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Lee CM, Kaplan RM, Nelson SC, Horvitz-Lennon M. Financing the "Village": Establishing a Sustainable Financial System for Child Behavioral Health. Child Adolesc Psychiatr Clin N Am 2024; 33:457-470. [PMID: 38823817 PMCID: PMC11153862 DOI: 10.1016/j.chc.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2024]
Abstract
An increased need for child and adolescent behavioral health services compounded by a long-standing professional workforce shortage frames our discussion on how behavioral health services can be sustainably delivered and financed. This article provides an overview of different payment models, such as traditional fee-for-service and alternatives like provider salary, global payments, and pay for performance models. It discusses the advantages and drawbacks of each model, emphasizing the need to transition toward value-based care to improve health care quality and control costs.
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Affiliation(s)
- Chuan Mei Lee
- Department of Psychiatry and Behavioral Sciences, UCSF, 675 18th Street, Box 3132, San Francisco, CA 94143, USA; Clinical Excellence Research Center, Stanford University School of Medicine, Stanford, CA, USA.
| | - Robert M Kaplan
- Clinical Excellence Research Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Suzie C Nelson
- Department of Psychiatry, Wright State University, 2555 University Boulevard, Dayton, OH 45324, USA
| | - Marcela Horvitz-Lennon
- RAND Corporation, 20 Park Plaza, Suite 910, Boston, MA 02116, USA; Department of Psychiatry, Cambridge Health Alliance and Harvard Medical School, Cambridge, MA, USA
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2
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The role of pay-for-performance in reducing healthcare disparities: A narrative literature review. Prev Med 2022; 164:107274. [PMID: 36156282 DOI: 10.1016/j.ypmed.2022.107274] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 07/27/2022] [Accepted: 09/18/2022] [Indexed: 11/21/2022]
Abstract
As American healthcare shifts to value-based payment, Pay-for-Performance (P4P) has become an important and controversial topic. One of the main controversies pertains to its potential to narrow or widen existing healthcare disparities depending on how the program is designed and implemented. It is thus imperative to understand which design features are most likely to reduce disparities. We conducted a systematic literature review from 2004 to 2021 of P4P's impact on disparities. Given the interdisciplinary nature of P4P research, multiple search strategies were combined, and many study designs were eligible for analysis. The literature was then qualitatively analyzed, with themes and major findings developed using Grounded Theory. Six major design features emerged as most promising in leveraging P4P to reduce disparities: 1) Risk/Case-Mix Adjustment; 2) Stratified Performance Measures/Stratification; 3) Disparity Reduction Metrics; 4) Exception Reporting; 5) Pay-for-Improvement; and 6) Population-Specific Metrics. Each design feature has its own mechanism, strengths, and weaknesses. We identify and define these features' direct and indirect effects on healthcare disparities. The interaction of each design feature with one another, with P4P as a whole, and within the larger reimbursement system can have considerable effects on disparities. Promising strategies exist to leverage P4P to narrow disparities for clinically and socially complex patients. The six design features discussed in this review help P4P programs address structural disadvantages faced by such patients and their providers. In regard to health equity, these design features can transform P4P from being part of the problem to being part of the solution.
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Hanson K, Brikci N, Erlangga D, Alebachew A, De Allegri M, Balabanova D, Blecher M, Cashin C, Esperato A, Hipgrave D, Kalisa I, Kurowski C, Meng Q, Morgan D, Mtei G, Nolte E, Onoka C, Powell-Jackson T, Roland M, Sadanandan R, Stenberg K, Vega Morales J, Wang H, Wurie H. The Lancet Global Health Commission on financing primary health care: putting people at the centre. Lancet Glob Health 2022; 10:e715-e772. [PMID: 35390342 PMCID: PMC9005653 DOI: 10.1016/s2214-109x(22)00005-5] [Citation(s) in RCA: 109] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 12/16/2021] [Accepted: 12/17/2021] [Indexed: 01/18/2023]
Affiliation(s)
- Kara Hanson
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
| | - Nouria Brikci
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Darius Erlangga
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Abebe Alebachew
- Breakthrough International Consultancy, Addis Ababa, Ethiopia
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, University of Heidelberg, Heidelberg, Germany
| | - Dina Balabanova
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | | | - Ina Kalisa
- World Health Organization, Kigali, Rwanda
| | | | - Qingyue Meng
- China Center for Health Development Studies, Peking University, Beijing, China
| | - David Morgan
- Health Division, The Organisation for Economic Co-operation and Development, Paris, France
| | | | - Ellen Nolte
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Chima Onoka
- Department of Community Medicine, University of Nigeria, Enugu, Nigeria
| | - Timothy Powell-Jackson
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Martin Roland
- Department of Public Health and Primary Care, University of Cambridge, UK
| | | | | | | | - Hong Wang
- Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
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Francetic I, Meacock R, Elliott J, Kristensen SR, Britteon P, Lugo-Palacios DG, Wilson P, Sutton M. Framework for identification and measurement of spillover effects in policy implementation: intended non-intended targeted non-targeted spillovers (INTENTS). Implement Sci Commun 2022; 3:30. [PMID: 35287757 PMCID: PMC8919154 DOI: 10.1186/s43058-022-00280-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 03/01/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is increasing awareness among researchers and policymakers of the potential for healthcare interventions to have consequences beyond those initially intended. These unintended consequences or "spillover effects" result from the complex features of healthcare organisation and delivery and can either increase or decrease overall effectiveness. Their potential influence has important consequences for the design and evaluation of implementation strategies and for decision-making. However, consideration of spillovers remains partial and unsystematic. We develop a comprehensive framework for the identification and measurement of spillover effects resulting from changes to the way in which healthcare services are organised and delivered. METHODS We conducted a scoping review to map the existing literature on spillover effects in health and healthcare interventions and used the findings of this review to develop a comprehensive framework to identify and measure spillover effects. RESULTS The scoping review identified a wide range of different spillover effects, either experienced by agents not intentionally targeted by an intervention or representing unintended effects for targeted agents. Our scoping review revealed that spillover effects tend to be discussed in papers only when they are found to be statistically significant or might account for unexpected findings, rather than as a pre-specified feature of evaluation studies. This hinders the ability to assess all potential implications of a given policy or intervention. We propose a taxonomy of spillover effects, classified based on the outcome and the unit experiencing the effect: within-unit, between-unit, and diagonal spillover effects. We then present the INTENTS framework: Intended Non-intended TargEted Non-Targeted Spillovers. The INTENTS framework considers the units and outcomes which may be affected by an intervention and the mechanisms by which spillover effects are generated. CONCLUSIONS The INTENTS framework provides a structured guide for researchers and policymakers when considering the potential effects that implementation strategies may generate, and the steps to take when designing and evaluating such interventions. Application of the INTENTS framework will enable spillover effects to be addressed appropriately in future evaluations and decision-making, ensuring that the full range of costs and benefits of interventions are correctly identified.
