What works in market-oriented health policy?

Impact of Present-on-admission Indicators on Risk-adjusted Hospital Mortality Measurement

Background:

Benchmarking performance across hospitals requires proper adjustment for differences in baseline patient and procedural risk. Recently, a Risk Stratification Index was developed from Medicare data, which used all diagnosis and procedure codes associated with each stay, but did not distinguish present-on-admission (POA) diagnoses from hospital-acquired diagnoses. We sought to (1) develop and validate a risk index for in-hospital mortality using only POA diagnoses, principal procedures, and secondary procedures occurring before the date of the principal procedure (POARisk) and (2) compare hospital performance metrics obtained using the POARisk model with those obtained using a similarly derived model which ignored the timing of diagnoses and procedures (AllCodeRisk).

Methods:

We used the 2004–2009 California State Inpatient Database to develop, calibrate, and prospectively test our models (n = 24 million). Elastic net logistic regression was used to estimate the two risk indices. Agreement in hospital performance under the two respective risk models was assessed by comparing observed-to-expected mortality ratios; acceptable agreement was predefined as the AllCodeRisk-based observed-to-expected ratio within ±20% of the POARisk-based observed-to-expected ratio for more than 95% of hospitals.

Results:

After recalibration, goodness of fit (i.e., model calibration) within the 2009 data was excellent for both models. C-statistics were 0.958 and 0.981, respectively, for the POARisk and AllCodeRisk models. The AllCodeRisk-based observed-to-expected ratio was within ±20% of the POARisk-based observed-to-expected ratio for 89% of hospitals, which was slightly lower than the predefined limit of agreement.

Conclusion:

Consideration of POA coding meaningfully improved hospital performance measurement. The POARisk model should be used for risk adjustment when POA data are available.

The financial toxicity of cancer treatment: a pilot study assessing out-of-pocket expenses and the insured cancer patient's experience

PURPOSE

Cancer patients carry rising burdens of health care-related out-of-pocket expenses, and a growing number of patients are considered "underinsured." Our objective was to describe experiences of insured cancer patients requesting copayment assistance and to describe the impact of health care expenses on well-being and treatment.

METHODS

We conducted baseline and follow-up surveys regarding the impact of health care costs on well-being and treatment among cancer patients who contacted a national copayment assistance foundation along with a comparison sample of patients treated at an academic medical center.

RESULTS

Among 254 participants, 75% applied for drug copayment assistance. Forty-two percent of participants reported a significant or catastrophic subjective financial burden; 68% cut back on leisure activities, 46% reduced spending on food and clothing, and 46% used savings to defray out-of-pocket expenses. To save money, 20% took less than the prescribed amount of medication, 19% partially filled prescriptions, and 24% avoided filling prescriptions altogether. Copayment assistance applicants were more likely than nonapplicants to employ at least one of these strategies to defray costs (98% vs. 78%). In an adjusted analysis, younger age, larger household size, applying for copayment assistance, and communicating with physicians about costs were associated with greater subjective financial burden.

CONCLUSION

Insured patients undergoing cancer treatment and seeking copayment assistance experience considerable subjective financial burden, and they may alter their care to defray out-of-pocket expenses. Health insurance does not eliminate financial distress or health disparities among cancer patients. Future research should investigate coverage thresholds that minimize adverse financial outcomes and identify cancer patients at greatest risk for financial toxicity.

[Healthcare value chain: a model for the Brazilian healthcare system]

This article presents a model of the healthcare value chain which consists of a schematic representation of the Brazilian healthcare system. The proposed model is adapted for the Brazilian reality and has the scope and flexibility for use in academic activities and analysis of the healthcare sector in Brazil. It places emphasis on three components: the main activities of the value chain, grouped in vertical and horizontal links; the mission of each link and the main value chain flows. The proposed model consists of six vertical and three horizontal links, amounting to nine. These are: knowledge development; supply of products and technologies; healthcare services; financial intermediation; healthcare financing; healthcare consumption; regulation; distribution of healthcare products; and complementary and support services. Four flows can be used to analyze the value chain: knowledge and innovation; products and services; financial; and information.

Flexible recalibration of binary clinical prediction models

Calibration in binary prediction models, that is, the agreement between model predictions and observed outcomes, is an important aspect of assessing the models' utility for characterizing risk in future data. A popular technique for assessing model calibration first proposed by D. R. Cox in 1958 involves fitting a logistic model incorporating an intercept and a slope coefficient for the logit of the estimated probability of the outcome; good calibration is evident if these parameters do not appreciably differ from 0 and 1, respectively. However, in practice, the form of miscalibration may sometimes be more complicated. In this article, we expand the Cox calibration model to allow for more general parameterizations and derive a relative measure of miscalibration between two competing models from this more flexible model. We present an example implementation using data from the US Agency for Healthcare Research and Quality.

National profile of children with Down syndrome: disease burden, access to care, and family impact

OBJECTIVE

To measure the co-morbidities associated with Down syndrome compared with those in other children with special health care needs (CSHCN). Additionally, to examine reported access to care, family impact, and unmet needs for children with Down syndrome compared with other CSHCN.

STUDY DESIGN

An analysis was conducted on the nationally representative 2005 to 2006 National Survey of Children with Special Health Care Needs. Bivariate analyses compared children with Down syndrome with all other CSHCN. Multivariate analyses examined the role of demographic, socioeconomic, and medical factors on measures of care receipt and family impact.

RESULTS

An estimated 98,000 CSHCN have Down syndrome nationally. Compared with other CSHCN, children with Down syndrome had a greater number of co-morbid conditions, were more likely to have unmet needs, faced greater family impacts, and were less likely to have access to a medical home. These differences become more pronounced for children without insurance and from low socioeconomic status families.

