Case-mix groups for VA hospital-based home care

Implementing a mHealth intervention to increase colorectal cancer screening among high-risk cancer survivors treated with radiotherapy in the Childhood Cancer Survivor Study (CCSS)

Background

Cancer survivors treated with any dose of radiation to the abdomen, pelvis, spine, or total body irradiation (TBI) are at increased risk for developing colorectal cancer (CRC) compared to the general population. Since earlier detection of CRC is strongly associated with improved survival, the Children’s Oncology Group (COG) Long-Term Follow-Up Guidelines recommend that these high-risk cancer survivors begin CRC screening via a colonoscopy or a multitarget stool DNA test at the age of 30 years or 5 years following the radiation treatment (whichever occurs last). However, only 37% (95% CI 34.1–39.9%) of high-risk survivors adhere to CRC surveillance. The Activating cancer Survivors and their Primary care providers (PCP) to Increase colorectal cancer Screening (ASPIRES) study is designed to assess the efficacy of an intervention to increase the rate of CRC screening among high-risk cancer survivors through interactive, educational text-messages and resources provided to participants, and CRC screening resources provided to their PCPs.

Methods

ASPIRES is a three-arm, hybrid type II effectiveness and implementation study designed to simultaneously evaluate the efficacy of an intervention and assess the implementation process among participants in the Childhood Cancer Survivor Study (CCSS), a North American longitudinal cohort of childhood cancer survivors. The Control (C) arm participants receive electronic resources, participants in Treatment arm 1 receive electronic resources as well as interactive text messages, and participants in Treatment arm 2 receive electronic educational resources, interactive text messages, and their PCP’s receive faxed materials. We describe our plan to collect quantitative (questionnaires, medical records, study logs, CCSS data) and qualitative (semi-structured interviews) intervention outcome data as well as quantitative (questionnaires) and qualitative (interviews) data on the implementation process.

Discussion

There is a critical need to increase the rate of CRC screening among high-risk cancer survivors. This hybrid effectiveness-implementation study will evaluate the effectiveness and implementation of an mHealth intervention consisting of interactive text-messages, electronic tools, and primary care provider resources. Findings from this research will advance CRC prevention efforts by enhancing understanding of the effectiveness of an mHealth intervention and highlighting factors that determine the successful implementation of this intervention within the high-risk cancer survivor population.

Trial registration

This protocol was registered at clinicaltrials.gov (identifier NCT05084833) on October 20, 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08082-3.

Technology-enabled activation of skin cancer screening for hematopoietic cell transplantation survivors and their primary care providers (TEACH)

BACKGROUND

Hematopoietic cell transplantation (HCT) is a curative option for a growing number of patients with hematologic diseases and malignancies. However, HCT-related factors, such as total body irradiation used for conditioning, graft-versus-host disease, and prolonged exposure to immunosuppressive therapy, result in very high risk for melanoma and non-melanoma skin cancer (NMSC). In fact, skin cancer is the most common subsequent neoplasm in HCT survivors, tending to develop at a time when survivors' follow-up care has largely transitioned to the primary care setting. The goal of this study is to increase skin cancer screening rates among HCT survivors through patient-directed activation alone or in combination with physician-directed activation. The proposed intervention will identify facilitators of and barriers to risk-based screening in this population and help reduce the burden of cancer-related morbidity after HCT.

METHODS/DESIGN

720 HCT survivors will be enrolled in this 12-month randomized controlled trial. This study uses a comparative effectiveness design comparing (1) patient activation and education (PAE, N = 360) including text messaging and print materials to encourage and motivate skin examinations; (2) PAE plus primary care physician activation (PAE + Phys, N = 360) adding print materials for the physician on the HCT survivors' increased risk of skin cancer and importance of conducting a full-body skin exam. Patients on the PAE + Phys arm will be further randomized 1:1 to the teledermoscopy (PAE + Phys+TD) adding physician receipt of a portable dermatoscope to upload images of suspect lesions for review by the study dermatologist and an online course with descriptions of dermoscopic images for skin cancers.

DISCUSSION

When completed, this study will provide much-needed information regarding strategies to improve skin cancer detection in other high-risk (e.g. radiation-exposed) cancer survivor populations, and to facilitate screening and management of other late effects (e.g. cardiovascular, endocrine) in HCT survivors.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04358276 . Registered 24 April 2020.

Inpatient admission following anterior cruciate ligament reconstruction is associated with higher postoperative complications

PURPOSE

To compare the occurrence of short-term postoperative complications between inpatient and outpatient anterior cruciate ligament reconstruction.

METHODS

The ACS National Surgical Quality Improvement Program (NSQIP) database was utilized to identify patients undergoing arthroscopic anterior cruciate ligament reconstruction (ACLR) from 2007 to 2017. A total of 18,052 patients were available for analysis following application of exclusion criteria. Patients were categorized based on location of surgery. Inpatients and outpatient ACLR groups were matched by demographics and preoperative laboratory values and differences in 30-day complication rates following surgery were assessed. Significance was set with alpha < 0.05.

