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Nyongole O, Sirili N, Frumence G, Simba D, Urassa D, Sunguya B. Provision of prostate cancer services in Tanzania: perspectives from five tertiary hospitals. BMC Health Serv Res 2024; 24:1154. [PMID: 39350208 PMCID: PMC11443861 DOI: 10.1186/s12913-024-11580-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 09/11/2024] [Indexed: 10/04/2024] Open
Abstract
BACKGROUND Access to quality prostate cancer services remains a global challenge, particularly in Low- and Middle-Income countries. This is often due to weak health systems that struggle to meet the population's needs. The provision of quality health services to patients with prostate cancer requires a comprehensive approach involving multiple stakeholders and structural inputs. However, few studies have comprehensively assessed the relationship between these structural inputs and prostate cancer treatment outcomes. This study, therefore, aimed to determine the availability of selected structural inputs and descriptions of how they influence the provision of quality services to patients with prostate cancer in Tanzania. METHODS We conducted a cross-sectional study using an explanatory sequential mixed-method approach to collect data from five tertiary hospitals providing cancer services in Tanzania. A validated checklist was used to collect information on available structural inputs for prostate services at tertiary hospitals. A semi-structured interview guide was used to conduct 42 in-depth interviews with 20 healthcare providers, five hospital managers, and 17 patients undergoing treatment for prostate cancer. Descriptive analysis was performed for the quantitative data, and thematic analysis was conducted with the aid of NVivo 14 qualitative software for the interview transcripts. RESULTS All five assessed tertiary hospitals had inadequate human resources for health to provide prostate cancer services. Only one had 70% of the required HRH, while none had above 40% of the required HRH. Within the hospitals, the skill mix imbalance was severe across cadres. Five themes emerged: inadequate infrastructure, delays in diagnosis, delays in treatment, shortage of human resources for health (HRH), and inefficient organization of prostate cancer services. CONCLUSION The findings of this study, underscore the major health system deficiencies for the provision of prostate cancer services in tertiary hospitals. With the increased aging population, strong health systems are vital in addressing conditions of old aging, including prostate cancers. Studies on optimization of the available HRH and infrastructure are needed to improve the provision of prostate cancer in tertiary hospitals as an interim solution while long-term measures are needed for improving the HRH availability and conducive infrastructure.
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Affiliation(s)
- Obadia Nyongole
- Department of Surgery, Muhimbili University of Health and Allied Sciences, 9 United Nations Road, Upanga West 11103, Dar es salaam, Tanzania.
- Department of Community Health, Muhimbili University of Health and Allied Sciences, 9 United Nations Road, Upanga West 11103, Dar es salaam, Tanzania.
| | - Nathanael Sirili
- Department of Development Studies, Muhimbili University of Health and Allied Sciences, 9 United Nations Road, Upanga West 11103, Dar es salaam, Tanzania
| | - Gasto Frumence
- Department of Development Studies, Muhimbili University of Health and Allied Sciences, 9 United Nations Road, Upanga West 11103, Dar es salaam, Tanzania
| | - Daudi Simba
- Department of Community Health, Muhimbili University of Health and Allied Sciences, 9 United Nations Road, Upanga West 11103, Dar es salaam, Tanzania
| | - David Urassa
- Department of Community Health, Muhimbili University of Health and Allied Sciences, 9 United Nations Road, Upanga West 11103, Dar es salaam, Tanzania
| | - Bruno Sunguya
- Department of Community Health, Muhimbili University of Health and Allied Sciences, 9 United Nations Road, Upanga West 11103, Dar es salaam, Tanzania
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Amu-Nnadi CN, Ross ES, Garcia NH, Duncan ZN, Correya TA, Montgomery KB, Broman KK. Health System Integration and Cancer Center Access for Rural Hospitals. Am Surg 2024; 90:1023-1029. [PMID: 38073251 PMCID: PMC10984769 DOI: 10.1177/00031348231216497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
BACKGROUND Cancer centers provide superior care but are less accessible to rural populations. Health systems that integrate a cancer center may provide broader access to quality surgical care, but penetration to rural hospitals is unknown. METHODS Cancer center data were linked to health system data to describe health systems based on whether they included at least one accredited cancer center. Health systems with and without cancer centers were compared based on rural hospital presence. Bivariate tests and multivariable logistic regression were used with results reported as P-values and odds ratios (OR) with 95% confidence intervals (CIs). RESULTS Ninety percent of cancer centers are in a health system, and 72% of health systems (434/607) have a cancer center. Larger health systems (P = .03) with more trainees (P = .03) more often have cancer centers but are no more likely to include rural hospitals (11% vs 6%, P = .43; adjusted OR .69, 95% CI .28-1.70). The minority of cancer centers not in health systems (N = 95) more often serve low complexity patient populations (P = .02) in non-metropolitan areas (P = .03). DISCUSSION Health systems with rural hospitals are no more likely to have a cancer center. Ongoing health system integration will not necessarily expand rural patients' access to surgical care under existing health policy infrastructure and incentives.
