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Frimpong JA, Guerrero EG, Kong Y, Khachikian T, Wang S, D'Aunno T, Howard DL. Predicting and responding to change: Perceived environmental uncertainty among substance use disorder treatment programs. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 145:208947. [PMID: 36880916 DOI: 10.1016/j.josat.2022.208947] [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: 06/24/2022] [Revised: 10/03/2022] [Accepted: 11/29/2022] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Substance use disorder (SUD) treatment programs offering addiction health services (AHS) must be prepared to adapt to change in their operating environment. These environmental uncertainties may have implications for service delivery, and ultimately patient outcomes. To adapt to a multitude of environmental uncertainties, treatment programs must be prepared to predict and respond to change. Yet, research on treatment programs preparedness for change is sparse. We examined reported difficulties in predicting and responding to changes in the AHS system, and factors associated with these outcomes. METHODS Cross-sectional surveys of SUD treatment programs in the United States in 2014 and 2017. We used linear and ordered logistic regression to examine associations between key independent variables (e.g., program, staff, and client characteristics) and four outcomes, (1) reported difficulties in predicting change, (2) predicting effect of change on organization, (3) responding to change, and (4) predicting changes to make to respond to environmental uncertainties. Data were collected through telephone surveys. RESULTS The proportion of SUD treatment programs reporting difficulty predicting and responding to changes in the AHS system decreased from 2014 to 2017. However, a considerable proportion still reported difficulty in 2017. We identified that different organizational characteristics are associated with their reported ability to predict or respond to environmental uncertainty. Findings show that predicting change is significantly associated with program characteristics only, while predicting effect of change on organizations is associated with program and staff characteristics. Deciding how to respond to change is associated with program, staff, and client characteristics, while predicting changes to make to respond is associated with staff characteristics only. CONCLUSIONS Although treatment programs reported decreased difficulty predicting and responding to changes, our findings identify program characteristics and attributes that could better position programs with the foresight to more effectively predict and respond to uncertainties. Given resource constraints at multiple levels in treatment programs, this knowledge might help identify and optimize aspects of programs to intervene upon to enhance their adaptability to change. These efforts may positively influences processes or care delivery, and ultimately translate into improvements in patient outcomes.
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Affiliation(s)
| | - Erick G Guerrero
- Research to End Healthcare Disparities Corp., United States of America
| | - Yinfei Kong
- California State University, Fullerton, United States of America.
| | | | - Suojin Wang
- Texas A&M University, United States of America.
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Holloway K, Miller FA. The Consultant's intermediary role in the regulation of molecular diagnostics in the US. Soc Sci Med 2022; 304:112929. [PMID: 32201019 DOI: 10.1016/j.socscimed.2020.112929] [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: 08/31/2018] [Revised: 02/28/2020] [Accepted: 03/12/2020] [Indexed: 11/17/2022]
Abstract
Molecular diagnostics are fast becoming a big business, with the promise of personalized medicine fueling the growth of "blockbuster" tests with high expectations for health system impact and commercial success. We investigate the polycentric regulatory regime for molecular diagnostics in the US, drawing attention to the prominent role of coverage and reimbursement systems in setting regulatory standards for this industry. We hone in on the private consultants who assist molecular diagnostics companies to gain broad clinical uptake of their products. Through a web-based search of consulting companies, analysis of their online materials, and 13 qualitative interviews with consultants, we describe the role of these actors in the coverage and reimbursement of novel diagnostics and highlight the production of evidence as a critical part of the process. We argue that consultants operate as regulatory intermediaries, helping to develop the evidentiary standards for payment decisions that ultimately benefit their clients, the manufacturers. We suggest that public policy discussions over how best to realize the promise of personalized medicine should be re-oriented to consider whose interests are represented in the regulatory regime governing access to these technologies.