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Affiliation(s)
- Igor Francetic
- Health Organization, Policy and Economics (HOPE) Research Group, Centre for Primary Care and Health Services Research, School of Health Sciences, University of Manchester, Manchester, UK.
| | - Rachel Meacock
- Health Organization, Policy and Economics (HOPE) Research Group, Centre for Primary Care and Health Services Research, School of Health Sciences, University of Manchester, Manchester, UK
| | - Jack Elliott
- Health Organization, Policy and Economics (HOPE) Research Group, Centre for Primary Care and Health Services Research, School of Health Sciences, University of Manchester, Manchester, UK
| | - Søren R Kristensen
- Danish Centre for Health Economics, University of Southern Denmark, Odense, Denmark
- Centre for Health Policy, Institute of Global Health Innovation, Imperial College London, London, UK
| | - Phillip Britteon
- Health Organization, Policy and Economics (HOPE) Research Group, Centre for Primary Care and Health Services Research, School of Health Sciences, University of Manchester, Manchester, UK
| | - David G Lugo-Palacios
- Centre for Health Policy, Institute of Global Health Innovation, Imperial College London, London, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Paul Wilson
- Centre for Primary Care and Health Services Research, School of Health Sciences, University of Manchester, Manchester, UK
| | - Matt Sutton
- Health Organization, Policy and Economics (HOPE) Research Group, Centre for Primary Care and Health Services Research, School of Health Sciences, University of Manchester, Manchester, UK
- Melbourne Institute: Applied Economic and Social Research, University of Melbourne, Melbourne, Australia
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5
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Association of Primary Care Physician Compensation Incentives and Quality of Care in the United States, 2012-2016. J Gen Intern Med 2022; 37:359-366. [PMID: 33852143 PMCID: PMC8811085 DOI: 10.1007/s11606-021-06617-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 01/07/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Physician compensation incentives may have positive or negative effects on clinical quality. OBJECTIVE To assess the association between various physician compensation incentives on technical indicators of primary care quality. DESIGN Cross-sectional, nationally representative retrospective analysis. PARTICIPANTS Visits by adults to primary care physicians in the National Ambulatory Medical Care Survey from 2012-2016. We analyzed 49,580 sampled visits, representing 1.45 billion primary care visits. MAIN MEASURES We assessed the association between 5 compensation incentives - quality measure performance, patient experience scores, individual productivity, practice financial performance, or practice efficiency - and 10 high-value and 7 low-value care measures as well as high-value and low-value care composites. KEY RESULTS Quality measure performance was an incentive in 22% of visits; patient experience scores, 17%; individual productivity, 57%; practice financial performance, 63%; and practice efficiency, 12%. In adjusted models, none of the compensation incentives were consistently associated with individual high- and low-value measures. None of the compensation incentives were associated with high- or low-value care composites. For example, quality measure performance compensation was not significantly associated with high-value care (visits with quality incentive, 47% of eligible measures met; without quality incentive, 43%; adjusted odds ratio [aOR], 1.02; 95% confidence interval [CI], 0.91 to 1.15) or low-value care (aOR, 0.99; 95% CI, 0.82-1.19). Physician compensation incentives that might be expected to increase low-value care did not: patient experience (aOR for low-value care composite, 0.83; 95% CI, 0.65-1.05), individual productivity (aOR, 1.03; 95% CI, 0.88-1.22), and practice financial performance (aOR, 1.05; 95% CI, 0.81-1.36). CONCLUSION In this retrospective, cross-sectional, nationally representative analysis of care in the United States, physician compensation incentives were not generally associated with more or less high- or low-value care.
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McCahon D, Denholm RE, Huntley AL, Dawson S, Duncan P, Payne RA. Development of a model of medication review for use in clinical practice: Bristol medication review model. BMC Med 2021; 19:262. [PMID: 34753511 PMCID: PMC8579564 DOI: 10.1186/s12916-021-02136-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Medication review is a core aspect of medicine optimisation, yet existing models of review vary substantially in structure and content and are not necessarily easy to implement in clinical practice. This study aimed to use evidence from the existing literature to identify key medication review components and use this to inform the design of an improved review model. METHODS A systematic review was conducted (PROSPERO: CRD42018109788) to identify randomised control trials of stand-alone medication review in adults (18+ years). The review updated that by Huiskes et al. (BMC Fam Pract. 18:5, 2017), using the same search strategy implemented in MEDLINE and Embase. Studies were assessed using the Cochrane risk of bias tool. Key review components were identified, alongside relevant clinical and health service outcomes. A working group (patients, doctors and pharmacists) developed the model through an iterative consensus process (appraisal of documents plus group discussions), working from the systematic review findings, brief evidence summaries for core review components and examples of previous models, to agree on the main purpose of the review model, overarching model structure, review components and supporting material. RESULTS We identified 28 unique studies, with moderate bias overall. Consistent medication review components included reconciliation (26 studies), safety assessment (22), suboptimal treatment (19), patient knowledge/preferences (18), adherence (14), over-the-counter therapy (13) and drug monitoring (10). There was limited evidence from studies for improvement in key clinical outcomes. The review structure was underpinned by patient values and preferences, with parallel information gathering and evaluation stages, feeding into the final decision-making and implementation. Most key components identified in the literature were included. The final model was considered to benefit from a patient-centred, holistic approach, which captured both patient-orientated and medication-focused problems, and aligned with traditional consultation methods thus facilitating implementation in practice. CONCLUSIONS The Bristol Medication Review Model provides a framework for standardised delivery of structured reviews. The model has the potential for use by all healthcare professionals with relevant clinical experience and is designed to offer flexibility of implementation not limited to a particular healthcare setting.
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Affiliation(s)
- D McCahon
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Canynge Hall, Bristol, BS8 2PS, UK
| | - R E Denholm
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Canynge Hall, Bristol, BS8 2PS, UK
| | - A L Huntley
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Canynge Hall, Bristol, BS8 2PS, UK
| | - S Dawson
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Canynge Hall, Bristol, BS8 2PS, UK
| | - P Duncan
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Canynge Hall, Bristol, BS8 2PS, UK
| | - R A Payne
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Canynge Hall, Bristol, BS8 2PS, UK.
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Khedmati Morasae E, Rose TC, Gabbay M, Buckels L, Morris C, Poll S, Goodall M, Barnett R, Barr B. Evaluating the Effectiveness of a Local Primary Care Incentive Scheme: A Difference-in-Differences Study. Med Care Res Rev 2021; 79:394-403. [PMID: 34323143 PMCID: PMC9052704 DOI: 10.1177/10775587211035280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
National financial incentive schemes for improving the quality of primary care
have come under criticism in the United Kingdom, leading to calls for localized
alternatives. This study investigated whether a local general practice
incentive-based quality improvement scheme launched in 2011 in a city in the
North West of England was associated with a reduction in all-cause emergency
hospital admissions. Difference-in-differences analysis was used to compare the
change in emergency admission rates in the intervention city, to the change in a
matched comparison population. Emergency admissions rates fell by 19 per 1,000
people in the years following the intervention (95% confidence interval [17,
21]) in the intervention city, relative to the comparison population. This
effect was greater among more disadvantaged populations, narrowing socioeconomic
inequalities in emergency admissions. The findings suggest that similar
approaches could be an effective component of strategies to reduce unplanned
hospital admissions elsewhere.
