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Thangathurai G, Martel S, Montreuil J, Reindl R, Berry GK, Harvey EJ, Bernstein M. Predictors of Episode-of-Care Costs for Ankle Fractures. J Foot Ankle Surg 2024:S1067-2516(24)00049-8. [PMID: 38438103 DOI: 10.1053/j.jfas.2024.02.006] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 12/14/2023] [Accepted: 02/17/2024] [Indexed: 03/06/2024]
Abstract
Ankle fractures are one of the most resource-consuming traumatic orthopedic injuries. Few studies have successfully evaluated the episode-of-care costs (EOCC) of common traumatic orthopedic injuries. The objective of this study was to determine the EOCC associated with the surgical management of ankle fractures. A retrospective cohort study of 105 consecutive patients who underwent open reduction internal fixation of an isolated ankle fracture at a Canadian Level-1 trauma center was conducted. Episode-of-care costs were generated using an activity-based costing framework. The median global episode-of-care cost for ankle fracture surgeries performed at the studied institution was $3,487 CAD [IQR 880] ($2,685 USD [IQR 616]). Patients aged 60 to 90 years had a significantly higher median EOCC than younger patients (p=0.01). Supination-adduction injuries had a significantly higher median EOCC than other injury patterns (p=0.01). The median EOCC for patients who underwent surgery within 10 days of their injury ($3,347 CAD [582], $2,577 USD [448]) was significantly lower than the cost for patients who had their surgery delayed 10 days or more after the injury ($3,634 CAD [776], $2,798 USD [598]) (p=0.03). Patient sex, anesthesia type, ASA score and surgeon's fellowship training did not affect the EOCC. This study provides valuable data on predictors of EOCC in the surgical management of ankle fractures. Delaying simple ankle fracture cases due to operating time constraints can increase the total cost and burden of these fractures on the healthcare system. In addition, this study provides a framework for future episode-of-care cost analysis studies in orthopedic surgery. LEVEL OF EVIDENCE: Level III.
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Affiliation(s)
| | - Simon Martel
- Division of Orthopaedic Surgery, McGill University, Montreal, Quebec, Canada.
| | - Julien Montreuil
- Division of Orthopaedic Surgery, McGill University, Montreal, Quebec, Canada
| | - Rudolf Reindl
- Division of Orthopaedic Surgery, McGill University, Montreal, Quebec, Canada
| | - Gregory K Berry
- Division of Orthopaedic Surgery, McGill University, Montreal, Quebec, Canada
| | - Edward J Harvey
- Division of Orthopaedic Surgery, McGill University, Montreal, Quebec, Canada
| | - Mitchell Bernstein
- Division of Orthopaedic Surgery, McGill University, Montreal, Quebec, Canada
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Koochakpour K, Sofie Solheim F, Nytrø Ø, Clausen C, Frodl T, Koposov R, Leventhal B, Pant D, Brox Røst T, Stien L, Sverre Westbye O, Skokauskas N. Challenges in Interpreting Norwegian Child and Adolescent Mental Health Records. Stud Health Technol Inform 2024; 310:845-849. [PMID: 38269928 DOI: 10.3233/shti231084] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
The Electronic Health Record system BUPdata served Norwegian Child and Adolescent Mental Health Services (CAMHS) for over 35 years and is still an important source of information for understanding clinical practice. Secondary usage of clinical data enables learning and service quality improvement. We present some insights from explorative data analysis for interpreting the records of patients referred for hyperkinetic disorders. The major challenges were data preparation, pre-analysis, imputation, and validation. We summarize the main characteristics, spot anomalies, and detect errors. The results include observations about the patient referral diversity based on 12 different variables. We modeled the activities in an individual episode of care, described our clinical observations among data, and discussed the challenges of data analysis.
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Affiliation(s)
- Kaban Koochakpour
- Dept. Computer Science, The Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Frida Sofie Solheim
- Dept. Computer Science, The Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Bekk Consulting AS, Oslo, Norway
| | - Øystein Nytrø
- Dept. Computer Science, The Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Carolyn Clausen
- Reg. Centre for Child and Youth Mental Health and Child Welfare, NTNU, Trondheim, Norway
| | - Thomas Frodl
- Dept. of Psychiatry, Psychotherapy and -somatic, Univ. Hosp, RWTH Aachen, Germany
| | - Roman Koposov
- Reg. Centre for Child and Youth Mental Health and Child Welfare, Arctic Univ. of Norway
| | - Bennett Leventhal
- Dept. of Psychiatry, Division of Child and Adolescent Psychiatry, UCSF, USA
| | - Dipendra Pant
- Dept. Computer Science, The Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | | | - Line Stien
- Reg. Centre for Child and Youth Mental Health and Child Welfare, NTNU, Trondheim, Norway
| | - Odd Sverre Westbye
- Reg. Centre for Child and Youth Mental Health and Child Welfare, NTNU, Trondheim, Norway
- Department of Child and Adolescent Psychiatry, St. Olav's Univ. Hosp, Trondheim, Norway
| | - Norbert Skokauskas
- Reg. Centre for Child and Youth Mental Health and Child Welfare, NTNU, Trondheim, Norway
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Soler JK, Buono N, Cardillo E, Frese T, Vinker S, Ungan M. The fractured lens: a controversial revision of the International Classification of Primary Care. Front Med (Lausanne) 2024; 10:1230987. [PMID: 38274446 PMCID: PMC10808642 DOI: 10.3389/fmed.2023.1230987] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 12/15/2023] [Indexed: 01/27/2024] Open
Abstract
Background The International Classification of Primary Care (ICPC) has represented the international standard reduction for measuring the content of primary care for over 30 years. In the process of its third revision, its authors, the Wonca International Classification Committee (WICC), delegated a major part of the technical work to a purposely formed Consortium. However, in the process of such revision, standard classification principles and rules have been inconsistently applied with the result that ICPC-3 has been published with major errors and an inconsistent structure. Objectives To formally describe and critically appraise the revision process of ICPC-3. Methods The formal review of ICPC-3 performed by an expert group within WICC and commissioned by the Executive Council of Wonca Europe is presented in abridged form. Results ICPC-3 as currently presented introduces major departures from formal classification principles and rules, besides other major errors and inconsistencies, all of which are listed and described. Conclusion Major changes in ICPC-3 defy categorisation and conceptualisation standards. ICPC-3 now represents an untested departure from international standard presentations, without a formal academic base. The direct inclusion of measures of functioning in a classification of reasons for encounter and health problems fails to address the dichotomy of these domains, the boundaries of and relationships between which are not satisfactorily resolved by the system. Analysis of ICPC-3 data will require the development and implementation of alternative, as yet undefined, models of the relationships between disease and health. By including different domains without resolving ambiguity, and by splitting function from other body systems, ICPC-3 becomes an internally fractured instrument.
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Affiliation(s)
| | - Nicola Buono
- Department of General Practice, ICPC Club Italia, Caserta, Italy
| | - Elena Cardillo
- Institute of Informatics and Telematics, National Research Council, Rende, Italy
| | - Thomas Frese
- Institute of General Practice and Family Medicine, Medical Faculty, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Shlomo Vinker
- Department of Family Medicine, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Leumit Health Services, Tel Aviv, Israel
| | - Mehmet Ungan
- Department of Family Medicine, Ankara University School of Medicine, Ankara, Türkiye
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Porche K, Vaziri S, Stein A, Awan O, Kubilis PS, Lipori P, Hoh DJ, Polifka A, Fox WC. The effect of myelopathic symptoms on hospital costs, length of stay, and discharge location in anterior cervical discectomy and fusion. Neurosurg Focus 2023; 55:E8. [PMID: 37657101 DOI: 10.3171/2023.6.focus23288] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 06/13/2023] [Indexed: 09/03/2023]
Abstract
OBJECTIVE Cervical spondylotic myelopathy (CSM) is a common clinical degenerative disease treated with anterior cervical discectomy and fusion (ACDF), which seriously impacts quality of life and causes severe disability. The objective of the study was to determine the effect of different characteristics of the neurological deficit found in myelopathic patients undergoing ACDFs on hospital cost, length of stay (LOS), and discharge location. METHODS This is a retrospective review of ACDF cases performed at a single institution by multiple surgeons from 2011 to 2017. Patient symptomatology, complications, comorbidities, demographics, surgical time, LOS, and discharge location were collected. Patients with readmissions or reoperations were excluded. Symptoms evaluated were based on clinical diagnosis, Japanese Orthopaedic Association classification, Ranawat grade, and Cooper scales. Symptoms were further grouped using principal component analysis. Cost was defined as surgical episode hospital stay costs plus outpatient clinic costs plus discharge disposition cost. Multivariate linear regression models were created to evaluate correlations with outcomes. The primary outcome was total 90-day hospital costs. Secondary outcomes were discharge location and LOS. RESULTS A total of 250 patients were included in the analyses. Discharge location, neuromonitoring use, number of surgical vertebral levels, cage use, LOS, surgical time, having a complication, and sex were all found to be predictive of total 90-day costs. Myelopathic symptomatology was not found to be associated with increased 90-day costs (p ≥ 0.131) when correcting for these other factors. Lower-extremity functionality was found to be associated with increased LOS (p < 0.0001). Upper-extremity myelopathy was found to be associated with increased discharge location needs (p < 0.0001). CONCLUSIONS Cervical myelopathy was not found to be predictive of total 90-day costs using symptomatology based on multiple myelopathy grading systems. Lower-extremity functionality was, however, found to predict LOS, while upper-extremity myelopathy was found to predict increased discharge location needs. This implies that preoperative deficits from myelopathy should not be considered in a bundled payment system; however, certain myelopathic symptoms should be considered when determining the cost of care.
