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Funk RJ, Pagani FD, Hou H, Zhang M, Yang G, Malani PN, Chandanabhumma PP, Cabrera L, Kim KD, Likosky DS. Care fragmentation predicts 90-day durable ventricular assist device outcomes. THE AMERICAN JOURNAL OF MANAGED CARE 2022; 28:e444-e451. [PMID: 36525664 PMCID: PMC10405264 DOI: 10.37765/ajmc.2022.89280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To examine whether fragmentation of care is associated with worse in-hospital and 90-day outcomes following durable ventricular assist device (VAD) implant. STUDY DESIGN Cohort study. METHODS This study was conducted using Medicare claims linked to the Society of Thoracic Surgeons (STS) Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs) among patients undergoing VAD implant between July 2009 and April 2017. Medicare data were used to measure fragmentation of the multidisciplinary care delivery network for the treating hospital, based on providers' history of shared patients within the previous year. STS Intermacs data were used for risk adjustment and outcomes ascertainment. Hospitals were sorted into terciles based on the degree of network fragmentation, measured as the mean number of links separating providers in the network. Multivariable regression was used to associate network fragmentation with 90-day death or infection risk. RESULTS The cohort included 5159 patients who underwent VAD implant, with 11.2% dying and 27.6% experiencing an infection within 90 days after implant. After adjustment, a 1-unit increase in network fragmentation was associated with an increase of 0.179 in the probability of in-hospital infection and an increase of 0.183 in the probability of 90-day infection (both P < .05). Similar results were observed in models of the numbers of in-hospital and 90-day infections. Network fragmentation was predictive of the probability of 90-day mortality, although this relationship was not significant after adjustment. CONCLUSIONS Care delivery network fragmentation is associated with higher in-hospital and 90-day infection rates following durable VAD implant. These networks may serve as novel targets for enhancing outcomes for patients undergoing VAD implant.
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Affiliation(s)
- Russell J Funk
- Carlson School of Management, University of Minnesota, 321 19th Ave S, #3-354, Minneapolis, MN 55455.
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Kim KD, Funk RJ, Hou H, Airhart A, Nassar K, Pagani FD, Zhang M, Chandanabhumma PP, Aaronson KD, Chenoweth CE, Hider A, Cabrera L, Likosky DS. Association Between Care Fragmentation and Total Spending After Durable Left Ventricular Device Implant: A Mediation Analysis of Health Care-Associated Infections Within a National Medicare-Society of Thoracic Surgeons Intermacs Linked Dataset. Circ Cardiovasc Qual Outcomes 2022; 15:e008592. [PMID: 36065815 PMCID: PMC9489640 DOI: 10.1161/circoutcomes.121.008592] [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: 11/16/2022]
Abstract
BACKGROUND Care fragmentation is associated with higher rates of infection after durable left ventricular assist device (LVAD) implant. Less is known about the relationship between care fragmentation and total spending, and whether this relationship is mediated by infections. METHODS Total payments were captured from admission to 180 days post-discharge. Drawing on network theory, a measure of care fragmentation was developed based on the number of shared patients among providers (ie, anesthesiologists, cardiac surgeons, cardiologists, critical care specialists, nurse practitioners, physician assistants) caring for 4,987 Medicare beneficiaries undergoing LVAD implantation between July 2009 - April 2017. Care fragmentation was measured using average path length, which describes how efficiently information flows among network members; longer path length indicates greater fragmentation. Terciles based on the level of care fragmentation and multivariable regression were used to analyze the relationship between care fragmentation and LVAD payments and mediation analysis was used to evaluate the role of post-implant infections. RESULTS The patient cohort was 81% male, 73% white, 11% Intermacs Profile 1 with mean (SD) age of 63.1 years (11.1). The mean (SD) level of care fragmentation in provider networks was 1.7 (0.2) and mean (SD) payment from admission to 180 days post-discharge was $246,905 ($109,872). Mean (SD) total payments at the lower, middle, and upper terciles of care fragmentation were $250,135 ($111,924), $243,288 ($109,376), and $247,290 ($108,241), respectively. In mediation analysis, the indirect effect of care fragmentation on total payments, through infections, was positive and statistically significant (β=16032.5, p=0.008). CONCLUSIONS Greater care fragmentation in the delivery of care surrounding durable LVAD implantation is associated with a higher incidence of infections, and consequently, higher payments for Medicare beneficiaries. Interventions to reduce care fragmentation may reduce the incidence of infections and in turn enhance the value of care for patients undergoing durable LVAD implantation.
