1
|
Doll JA, Nelson AJ, Kaltenbach LA, Wojdyla D, Waldo SW, Rao SV, Wang TY. Percutaneous Coronary Intervention Operator Profiles and Associations With In-Hospital Mortality. Circ Cardiovasc Interv 2021; 15:e010909. [PMID: 34847693 DOI: 10.1161/circinterventions.121.010909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Percutaneous coronary intervention is performed by operators with differing experience, technique, and case mix. It is unknown if operator practice patterns impact patient outcomes. We sought to determine if a cluster algorithm can identify distinct profiles of percutaneous coronary intervention operators and if these profiles are associated with patient outcomes. METHODS Operators performing at least 25 annual procedures between 2014 and 2018 were clustered using an agglomerative hierarchical clustering algorithm. Risk-adjusted in-hospital mortality was compared between clusters. RESULTS We identified 4 practice profiles among 7706 operators performing 2 937 419 procedures. Cluster 1 (n=3345) demonstrated case mix and practice patterns similar to the national median. Cluster 2 (n=1993) treated patients with lower clinical acuity and were less likely to use intracoronary diagnostics, atherectomy, and radial access. Cluster 3 (n=1513) had the lowest case volume, were more likely to work at rural hospitals, and cared for a higher proportion of patients with ST-segment-elevation myocardial infarction and cardiogenic shock. Cluster 4 (n=855) had the highest case volume, were most likely to treat patients with high anatomic complexity and use atherectomy, intracoronary diagnostics, and mechanical support. Compared with cluster 1, adjusted in-hospital mortality was similar for cluster 2 (estimated difference, -0.03 [95% CI, -0.10 to 0.04]), higher for cluster 3 (0.14 [0.07-0.22]), and lower for cluster 4 (-0.15 [-0.24 to -0.06]). CONCLUSIONS Distinct percutaneous coronary intervention operator profiles are differentially associated with patient outcomes. A phenotypic approach to physician assessment may provide actionable feedback for quality improvement.
Collapse
Affiliation(s)
- Jacob A Doll
- Division of Cardiology, Department of Medicine, University of Washington (J.A.D.).,Section of Cardiology, VA Puget Sound Health Care System, Seattle, WA (J.A.D.)
| | - Adam J Nelson
- Duke Clinical Research Institute (A.J.N., L.A.K., D.W., S.V.R., T.Y.W.)
| | - Lisa A Kaltenbach
- Duke Clinical Research Institute (A.J.N., L.A.K., D.W., S.V.R., T.Y.W.)
| | - Daniel Wojdyla
- Duke Clinical Research Institute (A.J.N., L.A.K., D.W., S.V.R., T.Y.W.)
| | - Stephen W Waldo
- University of Colorado School of Medicine (S.W.W.).,Department of Medicine, Rocky Mountain Regional VA Medical Center (S.W.W.).,VA CART Program, VHA Office of Quality and Patient Safety (S.W.W.)
| | - Sunil V Rao
- Duke Clinical Research Institute (A.J.N., L.A.K., D.W., S.V.R., T.Y.W.).,Department of Medicine, Duke University School of Medicine (S.V.R., T.Y.W.)
| | - Tracy Y Wang
- Duke Clinical Research Institute (A.J.N., L.A.K., D.W., S.V.R., T.Y.W.).,Department of Medicine, Duke University School of Medicine (S.V.R., T.Y.W.)
| |
Collapse
|
2
|
Pitocco C, Sexton TR. A Novel Approach to Evaluating Cardiac Surgery Providers: An Alternative to the RAMR. Int J Health Plann Manage 2021; 37:352-360. [PMID: 34585434 DOI: 10.1002/hpm.3345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 07/27/2021] [Accepted: 09/18/2021] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE We propose an alternative to the Risk Adjusted Mortality Rate (RAMR), about which we identify four serious concerns. We apply our method to cardiac surgery. DESIGN We present a methodology that uses the upper and lower tail probabilities (UTP/LTP) of the binomial distribution to screen for poor/high performing providers. STUDY SETTING The New York State Department of Health (NYS DOH) publicly releases data on all cardiac surgery patients in the state. We download cardiac surgery data from the NYS DOH website for the years 2011 through 2013. The state's objective is to identify poorly performing hospitals and surgeons and thereby reduce deaths. NYS employs the RAMR. RESULTS The UTP/LTP approach agrees with the RAMR in its classification of all 132 surgeons and all 40 hospitals. However, performance is a continuous construct and strict categorization can lead to failure to identify marginal providers. CONCLUSIONS Our methodology addresses all four concerns regarding the RAMR. The UTP/LTP approach avoids inappropriate hypothesis testing and is consistent with standard statistical theory and practice in its approach to case volume. It does not require confidence intervals and it applies to all providers regardless of case volume.
Collapse
Affiliation(s)
- Christine Pitocco
- College of Business, Stony Brook University, Stony Brook, New York, USA
| | - Thomas R Sexton
- College of Business, Stony Brook University, Stony Brook, New York, USA
| |
Collapse
|
3
|
Chang CY, Obermeyer Z. Association of Clinical Characteristics With Variation in Emergency Physician Preferences for Patients. JAMA Netw Open 2020; 3:e1919607. [PMID: 31968113 PMCID: PMC6991274 DOI: 10.1001/jamanetworkopen.2019.19607] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 11/18/2019] [Indexed: 11/14/2022] Open
Abstract
Importance Much of the wide variation in health care has been associated with practice variation among physicians. Physicians choosing to see patients with more (or fewer) care needs could also produce variations in care observed across physicians. Objective To quantify emergency physician preferences by measuring nonrandom variations in patients they choose to see. Design, Setting, and Participants This cross-sectional study used a large, detailed clinical data set from an electronic health record system of a single academic hospital. The data set included all emergency department (ED) encounters of adult patients from January 1, 2010, to May 31, 2015, as well as ED visits information. Data were analyzed from September 1, 2018, to March 31, 2019. Exposure Patient assignment to a particular emergency physician. Main Outcomes and Measures Variation in patient characteristics (age, sex, acuity [Emergency Severity Index score], and comorbidities) seen by emergency physicians before patient selection, adjusted for temporal factors (seasonal, weekly, and hourly variation in patient mix). Results This study analyzed 294 915 visits to the ED seen by 62 attending physicians. Of the 294 915 patients seen, the mean (SD) age was 48.6 (19.8) years and 176 690 patients (59.9%) were women. Many patient characteristics, such as age (F = 2.2; P < .001), comorbidities (F = 1.7; P < .001), and acuity (F = 4.7; P < .001), varied statistically significantly. Compared with the lowest-quintile physicians for each respective characteristic, the highest-quintile physicians saw patients who were older (mean age, 47.9 [95% CI, 47.8-48.1] vs 49.7 [95% CI, 49.5-49.9] years, respectively; difference, +1.8 years; 95% CI, 1.5-2.0 years) and sicker (mean comorbidity score: 0.4 [95% CI, 0.3-0.5] vs 1.8 [95% CI, 1.7-1.8], respectively; difference, +1.3; 95% CI, 1.2-1.4). These differences were absent or highly attenuated during overnight shifts, when only 1 physician was on duty and there was limited room for patient selection. Compared with earlier in the shift, the same physician later in the shift saw patients who were younger (mean age, 49.7 [95% CI, 49.4-49.7] vs 44.6 [95 % CI, 44.3-44.9] years, respectively; difference, -5.1 years; 95% CI, 4.8-5.5) and less sick (mean comorbidity score: 0.7 [95% CI, 0.7-0.8] vs 1.1 [95% CI, 1.1-1.1], respectively; difference, -0.4; 95% CI, 0.4-0.4). Accounting for preference variation resulted in substantial reordering of physician ranking by care intensity, as measured by ED charges, with 48 of 62 physicians (77%) being reclassified into a different quintile and 9 of 12 physicians (75%) in the highest care intensity quintile moving into a lower quintile. A regression model demonstrated that 22% of reported ED charges were associated with physician preference. Conclusions and Relevance This study found preference variation across physicians and within physicians during the course of a shift. These findings suggest that current efforts to reduce practice variation may not affect the variation associated with physician preferences, which reflect underlying differences in patient needs and not physician practice.