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Affiliation(s)
| | | | | | - Laura Buckels
- Liverpool Clinical Commissioning Group, Liverpool, UK
| | | | - Sharon Poll
- Liverpool Clinical Commissioning Group, Liverpool, UK
| | | | - Rob Barnett
- Liverpool Local Medical Committee, Liverpool, UK
| | - Ben Barr
- University of Liverpool, Liverpool, UK
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8
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Measured Performance and Vaccine Administration After Decision Support and Office Workflow Changes for Influenza Vaccination. J Healthc Qual 2021; 42:333-340. [PMID: 31917713 DOI: 10.1097/jhq.0000000000000243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Influenza vaccination is underused. We examined changes in vaccination following decision support and workflow changes in a cross-sectional analysis of three vaccination seasons among adult primary care patients from 21 practices. Interventions included clinical decision support changes to facilitate documentation; changes to rooming workflow for medical assistants and licensed practical nurses to promote vaccination, prepare orders, document care done elsewhere; and record patient refusals. We measured rates for a national vaccination performance measure and receipt of onsite vaccination. Approximately 120,000 patients were eligible each season. Performance on the quality measure increased each year (40.6% to 62.5% to 76.4%). Corresponding rates of onsite vaccination were 27.7%, 28.8%, and 31.5%. The adjusted odds ratio for onsite vaccination in the second season compared with the first was 0.94 (95% confidence interval [CI] 0.92, 0.96). Onsite vaccination was more likely in the third season compared with either previous season-adjusted odds ratio for third versus second 1.14 (95% CI, 1.12, 1.16) or adjusted odds ratio for third versus first 1.07 (95% CI 1.05-1.09). Sequential changes in decision support and patient rooming process workflows were associated with large improvements in measured performance and with a significant increase in clinic-administered influenza vaccination by the third season.
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Bekelman JE, Gupta A, Fishman E, Debono D, Fisch MJ, Liu Y, Sylwestrzak G, Barron J, Navathe AS. Association Between a National Insurer's Pay-for-Performance Program for Oncology and Changes in Prescribing of Evidence-Based Cancer Drugs and Spending. J Clin Oncol 2020; 38:4055-4063. [PMID: 33021865 DOI: 10.1200/jco.20.00890] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Cancer drug prescribing by medical oncologists accounts for the greatest variation in practice and the largest portion of spending on cancer care. We evaluated the association between a national commercial insurer's ongoing pay-for-performance (P4P) program for oncology and changes in the prescribing of evidence-based cancer drugs and spending. METHODS We conducted an observational difference-in-differences study using administrative claims data covering 6.7% of US adults. We leveraged the geographically staggered, time-varying rollout of the P4P program to simulate a stepped-wedge study design. We included patients age 18 years or older with breast, colon, or lung cancer who were prescribed cancer drug regimens by 1,867 participating oncologists between 2013 and 2017. The exposure was a time-varying dichotomous variable equal to 1 for patients who were prescribed a cancer drug regimen after the P4P program was offered. The primary outcome was whether a patient's drug regimen was a program-endorsed, evidence-based regimen. We also evaluated spending over a 6-month episode period. RESULTS The P4P program was associated with an increase in evidence-based regimen prescribing from 57.1% of patients in the preintervention period to 62.2% in the intervention period, for a difference of +5.1 percentage point (95% CI, 3.0 percentage points to 7.2 percentage points; P < .001). The P4P program was also associated with a differential $3,339 (95% CI, $1,121 to $5,557; P = .003) increase in cancer drug spending and a differential $253 (95% CI, $100 to $406; P = .001) increase in patient out-of-pocket spending, but no significant changes in total health care spending ($2,772; 95% CI, -$181 to $5,725; P = .07) over the 6-month episode period. CONCLUSION P4P programs may be effective in increasing evidence-based cancer drug prescribing, but may not yield cost savings.
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Affiliation(s)
- Justin E Bekelman
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Penn Center for Cancer Care Innovation at the Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA.,Healthcare Transformation Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Atul Gupta
- Penn Center for Cancer Care Innovation at the Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA.,Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA
| | - Ezra Fishman
- National Committee for Quality Assurance, Washington, DC
| | | | - Michael J Fisch
- AIM Specialty Health, Chicago, IL.,The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | - Amol S Navathe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Penn Center for Cancer Care Innovation at the Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA.,Healthcare Transformation Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Howard SJ, Elvey R, Ohrnberger J, Turner AJ, Anselmi L, Martindale AM, Blakeman T. Post-discharge care following acute kidney injury: quality improvement in primary care. BMJ Open Qual 2020; 9:e000891. [PMID: 33328317 PMCID: PMC7745694 DOI: 10.1136/bmjoq-2019-000891] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 10/27/2020] [Accepted: 11/03/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Over the past decade, targeting acute kidney injury (AKI) has become a priority to improve patient safety and health outcomes. Illness complicated by AKI is common and is associated with adverse outcomes including high rates of unplanned hospital readmission. Through national patient safety directives, NHS England has mandated the implementation of an AKI clinical decision support system in hospitals. In order to improve care following AKI, hospitals have also been incentivised to improve discharge summaries and general practices are recommended to establish registers of people who have had an episode of illness complicated by AKI. However, to date, there is limited evidence surrounding the development and impact of interventions following AKI. DESIGN We conducted a quality improvement project in primary care aiming to improve the management of patients following an episode of hospital care complicated by AKI. All 31 general practices within a single NHS Clinical Commissioning Group were incentivised by a locally commissioned service to engage in audit and feedback, education training and to develop an action plan at each practice to improve management of AKI. RESULTS AKI coding in general practice increased from 28% of cases in 2015/2016 to 50% in 2017/2018. Coding of AKI was associated with significant improvements in downstream patient management in terms of conducting a medication review within 1 month of hospital discharge, monitoring kidney function within 3 months and providing written information about AKI to patients. However, there was no effect on unplanned hospitalisation and mortality. CONCLUSION The findings suggest that the quality improvement intervention successfully engaged a primary care workforce in AKI-related care, but that a higher intensity intervention is likely to be required to improve health outcomes. Development of a real-time audit tool is necessary to better understand and minimise the impact of the high mortality rate following AKI.