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Affiliation(s)
- K. Dennie Kim
- Strategy, Ethics, and Entrepreneurship, Darden School of Business, University of Virginia, Charlottesville, VA
| | - Russell J. Funk
- Department of Strategic Management and Entrepreneurship, Carlson School of Management, University of Minnesota, Minneapolis, MN
| | - Hechuan Hou
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | | | - Khalil Nassar
- University Hospital, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Francis D Pagani
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - P. Paul Chandanabhumma
- Mixed Methods Program, Department of Family Medicine, University of Michigan, Ann Arbor, MI
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Carol E Chenoweth
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Ahmad Hider
- University of Michigan Medical School, Ann Arbor, MI
| | - Lourdes Cabrera
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Donald S Likosky
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
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Cohen-Mekelburg S, Yu X, Costa D, Hofer TP, Krein S, Hollingsworth J, Wiitala W, Saini S, Zhu J, Waljee A. Variation in Provider Connectedness Associates With Outcomes of Inflammatory Bowel Diseases in an Analysis of Data From a National Health System. Clin Gastroenterol Hepatol 2021; 19:2302-2311.e1. [PMID: 32798705 PMCID: PMC9131729 DOI: 10.1016/j.cgh.2020.08.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/28/2020] [Accepted: 08/11/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Inflammatory bowel diseases (IBD) often require multidisciplinary care with tight coordination among providers. Provider connectedness, a measure of the relationship among providers, is an important aspect of care coordination that has been linked to higher quality care. We aimed to assess variation in provider connectedness among medical centers, and to understand the association between this established measure of care coordination and outcomes of patients with IBD. METHODS We conducted a national cohort study of 32,949 IBD patients with IBD from 2005 to 2014. We used network analysis to examine provider connectedness, defined using network properties that measure the strength of the collaborative relationship, team cohesiveness, and between-facility collaborations. We used multilevel modeling to examine variations in provider connectedness and association with patient outcomes. RESULTS There was wide variation in provider connectedness among facilities in complexity, rural designation, and volume of patients with IBD. In a multivariable model, patients followed in a facility with team cohesiveness (odds ratio, 0.38; 95% CI, 0.16-0.88) and where providers often collaborated with providers outside their facility (odds ratio, 0.48; 95% CI, 0.31-0.75) were less likely to have clinically active disease, defined by a composite of outpatient flare, inpatient flare, and IBD-related surgery. CONCLUSIONS A national study found evidence for heterogeneity in patient-sharing among IBD care teams. Patients with IBD seen at health centers with higher provider connectedness appear to have better outcomes. Understanding provider connectedness is a step toward designing network-based interventions to improve coordination and quality of care.
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Affiliation(s)
- Shirley Cohen-Mekelburg
- Division of Gastroenterology & Hepatology, University of Michigan, Ann Arbor, Michigan; VA Center for Clinical Management Research, Ann Arbor, Michigan; Institute of Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan.
