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Kassie AM, Eakin E, Abate BB, Endalamaw A, Zewdie A, Wolka E, Assefa Y. The use of positive deviance approach to improve health service delivery and quality of care: a scoping review. BMC Health Serv Res 2024; 24:438. [PMID: 38589897 PMCID: PMC11003118 DOI: 10.1186/s12913-024-10850-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 03/11/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Quality has been a persistent challenge in the healthcare system, particularly in resource-limited settings. As a result, the utilization of innovative approaches is required to help countries in their efforts to enhance the quality of healthcare. The positive deviance (PD) approach is an innovative approach that can be utilized to improve healthcare quality. The approach assumes that solutions to problems are already available within the community and identifying and sharing those solutions can help others to resolve existing issues. Therefore, this scoping review aimed to synthesize the evidence regarding the use of the PD approach in healthcare system service delivery and quality improvement programs. METHODS Articles were retrieved from six international databases. The last date for article search was June 02, 2023, and no date restriction was applied. All articles were assessed for inclusion through a title and/or abstract read. Then, articles that passed the title and abstract review were screened by reading their full texts. In case of duplication, only the full-text published articles were retained. A descriptive mapping and evidence synthesis was done to present data with the guide of the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews checklist and the results are presented in text, table, and figure formats. RESULTS A total of 125 articles were included in this scoping review. More than half, 66 (52.8%), of the articles were from the United States, 11(8.8%) from multinational studies, 10 (8%) from Canada, 8 (6.4%) from the United Kingdom and the remaining, 30 (24%) are from other nations around the world. The scoping review indicates that several types of study designs can be applied in utilizing the PD approach for healthcare service and quality improvement programs. However, although validated performance measures are utilized to identify positive deviants (PDs) in many of the articles, some of the selection criteria utilized by authors lack clarity and are subject to potential bias. In addition, several limitations have been mentioned in the articles including issues in operationalizing PD, focus on leaders and senior managers and limited staff involvement, bias, lack of comparison, limited setting, and issues in generalizability/transferability of results from prospects perspective. Nevertheless, the limitations identified are potentially manageable and can be contextually resolved depending on the nature of the study. Furthermore, PD has been successfully employed in healthcare service and quality improvement programs including in increasing surgical care quality, hand hygiene practice, and reducing healthcare-associated infections. CONCLUSION The scoping review findings have indicated that healthcare systems have been able to enhance quality, reduce errors, and improve patient outcomes by identifying lessons from those who exhibit exceptional practices and implementing successful strategies in their practice. All the outcomes of PD-based research, however, are dependent on the first step of identifying true PDs. Hence, it is critical that PDs are identified using objective and validated measures of performance as failure to identify true PDs can subsequently lead to failure in identifying best practices for learning and dissemination to other contextually similar settings.
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Affiliation(s)
- Ayelign Mengesha Kassie
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia.
- School of Nursing, College of Health Sciences, Woldia University, Woldia, Ethiopia.
| | - Elizabeth Eakin
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Biruk Beletew Abate
- School of Nursing, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Aklilu Endalamaw
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Anteneh Zewdie
- International Institute for Primary Health Care, Ethiopia, Addis Ababa, Ethiopia
| | - Eskinder Wolka
- International Institute for Primary Health Care, Ethiopia, Addis Ababa, Ethiopia
| | - Yibeltal Assefa
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia
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Atallah FC, Caruso P, Nassar Junior AP, Torelly AP, Amendola CP, Salluh JIF, Romano TG. High-value care for critically ill oncohematological patients: what do we know thus far? CRITICAL CARE SCIENCE 2023; 35:84-96. [PMID: 37712733 PMCID: PMC10275311 DOI: 10.5935/2965-2774.20230405-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 02/26/2023] [Indexed: 09/16/2023]
Abstract
The number of patients with cancer requiring intensive care unit admission is increasing around the world. The improvement in the pathophysiological understanding of this group of patients, as well as the increasingly better and more targeted treatment options for their underlying disease, has led to a significant increase in their survival over the past three decades. Within the organizational concepts, it is necessary to know what adds value in the care of critical oncohematological patients. Practices in medicine that do not benefit patients and possibly cause harm are called low-value practices, while high-value practices are defined as high-quality care at relatively low cost. In this article, we discuss ten domains with high-value evidence in the care of cancer patients: (1) intensive care unit admission policies; (2) intensive care unit organization; (3) etiological investigation of hypoxemia; (4) management of acute respiratory failure; (5) management of febrile neutropenia; (6) urgent chemotherapy treatment in critically ill patients; (7) patient and family experience; (8) palliative care; (9) care of intensive care unit staff; and (10) long-term impact of critical disease on the cancer population. The disclosure of such policies is expected to have the potential to change health care standards. We understand that it is a lengthy process, and initiatives such as this paper are one of the first steps in raising awareness and beginning a discussion about high-value care in various health scenarios.
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Affiliation(s)
- Fernanda Chohfi Atallah
- Discipline of Anaesthesiology, Pain and Intensive Care, Escola
Paulista de Medicina, Universidade Federal de São Paulo - São Paulo
(SP), Brazil
| | - Pedro Caruso
- AC Camargo Cancer Center - São Paulo (SP), Brazil
| | | | - Andre Peretti Torelly
- Hospital Santa Rita - Santa Casa de Misericórdia de Porto
Alegre - Porto Alegre (RS), Brazil
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Mathew A, Benny SJ, Boby JM, Sirohi B. Value-Based Care in Systemic Therapy: The Way Forward. Curr Oncol 2022; 29:5792-5799. [PMID: 36005194 PMCID: PMC9406978 DOI: 10.3390/curroncol29080456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 08/11/2022] [Accepted: 08/12/2022] [Indexed: 11/16/2022] Open
Abstract
The rising cost of cancer care has shed light on an important aspect of healthcare delivery. Financial toxicity of therapy must be considered in clinical practice and policy-making. One way to mitigate the impact of financial toxicity of cancer care is by focusing on an approach of healthcare delivery that aims to deliver value to the patient. Should value of therapy be one of the most important determinants of cancer care? If so, how do we measure it? How can we implement it in routine clinical practice? In this viewpoint, we discuss value-based care in systemic therapy in oncology. Strategies to improve the quality of care by incorporating value-based approaches are discussed: use of composite tools to assess the value of drugs, alternative dosing strategies, and the use of Health Technology Assessment in regulatory procedures. We propose that there must be a greater emphasis on value of therapy in determining its use and its cost.