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Kokko P. Improving the value of healthcare systems using the Triple Aim framework: A systematic literature review. Health Policy 2022; 126:302-309. [DOI: 10.1016/j.healthpol.2022.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 02/11/2022] [Accepted: 02/16/2022] [Indexed: 12/30/2022]
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US private payers' perspectives on insurance coverage for genome sequencing versus exome sequencing: A study by the Clinical Sequencing Evidence-Generating Research Consortium (CSER). Genet Med 2021; 24:238-244. [PMID: 34906461 DOI: 10.1016/j.gim.2021.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 07/12/2021] [Accepted: 08/13/2021] [Indexed: 11/22/2022] Open
Abstract
PURPOSE There is limited payer coverage for genome sequencing (GS) relative to exome sequencing (ES) in the U.S. Our objective was to assess payers' considerations for coverage of GS versus coverage of ES and requirements payers have for coverage of GS. The study was conducted by the NIH-funded Clinical Sequencing Evidence-Generating Research Consortium (CSER). METHODS We conducted semi-structured interviews with representatives of private payer organizations (payers, N = 12) on considerations and evidentiary and other needs for coverage of GS and ES. Data were analyzed using thematic analysis. RESULTS We described four categories of findings and solutions: demonstrated merits of GS versus ES, enhanced methods for evidence generation, consistent laboratory processes/sequencing methods, and enhanced implementation/care delivery. Payers see advantages to GS vs. ES and are open to broader GS coverage but need more proof of these advantages to consider them in coverage decision-making. Next steps include establishing evidence of benefits in specific clinical scenarios, developing quality standards, ensuring transparency of laboratory methods, developing clinical centers of excellence, and incorporating the role of genetic professionals. CONCLUSION By comparing coverage considerations for GS and ES, we identified a path forward for coverage of GS. Future research should explicitly address payers' conditions for coverage.
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Zhao M, Hamadi H, Haley DR, Xu J, White-Williams C, Park S. Telehealth: Advances in Alternative Payment Models. Telemed J E Health 2020; 26:1492-1499. [DOI: 10.1089/tmj.2019.0294] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Mei Zhao
- Department of Health Administration, Brooks College of Health, University of North Florida, Jacksonville, Florida, USA
| | - Hanadi Hamadi
- Department of Health Administration, Brooks College of Health, University of North Florida, Jacksonville, Florida, USA
| | - D. Rob Haley
- Department of Health Administration, Brooks College of Health, University of North Florida, Jacksonville, Florida, USA
| | - Jing Xu
- Department of Health Administration, Brooks College of Health, University of North Florida, Jacksonville, Florida, USA
| | - Cynthia White-Williams
- Department of Health Administration, Brooks College of Health, University of North Florida, Jacksonville, Florida, USA
| | - Sinyoung Park
- Department of Health Administration, Brooks College of Health, University of North Florida, Jacksonville, Florida, USA
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Kokko P, Kork AA. Value-based healthcare logics and their implications for Nordic health policies. Health Serv Manage Res 2020; 34:3-12. [PMID: 33167726 DOI: 10.1177/0951484820971457] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Value-based healthcare (VBHC) is a widely approved logic for financing services, using innovative care models and evaluating healthcare outcomes. It is consistent with the Triple Aim framework of simultaneously improving population health, patient experience and the costs of care. In Nordic countries, VBHC has been mainly implemented as a strategic concept in developing hospitals. Despite the evident interest in VBHC as a management trend in healthcare organisations, the studies concerning the implications of VBHC logics on health policies have been scant. This study aimed to fill this gap by building a conceptual bridge between national health policy and value-based care. Through the Triple Aim framework, we explored how VBHC goals have evolved in Finnish Government Programmes from 1995 to 2015 by using qualitative document analysis and interviews. The study addresses the evolution and national impacts of VBHC. Our results show that the goals of Triple Aim gradually become evident at the Finnish health policies. All three Triple Aim goals were present, though the equal prioritisation of these goals only emerged in 2015, also highlighting patient experience. We argue that VBHC logics have indeed affected Nordic welfare policies, not only at the organisational level but also concerning performance measurement and care delivery. This may imply that the diffusion of VBHC logics evolves from healthcare organisations to policymaking instead of top-down. Particularly in publicly financed systems, VBHC indicates a transformation to a new public governance ideology, accelerating policy goals that promote customer responsiveness and value creation for citizens.