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Affiliation(s)
| | - Elizabeth S. Ross
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Natalie H. Garcia
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Zoey N. Duncan
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Tanya A. Correya
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Kristy K. Broman
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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Maganty A, Kaufman SR, Oerline MK, Faraj K, Caram ME, Shahinian VB, Hollenbeck BK. Association Between Urologist Merit-Based Incentive Payment System Performance and Quality of Prostate Cancer Care. UROLOGY PRACTICE 2024; 11:207-214. [PMID: 37748132 PMCID: PMC10842494 DOI: 10.1097/upj.0000000000000463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/12/2023] [Indexed: 09/27/2023]
Abstract
INTRODUCTION We performed a study to evaluate the association between urologist performance in the Merit-Based Incentive Payment System (MIPS), and quality and spending for prostate cancer care. METHODS Medicare beneficiaries with prostate cancer diagnosed between 2017 and 2019 were assigned to their primary urologist. Associated MIPS scores were identified and categorized based on thresholds for payment adjustment as low (worst), moderate, and high (best). Multivariable mixed effects models were used to measure the association between MIPS performance and adherence to quality measures and price standardized spending for prostate cancer. RESULTS Adherence to quality measures did not vary across MIPS performance groups for pretreatment counselling by both a urologist and radiation oncologist (low-76%, [95% CI 73%-80%], moderate-77% [95% CI 74%-79%], and high-75% [95% CI 74%-76%]) and avoiding treatment in men with a high risk of noncancer mortality within 10 years of diagnosis (low-40% [95% CI 35%-45%], moderate-39% [95% CI 36%-43%], high-38% [95% CI 36%-39%]). Men on active surveillance managed by high performers more likely received a confirmatory test (44% [95% CI 43%-46%]) compared to those managed by moderate (38% [95% CI 33%-42%]) performers, but not low performers (36% [95% CI 29%-44%]). There was no difference in adjusted spending across MIPS performance groups. CONCLUSIONS Better performance in MIPS is associated with a higher rate of confirmatory testing in men initiating active surveillance for prostate cancer. However, performance was not associated with other dimensions of quality nor spending.
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Affiliation(s)
- Avinash Maganty
- University of Michigan, Department of Urology, Division of Health Services Research
| | - Samuel R. Kaufman
- University of Michigan, Department of Urology, Division of Health Services Research
| | - Mary K. Oerline
- University of Michigan, Department of Urology, Division of Health Services Research
| | - Kassem Faraj
- University of Michigan, Department of Urology, Division of Health Services Research
| | - Megan E.V. Caram
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Vahakn B. Shahinian
- University of Michigan, Department of Urology, Division of Health Services Research
- Division of Nephrology, Department of Internal Medicine, University of Michigan
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Hu X, Lipscomb J, Jiang C, Graetz I. Vertical integration of oncologists and cancer outcomes and costs in metastatic castration-resistant prostate cancer. J Natl Cancer Inst 2023; 115:268-278. [PMID: 36583540 PMCID: PMC9996219 DOI: 10.1093/jnci/djac233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 10/13/2022] [Accepted: 11/29/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The share of oncology practices owned by hospitals (ie, vertically integrated) nearly doubled from 2007 to 2017. We examined how integration between hospitals and oncologists affected care quality, outcomes, and spending among metastatic castration-resistant prostate cancer (mCRPC) patients. METHODS Using Surveillance, Epidemiology, and End Results-Medicare linked data and the Medicare Data on Provider Practice and Specialty, we identified Medicare beneficiaries who initiated systemic therapy for mCRPC between 2008 and 2017 (n = 9172). Primary outcomes included 1) bone-modifying agents (BMA) use, 2) time on systemic therapy, 3) survival, and 4) Medicare spending for the first 3 months following therapy initiation. We used a differences-in-differences approach to estimate the impact of vertical integration on outcomes, adjusting for patient and provider characteristics. RESULTS The proportion of patients treated by integrated oncologists increased from 28% to 55% from 2008 to 2017. Vertical integration was associated with an 11.7 percentage point (95% confidence interval [CI] = 4.2 to 19.1) increased likelihood of BMA use. There were no satistically significant changes in time on systemic therapy, survival, or total per-patient Medicare spending. Further decomposition showed an increase in outpatient payment ($5190, 95% CI = $1451 to $8930) and decrease in professional service payment (-$4757, 95% CI = -$7644 to -$1870) but no statistically significant changes for other service types (eg, inpatient and prescription drugs). CONCLUSIONS Vertical integration was associated with statistically significant increased BMA use but not with other cancer outcomes among mCRPC patients. For oncologists who switched service billing from physician offices to outpatient departments, there was no statistically significant change in overall Medicare spending in the first 3 months of therapy initiation. Future studies should extend the investigation to other cancer types and patient outcomes.
