) = 7.82, p = .97]; cross-validated against estimates from the 5,000 bootstrap samples; and agreed with theory. One standardized increase in patient-centeredness increased PEC, likelihood of recommending, and care ratings by .807, .765, and .771. Results converged in sustaining the plausibility of the proposition.
Collapse
Affiliation(s)
- Stephen Aragon
- Department of Healthcare Management, Winston-Salem State University, Winston-Salem, North Carolina
| | - Mak Khojasteh
- Department of Marketing and Management, Winston-Salem State University, Winston-Salem, North Carolina
| | - Montrale Boykin
- Department of Healthcare Management, Winston-Salem State University, Winston-Salem, North Carolina
| | - Breanne Crumpton
- C.G. O’Kelly Library, Winston-Salem State University, Winston-Salem, North Carolina
| | - Laura McGuinn
- Department of Pediatrics, Division of Developmental and Behavioral Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sabina Gesell
- Departments of Public Health Sciences and the Maya Angelou Center for Health Equity, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| |
Collapse
|
5
|
Regueiro M, Click B, Anderson A, Shrank W, Kogan J, McAnallen S, Szigethy E. Reduced Unplanned Care and Disease Activity and Increased Quality of Life After Patient Enrollment in an Inflammatory Bowel Disease Medical Home. Clin Gastroenterol Hepatol 2018; 16:1777-1785. [PMID: 29654918 PMCID: PMC6185823 DOI: 10.1016/j.cgh.2018.04.007] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 02/26/2018] [Accepted: 04/02/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Specialty medical homes (SMHs) are a new health care model in which a multidisciplinary team and specialists manage patients with chronic diseases. As part of a large integrated payer-provider network, we formed an inflammatory bowel diseases (IBDs) SMH and investigated its effects on health care use, disease activity, and quality of life (QoL). METHODS We performed a retrospective analysis of 322 patients (58% female; mean age, 34.6 y; 62% with Crohn's disease; 32% with prior IBD surgery) enrolled in an IBD SMH, in conjunction with the University of Pittsburgh Medical Center Health Plan, from June 2015 through July 2016. Patients had at least 1 year of follow up. We evaluated changes in numbers of emergency department visits and hospitalizations from the year before vs after SMH enrollment. Secondary measures included IBD activity assessments and QoL. RESULTS Compared to the year before IBD SMH enrollment, patients had a 47.3% reduction in emergency department visits (P < .0001) and a 35.9% reduction in hospitalizations (P = .008). In the year following IBD SMH enrollment, patients had significant reductions in the median Harvey-Bradshaw Index score (reduced from 4 to 3.5; P = .002), and median ulcerative colitis activity index score (from 4 to 3; P = .0003), and increases in QoL (median short inflammatory bowel disease questionnaire score increased from 50 to 51.8; P < .0001). Patients in the most extreme (highest and lowest) quartiles had the most improvement when we compared scores at baseline vs after enrollment. Based on multivariable regression analysis, use of corticosteroids (odds ratio [OR], 2.72; 95% CI, 1.32-5.66; P = .007) or opioids (OR, 3.20; 95% CI, 1.32-7.78; P = .01), and low QoL (OR, 4.44; 95% CI, 1.08-18.250; P = .04) at enrollment were significantly associated with persistent emergency department visits and hospitalizations. CONCLUSIONS We found development of an IBD SMH to be feasible and significantly reduce unplanned care and disease activity and increase patient QoL 1 year after enrollment.
Collapse
Affiliation(s)
- Miguel Regueiro
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - Benjamin Click
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Alyce Anderson
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - William Shrank
- UPMC Center for High-Value Health Care, Insurance Services Division, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jane Kogan
- UPMC Center for High-Value Health Care, Insurance Services Division, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sandra McAnallen
- UPMC Center for High-Value Health Care, Insurance Services Division, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Eva Szigethy
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania,Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| |
Collapse
|