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Affiliation(s)
- Petra Kokko
- Faculty of Management and Business, Tampere University, Tampere, Finland
| | - Anna-Aurora Kork
- Faculty of Management and Business, Tampere University, Tampere, Finland
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Wadovski R, Nogueira R, Chimenti P. Genetic services diffusion in the precision medicine ecosystem. INTERNATIONAL JOURNAL OF PHARMACEUTICAL AND HEALTHCARE MARKETING 2020. [DOI: 10.1108/ijphm-02-2019-0010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
Genetic knowledge is advancing steadily while at the same time DNA sequencing prices are dropping fast, but the diffusion of genetic services (GS) has been slow. The purpose of this paper is to identify GS diffusion drivers in the precision medicine (PM) ecosystem.
Design/methodology/approach
After reviewing the literature on innovation diffusion, particularly on GS diffusion, the PM ecosystem actors are interviewed to obtain their perspective. Using content analysis, the interviewees’ visions were interplayed with the literature to achieve driver conceptualization, which posteriorly originated broad themes.
Findings
The results indicate that GS diffusion depends on satisfying aspects from three broad themes and respective drivers: technology (evidence strength and credibility, customization, knowledge, data and information, tech evolution speed and cost), human (ethics, privacy and security and user power) and business (prevention, holistic view of the individual, public policy and regulation, business model and management).
Practical implications
The main management implications refer to considering health care in a multidisciplinary way, investing in the propagation of genetic knowledge, standardizing medical records and interpreting data.
Originality/value
This study, to the best of authors’ knowledge, is the first attempt to understand GS diffusion from a broad perspective, taking into account the PM stakeholders’ view. The 13 drivers offer a comprehensive understanding of how GS could spread in health care and they can assist researchers and practitioners to discuss and set strategies based on an initial structured map.
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Bush WS, Cooke Bailey JN, Beno MF, Crawford DC. Bridging the Gaps in Personalized Medicine Value Assessment: A Review of the Need for Outcome Metrics across Stakeholders and Scientific Disciplines. Public Health Genomics 2019; 22:16-24. [PMID: 31454805 PMCID: PMC6752968 DOI: 10.1159/000501974] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 07/07/2019] [Indexed: 12/14/2022] Open
Abstract
Despite monumental advances in genomics, relatively few health care provider organizations in the United States offer personalized or precision medicine as part of the routine clinical workflow. The gaps between research and applied genomic medicine may be a result of a cultural gap across various stakeholders representing scientists, clinicians, patients, policy makers, and third party payers. Scientists are trained to assess the health care value of genomics by either quantifying population-scale effects, or through the narrow lens of clinical trials where the standard of care is compared with the predictive power of a single or handful of genetic variants. While these metrics are an essential first step in assessing and documenting the clinical utility of genomics, they are rarely followed up with other assessments of health care value that are critical to stakeholders who use different measures to define value. The limited value assessment in both the research and implementation science of precision medicine is likely due to necessary logistical constraints of these teams; engaging bioethicists, health care economists, and individual patient belief systems is incredibly daunting for geneticists and informaticians conducting research. In this narrative review, we concisely describe several definitions of value through various stakeholder viewpoints. We highlight the existing gaps that prevent clinical translation of scientific findings generally as well as more specifically using two present-day, extreme scenarios: (1) genetically guided warfarin dosing representing a handful of genetic markers and more than 10 years of basic and translational research, and (2) next-generation sequencing representing genome-dense data lacking substantial evidence for implementation. These contemporary scenarios highlight the need for various stakeholders to broadly adopt frameworks designed to define and collect multiple value measures across different disciplines to ultimately impact more universal acceptance of and reimbursement for genomic medicine.