Collapse
Affiliation(s)
- Cindy Y. Chang
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ziad Obermeyer
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Berkeley School of Public Health, University of California, Berkeley
| |
Collapse
|
4
|
Lewandrowski K. Integrating Decision Support into a Laboratory Utilization Management Program. Clin Lab Med 2019; 39:245-257. [DOI: 10.1016/j.cll.2019.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
5
|
Aiello FA, Judelson DR, Durgin JM, Doucet DR, Simons JP, Durocher DM, Flahive JM, Schanzer A. A physician-led initiative to improve clinical documentation results in improved health care documentation, case mix index, and increased contribution margin. J Vasc Surg 2018; 68:1524-1532. [DOI: 10.1016/j.jvs.2018.02.038] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 02/20/2018] [Indexed: 11/25/2022]
|
6
|
Bouck Z, Ferguson J, Ivers NM, Kerr EA, Shojania KG, Kim M, Cram P, Pendrith C, Mecredy GC, Glazier RH, Tepper J, Austin PC, Martin D, Levinson W, Bhatia RS. Physician Characteristics Associated With Ordering 4 Low-Value Screening Tests in Primary Care. JAMA Netw Open 2018; 1:e183506. [PMID: 30646242 PMCID: PMC6324437 DOI: 10.1001/jamanetworkopen.2018.3506] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
IMPORTANCE Efforts to reduce low-value tests and treatments in primary care are often ineffective. These efforts typically target physicians broadly, most of whom order low-value care infrequently. OBJECTIVES To measure physician-level use rates of 4 low-value screening tests in primary care to investigate the presence and characteristics of primary care physicians who frequently order low-value care. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted using administrative health care claims collected between April 1, 2012, and March 31, 2016, in Ontario, Canada. This study measured use of 4 low-value screening tests-repeated dual-energy x-ray absorptiometry (DXA) scans, electrocardiograms (ECGs), Papanicolaou (Pap) tests, and chest radiographs (CXRs)-among low-risk outpatients rostered to a common cohort of primary care physicians. EXPOSURES Physician sex, years since medical school graduation, and primary care model. MAIN OUTCOMES AND MEASURES This study measured the number of tests to which a given physician ranked in the top quintile by ordering rate. The resulting cross-test score (range, 0-4) reflects a physician's propensity to order low-value care across screening tests. Physicians were then dichotomized into infrequent or isolated frequent users (score, 0 or 1, respectively) or generalized frequent users for 2 or more tests (score, ≥2). RESULTS The final sample consisted of 2394 primary care physicians (mean [SD] age, 51.3 [10.0] years; 50.2% female), who were predominantly Canadian medical school graduates (1701 [71.1%]), far removed from medical school graduation (median, 25.3 years; interquartile range, 17.3-32.3 years), and reimbursed via fee-for-service in a family health group (1130 [47.2%]). They ordered 302 509 low-value screening tests (74 167 DXA scans, 179 855 ECGs, 19 906 Pap tests, and 28 581 CXRs) after 3 428 557 ordering opportunities. Within the cohort, generalized frequent users represented 18.4% (441 of 2394) of physicians but ordered 39.2% (118 665 of 302 509) of all low-value screening tests. Physicians who were male (odds ratio, 1.29; 95% CI, 1.01-1.64), further removed from medical school graduation (odds ratio, 1.03; 95% CI, 1.02-1.04), or in an enhanced fee-for-service payment model (family health group) vs a capitated payment model (family health team) (odds ratio, 2.04; 95% CI, 1.42-2.94) had increased odds of being generalized frequent users. CONCLUSIONS AND RELEVANCE This study identified a group of primary care physicians who frequently ordered low-value screening tests. Tailoring future interventions to these generalized frequent users might be an effective approach to reducing low-value care.
Collapse
Affiliation(s)
- Zachary Bouck
- Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
| | - Jacob Ferguson
- currently a student at Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Noah M. Ivers
- Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Eve A. Kerr
- Center for Clinical Management, Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Kaveh G. Shojania
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Min Kim
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Peter Cram
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine and Geriatrics, Sinai Health System and Health Network, Toronto, Ontario, Canada
| | - Ciara Pendrith
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Graham C. Mecredy
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Richard H. Glazier
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Joshua Tepper
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Peter C. Austin
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Danielle Martin
- Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Wendy Levinson
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - R. Sacha Bhatia
- Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
7
|
Wong H, Karaca Z, Gibson TB. A Quantitative Observational Study of Physician Influence on Hospital Costs. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2018; 55:46958018800906. [PMID: 30264626 PMCID: PMC6166308 DOI: 10.1177/0046958018800906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Physicians serve as the nexus of treatment decision-making in hospitalized
patients; however, little empirical evidence describes the influence of
individual physicians on hospital costs. In this study, we examine the extent to
which hospital costs vary across physicians and physician characteristics. We
used all-payer data from 2 states representing 15 237 physicians and 2.5 million
hospital visits. Regression analysis and propensity score matching were used to
understand the role of observable provider characteristics on hospital costs
controlling for patient demographics, socioeconomic characteristics, clinical
risk, and hospital characteristics. We used hierarchical models to estimate the
amount of variation attributable to physicians. We found that the average cost
of hospital inpatient stays registered to female physicians was consistently
lower across all empirical specifications when compared with male physicians. We
also found a negative association between physicians’ years of experience and
the average costs. The average cost of hospital inpatient stays registered to
foreign-trained physicians was lower than US-trained physicians. We observed
sizable variation in average costs of hospital inpatient stays across medical
specialties. In addition, we used hierarchical methods and estimated the amount
of remaining variation attributable to physicians and found that it was
nonnegligible (intraclass correlation coefficient [ICC]: 0.33 in the full
sample). Historically, most physicians have been reimbursed separately from
hospitals, and our study shows that physicians play a role in influencing
hospital costs. Future policies and practices should acknowledge these important
dependencies. This study lends further support for alignment of physician and
hospital incentives to control costs and improve outcomes.
Collapse
Affiliation(s)
- Herbert Wong
- 1 U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, Rockville, MD, USA
| | - Zeynal Karaca
- 1 U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, Rockville, MD, USA
| | | |
Collapse
|
8
|
Finison K, Mohlman M, Jones C, Pinette M, Jorgenson D, Kinner A, Tremblay T, Gottlieb D. Risk-adjustment methods for all-payer comparative performance reporting in Vermont. BMC Health Serv Res 2017; 17:58. [PMID: 28103923 PMCID: PMC5248440 DOI: 10.1186/s12913-017-2010-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 01/12/2017] [Indexed: 11/10/2022] Open
Abstract
Background As the emphasis in health reform shifts to value-based payments, especially through multi-payer initiatives supported by the U.S. Center for Medicare & Medicaid Innovation, and with the increasing availability of statewide all-payer claims databases, the need for an all-payer, “whole-population” approach to facilitate the reporting of utilization, cost, and quality measures has grown. However, given the disparities between the different populations served by Medicare, Medicaid, and commercial payers, risk-adjustment methods for addressing these differences in a single measure have been a challenge. Methods This study evaluated different levels of risk adjustment for primary care practice populations – from basic adjustments for age and gender to a more comprehensive “full model” risk-adjustment method that included additional demographic, payer, and health status factors. It applied risk adjustment to populations attributed to patient-centered medical homes (283,153 adult patients and 78,162 pediatric patients) in the state of Vermont that are part of the Blueprint for Health program. Risk-adjusted expenditure and utilization outcomes for calendar year 2014 were reported in 102 adult and 56 pediatric primary-care comparative practice profiles. Results Using total expenditures as the dependent variable for the adult population, the r2 for the model adjusted for age and gender was 0.028. It increased to 0.265 with the additional adjustment for 3M Clinical Risk Groups and to 0.293 with the full model. For the adult population at the practice level, the no-adjustment model had the highest variation as measured by the coefficient of variation (18.5) compared to the age and gender model (14.8); the age, gender, and CRG model (13.0); and the full model (11.7). Similar results were found for the pediatric population practices. Conclusions Results indicate that more comprehensive risk-adjustment models are effective for comparing cost, utilization, and quality measures across multi-payer populations. Such evaluations will become more important for practices, many of which do not distinguish their patients by payer type, and for the implementation of incentive-based or alternative payment systems that depend on “whole-population” outcomes. In Vermont, providers, accountable care organizations, policymakers, and consumers have used Blueprint profiles to identify priorities and opportunities for improving care in their communities.
Collapse
Affiliation(s)
- Karl Finison
- Onpoint Health Data, 254 Commercial Street, Suite 257, Portland, ME, 04101, USA.
| | - MaryKate Mohlman
- Vermont Blueprint for Health, 280 State Dr. Waterbury, Vermont, 05671, USA
| | - Craig Jones
- U.S. Department Health and Human Services, Vermont Blueprint for Health. Office of the National Coordinator for Health Information Technology, 330 C Street, SW; Floor 7, Washington, DC, 20024, USA
| | - Melanie Pinette
- Onpoint Health Data, 254 Commercial Street, Suite 257, Portland, ME, 04101, USA
| | - David Jorgenson
- Onpoint Health Data, 254 Commercial Street, Suite 257, Portland, ME, 04101, USA
| | - Amy Kinner
- Onpoint Health Data, 254 Commercial Street, Suite 257, Portland, ME, 04101, USA
| | - Tim Tremblay
- Vermont Blueprint for Health, 280 State Dr. Waterbury, Vermont, 05671, USA
| | - Daniel Gottlieb
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Hitchcock Medical Center, Lebanon, NH, 03766, USA
| |
Collapse
|
9
|
Garland A. Effect of collaborative care on cost variation in an intensive care unit. Am J Crit Care 2013; 22:232-8. [PMID: 23635932 DOI: 10.4037/ajcc2013141] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Improving the cost-effectiveness of health care requires an understanding of the genesis of health care costs and in particular the sources of cost variation. Little is known about how multiple physicians, caring collaboratively for patients, contribute to costs. OBJECTIVE To explore the effect of collaborative care by physicians on variation in discretionary costs in an intensive care unit (ICU) by determining the contributions of the attending intensivists and ICU fellows. METHODS Prospective, observational study using a multivariable model of median discretionary costs for the first day in the ICU, adjusting for confounding variables. Analysis included 3514 patients who spent more than 2 hours in the ICU on the initial day. Impact of the physicians was assessed via variables representing the specific intensivist and ICU fellow responsible on the first ICU day and allowing for interaction terms. RESULTS On the initial day, patients spent a median of 10.6 hours (interquartile range, 6.3-16.5) in the ICU, with median discretionary costs of $1343 (interquartile range, $788-2208). There was large variation in adjusted costs attributable to both the intensivists ($359; 95% CI, $244-$474) and the fellows ($756; 95% CI, $550-$965). The interaction terms were not significant (P = .12-.79). CONCLUSIONS In an ICU care model with intensivists and subspecialty fellows, both types of physicians contributed significantly to the observed variation in discretionary costs. However, even in the presence of a hierarchical arrangement of clinical responsibilities, the influences on costs of the 2 types of physicians were independent.
