Money and the changing culture of medicine

Gendering the beginning of life: Taiwanese gay fathers' navigation of preimplantation genetic diagnosis-assisted sex selection in transnational third-party reproduction

Preimplantation genetic diagnosis (PGD) has been used not only to avoid genetic diseases and increase conception success rates but also to perform non-medical sex selection, particularly in the surging cross-border reproductive care (CBRC). In the context of commercialised biomedicine, assisted reproductive technologies, such as lifestyle sex selection, have been tailored to meet intended parents' preferences. However, there is a lack of analysis on how individuals' reproductive decisions on PGD-assisted sex selection were shaped within the sociocultural norms and CBRC. This article explores Taiwanese gay fathers' navigations on sex selection while seeking third-party reproduction overseas because of local legal constraints. Drawing on in-depth interviews with 53 gay fathers (to-be), I analysed how 'individual preferences' were dynamically shaped by local sociocultural norms and embedded within transnational settings of routinising PGD in chosen repro-destinations. The findings showed that gay fathers mobilised strategic discourses on non-medical sex selection from both the local and the global to negotiate their decisions in coherence with their LGBTQ+ identity and their role as sons carrying familial responsibility to procreate male heirs. This article proposed a nuanced understanding of gay fathers' reproductive practices of 'gendering the beginning of life' through PGD-assisted sex selection.

[Hospital Profits: Ethical Aspects at the Interface Between Medicine and Economics]

Hospital profits and economization trends are increasingly becoming the focus of discussions on improving health care systems. Profit-based approaches to generate hospital returns have an ethical dimension, because patient well-being must remain the primary concern. A needs-oriented economic approach without the dominance of primary profit targets should become an overarching framework for the hospital sector.

Concierge care and patient reviews

We examine how patient numerical ratings and specific words in written reviews of family physicians and internists in the states of California and Florida differ based upon concierge doctor status. Data are drawn from Healthgrades.com, one of the largest providers of online reviews, and a machine-learning sentiment analysis is used to determine the predictors of concierge status and numerical patient ratings. We find that reviews of concierge doctors are more likely to contain technical words associated with health care, such as "staff" and "office," compared with traditional physicians. In contrast, interpersonal bedside-manner words, like "listen" or "concerns," are most likely in reviews for nonconcierge doctors. We further determine that, whereas interpersonal words exhibit both positive and negative effects on numerical ratings, technical terms seem to primarily correlate negatively with patient scores for all doctors. The present work represents a first step towards understanding the measures of quality of care that relate with the patient experience, and in particular with respect to the growing field of concierge medicine. It is also the first attempt we are aware of that employs sentiment analysis in this context.

Comparative preimplantation genetic diagnosis policy in Europe and the USA and its implications for reproductive tourism

Unlike many European nations, the USA has no regulations concerning the use of preimplantation genetic diagnosis (PGD), a technique employed during some fertility treatments to select embryos based on their genes. As such, PGD can and is used for a variety of controversial purposes, including sex selection, selection for children with disabilities such as deafness, and selection for 'saviour siblings' who can serve as tissue donors for sick relatives. The lack of regulation, which is due to particular features of the US political and economic landscape, has ethical and practical implications for patients seeking PGD around the world. This paper contrasts the absence of PGD oversight in the USA with existing PGD policies in Switzerland, Italy, France and the UK. The primary reasons why PGD is not regulated in the USA are addressed, with consideration of factors such as funding for assisted reproductive technology treatmemt and the proximity of PGD to the contentious abortion debate. The obstacles that would need to be overcome in the USA for PGD to be regulated in the future are outlined. Then, the significance of the current divergence in PGD policy for patients around the world are discussed. Regulatory differences create opportunities for reproductive tourism, which result in legal, health and moral challenges. The paper concludes with comments on the need for policymakers around the world to balance respect for the characters and constitutions of their individual countries with appreciation of the needs of infertile patients across the globe.

From Value Assessment to Value Cocreation: Informing Clinical Decision-Making with Medical Claims Data

Big data and advances in analytical processes represent an opportunity for the healthcare industry to make better evidence-based decisions on the value generated by various tests, procedures, and interventions. Value-based reimbursement is the process of identifying and compensating healthcare providers based on whether their services improve quality of care without increasing cost of care or maintain quality of care while decreasing costs. In this article, we motivate and illustrate the potential opportunities for payers and providers to collaborate and evaluate the clinical and economic efficacy of different healthcare services. We conduct a case study of a firm that offers advanced biomarker and disease state management services for cardiovascular and cardiometabolic conditions. A value-based analysis that comprised a retrospective case/control cohort design was conducted, and claims data for over 7000 subjects who received these services were compared to a matched control cohort. Study subjects were commercial and Medicare Advantage enrollees with evidence of CHD, diabetes, or a related condition. Analysis of medical claims data showed a lower proportion of patients who received biomarker testing and disease state management services experienced a MI (p < 0.01) or diabetic complications (p < 0.001). No significant increase in cost of care was found between the two cohorts. Our results illustrate the opportunity healthcare payers such as Medicare and commercial insurance companies have in terms of identifying value-creating healthcare interventions. However, payers and providers also need to pursue system integration efforts to further automate the identification and dissemination of clinically and economically efficacious treatment plans to ensure at-risk patients receive the treatments and interventions that will benefit them the most.