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Affiliation(s)
- Aju Mathew
- Department of Oncology, MOSC Medical College, Ernakulam 682311, Kerala, India
| | | | | | - Bhawna Sirohi
- Department of Oncology, Balco Medical Center, Raipur 493661, Chattisgarh, India
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Ma G, Jiang P, Mo B, Luo Y, Zhao Y, Wang X, Shi C, Huang Y. Take-Home Video Shortens the Time to First Ambulation in Patients With Inguinal Hernia Repair Under General Anesthesia: A Retrospective Observational Study. Front Med (Lausanne) 2022; 9:848280. [PMID: 35847805 PMCID: PMC9278018 DOI: 10.3389/fmed.2022.848280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 06/08/2022] [Indexed: 11/13/2022] Open
Abstract
Background Data on the relationship between take-home video and the time to first ambulation remains scant. Here, we aimed to investigate whether viewed take-home video during pre-hospitalization is independently associated with the time to first ambulation in postoperative patients with inguinal hernia repair under general anesthesia. Methods We retrospectively reviewed and analyzed the relationship between viewed take-home video and the time to first ambulation between September 2020 and October 2021.The independent t-tests or Mann-Whitney U-tests was used to compare the means of two groups (viewed take-home video and non-viewed take-home video). Chi-square test was used to compare the rates between the two groups. We used a linear regression model to see if there was a difference between exposure and outcome variable. Both models were used to observe the effect size of the exposed variable. Subgroup analysis was employed to assess the impact of various factors. Results This study included a total of 120 patients with inguinal hernia repair under general anesthesia following day surgery. The average age of the participants in the two groups was 43.16 and 44.83 years, respectively, and about 82.5% of the patients were male. Our fully adjusted linear regression results showed that individuals in the viewed video group were associated with a decreased time to first ambulation (h) after adjusting for confounders (β = −0.50, 95%CI: −0.83, −0.17; P = 0.004). In addition, the linear regression analysis of the relationship between viewed video and length of stay showed that β = −2.10 (95%CI:CI: −3.85, −0.34; P = 0.021). Similarly, subgroup analysis yielded similar results for the viewed video group patients compared to those in the non-viewed video group. Conclusion Taken together, our findings demonstrated that viewed video could shorten the time to first ambulation, which in turn reduce the length of stay in postoperative patients under general anesthesia.
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Affiliation(s)
- Guozhen Ma
- Day Surgery Care Unit, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
- School of Nursing, Philippine Women's University, Manila, Philippines
| | - Pengjun Jiang
- Department of Anorectal Surgery, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
| | - Beirong Mo
- Department of Nursing, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
- *Correspondence: Beirong Mo
| | - Yijun Luo
- Department of Anesthesiology, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
| | - Yongling Zhao
- Department of Gastrointestinal Surgery, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
| | - Xingguang Wang
- Day Surgery Care Unit, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
| | - Chunmiao Shi
- Day Surgery Care Unit, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
| | - Yanhui Huang
- Day Surgery Care Unit, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
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van Engen V, Bonfrer I, Ahaus K, Buljac-Samardzic M. Value-Based Healthcare From the Perspective of the Healthcare Professional: A Systematic Literature Review. Front Public Health 2022; 9:800702. [PMID: 35096748 PMCID: PMC8792751 DOI: 10.3389/fpubh.2021.800702] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 12/21/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Healthcare systems increasingly move toward “value-based healthcare” (VBHC), aiming to further improve quality and performance of care as well as the sustainable use of resources. Evidence about healthcare professionals' contributions to VBHC, experienced job demands and resources as well as employee well-being in VBHC is scattered. This systematic review synthesizes this evidence by exploring how VBHC relates to the healthcare professional, and vice versa.Method: Seven databases were systematically searched for relevant studies. The search yielded 3,782 records, of which 45 were eligible for inclusion based on a two-step screening process using exclusion criteria performed by two authors independently. The quality of the included studies was appraised using the Mixed Methods Appraisal Tool (MMAT). Based on inductive thematic analysis, the Job Demands-Resources (JD-R) model was modified. Subsequently, this modified model was applied deductively for a second round of thematic analysis.Results: Ten behaviors of healthcare professionals to enhance value in care were identified. These behaviors and associated changes in professionals' work content and work environment impacted the experienced job demands and resources and, in turn, employee well-being and job strain. This review revealed 16 constructs as job demand and/or job resource. Examples of these include role strain, workload and meaning in work. Four constructs related to employee well-being, including engagement and job satisfaction, and five constructs related to job strain, including exhaustion and concerns, were identified. A distinction was made between job demands and resources that were a pure characteristic of VBHC, and job demands and resources that resulted from environmental factors such as how care organizations shaped VBHC.Conclusion and Discussion: This review shows that professionals experience substantial job demands and resources resulting from the move toward VBHC and their active role therein. Several job demands are triggered by an unsupportive organizational environment. Hence, increased organizational support may contribute to mitigating or avoiding adverse psychosocial factors and enhance positive psychosocial factors in a VBHC context. Further research to estimate the effects of VBHC on healthcare professionals is warranted.
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Blayney DW, Seto T, Hoang N, Lindquist C, Kurian AW. Benchmark Method for Cost Computations Across Health Care Systems: Cost of Care per Patient per Day in Breast Cancer Care. JCO Oncol Pract 2021; 17:e1403-e1412. [PMID: 33646822 PMCID: PMC8791822 DOI: 10.1200/op.20.00462] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 12/08/2020] [Accepted: 01/19/2021] [Indexed: 01/07/2023] Open
Abstract
PURPOSE To estimate the value of cancer care and to compare value among episodes of care, a transparent, reproducible, and standardized cost computation methodology is needed. Charges, claims, and reimbursements are related to cost but are nontransparent and proprietary. We developed a method to measure the cost of the following phases of care: (1) initial treatment with curative intent, (2) surveillance and survivorship care, and (3) relapse and end-of-life care. METHODS We combined clinical data from our electronic health record, the state cancer registry, and the Social Security Death Index. We analyzed the care of patients with breast cancer and mapped Common Procedural Terminology (CPT) codes to the corresponding cost conversion factor and date in the CMS Medicare fee schedule. To account for varying duration of episodes of care, we computed a cost of care per day (CCPD) for each patient. RESULTS Median CCPD for initial treatment was $29.45 in US dollars (USD), the CCPD for surveillance and survivorship care was $2.45 USD, and the CCPD for relapse care was $13.80 USD. Among the three breast cancer types (hormone receptor-positive or human epidermal growth factor receptor 2 [HER2]-negative, HER2-positive, and triple-negative), there was no difference in CCPD. Relapsed patients in the most expensive surveillance CCPD group had significantly shorter survival. CONCLUSION We developed a method to identify high-value oncology care-cost of care per patient per day (CCPD)-in episodes of initial, survivorship, and relapse care. The methodology can help identify positive deviants (who have developed best practices) delivering high-value care. Merging our data with claims data from third-party payers can increase the accuracy and validity of the CCPD.