Collapse
Affiliation(s)
- Allan Garland
- Allan Garland is an associate professor in the Departments of Medicine and Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| |
Collapse
|
10
|
|
11
|
O'Brien JM, Aberegg SK, Ali NA, Diette GB, Lemeshow S. Results from the National Sepsis Practice Survey: use of drotrecogin α (activated) and other therapeutic decisions. J Crit Care 2010; 25:658.e7-15. [PMID: 20646906 DOI: 10.1016/j.jcrc.2010.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Revised: 03/24/2010] [Accepted: 04/20/2010] [Indexed: 12/01/2022]
Abstract
PURPOSE We sought to evaluate factors associated with choices about provided care for patients with septic shock, including the use of drotrecogin α (activated) (DAA). MATERIALS AND METHODS We administered a mail-based survey to a random sample of intensivists. Study vignettes presented patients with septic shock with identical severity of illness scores but different ages, body mass indices, and comorbidities. Respondents estimated outcomes and selected care beyond standardized initial care (eg, antibiotics) for each hypothetical patient. RESULTS For most vignettes (99.1%), respondents added care, most commonly low tidal volume ventilation (87.6%) and enteral nutrition (73.3%). Choosing to administer DAA was not associated with predictions about mortality or bleeding. Vignettes with early-stage lung cancer were less likely to receive DAA. Time since medical school graduation was also associated with lower odds of selecting DAA. Most respondents (52.6%) chose identical care for all 4 completed vignettes. CONCLUSIONS There was wide variability in the therapeutic choices of respondents. The use of DAA was not associated with perceived risk of mortality or bleeding, as recommended by consensus guidelines. Physicians appear to base treatment decisions in septic shock on a consistent pattern of practice rather than estimates of patient outcome.
Collapse
Affiliation(s)
- James M O'Brien
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Center for Critical Care, Department of Internal Medicine, The Ohio State University Medical Center, Columbus, OH 43210, USA.
| | | | | | | | | |
Collapse
|
12
|
Epstein AJ, Nicholson S. The formation and evolution of physician treatment styles: an application to cesarean sections. JOURNAL OF HEALTH ECONOMICS 2009; 28:1126-1140. [PMID: 19800141 DOI: 10.1016/j.jhealeco.2009.08.003] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2005] [Revised: 04/15/2009] [Accepted: 08/18/2009] [Indexed: 05/28/2023]
Abstract
Small-area-variation studies have shown that physician treatment styles differ substantially both between and within markets, controlling for patient characteristics. Using data on the universe of deliveries in Florida and New York over a 15-year period, we examine why treatment styles differ across obstetricians at a point in time and why styles change over time. We find that variation in c-section rates across physicians within a market is about twice as large as variation between markets. Surprisingly, residency programs explain no more than four percent of the variation in physicians' risk-adjusted c-section rates, even among newly trained physicians. Although we find evidence that physicians learn from their peers, they do not substantially revise their prior beliefs regarding treatment due to the local exchange of information. Our results indicate that physicians are not likely to converge over time to a community standard; thus, within-market variation in treatment styles is likely to persist.
Collapse
Affiliation(s)
- Andrew J Epstein
- Yale University, School of Public Health, Division of Health Policy and Administration, 60 College Street, 3rd Floor, New Haven, CT 06520-8034, United States.
| | | |
Collapse
|
13
|
Garland A, Shaman Z, Baron J, Connors AF. Physician-attributable differences in intensive care unit costs: a single-center study. Am J Respir Crit Care Med 2006; 174:1206-10. [PMID: 16973977 DOI: 10.1164/rccm.200511-1810oc] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Variation in practice and outcomes, not explained by patient or illness characteristics, is common in health care, including in intensive care units (ICUs). OBJECTIVE To quantify within-ICU, between-physician variation in resource use in a single medical ICU. METHODS This was a prospective, noninterventional study in a medical ICU where nine intensivists provide care in 14-d rotations. Consecutive sample consisted of 1,184 initial patient admissions whose care was provided by a single intensivist. Multivariate models were constructed for average daily discretionary costs, ICU length of stay, and hospital mortality, adjusting for patient and illness characteristics, and workload. MEASUREMENTS AND MAIN RESULTS The identity of the intensivist was a significant predictor for average daily discretionary costs (p < 0.0001), but not ICU length of stay (p = 0.33) or hospital mortality (p = 0.83). The intensivists had more influence on costs than all other variables except the severity and type of acute illness. Average daily discretionary costs varied by 43% across the different intensivists, equating to a mean difference of 1,003 dollars per admission between the highest and lowest terciles of intensivists. CONCLUSIONS There are large differences among intensivists in the amount of resources they use to manage critically ill patients. Higher resource use was not associated with lower length of stay or mortality.
Collapse
Affiliation(s)
- Allan Garland
- Division of Pulmonary and Critical Care Medicine, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109, USA.
| | | | | | | |
Collapse
|
14
|
Robinson JW, Zeger SL, Forrest CB. A Hierarchical Multivariate Two-Part Model for Profiling Providers' Effects on Health Care Charges. J Am Stat Assoc 2006. [DOI: 10.1198/016214506000000104] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
15
|
Abstract
ICUs are a vital component of modern health care. Improving ICU performance requires that we shift from a paradigm that concentrates on individual performance to a different paradigm that emphasizes the need to assess and improve ICU systems and processes. This is the first part of a two-part treatise. It discusses existing problems in ICU care, and the methods for defining and measuring ICU performance.
Collapse
Affiliation(s)
- Allan Garland
- Division of Pulmonary and Critical Care Medicine, MetroHealth Medical Center, Case Western Reserve University School of Medicine, 2500 MetroHealth Dr, Cleveland, OH 44109, USA.
| |
Collapse
|
16
|
Eisenstein EL, Bethea CF, Muhlbaier LH, Davidian M, Peterson ED, Stafford JA, Mark DB. Surgeons' economic profiles: can we get the "right" answers? J Med Syst 2005; 29:111-24. [PMID: 15931798 DOI: 10.1007/s10916-005-3000-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Hospitals and payers use economic profiling to evaluate physician and surgeon performance. However, there is significant variation in the data sources and analytic methods that are used. We used information from a hospital's cardiac surgery and cost accounting information systems to create surgeon economic profiles. Three scenarios were examined: (1) surgeon modeled as fixed effect with no patient-mix adjustment; (2) surgeon modeled as fixed effect with patient-mix adjustment; (3) and surgeon modeled as random effect with patient-mix adjustment. We included 574 patients undergoing coronary artery bypass surgery at Baptist Medical Center, Oklahoma City, OK between July 1, 1995 and April 30, 1996. We found that profiles reporting unadjusted average surgeon costs may incorrectly identify high- and low-cost outliers. Adjusting for patient-mix differences and treating surgeons as random effects was the preferred approach. These results demonstrate the need for hospitals to reexamine their economic profiling methods.
Collapse
Affiliation(s)
- Eric L Eisenstein
- Outcomes Research and Assessment Group, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, 27715-7969, USA.
| | | | | | | | | | | | | |
Collapse
|
17
|
Kim SS, Finch MD, Nash DB, McCarberg BH, Schnoll SH, Seifeldin R. A Systems Approach to Identifying Inappropriate Use of Controlled Substances: The Need for Balance. Jt Comm J Qual Patient Saf 2005; 31:167-72. [PMID: 15828600 DOI: 10.1016/s1553-7250(05)31022-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The diversion, abuse, and inappropriate use of controlled substances remain of concern among health care practitioners, insurers, and policy makers in the United States. The principle of "balance" represents a need to establish a system of control to prevent abuse, trafficking, and diversion of controlled substances, while ensuring their medical availability for legitimate patients. ADMINISTRATIVE DATABASES TO STUDY OUTCOMES AND QUALITY OF CARE Some models employ pattern recognition within administrative health databases, for example, to examine outcomes and quality of medical care and monitor fraudulent behaviors and inappropriate medical care. Patients' use of resources or variations in practitioners' practice patterns can be examined. A SYSTEMS APPROACH TO ADDRESS INAPPROPRIATE USE OF CONTROLLED SUBSTANCES A systems approach would require collaboration with medical and pharmacy directors, systems analysts, coding experts, legal experts, and clinicians to develop the claims-based model. Once a patient and/or practitioner with possible diversion or abuse are identified, a second step is required to distinguish inappropriate and appropriate behaviors and medical care. CONCLUSION Programs to detect misuse of controlled substances must be validated through clinical research, and a consensus should be reached as to what constitutes a breach of accepted medical practice.