RESULTS

From 2007 to 2017, there was an increasing frequency for outpatient ACLR (p < 0.001), while the incidence of inpatient ACLR remained largely constant (n.s). Groups were matched to include 1818 patients in each cohort. Within the first 30 days of surgery, patients in the inpatient ACLR group experienced significantly greater rates of superficial incisional SSI (0.6% vs 0.1%, p = 0.026) and composite surgical complications (0.6% vs 0.2%, p = 0.019), as well as a greater rate of reoperation (0.7% vs 0.2%, p = 0.029). Inpatient procedures also demonstrated a greater rate of deep surgical incisional SSI (0.2% vs 0.0%, n.s) and readmission to hospital (0.8% vs 0.7%, n.s).Outpatient ACLR procedures were also associated with a significantly greater relative value unit (RVU)/h compared with inpatient ACLRs (0.17 vs 0.14, p < 0.001).

CONCLUSIONS

Inpatient ACLR may have an increased risk of postoperative complications compared to outpatient ACLR during the short-term postoperative period. Although some patients may require admission post-operatively for medical and/or pain management, doing so is not necessarily without a degree of risk.

LEVEL OF EVIDENCE

III.

Derivation and validation of the Personal Support Algorithm: an evidence-based framework to inform allocation of personal support services in home and community care

Background

Personal support services enable many individuals to stay in their homes, but there are no standard ways to classify need for functional support in home and community care settings. The goal of this project was to develop an evidence-based clinical tool to inform service planning while allowing for flexibility in care coordinator judgment in response to patient and family circumstances.

Methods

The sample included 128,169 Ontario home care patients assessed in 2013 and 25,800 Ontario community support clients assessed between 2014 and 2016. Independent variables were drawn from the Resident Assessment Instrument-Home Care and interRAI Community Health Assessment that are standardised, comprehensive, and fully compatible clinical assessments. Clinical expertise and regression analyses identified candidate variables that were entered into decision tree models. The primary dependent variable was the weekly hours of personal support calculated based on the record of billed services.

Results

The Personal Support Algorithm classified need for personal support into six groups with a 32-fold difference in average billed hours of personal support services between the highest and lowest group. The algorithm explained 30.8% of the variability in billed personal support services. Care coordinators and managers reported that the guidelines based on the algorithm classification were consistent with their clinical judgment and current practice.

Conclusions

The Personal Support Algorithm provides a structured yet flexible decision-support framework that may facilitate a more transparent and equitable approach to the allocation of personal support services.

Value-Based Payment Reform and the Medicare Access and Children's Health Insurance Program Reauthorization Act of 2015: A Primer for Plastic Surgeons

In 2015, the U.S. Congress passed the Medicare Access and Children's Health Insurance Program Reauthorization Act, which effectively repealed the Centers for Medicare and Medicaid Services sustainable growth rate formula and established the Centers for Medicare and Medicaid Services Quality Payment Program. The Medicare Access and Children's Health Insurance Program Reauthorization Act represents an unparalleled acceleration toward value-based payment models and a departure from traditional volume-driven fee-for-service reimbursement. The Quality Payment Program includes two paths for provider participation: the Merit-Based Incentive Payment System and Advanced Alternative Payment Models. The Merit-Based Incentive Payment System pathway replaces existing quality reporting programs and adds several new measures to create a composite performance score for each provider (or provider group) that will be used to adjust reimbursed payment. The advanced alternative payment model pathway is available to providers who participate in qualifying Advanced Alternative Payment Models and is associated with an initial 5 percent payment incentive. The first performance period for the Merit-Based Incentive Payment System opens January 1, 2017, and closes on December 31, 2017, and is associated with payment adjustments in January of 2019. The Centers for Medicare and Medicaid Services estimates that the majority of providers will begin participation in 2017 through the Merit-Based Incentive Payment System pathway, but aims to have 50 percent of payments tied to quality or value through Advanced Alternative Payment Models by 2018. In this article, the authors describe key components of the Medicare Access and Children's Health Insurance Program Reauthorization Act to providers navigating through the Quality Payment Program and discuss how plastic surgeons may optimize their performance in this new value-based payment program.

Prevalence and Costs of Chronic Conditions in the VA Health Care System

Chronic conditions are among the most common causes of death and disability in the United States. Patients with such conditions receive disproportionate amounts of health care services and therefore cost more per capita than the average patient. This study assesses the prevalence among the Department of Veterans Affairs (VA) health care users and VA expenditures (costs) of 29 common chronic conditions. The authors used regression to identify the marginal impact of these conditions on total, inpatient, outpatient, and pharmacy costs. Excluding costs of contracted medical services at non-VA facilities, total VA health care expenditures in fiscal year 1999 (FY1999) were $14.3 billion. Among the 3.4 million VA patients in FY1999, 72 percent had 1 or more of the 29 chronic conditions, and these patients accounted for 96 percent of the total costs ($13.7 billion). In addition, 35 percent (1.2 million) of VA health care users had 3 or more of the 29 chronic conditions. These individuals accounted for 73 percent of the total cost. Overall, VA health care users have more chronic diseases than the general population.