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Affiliation(s)
- Douglas W. Blayney
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
- Clinical Excellence Research Center, Stanford University School of Medicine, Stanford, CA
| | - Tina Seto
- Technology and Digital Solutions, Stanford HealthCare and School of Medicine, Stanford, CA
| | - Nhat Hoang
- Technology and Digital Solutions, Stanford HealthCare and School of Medicine, Stanford, CA
| | - Craig Lindquist
- Clinical Excellence Research Center, Stanford University School of Medicine, Stanford, CA
| | - Allison W. Kurian
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
- Division of Medical Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, CA
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Hahn EE, Munoz-Plaza C, Altman DE, Hsu C, Cannizzaro NT, Ngo-Metzger Q, Wride P, Gould MK, Mittman BS, Hodeib M, Tewari KS, Ajamian LH, Eskander RN, Tewari D, Chao CR. De-implementation and substitution of clinical care processes: stakeholder perspectives on the transition to primary human papillomavirus (HPV) testing for cervical cancer screening. Implement Sci Commun 2021; 2:108. [PMID: 34556189 PMCID: PMC8461958 DOI: 10.1186/s43058-021-00211-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 09/06/2021] [Indexed: 12/27/2022] Open
Abstract
Background New cervical cancer screening guidelines recommend primary human papillomavirus (HPV) testing for women age 30–65 years. Healthcare organizations are preparing to de-implement the previous recommended strategies of Pap testing or co-testing (Pap plus HPV test) and substitute primary HPV testing. However, there may be significant challenges to the replacement of this entrenched clinical practice, even with an evidence-based substitution. We sought to identify stakeholder-perceived barriers and facilitators to this substitution within a large healthcare system, Kaiser Permanente Southern California. Methods We conducted semi-structured qualitative interviews with clinician, administrative, and patient stakeholders regarding (a) acceptability and feasibility of the planned substitution; (b) perceptions of barriers and facilitators, with an emphasis on those related to the de-implementation/implementation cycle of substitution; and (c) perceived readiness to change. Our interview guide was informed by the Consolidated Framework for Implementation Research (CFIR). Using a team coding approach, we developed an initial coding structure refined during iterative analysis; the data were subsequently organized thematically into domains, key themes, and sub-themes using thematic analysis, followed by framework analysis informed by CFIR. Results We conducted 23 interviews: 5 patient and 18 clinical/administrative. Clinicians perceived that patients feel more tests equals better care, and clinicians and patients expressed fear of missed cancers (“…it’ll be more challenging convincing the patient that only one test is…good enough to detect cancer.”). Patients perceived practice changes resulting in “less care” are driven by the desire to cut costs. In contrast, clinicians/administrators viewed changing from two tests to one as acceptable and a workflow efficiency (“…It’s very easy and half the work.”). Stakeholder-recommended strategies included focusing on the increased efficacy of primary HPV testing and developing clinician talking points incorporating national guidelines to assuage “cost-cutting” fears. Conclusions Substitution to replace an entrenched clinical practice is complex. Leveraging available facilitators is key to ease the process for clinical and administrative stakeholders—e.g., emphasizing the efficiency of going from two tests to one. Identifying and addressing clinician and patient fears regarding cost-cutting and perceived poorer quality of care is critical for substitution. Multicomponent and multilevel strategies for engagement and education will be required. Trial registration ClinicalTrials.gov, #NCT04371887 Supplementary Information The online version contains supplementary material available at 10.1186/s43058-021-00211-z.
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Affiliation(s)
- Erin E Hahn
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave, Pasadena, CA, 91101, USA. .,Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA.
| | - Corrine Munoz-Plaza
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave, Pasadena, CA, 91101, USA
| | - Danielle E Altman
- Center for Health Living, Kaiser Permanente Southern California, Pasadena, USA
| | - Chunyi Hsu
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave, Pasadena, CA, 91101, USA
| | - Nancy T Cannizzaro
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave, Pasadena, CA, 91101, USA
| | - Quyen Ngo-Metzger
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Patricia Wride
- Southern California Permanente Medical Group, Pasadena, USA
| | - Michael K Gould
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Brian S Mittman
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave, Pasadena, CA, 91101, USA
| | - Melissa Hodeib
- Southern California Permanente Medical Group, Pasadena, USA
| | - Krishnansu S Tewari
- Department of Gynecologic Oncology, University of California Irvine, Irvine, CA, USA
| | - Lena H Ajamian
- Southern California Permanente Medical Group, Pasadena, USA
| | - Ramez N Eskander
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Diego, La Jolla, CA, USA
| | - Devansu Tewari
- Southern California Permanente Medical Group, Pasadena, USA
| | - Chun R Chao
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave, Pasadena, CA, 91101, USA.,Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
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Deeb S, Chino FL, Diamond LC, Tao A, Aragones A, Shahrokni A, Yerramilli D, Gillespie EF, Tsai CJ. Disparities in Care Management During Terminal Hospitalization Among Adults With Metastatic Cancer From 2010 to 2017. JAMA Netw Open 2021; 4:e2125328. [PMID: 34550384 PMCID: PMC8459194 DOI: 10.1001/jamanetworkopen.2021.25328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
IMPORTANCE Many patients with metastatic cancer receive high-cost, low-value care near the end of life. Identifying patients with a high likelihood of receiving low-value care is an important step to improve appropriate end-of-life care. OBJECTIVE To analyze patterns of care and interventions during terminal hospitalizations and examine whether care management is associated with sociodemographic status among adult patients with metastatic cancer at the end of life. DESIGN, SETTING, AND PARTICIPANTS This retrospective, population-based cross-sectional study used data from the Healthcare Cost and Utilization Project to analyze all-payer, encounter-level information from multiple inpatient centers in the US. All utilization and hospital charge records from national inpatient sample data sets between January 1, 2010, and December 31, 2017 (n = 58 761 097), were screened. The final cohort included 21 335 patients 18 years and older at inpatient admission who had a principal diagnosis of metastatic cancer and died during hospitalization. Data for the current study were analyzed from January 1, 2010, to December 31, 2017. EXPOSURES Patient demographic characteristics, patient insurance status, hospital location, and hospital teaching status. MAIN OUTCOMES AND MEASURES Receipt of systemic therapy (including chemotherapy and immunotherapy), receipt of invasive mechanical ventilation, emergency department (ED) admission, time from hospital admission to death, and total charges during a terminal hospitalization. RESULTS Among 21 335 patients with metastatic cancer who had terminal hospitalizations between 2010 and 2017, the median age was 65 years (interquartile range, 56-75 years); 54.0% of patients were female; 0.5% were American Indian, 3.3% were Asian or Pacific Islander, 14.1% were Black, 7.5% were Hispanic, 65.9% were White, and 3.1% were identified as other; 58.2% were insured by Medicare or Medicaid, and 33.2% were privately insured. Overall, 63.2% of patients were admitted from the ED, 4.6% received systemic therapy, and 19.2% received invasive mechanical ventilation during hospitalization. Racial and ethnic minority patients had a higher likelihood of being admitted from the ED (Asian or Pacific Islander patients: odds ratio [OR], 1.43 [95% CI, 1.20-1.72]; P < .001; Black patients: OR, 1.39 [95% CI, 1.27-1.52]; P < .001; and Hispanic patients: OR, 1.45 [95% CI, 1.28-1.64]; P < .001), receiving invasive mechanical ventilation (Black patients: OR, 1.59 [95% CI, 1.44-1.75]; P < .001), and incurring higher total charges (Asian or Pacific Islander patients: OR, 1.35 [95% CI, 1.13-1.60]; P = .001; Black patients: OR, 1.23 [95% CI, 1.13-1.34]; P < .001; and Hispanic patients: OR, 1.50 [95% CI, 1.34-1.69]; P < .001) compared with White patients. Privately insured patients had a lower likelihood of being admitted from the ED (OR, 0.47 [95% CI, 0.44-0.51]; P < .001), receiving invasive mechanical ventilation (OR, 0.75 [95% CI, 0.69-0.82]; P < .001), and incurring higher total charges (OR, 0.64 [95% CI, 0.59-0.68]; P < .001) compared with Medicare and Medicaid beneficiaries. CONCLUSIONS AND RELEVANCE In this study, patients with metastatic cancer from racial and ethnic minority groups and those with Medicare or Medicaid coverage were more likely to receive low-value, aggressive interventions at the end of life. Further studies are needed to evaluate the underlying factors associated with disparities at the end of life to implement prospective interventions.
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Affiliation(s)
- Stephanie Deeb
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Fumiko L. Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lisa C. Diamond
- Immigrant Health and Cancer Disparities Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anna Tao
- Tufts University School of Medicine, Boston, Massachusetts
| | - Abraham Aragones
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Armin Shahrokni
- Department of Geriatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Divya Yerramilli
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Erin F. Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - C. Jillian Tsai
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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Fauer A, Wright N, Lafferty M, Harrod M, Manojlovich M, Friese CR. Influences of Physical Layout and Space on Patient Safety and Communication in Ambulatory Oncology Practices: A Multisite, Mixed Method Investigation. HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 2021; 14:270-286. [PMID: 34169761 DOI: 10.1177/19375867211027498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To examine how physical layouts and space in ambulatory oncology practices influence patient safety and clinician communication. BACKGROUND Ambulatory oncology practices face unique challenges in delivering safe care. With increasing patient volumes, these settings require additional attention to support patient safety and efficient clinical work processes. METHODS This study used a mixed methods design with sequential data collection. Eight ambulatory oncology practices (of 29 participating practices) participated in both the quantitative and qualitative phases. In surveys, clinicians (n = 56) reported on safety organizing and communication satisfaction measures. Qualitative data included observations and semistructured interviews (n = 46) with insight into how physical layout influenced care delivery. Quantitative analysis of survey data included descriptive and correlational statistics. Qualitative analysis used inductive and thematic content analysis. Quantitative and qualitative data were integrated using side-by-side comparison tables for thematic analysis. RESULTS Safety organizing performance was positively correlated with clinician communication satisfaction, r(54 df) = .414, p = .002. Qualitative analyses affirmed that the physical layout affected communication around chemotherapy infusion and ultimately patient safety. After data integration, safety organizing and clinician communication were represented by two themes: visibility of patients during infusion and the proximity of clinicians in the infusion center to clinicians in the clinic where providers see patients. CONCLUSIONS Physical layouts of ambulatory oncology practices are an important factor to promote patient safety. Our findings inform efforts to construct new and modify existing infusion centers to enhance patient safety and clinician communication.
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Affiliation(s)
- Alex Fauer
- National Clinician Scholars Program, Division of General Internal Medicine and Health Services Research, School of Medicine, University of California, Los Angeles, CA, USA
| | - Nathan Wright
- Center for Improving Patient and Population Health, School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | | | | | | | - Christopher R Friese
- Center for Improving Patient and Population Health, School of Nursing, University of Michigan, Ann Arbor, MI, USA.,Rogel Cancer Center, Ann Arbor, MI, USA.,School of Public Health, University of Michigan, Ann Arbor, MI, USA
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Chua IS, Gaziel-Yablowitz M, Korach ZT, Kehl KL, Levitan NA, Arriaga YE, Jackson GP, Bates DW, Hassett M. Artificial intelligence in oncology: Path to implementation. Cancer Med 2021; 10:4138-4149. [PMID: 33960708 PMCID: PMC8209596 DOI: 10.1002/cam4.3935] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 04/06/2021] [Accepted: 04/07/2021] [Indexed: 12/21/2022] Open
Abstract
In recent years, the field of artificial intelligence (AI) in oncology has grown exponentially. AI solutions have been developed to tackle a variety of cancer‐related challenges. Medical institutions, hospital systems, and technology companies are developing AI tools aimed at supporting clinical decision making, increasing access to cancer care, and improving clinical efficiency while delivering safe, high‐value oncology care. AI in oncology has demonstrated accurate technical performance in image analysis, predictive analytics, and precision oncology delivery. Yet, adoption of AI tools is not widespread, and the impact of AI on patient outcomes remains uncertain. Major barriers for AI implementation in oncology include biased and heterogeneous data, data management and collection burdens, a lack of standardized research reporting, insufficient clinical validation, workflow and user‐design challenges, outdated regulatory and legal frameworks, and dynamic knowledge and data. Concrete actions that major stakeholders can take to overcome barriers to AI implementation in oncology include training and educating the oncology workforce in AI; standardizing data, model validation methods, and legal and safety regulations; funding and conducting future research; and developing, studying, and deploying AI tools through multidisciplinary collaboration.