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Affiliation(s)
- Xin Hu
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Joseph Lipscomb
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Changchuan Jiang
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Ilana Graetz
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Amado GC, Ferreira DC, Nunes AM. Vertical integration in healthcare: What does literature say about improvements on quality, access, efficiency, and costs containment? Int J Health Plann Manage 2022; 37:1252-1298. [PMID: 34981855 DOI: 10.1002/hpm.3407] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 06/27/2021] [Accepted: 12/09/2021] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION Vertical integration models involve integrating services from different levels of care (e.g., primary care, acute care, post-acute care). Therefore, one of their main objectives is to increase continuity of care, potentially improving outcomes like efficiency, quality, and access or even enabling cost containment. OBJECTIVES This study conducts a literature review and aims at contributing to the contentious discussion regarding the effects of vertical integration reforms in terms of efficiency, costs containment, quality, and access. METHODS We performed a systematic search of the literature published until February 2020. The articles respecting the conceptual framework were included in an exhaustive analysis to study the impact of vertical integration on costs, prices of care, efficiency, quality, and access. RESULTS A sample of 64 papers resulted from the screening process. The impact of vertical integration on costs and prices of care appears to be negative. Decreases in technical efficiency upon vertical integration are practically out of the question. Nevertheless, there is no substantial inclination to visualise a positive influence. The same happens with the quality of care. Regarding access, the lack of available articles on this outcome limits conjectures. CONCLUSIONS In summary, it is not clear yet whether vertically integrated healthcare providers positively impact the overall delivery care system. Nevertheless, the recent growing trend in the number of studies suggests a promising future on the analysis of this topic.
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Affiliation(s)
- Guilherme C Amado
- Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal
| | - Diogo C Ferreira
- CERIS, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal
| | - Alexandre M Nunes
- Instituto Superior de Ciências Sociais e Políticas, Universidade de Lisboa, Lisbon, Portugal
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Reitblat C, Bain PA, Porter ME, Bernstein DN, Feeley TW, Graefen M, Iyer S, Resnick MJ, Stimson CJ, Trinh QD, Gershman B. Value-Based Healthcare in Urology: A Collaborative Review. Eur Urol 2021; 79:571-585. [PMID: 33413970 DOI: 10.1016/j.eururo.2020.12.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 12/02/2020] [Indexed: 11/15/2022]
Abstract
CONTEXT In response to growing concerns over rising costs and major variation in quality, improving value for patients has been proposed as a fundamentally new strategy for how healthcare should be delivered, measured, and remunerated. OBJECTIVE To systematically review the literature regarding the implementation and impact of value-based healthcare in urology. EVIDENCE ACQUISITION A systematic review was performed to identify studies that described the implementation of one or more elements of value-based healthcare in urologic settings and in which the associated change in healthcare value had been measured. Twenty-two publications were selected for inclusion. EVIDENCE SYNTHESIS Reorganization of urologic care around medical conditions was associated with increased use of guidelines-compliant care for men with prostate cancer, and improved outcomes for patients with lower urinary tract symptoms. Measuring outcomes for every patient was associated with improved prostate cancer outcomes, while the measurement of costs using time-driven activity-based costing was associated with reduced resource utilization in a pediatric multidisciplinary clinic. Centralization of urologic cancer care in the UK, Denmark, and Canada was associated with overall improved outcomes, although systems integration in the USA yielded mixed results among urologic cancer patients. No studies have yet examined bundled payments for episodes of care, expanding the geographic reach for centers of excellence, or building enabling information technology platforms. CONCLUSIONS Few studies have critically assessed the actual or simulated implementation of value-based healthcare in urology, but the available literature suggests promising early results. In order to effectively redesign care, there is a need for further research to both evaluate the potential results of proposed value-based healthcare interventions and measure their effects where already implemented. PATIENT SUMMARY While few studies have evaluated the implementation of value-based healthcare in urology, the available literature suggests promising early results.