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Affiliation(s)
- Ken Porche
- 1College of Medicine, University of Florida, Gainesville
- 2Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville
| | - Sasha Vaziri
- 1College of Medicine, University of Florida, Gainesville
- 2Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville
| | - Alan Stein
- 1College of Medicine, University of Florida, Gainesville
- 3Department of General Surgery, University of Florida, Gainesville, Florida
- 4Department of Neurologic Surgery, Westchester Medical Center, Valhalla, New York
| | - Omar Awan
- 1College of Medicine, University of Florida, Gainesville
- 5Department of Neurologic Surgery, Inova Center for Personalized Health, Fairfax, Virginia; and
| | - Paul S Kubilis
- 2Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville
| | - Paul Lipori
- 2Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville
| | - Daniel J Hoh
- 1College of Medicine, University of Florida, Gainesville
- 2Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville
| | - Adam Polifka
- 1College of Medicine, University of Florida, Gainesville
- 2Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville
| | - W Christopher Fox
- 6Department of Neurologic Surgery, Mayo Clinic Florida, Jacksonville, Florida
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Koolmees DS, Ramkumar PN, Solsrud K, Yedulla NR, Elhage KG, Cross AG, Makhni EC. Time-Driven Activity-Based Costing Accurately Determines Bundle Cost for Rotator Cuff Repair. Arthroscopy 2022; 38:2370-7. [PMID: 35189303 DOI: 10.1016/j.arthro.2022.02.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 02/05/2022] [Accepted: 02/06/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to determine the cost of the episode of care for primary rotator cuff repair (RCR) from day of surgery to 90 days postoperatively using the time-driven activity-based costing (TDABC) method. The secondary purpose of this study was to identify the main drivers of cost for both phases of care. METHODS This retrospective case series study used the TDABC method to determine the bundled cost of care for an RCR. First, a process map of the RCR episode of care was constructed in order to determine drivers of fixed (i.e., rent, power), direct variable (i.e., healthcare personnel), and indirect costs (i.e., marketing, building maintenance). The study was performed at a Midwestern tertiary care medical system, and patients were included in the study if they underwent an RCR from January 2018 to January 2019 with at least 90 days of postoperative follow-up. In this article, all costs were included, but we did not account for fees to provider and professional groups. RESULTS The TDABC method calculated a cost of $10,569 for a bundled RCR, with 76% arising from the operative phase and 24% from the postoperative phase. The main driver of cost within the operative phase was the direct fixed costs, which accounted for 35% of the cost in this phase, and the largest contributor to cost within this category was the cost of implants, which accounted for 55%. In the postoperative phase of care, physical therapy visits were the greatest contributor to cost at 59%. CONCLUSION In a bundled cost of care for RCR, the largest cost driver occurs on the day of surgery for direct fixed costs, in particular, the implant. Physical therapy represents over half of the costs of the episode of care. Better understanding the specific cost of care for RCR will facilitate optimization with appropriately designed payment models and policies that safeguard the interests of the patient, physician, and payer. LEVEL OF EVIDENCE IV, therapeutic case series.
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Guduguntla V, Yaser JM, Keteyian SJ, Pagani FD, Likosky DS, Sukul D, Thompson MP. Variation in Cardiac Rehabilitation Participation During Aortic Valve Replacement Episodes of Care. Circ Cardiovasc Qual Outcomes 2022; 15:e009175. [PMID: 35559710 PMCID: PMC10068673 DOI: 10.1161/circoutcomes.122.009175] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite reported benefit in the setting of aortic valve replacement (AVR), cardiac rehabilitation (CR) utilization remains low, with few studies evaluating hospital and patient-level variation in CR participation. We explored determinants of CR variability during AVR episodes of care: transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). METHODS A cohort of 10 124 AVR episodes of care (TAVR n=5121 from 24 hospitals; SAVR n=5003 from 32 hospitals) were identified from the Michigan Value Collaborative statewide multipayer registry (2015-2019). CR enrollment was defined as the presence of a single professional or facility claim within 90 days of discharge: 93 797, 93 798, G0422, G0423. Annual trends and hospital variation in CR were described for TAVR, SAVR, and all AVR. Multilevel logistic regression was used to estimate effects of predictors and hospital risk-adjusted rates of CR enrollment. RESULTS Overall, 4027 (39.8%) patients enrolled in CR, with significant differences by treatment strategy: SAVR=50.9%, TAVR=28.9% (P<0.001). CR use after SAVR was significantly higher than after TAVR and increased over time for both modalities (P<0.001). There were significant differences in CR enrollment across age, gender, payer, and some comorbidities (P<0.05). At the hospital level, CR participation rates for all AVR varied 10-fold (4.8% to 68.7%) and were moderately correlated between SAVR and TAVR (Pearson r=0.56, P<0.01). CONCLUSIONS Substantial variation exists in CR participation during AVR episodes of care across hospitals. However, within-hospital CR participation rates were significantly correlated across treatment strategies. These findings suggest that CR participation is the product of hospital-specific practice patterns. Identifying hospital practices associated with higher CR participation can help assist future quality improvement efforts to increase CR use after AVR.
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Affiliation(s)
- Vinay Guduguntla
- Department of Internal Medicine, University of California, San Francisco (V.G.)
- Michigan Value Collaborative, University of Michigan, Ann Arbor (V.G., J.M.Y., M.P.T.)
| | - Jessica M Yaser
- Michigan Value Collaborative, University of Michigan, Ann Arbor (V.G., J.M.Y., M.P.T.)
| | - Steven J Keteyian
- Division of Cardiovascular Medicine, Henry Ford Health, Detroit, MI (S.J.K.)
| | - Francis D Pagani
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor (F.D.P., D.S.L., M.P.T.)
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, MI (F.D.P., D.S.L., M.P.T.)
| | - Donald S Likosky
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor (F.D.P., D.S.L., M.P.T.)
| | - Devraj Sukul
- Department of Internal Medicine, University of California, San Francisco (V.G.)
- Division of Cardiovascular Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor (D.S.)
| | - Michael P Thompson
- Michigan Value Collaborative, University of Michigan, Ann Arbor (V.G., J.M.Y., M.P.T.)
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor (F.D.P., D.S.L., M.P.T.)
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, MI (F.D.P., D.S.L., M.P.T.)
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7
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Wise KL, Parikh HR, Okelana B, Only AJ, Reams M, Harrison A, Braman J, Craig E, Cunningham BP. Measurement of value in rotator cuff repair: patient-level value analysis for the 1-year episode of care. J Shoulder Elbow Surg 2022; 31:72-80. [PMID: 34390841 DOI: 10.1016/j.jse.2021.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 06/25/2021] [Accepted: 07/11/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Rotator cuff repair (RCR) is one of the most common elective orthopedic procedures, with predictable indications, techniques, and outcomes. As a result, this surgical procedure is an ideal choice for studying value. The purpose of this study was to perform patient-level value analysis (PLVA) within the setting of RCR over the 1-year episode of care. METHODS Included patients (N = 396) underwent RCR between 2009 and 2016 at a single outpatient orthopedic surgery center. The episode of care was defined as 1-year following surgery. The Western Ontario Rotator Cuff index was collected at both the initial preoperative baseline assessment and the 1-year postoperative mark. The total cost of care was determined using time-driven activity-based costing (TDABC). Both PLVA and provider-level value analysis were performed. RESULTS The average TDABC cost of care was derived at $5413.78 ± $727.41 (95% confidence interval, $5341.92-$5485.64). At the patient level, arthroscopic isolated supraspinatus tears yielded the highest value coefficient (0.82; analysis-of-variance F test, P = .01). There was a poor correlation between the change in the 1-year Western Ontario Rotator Cuff score and the TDABC cost of care (r2 = 0.03). Provider-level value analysis demonstrated significant variation between the 8 providers evaluated (P < .01). CONCLUSION RCR is one of the most common orthopedic procedures, yet the correlations between cost of care and patient outcomes are unknown. PLVA quantifies the ratio of functional improvement to the TDABC-estimated cost of care at the patient level. This is the first study to apply PLVA over the first-year episode of care. With health care transitioning toward value-based delivery, PLVA offers a quantitative tool to measure the value of individual patient care delivery over the entire episode of care.
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Prodoehl J, Kraus S, Buros Stein A. Predicting the number of physical therapy visits and patient satisfaction in individuals with temporomandibular disorder: A cohort study. J Oral Rehabil 2021; 49:22-36. [PMID: 34674278 DOI: 10.1111/joor.13272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 09/21/2021] [Accepted: 10/12/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Temporomandibular disorders (TMD) can be challenging to manage for clinicians and patients alike. It is unclear which factors are associated with prolonging conservative care and patient dissatisfaction with treatment outcomes. OBJECTIVES To examine factors collected during a physical therapy (PT) evaluation in a cohort of individuals with TMD to determine factors associated with an increased number of PT visits and reduced patient satisfaction. METHODS Records of 511 patients referred to PT over 18 months were reviewed to extract 27 variables to develop a predictive model. Outcomes were patient satisfaction following PT and number of PT visits. Linear and zero inflated negative binomial regressions were used, and a multivariate regression model was built for both outcomes. RESULTS Two factors were associated with both lower patient satisfaction and an increased number of PT visits: higher patient rated functional neck disability and a greater number of healthcare professionals seen. Other factors associated with patient satisfaction were duration of symptoms, subluxation, and referral from an oral surgeon. Only patient rated functional neck disability score was a significant predictive factor in the multivariate model. Factors associated with number of PT visits were gender, educational level, time between initial visit and discharge, number of pain areas, bruxism, biopsychosocial factors, dizziness, pain rating, and presence of neck pain. In the multivariate model, gender, number of healthcare professionals seen, and resting pain rating were significant predictors of number of PT visits. CONCLUSION Considering key factors on initial evaluation, specifically functional neck disability and the number of prior healthcare professionals seen before starting PT, can help to predict a higher number of PT visits and reduced patient satisfaction with outcomes.