Collapse
Affiliation(s)
- Susan S Kim
- Health Economics and Outcomes Research, Purdue Pharma LP., Stamford, Connecticut, USA
| | | | | | | | | | | |
Collapse
|
18
|
Hollenbeak CS. Functional form and risk adjustment of hospital costs: Bayesian analysis of a Box-Cox random coefficients model. Stat Med 2005; 24:3005-18. [PMID: 15977298 DOI: 10.1002/sim.2172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
While risk-adjusted outcomes are often used to compare the performance of hospitals and physicians, the most appropriate functional form for the risk adjustment process is not always obvious for continuous outcomes such as costs. Semi-log models are used most often to correct skewness in cost data, but there has been limited research to determine whether the log transformation is sufficient or whether another transformation is more appropriate. This study explores the most appropriate functional form for risk-adjusting the cost of coronary artery bypass graft (CABG) surgery. Data included patients undergoing CABG surgery at four hospitals in the midwest and were fit to a Box-Cox model with random coefficients (BCRC) using Markov chain Monte Carlo methods. Marginal likelihoods and Bayes factors were computed to perform model comparison of alternative model specifications. Rankings of hospital performance were created from the simulation output and the rankings produced by Bayesian estimates were compared to rankings produced by standard models fit using classical methods. Results suggest that, for these data, the most appropriate functional form is not logarithmic, but corresponds to a Box-Cox transformation of -1. Furthermore, Bayes factors overwhelmingly rejected the natural log transformation. However, the hospital ranking induced by the BCRC model was not different from the ranking produced by maximum likelihood estimates of either the linear or semi-log model.
Collapse
Affiliation(s)
- Christopher S Hollenbeak
- Department of Surgery, MC H113, Penn State College of Medicine, P.O. Box 850, Hershey, PA 17033-0850, USA.
| |
Collapse
|
19
|
Murff HJ, Orav EJ, Lee TH, Bates DW, Fairchild DG. Patient satisfaction profiling of individual physicians: impact of panel status. J Eval Clin Pract 2004; 10:553-61. [PMID: 15482419 DOI: 10.1111/j.1365-2753.2003.00482.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Evaluation of physician performance is increasingly based on patient satisfaction. However, few data are available regarding the extent to which individual physician profiles might be influenced by factors such as whether a physician's practice is open or closed. We evaluated whether panel status (whether or not a physician is accepting new patients) is associated with patient satisfaction with their primary care physician (PCP). METHODS Cross-sectional analysis of patient satisfaction surveys. Surveys were available for 1,750 patients cared for by 69 PCPs. Patient satisfaction with their PCP was determined based on a composite of six questions derived from the Medical Outcomes Study. We used Generalized Estimating Equations to adjust for physician level variation. RESULTS Patients of closed-panel physicians were more likely to rate their satisfaction with the provider as 'Excellent' or 'Very Good' compared to patients of open-panel physicians (78% vs. 69%, P <0.0001). After adjusting for satisfaction with the practice site, provider years in practice, managed care coverage, provider productivity, and patient race, the association between a closed panel and satisfaction remained significant (odds ratio 1.60, 95% confidence interval 1.10-2.31). CONCLUSIONS Individual physicians' patient satisfaction data are confounded by factors not likely to be adjusted for in available profiles. After adjusting for other variables, physicians with closed panels still had better patient satisfaction compared to physicians with open panels. Further research is necessary to determine if panel status might also confound patient satisfaction.
Collapse
Affiliation(s)
- Harvey J Murff
- Vanderbilt University Medical Center, Division of General Internal Medicine, Nashville, TN, USA
| | | | | | | | | |
Collapse
|
20
|
Abstract
Goals of the quality-of-care initiative are to improve the structure, process, and outcome of health care. The effectiveness of methods to improve quality have been largely unverified. Most methods are costly to implement and time-consuming to perform; some threaten professional autonomy. The characteristic feature of modern medicine that fuels the debate over quality is the variation in the delivery of health care. This review examines the "variation phenomenon" in medicine and the roles that practice guidelines and physician profiling have in improving health care, in general, and for adult cataract, in particular.
Collapse
Affiliation(s)
- Curtis E Margo
- Department of Ophthalmology, Watson Clinic, LLP, Lakeland, Florida 33805, USA
| |
Collapse
|
21
|
Rosen AK, Loveland SA, Rakovski CC, Christiansen CL, Berlowitz DR. Do different case-mix measures affect assessments of provider efficiency? Lessons from the Department of Veterans Affairs. J Ambul Care Manage 2003; 26:229-42. [PMID: 12856502 DOI: 10.1097/00004479-200307000-00006] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Although case-mix adjustment is critical for provider profiling, little is known regarding whether different case-mix measures affect assessments of provider efficiency. We examine whether two case-mix measures, Adjusted Clinical Groups (ACGs) and Diagnostic Cost Groups (DCGs), result in different assessments of efficiency across service networks within the Department of Veterans Affairs (VA). Three profiling indicators examine variation in resource use. Although results from the ACGs and DCGs generally agree on which networks have greater or lesser efficiency than average, assessments of individual network efficiency vary depending upon the case-mix measure used. This suggests that caution should be used so that providers are not misclassified based on reported efficiency.
Collapse
Affiliation(s)
- Amy K Rosen
- Center for Health Quality, Outcomes and Economic Research, Bedford VAMC, 200 Springs Road (152), Bedford, MA 01730, USA
| | | | | | | | | |
Collapse
|
22
|
Flynn KE, Smith MA, Davis MK. From physician to consumer: the effectiveness of strategies to manage health care utilization. Med Care Res Rev 2002; 59:455-81. [PMID: 12508705 PMCID: PMC1635490 DOI: 10.1177/107755802237811] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Many strategies are commonly used to influence physician behavior in managed care organizations. This review examines the effectiveness of three mechanisms to influence physician behavior: financial incentives directed at providers or patients, policies/procedures for managing care, and the selection/education of both providers and patients. The authors reach three conclusions. First, all health care systems use financial incentives, but these mechanisms are shifting away from financial incentives directed at the physician to those directed at the consumer. Second, heavily procedural strategies such as utilization review and gatekeeping show some evidence of effectiveness but are highly unpopular due to their restrictions on physician and patient choice. Third, a future system built on consumer choice is contradicted by mechanisms that rely solely on narrow networks of providers or the education of physicians. If patients become the new locus of decision making in health care, provider-focused mechanisms to influence physician behavior will not disappear but are likely to decline in importance.
Collapse
Affiliation(s)
- Kathryn E. Flynn
- Department of Sociology, University of Wisconsin-Madison, 8128
Social Science Building, 1180 Observatory Drive, Madison, WI 53706-1393.
Telephone: (608) 263-4416 FAX: (608) 263-2820 E-mail:
| | - Maureen A. Smith
- Department of Population Health Sciences, University of
Wisconsin-Madison Medical School, 603 WARF Building, 610 Walnut Street, Madison,
WI 53705-2397. Telephone: (608) 262-4802 FAX: (608) 263-2820 E-mail:
| | - Margaret K. Davis
- Division of Health Services Research and Policy, University of
Minnesota School of Public Health, MMC 729, 420 Delaware Street SE, Minneapolis,
MN 55455-0392. Telephone: (612) 626-0696 FAX: (612) 626-4681 E-mail:
| |
Collapse
|
23
|
McNaughton Collins M, Barry MJ, Zietman A, Albertsen PC, Talcott JA, Walker Corkery E, Elliott DB, Fowler FJ. United States radiation oncologists' and urologists' opinions about screening and treatment of prostate cancer vary by region. Urology 2002; 60:628-33. [PMID: 12385923 DOI: 10.1016/s0090-4295(02)01832-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To examine whether physicians' views on prostate cancer screening and treatment vary by geographic region in the United States. METHODS A mail survey was sent in 1998 to a random sample of physicians in the United States who were listed as radiation oncologists (response rate 76%, n = 559) and urologists (response rate 64%, n = 504) in the American Medical Association Registry of Physicians and practicing at least 20 hr/wk. RESULTS Radiation oncologists and urologists in Florida were more likely to report recommending routine prostate-specific antigen testing for men aged 75 years and older than were their colleagues in other regions of the United States. The Florida physicians were more likely to report treating at least 20% of their patients with brachytherapy and to report believing that brachytherapy has survival value for men with a less than 10-year life expectancy. No regional differences were found in the radiation oncologists' and urologists' beliefs about the survival value of radical prostatectomy; however, for men with a less than 10-year life expectancy, Florida urologists had more confidence in the survival benefit of external beam radiotherapy than urologists in other regions (P = 0.04). Radiation oncologists in Florida reported higher rates of recommending early androgen deprivation for a rising PSA after both radiotherapy and surgery (P = 0.008 and P = 0.001, respectively) than did their colleagues in other regions. CONCLUSIONS Florida radiation oncologists and urologists reported beliefs and practices that differed from their colleagues in other regions of the United States. Whether the distinctive style of prostate cancer diagnosis and treatment in Florida results in improved outcomes has yet to be proved.