An Insufferable Business: Ethics, Nonhuman Animals and Biomedical Experiments

Each year millions of nonhuman animals suffer in biomedical experiments for human health benefits. Clinical ethics demand that nonhuman animals are used in the development of pharmaceuticals and vaccines. Nonhuman animals are also used for fundamental biomedical research. Biomedical research that uses nonhuman animals is big business but the financial gains are generally occluded. This paper explores how such research generates profits and gains for those associated with the industry. Research establishments, scientists, laboratories, companies that sell nonhuman animal subjects, that supply equipment for the research, and corporations that market the resulting products are among those that benefit financially. Given the complex articulation of ethical codes, enormous corporate profits that are secured and personal returns that are made, the accepted moral legitimacy of such experiments is compromised. In order to address this, within the confines of the moral orthodoxy, more could to be done to ensure transparency and to extricate the vested financial interests from the human health benefits. But such a determination would not address the fundamental issues that should be at the heart of human actions in respect of the nonhuman animals who are used in experiments. The paper concludes with such an address by calling for an end to the denigration of nonhuman animals as experimental subjects who can be used as commodities for profit-maximisation and as tools in experiments for human health benefits, and the implementation of a more inclusive ethic that is informed by universal concern about the suffering of and compassion for all oppressed beings.

A Call to Include Medical Humanities in the Curriculum of Colleges of Osteopathic Medicine and in Applicant Selection

Medicine stands at a crossroad. Disruptive physician behavior has increased, and patient satisfaction has decreased. A growing body of knowledge demonstrates that the medical humanities assist in the creation of compassionate, resilient physicians. Incorporating medical humanities into the medical school curriculum promotes the development of compassionate, culturally sensitive physicians, and also encourages the development of resilience in health care professionals at a time when internal and external pressures on physicians are increasing.

Using electronic health records to save money

OBJECTIVES

Health information technology, especially electronic health records (EHRs), can be used to improve the efficiency and effectiveness of healthcare providers. This study assessed the cost-savings of incorporating a list of preferred specialty care providers into the EHRs used by all primary care physicians (PCPs), accompanied by a comprehensive implementation plan.

METHODS

On January 1, 2005, all specialty clinic providers at the Israeli Defense Forces were divided into one of four financial classes based on their charges, class 1, the least expensive, being the most preferred, followed by classes 2-4. This list was incorporated into the EHRs used by all PCPs in primary care clinics. PCPs received comprehensive training. Target referral goals were determined for each class and measured for 4 years, together with the total cost of all specialist visits in the first year compared to the following years. Quality assessment (QA) scores were used as a measure of the program's effect on the quality of patient care.

RESULTS

During 2005-2008, a marginally significant decline in referrals to class 1 was observed (r=-0.254, p=0.078), however a significant increase in referral rates to class 2 was observed (r=0.957, p=0.042), concurrent with a decrease in referral rates to classes 3 and 4 (r=-0.312, p=0.024). An inverse correlation was observed between year and total costs for all visits to specialists (2008 prices; r=-0.96, p=0.04), and between the mean cost of one specialist visit over the 4 years, indicating a significant reduction in real costs (2008 prices; r=-0.995, p=0.005). QA was not affected by these changes (r=0.94, p=0.016).

CONCLUSIONS

From a policy perspective, our data suggest that EHR can facilitate effective utilization of healthcare providers and decrease costs.

Preliminary data of a HAMD-17 validated symptom scale derived from the ICD-10 to diagnose depression in outpatients

BACKGROUND

In outpatient settings diagnostic classification of depressive symptoms is mostly descriptive based on ICD-10. Depending on clinical experience and consultation time, diagnosis can be verified by validated scales. However, physicians working in primary care are familiar with ICD-10 criteria. Therefore, the aim of the present study was to examine the feasibility of the validation of an ICD-10-derived symptom scale for depression.

METHODS

For this preliminary trial we generated a symptom scale derived 1:1 from the diagnostic criteria for depression given in the ICD-10 with 10 items. The Hamilton Rating Scale for Depression (HAMD-17) was used as reference in a population of 226 outpatients suffering from depressive symptoms. Correlation between scales as well as sensitivity and specificity of the ICD-10 scale were calculated.