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Affiliation(s)
- William S Bush
- Cleveland Institute for Computational Biology, Case Western Reserve University, Cleveland, Ohio, USA
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Jessica N Cooke Bailey
- Cleveland Institute for Computational Biology, Case Western Reserve University, Cleveland, Ohio, USA
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Mark F Beno
- Cleveland Institute for Computational Biology, Case Western Reserve University, Cleveland, Ohio, USA
| | - Dana C Crawford
- Cleveland Institute for Computational Biology, Case Western Reserve University, Cleveland, Ohio, USA,
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA,
- Department of Genetics and Genome Sciences, Case Western Reserve University, Cleveland, Ohio, USA,
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Davis MM, Gunn R, Pham R, Wiser A, Lich KH, Wheeler SB, Coronado GD. Key Collaborative Factors When Medicaid Accountable Care Organizations Work With Primary Care Clinics to Improve Colorectal Cancer Screening: Relationships, Data, and Quality Improvement Infrastructure. Prev Chronic Dis 2019; 16:E107. [PMID: 31418685 PMCID: PMC6716418 DOI: 10.5888/pcd16.180395] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Purpose Accountable Care Organizations (ACOs) are implementing interventions to achieve triple-aim objectives of improved quality and experience of care while maintaining costs. Partnering across organizational boundaries is perceived as critical to ACO success. Methods We conducted a comparative case study of 14 Medicaid ACOs in Oregon and their contracted primary care clinics using public performance data, key informant interviews, and consultation field notes. We focused on how ACOs work with clinics to improve colorectal cancer (CRC) screening — one incentivized performance metric. Results ACOs implemented a broad spectrum of multi-component interventions designed to increase CRC screening. The most common interventions focused on reducing structural barriers (n = 12 ACOs), delivering provider assessment and feedback (n = 11), and providing patient reminders (n = 7). ACOs developed their processes and infrastructure for working with clinics over time. Facilitators of successful collaboration included a history of and commitment to collaboration (partnership); the ability to provide accurate data to prioritize action and monitor improvement (performance data), and supporting clinics’ reflective learning through facilitation, learning collaboratives; and support of ACO as well as clinic-based staffing (quality improvement infrastructure). Two unintended consequences of ACO–clinic partnership emerged: potential exclusion of smaller clinics and metric focus and fatigue. Conclusion Our findings identified partnership, performance data, and quality improvement infrastructure as critical dimensions when Medicaid ACOs work with primary care to improve CRC screening. Findings may extend to other metric targets.
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Affiliation(s)
- Melinda M Davis
- Oregon Rural Practice-based Research Network, Portland, Oregon.,Department of Family Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Mail Code L222, Portland, OR 97239.
| | - Rose Gunn
- Oregon Rural Practice-based Research Network, Portland, Oregon
| | - Robyn Pham
- Oregon Rural Practice-based Research Network, Portland, Oregon
| | - Amy Wiser
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Stephanie B Wheeler
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Pericleous L, Amin M, Goeree R. The value and consequences of using public health technology assessments for private payer decision-making in Canada: one size does not fit all. J Med Econ 2019; 22:478-487. [PMID: 30757934 DOI: 10.1080/13696998.2019.1582535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Both public and private insurers provide drug coverage in Canada. All payers are under pressure to contain costs. It has recently been proposed that private plans leverage the public health technology assessment (HTA) evaluation process in their decision-making. OBJECTIVES The objectives of the current study were to examine use of public health technology assessments (HTAs) for private payer decision-making in the literature, to gather the perspectives of experts from both public and private insurers on this practice, and to summarize which value parameters of public evaluations can be used for private payer decision-making. METHODS A targeted literature review was conducted to identify publications on the use of public HTA or cost-effectiveness data for private payer decision-making on pharmaceutical reimbursement. Concurrently, a roundtable meeting was organized with invited panelists, including private payer representatives and health economic consultants (total n = 9). The findings from both were synthesized and expressed in qualitative terms using the PICO framework. RESULTS The targeted review identified 20 studies meeting the inclusion criteria, primarily originating from the US and Canada. The panelists felt that, despite some similarities, there were substantial differences between both systems. The PICO framework highlighted the issues with transferability between the two systems. Most of the value parameters were either not applicable, needed to be added, needed to be adjusted, or their applicability to private payer systems needed to be confirmed. CONCLUSION Some components of public HTA may be relevant for private payers, however there are reservations that still exist on whether the HTA process in Canada, designed for a public system, can address the informational needs of private payers. Private insurers need to use caution in assessing which value parameters from public HTAs can be used and which need to be confirmed, ignored, enhanced, or adjusted. One size HTA does not fit all applications.