Collapse
Affiliation(s)
- Mary McNaughton Collins
- Medical Practices Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
| | | | | | | | | | | | | | | |
Collapse
|
24
|
Krein SL, Hofer TP, Kerr EA, Hayward RA. Whom should we profile? Examining diabetes care practice variation among primary care providers, provider groups, and health care facilities. Health Serv Res 2002; 37:1159-80. [PMID: 12479491 PMCID: PMC1464024 DOI: 10.1111/1475-6773.01102] [Citation(s) in RCA: 128] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To evaluate the amount of variation in diabetes practice patterns at the primary care provider (PCP), provider group, and facility level, and to examine the reliability of diabetes care profiles constructed using electronic databases. DATA SOURCES/STUDY SETTING Clinical and administrative data obtained from the electronic information systems at all facilities in a Department of Veterans Affairs' (VA) integrated service network for a study period of October 1997 through September 1998. STUDY DESIGN This is a cohort study. The key variables of interest are different types of diabetes quality indicators, including measures of technical process, intermediate outcomes, and resource use. DATA COLLECTION/EXTRACTION METHODS A coordinated registry of patients with diabetes was constructed by integrating laboratory, pharmacy, utilization, and primary care provider data extracted from the local clinical information system used at all VA medical centers. The study sample consisted of 12,110 patients with diabetes, 258 PCPs, 42 provider groups, and 13 facilities. PRINCIPAL FINDINGS There were large differences in the amount of practice variation across levels of care and for different types of diabetes care indicators. The greatest amount of variance tended to be attributable to the facility level. For process measures, such as whether a hemoglobin A1c was measured, the facility and PCP effects were generally comparable. However, for three resource use measures the facility effect was at least six times the size of the PCP effect, and for inter-mediate outcome indicators, such as hyperlipidemia, facility effects ranged from two to sixty times the size of the PCP level effect. A somewhat larger PCP effect was found (5 percent of the variation) when we examined a "linked" process-outcome measure linking hyperlipidemia and treatment with statins). When the PCP effect is small (i.e., 2 percent), a panel of two hundred diabetes patients is needed to construct profiles with 80 percent reliability. CONCLUSIONS little of the variation in many currently measured diabetes care practices is attributable to PCPs and, unless panel sizes are large, PCP profiling will be inaccurate. If profiling is to improve quality, it may be best to focus on examining facility-level performance variations and on developing indicators that promote specific, high-priority clinical actions.
Collapse
|
25
|
Cowper PA, Peterson ED, DeLong ER, Wightman MB, Wawrzynski RP, Muhlbaier LH, Sketch MH. The impact of statistical adjustment on economic profiles of interventional cardiologists. J Am Coll Cardiol 2001; 38:1416-23. [PMID: 11691517 DOI: 10.1016/s0735-1097(01)01538-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The objective of this study was to identify preprocedure patient factors associated with percutaneous intervention costs and to examine the impact of these patient factors on economic profiles of interventional cardiologists. BACKGROUND There is increasing demand for information about comparative resource use patterns of interventional cardiologists. Economic provider profiles, however, often fail to account for patient characteristics. METHODS Data were obtained from Duke Medical Center cost and clinical information systems for 1,949 procedures performed by 13 providers between July 1, 1997, and December 31, 1998. Patient factors that influenced cost were identified using multiple regression analysis. After assessing interprovider variation in unadjusted cost, mixed linear models were used to examine how much cost variability was associated with the provider when patient characteristics were taken into account. RESULTS Total hospital costs averaged $15,643 (median, $13,809), $6,515 of which represented catheterization laboratory costs. Disease severity, acuity, comorbid illness and lesion type influenced total costs (R(2) = 38%), whereas catheterization costs were affected by lesion type and acuity (R(2) = 32%). Patient characteristics varied significantly among providers. Unadjusted total costs were weakly associated with provider, and this association disappeared after accounting for patient factors. The provider influence on catheterization costs persisted after adjusting for patient characteristics. Furthermore, the pattern of variation changed: the adjusted analysis identified three new outliers, and two providers lost their outlier status. Only one provider was consistently identified as an outlier in the unadjusted and adjusted analyses. CONCLUSIONS Economic profiles of interventional cardiologists may be misleading if they do not adequately adjust for patient characteristics before procedure.
Collapse
Affiliation(s)
- P A Cowper
- Outcomes Research and Assessment Group, Duke Clinical Research Institute, Durham, North Carolina 27715, USA.
| | | | | | | | | | | | | |
Collapse
|
26
|
Ramsey SD, Cheadle AD, Neighbor WE, Gore E, Temple P, Staiger T, Goldberg HI. Relative impact of patient and clinic factors on adherence to primary care preventive service guidelines: an exploratory study. Med Care 2001; 39:979-89. [PMID: 11502955 DOI: 10.1097/00005650-200109000-00008] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Preventive care service use is commonly compared across health plans, clinics, or individual providers, yet little is known about the influence of the clinic versus patient factors on utilization of these services. OBJECTIVES To measure the relative influence of the facility (clinic) versus patient factors (demographic, behavioral and functional characteristics) on patients' utilization of mammography, Pap smears, cholesterol screening, and retinal exams for those with diabetes. RESEARCH DESIGN Retrospective analysis, using administrative and patient survey data. SUBJECTS Enrollees in 2 University-based clinics and a county hospital-based clinic serving a predominantly low-income population with limited access to health care. Eligibility for cervical cancer screening, screening mammography, cholesterol screening, or annual retinal exam (diabetes) was defined by age, sex, and diagnosis. MEASURES Multivariate models, one using readily available administrative data, and another using detailed health status and behavior data gathered from a clinics-wide survey. RESULTS Unadjusted screening rates for three of four procedures were significantly and substantially lower at the county hospital based clinic than the two University-based clinics. After adjusting for patient characteristics, utilization of three screening services at the county hospital remained significantly below the University-based clinics (Odds Ratios [95% CI]: mammogram 0.15 [0.06-0.35]; Pap smear 0.32 [0.21-0.50]; cholesterol 0.19 [0.09-0.38]; diabetes retinal exam10.68 [0.93-3.01]). The models with detailed survey data performed only marginally better than the models using only administrative data. CONCLUSIONS Patient characteristics were much less important than the clinic for predicting whether patients received primary care preventive services. Our results suggest that case mix adjustment is unlikely to explain away discrepancies in performance between clinics or provider groups.
Collapse
Affiliation(s)
- S D Ramsey
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington 98109-1024, USA.
| | | | | | | | | | | | | |
Collapse
|
27
|
Lichtman JH, Roumanis SA, Radford MJ, Riedinger MS, Weingarten S, Krumholz HM. Can practice guidelines be transported effectively to different settings? Results from a multicenter interventional study. THE JOINT COMMISSION JOURNAL ON QUALITY IMPROVEMENT 2001; 27:42-53. [PMID: 11147239 DOI: 10.1016/s1070-3241(01)27005-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
RATIONALE Although clinical guidelines have become increasingly popular as a means to reduce variation in care, increase efficiency, and improve patient outcomes, little is known about their effectiveness when they are transported outside their original setting, or about the factors that influence their successful translation into clinical practice. This study assessed whether a clinical guideline for low-risk chest pain patients, implemented with a standardized protocol, could be effectively transported to five hospital settings. METHODS In a prospective, interventional trial, a standardized protocol for low-risk chest pain was implemented at each site. A total of 553 consecutively hospitalized low-risk patients with chest pain were enrolled during a 3-month baseline period followed by a standardized 6-month intervention period. During the intervention period, each patient's physician was contacted about eligibility for discharge within the specified 2-day guideline period. Guideline adherence (discharged within 48 hours) and postdischarge patient outcomes were measured. Local guideline champions were interviewed about their implementation experience. RESULTS Guideline adherence during the intervention period ranged from 61% to 100%, with only two sites achieving significant increases of > or = 10% from the baseline values. Guideline implementation did not affect clinical outcomes or patient satisfaction. Implementation factors such as preexisting hospital environment, implementation team staffing, and the rapid identification and resolution of barriers may influence the successful translation of guidelines into practice. CONCLUSIONS Even with a standardized implementation protocol, consistent results across institutions were not obtained when a clinical guideline for chest pain was implemented beyond its original setting. These findings demonstrate the importance of understanding the local factors that influence guideline implementation.
Collapse
Affiliation(s)
- J H Lichtman
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, Department of Neurology, Yale University School of Medicine, New Haven, USA
| | | | | | | | | | | |
Collapse
|
28
|
Weiss KB, Wagner R. Performance measurement through audit, feedback, and profiling as tools for improving clinical care. Chest 2000; 118:53S-58S. [PMID: 10940000 DOI: 10.1378/chest.118.2_suppl.53s] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Clinical audits and practice profiling have become popular tools in the attempt to change physician behavior to improve quality of care. Unfortunately, the growing need for information on quality of care has often outpaced the development of standard, valid, and reliable approaches to using these tools. The studies of performance measurement published in the literature to date demonstrate varying impact on ability to improve clinical care; few are randomized controlled trials. While performance measurement has become a common practice, the science surrounding this field is still in its early stages of development; while it seems promising, it should be viewed as largely experimental.
Collapse
Affiliation(s)
- K B Weiss
- Center for Health Services Research, Rush Primary Care Institute, Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL 60612, USA
| | | |
Collapse
|
29
|
Burgess JF, Christiansen CL, Michalak SE, Morris CN. Medical profiling: improving standards and risk adjustments using hierarchical models. JOURNAL OF HEALTH ECONOMICS 2000; 19:291-309. [PMID: 10977193 DOI: 10.1016/s0167-6296(99)00034-x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
The conclusions from a profile analysis to identify performance extremes can be affected substantially by the standards and statistical methods used and by the adequacy of risk adjustment. Medically meaningful standards are proposed to replace common statistical standards. Hierarchical regression methods can handle several levels of random variation, make risk adjustments for the providers' case-mix differences, and address the proposed standards. These methods determine probabilities needed to make meaningful profiles of medical units based on standards set by all appropriate parties.