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Affiliation(s)
- Janey Prodoehl
- Physical Therapy Program, Midwestern University, Downers Grove, Illinois, USA
| | - Steven Kraus
- Horizon Physical Therapy LLC, Atlanta, Georgia, USA
| | - Amy Buros Stein
- Office of Research and Sponsored Programs, Midwestern University, Glendale, Arizona, USA
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9
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Ong CB, Krueger CA, Star AM. The Hospital Frailty Risk Score is Not an Accurate Predictor of Treatment Costs for Total Joint Replacement Patients in a Medicare Bundled Payment Population. J Arthroplasty 2021; 36:2658-2664.e2. [PMID: 33893001 DOI: 10.1016/j.arth.2021.03.049] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/17/2021] [Accepted: 03/23/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Medically complex patients require more resources and experience higher costs within total joint arthroplasty (TJA) bundled payment models. While risk adjustment would be beneficial for such patients, no tool currently exists which can reliably identify these patients preoperatively. The purpose of this study is to determine if the Hospital Frailty Risk Score (HFRS) is a valid predictor of high-TJA treatment costs. METHODS Retrospective analysis was performed on patients who underwent primary TJA between 2015 and 2020 from a single large orthopedic practice. ICD-10 codes from an institutional database were used to calculate HFRS. Cost data including inpatient, postacute, and episode of care (EOC) costs were collected. Charlson comorbidity index, demographics, readmissions, and complications were analyzed. RESULTS 4936 patients had a calculable HFRS and those with intermediate and high scores experienced more frequent readmissions/complications after TJA, as well as higher EOC costs. However, HFRS did not reliably predict EOC costs, yielding a sensitivity of 49% and specificity of 66%. Multivariate analysis revealed that both patient age and sex are superior individual cost predictors when compared with HFRS. Secondary analyses indicated that HFRS more effectively predicts TJA complications and readmissions but is still nonideal for clinical applications. CONCLUSION HFRS has poor sensitivity as a predictor of high-EOC costs for TJA patients but has adequate specificity for predicting postoperative readmissions and complications. Further research is needed to develop a scale that can appropriately predict orthopedic cost outcomes.
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Affiliation(s)
- Christian B Ong
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Chad A Krueger
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Andrew M Star
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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10
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Abstract
STUDY DESIGN The following is a narrative discussion of bundled payments in spine surgery. OBJECTIVE The cost of healthcare in the United States has continued to increase. To lower the cost of healthcare, reimbursement models are being investigated as potential cost saving interventions by driving incentives and quality improvement in fields such a spine surgery. METHODS Narrative overview of literature pertaining to bundled payments in spine surgery synthesizing findings from computerized databases and authoritative texts. RESULTS Spine surgery is challenging to define payment modes because of high cost variability and surgical decision-making nuances. While implementing bundled care payments in spine surgery, it is important to understand concepts such as value-based purchasing, episodes of care, prospective versus retrospective payment models, one versus two-sided risk, risk adjustment, and outlier protection. Strategies for implementation underscore the importance of risk stratification and modeling, adoption of evidence based clinical pathways, and data collection and dissemination. While bundled care models have been successfully implemented, challenges facing institutions adopting bundled care payment models include financial stressors during adoption of the model, distribution of risks, incentivization of treating only low risk patients, and nuanced variation in procedures leading to variation in costs. CONCLUSION An alternative for fee for service payments, bundled care payments may lead to higher cost savings and surgeon accountability in a patient's care.
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Affiliation(s)
- Kevin Hines
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA
| | - Nikolaos Mouchtouris
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA
| | - Charles Getz
- Department of Orthopedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | - Glenn Gonzalez
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA
| | - Thiago Montenegro
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA
| | - Adam Leibold
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA
| | - James Harrop
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA,James Harrop, Division of Spine and Peripheral Nerve Surgery, Department of Neurological Surgery, Thomas Jefferson University Hospital, 901 Walnut Street 3rd Floor, Philadelphia, PA 19107, USA.
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Banerjee S, Monteleone P, Novak S. Catheterization Laboratory Activity-Based Costing. Circ Cardiovasc Interv 2021; 14:e010228. [PMID: 33626899 DOI: 10.1161/circinterventions.120.010228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Subhash Banerjee
- University of Texas Southwestern Medical Center and Veterans Affairs North Texas Health Care System, Dallas (S.B.)
| | - Peter Monteleone
- University of Texas at Austin Dell Medical School, Austin (P.M.)
| | - Scott Novak
- Kingfish Statistics & Data Analytics, Durham, NC (S.N.)
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12
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Golinelli D, Boetto E, Mazzotti A, Rosa S, Rucci P, Berti E, Ugolini C, Fantini MP. Cost Determinants of Continuum-Care Episodes for Hip Fracture. Health Serv Insights 2021; 14:1178632921991122. [PMID: 33642863 PMCID: PMC7894600 DOI: 10.1177/1178632921991122] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 01/08/2021] [Indexed: 11/17/2022] Open
Abstract
Many factors affect the healthcare costs and outcomes in patients with hip fracture (HF). Through the construction of a Continuum-Care Episode (CCE), we investigated the costs of CCEs for HF and their determinants. We used data extracted from administrative databases of 5094 consecutive elderly patients hospitalized in 2017 in Emilia Romagna, Italy, to evaluate the overall costs of the CCE. We calculated the acute and post-acute costs from the date of the hospital admission to the end of the CCE. The determinants of costs by type of surgical intervention (total hip replacement, partial hip replacement, open reduction, and internal fixation) were investigated using generalized linear regression models. Regardless of the type of surgical intervention, hospital bed-based rehabilitation in public or private healthcare facilities either followed by rehabilitation in a community hospital/temporary nursing home beds or not were the strongest determinants of costs, while rehabilitation in intermediate care facilities alone was associated with lower costs. CCE's cost and its variability is mainly related to the rehabilitation setting. Cost-wise, intermediate care resulted to be an appropriate setting for providing post-acute rehabilitation for HF, representing the one associated with lower overall costs. Intermediate care organizational setting should be privileged when planning integrated care HF pathways.
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Affiliation(s)
- Davide Golinelli
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum–University of Bologna, Italy
| | - Erik Boetto
- School of Hygiene and Preventive Medicine, Alma Mater Studiorum–University of Bologna, Italy
| | - Antonio Mazzotti
- 1st Orthopedic and Traumatologic Clinic, IRCCS–Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Simona Rosa
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum–University of Bologna, Italy
| | - Paola Rucci
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum–University of Bologna, Italy
| | - Elena Berti
- Regional Agency for Health and Social Care, Emilia-Romagna Region - ASSR, Bologna, Italy
| | - Cristina Ugolini
- Department of Economics and CRIFSP-School of Advanced Studies in Health Policy, University of Bologna, Italy
| | - Maria Pia Fantini
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum–University of Bologna, Italy
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13
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Thompson MP, Yaser JM, Hou H, Syrjamaki JD, DeLucia A, Likosky DS, Keteyian SJ, Prager RL, Gurm HS, Sukul D. Determinants of Hospital Variation in Cardiac Rehabilitation Enrollment During Coronary Artery Disease Episodes of Care. Circ Cardiovasc Qual Outcomes 2021; 14:e007144. [PMID: 33541107 DOI: 10.1161/circoutcomes.120.007144] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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] [Indexed: 12/17/2022]
Abstract
BACKGROUND Cardiac rehabilitation (CR) is associated with improved outcomes for patients with coronary artery disease (CAD). However, CR enrollment remains low and there is a dearth of real-world data on hospital-level variation in CR enrollment. We sought to explore determinants of hospital variability in CR enrollment during CAD episodes of care: medical management of acute myocardial infarction (AMI-MM), percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG). METHODS A cohort of 71 703 CAD episodes of care were identified from 33 hospitals in the Michigan Value Collaborative statewide multipayer registry (2015 to 2018). CR enrollment was defined using professional and facility claims and compared across treatment strategies: AMI-MM (n=18 678), PCI (n=41 986), and CABG (n=11 039). Hierarchical logistic regression was used to estimate effects of predictors and hospital risk-adjusted rates of CR enrollment. RESULTS Overall, 20 613 (28.8%) patients enrolled in CR, with significant differences by treatment strategy: AMI-MM=13.4%, PCI=29.0%, CABG=53.8% (P<0.001). There were significant differences in CR enrollment across age groups, comorbidity status, and payer status. At the hospital-level, there was over 5-fold variation in hospital risk-adjusted CR enrollment rates (9.8%-51.6%). Hospital-level CR enrollment rates were highly correlated across treatment strategy, with the strongest correlation between AMI-MM versus PCI (R2=0.72), followed by PCI versus CABG (R2=0.51) and AMI-MM versus CABG (R2=0.46, all P<0.001). CONCLUSIONS Substantial variation exists in CR enrollment during CAD episodes of care across hospitals. However, within-hospital CR enrollment rates were significantly correlated across all treatment strategies. These findings suggest that CR enrollment during CAD episodes of care is the product of hospital-specific rather than treatment-specific practice patterns.
