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Abstract
Most antibiotics are prescribed in ambulatory setting and at least 30% to 50% of these prescriptions are unnecessary. The use of antibiotics when not needed promotes the development of antibiotic resistant organisms and harms patients by placing them at risk for adverse drug events and Clostridioides difficile infections. National guidelines recommend that health systems implement antibiotic stewardship programs in ambulatory settings. However, uptake of stewardship in ambulatory setting has remained low. This review discusses the current state of ambulatory stewardship in the United States, best practices for the successful implementation of effective ambulatory stewardship programs, and future directions to improve antibiotic use in ambulatory settings.
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Affiliation(s)
- Holly M Frost
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, CO, USA; Department of Pediatrics, Denver Health and Hospital Authority, Denver, CO, USA; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Adam L Hersh
- Division of Infectious Disease, Department of Pediatrics, 295 Chipeta Way, Salt Lake City, UT 8413, USA
| | - David Y Hyun
- Antimicrobial Resistance Project, The Pew Charitable Trusts, 901 East Street NW, Washington, DC 20004-2008, USA
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2
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Hooker ER, Chapa J, Vranas KC, Niederhausen M, Goodlin SJ, Slatore CG, Sullivan DR. Intersection of Palliative Care and Hospice Use Among Patients With Advanced Lung Cancer. J Palliat Med 2023; 26:1474-1481. [PMID: 37262128 PMCID: PMC10658737 DOI: 10.1089/jpm.2023.0040] [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] [Accepted: 04/27/2023] [Indexed: 06/03/2023] Open
Abstract
Background: Hospice and palliative care (PC) are important components of lung cancer care and independently provide benefits to patients and their families. Objective: To better understand the relationship between hospice and PC and factors that influence this relationship. Methods: A retrospective cohort study of patients diagnosed with advanced lung cancer (stage IIIB/IV) within the U.S. Veterans Health Administration (VA) from 2007 to 2013 with follow-up through 2017 (n = 22,907). Mixed logistic regression models with a random effect for site, adjustment for patient variables, and propensity score weighting were used to examine whether the association between PC and hospice use varied by U.S. region and PC team characteristics. Results: Overall, 57% of patients with lung cancer received PC, 69% received hospice, and 16% received neither. Of those who received hospice, 60% were already enrolled in PC. Patients who received PC had higher odds of hospice enrollment than patients who did not receive PC (adjusted odds ratio = 3.25, 95% confidence interval: 2.43-4.36). There were regional differences among patients who received PC; the predicted probability of hospice enrollment was 85% and 73% in the Southeast and Northeast, respectively. PC team and facility characteristics influenced hospice use in addition to PC; teams with the shortest duration of existence, with formal team training, and at lower hospital complexity were more likely to use hospice (all p < 0.05). Conclusions: Among patients with advanced lung cancer, PC was associated with hospice enrollment. However, this relationship varied by geographic region, and PC team and facility characteristics. Our findings suggest that regional PC resource availability may contribute to substitution effects between PC and hospice for end-of-life care.
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Affiliation(s)
- Elizabeth R. Hooker
- Center to Improve Veteran Involvement in their Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA
| | - Joaquin Chapa
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Kelly C. Vranas
- Center to Improve Veteran Involvement in their Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
- Portland Veterans Affairs Medical Center, Divisions of Pulmonary Critical Care Medicine, Portland, Oregon, USA
| | - Meike Niederhausen
- Center to Improve Veteran Involvement in their Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA
- Oregon Health and Science University—Portland State University School of Public Health, Oregon Health and Science University, Portland, Oregon, USA
| | - Sarah J. Goodlin
- Geriatrics Section, Veterans Affairs Portland Health Care System, Portland, Oregon, USA
| | - Christopher G. Slatore
- Center to Improve Veteran Involvement in their Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
- Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Donald R. Sullivan
- Center to Improve Veteran Involvement in their Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
- Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
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Maguire-Jack K, Yoon S, Hong S. Social Cohesion and Informal Social Control as Mediators Between Neighborhood Poverty and Child Maltreatment. CHILD MALTREATMENT 2022; 27:334-343. [PMID: 33853354 DOI: 10.1177/10775595211007566] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Neighborhoods have profound impacts on children and families. Using structural equation modeling and data from 4,898 children in the Fragile Families and Child Wellbeing Study, the current study examines the direct and indirect effects of neighborhood poverty on the likelihood of being maltreated at age 5. Two neighborhood social processes, social cohesion and informal social control, were examined as mediators. The study found that neighborhood poverty was indirectly related to physical assault and psychological aggression through its impact on social cohesion, and indirectly related to neglect through its impact on informal social control. The results highlight the need to reduce poverty across communities and increase social cohesion and social control as potential pathways for interrupting the impact of neighborhood poverty on maltreatment.
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Affiliation(s)
| | - Susan Yoon
- 2647The Ohio State University College of Social Work, Columbus, OH, USA
| | - Sunghyun Hong
- 1259University of Michigan School of Social Work, Ann Arbor, MI, USA
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Probst MA, Janke AT, Haimovich AD, Venkatesh AK, Lin MP, Kocher KE, Nemnom MJ, Thiruganasambandamoorthy V. Development of a Novel Emergency Department Quality Measure to Reduce Very Low-Risk Syncope Hospitalizations. Ann Emerg Med 2022; 79:509-517. [PMID: 35487840 PMCID: PMC9117517 DOI: 10.1016/j.annemergmed.2022.03.008] [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: 01/04/2022] [Revised: 03/02/2022] [Accepted: 03/07/2022] [Indexed: 11/29/2022]
Abstract
STUDY OBJECTIVE Emergency department (ED) evaluations for syncope are common, representing 1.3 million annual US visits and $2 billion in related hospitalizations. Despite evidence supporting risk stratification and outpatient management, variation in syncope hospitalization rates persist. We sought to develop a new quality measure for very low-risk adult ED patients with syncope that could be applied to administrative data. METHODS We developed this quality measure in 2 phases. First, we used an existing prospective, observational ED patient data set to identify a very low-risk cohort with unexplained syncope using 2 variables: age less than 50 years and no history of heart disease. We then applied this to the 2019 Nationwide Emergency Department Sample (NEDS) to assess its potential effect, assessing for hospital-level factors associated with hospitalization variation. RESULTS Of the 8,647 adult patients in the prospective cohort, 3,292 (38%) patients fulfilled these 2 criteria: age less than 50 years and no history of heart disease. Of these, 15 (0.46%) suffered serious adverse events within 30 days. In the NEDS, there were an estimated 566,031 patients meeting these 2 criteria, of whom 15,507 (2.7%; 95% confidence interval [CI] 2.48% to 3.00%) were hospitalized. We found substantial variation in the hospitalization rates for this very low-risk cohort, with a median rate of 1.7% (range 0% to 100%; interquartile range 0% to 3.9%). Factors associated with increased hospitalization rates included a yearly ED volume of more than 80,000 (odds ratio [OR] 3.14; 95% CI 2.02 to 4.89) and metropolitan teaching status (OR 1.5; 95% CI 1.24 to 1.81). CONCLUSION In summary, our novel syncope quality measure can assess variation in low-value hospitalizations for unexplained syncope. The application of this measure could improve the value of syncope care.
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Affiliation(s)
- Marc A Probst
- Department of Emergency Medicine, Columbia University Medical Center, New York, NY.
| | - Alexander T Janke
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Adrian D Haimovich
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Michelle P Lin
- Department of Emergency Medicine and Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Keith E Kocher
- Department of Emergency Medicine and Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI
| | - Marie-Joe Nemnom
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Aubrey-Bassler K, Laberge M, Knight J, Etchegary C, Rayner J, Tranmer J, Hogg W, Gao Z, Lukewich J, Breton M, Ryan A. Longitudinal costs and health service utilisation associated with primary care reforms in Ontario: a retrospective cohort study protocol. BMJ Open 2022; 12:e053878. [PMID: 35450896 PMCID: PMC9024230 DOI: 10.1136/bmjopen-2021-053878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Over the last 20 years, the Canadian province of Ontario implemented several new models of primary care focusing on changes to physician remuneration, clinics led by nurse practitioners and the introduction of interprofessional primary care teams. Health outcome and cost evaluations of these models thus far have been mostly cross-sectional and in some cases results from these studies were conflicting. The aim of this population-based study is to investigate short, medium and long-term effectiveness of these reforms over the past 15-20 years. METHODS AND ANALYSIS This is the protocol for a retrospective cohort study including fee-for-service (FFS) and community health centre cohorts (control cohorts) or patients who switched from either being unattached or from FFS to a new practice model (eg, capitation, enhanced FFS, team, nurse practitioner-led) from 1997 to 2020. The primary outcome is total healthcare costs and secondary outcomes are primary care costs, other (non-primary care) health costs, hospitalisations, length of stay, emergency department visits, accessibility and mortality. A combination of hard and propensity matching will be used where relevant. Outcomes will be adjusted for demographic and health factors and measured annually. Interrupted time series models will be used where data permits and difference-in-differences methods will be used otherwise. ETHICS AND DISSEMINATION Ethics approval has been received from Queens University and Memorial University. The dissemination plan includes conference presentations, papers, brief evidence summaries targeted at select audiences and knowledge brokering sessions with key stakeholders.
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Affiliation(s)
- Kris Aubrey-Bassler
- Primary Healthcare Research Unit, Memorial University, St. John's, Newfoundland and Labrador, Canada
- Discipline of Family Medicine, Memorial University, St. John's, Newfoundland and Labrador, Canada
- Division of Community Health and Humanities, Faculty of Medicine, Memorial University, St. John's, Newfoundland and Labrador, Canada
| | - Maude Laberge
- Department of Operations and Decision Systems, Université Laval Faculté de Médecine, Québec, Québec, Canada
- VITAM, Centre de recherche en santé durable, Université Laval, Québec, Québec, Canada
- Centre de recherce du CHU de Québec, Université Laval, Québec, Québec, Canada
| | - John Knight
- Division of Community Health and Humanities, Faculty of Medicine, Memorial University, St. John's, Newfoundland and Labrador, Canada
- Data and Information Services, Newfoundland and Labrador Centre for Health Information, St. John's, Newfoundland and Labrador, Canada
| | - Cheryl Etchegary
- NL SUPPORT, Memorial University, St. John's, Newfoundland and Labrador, Canada
| | - Jennifer Rayner
- Alliance for Healthier Communities, Toronto, Ontario, Canada
- Centre for Studies in Family Medicine, Western University, London, Ontario, Canada
- Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Joan Tranmer
- School of Nursing, Queen's University, Kingston, Ontario, Canada
| | - William Hogg
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Institut du Savoir Montfort, Hôpital Montfort, Ottawa, Ontario, Canada
| | - Zhiwei Gao
- Division of Community Health and Humanities, Faculty of Medicine, Memorial University, St. John's, Newfoundland and Labrador, Canada
| | - Julia Lukewich
- Faculty of Nursing, Memorial University, Saint John's, Newfoundland and Labrador, Canada
| | - Mylaine Breton
- Community Health, Université de Sherbrooke, Longueuil, Québec, Canada
| | - Ashley Ryan
- Eastern Health Regional Health Authority, St. John's, Newfoundland and Labrador, Canada
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Vogel K, Rojas CN, Tanna AP, French DD. Variation of iStent Procedure Rates by State in Response to the COVID-19 Pandemic. Clin Ophthalmol 2022; 16:461-464. [PMID: 35228793 PMCID: PMC8882025 DOI: 10.2147/opth.s351589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 01/18/2022] [Indexed: 12/03/2022] Open
Affiliation(s)
- Kelly Vogel
- Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Cole N Rojas
- Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Angelo P Tanna
- Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Dustin D French
- Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Medical Social Science, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Veterans Affairs Health Services Research and Development Service, Chicago, IL, USA
- Correspondence: Dustin D French, Tel +1 813 789 9382, Fax +1 312 695 3652, Email
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Cao P, Zhao X, Yang Y, Pan J. Creating accountable hospital service areas in China: a case analysis of health expenditure in the metropolis of Chengdu. BMJ Open 2022; 12:e051538. [PMID: 35074811 PMCID: PMC8788232 DOI: 10.1136/bmjopen-2021-051538] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES To delineate hospital service areas (HSAs) using the Dartmouth approach in China and identify the hypothesised demand-side, supply-side and region-specific factors of health expenditure within HSAs. DESIGN Population-based descriptive study. SETTING We selected the metropolis of Chengdu, one of the three most populous cities in China as a case for the analysis, where approximately 16.33 million residents living. PARTICIPANTS Individual-level in-patient discharge records (n=904 298) during the fourth quarter of 2018 (from 1 September to 31 December) were extracted from Sichuan Health Commission. Cases of non-residents of Chengdu were excluded from the datasets. METHODS We conducted three sets of analyses: (1) apply Dartmouth approach to delineate HSAs; (2) use Geographic Information System (GIS)-based method to demonstrate health expenditure variations across delineated HSAs and (3) employ a three-level multilevel linear model to examine the association between health expenditure and demand-side, supply-side and region-specific factors. RESULTS A total of 113 HSAs with a median population of 60 472 (ranging from 7022 to 827 750) was delineated. Total in-patient expenditure per admission varied more than threefold across HSAs after adjusting for age and gender. Apart from a list of demand-side factors, an increased number of physicians, healthcare facilities at higher levels and for-profit healthcare facilities were significantly associated with increased total in-patient expenditures. At the HSA level, the proportion of private healthcare facilities located in a single HSA was associated with increased total in-patient expenditure generated by that HSA, while the increased number of healthcare facilities in a HSA was negatively associated with the total in-patient expenditures. CONCLUSION HSAs were delineated to help establish an accountable healthcare delivery system, which serves as local hospital markets to provide in-patient healthcare via connecting demanders with suppliers inside particular HSAs. Policy-makers should adopt HSAs to identify variations of total in-patient expenditures among different areas and the potential associated factors. Findings from the HSA-based analysis could inform the formulation of relevant health policies and the optimisation of healthcare resource allocations.