Collapse
Affiliation(s)
- J F Burgess
- Management Science Group, Department of Veterans Affairs, Bedford, MA 01730, USA.
| | | | | | | |
Collapse
|
30
|
Becker ER, Mauldin PD, Culler SD, Kosinski AS, Weintraub WS, King SB. Applying the resource-based relative value scale to the Emory angioplasty versus surgery trial. Am J Cardiol 2000; 85:685-91. [PMID: 12004793 DOI: 10.1016/s0002-9149(99)00841-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The resource-based relative value scale developed for use in the Medicare fee schedule can also be very useful in profiling and comparing physicians' cardiovascular utilization across different medical activities. This article applies relative value units (RVUs) to data from the Emory Angioplasty versus Surgery Trial. The Emory Angioplasty versus Surgery Trial was a randomized clinical trial to determine the efficacy of percutaneous transluminal coronary angioplasty (PTCA) versus coronary artery bypass surgery (CABG). All physician services in the clinical trial provided to 2 groups of patients--those undergoing CABG and those receiving PTCA-over the course of 4 years were assigned physician work RVUs (representing the intensity of physician work required) and total RVUs (representing both the intensity and practice costs). Physician charges were also compiled. These data were used to profile and compare physician services to the 2 groups of patients by type of service, distribution over time, and clinical department. Comparisons based on RVUs contrast sharply with differences based on charges. Mean physician charges, in 1996 dollars, were $27,158 for CABG patients and $21,491 for PTCA patients, a 26% difference (p <0.001). Physician work RVUs generated an 18.3% difference (p = <0.001). Using total RVUs, the difference between the 2 groups was 3.3% (p = 0.249). Resource-based relative value weights are a valuable tool for analyzing and comparing physicians' use of cardiovascular resource. The results suggest that conclusions about physician resource utilization based on physician charges should be carefully evaluated. When possible, physician work RVUs should be compiled and evaluated along with physician charges.
Collapse
Affiliation(s)
- E R Becker
- Department of Health Policy and Management, Medical University of South Carolina, Charleston 30322, USA.
| | | | | | | | | | | |
Collapse
|
31
|
|
32
|
Wigder HN, Cohan Ballis SF, Lazar L, Urgo R, Dunn BH. Successful implementation of a guideline by peer comparisons, education, and positive physician feedback. J Emerg Med 1999; 17:807-10. [PMID: 10499693 DOI: 10.1016/s0736-4679(99)00087-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The objective of this study was to determine if peer comparisons, an educational intervention, and positive physician feedback would decrease ordering of knee X-ray studies. We prospectively studied the ordering of knee X-ray studies for patients presenting with knee injuries before and after an educational program to encourage use of the Ottawa decision rule for knee radiography. Physicians were able to privately compare their individual baseline X-ray utilization data with that of their colleagues. Although acceptance of the rule was voluntary, both oral and written feedback encouraged consideration of the rule in clinical decision-making. The percentage of knee injury patients who received X-ray studies, as well as the Percentage Abnormal Results (PAR, defined as the percentage of X-ray studies demonstrating a fracture or effusion), were calculated before and after the educational meeting. Results of the study showed that the percentage of patients presenting with knee injuries who received X-ray studies decreased 23%. In addition, the PAR increased 58.4% between the two study periods. In conclusion, physician behavior can be altered positively with reinforcement. Peer comparisons, education, and positive physician feedback decreased test ordering by physicians even without mandating use of a protocol. PAR is a useful outcome measure to track physician utilization.
Collapse
Affiliation(s)
- H N Wigder
- Department of Emergency Medicine, Lutheran General Hospital, Park Ridge, IL 60068-1174, USA
| | | | | | | | | |
Collapse
|
33
|
Librero J, Peiró S, Ordiñana R. [Chronic comorbidity and homogeneity in diagnostic related groups]. GACETA SANITARIA 1999; 13:292-302. [PMID: 10490668 DOI: 10.1016/s0213-9111(99)71371-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE [corrected] One of the ways to compare the efficiency of different hospitals and services is to evaluate Diagnostic Related Groups (DRGs), with the hypothesis that patients in the same RDG will present homogeneous behavior with respect to length of stay. The object of this study was to evaluate in the context os the National Health System the internal variability of specific DRGs in terms of the patients' comorbidity. METHODS On the basis of various comorbidity scores measured with the Charlson index (ChI), we analyzed length of stay, inhospital mortality and emergency readmissions at 30 and 365 days in 106.673 hospitalizations (excluding subjects younger than 17 years of age, and obstetrics and psychiatric patients) in 12 hospitals, and in 17 DRGs selected on the basis of their greater frequency and comorbidity. RESULTS In the aggregated analysis, length of stay (from 8.5 days in patients with no comorbidity to 17.0 days in patients with scores higher than 4) and inhospital mortality rates (from 3.7% in patients with no comorbidity to 17.6% in patients with highest score) increased significantly with each level of the Charlson index. The readmission rate at 30 days rose from 4.7% to 10.9% also in step with increases in comorbidity scores. Readmissions at one year varied from 14.8% in patients with scores of 0 to 35.2% in patients with scores of 3-4, and dropped to 27.9% in patients with scores higher than 4. When analysing different DRGs, 8 of the 17 groups studied showed a significantly higher length of stay with increased comorbidity scores. Some DRGs also showed intra-group variability with respect to mortality and readmission, particularly at 365 days. CONCLUSIONS Some DRGs show significant internal variability in terms of comorbidity that may be generating a false worse evaluation of the efficiency of hospitals that treat patients with higher comorbidity.
Collapse
Affiliation(s)
- J Librero
- Institut Valencià d'Estudis en Salud Pública (IVESP), Instituto de Investigación en Servicios de Salud (IISS), Valencia, España
| | | | | |
Collapse
|
34
|
Maxwell CI. Public disclosure of performance information in Pennsylvania: impact on hospital charges and the views of hospital executives. THE JOINT COMMISSION JOURNAL ON QUALITY IMPROVEMENT 1998; 24:491-502. [PMID: 9770639 DOI: 10.1016/s1070-3241(16)30398-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Forty states have now passed legislation establishing governmental agencies charged with the task of gathering hospital-level data. Since 1988 all acute care hospitals in Pennsylvania have been submitting data to the Pennsylvania Health Care Cost Containment Council (PHC4). Pennsylvania's policy was designed to make patients and purchasers more informed and selective buyers of medical services, to increase the public accountability of providers of these services, and to encourage hospitals and physicians to compete more on clinical outcomes and charges. The impact of Pennsylvania's policy of public disclosure of performance information on hospital charges over time has not previously been evaluated. Nor has the importance that hospital executives assign to the publication of comparative charges and clinical outcomes information been assessed. METHODS From 1990 through 1994 the PHC4 published a number of hospital-level performance reports (including the regional Hospital Effectiveness Reports and A Consumer's Guide to Coronary Artery Bypass Graft Surgery) containing hospital average charges, average lengths of stay, a rating of severity of illness, and two outcome measurements--morbidity and in-hospital mortality--on a total of 59 diagnosis-related groups. An 18-item survey designed to assess hospital executives' opinions of the usefulness and importance of the PCH4 information was sent to the chief executive officers at the study hospitals. DISCUSSION There were no significant trends toward a reduction in the dispersion of charges in either category of hospitals during the study period. Most hospital executives assigned low ratings of importance to published comparative charges information; however, executives of high-competition hospitals assigned significantly higher importance ratings to the information as a whole in enouraging hospital competition based on quality.
Collapse
Affiliation(s)
- C I Maxwell
- AMP Incorporated, Harrisburg, PA 17105-3608, USA.
| |
Collapse
|
35
|
Abstract
OBJECTIVES To review the high quality US evidence on performance of managed health care organisations and the available US evidence on specific managed care techniques; namely, financial incentives, utilisation management and review, physician profiling and disease management. METHODS Literature searches were conducted using numerous databases including Medline, Embase, the Social Sciences Citation Index and the National Health Service (NHS) Centre for Reviews and Dissemination library. For inclusion of evaluations of overall performance, studies had to use a comparison group (typically fee-for-service patients), make appropriate statistical adjustments for differences between groups, and be published in a peer-reviewed journal from 1980 forward. For assessments of techniques, less-demanding inclusion criteria reflected the paucity of generalisable literature; however, more current results were required (1990 forward). RESULTS We identified 70 articles for systematic review, covering 18 dimensions of performance (e.g. utilisation, quality of care, consumer satisfaction, equity). The strength of the evidence varied by dimension. It was strongest for utilisation and quality. In general, managed care seems to reduce hospitalisation and use of high-cost discretionary services, to increase preventive screening, and to be neutral in terms of patient outcomes. As for specific techniques, we identified 19 articles for review, but limitations of these studies prevented our drawing any definite conclusions about techniques' effectiveness. This is an important, if somewhat negative, conclusion. CONCLUSIONS Applying US evidence is complicated by an irrelevant comparator and a higher baseline of utilisation. Managed care brought Americans the familiar NHS practices of population-based health care and resource management through gatekeeping; hence, changes due to UK adoption of managed care techniques may be modest. US evidence should be used to generate hypotheses, not to predict UK behaviour.
Collapse
Affiliation(s)
- A Steiner
- Institute for Health Policy Studies, University of Southampton, UK
| | | |
Collapse
|
36
|
|
37
|
Harmon RL, Sheehy LM, Davis DM. The utility of external performance measurement tools in program evaluation. Rehabil Nurs 1998; 23:8-11. [PMID: 9460453 DOI: 10.1002/j.2048-7940.1998.tb01750.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Many rehabilitation hospitals use formal measurement tools to evaluate program performance. A potential advantage to using the Functional Independence Measure instrument through the Uniform Data System for Medical Rehabilitation (UDSMR) is that it provides information that allows an institution to compare its level of performance to those of other facilities. To assess whether joining UDSMR, along with an institution's continuous quality improvement efforts, could be associated with improved program performance, the records of a rehabilitation hospital's internal inpatient Program Evaluation System (PES) were reviewed for 6 fiscal years (1990-1995). Quality improvement efforts during 1995 (during which a 51% improvement in length of stay efficiency was noted) included education for staff, feedback on team performance, and efforts to formulate clinical pathways. Although external measures of performance do not have a direct effect on quality improvement, they could help identify areas of potential improvement that might not be appreciated when internal assessment systems are used alone.