CONCLUSIONS

Children with Down syndrome disproportionately face greater disease burden, more negatively pronounced family impacts, and greater unmet needs than other CSHCN. Promoting medical homes at the practice level and use of those services by children with Down syndrome and other CSHCN may help mitigate these family impacts.

Rationale for and methods of superiority, noninferiority, or equivalence designs in orthopaedic, controlled trials

BACKGROUND

To provide value-based healthcare in orthopaedics, controlled trials are needed to assess the comparative effectiveness of treatments. Typically comparative trials are based on superiority testing using statistical tests that produce a p value. However, as orthopaedic treatments continue to improve, superiority becomes more difficult to show and, perhaps, less important as margins of improvement shrink to clinically irrelevant levels. Alternative methods to compare groups in controlled trials are noninferiority and equivalence. It is important to equip the reader of the orthopaedic literature with the knowledge to understand and critically evaluate the methods and findings of trials attempting to establish superiority, noninferiority, and equivalence.

QUESTIONS/PURPOSES

I will discuss supplemental and alternative methods to superiority for assessment of the outcome of controlled trials in the context of diminishing returns on new therapies over old ones.

METHODS

The three methods-superiority, noninferiority, and equivalence-are presented and compared, with a discussion of implied pitfalls and problems.

RESULTS

Noninferiority and equivalence offer alternatives to superiority testing and allow one to judge whether a new treatment is no worse (within a margin) or substantively the same as an active control. Noninferiority testing also allows for inclusion of superiority testing in the same study without the need for adjustment of the statistical methods.

CONCLUSIONS

Noninferiority and equivalence testing might prove most valuable in orthopaedic, controlled trials as they allow for comparative assessment of treatments with similar primary end points but potentially important differences in secondary outcomes, safety profiles, and cost-effectiveness.

Impact of health care reform on the cancer patient: a view from cancer executives

Cancer leaders assess the impact on the cancer patient of the historic passage of Patient Protection and Affordable Care Act (HR 3590) (PPACA). The Association of Cancer Executives, a national organization for leadership development of oncology executives and improvements in patient care delivery, and the Association of Community Cancer Centers, a leading education and advocacy organization for the cancer team, weigh in on the impact of PPACA. Oncology leaders assess the impact of PPACA on cancer patients and families, cancer programs in the United States, and provider relations. The provisions of PPACA most impacting cancer patients are reviewed, including reimbursement changes, expansion of prevention and screening services, the development of accountable care organizations, physician relations, and the implementation of integrated electronic health records. Cancer executives prepare their programs for PPACA by changing the care delivery model to ensure the economic survival of private practices and hospital-based programs.

Building a departmental quality program: a patient-based and provider-led approach

Quality improvement in health care today requires a comprehensive approach. Improvement efforts led by patients, payers, regulators, or health care providers face many barriers. Obstacles include selecting measures with clinical value, building physician acceptance, establishing routine and efficient measurement, and resolving competing clinical demands and work flow impediments. To meet these challenges, the Brigham and Women's Hospital Department of Medicine created a grassroots quality program guided by four main principles: improvement is led by frontline clinicians who select measures important to their patients, performance measurement is automated and accurate, appropriate resources are provided, and interventions are system based and without financial incentives for individual providers. The quality program has engaged the department's physicians from the start. Given the flexibility to define their own metrics according to their patients' needs, clinicians have selected measures related to prevention and wellness, which are often based on national standards. The central quality team facilitates measurement and reporting while providers focus on patient care. The subsequent production of meaningful, actionable data has been instrumental in building physician acceptance and in providing clinicians the opportunity to evaluate and monitor performance. The program's largest challenges have been in capturing meaningful data from electronic systems. The program's system-based focus encourages providers to develop solutions within the existing framework of clinic resources, primarily targeting work flows and processes, while minimizing large expenditures on additional staffing.

Improving colonoscopy quality through health-care payment reform

Problems with the quality of colonoscopy are well recognized. Variation in colonoscopist performance is compounded by payment structures that reward volume rather than quality. Payment reform has emerged as one strategy to address these and more systemic problems in the quality of health care. Various forms of value-based purchasing might encourage a realignment of incentives, and allow reimbursement to be directly linked with clinically important goals of colonoscopy. This paper proposes criteria for the selection of quality measures, and three candidate indicators to define quality for the purpose of payment reform in colonoscopy: cecal intubation rate, adenoma detection rate, and recommended post-polypectomy surveillance interval. These measures represent valid, credible, and reliable indicators of the quality of colonoscopy for colorectal cancer screening and surveillance. Payment reform should explicitly link public reporting and performance on these quality measures to payment for colonoscopy.

A systematic review of applying patient satisfaction outcomes in plastic surgery

BACKGROUND

The authors performed a systematic review of patient satisfaction studies in the plastic surgery literature. The specific aim was to evaluate the status of satisfaction research that has been undertaken to date and to identify areas for improvement.

METHODS

Four medical databases were searched using satisfaction and plastic surgery-related search terms. Quality of selected articles was assessed by two trained reviewers.

RESULTS

Of the total of 2936 articles gleaned by the search, 178 were included in the final review. The majority of the articles (58 percent) in our review examined patient satisfaction in breast surgery populations. In addition, 53 percent of the articles were limited in scope and only measured features of care in one or two domains of satisfaction. Finally, the majority of the studies (68 percent) were based solely on the use of ad hoc satisfaction measurement instruments that did not undergo formal development.

CONCLUSIONS

Given the important policy implications of patient satisfaction data within plastic surgery, we found a need to further refine research in this area. The scarcity of satisfaction research in the craniofacial, hand, and other reconstructive specialties, the narrow scope of satisfaction measurement, and the use of unvalidated instruments are current barriers preventing plastic surgery patient satisfaction studies from producing meaningful results.