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Affiliation(s)
- Chanan Reitblat
- Division of Urologic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Harvard Business School, Boston, MA, USA
| | - Paul A Bain
- Countway Library, Harvard Medical School, Boston, MA, USA
| | - Michael E Porter
- Harvard Business School, Boston, MA, USA; Institute for Strategy and Competitiveness, Harvard Business School, Boston, MA, USA
| | - David N Bernstein
- Institute for Strategy and Competitiveness, Harvard Business School, Boston, MA, USA; Harvard Combined Orthopedic Residency Program (HCORP), Massachusetts General Hospital, Boston, MA, USA
| | - Thomas W Feeley
- Harvard Business School, Boston, MA, USA; Institute for Strategy and Competitiveness, Harvard Business School, Boston, MA, USA
| | - Markus Graefen
- Martini-Klinik, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | | | - Matthew J Resnick
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN, USA; Embold Health, Nashville, TN, USA
| | - C J Stimson
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Quoc-Dien Trinh
- Harvard Medical School, Boston, MA, USA; Division of Urology, Brigham and Women's Hospital, Boston, MA, USA
| | - Boris Gershman
- Division of Urologic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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A systematic review of vertical integration and quality of care, efficiency, and patient-centered outcomes. Health Care Manage Rev 2020; 44:159-173. [PMID: 29613860 DOI: 10.1097/hmr.0000000000000197] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Small independent practices are increasingly giving way to more complex affiliations between provider organizations and hospital systems. There are several ways in which vertically integrated health systems could improve quality and lower the costs of care. But there are also concerns that integrated systems may increase the price and costs of care without commensurate improvements in quality and outcomes. PURPOSE Despite a growing body of research on vertically integrated health systems, no systematic review that we know of compares vertically integrated health systems (defined as shared ownership or joint management of hospitals and physician practices) to nonintegrated hospitals or physician practices. METHODS We conducted a systematic search of the literature published from January 1996 to November 2016. We considered articles for review if they compared the performance of a vertically integrated health system and examined an outcome related to quality of care, efficiency, or patient-centered outcomes. RESULTS Database searches generated 7,559 articles, with 29 articles included in this review. Vertical integration was associated with better quality, often measured as optimal care for specific conditions, but showed either no differences or lower efficiency as measured by utilization, spending, and prices. Few studies evaluated a patient-centered outcome; among those, most examined mortality and did not identify any effects. Across domains, most studies were observational and did not address the issue of selection bias. PRACTICE IMPLICATIONS Recent evidence suggests the trend toward vertical integration will likely continue as providers respond to changing payment models and market factors. A growing body of research on comparative health system performance suggests that integration of physician practices with hospitals might not be enough to achieve higher-value care. More information is needed to identify the health system attributes that contribute to improved outcomes, as well as which policy levers can minimize anticompetitive effects and maximize the benefits of these affiliations.