Estimating the Costs of VA Ambulatory Care

This article reports how we matched Common Procedure Terminology (CPT)codes with Medicare payment rates and aggregate Veterans Affairs (VA)budget data to estimate the costs of every VA ambulatory encounter. Converting CPT codes to encounter-level costs was more complex than a simple match of Medicare reimbursements to CPT codes. About 40 percent of the CPT codes used in VA, representing about 20 percent of procedures, did not have a Medicare payment rate and required other cost estimates. Reconciling aggregated estimated costs to the VA budget allocations for outpatient care produced final VA cost estimates that were lower than projected Medicare reimbursements. The methods used to estimate costs for encounters could be replicated for other settings. They are potentially useful for any system that does not generate billing data, when CPT codes are simpler to collect than billing data, or when there is a need to standardize cost estimates across data sources.

Metrics for assessing improvements in primary health care

Metrics focus attention on what is important. Balanced metrics of primary health care inform purpose and aspiration as well as performance. Purpose in primary health care is about improving the health of people and populations in their community contexts. It is informed by metrics that include long-term, meaning- and relationship-focused perspectives. Aspirational uses of metrics inspire evolving insights and iterative improvement, using a collaborative, developmental perspective. Performance metrics assess the complex interactions among primary care tenets of accessibility, a whole-person focus, integration and coordination of care, and ongoing relationships with individuals, families, and communities; primary health care principles of inclusion and equity, a focus on people's needs, multilevel integration of health, collaborative policy dialogue, and stakeholder participation; basic and goal-directed health care, prioritization, development, and multilevel health outcomes. Environments that support reflection, development, and collaborative action are necessary for metrics to advance health and minimize unintended consequences.

Do market fees differ from relative value scale fees? Examining surgeon payments in New Zealand

OBJECTIVES

Health funders face the challenge of determining the appropriate level of surgeon fees in fee-for-service schemes.  A resource-based relative value scale (RBRVS) attempts to identify the fees that would exist in a competitive market.  Private insurance providers in New Zealand do not use a RBRVS but rather rely on a market.  We explore the extent to which private surgeon fees in New Zealand are consistent with fees that would be generated by a RBRVS.

METHODS

Data on 155,290 surgical procedures from 2004-06 were provided by New Zealand's largest private health insurer.  314 procedure codes were matched to the Australian Ministry of Health and Ageing's RBRVS. A random effects model determined predicted surgeon reimbursements based on the RBRVS, the location and the year. Procedure volume and specialty were explored as potential sources of deviations.

RESULTS

The RBRVS, location and year explain 79% of the variation in surgeon fees. After accounting for the RBRVS, location and year, no statistical differences were found between five out of the seven specialties, but higher volume procedures were associated with lower fees. There was some evidence that the model explained less variation in lower volume procedures.

CONCLUSIONS

Surgical fees were generally consistent with those predicted by the RBRVS. However, the fees for high volume procedures were relatively lower than predicted while the fees for low volume procedures appeared more variable. The findings are consistent with the hypothesis that market forces lowered prices for procedures with higher volumes. This has implications for how health funders might determine private surgical fees, especially in mixed public-private systems.

The impact of measuring patient-reported outcomes in clinical practice: a systematic review of the literature

OBJECTIVE

The purpose of this paper is to summarize the best evidence regarding the impact of providing patient-reported outcomes (PRO) information to health care professionals in daily clinical practice.

METHODS

Systematic review of randomized clinical trials (Medline, Cochrane Library; reference lists of previous systematic reviews; and requests to authors and experts in the field).

RESULTS

Out of 1,861 identified references published between 1978 and 2007, 34 articles corresponding to 28 original studies proved eligible. Most trials (19) were conducted in primary care settings performed in the USA (21) and assessed adult patients (25). Information provided to professionals included generic health status (10), mental health (14), and other (6). Most studies suffered from methodologic limitations, including analysis that did not correspond with the unit of allocation. In most trials, the impact of PRO was limited. Fifteen of 23 studies (65%) measuring process of care observed at least one significant result favoring the intervention, as did eight of 17 (47%) that measured outcomes of care.

CONCLUSIONS

Methodological concerns limit the strength of inference regarding the impact of providing PRO information to clinicians. Results suggest great heterogeneity of impact; contexts and interventions that will yield important benefits remain to be clearly defined.

A review and comparison of classification algorithms for medical decision making

Within a health care setting, it is often desirable from both clinical and operational perspective to capture the uncertainty and variability amongst a patient population, for example to predict individual patient outcomes, risks or resource needs. Homogeneity brings the benefits of increased certainty in individual patient needs and resource utilisation, thus providing an opportunity for both improved clinical diagnosis and more efficient planning and management of health care resources. A number of classification algorithms are considered and evaluated for their relative performances and practical usefulness on different types of health care datasets. The algorithms are evaluated using four criteria: accuracy, computational time, comprehensibility of the results and ease of use of the algorithm to relatively statistically naive medical users. The research has shown that there is not necessarily a single best classification tool, but instead the best performing algorithm will depend on the features of the dataset to be analysed, with particular emphasis on health care data, which are discussed in the paper.

A system of patient classification in long-term psychiatric inpatients: Resource Utilization Groups T-18 (RUG T-18)

This paper shows the application of a 'case mix' system (Resources Utilization Groups T18 or RUG-T18) to a Spanish long-term inpatient psychiatric sample.

OBJECTIVE

To examine the capacity of RUG-T18 to predict patient resource use (spent time of care) in a long-term psychiatric sample.