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Affiliation(s)
- Isaac S Chua
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Michal Gaziel-Yablowitz
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Zfania T Korach
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Kenneth L Kehl
- Harvard Medical School, Boston, MA, USA.,Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | | | - Gretchen P Jackson
- IBM Watson Health, Cambridge, MA, USA.,Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David W Bates
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Michael Hassett
- Harvard Medical School, Boston, MA, USA.,Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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11
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Fauer A, Choi SW, Wallner LP, Davis MA, Friese CR. Understanding quality and equity: patient experiences with care in older adults diagnosed with hematologic malignancies. Cancer Causes Control 2021; 32:379-389. [PMID: 33566250 PMCID: PMC7946754 DOI: 10.1007/s10552-021-01395-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 01/09/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Oncology settings increasingly use patient experience data to evaluate clinical performance. Given that older patients with hematologic malignancies are a high-risk population, this study examined factors associated with patient-reported health care experiences during the first year of their cancer diagnosis. METHODS Cross-sectional study using the 2000-2015 SEER-CAHPS® data to examine patient experiences of Medicare enrollees with a primary diagnosis of leukemia or lymphoma. The primary outcomes were three CAHPS assessments: overall care, personal doctor, and health plan overall. We estimated case-mix adjusted and fully adjusted associations between factors (i.e., clinical and sociodemographic) and the CAHPS outcomes using bivariate statistical tests and multiple linear regression. RESULTS The final sample included 1,151 patients, with 431 diagnosed with leukemia and 720 diagnosed with lymphoma (median time from diagnosis to survey 6 months). Patients who completed the survey further apart from the diagnosis date reported significantly higher adjusted ratings of care overall (β .39, p = .008) than those closer to diagnosis. American Indian/Alaska Native, Asian, and Pacific Islander patients had lower adjusted ratings of care overall (β - .73, p = .003) than Non-Hispanic white patients. Multimorbidity was significantly associated with higher adjusted personal doctor ratings (β .26, p = .003). CONCLUSIONS Unfavorable patient experiences among older adults diagnosed with hematologic malignancies warrant targeted efforts to measure and improve care quality. Future measurement of experiences of cancer care soon after diagnosis, coupled with careful sampling of high-priority populations, will inform oncology leaders and clinicians on strategies to improve care for high-risk, high-cost populations.
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Affiliation(s)
- Alex Fauer
- School of Nursing, University of Michigan, 400 North Ingalls St., Ann Arbor, MI, 48109, USA.
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA.
| | - Sung Won Choi
- Medical School, University of Michigan, Ann Arbor, MI, USA
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
| | - Lauren P Wallner
- Medical School, University of Michigan, Ann Arbor, MI, USA
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
| | - Matthew A Davis
- School of Nursing, University of Michigan, 400 North Ingalls St., Ann Arbor, MI, 48109, USA
- Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Christopher R Friese
- School of Nursing, University of Michigan, 400 North Ingalls St., Ann Arbor, MI, 48109, USA
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
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12
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Cinaroglu S. Oncology services efficiency in the age of pandemic: A jackknife and bootstrap sensitivity analysis for robustness check of DEA scores. J Cancer Policy 2021; 27:100262. [DOI: 10.1016/j.jcpo.2020.100262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 11/04/2020] [Accepted: 11/18/2020] [Indexed: 01/12/2023]
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13
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The Perceptions of Cancer Patients Regarding the Causes and Preventability of Unplanned Hospital Admissions. Am J Clin Oncol 2020; 43:734-740. [PMID: 32739972 DOI: 10.1097/coc.0000000000000739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to determine the attitudes of oncology patients regarding the causes and preventability of unplanned hospitalizations. METHODS Convenience sample using a 36-question survey instrument adapted from prior studies of hospital readmissions. RESULTS A total of 95 evaluable patients answered >75% of survey items. Majorities (64%) agreed that they desired to avoid the admission, but disagreed (79%) that their own admission was preventable. Patients did not generally express lack confidence in their overall self-management abilities (only 36% agreed) or dissatisfaction with the level of home support, emotional or equipment (only 11% to 26% agreed). Patients did not complain of an inability to access their oncology care team (only 14% agreed), yet a strong majority (79%) endorsed the idea that emergency department visits represent the "quickest and easiest way to get needed care" and that the "hospital is the best place for me when I am sick" (60%). Overall, 79% indicated that their oncology care team directed them to visit the emergency department for evaluation. Most results did not differ by demographic factors. CONCLUSIONS These results differ from previous results that use methods other than a direct patient survey to determine the preventability or root causes of unplanned hospital admissions/ or readmissions. Accordingly, patient support programs may not address the root causes of unplanned admissions. The use of the emergency department for unplanned care may represent local culture and institutions planning reduction efforts should include patent perceptions to plan a holistic solution.