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Herrel LA, Zhu Z, Griggs JJ, Kaye DR, Dupree JM, Ellimoottil CS, Miller DC. Association Between Delivery System Structure and Intensity of End-of-Life Cancer Care. JCO Oncol Pract 2020; 16:e590-e600. [PMID: 32069191 DOI: 10.1200/jop.19.00667] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To determine whether the type of delivery system is associated with intensity of care at the end of life for Medicare beneficiaries with cancer. PATIENTS AND METHODS We used SEER registry data linked with Medicare claims to evaluate intensity of end-of-life care for patients who died of one of ten common cancers diagnosed from 2009 through 2014. Patients were categorized as receiving the majority of their care in an integrated delivery system, designated cancer center, health system that was both integrated and a certified cancer center, or health system that was neither. We evaluated adherence to seven nationally endorsed end-of-life quality measures using generalized linear models across four delivery system types. RESULTS Among 100,549 beneficiaries who died of cancer during the study interval, we identified only modest differences in intensity of end-of-life care across delivery system structures. Health systems with no cancer center or integrated affiliation demonstrated higher proportions of patients with multiple hospitalizations in the last 30 days of life (11.3%), death in an acute care setting (25.9%), and lack of hospice use in the last year of life (31.6%; all P < .001). Patients enrolled in hospice had lower intensity care across multiple end-of-life quality measures. CONCLUSION Intensity of care at the end of life for patients with cancer was higher at delivery systems with no integration or cancer focus. Maximal supportive care delivered through hospice may be one avenue to reduce high-intensity care at the end of life and may impact quality of care for patients dying from cancer.
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Affiliation(s)
- Lindsey A Herrel
- The University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI
| | - Ziwei Zhu
- The University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI
| | - Jennifer J Griggs
- The University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI
| | - Deborah R Kaye
- The University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI
| | - James M Dupree
- The University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI
| | - Chandy S Ellimoottil
- The University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI
| | - David C Miller
- The University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI
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Moving from Care Coordination to Care Integration. J Gen Intern Med 2019; 34:1906-1909. [PMID: 31140096 PMCID: PMC6712191 DOI: 10.1007/s11606-019-05029-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 02/05/2019] [Accepted: 03/28/2019] [Indexed: 02/07/2023]
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10
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Contemporary Management of Incident Prostate Cancer in Large Community Urology Practices in the United States. Urology 2019; 129:79-86. [DOI: 10.1016/j.urology.2019.01.061] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 01/08/2019] [Accepted: 01/31/2019] [Indexed: 01/17/2023]
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Utilization of Prostate Cancer Quality Metrics for Research and Quality Improvement: A Structured Review. Jt Comm J Qual Patient Saf 2018; 45:217-226. [PMID: 30236510 DOI: 10.1016/j.jcjq.2018.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 06/21/2018] [Accepted: 06/26/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The shift toward value-based care in the United States emphasizes the role of quality measures in payment models. Many diseases, such as prostate cancer, have a proliferation of quality measures, resulting in resource burden and physician burnout. This study aimed to identify and summarize proposed prostate cancer quality measures and describe their frequency and use in peer-reviewed literature. METHODS The PubMed database was used to identify quality measures relevant to prostate cancer care, and included articles in English through April 2018. A gray literature search for other documents was also conducted. After the selection process of the pertinent articles, measure characteristics were abstracted, and uses were summarized for the 10 most frequently utilized measures in the literature. RESULTS A total of 26 articles were identified for review. Of the 71 proposed prostate cancer quality measures, only 47 were used, and less than 10% of these were endorsed by the National Quality Forum. Process measures were most frequently reported (84.5%). Only 6 outcome measures (8.5%) were proposed-none of which were among the most frequently utilized. CONCLUSION Although a high number of proposed prostate cancer quality measures are reported in the literature, few were assessed, and the majority of these were non-endorsed process measures. Process measures were most commonly assessed; outcome measures were rarely evaluated. In a step to close the quality chasm, a "top 5" core set of quality measures for prostate cancer care, including structure, process, and outcomes measures, is suggested. Future studies should consider this comprehensive set of quality measures.