| | - Xianshi Yu
- Department of Statistics, University of Michigan, Ann Arbor, Michigan
| | - Deena Costa
- Institute of Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan, University of Michigan School of Nursing, Ann Arbor, Michigan
| | - Timothy P. Hofer
- VA Center for Clinical Management Research, Ann Arbor, Michigan, Institute of Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Sarah Krein
- VA Center for Clinical Management Research, Ann Arbor, Michigan, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - John Hollingsworth
- Institute of Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Wyndy Wiitala
- VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Sameer Saini
- Division of Gastroenterology & Hepatology, University of Michigan, Ann Arbor, Michigan, VA Center for Clinical Management Research, Ann Arbor, Michigan, Institute of Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Ji Zhu
- Department of Statistics, University of Michigan, Ann Arbor, Michigan
| | - Akbar Waljee
- Division of Gastroenterology & Hepatology, University of Michigan, Ann Arbor, Michigan, VA Center for Clinical Management Research, Ann Arbor, Michigan, Institute of Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan
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Hollingsworth JM, Yu X, Yan PL, Yoo H, Telem DA, Yankah EN, Zhu J, Waljee AK, Nallamothu BK. Provider Care Team Segregation and Operative Mortality Following Coronary Artery Bypass Grafting. Circ Cardiovasc Qual Outcomes 2021; 14:e007778. [PMID: 33926210 PMCID: PMC8137653 DOI: 10.1161/circoutcomes.120.007778] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 09/08/2023] [Indexed: 11/16/2022]
Abstract
BACKGROUND Studies have shown that Black patients die more frequently following coronary artery bypass grafting than their White counterparts for reasons not fully explained by disease severity or comorbidity. To examine whether provider care team segregation within hospitals contributes to this inequity, we analyzed national Medicare data. METHODS Using national Medicare data, we identified beneficiaries who underwent coronary artery bypass grafting at hospitals where this procedure was performed on at least 10 Black and 10 White patients between 2008 and 2014 (n=12 646). After determining the providers who participated in their perioperative care, we examined the extent to which Black and White patients were cared for by unique networks of provider care teams within the same hospital. We then evaluated whether a lack of overlap in composition of the provider care teams treating Black versus White patients (ie, high segregation) was associated with higher 90-day operative mortality among Black patients. RESULTS The median level of provider care team segregation was high (0.89) but varied across hospitals (interquartile range, 0.85-0.90). On multivariable analysis, after controlling for patient-, hospital-, and community-level differences, mortality rates for White patients were comparable at hospitals with high and low levels of provider care segregation (5.4% [95% CI, 4.7%-6.1%] versus 5.8% [95% CI, 4.7%-7.0%], respectively; P=0.601), while Black patients treated at high-segregation hospitals had significantly higher mortality than those treated at low-segregation hospitals (8.3% [95% CI, 5.4%-12.4%] versus 3.3% [95% CI, 2.0%-5.4%], respectively; P=0.017). The difference in mortality rates for Black and White patients treated at low-segregation hospitals was nonsignificant (-2.5%; P=0.098). CONCLUSIONS Black patients who undergo coronary artery bypass grafting at a hospital with a higher level of provider care team segregation die more frequently after surgery than Black patients treated at a hospital with a lower level.
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Affiliation(s)
| | - Xianshi Yu
- Michigan Integrated Center for Health Analytics and Medical Prediction, University of Michigan, Ann Arbor, MI
- Department of Statistics, University of Michigan College of Literature, Science, and Arts, Ann Arbor, MI
| | - Phyllis L. Yan
- Department of Urology, University of Michigan Medical School, Ann Arbor, MI
| | - Hyesun Yoo
- Michigan Integrated Center for Health Analytics and Medical Prediction, University of Michigan, Ann Arbor, MI
- Department of Statistics, University of Michigan College of Literature, Science, and Arts, Ann Arbor, MI
| | - Dana A. Telem
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | | | - Ji Zhu
- Michigan Integrated Center for Health Analytics and Medical Prediction, University of Michigan, Ann Arbor, MI
- Department of Statistics, University of Michigan College of Literature, Science, and Arts, Ann Arbor, MI
| | - Akbar K. Waljee
- Michigan Integrated Center for Health Analytics and Medical Prediction, University of Michigan, Ann Arbor, MI
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Brahmajee K. Nallamothu
- Michigan Integrated Center for Health Analytics and Medical Prediction, University of Michigan, Ann Arbor, MI