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Affiliation(s)
- Michael P Thompson
- Department of Cardiac Surgery (M.P.T., H.H., D.S.L., R.L.P.), Michigan Medicine, Ann Arbor MI.,Michigan Value Collaborative, University of Michigan, Ann Arbor (M.P.T., J.M.Y., J.D.S.)
| | - Jessica M Yaser
- Michigan Value Collaborative, University of Michigan, Ann Arbor (M.P.T., J.M.Y., J.D.S.)
| | - Hechuan Hou
- Department of Cardiac Surgery (M.P.T., H.H., D.S.L., R.L.P.), Michigan Medicine, Ann Arbor MI
| | - John D Syrjamaki
- Michigan Value Collaborative, University of Michigan, Ann Arbor (M.P.T., J.M.Y., J.D.S.)
| | - Alphonse DeLucia
- Department of Cardiac Surgery, Bronson Methodist Hospital, Kalamazoo, MI (A.D.)
| | - Donald S Likosky
- Department of Cardiac Surgery (M.P.T., H.H., D.S.L., R.L.P.), Michigan Medicine, Ann Arbor MI.,Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, MI (D.S.L., R.L.P.)
| | - Steven J Keteyian
- Division of Cardiovascular Medicine, Henry Ford Health System, Detroit, MI (S.J.K.)
| | - Richard L Prager
- Department of Cardiac Surgery (M.P.T., H.H., D.S.L., R.L.P.), Michigan Medicine, Ann Arbor MI.,Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, MI (D.S.L., R.L.P.)
| | - Hitinder S Gurm
- Division of Cardiovascular Medicine, Department of Internal Medicine (H.S.G., D.S.), Michigan Medicine, Ann Arbor MI.,Blue Cross Blue Shield of Michigan Cardiovascular Consortium, (BMC2), Ann Arbor, MI (H.S.G., D.S.)
| | - Devraj Sukul
- Division of Cardiovascular Medicine, Department of Internal Medicine (H.S.G., D.S.), Michigan Medicine, Ann Arbor MI.,Blue Cross Blue Shield of Michigan Cardiovascular Consortium, (BMC2), Ann Arbor, MI (H.S.G., D.S.)
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14
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Cohen RV, Nishikawa AM, Ribeiro RA, Oliveira FM, Andrade PC, Junqueira SM, Toldo B. Surgical Management of Obesity in Brazil: Proposal for a Value-Based Healthcare Model and Preliminary Results. Value Health Reg Issues 2021; 26:10-14. [PMID: 33550039 DOI: 10.1016/j.vhri.2020.11.005] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 10/27/2020] [Accepted: 11/03/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To describe the implementation and 1-year results of a value-based bariatric surgery program in Brazil. METHODS The study was conducted at a private hospital in São Paulo, Brazil (Hospital Alemão Oswaldo Cruz). A value-based healthcare program was implemented by designing an episode of care for eligible patients and developing a bundled payment model in which a single payment was made for the bariatric surgery covering the preoperative workup and ending 30 days after discharge. Assessment of outcomes included complication rate, hospital length of stay, intensive care admissions, reoperations, readmissions, and visits to the emergency department in the 30-day postoperative period. The results were compared with real-world evidence retrieved from a Brazilian private insurance database containing information on bariatric procedures performed in similar institutions (benchmark group). RESULTS Eighty-three patients were enrolled in the value-based healthcare program (80.7% women; 18.0% with type 2 diabetes mellitus; 31.0% with high blood pressure). The mean age was 40.9 years, and body mass index was 42.1 kg/m2. The outcomes recorded in the benchmark group versus the value-based healthcare group involved complication rate, 2.6% versus 1.4% (P = 0.69); length of stay, 2.5 versus 2.0 days (P = 0.0001); intensive care admissions, 4.0% versus 1.2% (P = 0.31); emergency care visits, 15.0% versus 6.0% (P = 0.04); and readmissions, 2.3% versus 0 (P = 0.35), with an estimated cost reduction of 7.1%. CONCLUSIONS These initial results showed favorable surgical and 30-day outcomes, demonstrating the benefits of a value-based approach for the surgical management of obesity and its comorbidities.
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Affiliation(s)
- Ricardo Vitor Cohen
- Oswaldo Cruz German Hospital, Center for the Treatment of Obesity and Diabetes, São Paulo, São Paulo, Brazil.
| | | | | | - Fernanda Maria Oliveira
- Johnson and Johnson Medical Devices, Health Economics and Market Access São Paulo, São Paulo, Brazil
| | - Priscila Caldeira Andrade
- Johnson and Johnson Medical Devices, Health Economics and Market Access São Paulo, São Paulo, Brazil
| | - Silvio Mauro Junqueira
- Johnson and Johnson Medical Devices, Health Economics and Market Access São Paulo, São Paulo, Brazil
| | - Bruno Toldo
- Oswaldo Cruz German Hospital, São Paulo, São Paulo, Brazil
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15
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Carducci MP, Mahendraraj KA, Menendez ME, Rosen I, Klein SM, Namdari S, Ramsey ML, Jawa A. Identifying surgeon and institutional drivers of cost in total shoulder arthroplasty: a multicenter study. J Shoulder Elbow Surg 2021; 30:113-119. [PMID: 32807371 DOI: 10.1016/j.jse.2020.04.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 03/02/2020] [Revised: 04/06/2020] [Accepted: 04/12/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Despite rapid increases in the demand for total shoulder arthroplasty, data describing cost trends are scarce. We aim to (1) describe variation in the cost of shoulder arthroplasty performed by different surgeons at multiple hospitals and (2) determine the driving factors of such variation. METHODS A standardized, highly accurate cost accounting method, time-driven activity-based costing, was used to determine the cost of 1571 shoulder arthroplasties performed by 12 surgeons at 4 high-volume institutions between 2016 and 2018. Costs were broken down into supply costs (including implant price and consumables) and personnel costs, including physician fees. Cost parameters were compared with total cost for surgical episodes and case volume. RESULTS Across 4 institutions and 12 surgeons, surgeon volume and hospital volume did not correlate with episode-of-care cost. Average cost per case of each institution varied by factors of 1.6 (P = .47) and 1.7 (P = .06) for anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RSA), respectively. Implant (56% and 62%, respectively) and personnel costs from check-in through the operating room (21% and 17%, respectively) represented the highest percentages of cost and highly correlated with the cost of the episode of care for TSA and RSA. CONCLUSIONS Variation in episode-of-care total costs for both TSA and RSA had no association with hospital or surgeon case volume at 4 high-volume institutions but was driven primarily by variation in implant and personnel costs through the operating room. This analysis does not address medium- or long-term costs.
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Affiliation(s)
| | | | - Mariano E Menendez
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA, USA
| | | | - Steven M Klein
- Department of Orthopaedic Surgery, Gundersen Health System, La Crosse, WI, USA
| | - Surena Namdari
- Department of Orthopaedic Surgery, Rothman Institute, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Matthew L Ramsey
- Department of Orthopaedic Surgery, Rothman Institute, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Andrew Jawa
- New England Baptist Hospital, Boston, MA, USA.
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16
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Thompson MP, Yost ML, Syrjamaki JD, Norton EC, Nathan H, Theurer P, Prager RL, Pagani FD, Likosky DS. Sources of Hospital Variation in Postacute Care Spending After Cardiac Surgery. Circ Cardiovasc Qual Outcomes 2020; 13:e006449. [PMID: 33176467 DOI: 10.1161/circoutcomes.119.006449] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Postacute care is a major driver of cardiac surgical episode spending, but the sources of variation in spending have not been explored. The objective of this study was to identify sources of variation in postacute care spending within 90-days of discharge following coronary artery bypass grafting (CABG) and aortic valve replacement (AVR) and the relationship between postacute care spending and other postdischarge utilization. METHODS AND RESULTS A retrospective analysis was conducted of public and private administrative claims for Michigan residents insured by Medicare fee-for-service and Blue Cross Blue Shield of Michigan/Blue Care Network commercial and Medicare Advantage plans undergoing CABG (n=11 208) or AVR (n=6122) in 33 nonfederal acute care Michigan hospitals between January 1, 2015 and December 31, 2018. Postacute care use was present in 9662 (86.2%) CABG episodes and 4242 (69.3%) AVR episodes, with respective mean (SD) 90-day spending of $4398±$6124 and $3465±$5759. Across hospitals, mean postacute care spending ranged from $3280 to $8186 for CABG and $2246 to $7710 for AVR. Inpatient rehabilitation and skilled nursing facility care accounted for over 80% of the variation spending between low and high postacute care spending hospitals. At the hospital-level, postacute care spending was modestly correlated across procedures and payers. Spending associated with readmissions, emergency department visits, and outpatient facility care was significantly different between low and high postacute care spending hospitals in CABG and AVR episodes. CONCLUSIONS There was wide hospital variation in postacute care spending after cardiac surgery, which was primarily driven by differential use and intensity in facility-based postacute care. Optimizing facility-based postacute care after cardiac surgery offers unique opportunities to reduce potentially unwarranted care variation.