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Affiliation(s)
- Susan J Howard
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Health Innovation Manchester, Manchester, UK
| | - Rebecca Elvey
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Health Innovation Manchester, Manchester, UK
- Centre for Primary Care and Health Services Research, Division of Population Health, Health Services Research and Primary Care; School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK, The University of Manchester, Manchester, UK
| | - Julius Ohrnberger
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Alex J Turner
- Health Organisation, Policy and Economics (HOPE) group, Centre for Primary Care and Health Services Research, The University of Manchester, Manchester, UK
| | - Laura Anselmi
- Health Organisation, Policy and Economics (HOPE) group, Centre for Primary Care and Health Services Research, The University of Manchester, Manchester, UK
| | - Anne-Marie Martindale
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Health Innovation Manchester, Manchester, UK
- Centre for Primary Care and Health Services Research, Division of Population Health, Health Services Research and Primary Care; School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK, The University of Manchester, Manchester, UK
| | - Tom Blakeman
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Health Innovation Manchester, Manchester, UK
- Centre for Primary Care and Health Services Research, Division of Population Health, Health Services Research and Primary Care; School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK, The University of Manchester, Manchester, UK
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11
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Heider AK, Mang H. Effects of Monetary Incentives in Physician Groups: A Systematic Review of Reviews. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2020; 18:655-667. [PMID: 32207083 PMCID: PMC7519000 DOI: 10.1007/s40258-020-00572-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Reimbursement systems that contribute to the cooperation and integration of providers have become increasingly important within the healthcare sector. Reimbursement systems not only serve as payment mechanisms but also provide control and incentive functions. Thus, the design of reimbursement systems is extremely important. OBJECTIVES The aims of this systematic review were to describe and gain a better understanding of the effects of monetary incentives in the setting of physician groups. METHODS In January 2020, we searched the MEDLINE (PubMed), Cochrane Library, CINAHL, PsycINFO, EconLit, and ISI Web of Science databases as well as the gray literature and authors' personal collections. RESULTS We included 21 reviews containing seven different incentive schemes/initiatives. The study settings and outcome measures varied considerably, as did the results within the incentive schemes and initiatives. However, we found positive effects on process quality for two types of incentives: pay-for-performance and accountable care organizations. The main limitations of this review were the variations in study settings and outcome measures of the studies included. CONCLUSIONS Monetary incentives in healthcare are often implemented as a control measure and are supposed to increase quality of care and reduce costs. The heterogeneity of the study results indicates that this is not always successful. The results reveal a need for research into the effects of monetary incentives in healthcare.
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Affiliation(s)
- Ann-Kathrin Heider
- Faculty of Medicine, Master Program Medical Process Management, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany.
| | - Harald Mang
- Master Program Medical Process Management, Universitätsklinikum Erlangen, Erlangen, Germany
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12
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Jackson J, Urick B. Performance-based pharmacy payment models: the case for change. AUST HEALTH REV 2020; 43:502-507. [PMID: 31505158 DOI: 10.1071/ah18201] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 04/03/2019] [Indexed: 11/23/2022]
Abstract
In response to rising healthcare costs, healthcare payers across the globe have been experimenting with performance-based payment models that link payments to providers with the quality of care that they provide. Community pharmacy in Australia has yet to be significantly affected by these changes. Initial steps have been taken to fund quality-linked interventions by pharmacists, such as the provision of medicines in dose administration aids, but funding for dispensing prescriptions remains solely based on a fee-for-service model. At the foundation of any performance-based payment model are measures that, in aggregate, reflect the quality of care that is provided. Patient adherence to prescription regimens can be correlated with the counselling provided by pharmacists and, as such, can serve as the measure on which a performance-based payment model for dispensing can be constructed. Experience in the US suggests per-prescription payments to a pharmacy can be increased or decreased by a small, yet meaningful, amount based on a measure of the level of adherence of patients of the pharmacy. The current dispensing payment model in the Australian Pharmaceutical Benefits Scheme may be able to be modified in a similar manner to support provision by pharmacists of improved quality of care.
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Affiliation(s)
- John Jackson
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Vic. 3052, Australia; and Corresponding author.
| | - Ben Urick
- UNC Eshelman School of Pharmacy, 2400 Kerr Hall, 301 Pharmacy Lane, University of North Carolina at Chapel Hill, NC 27599-7475, USA.
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Goncharuk AG, Lewandowski R, Cirella GT. Motivators for medical staff with a high gap in healthcare efficiency: Comparative research from Poland and Ukraine. Int J Health Plann Manage 2020; 35:1314-1334. [PMID: 32744754 DOI: 10.1002/hpm.3037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/23/2020] [Accepted: 07/10/2020] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION This article examines different motivators for medical staff in countries with a high gap in healthcare efficiency by comparing them in two healthcare systems-Polish (ie efficient) and Ukrainian (ie inefficient). METHOD This survey-based study applies a six-stage conceptual framework to two Polish and two Ukrainian hospitals as well as medical faculties of one university from each country. Following ethical approval, data were collected in the first quarter of 2019, using the 'Evaluation of motivators questionnaire for medical staff'. FINDINGS Medical staff perceived their working conditions in the inefficient healthcare system much worse than in the efficient system; however, they generally had a more optimistic outlook. Medical staff in efficient and inefficient healthcare systems has different motivational targets, including sizable differences from profession, gender, and age. These factors play an important role in developing a high-performance healthcare system. Results are illustrated in terms of motivators for medical staff. CONCLUSION Optimising a healthcare system requires useful reform of enablers, especially in countries with inefficient systems, including policymaking and regulatory action. Best practices must incorporate all stakeholders interested in high healthcare performance-usage of suitable practices from abroad can act as an important resource.
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Affiliation(s)
- Anatoliy G Goncharuk
- Department of Management, International Humanitarian University, Odessa, Ukraine
| | - Roman Lewandowski
- Faculty of Management, University of Social Sciences, Lodz, Poland.,Voivodeship Rehabilitation Hospital for Children in Ameryka, Ameryka, Poland
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Korlén S, Amer‐Wåhlin I, Lindgren P, Thiele Schwarz U. Exploring staff experience of economic efficiency requirements in health care: A mixed method study. Int J Health Plann Manage 2019; 34:1439-1455. [DOI: 10.1002/hpm.2813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 04/29/2019] [Indexed: 11/10/2022] Open
Affiliation(s)
- Sara Korlén
- Medical Management Centre, Department of LIME Karolinska Institutet Stockholm Sweden
| | - Isis Amer‐Wåhlin
- Medical Management Centre, Department of LIME Karolinska Institutet Stockholm Sweden
| | - Peter Lindgren
- Medical Management Centre, Department of LIME Karolinska Institutet Stockholm Sweden
- The Swedish Insitute for Health Economics Sweden
| | - Ulrica Thiele Schwarz
- Medical Management Centre, Department of LIME Karolinska Institutet Stockholm Sweden
- School of Health, Care and Social Welfare Mälardalen University Västerås Sweden
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Garabedian LF, Ross-Degnan D, Wharam JF. Provider Perspectives on Quality Payment Programs Targeting Diabetes in Primary Care Settings. Popul Health Manag 2019; 22:248-254. [PMID: 30204544 PMCID: PMC6555171 DOI: 10.1089/pop.2018.0093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Public and private insurers increasingly use quality payment programs as a tool to improve quality of care in primary care settings. However, little is known about primary care providers' perspectives on whether and how quality payment programs improve diabetes quality of care. In this qualitative study, the authors conducted semi-structured interviews and focus groups with 23 providers from March to June 2015. Transcripts were analyzed to identify key themes using the immersion-crystallization method. Almost all of the providers believed that insurers play a meaningful role in improving quality of care for diabetes patients. Most thought that insurers' efforts are more effective when channeled through providers and delivery systems rather than directed at patients. Providers generally believed that quality payment programs have had a positive impact on quality of diabetes care, although provider views were not evidence based. Providers in practices in which quality payment programs were believed to have had a positive impact stated that the programs provided financial incentives and resources for improved population health management systems and additional staff. Conversely, most providers did not believe that quality payment programs have had any impact via direct financial incentives to individual physicians. A few providers were skeptical about the impact of quality payment programs and noted negative consequences that they had observed. Providers recommended strategies to improve quality payment programs (eg, refine quality measures, provide regular feedback on quality and costs) and additional strategies that insurers could consider to address provider- and patient-level barriers to high-quality diabetes care.