SUBJECTS AND RESEARCH DESIGN

Data included an assessment of 163 patients' characteristics, corresponding to groups of the RUG-T18, and detailed measurement of nursing staff care over a 24-h period.

RESULTS

'Severe behavioural problems' was the most frequent RUG-T18 category. There were significant differences in the spent time of care in the different groups and high variability in the distribution of time of care within groups and in the total sample.

CONCLUSIONS

The RUG T-18 system should be improved to become a useful case mix system in long-term psychiatric inpatients. The high variance intragroups could be minimized improving the psychopathological aspects of the system.

Are physician-derived disease severity indices associated with health-related quality of life in patients with end-stage liver disease?

OBJECTIVES

Model for end-stage liver disease (MELD) score is now often used as an overall indicator of health status for patients with end-stage liver disease. However, there are no data evaluating the associations between MELD scores and patient reports of health-related quality of life (HRQOL).

METHODS

Two hundred-three patients with end-stage liver disease completed a disease-targeted HRQOL instrument (the LDQOL 1.0). Patients also rated the severity of their liver disease and reported number of disability days attributed to their liver disease in the preceding month. MELD and Child Turcott Pugh (CTP) scores were calculated for all patients. Associations of MELD and CTP scores with patient-derived outcomes were estimated.

RESULTS

The mean MELD and CTP scores were 12 and 7, respectively, indicating mild severity of liver disease. HRQOL of patients was generally poor, with the mean SF-36 physical and mental component summary scores of 35 and 40. Seventy percent of patients rated their liver disease symptoms as moderate to severe. Similarly, 70% reported being disabled from their liver disease. MELD was associated with physical functioning scale and the physical component summary (PCS) score in patients with end-stage liver disease. In contrast, CTP score was significantly associated with physical functioning, role limitations due to physical health problems, PCS score, effects of liver disease, sexual functioning, and sexual problems. Both MELD and CTP scores correlated with self-rated severity of liver disease symptoms but not with self-reported disability days.

CONCLUSIONS

Despite objectively mild liver disease, the subjective HRQOL of this cohort was severely impaired. CTP score was more closely associated with patient-reported estimates of HRQOL than the MELD score. CTP or disease-specific HRQOL instruments may compliment MELD by providing insights into outcomes of importance to patients with low risk of mortality.

Measuring Quality of Life in Routine Oncology Practice Improves Communication and Patient Well-Being: A Randomized Controlled Trial

Purpose

To examine the effects on process of care and patient well-being, of the regular collection and use of health-related quality-of-life (HRQL) data in oncology practice.

Patients and Methods

In a prospective study with repeated measures involving 28 oncologists, 286 cancer patients were randomly assigned to either the intervention group (regular completion of European Organization for Research and Treatment of Cancer-Core Quality of Life Questionnaire version 3.0, and Hospital Anxiety and Depression Scale on touch-screen computers in clinic and feedback of results to physicians); attention-control group (completion of questionnaires, but no feedback); or control group (no HRQL measurement in clinic before encounters). Primary outcomes were patient HRQL over time, measured by the Functional Assessment of Cancer Therapy-General questionnaire, physician-patient communication, and clinical management, measured by content analysis of tape-recorded encounters. Analysis employed mixed-effects modeling and multiple regression.

Results

Patients in the intervention and attention-control groups had better HRQL than the control group (P = .006 and P = .01, respectively), but the intervention and attention-control groups were not significantly different (P = .80). A positive effect on emotional well-being was associated with feedback of data (P = .008), but not with instrument completion (P = .12). A larger proportion of intervention patients showed clinically meaningful improvement in HRQL. More frequent discussion of chronic nonspecific symptoms (P = .03) was found in the intervention group, without prolonging encounters. There was no detectable effect on patient management (P = .60). In the intervention patients, HRQL improvement was associated with explicit use of HRQL data (P = .016), discussion of pain, and role function (P = .046).

Conclusion

Routine assessment of cancer patients' HRQL had an impact on physician-patient communication and resulted in benefits for some patients, who had better HRQL and emotional functioning.

Motility and GI function studies billing and coding guidelines: a position paper of the American Motility Society

Tests that measure gastrointestinal function, such as esophageal motility testing, ambulatory twenty-four hour pH, electrogastrography, gastroduodenal, sphincter of Oddi, and anorectal manometry, as well as hydrogen breath testing are now an essential part in the evaluation of patients with functional gastrointestinal disorders. They are widely performed in a variety of clinical settings. In this paper we outline the position of the American Motility Society on billing and coding for these studies, and review the issues for these studies under the current United States Relative Value Scale system. We have also provided an outline for standardization of reports for these procedures, and propose changes and modifications of current medical necessity diagnoses.

Feasibility and compliance of automated measurement of quality of life in oncology practice

PURPOSE

Systematic quality-of-life (QOL) assessment may have value in oncology practice by increasing awareness of a wide range of issues, possibly increasing detection of psychologic morbidity, social problems, and changes in physical status, and improving care and its outcomes. However, logistic problems are substantial. Automated systems solve many of these problems. We field-tested the feasibility and compliance that can be achieved using a computer touchscreen system in two consecutive studies.