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14
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Berry LL, Keiningham T, Aksoy L, Deming KA. When Cancer Centers Mislead Prospective Patients. JCO Oncol Pract 2020; 16:219-222. [DOI: 10.1200/jop.19.00783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Leonard L. Berry
- Mays Business School, Texas A&M University, College Station, TX
- Institute for Healthcare Improvement, Boston, MA
| | - Timothy Keiningham
- St John’s University, The Peter J. Tobin College of Business, Queens, NY
| | - Lerzan Aksoy
- Fordham University, Gabelli School of Business, Bronx, NY
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15
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Lam MB, Zheng J, Orav EJ, Jha AK. Early Accountable Care Organization Results in End-of-Life Spending Among Cancer Patients. J Natl Cancer Inst 2019; 111:1307-1313. [PMID: 30859226 PMCID: PMC6910163 DOI: 10.1093/jnci/djz033] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 01/26/2019] [Accepted: 03/08/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Spending on cancer patients is substantial and has increased in recent years. Accountable care organizations (ACOs) are arguably the most important national experiment to control health-care spending. How ACOs are managing patients with cancer at the end of life (EOL) is largely unknown. We conducted this study with the objective of determining whether becoming an ACO is associated with subsequent changes in EOL spending or utilization among patients with cancer. METHODS Using national Medicare claims from 2011 to 2015, we identified patients who died in 2012 (pre-ACO, n = 12 248) and 2015 (post-ACO, n = 12 248), assigning each decedent to a practice. ACOs were matched to non-ACOs within the same geographic region. We used a difference-in-difference model to examine changes in EOL spending and utilization associated with becoming an ACO in the Medicare Shared Savings Program for beneficiaries with cancer. RESULTS We found that the introduction of ACOs had no meaningful impact on overall EOL spending in cancer patients (change in overall spending in ACOs = -$1687 vs -$1434 in non-ACOs, difference = $253, 95% confidence interval = -$1809 to $1304, P= .75). We found no changes in total patient spending by cancer type examined or by spending categories, including cancer-specific categories of radiation, therapy, and hospice services. Finally, emergency department visits, inpatient hospitalization, intensive care unit admissions, radiation therapy, chemotherapy, and hospice use did not meaningfully differ between ACO and non-ACO patients. CONCLUSIONS The introduction of ACOs does not appear to have had any meaningful effect on EOL spending or utilization for patients with a cancer diagnosis.
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Affiliation(s)
- Miranda B Lam
- Correspondence to: Miranda B. Lam, MD, MBA, Department of Radiation Oncology, Brigham and Women’s Hospital, Dana Farber Cancer Institute, 75 Francis Street, Boston, MA 02115 ()
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16
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Brady BM, Ragavan MV, Simon M, Chertow GM, Milstein A. Exploring Care Attributes of Nephrologists Ranking Favorably on Measures of Value. J Am Soc Nephrol 2019; 30:2464-2472. [PMID: 31727849 DOI: 10.1681/asn.2019030219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 09/15/2019] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Despite growth in value-based payment, attributes of nephrology care associated with payer-defined value remains unexplored. METHODS Using national health insurance claims data from private preferred provider organization plans, we ranked nephrology practices using total cost of care and a composite of common quality metrics. Blinded to practice rankings, we conducted site visits at four highly ranked and three average ranked practices to identify care attributes more frequently present in highly ranked practices. A panel of nephrologists used a modified Delphi method to score each distinguishing attribute on its potential to affect quality and cost of care and ease of transfer to other nephrology practices. RESULTS Compared with average-value peers, high-value practices were located in areas with a relatively higher proportion of black and Hispanic patients and a lower proportion of patients aged >65 years. Mean risk-adjusted per capita monthly total spending was 24% lower for high-value practices. Twelve attributes comprising five general themes were observed more frequently in high-value nephrology practices: preventing near-term costly health crises, supporting patient self-care, maximizing effectiveness of office visits, selecting cost-effective diagnostic and treatment options, and developing infrastructure to support high-value care. The Delphi panel rated four attributes highly on effect and transferability: rapidly adjustable office visit frequency for unstable patients, close monitoring and management to preserve kidney function, early planning for vascular access, and education to support self-management at every contact. CONCLUSIONS Findings from this small-scale exploratory study may serve as a starting point for nephrologists seeking to improve on payer-specified value measures.
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Affiliation(s)
- Brian M Brady
- Division of Nephrology, .,Clinical Excellence Research Center, and.,Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Meera V Ragavan
- Clinical Excellence Research Center, and.,Department of Medicine, Stanford University School of Medicine, Stanford, California
| | | | - Glenn M Chertow
- Division of Nephrology.,Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Arnold Milstein
- Clinical Excellence Research Center, and.,Department of Medicine, Stanford University School of Medicine, Stanford, California
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17
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Baumgardner JR, Shahabi A, Linthicum MT, Zacker C, Lakdawalla DN. Share of Oncology Versus Nononcology Spending in Episodes Defined by the Centers for Medicare & Medicaid Services Oncology Care Model. J Oncol Pract 2019; 14:e699-e710. [PMID: 30423271 DOI: 10.1200/jop.18.00309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Performance-based payments to oncology providers participating in the Centers for Medicare & Medicaid Services (CMS) Oncology Care Model (OCM) are based, in part, on overall spending in 6-month episodes of care, including spending unrelated to oncology care. The amount of spending likely to occur outside of oncologists' purview is unknown. METHODS Following the OCM definition of an episode, we used SEER-Medicare data from 2006 to 2013 to identify episodes of cancer care for the following diagnoses: breast cancer (BC), non-small-cell lung cancer, renal cell carcinoma, multiple myeloma (MM), and chronic myeloid leukemia. Claims were categorized by service type and, separately, whether the content fell within the purview of oncology providers (classified as oncology, with all other claims nononcology). We calculated the shares of episode spending attributable to oncology versus nononcology services. RESULTS The percentage of oncology spending within OCM episodes ranged from 62.4% in BC to 85.5% in MM. The largest source of oncology spending was antineoplastic drug therapy, ranging from 21.8% of total episode spending in BC to 67.6% in chronic myeloid leukemia. The largest source of nononcology spending was acute hospitalization and inpatient physician costs, ranging from 6.6% of overall spending for MM to 10.4% for non-small-cell lung cancer; inpatient oncology spending contributed roughly similar shares to overall spending. CONCLUSION Most spending in OCM-defined episodes was attributable to services related to cancer care, especially antineoplastic drug therapy. Inability to control nononcology spending may present challenges for practices participating in the OCM, however.