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Glaser SM, Kalash R, Bongiorni DR, Roberts MS, Balasubramani GK, Jacobs BL, Beriwal S, Heron DE, Greenberger JS. Challenges in the Analysis of Outcomes for Surgical Compared to Radiotherapy Treatment of Prostate Cancer. In Vivo 2018; 32:113-120. [PMID: 29275307 PMCID: PMC5892645 DOI: 10.21873/invivo.11212] [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: 10/10/2017] [Revised: 11/19/2017] [Accepted: 11/29/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Prostate cancer can be treated with radical prostatectomy (RP), external-beam radiotherapy (EBRT), or brachytherapy (BT). These modalities have similar cancer-related outcomes. We used an innovative method to analyze the cost of such treatment. MATERIALS AND METHODS We queried our Institution's Insurance Division [University of Pittsburgh Medical Center (UPMC) Health Plan] beneficiaries from 2003-2008, who were diagnosed with prostate cancer and also queried the UPMC tumor registry for all patients with prostate cancer treated at our Institution. In a de-identified manner, data from the Health Plan and Tumor Registry were merged. RESULTS A total of 354 patients with non-metastatic disease with treatment initiated within 9 months of diagnosis were included (RP=236, EBRT=55, and BT=63). Radiotherapy-treated patients tended to be older, higher-risk, and have more comorbidities. Unadjusted median total health care expenditures during the first year after diagnosis were: RP: $16,743, EBRT: $47,256, and BT: $23,237 (p<0.0005). A propensity score-matched model comparing RP and EBRT demonstrated median total health care expenditures during year one: RP: $8,189, EBRT: $10,081; p=0.48. In a propensity-matched model comparing RP and BT, the median total health care expenditures during year one were: RP: $18,143, BT: $26,531; p=0.015 and per year during years 2 through 5 from diagnosis were: RP: $5,913, BT: $6,110; p=0.68. CONCLUSION This pilot study demonstrates the feasibility of combining healthcare costs from the payer's perspective with clinical data from a Tumor Registry within an IDFS and represents a novel approach to investigating the economic impact of cancer treatment.
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Affiliation(s)
- Scott M Glaser
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, U.S.A
| | - Ronny Kalash
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, U.S.A
| | - Dante R Bongiorni
- Department of Health Policy and Management, School of Public Health, University of Pittsburgh, Pittsburgh, PA, U.S.A
| | - Mark S Roberts
- Department of Health Policy and Management, School of Public Health, University of Pittsburgh, Pittsburgh, PA, U.S.A
| | - Goundappa K Balasubramani
- Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, PA, U.S.A
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA, U.S.A
| | - Sushil Beriwal
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, U.S.A
| | - Dwight E Heron
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, U.S.A
| | - Joel S Greenberger
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, U.S.A.
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Li J, Ye Z, Dupree JM, Hollenbeck BK, Min HS, Kaye D, Herrel LA, Miller DC, Ellimoottil C. Association of Delivery System Integration and Outcomes for Major Cancer Surgery. Ann Surg Oncol 2017; 25:856-863. [PMID: 29285642 DOI: 10.1245/s10434-017-6312-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Indexed: 01/17/2023]
Abstract
BACKGROUND Integrated delivery systems (IDSs) are postulated to reduce spending and improve outcomes through successful coordination of care across multiple providers. Nonetheless, the actual impact of IDSs on outcomes for complex multidisciplinary care such as major cancer surgery is largely unknown. METHODS Using 2011-2013 Medicare data, this study identified patients who underwent surgical resection for prostate, bladder, esophageal, pancreatic, lung, liver, kidney, colorectal, or ovarian cancer. Rates of readmission, 30-day mortality, surgical complications, failure to rescue, and prolonged hospital stay for cancer surgery were compared between patients receiving care at IDS hospitals and those receiving care at non-IDS hospitals. Generalized estimating equations were used to adjust results by cancer type and patient- and hospital-level characteristics while accounting for clustering of patients within hospitals. RESULTS The study identified 380,053 patients who underwent major resection of cancer, with 38% receiving care at an IDS. Outcomes did not differ between IDS and non-IDS hospitals regarding readmission and surgical complication rates, whereas only minor differences were observed for 30-day mortality (3.5% vs 3.2% for IDS; p < 0.001) and prolonged hospital stay (9.9% vs 9.2% for IDS; p < 0.001). However, after adjustment for patient and hospital characteristics, the frequencies of adverse perioperative outcomes were not significantly associated with IDS status. CONCLUSIONS The collective findings suggest that local delivery system integration alone does not necessarily have an impact on perioperative outcomes in surgical oncology. Moving forward, stakeholders may need to focus on surgical and oncology-specific methods of care coordination and quality improvement initiatives to improve outcomes for patients undergoing cancer surgery.
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Affiliation(s)
- Jonathan Li
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Zaojun Ye
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - James M Dupree
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Brent K Hollenbeck
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Hye Sung Min
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Deborah Kaye
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Lindsey A Herrel
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - David C Miller
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Chad Ellimoottil
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA. .,Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI, USA.