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Affiliation(s)
- Michael P Thompson
- Michigan Value Collaborative (M.P.T., M.L.Y., J.D.S., E.C.N.), University of Michigan, Ann Arbor.,Department of Cardiac Surgery (M.P.T., R.L.P., F.D.P., D.S.L.), University of Michigan Medical School, Ann Arbor
| | - Monica L Yost
- Michigan Value Collaborative (M.P.T., M.L.Y., J.D.S., E.C.N.), University of Michigan, Ann Arbor
| | - John D Syrjamaki
- Michigan Value Collaborative (M.P.T., M.L.Y., J.D.S., E.C.N.), University of Michigan, Ann Arbor
| | - Edward C Norton
- Michigan Value Collaborative (M.P.T., M.L.Y., J.D.S., E.C.N.), University of Michigan, Ann Arbor.,Department of Health Management and Policy, School of Public Health (E.C.N.), University of Michigan, Ann Arbor
| | - Hari Nathan
- Department of Surgery (H.N.), University of Michigan Medical School, Ann Arbor
| | - Patricia Theurer
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor (P.T., R.L.P., D.S.L.)
| | - Richard L Prager
- Department of Cardiac Surgery (M.P.T., R.L.P., F.D.P., D.S.L.), University of Michigan Medical School, Ann Arbor.,Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor (P.T., R.L.P., D.S.L.)
| | - Francis D Pagani
- Department of Cardiac Surgery (M.P.T., R.L.P., F.D.P., D.S.L.), University of Michigan Medical School, Ann Arbor
| | - Donald S Likosky
- Department of Cardiac Surgery (M.P.T., R.L.P., F.D.P., D.S.L.), University of Michigan Medical School, Ann Arbor.,Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor (P.T., R.L.P., D.S.L.)
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17
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Yayac M, Moltz R, Pivec R, Lonner JH, Courtney PM, Austin MS. Formal Physical Therapy Following Total Hip and Knee Arthroplasty Incurs Additional Cost Without Improving Outcomes. J Arthroplasty 2020; 35:2779-2785. [PMID: 32674941 DOI: 10.1016/j.arth.2020.04.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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: 12/12/2019] [Revised: 03/31/2020] [Accepted: 04/09/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Recent evidence has demonstrated that formal physical therapy (PT) may not be required for most patients undergoing total hip (THA) and knee (TKA) arthroplasty. This study compared the differences in costs and functional outcomes in patients receiving formal PT and those who did not follow primary THA and TKA. METHODS We queried claims data from a single private insurer identifying patients who underwent primary THA or TKA from 2015 to 2017 in our practice. Demographics, comorbidities, number, and cost of PT visits in a 90-day episode of care were recorded. Outcomes were compared between patients using self-directed home exercises, home PT, outpatient PT, or both home and outpatient PT. A multivariate analysis was performed to identify significant predictors of outcomes. RESULTS Of the 2971 patients included in analysis, patients using both services had higher 90-day PT costs (mean $2091, P < .001) than those using home PT alone ($1146), outpatient PT alone ($1356), or no formal PT ($0). Home PT had the greatest cost per visit for both private insurance patients ($177/visit) and Medicare Advantage patients ($157/visit), but patients using both home PT and outpatient PT services had the greatest overall PT cost, $2091 for private insurance and $1891 for Medicare Advantage. Patients who used home PT were at significantly higher risk of both complications (odds ratio = 3.21; 95% confidence interval, 2.1-4.9; P < .001) and readmissions (odds ratio = 3.4; 95% confidence interval, 2.1-5.5; P < .001). CONCLUSION Participation in formal PT accounts for up to 8% of the episode of care following THA and TKA. The role of formal PT for most patients should take into account the cost-effectiveness of the intervention.
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Affiliation(s)
- Michael Yayac
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Rachel Moltz
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA
| | - Robert Pivec
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Jess H Lonner
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - P Maxwell Courtney
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Matthew S Austin
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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18
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Abstract
OBJECTIVES To describe an approach using concomitant medication log records for the construction of treatment episodes. Concomitant medication log records are routinely collected in clinical studies. Unlike prescription and dispensing records, concomitant medication logs collect utilisation data. Logs can provide information about drug safety and drug repurposing. DESIGN A prospective multicentre, multicohort observational study. SETTING Twenty-one clinical sites in the USA, Europe, Israel and Australia. PARTICIPANTS 415 subjects from the de novo cohort of the Parkinson's Progression Markers Initiative. METHODS We construct treatment episodes of concomitant medication use. The proposed approach treats temporal gaps as a stoppage of medication and temporal overlaps as simultaneous use or changes in dose. Log records with no temporal gaps were combined into a single treatment episode. RESULTS 5723 concomitant medication log records were used to construct 3655 treatment episodes for 65 medications. There were 405 temporal gaps representing a stoppage of medication; 985 temporal overlaps representing simultaneous regimens of the same medication and 2696 temporal overlaps representing a change in dose regimen. The median episode duration was 37 months (IQ interval: 11-73 months). CONCLUSIONS The proposed approach for constructing treatment episodes offers a method of estimating duration and dose of treatment from concomitant medication log records. The accompanying recommendations guide log data collection to improve their quality for drug safety and drug repurposing.
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Affiliation(s)
- Lisa K Kuramoto
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Boris G Sobolev
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, The University of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Penelope M A Brasher
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael W Tang
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Jacquelyn J Cragg
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
- International Collaboration on Repair Discoveries (ICORD), The University of British Columbia, Vancouver, British Columbia, Canada
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19
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Ver MLP, Gum JL, Crawford CH, Djurasovic M, Owens RK, Brown M, Steele P, Carreon LY. Index episode-of-care propensity-matched comparison of transforaminal lumbar interbody fusion (TLIF) techniques: open traditional TLIF versus midline lumbar interbody fusion (MIDLIF) versus robot-assisted MIDLIF. J Neurosurg Spine 2020; 32:1-7. [PMID: 31978884 DOI: 10.3171/2019.9.spine1932] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 09/16/2019] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Posterior fixation with interbody cage placement can be accomplished via numerous techniques. In an attempt to expedite recovery by limiting muscle dissection, midline lumbar interbody fusion (MIDLIF) has been described. More recently, the authors have developed a robot-assisted MIDLIF (RA-MIDLIF) technique. The purpose of this study was to compare the index episode-of-care (iEOC) parameters between patients undergoing traditional open transforaminal lumbar interbody fusion (tTLIF), MIDLIF, and RA-MIDLIF. METHODS A retrospective review of a prospective, multisurgeon surgical database was performed. Consecutive patients undergoing 1- or 2-level tTLIF, MIDLIF, or RA-MIDLIF for degenerative lumbar conditions were identified. Patients in each cohort were propensity matched based on age, sex, smoking status, BMI, diagnosis, American Society of Anesthesiologists (ASA) class, and number of levels fused. Index EOC parameters such as length of stay (LOS), estimated blood loss (EBL), operating room (OR) time, and actual, direct hospital costs for the index surgical visit were analyzed. RESULTS Of 281 and 249 patients undergoing tTLIF and MIDLIF, respectively, 52 cases in each cohort were successfully propensity matched to the authors' first 55 RA-MIDLIF cases. Consistent with propensity matching, there was no significant difference in age, sex, BMI, diagnosis, ASA class, or levels fused. Spondylolisthesis was the most common indication for surgery in all cohorts. The mean total iEOC was similar across all cohorts. Patients undergoing RA-MIDLIF had a shorter average LOS (1.53 days) than those undergoing either MIDLIF (2.71 days) or tTLIF (3.58 days). Both MIDLIF and RA-MIDLIF were associated with lower EBL and less OR time compared with tTLIF. CONCLUSIONS Despite concerns for additional cost and time while introducing navigation or robotic technology, a propensity-matched comparison of the authors' first 52 RA-MIDLIF surgeries with tTLIF and MIDLIF showed promising results for reducing OR time, EBL, and LOS without increasing cost.
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20
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Sukul D, Seth M, Dupree JM, Syrjamaki JD, Ryan AM, Nallamothu BK, Gurm HS. Drivers of Variation in 90-Day Episode Payments After Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2020; 12:e006928. [PMID: 30608883 DOI: 10.1161/circinterventions.118.006928] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) is a common and expensive procedure that has become a target for bundled payment initiatives. We described the magnitude and determinants of variation in 90-day PCI episode payments across a diverse array of patients and hospitals. METHODS AND RESULTS We linked clinical registry data from PCIs performed at 33 Michigan hospitals to 90-day episodes of care constructed using Medicare fee-for-service and commercial insurance claims from January 2012 to October 2016. Payments were price standardized and risk adjusted using clinical and administrative variables in an observed-over-expected framework. Hospitals were stratified into quartiles based on average episode payments. Payment components between the highest and the lowest quartiles were compared with identified drivers of variation (ie, index hospitalization/procedure, readmissions, postacute care, and professional fees). Among 40 925 90-day PCI episodes, the average risk-adjusted 90-day episode payment by hospital ranged between $22 154 and $27 205 with a median of $24 696 (interquartile range, $24 190-$25 643). Hospitals in the lowest and the highest quartiles had average episode payments of $23 744 and $26 504, respectively (difference, $2760). Readmission payments were the primary driver of this variation (46.2%), followed by postacute care (22.6%). Readmissions remained the primary driver of variation in key subgroups, including inpatient and outpatient PCI, as well as PCI for acute myocardial infarction and nonacute myocardial infarction indications. CONCLUSIONS Substantial hospital-level variation exists in 90-day PCI episode payments. Over half the variation between high- and low-payment hospitals was related to care after the index procedure, primarily because of readmissions and postacute care. Hospitals and policymakers should consider targeting these components when developing initiatives to reduce PCI-related spending.