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Affiliation(s)
- Peiya Cao
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
- HEOA Group, Institute for Healthy Cities and West China Center for Rural Health Development, Sichuan University, Chengdu, Sichuan, China
| | - Xiaoshuang Zhao
- Shenzhen Longgang Chronic Disease Hospital, Shenzhen, Guangdong, China
| | - Yili Yang
- HEOA Group, Institute for Healthy Cities and West China Center for Rural Health Development, Sichuan University, Chengdu, Sichuan, China
| | - Jay Pan
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
- HEOA Group, Institute for Healthy Cities and West China Center for Rural Health Development, Sichuan University, Chengdu, Sichuan, China
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8
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N’Dri LA, Waters DD, Walsh K, Mehta F, Oliver BJ. System-Level Variation in Multiple Sclerosis Disease-Modifying Therapy Utilization: Findings From the Multiple Sclerosis Continuous Quality Improvement Research Collaborative. Perm J 2021; 25:21.025. [PMID: 35348092 PMCID: PMC8784072 DOI: 10.7812/tpp/21.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/30/2021] [Accepted: 05/17/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Multiple Sclerosis Continuous Quality Improvement (MS-CQI) Collaborative is the first multicenter improvement research collaborative for multiple sclerosis (MS). The main objective of this study is to describe baseline system-level variation in disease-modifying therapy (DMT) utilization across 4 MS centers participating in MS-CQI. METHODS Electronic health record data from the first year of the 3-year MS-CQI study were analyzed. Participants were adults ≥ 18 years with MS presenting to any of the 4 MS-CQI centers. DMT utilization was categorized into oral, infusion, and injection types. Multinomial logistic regression was used to investigate associations between centers and DMT utilization. RESULTS Overall, 2,029 patients were included in the analysis. Of those patients, 75.1% were female, mean age was 50 years, and 87.4% had relapsing-remitting MS. Overall, 32.7% were on an oral DMT, 23.5% on an infusion DMT, and 43.9% on an injection DMT. Overall, statistically significant differences (p < 0.01) were observed across centers for proportions of patients who received oral, infusion, and no DMTs. There were also overall significant differences (p < 0.01) across MS types for proportions of encounters who received oral, infusion, injection, no DMTs, and mean age varied significantly across centers. CONCLUSION System-level effects on MS treatment and outcomes have not been previously studied and our findings contribute initial evidence concerning system-level variation in DMT utilization. Results suggest system-level variation in DMT utilization (ie, after adjusting for individual level factors, MS center or location of care a person with MS engages in care influences DMT treatment choices), resulting in a lack of standardization in DMT management. Continued research and improvement efforts targeting system-level performance could improve outcomes for people with MS.
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Affiliation(s)
| | | | - Karen Walsh
- Jefferson College of Population Health, Philadelphia, PA
| | - Falguni Mehta
- Departments of Community and Family Medicine, Psychiatry, and the Dartmouth Institute for Health Policy and Clinical Practice (TDI), Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Brant J Oliver
- Departments of Community and Family Medicine, Psychiatry, and the Dartmouth Institute for Health Policy and Clinical Practice (TDI), Geisel School of Medicine at Dartmouth, Hanover, NH
- Dartmouth-Hitchcock Health, Lebanon, NH
- Department of Veterans Affairs National Quality Scholars (VAQS) and Health Professions Education and Evaluation Research (HPEER) Advanced Fellowship Programs, White River Junction, VT and Houston, TX
| | - for the MS-CQI Investigators
- Jefferson College of Population Health, Philadelphia, PA
- Departments of Community and Family Medicine, Psychiatry, and the Dartmouth Institute for Health Policy and Clinical Practice (TDI), Geisel School of Medicine at Dartmouth, Hanover, NH
- Dartmouth-Hitchcock Health, Lebanon, NH
- Department of Veterans Affairs National Quality Scholars (VAQS) and Health Professions Education and Evaluation Research (HPEER) Advanced Fellowship Programs, White River Junction, VT and Houston, TX
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Chronic care services and variation between Danish general practices: a nationwide cohort study. Br J Gen Pract 2021; 72:e285-e292. [PMID: 34990398 PMCID: PMC8843375 DOI: 10.3399/bjgp.2021.0419] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 10/11/2021] [Indexed: 11/15/2022] Open
Abstract
Background Little is known about variations in the provision of chronic care services in primary care. Aim To describe the frequency of chronic care services provided by GPs and analyse the extent of non-random variation in service provision. Design and setting Nationwide cohort study undertaken in Denmark using data from 2016. Method Information on chronic care services was obtained from national health registers, including annual chronic care consultations, chronic care procedures, outreach home visits, and talk therapy. The associations between services provided, patient morbidity, and socioeconomic factors were estimated. Service variations were analysed, and excess variation related to practice-specific factors was estimated while accounting for random variation. Results Chronic care provision was associated with increasing patient age, increasing number of long-term conditions, and indicators of low socioeconomic status. Variation across practices ranged from 1.4 to 128 times more than expected after adjusting for differences in patient population and random variation. Variation related to practice-specific factors was present for all the chronic care services that were investigated. Older patients with lower socioeconomic status and multimorbidity were clustered in practices with low propensity to provide certain chronic care services. Conclusion Chronic care was provided to patients typically in need of health care, that is, older adults, those with multimorbidity, and those with low socioeconomic status, but service provision varied more than expected across practices. GPs provided slightly fewer chronic care services than expected in practices where many patients with multimorbidity and low socioeconomic status were clustered, suggesting inverse care law mechanisms.
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Dufort VM, Bernardy N, Maguen S, Hoyt JE, Litt ER, Patterson OV, Leonard CE, Shiner B. Geographic Variation in Initiation of Evidence-based Psychotherapy Among Veterans With PTSD. Mil Med 2021; 186:e858-e866. [DOI: 10.1093/milmed/usaa389] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/14/2020] [Accepted: 09/23/2020] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
The United States Department of Veterans Affairs (VA) has invested in implementation of evidence-based psychotherapy (EBP) for post-traumatic stress disorder (PTSD) for over a decade, resulting in slow but steady uptake of these treatments nationally. However, no prior research has investigated the geographic variation in initiation of EBP. Our objectives were to determine whether there is geographic variation in the initiation of EBP for PTSD in the VA and to identify patient and clinic factors associated with EBP initiation.
Materials and Methods
We identified VA patients with PTSD who had not received EBP as of January 2016 (N = 946,667) using retrospective electronic medical records data and determined whether they initiated EBP by December 2017. We illustrated geographic variation in EBP initiation using national and regional maps. Using multivariate logistic regression, we determined patient, regional, and nearest VA facility predictors of initiating treatment. This study was approved by the Veterans Institutional Review Board of Northern New England.
Results
Nationally, 4.8% (n = 45,895) initiated EBP from 2016 to 2017, and there was geographic variation, ranging from none to almost 30% at the 3-digit ZIP code level. The strongest patient predictors of EBP initiation were the negative predictor of being older than 65 years (OR = 0.47; 95% CI, 0.45-0.49) and the positive predictor of reporting military-related sexual trauma (OR = 1.96; 95% CI, 1.90-2.03). The strongest regional predictors of EBP initiation were the negative predictor of living in the Northeast (OR = 0.89; 95% CI, 0.86-0.92) and the positive predictor of living in the Midwest (OR = 1.47; 95% CI, 1.44-1.51). The only nearest VA facility predictor of EBP initiation was the positive predictor of whether the facility was a VA Medical Center with a specialized PTSD clinic (OR = 1.23; 95% CI, 1.20-1.26).
Conclusion
Although less than 5% of VA patients with PTSD initiated EBP, there was regional variation. Patient factors, region of residence, and nearest VA facility characteristics were all associated with whether patients initiated EBP. Strengths of this study include the use of national longitudinal data, while weaknesses include the potential for misclassification of PTSD diagnoses as well as the potential for misidentification of EBP. Our work indicates geographic areas where access to EBP for PTSD may be poor and can help target work improving access. Future studies should also assess completion of EBP for PTSD and related symptomatic and functional outcomes across geographic areas.
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Affiliation(s)
| | - Nancy Bernardy
- National Center for PTSD Executive Division, VT 05009, USA
- Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH 03755, USA
| | - Shira Maguen
- San Francisco VA Health Care System, San Francisco, CA 94121, USA
- Psychiatry, University of California San Francisco, San Francisco, CA 94115, USA
| | | | - Eric R Litt
- Veterans Rural Health Resource Center, Gainesville, FL 32608, USA
| | - Olga V Patterson
- VA Salt Lake City Health Care System, Salt Lake City, UT 84148, USA
- Internal Medicine, University of Utah, Salt Lake City, UT 84132, USA
| | | | - Brian Shiner
- White River Junction VA Medical Center, VT 05009, USA
- Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH 03755, USA
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Oliver BJ, Walsh K, Messier R, Mehta F, Cabot A, Klawiter E, Pagnotta P, Solomon A, England SE. System-Level Variation in Multiple Sclerosis Care Outcomes: Initial Findings from the Multiple Sclerosis Continuous Quality Improvement Research Collaborative. Popul Health Manag 2021; 25:46-56. [PMID: 34134513 DOI: 10.1089/pop.2021.0040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Multiple sclerosis (MS) is a "3C" (complex, chronic, costly) condition that is a common and disabling neurological illness affecting approximately 1 million adults in the United States. MS has been studied at the basic science, individual, and population levels, but not at the system level to assess small-area variation effects on MS population health outcomes. System-level effects have been observed in other 3C conditions including cystic fibrosis, rheumatoid arthritis, and inflammatory bowel disease. The authors report here on system-level variation findings from the baseline period during the first year of the Multiple Sclerosis Continuous Quality Improvement (MS-CQI) study. Stepwise binary logistic regression analyses were conducted to investigate system-level (small-area variation) effects on MS relapses (exacerbations), disease-modifying therapy (DMT) utilization, and brain MRI utilization, controlling for demographics (age and sex) and other potential confounders. Significant differences were observed in people with MS (PwMS) between centers for a number of demographic and disease characteristics, including sex, age, and MS subtype. Controlling for these factors, significant system-level effects were observed on outcomes, including DMT utilization, MRI utilization, and relapses. Significant relationships also were observed between outcomes and urgent care utilization, including emergency department visits and hospitalizations. This initial study provides evidence establishing the presence of system-level variation effects on MS outcomes in a multicenter population study - where PwMS get their care can influence their outcomes. Results support continued systems-level research and improvement initiatives to optimize MS population health outcomes in this challenging and costly complex chronic condition.
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Affiliation(s)
- Brant J Oliver
- Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth and Dartmouth-Hitchcock-Health, Lebanon, New Hampshire, USA.,The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA.,Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA.,Multiple Sclerosis Specialty Care Program, Concord Hospital Neurology, Concord, New Hampshire, USA
| | - Karen Walsh
- Jefferson College of Population Health, Philadelphia, Pennsylvania, USA
| | | | - Falguni Mehta
- Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth and Dartmouth-Hitchcock-Health, Lebanon, New Hampshire, USA
| | - Ann Cabot
- Multiple Sclerosis Specialty Care Program, Concord Hospital Neurology, Concord, New Hampshire, USA
| | - Eric Klawiter
- Multiple Sclerosis Center, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Patricia Pagnotta
- Multiple Sclerosis Center, Department of Neurology, University of Vermont Medical Center and Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
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Wu SY, Terrell J, Park A, Perrier N. Understanding Thyroidectomy Cost Variations Among National Cancer Institute-Designated Cancer Centers. World J Surg 2020; 44:385-392. [PMID: 31576441 DOI: 10.1007/s00268-019-05176-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The cost of thyroidectomy varies across the USA, while the causes of this variation are poorly understood. We examined the cost of inpatient thyroidectomy among National Cancer Institute-designated cancer centers nationwide to determine why it differs. METHODS A retrospective study of inpatient thyroidectomies was performed using the Vizient Clinical Data Base. Fifty-two of 70 eligible hospitals were grouped into five geographic regions (Mid-Atlantic and New England, East Central, South Atlantic, West Central, and Mountain and Pacific). We identified drivers of cost variation in the five geographic regions and used risk adjustment model to evaluate the rationality of cost from each hospital. RESULTS Male sex, more extended hospital stays, and occurrence of complications were consistently associated with increased costs in all regions. Also, the cost was significantly lower in the Mid-Atlantic and New England region. The higher than expected costs did not correlate well with the case mix index among hospitals (p = 0.289), but the lower than expected costs were more common in high-volume hospitals. The average length of stay was the shortest in high-volume hospitals, which might account for the lower cost in the Mid-Atlantic and New England region; however, the overages of costs still varied widely among hospitals in all regions even if the length of stay was adjusted. CONCLUSIONS Cost variation may result from both patient-related factors and volume-related practice pattern differences among hospitals. A more standard of care and charge transparency is still needed for patients seeking affordable care at cancer centers.
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Affiliation(s)
- Si-Yuan Wu
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
- Division of General Surgery, Departments of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - John Terrell
- Office of Performance Improvement, Unit 466, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Anne Park
- Office of Performance Improvement, Unit 466, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Nancy Perrier
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA.