Collapse
Affiliation(s)
- R L Harmon
- Department of Physical Medicine and Rehabilitation, Medical College of Ohio, Toledo 43699-0008, USA
| | | | | |
Collapse
|
38
|
Dans PE. Caveat doctor: how to analyze claims-based report cards. THE JOINT COMMISSION JOURNAL ON QUALITY IMPROVEMENT 1998; 24:21-30. [PMID: 9494871 DOI: 10.1016/s1070-3241(16)30356-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
"Report cards" based on claims (billing) data are being widely used to evaluate the quality of care given by providers, even though they often lack sufficient clinical detail to render definitive judgments. Furthermore, their accuracy, especially for outpatient care, is quite variable. Nevertheless, claims data will continue to be used until better clinical information becomes widely available. To determine the suitability of automated claims data for measuring clinical performance, careful attention should be paid to the integrity of the data. Providers profiled by claims-based report cards should ask four questions about the source, robustness, management, and analysis of the data: 1. What are the key characteristics of the data set used to construct the profile? These include the insurer's name, coverage type, time period, geographic area, and number of patients, claims lines, and providers. 2. What clinical conditions and events are being measured and how well? In short, are the patients' conditions and their clinical encounters reasonably well characterized? 3. Is the information about the patients and providers accurate and up to date? 4. Once the insurer receives the medical claim, are data elements deleted or altered in ways that might affect their accuracy and completeness? Ensuring data integrity is not sufficient; the analysis of the data must be scrutinized. Potential pitfalls in analyzing claims data arise in choosing clinically meaningful measures, recognizing important differences in patients and their providers, and making fair comparisons against appropriate benchmarks. Monitoring patient care outcomes is no longer voluntary. By routinely constructing and augmenting profiles using outpatient claims data, provider groups become proactive rather than reactive in evaluating their patients' care.
Collapse
Affiliation(s)
- P E Dans
- Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
39
|
Aron DC, Landefeld CS. Health services research and the endocrinologist. Endocrinol Metab Clin North Am 1997; 26:113-24. [PMID: 9074855 DOI: 10.1016/s0889-8529(05)70236-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This article highlights the importance of health services research to endocrinologists. The content and goals of health services research are defined, and, with examples related to endocrinology, the field's focus and key themes are described and its methods and sources of data delineated. Considerations that informed readers should keep in mind when reading this literature are illustrated, with a recent example that has important implications for the role of endocrinologists in the management of diabetic patients.
Collapse
Affiliation(s)
- D C Aron
- Division of Clinical and Molecular Endocrinology, Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | | |
Collapse
|
40
|
|
41
|
Powe NR, Weiner JP, Starfield B, Stuart M, Baker A, Steinwachs DM. Systemwide provider performance in a Medicaid program. Profiling the care of patients with chronic illnesses. Med Care 1996; 34:798-810. [PMID: 8709661 DOI: 10.1097/00005650-199608000-00007] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVES This study illustrates how claims data can be applied to examine cost and clinical performance of providers in the Medicaid program. METHODS The authors conducted a cross-sectional analysis of Medicaid beneficiaries in Maryland with diabetes mellitus, hypertension, and asthma treated on an ambulatory basis by hospital-based outpatient departments, physician office-based providers, and community health centers. The study year was July 1987 to June 1988. The authors defined the cost performance (high, medium, or low) of providers in the management of each of the three chronic illnesses, both before and after casemix adjustment, using a classification system based on ambulatory diagnoses (ambulatory care groups). The authors constructed claims-based clinical performance indicators for each of the three conditions. These included the number of patients admitted to acute-care hospitals for any and specific (diabetes mellitus, hypertension, and asthma) causes, the number of patients without a follow-up visit within 30 days of being discharged from the hospital, and the number of patients with consecutive emergency room visits during the study period. RESULTS The ambulatory care group casemix classification system explained 23%, 33%, and 36% of the variation in total payments for patients with hypertension, diabetes, and asthma, respectively. Without adjustment for casemix, 35% to 50% of providers would be misclassified regarding their cost performance. Forty-one (19.4%) of 211 providers who treated all three illnesses were in the same cost group for all three illnesses and 95 (43%) of 223 providers who treated two of the three illnesses were in the same cost group for both illnesses. Among office-based physicians, for all three chronic illnesses, high-cost providers had more admissions (P < 0.01) for ambulatory care-sensitive conditions than low-cost providers. Among hospital outpatient departments, only high-cost providers of asthma had more admissions (P < 0.05) for asthma than low-cost providers. There was no statistically significant (P > 0.05) difference in the clinical performance indicators between high-cost and low-cost hospital outpatient department providers of primary care for hypertensive and diabetic Medicaid beneficiaries. For the other clinical performance indicators, the results were not consistent across the three illnesses or across the different types of providers. CONCLUSIONS Without adjustments for casemix, a large number of providers are misclassified regarding to cost performance. In addition, most providers are not equally efficient in managing different chronic illnesses. Provider cost performance is not associated consistently with clinical performance, although severity differences not captured by the casemix adjustment may account for these observations. These measurement methods and relationships between provider performance measures may be useful to state Medicaid programs that seek to contain costs, enhance coordination of care, and improve health.
Collapse
Affiliation(s)
- N R Powe
- Department of Health Policy and Management, Johns Hopkins University School of Public Health, Baltimore, MD, USA
| | | | | | | | | | | |
Collapse
|
42
|
Schneider EC, Epstein AM. Influence of cardiac-surgery performance reports on referral practices and access to care. A survey of cardiovascular specialists. N Engl J Med 1996; 335:251-6. [PMID: 8657242 DOI: 10.1056/nejm199607253350406] [Citation(s) in RCA: 286] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Reports on the comparative performance of physicians are becoming increasingly common. Little is known, however, about the credibility of these reports with target audiences or their influence on the delivery of medical services. METHODS Since 1992, Pennsylvania has published the Consumer Guide to Coronary Artery Bypass Graft Surgery, which lists annual risk-adjusted mortality rates for all hospitals and surgeons providing such surgery in the state. In 1995, we surveyed a randomly selected sample of 50 percent of Pennsylvania cardiologists and cardiac surgeons to find out whether they were aware of the guide and, if so, to determine their views on its usefulness, limitations, and influence on providers. RESULTS Eighty-two percent of the cardiologists and all the cardiac surgeons were aware of the guide. Only 10 percent of these respondents reported that its mortality rates were "very important" in assessing the performance of a cardiothoracic surgeon. Less than 10 percent reported discussing the guide with more than 10 percent of their patients who were candidates for a coronary-artery bypass graft (CABG). Eighty-seven percent of the cardiologists reported that the guide had a minimal influence or none on their referral recommendations. For both groups, the most important limitations of the guide were the absence of indicators of quality other than mortality (cited by 78 percent), inadequate risk adjustment (79 percent), and the unreliability of data provided by hospitals and surgeons (53 percent). Fifty-nine percent of the cardiologists reported increased difficulty in finding surgeons willing to perform CABG surgery in severely ill patients who required it, and 63 percent of the cardiac surgeons reported that they were less willing to operate on such patients. CONCLUSIONS The Consumer Guide to Coronary Artery Bypass Graft Surgery has limited credibility among cardiovascular specialists. It has little influence on referral recommendations and may introduce a barrier to care for severely ill patients. If publicly released performance reports are intended to guide the choice of providers without impeding access to medical care, a collaborative process involving physicians may enhance the credibility and usefulness of the reports.
Collapse
Affiliation(s)
- E C Schneider
- Section on Health Services and Policy Research, Brigham and Women's Hospital, Boston, MA, USA
| | | |
Collapse
|
43
|
|
44
|
Du W, Ash AS, Berlowitz DR, Schwartz JS, Moskowitz MA. Variations in the management of acute myocardial infarction. Importance of clinical measures of disease severity. J Gen Intern Med 1996; 11:334-41. [PMID: 8803739 DOI: 10.1007/bf02600043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the extent to which resource use for patients hospitalized with acute myocardial infarction varies with clinical status, and to see if an observed difference in resource use between two states can be explained by clinically detailed risk adjustment. DESIGN Retrospective review of the clinical characteristics and resource use of 342 patients hospitalised in two states with acute myocardial infarction. DATA SOURCES Merged data from three sources: a large, existing research database used in developing the Medicare Mortality Predictor Score, clinical data abstracted from medical charts specifically for this study, and Medicare Parts A and B claims records. PATIENTS A probability sample of Medicare patients hospitalized in 1986 with a diagnosis of acute myocardial infarction and residing in either Wisconsin or Washington state; patients dying within 30 days are oversampled. MEASUREMENTS AND MAIN RESULTS Although patients were clinically similar in the two states, there were systematic differences in resource use. Patients in Wisconsin spent more than one extra day in the intensive care unit (ICU) (2.8 vs 1.7) as well as more than one extra non-ICU day in the hospital (8.0 vs 6.5) than patients in Washington. Patients in Wisconsin were also more likely to receive an echocardiogram (35.6% vs 15.8%), nuclear ventriculogram (12.8% vs 4.1%), exercise tolerance test (21.5% vs 3.4), and Holter monitoring (5.4% vs 0%). (All p < .01.) Differences in utilization were greater for patients at lower risk of dying. The average cost of care was 20.8% higher in Wisconsin (p = .01); risk adjustment for clinical and other factors reduced this difference to 11.8%, but did not eliminate it (p = .04). CONCLUSIONS Patients with acute myocardial infarction vary in resource use as a function of clinical factors present at admission and occurring during the hospital stay; comparisons that do not take account of these factors may not discriminate well between providers who care for sicker patients and those who are inefficient. The greater use of resources for patients in Wisconsin is at least partially explained by differences in clinical characteristics that are not presently captured in administrative data.