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Affiliation(s)
- Devraj Sukul
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (D.S., M.S., B.K.N., H.S.G.).,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor (D.S., J.M.D., A.M.R., B.K.N.)
| | - Milan Seth
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (D.S., M.S., B.K.N., H.S.G.)
| | - James M Dupree
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor (D.S., J.M.D., A.M.R., B.K.N.).,Michigan Value Collaborative, University of Michigan, Ann Arbor (J.M.D., J.D.S.).,Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor (J.M.D.)
| | - John D Syrjamaki
- Michigan Value Collaborative, University of Michigan, Ann Arbor (J.M.D., J.D.S.)
| | - Andrew M Ryan
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor (D.S., J.M.D., A.M.R., B.K.N.).,Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor (A.M.R.).,University of Michigan Center for Evaluating Health Reform, Ann Arbor (A.M.R.)
| | - Brahmajee K Nallamothu
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (D.S., M.S., B.K.N., H.S.G.).,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor (D.S., J.M.D., A.M.R., B.K.N.).,Michigan Integrated Center for Health Analytics and Medical Prediction, Ann Arbor (B.K.N.).,Division of Cardiovascular Medicine, Department of Internal Medicine, VA Ann Arbor Healthcare System, Ann Arbor (B.K.N., H.S.G.)
| | - Hitinder S Gurm
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (D.S., M.S., B.K.N., H.S.G.).,Division of Cardiovascular Medicine, Department of Internal Medicine, VA Ann Arbor Healthcare System, Ann Arbor (B.K.N., H.S.G.)
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21
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Abstract
Purpose: Pressure to eliminate low-value health care is increasing internationally. This pressure has produced an urgent need to identify evidence-based methods to determine the value of allied health (AH) care, particularly to recognize when additional AH care adds no further benefits. This article reports on the published methods of determining the value of AH care. Method: We systematically scanned PubMed, MEDLINE, AMED, CINAHL, PsycINFO, and the Grey Literature Review database from inception until July 2018 for peer-reviewed English-language literature. Hierarchy of evidence and information on study design and the methods or measures used to determine the value of AH care were extracted. Results: Of 189 articles, 30 were potentially relevant; after the full text was read, all were included. Of these, 24 reported on ways of determining the value of AH care, and 6 described the optimal provision of AH episodes of care. No methods were reported that could be applied to establish when enough AH therapy had been provided. Conclusion: This review found a variety of attributes of value in AH care, but no standard value measure or methods to determine what constituted enough AH care. Repeated measurement of the standard attributes of value and costs is required throughout episodes of AH care to better understand the impact of AH care from the different stakeholders' perspectives.
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Affiliation(s)
- Asterie Twizeyemariya
- International Centre for Allied Health Evidence, University of South Australia.,Faculty of Health, University of Canberra, Canberra, A.C.T., Australia
| | - Karen Grimmer
- Physiotherapy Department, Faculty of Medical and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Clinical Teaching and Education Centre, College of Nursing and Health Sciences, Flinders University, Adelaide, S.A
| | - Steven Milanese
- Physiotherapy Department, Faculty of Medical and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Clinical Teaching and Education Centre, College of Nursing and Health Sciences, Flinders University, Adelaide, S.A
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22
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Everall AC, Guilcher SJT, Cadel L, Asif M, Li J, Kuluski K. Patient and caregiver experience with delayed discharge from a hospital setting: A scoping review. Health Expect 2019; 22:863-873. [PMID: 31099969 PMCID: PMC6803563 DOI: 10.1111/hex.12916] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 04/29/2019] [Accepted: 05/03/2019] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Delayed hospital discharge occurs when patients are medically cleared but remain hospitalized because a suitable care setting is not available. Delayed discharge typically results in reduced levels of treatment, placing patients at risk of functional decline, falls and hospital-related adverse events. Caregivers often take on an active role in hospital to mitigate these risks. OBJECTIVE This scoping review aimed to summarize the literature on patient and caregiver experiences with delayed hospital discharge. SEARCH STRATEGY Seven electronic databases and grey literature were searched using keywords including alternate level of care, delayed discharge, patients, caregivers and experiences. INCLUSION CRITERIA Included articles met the following criteria: (a) patient or caregiver population 18 years or older; (b) delayed discharge from a hospital setting; (c) included experiences with delayed discharge; (d) peer-reviewed or grey literature; and (e) published between 1 January 1998 and 16 July 2018. DATA EXTRACTION Data were extracted from the seven included articles using Microsoft Excel 2016 to facilitate a thorough analysis and comparison. MAIN RESULTS Study themes were grouped into five elements of the delayed discharge experience: (1) overall uncertainty; (2) impact of hospital staff and physical environment; (3) mental and physical deterioration; (4) lack of engagement in decision making and need for advocacy; and (5) initial disbelief sometimes followed by reluctant acceptance. CONCLUSION This review provides a foundation to guide future research, policies and practices to improve patient and caregiver experiences with delayed hospital discharge, including enhanced communication with patients and families and programmes to reduce deconditioning.
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Affiliation(s)
- Amanda C Everall
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Sara J T Guilcher
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Lauren Cadel
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Maliha Asif
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Joyce Li
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Kerry Kuluski
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada.,Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
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23
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Johnson DC, Kwok E, Ahn C, Pashchinskiy A, Laviana AA, Golla V, Rosenthal JT, Bravo F, Litwin MS, Saigal CS. Financial Margins for Prostate Cancer Surgery: Quantifying the Impact of Modifiable Cost Inputs in an Episode Based Reimbursement Model. J Urol 2019; 202:539-45. [PMID: 31009291 DOI: 10.1097/JU.0000000000000283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The United States health care system is rapidly moving away from fee for service reimbursement in an effort to improve quality and contain costs. Episode based reimbursement is an increasingly relevant value based payment model of surgical care. We sought to quantify the impact of modifiable cost inputs on institutional financial margins in an episode based payment model for prostate cancer surgery. MATERIALS AND METHODS A total of 157 consecutive patients underwent robotic radical prostatectomy in 2016 at a tertiary academic medical center. We compiled comprehensive episode costs and reimbursements from the most recent urology consultation for prostate cancer through 90 days postoperatively and benchmarked the episode price as a fixed reimbursement to the median reimbursement of the cohort. We identified 2 sources of modifiable costs with undefined empirical value, including preoperative prostate magnetic resonance imaging and perioperative functional recovery counseling visits, and then calculated the impact on financial margins (reimbursement minus cost) under an episode based payment. RESULTS Although they comprised a small proportion of the total episode costs, varying the use of preoperative magnetic resonance imaging (33% vs 100% of cases) and functional recovery counseling visits (1 visit in 66% and 2 in 100%) reduced average expected episode financial margins up to 22.6% relative to the margin maximizing scenario in which no patient received these services. CONCLUSIONS Modifiable cost inputs have a substantial impact on potential operating margins for prostate cancer surgery under an episode based payment model. High cost health systems must develop the capability to analyze individual cost inputs and quantify the contribution to quality to inform value improvement efforts for multiple service lines.
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24
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Sheehan KJ, Levy AR, Sobolev B, Guy P, Tang M, Kuramoto L, Sutherland JM, Beaupre L, Morin SN, Harvey E, Bradley N. Operationalising a conceptual framework for a contiguous hospitalisation episode to study associations between surgical timing and death after first hip fracture: a Canadian observational study. BMJ Open 2018; 8:e020372. [PMID: 30530471 PMCID: PMC6287122 DOI: 10.1136/bmjopen-2017-020372] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE We describe steps to operationalise a published conceptual framework for a contiguous hospitalisation episode using acute care hospital discharge abstracts. We then quantified the degree of bias induced by a first abstract episode, which does not account for hospital transfers. DESIGN Retrospective observational study. SETTING All acute care hospitals in nine Canadian provinces. PARTICIPANTS We retrieved acute hospitalisation discharge abstracts for 189 448 patients aged 65 years and older admitted to acute care with hip fracture between 2003 and 2013. PRIMARY AND SECONDARY OUTCOME MEASURES The percentage of patients treated surgically, delayed to surgery (defined as two or more days after admission) and dying, between contiguous hospitalisation episodes and the first abstract episodes of care. RESULTS Using contiguous hospitalisation episodes, 91.6% underwent surgery, 35.7% were delayed two or more days after admission and 6.7% died postoperatively, whereas, using the first abstract only, these percentages were 83.7%, 32.5% and 6.5%, respectively. CONCLUSION We demonstrate that not accounting for hospital transfers when evaluating the association between surgical timing and death underestimates reporting of the percentage of patients treated surgically and delayed to surgery by 9%, and the percentage who die after surgery by 3%. Researchers must be aware of this potential and avoidable bias as, depending on the purpose of the study, erroneous inferences may be drawn.
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Affiliation(s)
- Katie Jane Sheehan
- Department of Population Health Sciences, School of Population Health and Environmental Sciences, Kings College London, London, UK
| | - Adrian R Levy
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Boris Sobolev
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Pierre Guy
- Centre for Hip Health and Mobility, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael Tang
- Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lisa Kuramoto
- Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason M Sutherland
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lauren Beaupre
- Department of Physical Therapy and Division of Orthopaedic Surgery, University of Alberta, Alberta, Edmonton, Canada
| | - Suzanne N Morin
- Department of Medicine, McGill University, Montreal, Québec, Canada
| | - Edward Harvey
- Division of Orthopaedic Surgery, McGill University, Montreal, Québec, Canada
| | - Nick Bradley
- Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
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25
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Abstract
Removing the geographic barriers to health care and extending care to the home has been the goal of the health-care system for decades as the introduction of new information technology capabilities has driven operational efficiencies in our daily lives. Patient demand for convenience and access continues to surge as these technologies are used for their personal lives. Coupled with the need to lower our health-care cost structure, distance health technologies are emerging as a care facilitator for our arthroplasty patients. A critical aspect of introducing distance health technologies is the requirement to define the entire episode of care. Once defined, metrics to assess success can be measured, and clinical and technical outcomes can be determined. Distance health technologies are emerging in the management of the arthroplasty episode of care through the preponderance of connectivity coupled with the adoption of mobile technologies, ushering in a new era of improved efficiency, efficacy, satisfaction, and outcomes while providing greater value for our patients.