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Affiliation(s)
- Laura F. Garabedian
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Dennis Ross-Degnan
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - James F. Wharam
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
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Allen T, Whittaker W, Kontopantelis E, Sutton M. Influence of financial and reputational incentives on primary care performance: a longitudinal study. Br J Gen Pract 2018; 68:e811-e818. [PMID: 30397016 PMCID: PMC6255225 DOI: 10.3399/bjgp18x699797] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 07/25/2018] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND The Quality and Outcomes Framework has generated reputational as well as financial rewards for general practices because the number of quality points a practice receives is publicly reported. These rewards vary across diseases and practices, and over time. AIM To determine the relative effects on performance of the financial and reputational rewards resulting from a pay-for-performance programme. DESIGN AND SETTING Observational study of the published performance on 42 indicators of 8929 practices in England between 2004 and 2013. METHOD The authors calculated the revenue offered (financial reward, measured in £100s) and the points offered (reputational reward) per additional patient treated for each indicator for each practice in each year. Fixed-effects multivariable regression models were used to estimate whether the percentage of eligible patients treated responded to changes in these financial and reputational rewards. RESULTS Both the offered financial rewards and reputational rewards had small but statistically significant associations with practice performance. The effect of the financial reward on performance decreased from 0.797 percentage points per £100 (95% confidence interval [CI] = 0.614 to 0.979) in 2004, to 0.092 (95% CI = 0.045 to 0.138) in 2013. The effect of the reputational reward increased from -0.121 percentage points per quality point (95% CI = -0.220 to -0.022) in 2004, to 0.209 (95% CI = 0.147 to 0.271) in 2013. CONCLUSION In the short term, general practices were more sensitive to revenue than reputational rewards. In the long term, general practices appeared to divert their focus towards the reputational reward, once benchmarks of performance became established.
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Affiliation(s)
| | | | | | - Matt Sutton
- School of Health Sciences, University of Manchester, Manchester
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Efficiency of HIV services in Nigeria: Determinants of unit cost variation of HIV counseling and testing and prevention of mother-to-child transmission interventions. PLoS One 2018; 13:e0201706. [PMID: 30192765 PMCID: PMC6128456 DOI: 10.1371/journal.pone.0201706] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 07/20/2018] [Indexed: 11/22/2022] Open
Abstract
Background Like most countries with a substantial HIV burden, Nigeria continues to face challenges in reaching coverage targets of HIV services. A fundamental problem is stagnated funding in recent years. Improving efficiency is therefore paramount to effectively scale-up HIV services. In this study, we estimated the facility-level average costs (or unit costs) of HIV Counseling and Testing (HCT) and Prevention of Mother-to-Child Transmission (PMTCT) services and characterized determinants of unit cost variation. We investigated the role of service delivery modalities and the link between facility-level management practices and unit cost variability along both services’ cascades. Methods We conducted a cross-sectional, observational, micro-costing study in Nigeria between December 2014 and May 2015 in 141 HCT, and 137 PMTCT facilities, respectively. We retrospectively collected relevant input quantities (personnel, supplies, utilities, capital, and training), input prices, and output data for the year 2013. Staff costs were adjusted using time-motion methods. We estimated the facility-level average cost per service along the HCT and PMTCT service cascades and analyzed their composition and variability. Through linear regressions analysis, we identified aspects of service delivery and management practices associated with unit costs variations. Results The weighted average cost per HIV-positive client diagnosed through HCT services was US$130. The weighted average cost per HIV-positive woman on prophylaxis in PMTCT services was US$858. These weighted values are estimates of nationally representative unit costs in Nigeria. For HCT, the facility-level unit costs per client tested and per HIV-positive client diagnosed were US$30 and US$1,364, respectively; and the median unit costs were US$17 and US$245 respectively. For PMTCT, the facility-level unit costs per woman tested, per HIV-positive woman diagnosed, and per HIV-positive woman on prophylaxis were US$46, US$2,932, and US$3,647, respectively, and the median unit costs were US$24, US$1,013 and US$1,448, respectively. Variability in costs across facilities was principally explained by the number of patients, integration of HIV services, task shifting, and the level of care. Discussion Our findings demonstrate variability in unit costs across facilities. We found evidence consistent with economies of scale and scope, and efficiency gains in facilities implementing task-shifting. Our results could inform program design by suggesting ways to improve resource allocation and efficiently scale-up the HIV response in Nigeria. Some of our findings might also be relevant for other settings.
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Minchin M, Roland M, Richardson J, Rowark S, Guthrie B. Quality of Care in the United Kingdom after Removal of Financial Incentives. N Engl J Med 2018; 379:948-957. [PMID: 30184445 DOI: 10.1056/nejmsa1801495] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The benefits of pay-for-performance schemes in improving the quality of care remain uncertain. There is little information on the effect of removing incentives from existing pay-for-performance schemes. METHODS We conducted interrupted time-series analyses of electronic medical record (EMR) data from 2010 to 2017 for 12 quality-of-care indicators in the United Kingdom's Quality and Outcomes Framework for which financial incentives were removed in 2014 and 6 indicators for which incentives were maintained. We estimated the effects of removing incentives on changes in performance on quality-of-care measures. RESULTS Complete longitudinal data were available for 2819 English primary care practices with more than 20 million registered patients. There were immediate reductions in documented quality of care for all 12 indicators in the first year after the removal of financial incentives. Reductions were greatest for indicators related to health advice, with a reduction of 62.3 percentage points (95% confidence interval [CI], -65.6 to -59.0) in EMR documentation of lifestyle counseling for patients with hypertension. Changes were smaller for indicators involving clinical actions that automatically update the EMR, such as laboratory testing, with a reduction of 10.7 percentage points (95% CI, -13.6 to -7.8) in control of cholesterol in patients with coronary heart disease and 12.1 percentage points (95% CI, -13.6 to -10.6) for thyroid-function testing in patients with hypothyroidism. There was little change in performance on the 6 quality measures for which incentives were maintained. CONCLUSIONS Removal of financial incentives was associated with an immediate decline in performance on quality measures. In part, the decline probably reflected changes in EMR documentation, but declines on measures involving laboratory testing suggest that incentive removal also changed the care delivered.