PATIENTS AND METHODS

In study 1, a prospective cohort of 272 patients was offered QOL assessment at each clinic appointment for 6 months. In study 2, all patients (N = 1,291) were offered QOL assessment as part of clinic routine during a 12-week period.

RESULTS

In study 1, 82% of patients agreed to take part, but over time, compliance was poor (median, 40%; mean, 43%) and deteriorated with longer follow-up. In study 2, the overall compliance was greatly increased (median, 100%; mean, 70%), and compliance was retained over multiple visits. In study 1, compliance was better in younger patients, males, and socially advantaged patients, but was not affected by the presence of depression or anxiety, or QOL. In the second study, building on experience in the first study, data collection and storage in the computer system was excellent, achieving 98% of collected data stored in one center. In general, patients were comfortable with the computers and the approach. Data collection on the wards was more difficult and less complete than in clinics, especially for patients undergoing acute admissions.

CONCLUSION

Feasibility with higher compliance was demonstrated in study 2, in which the data collection was integrated into routine care, and can be improved with further technical initiatives and education of staff.

A framework for operational modelling of hospital resources

The provision of hospital resources, such as beds, operating theatres and nurses, is a matter of considerable public and political concern and has been the subject of widespread debate [1,2,31. The political element of healthcare emphasises the need for objective methods and tools to inform the debate and provide a better foundation for decision-making. There is considerable scope for operational models to be widely used for this purpose. An appreciation of the dynamics governing a hospital system, and the flow of patients through it, point towards the need for sophisticated capacity models reflecting the complexity, uncertainty, variability and limited resources. Working alongside managers and clinicians from participating hospitals, this paper proposes a generic framework for modelling of hospital resources in the light of perceived user-needs and real-life hospital processes. The proposed framework incorporates the need for patient classification techniques to be adopted, which forms a key differentiator between this approach and other attempts to produce practical capacity planning and management tools. Statistically and clinically meaningful patient groupings may then be fed into developed simulation models and individual patients from each group passed through the particular hospital system of concern. The effectiveness of the framework is demonstrated through the development and use of an integrated hospital capacity tool.

The health-line--a method for collecting data on self-rated health over time: a pilot study

BACKGROUND

There is a need for an instrument to record a life-course perspective of self-rated health.

AIM

To test the "health-line", a simple, comprehensive method of collecting data on self-rated health over time.

METHOD

In 1996, a questionnaire was mailed to people who in 1985 were aged between 25 and 34 years old and had a sick-leave spell >28 days with "back diagnoses". They were asked to rate their global health graphically with a "health-line" for the years 1985-95. Official data on sick leave and disability pension were obtained for the same period. In all, 37 out of 52 men and 60 out of 83 women answered; that is, they drew a health-line.

RESULT

A statistically significant negative correlation between the mean number of absence days due to ill health and the health-line data was found for every year (r= -0.35 to -0.53; p<0.001) and for the whole period 1985-95 (r=-0.546; p<0.001) respectively.

CONCLUSION

The method worked well and is well worth further development and testing.

Use of point-of-service health status assessments by community pharmacists to identify and resolve drug-related problems in patients with musculoskeletal disorders

STUDY OBJECTIVE

To determine whether community pharmacists can use point-of-service health status assessments to identify and resolve drug-related problems (DRPs) in ambulatory patients with selected musculoskeletal (MSK) disorders.

DESIGN

Twelve-month, prospective, multicenter demonstration project.

SETTING

Twelve independent community pharmacies in eastern Iowa.

PATIENTS

Ambulatory patients with self-reported diagnosis of osteoarthritis, rheumatoid arthritis, or low back pain.

MEASUREMENTS

During quarterly pharmacy visits for 1 year, patients used touch-screen computers to report their health status. Patients answered questions on the Short Form-36 (SF-36) general health survey, as well as questions assessing limitations associated with their MSK condition. Pharmacists used this data in interviewing patients to assess for DRPs.

MAIN RESULTS

The study enrolled 461 patients, of whom 388 returned for the 12-month visit. During this 1-year period, community pharmacists identified 926 cumulative DRPs. Patients with no DRPs had significantly higher physical component summary scores on the SF-36 (p<0.05) than patients with more than one DRP at baseline (36.2 vs 31.6), 6 months (39.2 vs 33.3), and 12 months (40.1 vs 35.4). At 12 months, actions performed by pharmacists led to resolution or improvement of 70.7% of DRPs.

CONCLUSION

Drug-related problems are numerous in community-dwelling patients with MSK disorders and correspond to decreased physical health status. Community pharmacists can use patient-reported measures of health status to identify DRPs and initiate processes to resolve them.

Labor epidurals improve outcomes for babies of mothers at high risk for unscheduled cesarean section

CONTEXT

Epidural placement for labor in the general population of laboring women is associated with increased incidence of operative deliveries, prolongation of labor, and may be associated with an increased cesarean section rate. The risks and benefits associated with epidural placement for labor in the subpopulation of mothers at high risk for cesarean section have not been studied.

OBJECTIVE

To determine if a population of mothers and babies at high risk for cesarean section will have improved outcomes with labor epidural placement.