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Hswen Y, Zhang A, Sewalk KC, Tuli G, Brownstein JS, Hawkins JB. Investigation of Geographic and Macrolevel Variations in LGBTQ Patient Experiences: Longitudinal Social Media Analysis. J Med Internet Res 2020; 22:e17087. [PMID: 33137713 PMCID: PMC7428906 DOI: 10.2196/17087] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 04/25/2020] [Accepted: 04/26/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Discrimination in the health care system contributes to worse health outcomes among lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients. OBJECTIVE The aim of this study is to examine disparities in patient experience among LGBTQ persons using social media data. METHODS We collected patient experience data from Twitter from February 2013 to February 2017 in the United States. We compared the sentiment of patient experience tweets between Twitter users who self-identified as LGBTQ and non-LGBTQ. The effect of state-level partisan identity on patient experience sentiment and differences between LGBTQ users and non-LGBTQ users were analyzed. RESULTS We observed lower (more negative) patient experience sentiment among 13,689 LGBTQ users compared to 1,362,395 non-LGBTQ users. Increasing state-level liberal political identification was associated with higher patient experience sentiment among all users but had stronger effects for LGBTQ users. CONCLUSIONS Our findings highlight that social media data can yield insights about patient experience for LGBTQ persons and suggest that a state-level sociopolitical environment influences patient experience for this group. Efforts are needed to reduce disparities in patient care for LGBTQ persons while taking into context the effect of the political climate on these inequities.
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Affiliation(s)
- Yulin Hswen
- Bakar Computational Health Sciences Institute, Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, United States
- Computational Epidemiology Lab, Harvard Medical School, Boston, MA, United States
| | - Amanda Zhang
- Innovation Program, Boston Children's Hospital, Boston, MA, United States
- Pritzker School of Medicine, The University of Chicago, Chicago, IL, United States
| | - Kara C Sewalk
- Innovation Program, Boston Children's Hospital, Boston, MA, United States
| | - Gaurav Tuli
- Innovation Program, Boston Children's Hospital, Boston, MA, United States
| | - John S Brownstein
- Computational Epidemiology Lab, Harvard Medical School, Boston, MA, United States
- Innovation Program, Boston Children's Hospital, Boston, MA, United States
| | - Jared B Hawkins
- Computational Epidemiology Lab, Harvard Medical School, Boston, MA, United States
- Innovation Program, Boston Children's Hospital, Boston, MA, United States
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14
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The promise of big data for precision population health management in the US. Public Health 2020; 185:110-116. [PMID: 32615477 DOI: 10.1016/j.puhe.2020.04.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 02/16/2020] [Accepted: 04/30/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVES As we enter the year 2020, health data in the United States (US) is still in the process of being curated into a usable format. With coordinated data systems, it becomes possible to answer, with relative certainty, what preventive and medical interventions work in the real world and for whom they might work. STUDY DESIGN This is a non-systematic expert review. METHODS A non-systematic expert review was undertaken to identify relevant scientific and gray literature on the current state and the limitations of evaluation of health interventions and the health data infrastructure in the US. This review also included the literature on nations with unified data systems. We coupled this review with non-structured interviews of data scientists to gain insight into the progress in establishing the components necessary to support a unified data system and to facilitate data exchange for evaluations, as well as further guide our review. Our goal was to produce a critical analysis of the existing attempts to standardize and use data collected during patient encounters with physicians for public health purposes. RESULTS Data obtained from electronic health records are produced in a way that is challenging to use and difficult to compile across platforms in the US. One response to this problem has been to encourage the exchange and standardization of health record information through Distributed Research Networks and Common Data Models (CDMs). These data can be combined with mobile health, social media, and other sources of data to radically transform what we know about the prevention and management of disease. However, issues with the variety of CDMs and growing sense of distrust of institutions that maintain data continue to impede medical progress. CONCLUSIONS We present a framework for data use that will allow public health to answer a swath of unanswered research questions that can improve public health practice.
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Krumholz HM, Wang Y, Wang K, Lin Z, Bernheim SM, Xu X, Desai NR, Normand SLT. Association of Hospital Payment Profiles With Variation in 30-Day Medicare Cost for Inpatients With Heart Failure or Pneumonia. JAMA Netw Open 2019; 2:e1915604. [PMID: 31730185 PMCID: PMC6902811 DOI: 10.1001/jamanetworkopen.2019.15604] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Some uncertainty exists about whether hospital variations in cost are largely associated with differences in case mix. OBJECTIVE To establish whether the same patients admitted with the same diagnosis (heart failure or pneumonia) at 2 different hospitals incur different costs associated with the hospital's Medicare payment profile. DESIGN, SETTING, AND PARTICIPANTS This observational cohort study used Centers for Medicare & Medicaid Services (CMS) discharge data of patients with a principal diagnosis of heart failure (n = 1615) or pneumonia (n = 708) occurring between July 1, 2013, and June 30, 2016. Patients were individuals aged 65 years or older who were enrolled in Medicare fee-for-service Part A and Part B and were discharged from nonfederal, short-term, acute care or critical access hospitals in the United States. Data were analyzed from March 16, 2018, to September 25, 2019. MAIN OUTCOMES AND MEASURES The CMS heart failure and pneumonia payment measure cohorts were divided into 2 random samples. In the first sample, hospitals were classified into payment quartiles for heart failure and pneumonia. In the second sample, patients with 2 admissions for heart failure or pneumonia, one in a lowest-quartile hospital and one in a highest-quartile hospital more than 1 month apart, were identified. Standardized Medicare payments for these patients were compared for the lowest- and the highest-quartile payment hospitals. RESULTS The study sample included 1615 patients with heart failure (mean [SD] age, 78.7 [8.0] years; 819 [50.7%] male) and 708 with pneumonia (mean [SD] age, 78.3 [8.0] years; 401 [56.6%] male). The observed 30-day mortality rates for patients among lowest- compared with highest-payment hospitals were not significantly different. The median (interquartile range) hospital 30-day risk-standardized mortality rates were 8.1% (7.7%-8.5%) for heart failure and 11.3% (10.7%-12.1%) for pneumonia. The 30-day episode payment for hospitalization for the same patients at the lowest-payment hospitals was $2118 (95% CI, $1168-$3068; P < .001) lower for heart failure and $2907 (95% CI, $1760-$4054; P < .001) lower for pneumonia than at the highest-payment hospitals. More than half of the difference was associated with the payment during the index hospitalization ($1425 [95% CI, $695-$2154; P < .001] for heart failure and $1659 [95% CI, $731-$2588; P < .001] for pneumonia). CONCLUSIONS AND RELEVANCE This study found that the same Medicare beneficiaries who were admitted with the same diagnosis to hospitals with the highest payment profiles incurred higher costs than when they were admitted to hospitals with the lowest payment profiles. The findings suggest that variations in payments to hospitals are, at least in part, associated with the hospitals independently of non-time-varying patient characteristics.
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Affiliation(s)
- Harlan M. Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Yongfei Wang
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Kun Wang
- Real World Analytic and Alliance, Janssen Scientific Affairs, Titusville, New Jersey
| | - Zhenqiu Lin
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Susannah M. Bernheim
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Xiao Xu
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Nihar R. Desai
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Sharon-Lise T. Normand
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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16
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Keating NL, Huskamp HA, Kouri E, Schrag D, Hornbrook MC, Haggstrom DA, Landrum MB. Factors Contributing To Geographic Variation In End-Of-Life Expenditures For Cancer Patients. Health Aff (Millwood) 2019; 37:1136-1143. [PMID: 29985699 DOI: 10.1377/hlthaff.2018.0015] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Health care spending in the months before death varies across geographic areas but is not associated with outcomes. Using data from the prospective multiregional Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) study, we assessed the extent to which such variation is explained by differences in patients' sociodemographic factors, clinical factors, and beliefs; physicians' beliefs; and the availability of services. Among 1,132 patients ages sixty-five and older who were diagnosed with lung or colorectal cancer in 2003-05, had advanced-stage cancer, died before 2013, and were enrolled in fee-for-service Medicare, mean expenditures in the last month of life were $13,663. Physicians in higher-spending areas reported less knowledge about and comfort with treating dying patients and less positive attitudes about hospice, compared to those in lower-spending areas. Higher-spending areas also had more physicians and fewer primary care providers and hospices in proportion to their total population than lower-spending areas did. Availability of services and physicians' beliefs, but not patients' beliefs, were important in explaining geographic variations in end-of-life spending. Enhanced training to better equip physicians to care for patients at the end of life and strategic resource allocation may have potential for decreasing unwarranted variation in care.
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Affiliation(s)
- Nancy L Keating
- Nancy L. Keating ( ) is a professor of health care policy and medicine in the Department of Health Care Policy, Harvard Medical School and the Division of General Internal Medicine at Brigham and Women's Hospital, both in Boston, Massachusetts
| | - Haiden A Huskamp
- Haiden A. Huskamp is the 30th Anniversary Professor of Health Care Policy in the Department of Health Care Policy, Harvard Medical School
| | - Elena Kouri
- Elena Kouri is project director in the Department of Health Care Policy at Harvard Medical School
| | - Deborah Schrag
- Deborah Schrag is a professor of medicine at Harvard Medical School and a research scientist in medical oncology and population sciences at the Dana-Farber Cancer Institute, in Boston
| | - Mark C Hornbrook
- Mark C. Hornbrook is a senior investigator emeritus in the Center for Health Research, Kaiser Permanente Northwest, in Portland, Oregon
| | - David A Haggstrom
- David A. Haggstrom is an associate professor of medicine at Indiana University School of Medicine and core investigator at the Indianapolis Veterans Affairs Medical Center, in Indianapolis
| | - Mary Beth Landrum
- Mary Beth Landrum is a professor of health care policy in the Department of Health Care Policy, Harvard Medical School
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Church DL, Naugler C. Benefits and risks of standardization, harmonization and conformity to opinion in clinical laboratories. Crit Rev Clin Lab Sci 2019; 56:287-306. [PMID: 31060412 DOI: 10.1080/10408363.2019.1615408] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Large laboratory systems that include facilities with a range of capabilities and capacity are being created within consolidated healthcare systems. This paradigm shift is being driven by administrators and payers seeking to achieve resource efficiencies and to conform practice to the requirements of computerization as well as the adoption of electronic medical records. Although standardization and harmonization of practice improves patient care outcomes and operational efficiencies, administratively driven practice conformity (conformity to opinion) also has serious drawbacks and may lead to significant system failure. Juxtaposition of the distinct philosophical approaches of physicians and scientists (i.e. "professionalism") versus administrators and managers (i.e. "managerialism") towards bringing about conformity of the laboratory system inherently creates conflict. Despite an administrative edict to "perform all tests using the same methods" regardless of available "best practice" evidence to do so, medical/scientific input on these decisions is critical to ensure quality and safety of patient care. Innovation within the laboratory system, including the adoption of advanced technologies, practices, and personalized medicine initiatives, will be enabled by balancing the relentless drive by non-medical administration to meet "business" requirements, the medical responsibility to provide the best care possible, and customizing practice to meet individual patient care needs.
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Affiliation(s)
- Deirdre L Church
- a Department of Pathology and Laboratory Medicine , University of Calgary , Calgary , Canada.,b Department of Medicine , University of Calgary , Calgary , Canada
| | - Christopher Naugler
- a Department of Pathology and Laboratory Medicine , University of Calgary , Calgary , Canada.,c Department of Community Health Sciences , University of Calgary , Calgary , Canada.,d Department of Family Medicine , University of Calgary , Calgary , Canada
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18
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Nguyen LT, Guo M, Hemmelgarn B, Quan H, Clement F, Sajobi T, Thomas R, Turin TC, Naugler C. Evaluating practice variance among family physicians to identify targets for laboratory utilization management. Clin Chim Acta 2019; 497:1-5. [PMID: 31228416 DOI: 10.1016/j.cca.2019.06.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 06/05/2019] [Accepted: 06/18/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is widespread variation in testing practice among practitioners, however there has been no objective way to pinpoint target tests for utilization management. We propose to take advantage of inter-physician variance in clinical practice as a quantitative measure to generate lists of potentially misutilized tests. METHODS Testing frequencies from a database of clinical testing volumes for outpatients in Calgary, Canada, were obtained for the study period of 2016. For each chemistry, microbiology or hematology test, an arithmetic coefficient of variation (CV) was calculated from family physicians' ordering frequencies. RESULTS The mean CV for all 358 tests considered was 219% (95% CI 206-231%) with a range of 52-729%. The highest variance was observed for human T-lymphotropic virus antibody testing and several tests for heavy metal levels (mercury, copper, zinc and chromium). Among the 100 most commonly run tests, high variance was found for several endocrinology tests including cortisol. CONCLUSIONS The utility of ranking clinical tests by ordering variance presents a practical approach to evaluate relative variation in physician practice strategy and to identify potential areas of misutilization.
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Affiliation(s)
- Leonard T Nguyen
- Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Maggie Guo
- Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Brenda Hemmelgarn
- Department Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Hude Quan
- Department Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Fiona Clement
- Department Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Tolulope Sajobi
- Department Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Roger Thomas
- Department of Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Tanvir C Turin
- Department of Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Christopher Naugler
- Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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19
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Lifland B, Wright DR, Mangione-Smith R, Desai AD. The Impact of an Adolescent Depressive Disorders Clinical Pathway on Healthcare Utilization. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2019; 45:979-987. [PMID: 29779180 DOI: 10.1007/s10488-018-0878-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Clinical pathways are known to improve the value of health care in medical and surgical settings but have been rarely studied in the psychiatric setting. This study examined the association between level of adherence to an adolescent depressive disorders inpatient clinical pathway and length of stay (LOS), cost, and readmissions. Patients in the high adherence category had significantly longer LOS and higher costs compared to the low adherence category. There was no difference in the odds of 30-day emergency department return visits or readmissions. Understanding which care processes within the pathway are most cost-effective for improving patient-centered outcomes requires further investigation.
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Affiliation(s)
- Brooke Lifland
- University of Washington School of Medicine, Seattle, WA, USA.,Seattle Children's Research Institute, 2001 Eighth Avenue, Suite 400, Seattle, WA, 98121, USA
| | - Davene R Wright
- Seattle Children's Research Institute, 2001 Eighth Avenue, Suite 400, Seattle, WA, 98121, USA
| | - Rita Mangione-Smith
- University of Washington School of Medicine, Seattle, WA, USA.,Seattle Children's Research Institute, 2001 Eighth Avenue, Suite 400, Seattle, WA, 98121, USA
| | - Arti D Desai
- University of Washington School of Medicine, Seattle, WA, USA. .,Seattle Children's Research Institute, 2001 Eighth Avenue, Suite 400, Seattle, WA, 98121, USA.