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Affiliation(s)
- Jonathan L Schaffer
- Digital Health, Information Technology Division, Department of Orthopaedic Surgery, Center for Joint Replacement and Adult Reconstruction, Orthopaedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, OH
| | - Peter A Rasmussen
- Digital Health, Information Technology Division, Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Matthew R Faiman
- Digital Health, Information Technology Division, Community Internal Medicine, Cleveland Clinic Community Health, Cleveland Clinic, Cleveland, OH
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26
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McLawhorn AS, Levack AE, Lee YY, Ge Y, Do H, Dodwell ER. Bariatric Surgery Improves Outcomes After Lower Extremity Arthroplasty in the Morbidly Obese: A Propensity Score-Matched Analysis of a New York Statewide Database. J Arthroplasty 2018; 33:2062-2069.e4. [PMID: 29366728 DOI: 10.1016/j.arth.2017.11.056] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [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: 12/15/2016] [Revised: 11/21/2017] [Accepted: 11/24/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The purpose of this study was to compare risks for revision and short-term complications after total joint arthroplasty (TJA) in matched cohorts of morbidly obese patients, receiving and not receiving prior bariatric surgery. METHODS Patients undergoing elective TJA between 1997 and 2011 were identified in a New York Statewide database, analyzing total knee arthroplasty (TKA) and total hip arthroplasty (THA) separately. Propensity scores were used to match morbidly obese patients receiving and not receiving bariatric surgery prior to TJA. Cox proportional hazard modeling assessed revision risk. Logistic regression evaluated odds for complications. RESULTS For TKA, 2636 bariatric surgery patients were matched to 2636 morbidly obese patients. For THA, 792 bariatric surgery patients were matched to 792 morbidly obese patients. Matching balanced all covariates. Bariatric surgery reduced co-morbidities prior to TJA (TKA P < .0001; THA P < .005). Risks for in-hospital complications were lower for THA and TKA patients receiving prior bariatric surgery (odds ratio [OR] 0.25, P < .001; and OR = 0.69, P = .021, respectively). Risks for 90-day complications were lower for TKA (OR 0.61, P = .002). Revision risks were not different for either THA (P = .634) or TKA (P = .431), nor was THA dislocation risk (P = 1.000). CONCLUSION After accounting for relevant selection biases, bariatric surgery prior to TJA was associated with reduced co-morbidity burden at the time of TJA and with reduced post-TJA complications. However, bariatric surgery did not reduce the risk for revision surgery for either TKA or THA.
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Affiliation(s)
| | - Ashley E Levack
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Yuo-Yu Lee
- Department of Epidemiology and Biostatistics, Hospital for Special Surgery, New York, New York
| | - Yile Ge
- Department of Epidemiology and Biostatistics, Hospital for Special Surgery, New York, New York
| | - Huong Do
- Department of Epidemiology and Biostatistics, Hospital for Special Surgery, New York, New York
| | - Emily R Dodwell
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
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27
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Cooper HJ, Olswing AD, Berliner ZP, Scuderi GR, Brown ZJ, Hepinstall MS. Variation in Treatment Patterns Correlate With Resource Utilization in the 30-Day Episode of Care of Displaced Femoral Neck Fractures. J Arthroplasty 2018; 33:S43-S48. [PMID: 29478677 DOI: 10.1016/j.arth.2018.01.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 06/21/2017] [Revised: 01/04/2018] [Accepted: 01/04/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND We evaluated which treatment decisions in the management of displaced femoral neck fractures (FNFs) may associate with measures of resource utilization relevant to a value-based episode-of-care model. METHODS A total of 1139 FNFs treated with hip arthroplasty at 7 hospitals were retrospectively reviewed. Treatment choices were procedure (hemiarthroplasty vs total hip arthroplasty [THA]), surgeon training status, admitting service, and time to surgery. Dependent variables were length of stay, discharge disposition, 30-day readmission, and in-hospital mortality. Variation across hospitals was evaluated with analysis of variance and chi-square tests. Treatment choices were evaluated for the dependent variables of interest with univariable and multivariable regression. RESULTS There was significant variation between hospitals regarding proportion of cases treated with THA (range = 3.0%-73.2%, P < .001), proportion treated by arthroplasty fellowship-trained surgeons (range = 0%-74.9%, P < .001), proportion admitted to the orthopedic service (range = 2.8%-91.3%, P < .001), mean time to surgery (range = 0.9-2.1 days, P < .001), and proportion of discharge home (range = 63.9%-97.8%, P < .001). Multivariable analysis adjusting for age, gender, and Charlson Comorbidity Index demonstrated correlations between (1) decreased length of stay and admission to orthopedics (B = -1.256, P < .001); (2) lower 30-day readmission and THA (odds ratio [OR] = .376, P = .004), and (3) decreased discharge to a care facility and admission to orthopedics (OR = 0.402, P = <.001), THA (OR = 0.435, P = .002), and treatment by an arthroplasty fellowship-trained surgeon (OR = 0.572, P = .016). None of the treatment variables tested associated with in-hospital mortality. CONCLUSION We observed significant variation in the treatment of displaced FNF patients across 7 hospitals and identified treatment choices that associated with resource utilization within the episode of care. Future, prospective study is necessary to understand whether care pathways that adapt some combination of these characteristics may result in more value-based care.
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Affiliation(s)
- H John Cooper
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY
| | - Andrew D Olswing
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY
| | | | - Giles R Scuderi
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY
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28
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Clancy U, Brown M, Alio Z, Wardle K, Pendleton N. Older people with hip fracture transferred to intermediate care: outcomes in an integrated health and social care model. Future Healthc J 2018; 5:58-63. [PMID: 31098534 PMCID: PMC6510036 DOI: 10.7861/futurehosp.5-1-58] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Following surgery for hip fracture almost a quarter of patients do not return directly to their usual residence, using the resources within intermediate care and enablement. This was a retrospective cohort study involving 156 Salford residents admitted with hip fracture in 2015. Linked health data were collected on those discharged to intermediate care vs home in terms of readmissions, mortality, lengths of stay, delayed transfers of care, diagnoses of delirium and pre-existing forms of dementia. The median duration of the continuous care episode in the intermediate care cohort, inclusive of readmissions to hospital, was 52 days. There was a 26% (n=20) readmission rate from intermediate care. Readmission rates at 120 days were higher among those discharged to intermediate care vs home (OR 3.21, 95% CI 1.37-7.54, p=0.007) and among those with a form of dementia (OR 4.76, 95% CI 1.79-12.63, p=0.0017). Patients with delirium during their acute admission were more likely to be discharged to intermediate care (OR 5.43, 95% CI 2.36-12.47, p=0.0001) and were less likely to ultimately be discharged home (OR 6.40, 95% CI 2.25-18.21, p=0.0005), as were those with some form of dementia (OR 6.60, 95% CI 1.97-22.08, p=0.002). Measurement of the entire care episode demonstrates significant lengths of stay. Medium term readmission rates are higher in those discharged to intermediate care. Delirium and dementia are associated with higher readmission rates and lower rates of discharge to own home. It is imperative that a whole pathway approach to commissioning hip fracture services is established.
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Affiliation(s)
| | - Mark Brown
- Salford Royal Foundation Trust, Salford, UK
| | - Ziad Alio
- Salford Royal Foundation Trust, Salford, UK
| | | | - Neil Pendleton
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Manchester Academic Health Science Centre, University of Manchester Salford Royal Hospital, Manchester, UK
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29
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McLawhorn AS, Fu MC, Schairer WW, Sculco PK, MacLean CH, Padgett DE. Continued Inpatient Care After Primary Total Knee Arthroplasty Increases 30-Day Post-Discharge Complications: A Propensity Score-Adjusted Analysis. J Arthroplasty 2017; 32:S113-8. [PMID: 28285902 DOI: 10.1016/j.arth.2017.01.039] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 01/22/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Discharge destination, either home or skilled care facility, after total knee arthroplasty (TKA) may be associated with significant variation in postacute care outcomes. The purpose of this study was to characterize the 30-day postdischarge outcomes after primary TKA relative to discharge destination. METHODS All primary unilateral TKAs performed for osteoarthritis from 2011-2014 were identified in the National Surgical Quality Improvement Program database. Propensity scores based on predischarge characteristics were used to adjust for selection bias in discharge destination. Propensity-adjusted multivariable logistic regressions were used to examine associations between discharge destination and postdischarge complications. RESULTS Among 101,256 primary TKAs identified, 70,628 were discharged home and 30,628 to skilled care facilities. Patients discharged to facilities were more frequently were female, older, higher body mass index class, higher Charlson comorbidity index and American Society of Anesthesiologists scores, had predischarge complications, received general anesthesia, and classified as nonindependent preoperatively. Propensity adjustment accounted for this selection bias. Patients discharged to skilled care facilities after TKA had higher odds of any major complication (odds ratio = 1.25; 95% confidence interval, 1.13-1.37) and readmission (odds ratio = 1.81; 95% confidence interval, 1.50-2.18). Skilled care was associated with increased odds for respiratory, septic, thromboembolic, and urinary complications. Associations with death, cardiac, and wound complications were not significant. CONCLUSION After controlling for predischarge characteristics, discharge to skilled care facilities vs home after primary TKA is associated with higher odds of numerous complications and unplanned readmission. These results support coordination of care pathways to facilitate home discharge after hospitalization for TKA whenever possible.