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14
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Evans SM, Millar JL, Moore CM, Lewis JD, Huland H, Sampurno F, Connor SE, Villanti P, Litwin MS. Cohort profile: the TrueNTH Global Registry - an international registry to monitor and improve localised prostate cancer health outcomes. BMJ Open 2017; 7:e017006. [PMID: 29183925 PMCID: PMC5719323 DOI: 10.1136/bmjopen-2017-017006] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
PURPOSE Globally, prostate cancer treatment and outcomes for men vary according to where they live, their race and the care they receive. The TrueNTH Global Registry project was established as an international registry monitoring care provided to men with localised prostate cancer (CaP). PARTICIPANTS Sites with existing CaP databases in Movember fundraising countries were invited to participate in the international registry. In total, 25 Local Data Centres (LDCs) representing 113 participating sites across 13 countries have nominated to contribute to the project. It will collect a dataset based on the International Consortium for Health Outcome Measures (ICHOM) standardised dataset for localised CaP. FINDINGS TO DATE A governance strategy has been developed to oversee registry operation, including transmission of reversibly anonymised data. LDCs are represented on the Project Steering Committee, reporting to an Executive Committee. A Project Coordination Centre and Data Coordination Centre (DCC) have been established. A project was undertaken to compare existing datasets, understand capacity at project commencement (baseline) to collect the ICHOM dataset and assist in determining the final data dictionary. 21/25 LDCs provided data dictionaries for review. Some ICHOM data fields were well collected (diagnosis, treatment start dates) and others poorly collected (complications, comorbidities). 17/94 (18%) ICHOM data fields were relegated to non-mandatory fields due to poor capture by most existing registries. Participating sites will transmit data through a web interface biannually to the DCC. FUTURE PLANS Recruitment to the TrueNTH Global Registry-PCOR project will commence in late 2017 with sites progressively contributing reversibly anonymised data following ethical review in local regions. Researchers will have capacity to source deidentified data after the establishment phase. Quality indicators are to be established through a modified Delphi approach in later 2017, and it is anticipated that reports on performance against quality indicators will be provided to LDCs.
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Affiliation(s)
- Sue M Evans
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jeremy L Millar
- William Buckland Radiotherapy Centre, Alfred Hospital, Melbourne, Victoria, Australia
| | - Caroline M Moore
- Department of Urology, Division of Surgical and Interventional Science, University College London, London, UK
| | - John D Lewis
- Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Hartwig Huland
- Universitatsklinikum Hamburg-Eppendorf, Hamburg, Hamburg, Germany
| | - Fanny Sampurno
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Sarah E Connor
- Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, USA
| | - Paul Villanti
- Movember Foundation, East Melbourne, Victoria, Australia
| | - Mark S Litwin
- Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, USA
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15
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Mutemwa R, Mayhew SH, Warren CE, Abuya T, Ndwiga C, Kivunaga J. Does service integration improve technical quality of care in low-resource settings? An evaluation of a model integrating HIV care into family planning services in Kenya. Health Policy Plan 2017; 32:iv91-iv101. [PMID: 29194543 PMCID: PMC5886058 DOI: 10.1093/heapol/czx090] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2017] [Indexed: 12/29/2022] Open
Abstract
The aim of this study was to investigate association between HIV and family planning integration and technical quality of care. The study focused on technical quality of client-provider consultation sessions. The cross-sectional study observed 366 client-provider consultation sessions and interviewed 37 health care providers in 12 public health facilities in Kenya. Multilevel random intercept and linear regression models were fitted to the matched data to investigate relationships between service integration and technical quality of care as well as associations between facility-level structural and provider factors and technical quality of care. A sensitivity analysis was performed to test for hidden bias. After adjusting for facility-level structural factors, HIV/family planning integration was found to have significant positive effect on technical quality of the consultation session, with average treatment effect 0.44 (95% CI: 0.63-0.82). Three of the 12 structural factors were significantly positively associated with technical quality of consultation session including: availability of family planning commodities (9.64; 95% CI: 5.07-14.21), adequate infrastructure (5.29; 95% CI: 2.89-7.69) and reagents (1.48; 95% CI: 1.02-1.93). Three of the nine provider factors were significantly positively associated with technical quality of consultation session: appropriate provider clinical knowledge (3.14; 95% CI: 1.92-4.36), job satisfaction (2.02; 95% CI: 1.21-2.83) and supervision (1.01; 95% CI: 0.35-1.68), while workload (-0.88; 95% CI: -1.75 to - 0.01) was negatively associated. Technical quality of the client-provider consultation session was also determined by duration of the consultation and type of clinic visit and appeared to depend on whether the clinic visit occurred early or later in the week. Integration of HIV care into family planning services can improve the technical quality of client-provider consultation sessions as measured by both health facility structural and provider factors.