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20
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Mohammadshahi M, Yazdani S, Olyaeemanesh A, Akbari Sari A, Yaseri M, Emamgholipour Sefiddashti S. A Scoping Review of Components of Physician-induced Demand for Designing a Conceptual Framework. J Prev Med Public Health 2019; 52:72-81. [PMID: 30971073 PMCID: PMC6459765 DOI: 10.3961/jpmph.18.238] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 12/10/2018] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES The current study presents a new conceptual framework for physician-induced demand that comprises several influential components and their interactions. METHODS This framework was developed on the basis of the conceptual model proposed by Labelle. To identify the components that influenced induced demand and their interactions, a scoping review was conducted (from January 1980 to January 2017). Additionally, an expert panel was formed to formulate and expand the framework. RESULTS The developed framework comprises 2 main sets of components. First, the supply side includes 9 components: physicians' incentive for pecuniary profit or meeting their target income, physicians' current income, the physician/population ratio, service price (tariff), payment method, consultation time, type of employment of physicians, observable characteristics of the physician, and type and size of the hospital. Second, the demand side includes 3 components: patients' observable characteristics, patients' non-clinical characteristics, and insurance coverage. CONCLUSIONS A conceptual framework that can clearly describe interactions between the components that influence induced demand is a critical step in providing a scientific basis for understanding physicians' behavior, particularly in the field of health economics.
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Affiliation(s)
- Marita Mohammadshahi
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahrooz Yazdani
- Department of Cardiology, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Alireza Olyaeemanesh
- National Institute of Health Research, Group of Payment and Financial Resources of the Health System, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Akbari Sari
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Yaseri
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Sara Emamgholipour Sefiddashti
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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21
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Sunshine JE, Meo N, Kassebaum NJ, Collison ML, Mokdad AH, Naghavi M. Association of Adverse Effects of Medical Treatment With Mortality in the United States: A Secondary Analysis of the Global Burden of Diseases, Injuries, and Risk Factors Study. JAMA Netw Open 2019; 2:e187041. [PMID: 30657530 PMCID: PMC6484545 DOI: 10.1001/jamanetworkopen.2018.7041] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
IMPORTANCE More than 20 years have passed since the first publication of estimates of the extent of medical harm occurring in hospitals in the United States. Since then, considerable resources have been allocated to improve patient safety, yet policymakers lack a clear gauge of the progress made. OBJECTIVES To quantify the cause-specific mortality associated with adverse effects of medical treatment (AEMT) in the United States from 1990 to 2016 by age group, sex, and state of residence and to describe trends in types of harm and associations with other diseases and injuries. DESIGN, SETTING, AND PARTICIPANTS Cohort study using 1990-2016 data on mortality due to AEMT from the Global Burden of Diseases, Injuries, and Risk Factors (GBD) 2016 study, which assessed death certificates of US decedents. EXPOSURES Death with International Classification of Diseases (ICD)-coded registration. MAIN OUTCOMES AND MEASURES Mortality associated with AEMT. Secondary analyses were performed on all ICD codes in the death certificate's causal chain to describe associations between AEMT and other diseases and injuries. RESULTS From 1990 to 2016, there were an estimated 123 603 deaths (95% uncertainty interval [UI], 100 856-163 814 deaths) with AEMT as the underlying cause. Despite an overall increase in the number of deaths due to AEMT over time, the national age-standardized mortality rate due to AEMT decreased by 21.4% (95% UI, 1.3%-32.2%) from 1.46 (95% UI, 1.09-1.76) deaths per 100 000 population in 1990 to 1.15 (95% UI, 1.00-1.60) deaths per 100 000 population in 2016. Men and women had similar rates of AEMT mortality, and those 70 years or older had mortality rates nearly 20-fold greater compared with those aged 15 to 49 years (mortality rate in 2016 for both sexes, 7.93 [95% UI, 7.23-11.45] per 100 000 population for those aged ≥70 years vs 0.38 [95% UI, 0.34-0.43] per 100 000 population for those aged 15-49 years). Per 100 000 population, California had the lowest age-standardized AEMT mortality rate at 0.84 deaths (95% UI, 0.57-1.47 deaths), whereas Mississippi had the highest mortality rate at 1.67 deaths (95% UI, 1.19-2.03 deaths). Surgical and perioperative events were the most common subtype of AEMT, accounting for 63.6% of all deaths for which an AEMT was identified as the underlying cause. CONCLUSIONS AND RELEVANCE This study's findings suggest a modest reduction in the mortality rate associated with AEMT in the United States from 1990 to 2016 while also observing increased mortality associated with advancing age and noted geographic variability. The annual GBD releases may allow for tracking of the burden of AEMT in the United States.
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Affiliation(s)
- Jacob E. Sunshine
- Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, Seattle
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Nicholas Meo
- Department of Medicine, University of Washington School of Medicine, Seattle
| | - Nicholas J. Kassebaum
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
- Pediatric Anesthesiology and Pain Medicine, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle
| | - Michael L. Collison
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Ali H. Mokdad
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Mohsen Naghavi
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
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22
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Cram P, Lix LM, Bohm E, Yan L, Roos L, Matelski J, Gandhi R, Landon B, Leslie WD. Hip fracture care in Manitoba, Canada and New York State, United States: an analysis of administrative data. CMAJ Open 2019; 7:E55-E62. [PMID: 30755412 PMCID: PMC6404962 DOI: 10.9778/cmajo.20180126] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Nearly 30 years ago, a series of studies showed increased hip fracture mortality in Manitoba compared to the United States, but these data have not been updated. Our objective was to compare the organization of hip fracture care and short-term outcomes in Manitoba and New York State using contemporary data. METHODS This was a retrospective cohort study of administrative data for all adults aged 50 years or more admitted to hospital with hip fracture between Jan. 1, 2011, and Oct. 31, 2013 in Manitoba and New York State. We compared the 2 jurisdictions with respect to: 1) the proportion of hospitals treating hip fracture and annual hip fracture volume, 2) hospital length of stay, 3) death and 4) hospital readmission. We used descriptive statistics, univariate methods and regression models to compare differences in care between jurisdictions. RESULTS We identified 2845 patients (mean age 82.2 yr, 2061 women [72.4%]) with hip fracture in Manitoba and 31 524 patients (mean age 81.9 yr, 22 973 women [72.9%]) with hip fracture in New York. A smaller proportion of hospitals in Manitoba than in New York treated hip fracture (7/30 [23%] v. 180/239 [75.3%]) (p < 0.001); the mean annual hospital hip fracture volume was higher in Manitoba (140.0) than in New York (68.9), but the difference did not reach statistical significance (p = 0.2). For patients with femoral neck fractures, the median hospital length of stay was longer in Manitoba than in New York (13 d v. 7 d). The rate of death within 7 days of admission was similar in Manitoba and New York (1.3% v. 2.0%, p = 0.07), although the rate of in-hospital death was higher in Manitoba (5.7% v. 3.5%, p < 0.001). Readmission within 30 days of discharge was less frequent in Manitoba than in New York (9.8% v. 12.0%, p = 0.02). Results were similar for patients with intertrochanteric fractures. INTERPRETATION Poor short-term outcomes for patients with hip fracture in Manitoba that were documented in the 1980s seem to have been eliminated. Our results should provide optimism that reengineering of clinical care can produce substantive improvements in quality.
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Affiliation(s)
- Peter Cram
- North American Observatory on Health Systems and Policies (Cram), Institute for Health Policy, Management and Evaluation, University of Toronto; Departments of Medicine (Cram) and Surgery (Gandhi), University of Toronto; Division of General Internal Medicine and Geriatrics (Cram), Sinai Health System and University Health Network, Toronto, Ont.; Departments of Community Health Sciences (Lix, Bohm, Yan, Roos), Surgery (Bohm) and Medicine (Leslie), University of Manitoba, Winnipeg, Man.; Biostatistics Research Unit (Matelski) and Arthritis Program (Gandhi), University Health Network, Toronto, Ont.; Department of Health Care Policy (Landon), Harvard Medical School; Division of General Medicine and Primary Care (Landon), Beth Israel Deaconess Medical Center, Boston, Mass.
| | - Lisa M Lix
- North American Observatory on Health Systems and Policies (Cram), Institute for Health Policy, Management and Evaluation, University of Toronto; Departments of Medicine (Cram) and Surgery (Gandhi), University of Toronto; Division of General Internal Medicine and Geriatrics (Cram), Sinai Health System and University Health Network, Toronto, Ont.; Departments of Community Health Sciences (Lix, Bohm, Yan, Roos), Surgery (Bohm) and Medicine (Leslie), University of Manitoba, Winnipeg, Man.; Biostatistics Research Unit (Matelski) and Arthritis Program (Gandhi), University Health Network, Toronto, Ont.; Department of Health Care Policy (Landon), Harvard Medical School; Division of General Medicine and Primary Care (Landon), Beth Israel Deaconess Medical Center, Boston, Mass
| | - Eric Bohm
- North American Observatory on Health Systems and Policies (Cram), Institute for Health Policy, Management and Evaluation, University of Toronto; Departments of Medicine (Cram) and Surgery (Gandhi), University of Toronto; Division of General Internal Medicine and Geriatrics (Cram), Sinai Health System and University Health Network, Toronto, Ont.; Departments of Community Health Sciences (Lix, Bohm, Yan, Roos), Surgery (Bohm) and Medicine (Leslie), University of Manitoba, Winnipeg, Man.; Biostatistics Research Unit (Matelski) and Arthritis Program (Gandhi), University Health Network, Toronto, Ont.; Department of Health Care Policy (Landon), Harvard Medical School; Division of General Medicine and Primary Care (Landon), Beth Israel Deaconess Medical Center, Boston, Mass
| | - Lin Yan
- North American Observatory on Health Systems and Policies (Cram), Institute for Health Policy, Management and Evaluation, University of Toronto; Departments of Medicine (Cram) and Surgery (Gandhi), University of Toronto; Division of General Internal Medicine and Geriatrics (Cram), Sinai Health System and University Health Network, Toronto, Ont.; Departments of Community Health Sciences (Lix, Bohm, Yan, Roos), Surgery (Bohm) and Medicine (Leslie), University of Manitoba, Winnipeg, Man.; Biostatistics Research Unit (Matelski) and Arthritis Program (Gandhi), University Health Network, Toronto, Ont.; Department of Health Care Policy (Landon), Harvard Medical School; Division of General Medicine and Primary Care (Landon), Beth Israel Deaconess Medical Center, Boston, Mass
| | - Leslie Roos
- North American Observatory on Health Systems and Policies (Cram), Institute for Health Policy, Management and Evaluation, University of Toronto; Departments of Medicine (Cram) and Surgery (Gandhi), University of Toronto; Division of General Internal Medicine and Geriatrics (Cram), Sinai Health System and University Health Network, Toronto, Ont.; Departments of Community Health Sciences (Lix, Bohm, Yan, Roos), Surgery (Bohm) and Medicine (Leslie), University of Manitoba, Winnipeg, Man.; Biostatistics Research Unit (Matelski) and Arthritis Program (Gandhi), University Health Network, Toronto, Ont.; Department of Health Care Policy (Landon), Harvard Medical School; Division of General Medicine and Primary Care (Landon), Beth Israel Deaconess Medical Center, Boston, Mass
| | - John Matelski
- North American Observatory on Health Systems and Policies (Cram), Institute for Health Policy, Management and Evaluation, University of Toronto; Departments of Medicine (Cram) and Surgery (Gandhi), University of Toronto; Division of General Internal Medicine and Geriatrics (Cram), Sinai Health System and University Health Network, Toronto, Ont.; Departments of Community Health Sciences (Lix, Bohm, Yan, Roos), Surgery (Bohm) and Medicine (Leslie), University of Manitoba, Winnipeg, Man.; Biostatistics Research Unit (Matelski) and Arthritis Program (Gandhi), University Health Network, Toronto, Ont.; Department of Health Care Policy (Landon), Harvard Medical School; Division of General Medicine and Primary Care (Landon), Beth Israel Deaconess Medical Center, Boston, Mass
| | - Rajiv Gandhi
- North American Observatory on Health Systems and Policies (Cram), Institute for Health Policy, Management and Evaluation, University of Toronto; Departments of Medicine (Cram) and Surgery (Gandhi), University of Toronto; Division of General Internal Medicine and Geriatrics (Cram), Sinai Health System and University Health Network, Toronto, Ont.; Departments of Community Health Sciences (Lix, Bohm, Yan, Roos), Surgery (Bohm) and Medicine (Leslie), University of Manitoba, Winnipeg, Man.; Biostatistics Research Unit (Matelski) and Arthritis Program (Gandhi), University Health Network, Toronto, Ont.; Department of Health Care Policy (Landon), Harvard Medical School; Division of General Medicine and Primary Care (Landon), Beth Israel Deaconess Medical Center, Boston, Mass
| | - Bruce Landon
- North American Observatory on Health Systems and Policies (Cram), Institute for Health Policy, Management and Evaluation, University of Toronto; Departments of Medicine (Cram) and Surgery (Gandhi), University of Toronto; Division of General Internal Medicine and Geriatrics (Cram), Sinai Health System and University Health Network, Toronto, Ont.; Departments of Community Health Sciences (Lix, Bohm, Yan, Roos), Surgery (Bohm) and Medicine (Leslie), University of Manitoba, Winnipeg, Man.; Biostatistics Research Unit (Matelski) and Arthritis Program (Gandhi), University Health Network, Toronto, Ont.; Department of Health Care Policy (Landon), Harvard Medical School; Division of General Medicine and Primary Care (Landon), Beth Israel Deaconess Medical Center, Boston, Mass
| | - William D Leslie
- North American Observatory on Health Systems and Policies (Cram), Institute for Health Policy, Management and Evaluation, University of Toronto; Departments of Medicine (Cram) and Surgery (Gandhi), University of Toronto; Division of General Internal Medicine and Geriatrics (Cram), Sinai Health System and University Health Network, Toronto, Ont.; Departments of Community Health Sciences (Lix, Bohm, Yan, Roos), Surgery (Bohm) and Medicine (Leslie), University of Manitoba, Winnipeg, Man.; Biostatistics Research Unit (Matelski) and Arthritis Program (Gandhi), University Health Network, Toronto, Ont.; Department of Health Care Policy (Landon), Harvard Medical School; Division of General Medicine and Primary Care (Landon), Beth Israel Deaconess Medical Center, Boston, Mass
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Kotwal AA, Abdoler E, Diaz-Ramirez LG, Kelley AS, Ornstein KA, Boscardin WJ, Smith AK. 'Til Death Do Us Part: End-of-Life Experiences of Married Couples in a Nationally Representative Survey. J Am Geriatr Soc 2018; 66:2360-2366. [PMID: 30251423 DOI: 10.1111/jgs.15573] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 07/17/2018] [Accepted: 07/17/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To determine whether end-of-life (EOL) experiences in the first spouse in a marriage are associated with EOL experiences in the other spouse. DESIGN Nationally representative, longitudinal survey. SETTING Health and Retirement Study, Waves 1992-2012 linked to Medicare claims PARTICIPANTS: Community-dwelling older adults who died (N=4,558), representing 2,279 married heterosexual couples. MEASUREMENTS We examined 3 EOL experiences: enrollment in hospice for >3 days before death, lack of advance care planning (ACP) before death, and intensive care unit (ICU) use during the last 30 days of life. We used multiple logistic regression to determine whether the EOL experience of the first spouse was a significant predictor of the EOL experience of the second spouse after adjusting for demographic characteristics, socioeconomic status, health status, and time between the first and second spouses' deaths. RESULTS First spouses who died were on average 80 years old, and 62% were male; second spouses were on average 85 years old, and 62% were female. After adjustment, second spouses were more likely to use hospice if the first spouse used hospice (odds ratio (OR)=1.68, 95% confidence interval (CI)=1.29-2.20). Second spouses were less likely to have ACP when the first spouse did not have ACP (OR=2.91, 95% CI=2.02-4.21). Hospice and ACP associations were stronger when deaths were closer in time to one another (p-value for interaction < .05). Second spouses were more likely to use ICU services if the first spouse did (OR=1.80, 95% CI=1.27-2.55). CONCLUSIONS The EOL experiences of older spouses are strongly associated, which may be relevant when framing ACP discussions. J Am Geriatr Soc 66:2360-2366, 2018.