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Affiliation(s)
- Louisa Pericleous
- a Value and Access , Amgen Canada Inc , Mississauga , Ontario , Canada
| | - Mo Amin
- a Value and Access , Amgen Canada Inc , Mississauga , Ontario , Canada
| | - Ron Goeree
- b Department of Clinical Epidemiology and Biostatistics (CEB) , McMaster University , Hamilton , Ontario , Canada
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Osteguin V, Cheng TW, Farber A, Eslami MH, Kalish JA, Jones DW, Rybin D, Raulli SJ, Siracuse JJ. Emergency Department Utilization after Lower Extremity Bypass for Critical Limb Ischemia. Ann Vasc Surg 2019; 54:134-143. [DOI: 10.1016/j.avsg.2018.03.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 03/07/2018] [Accepted: 03/08/2018] [Indexed: 01/10/2023]
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Short- and long-term readmission rates after infrainguinal bypass in a safety net hospital are higher than expected. J Vasc Surg 2017; 66:1786-1791. [PMID: 28965800 DOI: 10.1016/j.jvs.2017.07.120] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 07/16/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Readmission rates are expected to have an increasing effect on both the hospital bottom line and physician reimbursements. Safety net hospitals may be most vulnerable. We examined readmissions at 30 days, 90 days, and 1 year in a large safety net hospital to determine the magnitude and effect of short- and long-term readmission rates after lower extremity infrainguinal bypass in this setting. METHODS All nonemergent extremity infrainguinal bypass performed at a large safety net hospital between 2008 and 2016 were identified. Patient demographic, social, clinical, and procedural details were extracted from the electronic medical record. An analysis of patients readmitted at 30 days, 90 days, and 1 year was completed to determine the details of the readmission. RESULTS A total of 350 patients undergoing extremity infrainguinal bypass were identified. The most frequent indication was tissue loss (57%), followed by claudication (25.6%), and rest pain (17.4%). Patient insurance carriers included Medicare (61.7%), Medicaid (25.4%), and private (13%). The distal target was the popliteal and tibial artery in 52.6% and 47.4% cases, respectively. The majority of bypasses used autologous vein (73.1%). In-hospital complications included pulmonary complications (4.3%), urinary tract infection (3.1%), acute renal failure (2%), graft occlusion (2%), myocardial infarction (1.7%), bleeding (1.4%), surgical wound complications (1.1%), and stroke (0.9%). The 30-day readmission rate was 30% with the most common reasons for readmission being surgical wound complications, nonsurgical foot/leg wounds, nonextremity infectious causes, cardiac ischemia, and congestive heart failure. The 90-day readmission rate was 49.4% and the most common reasons for readmission from 31 to 90 days were nonsurgical foot/leg wounds, graft complications, surgical wound complications, cardiac ischemia, and contralateral leg morbidity. The readmission rate within 1 year was 72.2%. Readmission causes from 91 days to 1 year included graft complications, contralateral leg morbidity, nonextremity infectious, nonsurgical foot/leg wounds, cardiac ischemia, and congestive heart failure. A tibial bypass target was associated with 30-day (odds ratio [OR], 1.69; 95% confidence interval [CI], 1.06-2.69; P = .029) and 90-day (OR, 1.77; 95% CI, 1.14-2.74, P = .011) readmission. Nonprivate insurance (OR, 2.31; 95% CI, 1.17-4.57, P = .016), and critical limb ischemia (OR, 1.77; 95% CI, 1.14-2.74; P = .035) were associated with 1-year readmission. CONCLUSIONS Short- and long-term readmission rates in a safety net setting are high. The 30-day rates in this study are higher than historically reported. This data sets baseline rates for 90-day and 1-year readmission for future analyses. Although the majority of short-term readmissions are related to the index procedure, long-term readmission rates are more frequently related to systemic comorbidities. Targeted patient interventions aimed at preventing the most common reasons for readmission may improve readmission rates, particularly among patients with nonprivate insurance. However, other risk factors, such as tibial target, may not be modifiable and a higher readmission rate may need to be accepted in this population.
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Phillips KA. Assessing the Value and Implications of Personalized/Precision Medicine and the "Lessons Learned" for Emerging Technologies: An Introduction. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:30-31. [PMID: 28212965 DOI: 10.1016/j.jval.2016.09.2405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 09/18/2016] [Indexed: 06/06/2023]
Affiliation(s)
- Kathryn A Phillips
- Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California, San Francisco, CA, USA; Philip R. Lee Institute for Health Policy, University of California, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
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