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Affiliation(s)
- Richard Mutemwa
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Susannah H Mayhew
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Charlotte E Warren
- Population Council, 4301 Connecticut Avenue NW, Suite 280 Washington, DC 20008 United States
| | - Timothy Abuya
- Population Council, Ralph Bunche Rd, Upper Hill, Nairobi, Kenya
| | - Charity Ndwiga
- Population Council, Ralph Bunche Rd, Upper Hill, Nairobi, Kenya
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16
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Borza T, Kaufman SR, Yan P, Herrel LA, Luckenbaugh AN, Miller DC, Skolarus TA, Jacobs BL, Hollingsworth JM, Norton EC, Shahinian VB, Hollenbeck BK. Early effect of Medicare Shared Savings Program accountable care organization participation on prostate cancer care. Cancer 2017; 124:563-570. [PMID: 29053177 DOI: 10.1002/cncr.31081] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 09/18/2017] [Accepted: 09/20/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Accountable care organizations (ACOs) can improve prostate cancer care by decreasing treatment variations (ie, avoidance of treatment in low-value settings). Herein, the authors performed a study to understand the effect of Medicare Shared Savings Program ACOs on prostate cancer care. METHODS Using a 20% Medicare sample, the authors identified men with newly diagnosed prostate cancer from 2010 through 2013. Rates of treatment, potential overtreatment (ie, treatment in men with a ≥75% chance of 10-year mortality from competing risks), and Medicare payments were measured using regression models. The impact of ACO participation was assessed using difference-in-differences analyses. RESULTS Before implementation of ACOs, the treatment rate was 71.8% (95% confidence interval [95% CI], 70.2%-73.3%) for ACO-aligned beneficiaries and 72.3% (95% CI, 71.7%-73.0% [P = .51]) for non-ACO-aligned beneficiaries. After implementation, this rate declined to 68.4% (95% CI, 66.1%-70.7% [P = .017]) for ACO-aligned beneficiaries and 69.3% (95% CI, 68.5%-70.1% [P<.001]) for non-ACO-aligned beneficiaries. There was no differential effect noted for ACO participation. The rate of potential overtreatment decreased from 48.2% (95% CI, 43.1%-53.3%) to 40.2% (95% CI, 32.4%-48.0% [P = .087]) for ACO-aligned beneficiaries and increased from 44.3% (95% CI, 42.1%-46.5%) to 47.0% (95% CI, 44.5%-49.5% [P = .11]) for non-ACO-aligned beneficiaries. These changes resulted in a significant relative decrease in overtreatment of 17% for ACO-aligned beneficiaries (difference-in-differences, 10.8%; P = .031). Payments were not found to be differentially affected by ACO alignment. CONCLUSIONS The treatment of prostate cancer and annual payments decreased significantly between 2010 and 2013, but ACO participation did not appear to impact these trends. Among men least likely to benefit, Medicare Shared Savings Program ACO alignment was associated with a significant decline in prostate cancer treatment. Cancer 2018;124:563-70. © 2017 American Cancer Society.
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Affiliation(s)
- Tudor Borza
- Division of Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan.,Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Samuel R Kaufman
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Phyllis Yan
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Lindsey A Herrel
- Division of Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan.,Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Amy N Luckenbaugh
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - David C Miller
- Division of Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan.,Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Ted A Skolarus
- Division of Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan.,Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan.,Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John M Hollingsworth
- Division of Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan.,Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Edward C Norton
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan.,Department of Economics, University of Michigan, Ann Arbor, Michigan.,National Bureau of Economic Research, Cambridge, Massachusetts
| | - Vahakn B Shahinian
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Brent K Hollenbeck
- Division of Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan.,Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
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