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Affiliation(s)
- Mark Minchin
- From the National Institute for Health and Care Excellence (NICE), Manchester (M.M., J.R., S.R.), the Department of Public Health and Primary Care, University of Cambridge, Cambridge (M.R.), and the Population Health and Genomics Division, University of Dundee, Dundee (B.G.) - all in the United Kingdom
| | - Martin Roland
- From the National Institute for Health and Care Excellence (NICE), Manchester (M.M., J.R., S.R.), the Department of Public Health and Primary Care, University of Cambridge, Cambridge (M.R.), and the Population Health and Genomics Division, University of Dundee, Dundee (B.G.) - all in the United Kingdom
| | - Judith Richardson
- From the National Institute for Health and Care Excellence (NICE), Manchester (M.M., J.R., S.R.), the Department of Public Health and Primary Care, University of Cambridge, Cambridge (M.R.), and the Population Health and Genomics Division, University of Dundee, Dundee (B.G.) - all in the United Kingdom
| | - Shaun Rowark
- From the National Institute for Health and Care Excellence (NICE), Manchester (M.M., J.R., S.R.), the Department of Public Health and Primary Care, University of Cambridge, Cambridge (M.R.), and the Population Health and Genomics Division, University of Dundee, Dundee (B.G.) - all in the United Kingdom
| | - Bruce Guthrie
- From the National Institute for Health and Care Excellence (NICE), Manchester (M.M., J.R., S.R.), the Department of Public Health and Primary Care, University of Cambridge, Cambridge (M.R.), and the Population Health and Genomics Division, University of Dundee, Dundee (B.G.) - all in the United Kingdom
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Goncharuk AG. Exploring a motivation of medical staff. Int J Health Plann Manage 2018; 33:1013-1023. [PMID: 29882334 DOI: 10.1002/hpm.2555] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 05/02/2018] [Accepted: 05/06/2018] [Indexed: 11/07/2022] Open
Abstract
This paper aims to identify the true motivators (needs) of medical staff, compare them with the current labor incentives, and detect possible differences in motivators for main groups of medical staff. Observing personnel of 5 hospitals and students of the medical institute by special questionnaires, the author confirmed the hypothesis of different motivators for groups of medical staff with different ages, professions, and gender. The author used special questionnaires to collect the data. Study results confirmed the hypothesis of different motivators for groups of medical staff with different ages, professions, and gender. The author also found significant differences between the motivation of Ukrainian health workers and their colleagues from other countries. The main conclusion is that no matter how we would like to satisfy gender and age equality, all people are individual and what is good for an elderly male doctor cannot be acceptable for a young female nurse. Therefore, forming the motivation system for employees of medical institutions, it is necessary to take into account the age, gender, professions, and other characteristics of each employee. In this way, we can achieve the highest health-care performance.
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Affiliation(s)
- Anatoliy G Goncharuk
- Department of Business Administration and Corporate Security, International Humanitarian University, Odessa, Ukraine
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20
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Naunheim MR, Paddle PM, Husain I, Wangchalabovorn P, Rosario D, Franco RA. Quality-of-Life Metrics Correlate With Disease Severity in Idiopathic Subglottic Stenosis. Laryngoscope 2018; 128:1398-1402. [PMID: 29513385 DOI: 10.1002/lary.26930] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 08/01/2017] [Accepted: 08/22/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVES Idiopathic subglottic stenosis (ISGS) can have significant impacts on quality of life (QOL), but it remains unclear how patients' subjective responses correlate with objective measurement of disease severity. Peak expiratory flow percentage (PEF%) has been shown to be an effective measure of disease severity in subglottic stenosis. This study aims to identify the key QOL questions correlated with PEF% and proposes a statistical model for prediction of disease severity. METHODS Patients with ISGS presenting to an academic laryngologist were included retrospectively from 2012 to 2016. Peak expiratory flow percentage (age, sex, and height adjusted) was recorded for each visit, along with four validated QOL instruments (European QOL-Five Dimensions; RAND 36-Item Health Survey; Clinical COPD [Chronic Obstructive Pulmonary Disease] Questionnaire; and the Airway, Dyspnea, Voice, and Swallowing Summary Assessment). A stepwise multiple linear regression was used to identify statistically significant independent variables correlated with PEF%, and a model was built with these variables. RESULTS Thirty-two patients were included, with a total of 271 patient encounters. Overall scores from each of the four QOL instruments were correlated with PEF% values recorded each visit (P < 0.05). Question responses correlating most positively included overall breathlessness, difficulty catching breath, cough within the past week, dyspnea with moderate activity, perception that voice changes are restricting social life, and overall general health (all P < 0.01). A model constructed using six nonoverlapping questions yielded an adjusted R2 of 0.58. CONCLUSION Quality of life is correlated to PEF% in ISGS. Using a limited number of QOL questions, clinicians can predict objective worsening or improvement of disease severity, as measured by spirometry. LEVEL OF EVIDENCE 2b. Laryngoscope, 2017.
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Affiliation(s)
- Matthew R Naunheim
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
| | - Paul M Paddle
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
- Melbourne ENT Group, Melbourne, Australia
| | - Inna Husain
- Department of Otorhinolaryngology, Rush Medical College, Chicago, Illinois, U.S.A
| | | | - David Rosario
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
| | - Ramon A Franco
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
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Shenoy A, Begley C, Revere L, Linder S, Daiger SP. Delivery system innovation and collaboration: A case study on influencers of preventable hospitalizations. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2017. [DOI: 10.1080/20479700.2017.1405777] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Amrita Shenoy
- Math, Science and Technology Department, University of Minnesota Crookston, Crookston, MN, USA
| | - Charles Begley
- Department of Management, Policy and Community Health, UTHealth School of Public Health, Houston, TX, USA
| | - Lee Revere
- Fleming Center for Healthcare Management, UTHealth School of Public Health, Houston, TX, USA
| | - Stephen Linder
- Health Policy Institute, Texas Medical Center, Houston, TX, USA
| | - Stephen P. Daiger
- Human Genetics Center, UTHealth School of Public Health, Houston, TX, USA
- Ruiz Department of Ophthalmology and Visual Science, The University of Texas Health Science Center at Houston, Houston, TX, USA
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Abstract
This paper advances scientific understanding of social preference—a topic of longstanding cross-disciplinary interest—by studying the preferences of future physicians. In making treatment decisions, physicians make fundamental tradeoffs between their own (financial) self-interest, patient benefit, and stewardship of social resources. These tradeoffs affect patient health, adoption of new scientific medical technologies, and the equity and efficiency of our health care system. Understanding physicians’ decisions about these tradeoffs requires understanding the social preferences that are behind them. Our main finding that future physicians are substantially less altruistic and more efficiency focused than the average American challenges notions of physician altruism, the fundamental feature of medical professionalism, and has potential implications for policy in a host of health care areas. We measure the social preferences of a sample of US medical students and compare their preferences with those of the general population sampled in the American Life Panel (ALP). We also compare the medical students with a subsample of highly educated, wealthy ALP subjects as well as elite law school students and undergraduate students. We further associate the heterogeneity in social preferences within medical students to the tier ranking of their medical schools and their expected specialty choice. Our experimental design allows us to rigorously distinguish altruism from preferences regarding equality–efficiency tradeoffs and accurately measure both at the individual level rather than pooling data or assuming homogeneity across subjects. This is particularly informative, because the subjects in our sample display widely heterogeneous social preferences in terms of both their altruism and equality–efficiency tradeoffs. We find that medical students are substantially less altruistic and more efficiency focused than the average American. Furthermore, medical students attending the top-ranked medical schools are less altruistic than those attending lower-ranked schools. We further show that the social preferences of those attending top-ranked medical schools are statistically indistinguishable from the preferences of a sample of elite law school students. The key limitation of this study is that our experimental measures of social preferences have not yet been externally validated against actual physician practice behaviors. Pending this future research, we probed the predictive validity of our experimental measures of social preferences by showing that the medical students choosing higher-paying medical specialties are less altruistic than those choosing lower-paying specialties.