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Affiliation(s)
- James R Baumgardner
- Precision Health Economics; University of Southern California, Los Angeles, CA; and Novartis Pharmaceuticals Corporation, Emmaus, PA
| | - Ahva Shahabi
- Precision Health Economics; University of Southern California, Los Angeles, CA; and Novartis Pharmaceuticals Corporation, Emmaus, PA
| | - Mark T Linthicum
- Precision Health Economics; University of Southern California, Los Angeles, CA; and Novartis Pharmaceuticals Corporation, Emmaus, PA
| | - Christopher Zacker
- Precision Health Economics; University of Southern California, Los Angeles, CA; and Novartis Pharmaceuticals Corporation, Emmaus, PA
| | - Darius N Lakdawalla
- Precision Health Economics; University of Southern California, Los Angeles, CA; and Novartis Pharmaceuticals Corporation, Emmaus, PA
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18
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Hannum SM, Dy SM, Smith KC, Kamal AH. Proposed Criteria for Systematic Evaluation of Qualitative Oncology Research. J Oncol Pract 2019; 15:523-529. [PMID: 31386609 DOI: 10.1200/jop.19.00125] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Oncology has made significant advances in standardizing how clinical research is conducted and reported. The advancement of such research that improves oncology practice requires an expansion of not only our research questions but also the research methods we deploy to address them. In particular, there is increasing recognition of the value of qualitative research methods to develop more comprehensive understandings of phenomena of interest and to describe and explain underlying motivations and potential causes of specific outcomes. However, qualitative researchers in oncology have lacked guidance to produce and evaluate methodologically rigorous qualitative publications. In this review, we highlight characteristics of high-quality, methodologically rigorous reports of qualitative research, provide criteria for readers and reviewers to appraise such publications critically, and proffer guidance for preparing publications for submission to Journal of Oncology Practice. Namely, the quality of qualitative research in oncology practice is best assessed according to key domains that include fitness of purpose, theoretical framework, methodological rigor, ethical concerns, analytic comprehensives, and the dissemination/application of findings. In particular, determinations of rigor in qualitative research in oncology practice should consider definitions of the appropriateness of qualitative methods for the research objectives against the setting of current literature, use of an appropriate theoretical framework, inclusion of a rigorous and innovative measurement plan, application of appropriate analytic techniques, and clear explanation and dissemination of the research findings.
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Affiliation(s)
- Susan M Hannum
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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19
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Barkley R, Soobader MJ, Wang J, Blau S, Page RD. Reducing Cancer Costs Through Symptom Management and Triage Pathways. J Oncol Pract 2018; 15:e91-e97. [PMID: 30576262 DOI: 10.1200/jop.18.00082] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Value-based care infers care that is high quality at a comparatively low total cost. A key strategy for value-based oncology care is to avoid unnecessary emergency room (ER) visits and associated hospitalizations of patients receiving treatment for cancer. Early experience with this strategy showed that symptom management in patients with cancer can result in the reduction of ER events and hospitalizations. However, quantifying the actual savings achieved has been elusive. In this article, we present the impact of symptom management and triage pathways programs deployed at two midsize community oncology practices. We then quantify the actual dollar saving in their Medicare and commercial populations. METHODS Symptom management records generated through the ER triage programs at the two practices were screened to identify avoided ER events. This approach was validated with an independent analysis using Medicare claim data from the Oncology Care Model program in which both practices participate. Bootstrap simulations were used to test for statistical significance of the ER event rate changes before and after the launch of the program. Average event and annual total cost savings from avoided ER incidents and ER-related hospitalizations were then calculated. RESULTS Two hundred twenty-two avoided ER events were identified, for an estimated net annualized savings generated by the two practices of $3.85 million. Although the ER rate reduction was not statistically significant, these findings are consistent with the observed reduction of ER event rates among a subset of Oncology Care Model beneficiaries at the two practices. CONCLUSION ER events and associated hospitalizations can be avoided as well as quantified as a result of the deployment of a practice-level integrated platform that incorporates physician-scripted symptom management protocols and telephone triage pathways.
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Affiliation(s)
- Ronald Barkley
- 1 Cancer Center Business Development Group, Lighthouse Point, FL
| | | | | | - Sibel Blau
- 3 Northwest Medical Specialties, Tacoma, WA
| | - Ray D Page
- 4 Center for Cancer and Blood Disorders, Fort Worth, TX
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20
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Finlay E, Rabow MW, Buss MK. Filling the Gap: Creating an Outpatient Palliative Care Program in Your Institution. Am Soc Clin Oncol Educ Book 2018; 38:111-121. [PMID: 30231351 DOI: 10.1200/edbk_200775] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Well-designed, randomized trials demonstrate that outpatient palliative care improves symptom burden and quality of life (QOL) while it reduces unnecessary health care use in patients with cancer. Despite the strong evidence of benefit and ASCO recommendations, implementation of outpatient palliative care, especially in community oncology settings, faces considerable hurdles. This article, which is based on published literature and expert opinion, presents practical strategies to help oncologists make a strong clinical and fiscal case for outpatient palliative care. This article outlines key considerations for how to build an outpatient palliative care program in an institution by (1) defining the scope and benefits; (2) identifying strategies to overcome common barriers to integration of outpatient palliative care into cancer care; (3) outlining a business case; (4) describing successful models of outpatient palliative care; and (5) examining important factors in design and operation of a palliative care clinic. The advantages and disadvantages of different delivery models (e.g., embedded vs. independent) and different methods of referral (triggered vs. physician discretion) are reviewed. Strategies to make the case for outpatient palliative care that align with institutional values and/or are supported by local institutional data on cost savings are included.
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Affiliation(s)
- Esme Finlay
- From the Division of Palliative Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, NM; Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA; Section of Palliative Care, Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Michael W Rabow
- From the Division of Palliative Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, NM; Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA; Section of Palliative Care, Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Mary K Buss
- From the Division of Palliative Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, NM; Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA; Section of Palliative Care, Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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21
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Balboni TA, Hui KKP, Kamal AH. Supportive Care in Lung Cancer: Improving Value in the Era of Modern Therapies. Am Soc Clin Oncol Educ Book 2018; 38:716-725. [PMID: 30231310 DOI: 10.1200/edbk_201369] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Driven by a discipline-wide imperative to maximize patient centeredness and value, supportive care services have experienced remarkable growth and acceptance in oncology care. Two such services with a growing evidence base and examples of routine integration into usual oncology care are palliative care and integrative medicine. Both focus on the patient experience with cancer during and after cancer-directed treatments occur, from diagnosis through survivorship or end-of-life care. With a frame of increasing value for all in the oncology care ecosystem, we highlight the evidence for how these two disciplines can improve the experience of patients with cancer and their loved ones. We further highlight how additional focus in palliative care and integrative medicine can continue to build toward a shared vision of high-value, high-quality cancer care.