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Affiliation(s)
- Ashwin A Kotwal
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.,Geriatrics, Palliative, and Extended Care, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Emily Abdoler
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - L Grisell Diaz-Ramirez
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Amy S Kelley
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Katherine A Ornstein
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - W John Boscardin
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.,Geriatrics, Palliative, and Extended Care, San Francisco Veterans Affairs Medical Center, San Francisco, California.,Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Alexander K Smith
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.,Geriatrics, Palliative, and Extended Care, San Francisco Veterans Affairs Medical Center, San Francisco, California
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Deng H, Yue JK, Winkler EA, Dhall SS, Manley GT, Tarapore PE. Adult Firearm-Related Traumatic Brain Injury in United States Trauma Centers. J Neurotrauma 2018; 36:322-337. [PMID: 29855212 DOI: 10.1089/neu.2017.5591] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Civilian firearm injury is an important public health concern in the United States. Gunshot wounds to the head (GSWH) remain in need of update and systematic characterization. We identify predictors of prolonged hospital length of stay (HLOS), intensive care unit length of stay (ICU LOS), medical complications, mortality, and discharge disposition from a population-based sample using the National Sample Program (NSP) of the National Trauma Data Bank (NTDB), years 2003-2012. Statistical significance was assessed at α < 0.001 to correct for multiple comparisons. In total, 8148 adult GSWH patients were included extrapolating to 32,439 national incidents. Age was 36.6 ± 16.4 years and 64.4% were severe traumatic brain injury (TBI; Glasgow Coma Scale [GCS] score 3-8). Assault (49.2%), handgun (50.3%), and residential injury (43.2%) were of highest incidence. HLOS and ICU LOS were 7.7 ± 14.2 and 5.7 ± 13.4 days, respectively. Overall mortality was 54.6%; suicide/self-injury was associated with the highest mortality rate (71.6%). GCS, Injury Severity Score, and hypotension were significant predictors for outcomes overall. Medicare/Medicaid patients had longer HLOS compared to private/commercial insured (mean increase, 4.4 days; 95% confidence interval [2.6-6.3]). Compared to the Midwest, the South had longer HLOS (mean increase, 3.7 days; [2.0-5.4]) and higher odds of complications (odds ratio [OR], 1.7 [1.4-2.0]); the West had lower odds of complications (OR, 0.6; [0.5-0.7]). Versus handgun, shotgun (OR, 0.3; [0.2-0.4]) and hunting rifle (OR, 0.5; [0.4-0.8]) resulted in lower mortality. Patients with government/other insurance had higher odds of discharging home compared to private/commercially insured (OR, 1.7; [1.3-2.3]). In comparison to level I trauma centers, level II trauma centers had lower odds of discharge to home (OR, 0.7; [0.5-0.8]). Our results support hypotension, injury severity, injury intent, firearm type, and U.S. geographical location as important prognostic variables in firearm-related TBI. Improved understanding of civilian GSWH is critical to promoting increased awareness of firearm injuries as a public health concern and reducing its debilitating injury burden to patients, families, and healthcare systems.
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Affiliation(s)
- Hansen Deng
- 1 Department of Neurological Surgery, University of California, San Francisco, San Francisco, California.,2 Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
| | - John K Yue
- 1 Department of Neurological Surgery, University of California, San Francisco, San Francisco, California.,2 Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
| | - Ethan A Winkler
- 1 Department of Neurological Surgery, University of California, San Francisco, San Francisco, California.,2 Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
| | - Sanjay S Dhall
- 1 Department of Neurological Surgery, University of California, San Francisco, San Francisco, California.,2 Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
| | - Geoffrey T Manley
- 1 Department of Neurological Surgery, University of California, San Francisco, San Francisco, California.,2 Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
| | - Phiroz E Tarapore
- 1 Department of Neurological Surgery, University of California, San Francisco, San Francisco, California.,2 Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
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25
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Kurant DE, Baron JM, Strazimiri G, Lewandrowski KB, Rudolf JW, Dighe AS. Creation and Use of an Electronic Health Record Reporting Database to Improve a Laboratory Test Utilization Program. Appl Clin Inform 2018; 9:519-527. [PMID: 29998456 PMCID: PMC6041118 DOI: 10.1055/s-0038-1666843] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 05/26/2018] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVES Laboratory-based utilization management programs typically rely primarily on data derived from the laboratory information system to analyze testing volumes for trends and utilization concerns. We wished to examine the ability of an electronic health record (EHR) laboratory orders database to improve a laboratory utilization program. METHODS We obtained a daily file from our EHR containing data related to laboratory test ordering. We then used an automated process to import this file into a database to facilitate self-service queries and analysis. RESULTS The EHR laboratory orders database has proven to be an important addition to our utilization management program. We provide three representative examples of how the EHR laboratory orders database has been used to address common utilization issues. We demonstrate that analysis of EHR laboratory orders data has been able to provide unique insights that cannot be obtained by review of laboratory information system data alone. Further, we provide recommendations on key EHR data fields of importance to laboratory utilization efforts. CONCLUSION We demonstrate that an EHR laboratory orders database may be a useful tool in the monitoring and optimization of laboratory testing. We recommend that health care systems develop and maintain a database of EHR laboratory orders data and integrate this data with their laboratory utilization programs.
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Affiliation(s)
- Danielle E. Kurant
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Jason M. Baron
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, United States
| | | | - Kent B. Lewandrowski
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Joseph W. Rudolf
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, United States
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis, Minnesota, United States
| | - Anand S. Dighe
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, United States
- Partners HealthCare, Boston, Massachusetts, United States
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26
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Briasoulis A, Inampudi C, Akintoye E, Adegbala O, Asleh R, Alvarez P, Bhama J. Regional Variation in Mortality, Major Complications, and Cost After Left Ventricular Assist Device Implantation in the United States (2009 to 2014). Am J Cardiol 2018; 121:1575-1580. [PMID: 29731117 DOI: 10.1016/j.amjcard.2018.02.047] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 02/14/2018] [Accepted: 02/26/2018] [Indexed: 11/26/2022]
Abstract
The objective of this analysis was to provide evidence on regional differences in outcomes, cost and disposition among patients who undergo continuous-flow LVAD implantation. Using data from the National Inpatient Sample and US Census Bureau, annual national estimates in utilization, in-hospital mortality, major complications, cost, length of stay (LOS), and disposition were estimated for years 2009 to 2014. Main outcomes and complications were identified using patient safety indicators and International Classification of Diseases-Ninth Revision, Clinical Modification codes. We analyzed a total of 3,572 (weighted = 17,552) patients with LVAD implants among the 4 Census regions of the United States. The patient population in the Southern region was younger with higher percentage of African-Americans. Overall, the comorbidity burden was higher in the Midwest. The risk-adjusted rate of in-hospital mortality did not differ significantly among the geographical regions (p = 0.8). With the exception of cardiac tamponade rates which were higher in the Northeast and West, all other post-operative complications did not differ between regions. LOS was higher in the Northeast (median 32 days) and lower in the South (median 27 days). The cost analysis suggested higher median cost in the West (median $246,292) and lowest in the Northeast region (median $192,604). Finally, higher percentages of patients were transferred to an extended care facility in the Northeast, whereas more patients were discharged to home in the Western region. We identified region disparities in LOS, cost and disposition but not in-hospital mortality and complications, among patients who underwent LVAD implantation between 2009 and 2014.
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27
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Johansson N, Jakobsson N, Svensson M. Regional variation in health care utilization in Sweden - the importance of demand-side factors. BMC Health Serv Res 2018; 18:403. [PMID: 29866201 PMCID: PMC5987462 DOI: 10.1186/s12913-018-3210-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 05/16/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Differences in health care utilization across geographical areas are well documented within several countries. If the variation across areas cannot be explained by differences in medical need, it can be a sign of inefficiency or misallocation of public health care resources. METHODS In this observational, longitudinal panel study we use regional level data covering the 21 Swedish regions (county councils) over 13 years and a random effects model to assess to what degree regional variation in outpatient physician visits is explained by observed demand factors such as health, demography and socio-economic factors. RESULTS The results show that regional mortality, as a proxy for population health, and demography do not explain regional variation in visits to primary care physicians, but explain about 50% of regional variation in visits to outpatient specialists. Adjusting for socio-economic and basic supply-side factors explains 33% of the regional variation in primary physician visits, but adds nothing to explaining the variation in specialist visits. CONCLUSION 50-67% of regional variation remains unexplained by a large number of observable regional characteristics, indicating that omitted and possibly unobserved factors contribute substantially to the regional variation. We conclude that variations in health care utilization across regions is not very well explained by underlying medical need and demand, measured by mortality, demographic and socio-economic factors.
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Affiliation(s)
- Naimi Johansson
- Health Metrics, Sahlgrenska Academy, University of Gothenburg, PO Box 463, SE-405 30 Gothenburg, Sweden
| | - Niklas Jakobsson
- Department of Economics, Karlstad University, SE-651 88 Karlstad, Sweden
- Norwegian Social Research (NOVA), Oslo, Norway
| | - Mikael Svensson
- Health Metrics, Sahlgrenska Academy, University of Gothenburg, PO Box 463, SE-405 30 Gothenburg, Sweden
- Department of Economics, Williams College, Williamstown, MA USA
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28
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Rayo MF, Pawar C, Sanders EBN, Liston BW, Patterson ES. PARTICIPATORY BULLSEYE TOOLKIT INTERVIEW: IDENTIFYING PHYSICIANS' RELATIVE PRIORITIZATION OF DECISION FACTORS WHEN ORDERING RADIOLOGIC IMAGING IN A HOSPITAL SETTING. PROCEEDINGS OF THE INTERNATIONAL SYMPOSIUM OF HUMAN FACTORS AND ERGONOMICS IN HEALTHCARE. INTERNATIONAL SYMPOSIUM OF HUMAN FACTORS AND ERGONOMICS IN HEALTHCARE 2018; 7:1-7. [PMID: 30035146 PMCID: PMC6054591 DOI: 10.1177/2327857918071001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Critical Decision Method (CDM), a popular cognitive task analysis (CTA) method, is an in-depth retrospective interview that uses a historical non-routine incident to identify experts' decision-making factors in complex socio-technical settings with high consequences for failure. However, it is challenging to use CDM to make comparisons, including those between experts and trainees. We describe an alternative CTA method used to study physicians' decision making for ordering diagnostic imaging. After being primed with 11 simulated patient scenarios, nine attending and 11 resident physicians were asked to map out and present their decision-making process with a bullseye participatory design toolkit. Interviews were analyzed qualitatively, revealing four common decision factors: diagnostic efficacy, patient safety, organizational constraints, and patient comfort. The bullseye maps were used to quantitatively measure priority differences between these decision factors. Attending and resident physicians both prioritized diagnostic efficacy over the other factors (2.38 vs. 3.71, p <.01, and 2.59 vs. 3.52, p<.01, respectively), but attending physicians' decisions had a higher proportion of non-diagnostic items (65% vs. 50%, p = .008). Our results demonstrate the usefulness of this method in eliciting decision factors for a complex, face-valid task and for identifying differences due to levels of expertise and training.