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Mandavia R, Mehta N, Schilder A, Mossialos E. Effectiveness of UK provider financial incentives on quality of care: a systematic review. Br J Gen Pract 2017; 67:e800-e815. [PMID: 28993305 PMCID: PMC5647924 DOI: 10.3399/bjgp17x693149] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Accepted: 03/17/2017] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Provider financial incentives are being increasingly adopted to help improve standards of care while promoting efficiency. AIM To review the UK evidence on whether provider financial incentives are an effective way of improving the quality of health care. DESIGN AND SETTING Systematic review of UK evidence, undertaken in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. METHOD MEDLINE and Embase databases were searched in August 2016. Original articles that assessed the relationship between UK provider financial incentives and a quantitative measure of quality of health care were included. Studies showing improvement for all measures of quality of care were defined as 'positive', those that were 'intermediate' showed improvement in some measures, and those classified as 'negative' showed a worsening of measures. Studies showing no effect were documented as such. Quality was assessed using the Downs and Black quality checklist. RESULTS Of the 232 published articles identified by the systematic search, 28 were included. Of these, nine reported positive effects of incentives on quality of care, 16 reported intermediate effects, two reported no effect, and one reported a negative effect. Quality assessment scores for included articles ranged from 15 to 19, out of a maximum of 22 points. CONCLUSION The effects of UK provider financial incentives on healthcare quality are unclear. Owing to this uncertainty and their significant costs, use of them may be counterproductive to their goal of improving healthcare quality and efficiency. UK policymakers should be cautious when implementing these incentives - if used, they should be subject to careful long-term monitoring and evaluation. Further research is needed to assess whether provider financial incentives represent a cost-effective intervention to improve the quality of care delivered in the UK.
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Olivella P, Siciliani L. Reputational concerns with altruistic providers. JOURNAL OF HEALTH ECONOMICS 2017; 55:1-13. [PMID: 28602394 DOI: 10.1016/j.jhealeco.2017.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 05/22/2017] [Accepted: 05/24/2017] [Indexed: 06/07/2023]
Abstract
We study a model of reputational concerns when doctors differ in their degree of altruism and they can signal their altruism by their (observable) quality. When reputational concerns are high, following the introduction or enhancement of public reporting, the less altruistic (bad) doctor mimics the more altruistic (good) doctor. Otherwise, either a separating or a semi-separating equilibrium arises: the bad doctor mimics the good doctor with probability less than one. Pay-for-performance incentive schemes are unlikely to induce crowding out, unless some dimensions of quality are unobservable. Under the pooling equilibrium a purchaser can implement the first-best quality by appropriately choosing a simple payment scheme with a fixed price per unit of quality provided. This is not the case under the separating equilibrium. Therefore, policies that enhance public reporting complement pay-for-performance schemes.
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Affiliation(s)
- Pau Olivella
- Department of Economics, Universitat Autònoma de Barcelona, Spain; Barcelona GSE, Spain.
| | - Luigi Siciliani
- Department of Economics and Related Studies, University of York, Heslington, York YO10 5DD, United Kingdom.
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25
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“The final arbiter of everything”: a genealogy of concern with patient experience in Britain. SOCIAL THEORY & HEALTH 2017. [DOI: 10.1057/s41285-017-0045-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Markovitz AA, Ramsay PP, Shortell SM, Ryan AM. Financial Incentives and Physician Practice Participation in Medicare's Value-Based Reforms. Health Serv Res 2017; 53 Suppl 1:3052-3069. [PMID: 28748535 DOI: 10.1111/1475-6773.12743] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To evaluate whether greater experience and success with performance incentives among physician practices are related to increased participation in Medicare's voluntary value-based payment reforms. DATA SOURCES/STUDY SETTING Publicly available data from Medicare's Physician Compare (n = 1,278; January 2012 to November 2013) and nationally representative physician practice data from the National Survey of Physician Organizations 3 (NSPO3; n = 907,538; 2013). STUDY DESIGN We used regression analysis to examine practice-level relationships between prior exposure to performance incentives and participation in key Medicare value-based payment reforms: accountable care organization (ACO) programs, the Physician Quality Reporting System ("Physician Compare"), and the Meaningful Use of Health Information Technology program ("Meaningful Use"). Prior experience and success with financial incentives were measured as (1) the percentage of practices' revenue from financial incentives for quality or efficiency; and (2) practices' exposure to public reporting of quality measures. DATA COLLECTION/EXTRACTION METHODS We linked physician participation data from Medicare's Physician Compare to the NSPO3 survey. PRINCIPAL FINDINGS There was wide variation in practices' exposure to performance incentives, with 64 percent exposed to financial incentives, 45 percent exposed to public reporting, and 2.2 percent of practice revenue coming from financial incentives. For each percentage-point increase in financial incentives, there was a 0.9 percentage-point increase in the probability of participating in ACOs (standard error [SE], 0.1, p < .001) and a 0.8 percentage-point increase in the probability of participating in Meaningful Use (SE, 0.1, p < .001), controlling for practice characteristics. Financial incentives were not associated with participation in Physician Compare. Among ACO participants, a 1 percentage-point increase in incentives was associated with a 0.7 percentage-point increase in the probability of being "very well" prepared to utilize cost and quality data (SE, 0.1, p < .001). CONCLUSIONS Physicians organizations' prior experience and success with performance incentives were related to participation in Medicare ACO arrangements and participation in the meaningful use criteria but not to participation in Physician Compare. We conclude that Medicare must complement financial incentives with additional efforts to address the needs of practices with less experience with such incentives to promote value-based payment on a broader scale.