DESIGN

A decision and cost analysis examining epidural placement for labor on a population of women who are at high risk for unscheduled cesarean section and may benefit from scheduled cesarean section as determined by threshold analysis was performed. Outcomes and probabilities were determined through analysis of the Department of Defense's 1996 National Quality Management Program (NQMP) Birth Product Line data set containing more than 7000 deliveries. Outcomes were defined using variables comprised of all documented conditions that occurred during the peripartum and neonatal hospitalizations. The 1997 NQMP data set was used to validate the results.

SETTING

Military Treatment Facilities throughout the United States and abroad and civilian facilities in the United States providing care to military dependents.

PATIENT POPULATION

Active duty and dependent pregnant women and babies.

RESULTS

About 8% of mothers in this patient population were found to be at high risk for cesarean section. The decision and cost analyses showed that babies of the high risk mothers who received epidurals for labor had better clinical outcomes (p<0.05) and the procedure was cost neutral (p=0.23). The procedure did not increase the frequency of cesarean section, and there was no effect on maternal outcomes scores. These results were confirmed by the validation study.

CONCLUSIONS

There is a sizable subpopulation of women at high risk for cesarean section whose babies may have better outcomes with epidural placement with no sacrifice in maternal outcomes or costs.

Self-reported quality of life of individual cancer patients: concordance of results with disease course and medical records

PURPOSE

To investigate the applicability of a standard quality of life (QL) questionnaire to individual cancer patients and to explore the potential for impact of QL information on the process of care by comparing at group level the QL results with the medical records.

PATIENTS AND METHODS

One hundred fourteen consecutive patients at the oncology clinics at St James's Hospital, Leeds, United Kingdom, completed the European Organization for the Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ)-C30 on a touch-screen computer over a 6-month period. The QL results were compared with the corresponding medical records at individual and group level.

RESULTS

For individual patients, the serial measurement of QL allowed recognition of patterns over time corresponding to disease course. At group level, a higher proportion of patients reported problems on EORTC QLQ-C30 than were mentioned in the medical records (McNemar paired test, P <.01). Most often clinicians mentioned pain (22% to 39%), and at the initial visit role (66%), and social issues (77%). For the rest of the symptoms and functions, the problems were recorded in between 1% and 25% of the notes, but 20% to 76% of the patients reported QL impairment. Problems that were not recorded in the medical notes tended to be of low severity, with a significant trend observed for pain, fatigue, nausea/vomiting, dyspnea, loss of appetite, and physical function scale (chi(2) test, 11.55 to 34.42, df = 1, P <.001).

CONCLUSION

The QL data on individual patients was consistent with the clinical records, thus providing evidence for the validity of these measures in assessment of the individual. The QL profiles had more information on symptoms and particularly on functional issues, such as emotional distress and physical performance.

How are you feeling? Who wants to know? Patients' and oncologists' preferences for discussing health-related quality-of-life issues

PURPOSE

This study investigated (1) the attitudes of cancer patients toward discussing health-related quality-of-life (HRQL) issues; (2) the association between such attitudes and patients' characteristics; and (3) oncologists' attitudes and self-reported behavior regarding these same issues.

PATIENTS AND METHODS

Two hundred seventy-three patients receiving palliative chemotherapy and ten physicians were asked to complete a series of questionnaires.

RESULTS

Almost all patients wanted to discuss their physical symptoms and physical functioning and were also willing to address their emotional functioning and daily activities. However, 25% of the patients were only willing to discuss these latter two issues at the initiative of their physician. Patients varied most in their willingness to discuss their family and social life, with 20% reporting no interest in discussing these issues at all. Female patients were more reluctant to discuss various HRQL issues than male patients. Older and less well-educated patients were more likely to prefer that their physician initiate discussion of HRQL issues. All physicians considered it to be primarily their task to discuss the physical aspects of their patients' health, whereas four physicians indicated that discussion of psychosocial issues was a task to be shared with other health care providers. All physicians indicated that they generally defer to their patients in initiating discussion of psychosocial issues.

CONCLUSION

Although both patients and oncologists seem willing to discuss a wide range of HRQL issues, communication regarding psychosocial issues may be hampered by competing expectations as to who should take the lead in initiating such discussions.

Measuring costs of guideline-driven mental health care: the Texas Medication Algorithm Project