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29
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Romano MJ, Toye P, Patchen L. Continuation of long-acting reversible contraceptives among Medicaid patients. Contraception 2018; 98:S0010-7824(18)30148-3. [PMID: 29702080 DOI: 10.1016/j.contraception.2018.04.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 04/12/2018] [Accepted: 04/18/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Our objective was to compare continuation and complication rates of subdermal etonogestrel implants and intrauterine devices (IUDs) using Medicaid insurance claims. STUDY DESIGN We performed a retrospective cohort study using insurance claims data for 15- to 44-year-old subjects receiving implants or IUDs from 2012 to 2015 in a Medicaid managed care organization in Washington, DC, and Maryland. We performed a planned Kaplan-Meier survival analysis for long-acting reversible contraceptive (LARC) continuation, defined as the absence of a claim for LARC removal, during periods of continuous insurance plan enrollment. RESULTS Three thousand one hundred three subjects received 1335 implants and 1970 IUDs, with implants more common than IUDs among subjects 15-19 years old (rate ratio=2.42), and implants less common than IUDs for subjects 20-44 years old (rate ratio=0.54). Implants had higher continuation rates at 1 year than IUDs (81.0% vs. 76.7%, p=.01). The difference was larger among subjects 25 to 44 years old (84.1% vs. 79.3%, p=.03) compared with subjects 15 to 19 years old (89.5% vs. 86.8%, p=.09) and subjects 20 to 24 years old (75.7% vs. 73.2%, p=.44). Claims for potential complications were similarly uncommon for both implants and IUDs (8.09% vs. 6.95%, p=.65), as were claims for pregnancies prior to LARC removal (0.82% vs. 0.86%, p=.86). CONCLUSION Among a sample of 15- to 44-year-old Medicaid recipients, both implants and IUDs had high continuation rates and low complication rates; however, implants were slightly more likely than IUDs to remain in use 1 year after insertion. IMPLICATIONS Among 15- to 44-year-old Medicaid recipients, both etonogestrel implants and IUDs have high continuation rates and low complication rates at 1-year postinsertion; however, implants are slightly more likely than IUDs to remain in use at 1 year.
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Affiliation(s)
- Max J Romano
- MedStar Franklin Square Medical Center Department of Family Medicine, 9101 Franklin Square Dr. Baltimore, MD 21237; Johns Hopkins Bloomberg School of Public Health General Preventive Medicine Residency, 615 N. Wolfe St. Room WB602, Baltimore, MD 21205-1996.
| | - Patryce Toye
- MedStar Family Choice, 5233 King Ave, Ste. 400, Rosedale, MD 21237
| | - Loral Patchen
- MedStar Health Research Institute, 110 Irving St. NW Suite EB-7113, Washington, DC 20010; MedStar Washington Hospital Center, 110 Irving St. NW Suite EB-7113, Washington, DC 20010
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30
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Cole AP, Friedlander DF, Trinh QD. Secondary data sources for health services research in urologic oncology. Urol Oncol 2018; 36:165-173. [DOI: 10.1016/j.urolonc.2017.08.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 08/03/2017] [Accepted: 08/09/2017] [Indexed: 12/15/2022]
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Lord J, Davlyatov G, Thomas KS, Hyer K, Weech-Maldonado R. The Role of Assisted Living Capacity on Nursing Home Financial Performance. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2018; 55:46958018793285. [PMID: 30141704 PMCID: PMC6109846 DOI: 10.1177/0046958018793285] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 07/05/2018] [Accepted: 07/06/2018] [Indexed: 11/16/2022]
Abstract
The rapid growth of the assisted living industry has coincided with decreased levels of nursing home occupancy and financial performance. The purpose of this article is to examine the relationships among assisted living capacity, nursing home occupancy, and nursing home financial performance. In addition, we explore whether the relationship between assisted living capacity and nursing home financial performance is mediated by nursing home occupancy. This research utilized publicly available secondary data, for the state of Florida from 2003 through 2015. General descriptive statistics were used to assess the relationships among financial performance, assisted living capacity, and occupancy. To explore the relationships among financial performance, assisted living capacity and occupancy, and test potential mediation of occupancy, we followed Baron and Kenny's approach and estimated 3 models examining the relationships between (1) assisted living capacity and nursing home financial performance, (2) assisted living capacity and nursing home occupancy, and (3) nursing home occupancy and financial performance after assisted living capacity is included in the model. We used generalized estimating equations, to adjust for repeated measures and to model the above relationships. Year fixed effects control for time trend. The independent variable, assisted living beds, was lagged for 1 year to account for the potential influence on financial performance. The final analytic sample consisted of 7688 nursing home-year observations from 657 unique nursing homes. Our findings suggest that assisted living capacity does have a negative impact on nursing homes' financial performance. Even though, assisted living capacity seems not to significantly decrease nursing home occupancy. The relationship between assisted living capacity and financial performance was not mediated through occupancy. These findings suggest that assisted living communities may not be able to significantly reduce nursing home occupancy; however, the presence of assisted living communities may create additional financial/competitive pressures that result in decreased nursing home financial performance.
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Glass DP, Kanter MH, Jacobsen SJ, Minardi PM. The impact of improving access to primary care. J Eval Clin Pract 2017; 23:1451-1458. [PMID: 28984018 PMCID: PMC5765488 DOI: 10.1111/jep.12821] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Revised: 08/03/2017] [Accepted: 08/04/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To measure the size and timing of changes in utilization and costs for employees and dependents who had major access barriers to primary care removed, across an 8-year period (2007 to 2014). STUDY DESIGN AND METHODS Retrospective observational study examining patterns of utilization and costs before and after the implementation of a worksite medical office in 2010. The worksite office offered convenient primary care services with no travel from work, essentially guaranteed same day access, and no co-pay. Trends in visit rates and costs were compared for an intervention fixed cohort group (employees and dependents) at the employer (n = 1211) with a control fixed cohort group (n = 542 162) for 6 types of visits (primary, urgent, emergency, inpatient, specialty, and other outpatient). Difference-in-differences methods assessed the significance of between-group changes in utilization and costs. RESULTS The worksite medical office intervention group had an increase in primary care visits relative to the control group (+43% vs +4%, P < 0.001). This was accompanied by a reduction in urgent care visits by the intervention group compared with the control group (-43% vs -5%, P < 0.001). There were no differences in the other types of visits, and the total visit costs for the intervention group increased 5.7% versus 2.7% for the control group (P = 0.008). A sub-group analysis of the intervention group (comparing dependents to employees) found that that the dependents achieved a reduction in costs of 2.7% (P < 0.001) across the study period. CONCLUSIONS The potential for long-term reduction in utilization and costs with better access to primary care is significant, but not easily nor automatically achieved.
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Affiliation(s)
- David P Glass
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Michael H Kanter
- The Permanente Federation and Associate Dean of the Medical School, Pasadena, CA, USA
| | - Steven J Jacobsen
- Department of Research & Evaluation, Kaiser Permanente Southern California, CA, USA
| | - Paul M Minardi
- Southern California Permanente Medical Group, Pasadena, CA, USA
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Crouch EL, Probst JC, Bennett KJ, Hardin JW. Supply-Side Differences Only Modestly Associated With Inpatient Hospitalizations Among Medicare Beneficiaries in the Last Six Months of Life. J Pain Symptom Manage 2017; 54:661-669. [PMID: 28754441 DOI: 10.1016/j.jpainsymman.2017.06.002] [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] [Received: 03/17/2017] [Revised: 05/08/2017] [Accepted: 06/07/2017] [Indexed: 10/19/2022]
Abstract
CONTEXT Inpatient hospitalizations are a driver of expenditures at the end of life and are a useful proxy for the intensity of care at that time. OBJECTIVES Our study profiled rural and urban Medicare decedents to examine whether they differed in rates of inpatient hospital admissions in the last six months of life. METHODS Using a sample of 35,831 beneficiaries from the 2013 Medicare Research Identifiable Files, we examined inpatient hospital utilization patterns for a full six months before death. Supply-side variables included the number of hospital beds, certified skilled nursing facility beds, and hospice beds per 1000 residents, plus primary care provider/population ratios. Patient characteristics included age, sex, race/ethnicity, dual eligibility status, region, and chronic conditions. RESULTS In both adjusted and unadjusted analysis, rural vs. urban residence was not associated with an increased risk for hospitalization at the end of life among Medicare beneficiaries nor was there a relationship between the supply of hospital, skilled nursing, and hospice services and the rate of hospitalization. Within rural residents alone, modest effects were found for facility supply. Rural residents in a county without a hospital were slightly less likely than other rural decedents to have been hospitalized during their last six months of life but were no less likely to have used skilled nursing facilities or hospice. CONCLUSIONS The absence of major disparities in utilization suggests that end-of-life care is reasonably equitable for rural Medicare beneficiaries.
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Affiliation(s)
- Elizabeth L Crouch
- South Carolina Rural Health Research Center and Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA.
| | - Janice C Probst
- Department of Health Services Policy and Management, South Carolina Rural Health Research Center and Center for Research in Nutrition and Health Disparities, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - Kevin J Bennett
- South Carolina Rural Health Research Center, Arnold School of Public Health and Department of Family and Preventive Medicine, School of Medicine, University of South Carolina, Columbia, South Carolina, USA
| | - James W Hardin
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
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Sullivan DR, Ganzini L, Lapidus JA, Hansen L, Carney PA, Osborne ML, Fromme EK, Izumi S, Slatore CG. Improvements in hospice utilization among patients with advanced-stage lung cancer in an integrated health care system. Cancer 2017; 124:426-433. [PMID: 29023648 DOI: 10.1002/cncr.31047] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 08/12/2017] [Accepted: 09/05/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND Hospice, a patient-centered care system for those with limited life expectancy, is important for enhancing quality of life and is understudied in integrated health care systems. METHODS This was a retrospective cohort study of 21,860 decedents with advanced-stage lung cancer diagnosed from January 2007 to June 2013 in the national US Veterans Affairs Health Care System. Trends over time, geographic regional variability, and patient and tumor characteristics associated with hospice use and the timing of enrollment were examined. Multivariable logistic regression and Cox proportional hazards modeling were used. RESULTS From 2007 to 2013, 70.3% of decedents with advanced-stage lung cancer were enrolled in hospice. Among patients in hospice, 52.9% were enrolled in the last month of life, and 14.7% were enrolled in the last 3 days of life. Hospice enrollment increased (adjusted odds ratio [AOR], 1.07; P < .001), whereas the mean time from the cancer diagnosis to hospice enrollment decreased by 65 days (relative decrease, 32%; adjusted hazard ratio, 1.04; P < .001). Relative decreases in late hospice enrollment were observed in the last month (7%; AOR, 0.98; P = .04) and last 3 days of life (26%; AOR, 0.95; P < .001). The Southeast region of the United States had both the highest rate of hospice enrollment and the lowest rate of late enrollment. Patient sociodemographic and lung cancer characteristics were associated with hospice enrollment. CONCLUSIONS Among patients with advanced-stage lung cancer in the Veterans Affairs Health Care System, overall and earlier hospice enrollment increased over time. Considerable regional variability in hospice enrollment and the persistence of late enrollment suggests opportunities for improvement in end-of-life care. Cancer 2018;124:426-33. © 2017 American Cancer Society.
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Affiliation(s)
- Donald R Sullivan
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon.,Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, Oregon.,Cancer Prevention and Control Program, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Linda Ganzini
- Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, Oregon.,Division of Geriatric Psychiatry, Department of Psychiatry, Oregon Health and Science University, Portland, Oregon
| | - Jodi A Lapidus
- Biostatistics, School of Public Health, Oregon Health and Science University, Portland, Oregon
| | - Lissi Hansen
- School of Nursing, Oregon Health and Science University, Portland, Oregon
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon
| | - Molly L Osborne
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon.,Palliative Care Service, Oregon Health and Science University, Portland, Oregon
| | - Erik K Fromme
- Palliative Care Service, Oregon Health and Science University, Portland, Oregon.,Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Seiko Izumi
- School of Nursing, Oregon Health and Science University, Portland, Oregon
| | - Christopher G Slatore
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon.,Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, Oregon.,Cancer Prevention and Control Program, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon.,Section of Pulmonary and Critical Care Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon
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Akintoye E, Briasoulis A, Egbe A, Adegbala O, Sheikh M, Singh M, Alliu S, Ahmed A, Asleh R, Kushwaha S, Levine D. Regional Variation in Mortality, Length of Stay, Cost, and Discharge Disposition Among Patients Admitted for Heart Failure in the United States. Am J Cardiol 2017; 120:817-824. [PMID: 28705376 DOI: 10.1016/j.amjcard.2017.05.058] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 05/11/2017] [Accepted: 05/23/2017] [Indexed: 11/16/2022]
Abstract
The objective of the study was to provide contemporary evidence on regional variation in hospitalization outcomes in patients with heart failure (HF) in the United States. Using the National Inpatient Sample, we compared hospitalization outcomes among primary HF admissions (2013 to 2014) among the 4 Census regions of the United States. Overall, an estimated 1.9 million HF hospitalizations occurred in the United States over the study period. Mortality rate was 3%, the mean length of stay was 5.3 days, the median cost of hospitalization was US$7,248, and the rate of routine home discharge was 51%. There was a significant regional variation for all end points (p <0.001); for example, compared with other regions of the country, the risk-adjusted rate of in-hospital mortality was highest in the Northeast (3.2%) and lowest in the Midwest (2.7%); and within each region, these mortalities were higher in the rural locations (range: 3.0% to 3.8%) than in the urban locations (range: 2.7% to 3.1%). In addition, the Northeast region had the longest length of stay (mean: 5.9 days) and the lowest risk-adjusted rate of routine home discharge (42%). However, the cost of hospitalization was highest in the West (median: US$8,898) and lowest in the South (US$6,366). A similar pattern of variation was found in subgroup analysis except that the risk-adjusted rate of in-hospital mortality was highest in the West among patients <65 years (1.7% vs 1.2% [lowest] in the Midwest), male gender (3.2% vs 2.8% in the Midwest), and rural location (3.8% vs 3% in the Midwest). In conclusion, HF hospitalization outcomes tend to be worse in the Northeast compared with other regions of the country. In addition, the in-hospital mortality rate was higher in rural locations than in urban locations.