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Affiliation(s)
- Tracy A Balboni
- From the Departments of Radiation Oncology and Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA; Department of Medicine, David Geffen School of Medicine, UCLA Center for East West Medicine, University of California, Los Angeles, CA; Duke Cancer Institute and Duke Fuqua School of Business, Duke University, Durham, NC
| | - Ka-Kit P Hui
- From the Departments of Radiation Oncology and Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA; Department of Medicine, David Geffen School of Medicine, UCLA Center for East West Medicine, University of California, Los Angeles, CA; Duke Cancer Institute and Duke Fuqua School of Business, Duke University, Durham, NC
| | - Arif H Kamal
- From the Departments of Radiation Oncology and Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA; Department of Medicine, David Geffen School of Medicine, UCLA Center for East West Medicine, University of California, Los Angeles, CA; Duke Cancer Institute and Duke Fuqua School of Business, Duke University, Durham, NC
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22
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Lam MB, Figueroa JF, Zheng J, Orav EJ, Jha AK. Spending Among Patients With Cancer in the First 2 Years of Accountable Care Organization Participation. J Clin Oncol 2018; 36:2955-2960. [DOI: 10.1200/jco.18.00270] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Spending on patients with cancer can be substantial and has continued to increase in recent years. Accountable Care Organizations (ACOs) are arguably the most important national experiment to control health care spending, yet how ACOs are managing patients with cancer diagnoses is largely unknown. We aimed to determine whether practices that became ACOs had changes in overall or cancer-specific spending among patients with cancer. Methods Using 2011 to 2015 national Medicare claims, practices that became part of ACOs were identified and matched to non-ACO practices within the same geographic region. We calculated total and category-specific annual spending per beneficiary as well as spending for and utilization of emergency departments, inpatient admissions, hospice, chemotherapy, and radiation therapy. A difference-in-differences model was used to examine changes in spending and utilization associated with ACO contracts in the Medicare Shared Savings Program for beneficiaries with cancer. Results We found that the introduction of ACOs had no meaningful impact on overall spending in patients with cancer (−$308 per beneficiary in ACOs v −$319 in non-ACOs; difference, $11; 95% CI, −$275 to $297; P = .94). We found no changes in total spending in patients within any of the 11 different cancer types examined. Finally, changes in spending and utilization did not meaningfully differ between ACO and non-ACO patients within various categories, including cancer-specific categories. Conclusion Compared with patients with cancer treated at non-ACO practices, being a patient with a cancer diagnosis in a Medicare ACO is not associated with significantly reduced spending or heath care utilization. The introduction of ACOs does not seem to have had any meaningful effect on spending or utilization for patients with a cancer diagnosis.
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Affiliation(s)
- Miranda B. Lam
- Miranda B. Lam, Jose F. Figueroa, Jie Zheng, E. John Orav, and Ashish K. Jha, Harvard T.H. Chan School of Public Health; Miranda B. Lam, Brigham and Women’s Hospital/Dana-Farber Cancer Institute; Jose F. Figueroa and Ashish K. Jha, Brigham and Women’s Hospital; and Miranda B. Lam, Jose F. Figueroa, E. John Orav, and Ashish K. Jha, Harvard Medical School, Boston, MA
| | - Jose F. Figueroa
- Miranda B. Lam, Jose F. Figueroa, Jie Zheng, E. John Orav, and Ashish K. Jha, Harvard T.H. Chan School of Public Health; Miranda B. Lam, Brigham and Women’s Hospital/Dana-Farber Cancer Institute; Jose F. Figueroa and Ashish K. Jha, Brigham and Women’s Hospital; and Miranda B. Lam, Jose F. Figueroa, E. John Orav, and Ashish K. Jha, Harvard Medical School, Boston, MA
| | - Jie Zheng
- Miranda B. Lam, Jose F. Figueroa, Jie Zheng, E. John Orav, and Ashish K. Jha, Harvard T.H. Chan School of Public Health; Miranda B. Lam, Brigham and Women’s Hospital/Dana-Farber Cancer Institute; Jose F. Figueroa and Ashish K. Jha, Brigham and Women’s Hospital; and Miranda B. Lam, Jose F. Figueroa, E. John Orav, and Ashish K. Jha, Harvard Medical School, Boston, MA
| | - E. John Orav
- Miranda B. Lam, Jose F. Figueroa, Jie Zheng, E. John Orav, and Ashish K. Jha, Harvard T.H. Chan School of Public Health; Miranda B. Lam, Brigham and Women’s Hospital/Dana-Farber Cancer Institute; Jose F. Figueroa and Ashish K. Jha, Brigham and Women’s Hospital; and Miranda B. Lam, Jose F. Figueroa, E. John Orav, and Ashish K. Jha, Harvard Medical School, Boston, MA
| | - Ashish K. Jha
- Miranda B. Lam, Jose F. Figueroa, Jie Zheng, E. John Orav, and Ashish K. Jha, Harvard T.H. Chan School of Public Health; Miranda B. Lam, Brigham and Women’s Hospital/Dana-Farber Cancer Institute; Jose F. Figueroa and Ashish K. Jha, Brigham and Women’s Hospital; and Miranda B. Lam, Jose F. Figueroa, E. John Orav, and Ashish K. Jha, Harvard Medical School, Boston, MA
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Berry LL, Deming KA, Danaher TS. Improving Nonclinical and Clinical-Support Services: Lessons From Oncology. Mayo Clin Proc Innov Qual Outcomes 2018; 2:207-217. [PMID: 30225452 PMCID: PMC6132219 DOI: 10.1016/j.mayocpiqo.2018.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 05/03/2018] [Accepted: 05/16/2018] [Indexed: 01/30/2023] Open
Abstract
Nonclinical and clinical-support personnel serve patients on the front lines of care. Their service interactions have a powerful influence on how patients perceive their entire care experience, including the all-important interactions with clinical staff. Ignoring this reality means squandering opportunities to start patients out on the right foot at each care visit. Medical practices can improve the overall care they provide by focusing on nonclinical and clinical-support services in 5 crucial ways: (1) creating strong first impressions at every care visit by prioritizing superb front-desk service; (2) thoroughly vetting prospective hires to ensure that their values and demeanor align with the organization's; (3) preparing hired staff to deliver excellent service with a commitment to ongoing training and education at all staff levels; (4) minimizing needless delays in service delivery that can overburden patients and their families in profound ways; and (5) prioritizing the services that patients consider to be most important. We show how cancer care illustrates these principles, which are relevant across medical contexts. Without nonclinical and clinical-support staff who set the right tone for care at every service touchpoint, even the best clinical services cannot be truly optimal.
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Affiliation(s)
- Leonard L. Berry
- Department of Marketing, Mays Business School, Texas A&M University, College Station, TX
- Institute for Healthcare Improvement, Cambridge, MA
- Correspondence: Address to Leonard L. Berry, PhD, MBA, Department of Marketing, Mays Business School, 4112 TAMU, College Station, TX 77843.
| | - Katie A. Deming
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR
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