BACKGROUND: Algorithms describe clinical choices to treat a specific disorder. To many, algorithms serve as important tools helping practitioners make informed choices about how best to treat patients, achieving better outcomes more quickly and at a lower cost. Appearing as flow charts and decision trees, algorithms are developed during consensus conferences by leading experts who explore the latest scientific evidence to describe optimal treatment for each disorder. Despite a focus on "optimal" care, there has been little discussion in the literature concerning how costs should be defined and measured in the context of algorithm-based practices. AIMS OF THE STUDY: This paper describes the strategy to measure costs for the Texas Medication Algorithm project, or TMAP. Launched by the Texas Department of Mental Health and Mental Retardation and the University of Texas Southwestern Medical Center at Dallas, this multi-site study investigates outcomes and costs of medication algorithms for bipolar disorder, schizophrenia and depression. METHODS: To balance costs with outcomes, we turned to cost-effectiveness analyses as a framework to define and measure costs. Alternative strategies (cost-benefit, cost-utility, cost-of-illness) were inappropriate since algorithms are not intended to guide resource allocation across different diseases or between health- and non-health-related commodities. "Costs" are operationalized consistent with the framework presented by the United States Public Health Service Panel on Cost Effectiveness in Medicine. Patient specific costs are calculated by multiplying patient units of use by a unit cost, and summing over all service categories. Outpatient services are counted by procedures. Inpatient services are counted by days classified into diagnosis groups. Utilization information is derived from patient self-reports, medical charts and administrative file sources. Unit costs are computed by payer source. Finally, hierarchical modeling is used to describe how costs and effectiveness differ between algorithm-based and treatment-as-usual practices. DISCUSSION: Cost estimates of algorithm-based practices should (i) measure opportunity costs, (ii) employ structured data collection methods, (iii) profile patient use of both mental health and general medical providers and (iv) reflect costs by payer status in different economic environments. IMPLICATION FOR HEALTH CARE PROVISION AND USE: Algorithms may help guide clinicians, their patients and third party payers to rely on the latest scientific evidence to make treatment choices that balance costs with outcomes. IMPLICATION FOR HEALTH POLICIES: Planners should consider consumer wants and economic costs when developing and testing new clinical algorithms. IMPLICATIONS FOR FURTHER RESEARCH: Future studies may wish to consider similar methods to estimate costs in evaluating algorithm-based practices.

Determinants of home health visit length: results of a multisite prospective study

OBJECTIVES

The authors (1) compare visit length across four categories of skilled nursing home health visits which reflect recent changes in home health casemix-AIDS-related, hospice/terminal (HT), intravenous (IV) therapy, and maternal and child health (MCH)-with general adult medical/surgical (MS) visits and (2) identify factors influencing visit length.

METHODS

The study sites were 12 nonproprietary Massachusetts home health agencies (HHAs). Staff nurses collected data concurrently on a sample of visits they provided between December 1, 1992 and November 30, 1993. The visits were stratified by agency, time of year, and visit category. The authors used analysis of variance to test for significant differences across visit categories in Home Length of Visit (the number of minutes between when the nurse entered and left the home) (HLOV). The authors used multivariate regression analysis to develop models identifying determinants of HLOV and adjusted R2 to measure the explanatory power of partial models.

RESULTS

In univariate analysis, the categories differed significantly from each other in length (P < 0.0001). HT visits were the longest (median visit length = 60, 80, and 59 minutes for HT Only visits, visits in both the HT and AIDS categories (HT/AIDS), and HT/IV visits, respectively). MS visits were the shortest (median = 30 minutes). The remaining categories were intermediate in length (medians = 37 to 50 minutes). Almost half the variability in HLOV was explained by the full multivariate regression model, which includes all independent variables (adjusted R2 = .4486; P < 0.0001). Visit characteristics alone in a partial model explained 18% of the variability in HLOV. Three other variable sub-groups-agency, client characteristics, and nursing workload-each explained about 15% of the variability in HLOV. Nursing activities performed during the visit explained 11%; several of these related to teaching, education, or assessment.

CONCLUSIONS

Accurate reimbursement reflecting casemix differences is important to protect the teaching, education, and assessment functions of nurses; measure nurse productivity and allocate caseloads; maintain access to services for clients with greater needs; and avoid creating economic disincentives to the agencies that serve them. Payers formulating prospective payment systems can adjust per visit reimbursement rates to reflect differences in visit length by category and incorporate functional limitations, clinical instability, and case coordination as classification variables. Developers of home health casemix systems can use factor analysis to improve the robustness of multivariate models and include nursing workload in predicting visit length. Home health agencies measuring productivity and caseload across complex client populations can classify visits into three groups-MS; HT; and AIDS, IV, and MCH-or use the regression results to develop more refined predictors of visit length and nursing caseload.

Classification trees. A possible method for iso-resource grouping in intensive care

Classification and grouping of clinical data into defined categories or hierarchies is difficult in intensive care practice. Diagnosis-related groups are used to categorise patients on the basis of diagnosis. However, this approach may not be applicable to intensive care where there is wide heterogeneity within diagnostic groups. Classification tree analysis uses selected independent variables to group patients according to a dependent variable in a way that reduces variation. In this study, the influence of three easily identified patient attributes on their length of intensive care unit stay was explored using classification analysis. Two thousand five hundred and forty-five critically ill patients from three hospitals were classified into groups so that the variation in length of stay within each group was minimised. In 23 out of 39 terminal groups, the interquartile range of the length of stay was < or = 3 days.

Generic versus disease-specific health status measures. An example using coronary artery disease and congestive heart failure patients

The objectives of this study were to evaluate and compare the psychometric properties of a generic health status measure, the Medical Outcomes Study SF-36, and a disease-specific health status measure, a modified version of the Chronic Heart Failure Questionnaire (CHQ), among outpatients known to have coronary artery disease (CAD) and/or congestive heart failure (CHF). A cross-sectional analysis of baseline data obtained from 670 outpatients participating in a randomized controlled clinical trial in the general medicine clinics of a major academic medical center was performed. The SF-36 was more comprehensive in its coverage of different health status domains. In contrast, the CHQ had fewer problems with floor and ceiling effects, was more internally consistent, had better dimensional reproducibility, and exhibited less factorial complexity. Although both instruments are appropriate for use among outpatients known to have CAD and/or CHF, the CHQ has significantly better psychometric properties than does the SF-36.