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Affiliation(s)
- Emmanuel Akintoye
- Department of Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, Michigan.
| | | | - Alexander Egbe
- Department of Cardiology, Mayo Clinic, Rochester, New York
| | - Oluwole Adegbala
- Department of Internal Medicine, Englewood Hospital and Medical Center, Mount Sinai Health System, Englewood, New Jersey
| | - Muhammad Sheikh
- Department of Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, Michigan
| | - Manmohan Singh
- Department of Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, Michigan
| | - Samson Alliu
- Department of Internal Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Abdelrahman Ahmed
- Department of Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, Michigan
| | - Rabea Asleh
- Department of Cardiology, Mayo Clinic, Rochester, New York
| | | | - Diane Levine
- Department of Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, Michigan
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Nash R, Goodman M, Lin CC, Freedman RA, Dominici LS, Ward K, Jemal A. State Variation in the Receipt of a Contralateral Prophylactic Mastectomy Among Women Who Received a Diagnosis of Invasive Unilateral Early-Stage Breast Cancer in the United States, 2004-2012. JAMA Surg 2017; 152:648-657. [PMID: 28355431 DOI: 10.1001/jamasurg.2017.0115] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance The use of contralateral prophylactic mastectomies (CPMs) among patients with invasive unilateral breast cancer has increased substantially during the past decade in the United States despite the lack of evidence for survival benefit. However, whether this trend varies by state or whether it is correlated with changes in proportions of reconstructive surgery among these patients is unclear. Objective To determine state variation in the temporal trend and in the proportion of CPMs among women with early-stage unilateral breast cancer treated with surgery. Design, Setting, and Participants A retrospective cohort study of 1.2 million women 20 years of age or older diagnosed with invasive unilateral early-stage breast cancer and treated with surgery from January 1, 2004, through December 31, 2012, in 45 states and the District of Columbia as compiled by the North American Association of Central Cancer Registries. Data analysis was performed from August 1, 2015, to August 31, 2016. Exposure Contralateral prophylactic mastectomy. Main Outcomes and Measures Temporal changes in the proportion of CPMs among women with early-stage unilateral breast cancer treated with surgery by age and state, overall and in relation to changes in the proportions of those who underwent reconstructive surgery. Results Among the 1 224 947 women with early-stage breast cancer treated with surgery, the proportion who underwent a CPM nationally increased between 2004 and 2012 from 3.6% (4013 of 113 001) to 10.4% (12 890 of 124 231) for those 45 years or older and from 10.5% (1879 of 17 862) to 33.3% (5237 of 15 745) for those aged 20 to 44 years. The increase was evident in all states, although the magnitude of the increase varied substantially across states. For example, among women 20 to 44 years of age, the proportion who underwent a CPM from 2004-2006 to 2010-2012 increased from 14.9% (317 of 2121) to 24.8% (436 of 1755) (prevalence ratio [PR], 1.66; 95% CI, 1.46-1.89) in New Jersey compared with an increase from 9.8% (162 of 1657) to 32.2% (495 of 1538) (PR, 3.29; 95% CI, 2.80-3.88) in Virginia. In this age group, CPM proportions for the period from 2010 to 2012 were over 42% in the contiguous states of Nebraska, Missouri, Colorado, Iowa, and South Dakota. From 2004 to 2012, the proportion of reconstructive surgical procedures among women aged 20 to 44 years who were diagnosed with early-stage breast cancer and received a CPM increased in many states; however, it did not correlate with the proportion of women who received a CPM. Conclusions and Relevance The increase in the proportion of CPMs among women with early-stage unilateral breast cancer treated with surgery varied substantially across states. Notably, in 5 contiguous Midwest states, nearly half of young women with invasive early-stage breast cancer underwent a CPM from 2010 to 2012. Future studies should examine the reasons for the geographic variation and increasing trend in the use of CPMs.
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Affiliation(s)
- Rebecca Nash
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Michael Goodman
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Chun Chieh Lin
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
| | | | - Laura S Dominici
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kevin Ward
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Ahmedin Jemal
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
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Chan K, Abouzamzam A, Woo K. Carotid Endarterectomy in the Southern California Vascular Outcomes Improvement Collaborative. Ann Vasc Surg 2017; 42:11-15. [PMID: 28323231 PMCID: PMC5559870 DOI: 10.1016/j.avsg.2016.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 11/10/2016] [Accepted: 11/21/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND The objective of this study was to examine the variation in practice patterns and associated outcomes for carotid endarterectomy (CEA) within the Southern California Vascular Outcomes Improvement Collaborative (So Cal VOICe), a regional quality group of the Vascular Quality Initiative. METHODS All cases entered in the CEA registry by the So Cal VOICe were included in the study. RESULTS From September 2010 through September 2015, 1,110 CEA cases were entered by 9 centers in the So Cal VOICe. Six hundred seventy-seven patients (61%) were male with mean age of 73 years. Nine hundred eighty-eight (89%) were hypertensive, 655 (59%) were prior or current smokers, 389 (35%) were diabetics, and 233 (21%) had coronary artery disease. Eight hundred twenty-one (74%) patients were asymptomatic (no history of ipsilateral neurologic event). The percentage of asymptomatic patients varied across the 9 centers from 57% to 91%. Preoperatively, 344 (31%) underwent cardiac stress test, center variation 13-75%, 500 (45%) underwent only duplex, center variation 11-72%. Intraoperatively, 600 (54%) underwent routine shunting, whereas 67 (6%) were shunted for an indication, and 444 (40%) were not shunted. Wound drainage was used in 422 (38%) cases, center variation 2-98%. Completion imaging by duplex and/or angiogram was performed in 766 (69%) cases, center variation 0-100%. Postoperatively, 11 (1%) patients had a new ipsilateral postoperative neurologic event, center variation 0-1.3%, 6 (0.5%) had a postoperative myocardial infarction, center variation 0-1.3%, and 8 (0.7%) required return to operating room for bleeding, center variation 0-1.3%. CONCLUSIONS Despite wide variation in practice patterns surrounding CEA in the So Cal VOICe, postoperative complications were uniformly low. Further work will focus on identifying practices that can be modified to improve cost-effectiveness while maintaining excellent outcomes.
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Affiliation(s)
- Kaelan Chan
- Department of Surgery, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA
| | - Ahmed Abouzamzam
- Department of Surgery, Loma Linda University School of Medicine, Loma Linda, CA
| | - Karen Woo
- Department of Surgery, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA.
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Rosenkrantz AB, Hughes DR, Prabhakar AM, Duszak R. County-Level Population Economic Status and Medicare Imaging Resource Consumption. J Am Coll Radiol 2017; 14:725-732. [DOI: 10.1016/j.jacr.2016.11.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Revised: 11/09/2016] [Accepted: 11/25/2016] [Indexed: 11/30/2022]
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40
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Schmocker RK, Vanness DJ, Greenberg CC, Havlena JA, LoConte NK, Weiss JM, Neuman HB, Leverson G, Smith MA, Winslow ER. Utilization of preoperative endoscopic ultrasound for pancreatic adenocarcinoma. HPB (Oxford) 2017; 19:465-472. [PMID: 28237627 PMCID: PMC5695546 DOI: 10.1016/j.hpb.2017.01.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Revised: 12/21/2016] [Accepted: 01/04/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endoscopic ultrasound (EUS) is used for pancreatic adenocarcinoma staging and obtaining a tissue diagnosis. The objective was to determine patterns of preoperative EUS and the impact on downstream treatment. METHODS The Surveillance, Epidemiology, and End Results (SEER) Medicare-linked database was used to identify patients with pancreatic adenocarcinoma. The staging period was the first staging procedure within 6 months of surgery until surgery. Logistic regression was used to determine factors associated with preoperative EUS. The main outcome was EUS in the staging period, with secondary outcomes including number of staging tests and time to surgery. RESULTS 2782 patients were included, 56% were treated at an academic hospital (n = 1563). 1204 patients underwent EUS (43.3%). The factors most associated with receipt of EUS were: earlier year of diagnosis, SEER area, and a NCI or academic hospital (all p < 0.0001). EUS was associated with a longer time to surgery (17.8 days; p < 0.0001), and a higher number of staging tests (40 tests/100 patients; p < 0.0001). CONCLUSIONS Factors most associated with receipt of EUS are geographic, temporal, and institutional, rather than clinical/disease factors. EUS is associated with a longer time to surgery and more preoperative testing, and additional study is needed to determine if EUS is overused.
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Affiliation(s)
- Ryan K Schmocker
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, USA
| | - David J Vanness
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, USA
| | - Caprice C Greenberg
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, USA; Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, USA
| | - Jeff A Havlena
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, USA
| | - Noelle K LoConte
- Department of Medicine, Division of Oncology, University of Wisconsin School of Medicine and Public Health, USA
| | - Jennifer M Weiss
- Department of Medicine, Division of Gastroenterology & Hepatology, University of Wisconsin School of Medicine and Public Health, USA
| | - Heather B Neuman
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, USA
| | - Glen Leverson
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, USA
| | - Maureen A Smith
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, USA; Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, USA
| | - Emily R Winslow
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, USA.
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Rudolf J, Jackson BR, Wilson AR, Smock KJ, Schmidt RL. Organizational Benchmarks for Test Utilization Performance: An Example Based on Positivity Rates for Genetic Tests. Am J Clin Pathol 2017; 147:382-389. [PMID: 28340161 DOI: 10.1093/ajcp/aqx019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Health care organizations are under increasing pressure to deliver value by improving test utilization management. Many factors, including organizational factors, could affect utilization performance. Past research has focused on the impact of specific interventions in single organizations. The impact of organizational factors is unknown. The objective of this study is to determine whether testing patterns are subject to organizational effects, ie, are utilization patterns for individual tests correlated within organizations. METHODS Comparative analysis of ordering patterns (positivity rates for three genetic tests) across 659 organizations. Hierarchical regression was used to assess the impact of organizational factors after controlling for test-level factors (mutation prevalence) and hospital bed size. RESULTS Test positivity rates were correlated within organizations. CONCLUSIONS Organizations have a statistically significant impact on the positivity rate of three genetic tests.
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Affiliation(s)
- Joseph Rudolf
- From the Department of Pathology and Harvard Medical School, Massachusetts General Hospital, Boston
| | - Brian R Jackson
- Center for Effective Medical Testing, Department of Pathology, University of Utah, Salt Lake City
| | - Andrew R Wilson
- School of Nursing, University of Utah Health Sciences Center, Salt Lake City
| | - Kristi J Smock
- Center for Effective Medical Testing, Department of Pathology, University of Utah, Salt Lake City
| | - Robert L Schmidt
- Center for Effective Medical Testing, Department of Pathology, University of Utah, Salt Lake City
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Lee CC, Kimmell KT, Lalonde A, Salzman P, Miller MC, Calvi LM, Manuylova E, Shafiq I, Edward Vates G. Geographic variation in cost of care for pituitary tumor surgery. Pituitary 2016; 19:515-21. [PMID: 27514727 DOI: 10.1007/s11102-016-0738-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE Geography is known to affect cost of care in surgical procedures. Understanding the relationship between geography and hospital costs is pertinent in the effort to reduce healthcare costs. We studied the geographic variation in cost for transsphenoidal pituitary surgery in hospitals across New York State. METHODS Using the Healthcare Cost and Utilization Project State Inpatient Database for New York from 2008 to 2011, we analyzed records of patients who underwent elective transsphenoidal pituitary tumor surgery and were discharged to home or self-care. N.Y. State was divided into five geographic regions: Buffalo, Rochester, Syracuse, Albany, and Downstate. These five regions were compared according to median charge and cost per day. RESULTS From 2008 to 2011, 1803 transsphenoidal pituitary tumor surgeries were performed in New York State. Mean patient age was 50.7 years (54 % were female). Adjusting prices for length of stay, there was substantial variation in prices. Median charges per day ranged from $8485 to $13,321 and median costs per day ranged from $2962 to $6837 between the highest and lowest regions from 2008 to 2011. CONCLUSION Within New York State, significant geographic variation exists in the cost for transsphenoidal pituitary surgery. The significance of and contributors to such variation is an important question for patients, providers, and policy makers. Transparency of hospital charges, costs, and average length of stay for procedures to the public provides useful information for informed decision-making, especially for a highly portable disease entity like pituitary tumors.
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Affiliation(s)
- Charles C Lee
- Department of Neurosurgery, School of Medicine and Dentistry, University of Rochester Medical Center, 601 Elmwood Ave, Box 670, Rochester, NY, 14642, USA.