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30
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Wijeysundera HC, Li L, Braga V, Pazhaniappan N, Pardhan AM, Lian D, Leeksma A, Peterson B, Cohen EA, Forsey A, Kingsbury KJ. Drivers of healthcare costs associated with the episode of care for surgical aortic valve replacement versus transcatheter aortic valve implantation. Open Heart 2016; 3:e000468. [PMID: 27621832 PMCID: PMC5013496 DOI: 10.1136/openhrt-2016-000468] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 06/25/2016] [Accepted: 07/24/2016] [Indexed: 01/20/2023] Open
Abstract
Objective Transcatheter aortic valve implantation (TAVI) is generally more expensive than surgical aortic valve replacement (SAVR) due to the high cost of the device. Our objective was to understand the patient and procedural drivers of cumulative healthcare costs during the index hospitalisation for these procedures. Design All patients undergoing TAVI, isolated SAVR or combined SAVR+coronary artery bypass grafting (CABG) at 7 hospitals in Ontario, Canada were identified during the fiscal year 2012–2013. Data were obtained from a prospective registry. Cumulative healthcare costs during the episode of care were determined using microcosting. To identify drivers of healthcare costs, multivariable hierarchical generalised linear models with a logarithmic link and γ distribution were developed for TAVI, SAVR and SAVR+CABG separately. Results Our cohort consisted of 1310 patients with aortic stenosis, of whom 585 underwent isolated SAVR, 518 had SAVR+CABG and 207 underwent TAVI. The median costs for the index hospitalisation for isolated SAVR were $21 811 (IQR $18 148–$30 498), while those for SAVR+CABG were $27 256 (IQR $21 741–$39 000), compared with $42 742 (IQR $37 295–$56 196) for TAVI. For SAVR, the major patient-level drivers of costs were age >75 years, renal dysfunction and active endocarditis. For TAVI, chronic lung disease was a major patient-level driver. Procedural drivers of cost for TAVI included a non-transfemoral approach. A prolonged intensive care unit stay was associated with increased costs for all procedures. Conclusions We found wide variation in healthcare costs for SAVR compared with TAVI, with different patient-level drivers as well as potentially modifiable procedural factors. These highlight areas of further study to optimise healthcare delivery.
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Affiliation(s)
- Harindra C Wijeysundera
- Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Ontario, Canada; Institute for Clinical Evaluative Sciences (ICES), Ontario, Ontario, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
| | - Lindsay Li
- Cardiac Care Network , Toronto, Ontario , Canada
| | - Vevien Braga
- Cardiac Care Network , Toronto, Ontario , Canada
| | - Nandhaa Pazhaniappan
- Division of Cardiology , Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto , Ontario, Ontario , Canada
| | | | - Dana Lian
- Cardiac Care Network , Toronto, Ontario , Canada
| | - Aric Leeksma
- Cardiac Care Network , Toronto, Ontario , Canada
| | - Ben Peterson
- Royal Victoria Regional Health Centre , Barrie, Ontario , Canada
| | - Eric A Cohen
- Division of Cardiology , Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto , Ontario, Ontario , Canada
| | - Anne Forsey
- Cardiac Care Network , Toronto, Ontario , Canada
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31
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Abstract
Most currently available quality measures reflect point-in-time provider tasks, providing a limited and fragmented assessment of care. The concept of episodes of care could be used to develop quality measurement approaches that reflect longer periods of care. With input from clinical experts, we constructed episode-of-care frameworks for six illustrative conditions and identified potential gaps and measure development priority areas. Episode-based measures could assess changes in health outcomes ("delta measures"), the amount of time during an episode in which a patient has suboptimal health status ("integral measures"), quality contingent upon events occurring previously ("contingent measures"), and composites of measures throughout the episode. This article identifies a number of challenges that will need to be addressed to advance operationalization of episode-based quality measurement.
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Affiliation(s)
| | - Mark W Friedberg
- 1 RAND Corporation, Boston, MA, USA.,5 Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA.,6 Harvard Medical School, Boston, MA
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32
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Sheehan KJ, Sobolev B, Guy P, Bohm E, Hellsten E, Sutherland JM, Kuramoto L, Jaglal S. Constructing an episode of care from acute hospitalization records for studying effects of timing of hip fracture surgery. J Orthop Res 2016; 34:197-204. [PMID: 26228250 PMCID: PMC4995103 DOI: 10.1002/jor.22997] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [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: 02/19/2015] [Accepted: 07/20/2015] [Indexed: 02/04/2023]
Abstract
Episodes of care defined by the event of hip fracture surgery are widely used for the assessment of surgical wait times and outcomes. However, this approach does not consider nonoperative deaths, implying that survival time begins at the time of procedure. This approach makes treatment effect implicitly conditional on surviving to treatment. The purpose of this article is to describe a novel conceptual framework for constructing an episode of hip fracture care to fully evaluate the incidence of adverse events related to time after admission for hip fracture. This admission-based approach enables the assessment of the full harm of delay by including deaths while waiting for surgery, not just deaths after surgery. Some patients wait until their conditions are optimized for surgery, whereas others have to wait until surgical service becomes available. We provide definitions, linkage rules, and algorithms to capture all hip fracture patients and events other than surgery. Finally, we discuss data elements for stratifying patients according to administrative factors for delay to allow researchers and policymakers to determine who will benefit most from expedited access to surgery.
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33
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Vostanis P, Martin P, Davies R, De Francesco D, Jones M, Sweeting R, Ritchie B, Allen P, Wolpert M. Development of a framework for prospective payment for child mental health services. J Health Serv Res Policy 2015; 20:202-9. [PMID: 25899484 DOI: 10.1177/1355819615580868] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES There is a need to develop a payment system for services for children with mental health problems that allows more targeted commissioning based on fairness and need. This is currently constrained by lack of clinical consensus on the best way forward, wide variation in practice, and lack of data about activity and outcomes. In the context of a national initiative in England our aim was to develop a basis for an improved payment system. METHODS Three inter-related studies: a qualitative consultation with child and adolescent mental health services (CAMHS) stakeholders on what the key principles for establishing a payment system should be, via online survey (n = 180) and two participatory workshops (n = 91); review of relevant national clinical guidelines (n = 15); and a quantitative study of the relationship between disorders and resource use (n = 1774 children from 23 teams). RESULTS CAMHS stakeholders stressed the need for a broader definition of need than only diagnosis, including the measurement of indirect service activities and appropriate outcome measurement. National clinical guidance suggested key aspects of best practice for care packages but did not include consideration of contextual factors such as complexity. Modelling data on cases found that problem type and degree of impairment independently predicted resource use, alongside evidence for substantial service variation in the allocation of resources for similar problems. CONCLUSIONS A framework for an episode-based payment system for CAMHS should include consideration of: complexity and indirect service activities; evidence-based care packages; different needs in terms of impairment and symptoms; and outcome measurement as a core component.
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Affiliation(s)
- Panos Vostanis
- Professor of Child Psychiatry, University of Leicester, UK
| | - Peter Martin
- Lead Statistician, Evidence Based Practice Unit, University College London and the Anna Freud Centre, UK
| | - Roger Davies
- Clinical Psychologist, City and Hackney CAMHS, East London Foundation Trust, UK
| | | | - Melanie Jones
- Improvement Programme Lead, Evidence Based Practice Unit, University College London and the Anna Freud Centre, UK
| | - Ruth Sweeting
- Clinical Psychologist, City and Hackney CAMHS, East London Foundation Trust, UK
| | - Benjamin Ritchie
- Pilot Site Manager, Evidence Based Practice Unit, University College London and the Anna Freud Centre, UK
| | - Pauline Allen
- Reader in Health Services Organisation, Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, UK
| | - Miranda Wolpert
- Director, Evidence Based Practice Unit and Child Outcomes Research Consortium, University College London and the Anna Freud Centre, London
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34
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Abstract
High quality, safe care for patients depends on effective teamwork, and where multi-professional teams work together there is higher patient satisfaction, increased staff innovation, less stress and more communication ( West 2013 ). Conversely, lapses in teamwork and poor communication can result in adverse events ranging from retained foreign objects to perinatal events and medication errors ( Peter and Pronovost 2013 ), and even the death of patients ( Resuscitation Council UK 2011 ). Teamwork requires a set of skills and behaviours that, once learned by clinicians, can save lives ( Peter and Pronovost 2013 ). This article refers to a case study to explore the topic of teamwork in a tertiary care emergency setting.
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Froimson MI, Rana A, White RE, Marshall A, Schutzer SF, Healy WL, Naas P, Daubert G, Iorio R, Parsley B. Bundled payments for care improvement initiative: the next evolution of payment formulations: AAHKS Bundled Payment Task Force. J Arthroplasty 2013; 28:157-65. [PMID: 24034511 DOI: 10.1016/j.arth.2013.07.012] [Citation(s) in RCA: 101] [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: 04/18/2013] [Revised: 06/28/2013] [Accepted: 07/02/2013] [Indexed: 02/01/2023] Open
Abstract
The Patient Protection and Affordable Care Act contains a number of provision for improving the delivery of healthcare in the United States, among the most impactful of which may be the call for modifications in the packaging of and payment for care that is bundled into episodes. The move away from fee for service payment models to payment for coordinated care delivered as comprehensive episodes is heralded as having great potential to enhance quality and reduce cost, thereby increasing the value of the care delivered. This effort builds on the prior experience around delivering care for arthroplasty under the Acute Care Episode Project and offers extensions and opportunities to modify the experience moving forward. Total hip and knee arthroplasties are viewed as ideal treatments to test the effectiveness of this payment model. Providers must learn the nuances of these modified care delivery concepts and evaluate whether their environment is conducive to success in this arena. This fundamental shift in payment for care offers both considerable risk and tremendous opportunity for physicians. Acquiring an understanding of the recent experience and the determinants of future success will best position orthopaedic surgeons to thrive in this new environment. Although this will remain a dynamic exercise for some time, early experience may enhance the chances for long term success, and physicians can rightfully lead the care delivery redesign process.
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