Three-year changes in self-perceived oral health status in an older Canadian population

Although change is a central goal of oral health care interventions, little attention has yet been paid to change in self-perceptions of oral health status. This is an important omission, given the current emphasis on assessing health outcomes. This paper reports the results of a study which examined changes over a period of three years in self-perceived oral health among 611 community-dwelling Canadians aged 50 years and over. Change in self-perceptions was measured by means of a global transition item and change scores derived from repeat administrations of four subjective oral health status indicators. Overall, 20.5% reported that their oral health had deteriorated over the three-year observation period, 68.5% that it had remained the same, and 10.5% that it had improved. There was a significant association between these global change categories and change scores for the four subjective indicators. Because of the small number of edentulous subjects, the analysis of baseline characteristics predicting change was confined to dentate subjects. Bivariate and logistic regression analyses were used to compare the two groups reporting change with those whose oral health status remained stable over the observation period. The results suggest that, when compared with this reference group, those who deteriorated and those who improved were similar in some respects but distinct in others. Those who improved appeared to have specific oral conditions at baseline causing pain. Those who deteriorated had poor oral health in general and came from more disadvantaged backgrounds. However, the explanatory power of logistic regression models predicting change in self-perceived oral health was poor when judged in terms of model sensitivities. This was to be expected, given that the models did not include variables documenting the incidence of disease, receipt of dental care, or changes in social and personal circumstances over the observation period.

The routine use of health-related quality of life measures in the care of patients with epilepsy: rationale and research agenda

Reliable and valid patient-completed questionnaires to assess the health related quality of life (HRQOL) of people with epilepsy are becoming increasingly available. At present, however, they are not routinely used in epilepsy patients' care. The use of HRQOL measurement in clinical practice settings may improve the quality of care for people with epilepsy through (1) increasing the detection of patients' problems with daily functioning and well-being: (2) guiding therapeutic management; and (3) leading to improvements in patients' HRQOL and satisfaction with care. To realize the potential benefits of HRQOL assessment in the care of people with epilepsy, research into the feasibility of the office-based use of HRQOL questionnaires, measurement quality, and the impact of routine HRQOL assessment on the quality of epilepsy patients' care needs to be undertaken. The transfer of HRQOL questionnaires from research tools into clinical tools requires the collaboration of social scientists, health services researchers, and clinicians. HRQOL questionnaires have the potential to become a new clinical tool which could enhance the quality of care physicians are able to provide for their patients with epilepsy.

Delayed discharge of elderly hospital patients--a study of bed-blockers in a health care district in Sweden

With an ageing population an increased pressure on health care resources will be seen in most countries. Patients with delayed discharge from short-term hospitals, sometimes called "bed-blockers", are of special interest in Sweden, especially as liability for payments for these patients has been placed on the municipal authorities by a new reform in 1992. A retrospective study was made of 428 bed-blockers above the age of 64 years from one health district in Uppsala during the two-year period 1987-1988. The median age was 81.6 years, and the majority were women. The patients had a median number of diagnoses of 4.1. Additional medical events/symptoms were noted in half of the patients after they had been classified as medically ready for discharge. Even though they were classified "medically ready" for discharge, they still needed care. One-third needed further rehabilitation and another 1/3 further medical attention. Only 1/10 were independent in daily activities of living. At the final discharge 1/3 actually returned home and 16% died on the acute ward. The results clearly demonstrate that these patients often still had further medical needs after the application for transfer. One crucial question, that needs discussion, is the vague definition of a "bed-blocker". Related questions are when and where should these patients be transferred, as well as the relevance of the term "bed-blocker" from ethical perspectives.

'Bed-blockers': delayed discharge of hospital patients in a nationwide perspective in Sweden

Between 1989 and 1992 the number of 'bed-blocking' patients in Sweden decreased from 15 to 7% according to national registers containing approx. 4000 patients. Part of this reduction can be explained by the 1992 Elderly Reform, which placed economic responsibility for bed-blockers on municipalities. However, the decrease began before the economic reform, implying that other factors are also involved, such as access to alternative institutional beds and other forms of care. An in-depth study of one district has provided a description of these often elderly patients, their heavy hospital utilization both before and after the bed-blocking period and their mortality. Nearly half the patients were dead within a year. Bed-blocking is a poorly defined concept requiring urgent discussion. Other related topics to which attention should be drawn are the administrative costs of economic control systems and efficient utilization of public resources as a whole.

Using patient reports to assess health-related quality of life after total hip replacement

Data on disease severity, co-morbidity, and process of care were obtained from the medical records of 356 patients without rheumatoid arthritis undergoing a first unilateral total hip replacement at four teaching hospitals in California and Massachusetts. Socio-demographic characteristics, functional status prior and subsequent to hospitalization, and improvement in health status were measured with a patient questionnaire 12 months after discharge. Completed questionnaires were received from 284 patients, a response rate of 79.8%. The questionnaire was acceptable to patients, reliable, and had good construct validity. The data indicate substantial benefits from hip arthroplasty. As expected, pre-surgical functioning was a strong predictor of outcomes 1 year after surgery. Controlling for pre-surgical functioning, age was not related to outcomes.