- UR Medicine Pituitary Program, University of Rochester Medical Center, 601 Elmwood Ave, Box 670, Rochester, NY, 14642, USA.
| | - Kristopher T Kimmell
- Department of Neurosurgery, School of Medicine and Dentistry, University of Rochester Medical Center, 601 Elmwood Ave, Box 670, Rochester, NY, 14642, USA
| | - Amy Lalonde
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, 601 Elmwood Ave, Box 630, Rochester, NY, 14642, USA
| | - Peter Salzman
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, 601 Elmwood Ave, Box 630, Rochester, NY, 14642, USA
| | - Matthew C Miller
- Department of Otolaryngology, University of Rochester Medical Center, 601 Elmwood Ave, Box 629, Rochester, NY, 14642, USA
| | - Laura M Calvi
- Division of Endocrine, Diabetes, and Metabolism, University of Rochester Medical Center, 601 Elmwood Ave, Box 693, Rochester, NY, 14642, USA
- UR Medicine Pituitary Program, University of Rochester Medical Center, 601 Elmwood Ave, Box 670, Rochester, NY, 14642, USA
| | - Ekaterina Manuylova
- Division of Endocrine, Diabetes, and Metabolism, University of Rochester Medical Center, 601 Elmwood Ave, Box 693, Rochester, NY, 14642, USA
- UR Medicine Pituitary Program, University of Rochester Medical Center, 601 Elmwood Ave, Box 670, Rochester, NY, 14642, USA
| | - Ismat Shafiq
- Division of Endocrine, Diabetes, and Metabolism, University of Rochester Medical Center, 601 Elmwood Ave, Box 693, Rochester, NY, 14642, USA
- UR Medicine Pituitary Program, University of Rochester Medical Center, 601 Elmwood Ave, Box 670, Rochester, NY, 14642, USA
| | - G Edward Vates
- Department of Neurosurgery, School of Medicine and Dentistry, University of Rochester Medical Center, 601 Elmwood Ave, Box 670, Rochester, NY, 14642, USA
- Department of Otolaryngology, University of Rochester Medical Center, 601 Elmwood Ave, Box 629, Rochester, NY, 14642, USA
- Division of Endocrine, Diabetes, and Metabolism, University of Rochester Medical Center, 601 Elmwood Ave, Box 693, Rochester, NY, 14642, USA
- UR Medicine Pituitary Program, University of Rochester Medical Center, 601 Elmwood Ave, Box 670, Rochester, NY, 14642, USA
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Fortinsky RH, Wasson JH. How do physicians diagnose dementia? Evidence from clinical vignette responses. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/153331759701200202] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study examined how a sample of family practitioners, general internists, and osteopathic physicians practicing in the state of Maine (N=353) diagnose symptoms of cognitive dysfunction. Physicians' reported diagnostic approaches were compared to American and Canadian expert panel recommendations, and were associated with their sociodemographic and office practice characteristics. Sample members responded to a self-administered questionnaire, which was completed in response to a clinical vignette describing a patient with either mild symptoms or more progressive symptoms of cognitive dysfunction. Results showed that 59 percent of respondents would perform a formal cognitive status test and 32 percent would perform a depression screening test; both types of tests are recommended by American and Canadian expert panels. Adjusting for other factors, female physicians were twice as likely as males to perform a depression screening test (OR=2.04; 95 percent C1=1.13-3.67). Most respondents (87 percent) would order at least three of four recommended laboratory tests, and 59 percent would order a computerized tomography (CT) scan, even though expert guidelines are ambiguous about the value of CT scans in diagnostic workups. Diagnostic approaches were not significantly affected by plans to refer patients to other physicians for additional testing. Practicing physicians should be encouraged to perform recommended nueropsychological and mental status tests when patients present with symptoms of cognitive dysfunction.
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Affiliation(s)
- Richard H. Fortinsky
- General Internal Medicine and Health Care Research, Department of Medicine, Case Western Reserve University School of Medicine, University Hospitals of Cleveland, Cleveland, Ohio
| | - John H. Wasson
- Center for the Aging, Dartmouth Medical School, Hanover New Hampshire
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Brooks JV. Hostility During Training: Historical Roots of Primary Care Disparagement. Ann Fam Med 2016; 14:446-52. [PMID: 27621161 PMCID: PMC5394363 DOI: 10.1370/afm.1971] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 03/10/2016] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The environment during medical school has been shown to dissuade students from choosing primary care careers. The purpose of this study was (1) to explore how long-standing this hostility toward primary care is historically and (2) to understand the mechanisms through which the environment conveys disparagement of primary care to students. METHODS The study is based on a qualitative analysis of 52 primary care physician oral histories. The data are from the Primary Care Oral History Collection, created by Fitzhugh Mullan and deposited in the National Library of Medicine. Transcripts were analyzed using qualitative data analysis and the constant comparative method. RESULTS Respondents (63.5%) reported experiencing discouragement or disparagement about primary care, and this proportion remained fairly high through 5 decades. Findings indicate that hostility toward primary care operates through the culture and the structure of medical training, creating barriers to the portrayal of primary care as appealing and important. Support for primary care choice was uncommon but was reported by some respondents. CONCLUSION The primary care shortage and primary care's unfavorable representation during medical training is a multifaceted problem. The evidence reported here shows that cultural and structural factors are critical components of the problem, and have existed for decades. For policy responses to be most effective in meeting the primary care workforce problem, they must address the presence and power of persistent hostility against primary care during training.
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Schulman KA, Yabroff KR, Glick H. A Health Services Approach for the Evaluation of Innovative Pharmaceutical and Biotechnology Products. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/009286159502900446] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kevin A. Schulman
- Clinical Economics Research Unit and the Division of General Internal Medicine, Georgetown University Medical Center, Washington, District of Columbia
| | - K. Robin Yabroff
- Clinical Economics Research Unit and the Division of General Internal Medicine, Georgetown University Medical Center, Washington, District of Columbia
| | - Henry Glick
- Division of General Internal Medicine and the Leonard Davis Institute of Health Economics, the University of Pennsylvania, Philadelphia, Pennsylvania
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Kane RL. Commentary. Med Care Res Rev 2016. [DOI: 10.1177/107755879705400305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Van der Heyden J, Charafeddine R, De Bacquer D, Tafforeau J, Van Herck K. Regional differences in the validity of self-reported use of health care in Belgium: selection versus reporting bias. BMC Med Res Methodol 2016; 16:98. [PMID: 27528010 PMCID: PMC4986374 DOI: 10.1186/s12874-016-0198-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 07/28/2016] [Indexed: 11/24/2022] Open
Abstract
Background The Health Care Module of the European Health Interview Survey (EHIS) is aimed to obtain comparable information on the use of inpatient and ambulatory care in all EU member states. In this study we assessed the validity of self-reported information on the use of health care, collected through this instrument, in the Belgian Health Interview Survey (BHIS), and explored the impact of selection and reporting bias on the validity of regional differences in health care use observed in the BHIS. Methods To assess reporting bias, self-reported BHIS 2008 data were linked with register-based data from the Belgian compulsory health insurance (BCHI). The latter were compared with similar estimates from a random sample of the BCHI to investigate the selection bias. Outcome indicators included the prevalence of a contact with a GP, specialist, dentist and a physiotherapist, as well as inpatient and day patient hospitalisation. The validity of the estimates and the regional differences were explored through measures of agreement and logistic regression analyses. Results Validity of self-reported health care use varies by type of health service and is more affected by reporting than by selection bias. Compared to health insurance estimates, self-reported results underestimate the percentage of people with a specialist contact in the past year (50.5 % versus 65.0 %) and a day patient hospitalisation (7.8 % versus 13.9 %). Inversely, survey results overestimated the percentage of people having visited a dentist in the past year: 58.3 % versus 48.6 %. The best concordance was obtained for an inpatient hospitalisation (kappa 0.75). Survey data overestimate the higher prevalence of a contact with a specialist [OR 1.51 (95 % CI 1.33–1.72) for self-report and 1.08 (95 % CI 1.05–1.15) for register] and underestimate the lower prevalence of a contact with a GP [ORs 0.59 (95 % CI 0.51–0.70) and 0.41 (95 % CI 0.39–0.42) respectively] in Brussels compared to Flanders. Conclusion Cautiousness is needed to interpret self-reported use of health care, especially for ambulatory care. Regional differences in self-reported health care use may be influenced by regional differences in the validity of the self-reported information. Electronic supplementary material The online version of this article (doi:10.1186/s12874-016-0198-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- J Van der Heyden
- Department of Public Health and Surveillance, Scientific Institute of Public Health, 14, Juliette Wytsmanstraat, 1050, Brussels, Belgium. .,Department of Public Health, Ghent University, 185, De Pintelaan, 9000, Ghent, Belgium.
| | - R Charafeddine
- Department of Public Health and Surveillance, Scientific Institute of Public Health, 14, Juliette Wytsmanstraat, 1050, Brussels, Belgium
| | - D De Bacquer
- Department of Public Health, Ghent University, 185, De Pintelaan, 9000, Ghent, Belgium
| | - J Tafforeau
- Department of Public Health and Surveillance, Scientific Institute of Public Health, 14, Juliette Wytsmanstraat, 1050, Brussels, Belgium
| | - K Van Herck
- Department of Public Health, Ghent University, 185, De Pintelaan, 9000, Ghent, Belgium
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Caughey AB. In clinical care, volume matters. Am J Obstet Gynecol 2016; 215:6-8. [PMID: 27186868 DOI: 10.1016/j.ajog.2016.04.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 04/22/2016] [Indexed: 10/21/2022]
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Tawfik B, Collins JB, Fino NF, Miller DP. House Officer-Driven Reduction in Laboratory Utilization. South Med J 2016; 109:5-10. [PMID: 26741863 DOI: 10.14423/smj.0000000000000390] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To determine whether sharing laboratory charge and personal utilization information with physicians can reduce laboratory test orders and expenditures, thereby decreasing the overutilization of laboratory testing. METHODS This was a prospective study. By querying our electronic medical records, we calculated the median laboratory charges per patient/per day (PP/PD) and median laboratory tests ordered PP/PD for the resident general internal medicine and hospitalist services. For 10 weeks, we shared this team-based information with physicians with weekly updates. We calculated total laboratory charges for the 10 most common discharge diagnoses to capture laboratory charges for entire episodes of care. RESULTS During the intervention, the mean number of laboratory tests ordered PP/PD by resident service decreased from 5.56 to 5.17 (-0.389, P <0.001); the mean charge PP/PD decreased from $488 to $461 (-$27, P < 0.001). The hospitalist service decreased the number of laboratory tests ordered PP/PD from 3.54 to 3.36 (-0.18, P = 0.77) and the mean charge PP/PD decreased from $331 to $301 (-$30, P = 0.96). The statistically significant decline in laboratory charges persisted after controlling for the 10 most common discharge diagnoses. Compared with the 3-month period before the study began, physicians in the 10-week intervention period ordered 1464 fewer laboratory tests, resulting in a $188,000 reduction in charges and a 3% to 4% reduction in utilization. CONCLUSIONS Informing physicians of the charges for laboratory tests and their personal utilization patterns can reduce the number of laboratory tests ordered and laboratory expenditures, especially for physicians in training.
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Affiliation(s)
- Bernard Tawfik
- From the Department of Internal Medicine, Wake Forest School of Medicine, the Department of Biostatistical Sciences, Wake Forest Baptist Health Performance Improvement, and the Department of Biostatistics and Bioinformatics, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - J B Collins
- From the Department of Internal Medicine, Wake Forest School of Medicine, the Department of Biostatistical Sciences, Wake Forest Baptist Health Performance Improvement, and the Department of Biostatistics and Bioinformatics, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Nora F Fino
- From the Department of Internal Medicine, Wake Forest School of Medicine, the Department of Biostatistical Sciences, Wake Forest Baptist Health Performance Improvement, and the Department of Biostatistics and Bioinformatics, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - David P Miller
- From the Department of Internal Medicine, Wake Forest School of Medicine, the Department of Biostatistical Sciences, Wake Forest Baptist Health Performance Improvement, and the Department of Biostatistics and Bioinformatics, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Cole AP, Leow JJ, Chang SL, Chung BI, Meyer CP, Kibel AS, Menon M, Nguyen PL, Choueiri TK, Reznor G, Lipsitz SR, Sammon JD, Sun M, Trinh QD. Surgeon and Hospital Level Variation in the Costs of Robot-Assisted Radical Prostatectomy. J Urol 2016; 196:1090-5. [PMID: 27157376 DOI: 10.1016/j.juro.2016.04.087] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2016] [Indexed: 11/18/2022]
Abstract
PURPOSE We assessed surgeon and hospital level variation in robot-assisted radical prostatectomy costs and predictors of high and low cost surgery. MATERIALS AND METHODS The study population consisted of a weighted sample of 291,015 men who underwent robot-assisted radical prostatectomy for prostate cancer by 667 surgeons at 197 U.S. hospitals from 2003 to 2013. We evaluated 90-day direct hospital costs (2014 USD) in the Premier Hospital Database. High costs per robot-assisted radical prostatectomy were those above the 90th percentile and low costs were those below the 10th percentile. RESULTS Mean hospital cost per robot-assisted radical prostatectomy was $11,878 (95% CI $11,804-$11,952). Mean cost was $2,837 (95% CI $2,805-$2,869) in the low cost group vs $25,906 (95% CI $24,702-$25,490) in the high cost group. Nearly a third of the variation in robot-assisted radical prostatectomy cost was attributable to hospital characteristics and more than a fifth was attributable to surgeon characteristics (R-squared 30.43% and 21.25%, respectively). High volume surgeons and hospitals (90th percentile or greater) had decreased odds of high cost surgery (surgeons: OR 0.24, 95% CI 0.11-0.54; hospitals: OR 0.105, 95% CI 0.02-0.46). The performance of robot-assisted radical prostatectomy at a high volume hospital was associated with increased odds of low cost robot-assisted radical prostatectomy (OR 839, 95% CI 122-greater than 999). CONCLUSIONS This study provides insight into the role of surgeons and hospitals in robot-assisted radical prostatectomy costs. Given the substantial variability, identifying and remedying the root cause of outlier costs may yield substantial benefits.
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Affiliation(s)
- Alexander P Cole
- Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jeffrey J Leow
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Steven L Chang
- Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Benjamin I Chung
- Department of Urology, Stanford University Medical Center, Stanford, California
| | - Christian P Meyer
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Adam S Kibel
- Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mani Menon
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, Michigan
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Toni K Choueiri
- Lank Center for Genitourinary Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Gally Reznor
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stuart R Lipsitz
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jesse D Sammon
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, Michigan
| | - Maxine Sun
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Quoc-Dien Trinh
- Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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