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Affiliation(s)
- Adam A Markovitz
- Medical Scientist Training Program, University of Michigan Medical School, Ann Arbor, MI.,Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI
| | - Patricia P Ramsay
- Center for Healthcare Organizational and Innovation Research, University of California Berkeley School of Public Health, Berkeley, CA
| | - Stephen M Shortell
- Center for Healthcare Organizational and Innovation Research, University of California Berkeley School of Public Health, Berkeley, CA
| | - Andrew M Ryan
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
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Abstract
The use of financial incentives to improve quality in health care has become widespread. Yet evidence on the effectiveness of incentives suggests that they have generally had limited impact on the value of care and have not led to better patient outcomes. Lessons from social psychology and behavioral economics indicate that incentive programs in health care have not been effectively designed to achieve their intended impact. In the United States, Medicare's Hospital Readmission Reduction Program and Hospital Value-Based Purchasing Program, created under the Affordable Care Act (ACA), provide evidence on how variations in the design of incentive programs correspond with differences in effect. As financial incentives continue to be used as a tool to increase the value and quality of health care, improving the design of programs will be crucial to ensure their success.
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Affiliation(s)
- Tim Doran
- Department of Health Sciences, University of York, Heslington, York YO10 5DD, United Kingdom;
| | - Kristin A Maurer
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan 48109; ,
| | - Andrew M Ryan
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan 48109; ,
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Power M, Brewster L, Parry G, Brotherton A, Minion J, Ozieranski P, McNicol S, Harrison A, Dixon-Woods M. Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach. BMJ Open 2016; 6:e011886. [PMID: 27660317 PMCID: PMC5051472 DOI: 10.1136/bmjopen-2016-011886] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 07/07/2016] [Accepted: 07/15/2016] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES We aimed to evaluate whether a large-scale two-phase quality improvement programme achieved its aims and to characterise the influences on achievement. SETTING National Health Service (NHS) in England. PARTICIPANTS NHS staff. INTERVENTIONS The programme sought to (1) develop a shared national, regional and locally aligned safety focus for 4 high-cost, high volume harms; (2) establish a new measurement system based on a composite measure of 'harm-free' care and (3) deliver improved outcomes. Phase I involved a quality improvement collaborative intended to involve 100 organisations; phase II used financial incentives for data collection. MEASURES Multimethod evaluation of the programme. In phase I, analysis of regional plans and of rates of data submission and clinical outcomes reported to the programme. A concurrent process evaluation was conducted of phase I, but only data on submission rates and clinical outcomes were available for phase II. RESULTS A context of extreme policy-related structural turbulence impacted strongly on phase I. Most regions' plans did not demonstrate full alignment with the national programme; most fell short of recruitment targets and attrition in attendance at the collaborative meetings occurred over time. Though collaborative participants saw the principles underlying the programme as attractive, useful and innovative, they often struggled to convert enthusiasm into change. Developing the measurement system was arduous, yet continued to be met by controversy. Data submission rates remained patchy throughout phase I but improved in reach and consistency in phase II in response to financial incentives. Some evidence of improvement in clinical outcomes over time could be detected but was hard to interpret owing to variability in the denominators. CONCLUSIONS These findings offer important lessons for large-scale improvement programmes, particularly when they seek to develop novel concepts and measures. External contexts may exert far-reaching influence. The challenges of developing measurement systems should not be underestimated.
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Affiliation(s)
- Maxine Power
- HAELO, Salford Royal NHS Foundation Trust, Salford, UK
| | - Liz Brewster
- Faculty of Health and Medicine, Lancaster Medical School, Lancaster University, Lancaster, UK
| | - Gareth Parry
- Institute for Healthcare Improvement, Cambridge, Massachusetts, USA
| | | | - Joel Minion
- Data to Knowledge Group, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Piotr Ozieranski
- Department of Social and Policy Sciences, University of Bath, Bath, UK
| | - Sarah McNicol
- Education and Social Research Institute, Manchester Metropolitan University, Crewe, UK
| | | | - Mary Dixon-Woods
- Cambridge Centre for Health Services Research, University of Cambridge School of Clinical Medicine, Cambridge, UK
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Abstract
Martin Roland and Frede Olesen explore what other countries can learn from the UK’s experience with the Quality and Outcomes Framework
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Affiliation(s)
| | - Frede Olesen
- Department of Public Health, 8000 Aarhus, Denmark
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Affiliation(s)
- Martin Roland
- Public Health and Primary Care, Institute of Public Health, University of Cambridge, Cambridge CB2 8PN, UK.
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Naci H, Soumerai SB. History Bias, Study Design, and the Unfulfilled Promise of Pay-for-Performance Policies in Health Care. Prev Chronic Dis 2016; 13:E82. [PMID: 27337559 PMCID: PMC4927268 DOI: 10.5888/pcd13.160133] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Huseyin Naci
- Department of Social Policy, London School of Economics and Political Science, London, United Kingdom
| | - Stephen B Soumerai
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Landmark Center, 401 Park Dr, Boston, MA 02215.
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Rosen EB, Donoff RB, Riedy CA. U.S. Dental School Deans’ Views on the Value of Patient-Reported Outcome Measures in Dentistry. J Dent Educ 2016. [DOI: 10.1002/j.0022-0337.2016.80.6.tb06134.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Kronick R, Casalino LP, Bindman AB. Introduction. Apple Pickers or Federal Judges: Strong versus Weak Incentives in Physician Payment. Health Serv Res 2016; 50 Suppl 2:2049-56. [PMID: 26769059 DOI: 10.1111/1475-6773.12424] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
| | - Lawrence P Casalino
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY
| | - Andrew B Bindman
- Departments of Medicine and Epidemiology & Biostatistics, PRL-Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA
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Kao AC. Driven to Care: Aligning External Motivators with Intrinsic Motivation. Health Serv Res 2015; 50 Suppl 2:2216-22. [PMID: 26769060 PMCID: PMC5338198 DOI: 10.1111/1475-6773.12422] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Luft HS. Policy-Oriented Research on Improved Physician Incentives for Higher Value Health Care. Health Serv Res 2015; 50 Suppl 2:2187-215. [PMID: 26573894 PMCID: PMC5114715 DOI: 10.1111/1475-6773.12423] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Policy makers (both public and private) are seeking ways to improve the value delivered within our health care system, that is, using fewer resources to provide the same benefit to patients, or using equivalent resources to provide more benefit. One strategy is to alter the predominant fee‐for‐service (FFS) economic incentives in the current system. To inform such policy changes, this paper identifies areas in which little is known about the effects of specific incentives (FFS, salary, etc.) on the two components of value: resource use and quality. Specific suggestions are offered regarding research that would be informative for policy makers, focusing on fundamental “building block” studies rather than overall evaluations of complex interventions, such as accountable care organizations. This research would better identify critical aspects of the FFS model and salary‐based payments that are particularly problematic, as well as situations in which FFS or salary may be less problematic. The research would also explore when alternatives, such as episode‐based payment might be feasible, or simply be hypothetical solutions. The availability of electronic health record‐based data in various delivery systems would allow many of these studies to be accomplished in 3–5 years with budgets manageable by public and private funding sources.
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Affiliation(s)
- Harold S Luft
- Palo Alto Medical Foundation Research Institute, 795 El Camino Real, Ames Building, Palo Alto, CA 94301
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