Collapse
Affiliation(s)
- W Du
- Health Care Research Unit, Boston University School of Medicine, Mass, USA
| | | | | | | | | |
Collapse
|
45
|
Abstract
Although physicians are all too familiar with the psychologic impact of having multiple responsibilities, the associated impact on practice styles has not been examined systematically. To provide some data on the effects of "work dispersion," we examined the hypothesis that the inpatient resource use of physicians would rise with the number of hospitals in which they work. Data for 1991 from Medicare's National Claims History File were used to profile a sample of attending physicians (n = 33,756) in seven states. The attending physician "profile" was the case mix-adjusted relative value of all physician services (regardless of who delivered them) that were delivered during each patient's hospital stay. Relative value was measured in relative value units, used by Medicare in determining physician payments. The authors then categorized physicians in terms of the number of hospitals to which they admitted patients. Physician profiles were adjusted further to control for geography, physician specialty, and characteristics of the physician's primary (ie, most used) hospital. One third of the physicians in the sample had admissions to more than one hospital. Physicians working in one hospital had inpatient practice profiles 2.1% below the sample mean. Additional hospital affiliations were associated with progressively higher profiles: two hospitals, 2.3% above the mean; three hospitals, 4.5% above; four hospitals, 8.2% above; and five or more hospitals, 11.5% above (all P < 0.01). The practice of medicine in more than one hospital is associated with higher inpatient profiles and shows a dose-response relationship. Physicians and policy makers will need to consider carefully whether there are any associated benefits to justify the increased cost.
Collapse
|
46
|
Casparie AF. The ambiguous relationship between practice variation and appropriateness of care: an agenda for further research. Health Policy 1996; 35:247-65. [PMID: 10157401 DOI: 10.1016/0168-8510(95)00787-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The analysis of variation in the use of health care services, and particularly of practice variation, has been the subject of renewed interest because of the view that the inappropriate use of procedures could be a major cause of these differences. In this article, recent literature is reviewed and the results of personal research are described on both the variation in care provision and on appropriateness assessment. In the few studies which have focussed on both subjects no evidence has yet been found to suggest that practice variation is to be explained by differences in appropriateness rates. However, there are still many methodological pitfalls in both variation analyses (statistical problems) and appropriateness assessment (reliability of the judgement), implying that this conclusion is far from definitive. More research should therefore be conducted on methodological questions of variation analysis and appropriateness assessment. Furthermore in variation analysis the relative contribution of all potential determinants has to be studied on the various levels of care provision. Finally, to study the relationship between practice variation and appropriateness of care, the clinical problem and not the procedure should be the starting point.
Collapse
Affiliation(s)
- A F Casparie
- Institute for Health Policy and Management, Erasmus University Rotterdam, The Netherlands
| |
Collapse
|
47
|
Ullman M, Metzger CK, Kuzel T, Bennett CL. Performance measurement in prostate cancer care: beyond report cards. Urology 1996; 47:356-65. [PMID: 8633402 DOI: 10.1016/s0090-4295(99)80453-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVES Review and analyze various approaches to performance measurement in health care, demonstrating the value of provider-initiated performance measurement in which ongoing monitoring of both processes and outcomes of care coupled with the use of clinical guidelines enhances performance improvement efforts. Describe some of the issues and findings associated with the use of such a methodology in prostate cancer care. METHODS Literature review and case study. RESULTS There are a number of significant limitations in the use of a "report card" methodology to improve quality and efficiency in health care. The complementary approach of combining "instrument panels" and clinical guidelines within an overall continuous quality improvement framework appears to have resulted in improved clinical outcomes and reduced costs in a six-physician urology group located in a heavily managed-care penetrated market. CONCLUSIONS Performance measurement tools are integral to efforts to improve outcomes and efficiency in health care. Providers of care might consider adapting the kind of performance improvement methodology described in this article. Practice benefits including improved clinical and economic outcomes are likely to follow.
Collapse
Affiliation(s)
- M Ullman
- Lakeside Veterans Affairs Medical Center, Division of Hematology/Oncology, Chicago, IL 60611, USA
| | | | | | | |
Collapse
|
48
|
Sarría Santamera A, García Benito P. [Differences in hospital utilization between the autonomous communities of Madrid and Catalonia]. GACETA SANITARIA 1996; 10:12-7. [PMID: 8707465 DOI: 10.1016/s0213-9111(96)71871-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Regional differences in hospital utilization have been long recognized. The objective of this study is to find out differences in hospital utilization and structure between Madrid and Catalonia. We calculate the crude and adjusted discharge and bed days rates and average length of stay from 1987 through 1989 for all diagnoses, and for 30 selected diagnoses by province of residence in 1987. We obtained the located and allocated beds, and the distribution of discharges by payers and of beds by providers for both regions, Catalonia shows consistently higher discharge rates (40% of public beds and 3.70 used beds) and Madrid has longer hospital stays (70% of public beds and 3.98 used beds). This work allows to formulate two questions about how health services operate: 1) organizational aspects could affect medical behavior. 2) hospital bed days could depend more on discharge rates than on length of stay.
Collapse
Affiliation(s)
- A Sarría Santamera
- Center for the Evaluative Clinical Sciences, Darmouth Medical School, Hanover NH 01755-3863, USA
| | | |
Collapse
|
49
|
Abstract
The rapid change occurring in American healthcare is a direct response to rising costs. Managed care is the fastest growing model that attempts to control escalating costs through limitations in patient choice, the active use of guidelines, and placing providers at risk. Managed care is an information intensive system, and those providers who use information effectively will be at an advantage in the competitive healthcare marketplace. There are five classes of information that providers must collect to be competitive in a managed care environment: patient satisfaction, medical outcomes, continuous quality improvement, quality of the decision, and financial data. Each of these should be actively used in marketing, assuring the quality of patient care, and maintaining financial stability. Although changes in our healthcare system are occurring rapidly, we need to respond to the marketplace to maintain our viability, but as physicians, we have the singular obligation to maintain the supremacy of the individual patient and the physician-patient relationship.
Collapse
Affiliation(s)
- T A Denton
- Department of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | | |
Collapse
|
50
|
Rutledge R, Hunt JP, Lentz CW, Fakhry SM, Meyer AA, Baker CC, Sheldon GF. A statewide, population-based time-series analysis of the increasing frequency of nonoperative management of abdominal solid organ injury. Ann Surg 1995; 222:311-22; discussion 322-6. [PMID: 7677461 PMCID: PMC1234811 DOI: 10.1097/00000658-199509000-00009] [Citation(s) in RCA: 77] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
UNLABELLED Emergency operative intervention has been one of the cornerstones of the care of the injured patient. Over the past several years, nonoperative management has increasing been recommended for the care of selected blunt abdominal solid organ injuries. The purpose of this study was to utilize a large statewide, population-based data set to perform a time-series analysis of the practice of physicians caring for blunt solid organ injury of the abdomen. The study was designed to assess the changing frequency and the outcomes of operative and nonoperative treatments for blunt hepatic and splenic injuries. METHODS Data were obtained from the state hospital discharge data base, which tracks information on all hospitalized patients from each of the 157 hospitals in the state of North Carolina. All trauma patients who had sustained injury to a solid abdominal organ (kidney, liver, or spleen) were selected for initial analysis. RESULTS During the 5 years of the study, 210,256 trauma patients were admitted to the state's hospitals (42,051 +/- 7802 per year). The frequency of nonoperative interventions for hepatic and splenic injuries increased over the period studied. The frequency of nonoperative management of hepatic injuries increased from 55% in 1988 to 79% in 1992 in patients with hepatic injuries and from 34% to 46% in patients with splenic injuries. The rate of nonoperative management of hepatic injuries increased from 54% to 64% in nontrauma centers compared with an increase from 56% to 74% in trauma centers (p = 0.01). In patients with splenic injuries, the rate of nonoperative management increased from 35% to 44% in nontrauma centers compared with an increase from 33% to 49% in trauma centers (p < 0.05). The rate of nonoperative management was associated with the organ injury severity, ranging from 90% for minor injuries to 19%-40% for severe injuries. Finally, in an attempt to compare blood use in operatively and nonoperatively treated patients, the total charges for blood were compared in the two groups. When compared, based on organ injury severity, the total blood used, as measured by charges, was lower for nonoperatively treated patients. CONCLUSIONS This large, statewide, population-based time-series analysis shows that the management of blunt injury of solid abdominal organs has changed over time. The incidence of nonoperative management for both hepatic and splenic injuries has increased. The study indicates that the rates of nonoperative management vary in relation to the severity of the organ injury. The rates increase in nonoperative management were greater in trauma centers than in nontrauma centers. These findings are consistent with the hypothesis that this newer approach to the care of blunt injury of solid abdominal organs is being led by the state's trauma centers.
Collapse
Affiliation(s)
- R Rutledge
- Department of Surgery, University of North Carolina at Chapel Hill, USA
| | | | | | | | | | | | | |
Collapse
|