RESULTS

The generated ICD-10 symptom scale for depression could be analyzed in 219 patients and showed a significant and strong correlation with the HAMD-17 (p < 0.0001; ρ = 0.75). The best tradeoffs between specificity and sensitivity of the ICD-10 score were found at 10 points for the lower and 14 points for the upper cut-off. Overall sensitivity and specificity was 76.7 and 88.6%. Almost two thirds (i.e. 65.3%) of the patients were correctly classified by the ICD-10 scale.

CONCLUSION

The ICD-10 symptom scale examined in the current population was found to have fair correlation with the HAMD-17 as well as, in face of the limited variance of the patients' condition, acceptable sensitivity and specificity. Therefore, this preliminary study showed that the ICD-10-derived symptom scale seems appropriate to be investigated in a thorough validation trial.

Effect of compliance with quality performance measures for heart failure on clinical outcomes in high-risk patients

BACKGROUND

Although effects of the Joint Commission on Accreditation of Healthcare Organizations' (TJC) performance measures on national trends in patient outcomes have been reported, little information exists on the effects of these quality measures on patient outcomes in individual centers caring for high-risk patient populations.

OBJECTIVES

To determine the effects of compliance with TJC core quality measures for heart failure on patient outcomes at a university hospital caring for high-risk patients.

METHODS

We reviewed data collected for TJC in patients admitted with heart failure at a university hospital serving an indigent population in Louisiana. Patients were divided based on compliance with TJC measures into quality-compliant or quality-deficient groups. Of 646 reviewed records, 542, representing 357 patients, were included in the analysis. There were 193 patients in the quality-compliant and 164 in the quality-deficient group. Outcome measures included rate of heart failure admission/year and readmission within 90 days. Multivariate logistic and linear regression analyses were performed to identify independent associations between patient characteristics and heart failure admission.

RESULTS

Multiple linear regression analysis demonstrated higher rates of heart failure admission/year, and multiple logistic regression revealed higher readmissions at 90 days in the quality-compliant group (parameter estimate, 0.203; p = .02; odds ratio, 2.82; 95% confidence interval, 1.46-5.44, respectively).

CONCLUSION

Compliance with TJC quality measures for heart failure at a university hospital in Louisiana was associated with higher readmission rates for heart failure. Several factors may explain this trend, including patient characteristics and focus on national reporting benchmarks rather than patient-centered health care.

Association between primary care physicians' evidence-based medicine knowledge and quality of care

OBJECTIVE

Ample research has examined physicians' evidence-based medicine (EBM) knowledge and skills; however, previous research has not linked EBM knowledge to objective measures of process of care.

DESIGN

A cross-sectional study of quality of care measures extracted from electronic medical records and EBM knowledge assessed via a validated questionnaire.

SETTING

One region of the largest Health Maintenance Organization in Israel.

PARTICIPANTS

Seventy-four physicians and their 8334 diabetic patients, 7092 coronary heart disease patients and 17 132 hypertensive patients.

MAIN OUTCOME MEASURES

Outcome measures were four diabetes quality of care indicators (LDL tests, microalbumin tests, hemoglobin A1C tests, eye examination referrals), and two drug prescription indicators (statin prescription for coronary heart disease patients, and thiazide prescription for hypertensive patients). Independent variables were total EBM knowledge and its components: critical appraisal and information retrieval.

RESULTS

Total EBM knowledge was independently and significantly associated with LDL testing (b = 0.13; P = 0.036), microalbumin testing (b = 0.33; P = 0.001), hemoglobin A1C testing (b = 0.17; P = 0.036), eye examination referrals (b = 0.16; P = 0.021) and statin prescriptions (b = 0.18; P = 0.025). Critical appraisal was independently associated with microalbumin tests (b = 0.46; P = 0.002) and eye examination referrals (b = 0.20; P = 0.048). Information retrieval was only independently associated with hemoglobin A1C testing (b = 0.43; P = 0.004). Thiazide prescription was not associated with EBM knowledge scores.

CONCLUSIONS

Physicians' higher total EBM knowledge primarily correlates with better quality of care; however, correlations were modest and explained only a small portion in the variance of clinical performance. Results indicate that there might be a need to focus on teaching all the components of EBM rather than EBM microskills.

Pay for performance: quality- and value-based reimbursement

There is urgent need to reform health care reimbursement models, including physician compensation, to address high health care costs, despite numerous quality initiatives. Pay for performance (P4P) is a model that attempts to align financial incentives with better outcomes and value rather than the current system of rewarding volume and intensity of care delivered. P4P has been implemented in other countries besides the United States and is perhaps most advanced in the United Kingdom. Measurement for P4P is evolving, as are the types of incentives; neither is perfect at this time. For P4P to succeed, all health care stakeholders will need to collaborate.