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI
- Division of Cardiology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
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Occupational stress, burnout and patient safety culture among workers from critical care and non critical care units in a hospital in Brazil. Intensive Crit Care Nurs 2020; 63:102978. [PMID: 33257217 DOI: 10.1016/j.iccn.2020.102978] [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: 05/27/2020] [Revised: 11/08/2020] [Accepted: 11/11/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To evaluate the relationship among occupational stress, burnout and the perception of patient safety culture in health workers in critical care compared to non critical care units. RESEARCH METHODOLOGY A cross-sectional study with health workers in the critical care and non critical care units of a university public hospital in Brazil. Data were collected using the Demographic and Labour Profile Questionnaire, Safety Attitudes Questionnaire, Job Stress Scale and the Maslach Burnout Inventory. An analysis of descriptive and inferential statistics was performed in PASW Statistics® software. RESULTS A total of 393 health workers participated in the study, with 58.3% from critical care units and 41.7% from non critical care units. There was a prevalence of workers in high demand in non critical care units and 13.4% were experiencing burnout; there was a predominance of active work in the reviews and 8.3% were experiencing burnout. The patient safety culture perception was negative in both. The multivariate analysis pointed out that the variables such as high demand and burnout increased the prevalence of negatively assessing the safety culture. CONCLUSION Workers from non critical care units were more affected by occupational stress and burnout and seemed to evaluate the safety culture more negatively, which can interfere in the quality of care provided.
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Wise S, Duffield C, Fry M, Roche M. Clarifying workforce flexibility from a division of labor perspective: a mixed methods study of an emergency department team. HUMAN RESOURCES FOR HEALTH 2020; 18:17. [PMID: 32143632 PMCID: PMC7060538 DOI: 10.1186/s12960-020-0460-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 02/24/2020] [Indexed: 05/25/2023]
Abstract
BACKGROUND The need for greater flexibility is often used to justify reforms that redistribute tasks through the workforce. However, "flexibility" is never defined or empirically examined. This study explores the nature of flexibility in a team of emergency doctors, nurse practitioners (NPs), and registered nurses (RNs), with the aim of clarifying the concept of workforce flexibility. Taking a holistic perspective on the team's division of labor, it measures task distribution to establish the extent of multiskilling and role overlap, and explores the behaviors and organizational conditions that drive flexibly. METHODS The explanatory sequential mixed methods study was set in the Fast Track area of a metropolitan emergency department (ED) in Sydney, Australia. In phase 1, an observational time study measured the tasks undertaken by each role (151 h), compared as a proportion of time (Kruskal Wallis, Mann-Whitney U), and frequency (Pearson chi-square). The time study was augmented with qualitative field notes. In phase 2, 19 semi-structured interviews sought to explain the phase 1 observations and were analyzed thematically. RESULTS The roles were occupationally specialized: "Assessment and Diagnosis" tasks consumed the largest proportion of doctors' (51.1%) and NPs' (38.1%) time, and "Organization of Care" tasks for RNs (27.6%). However, all three roles were also multiskilled, which created an overlap in the tasks they performed. The team used this role overlap to work flexibly in response to patients' needs and adapt to changing demands. Flexibility was driven by the urgent and unpredictable workload in the ED and enabled by the stability provided by a core group of experienced doctors and nurses. CONCLUSION Not every healthcare team requires the type of flexibility found in this study since that was shaped by patient needs and the specific organizational conditions of the ED. The roles, tasks, and teamwork that a team requires to "be flexible" (i.e., responsive and adaptable) are highly context dependent. Workforce flexibility therefore cannot be defined as a particular type of reform or role; rather, it should be understood as the capacity of a team to respond and adapt to patients' needs within its organizational context. The study's findings suggest that solutions for a more flexible workforce may lay in the organization of healthcare work.
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Affiliation(s)
- Sarah Wise
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, PO Box 123, Broadway, NSW, 2007, Australia.
| | - Christine Duffield
- Faculty of Health, University of Technology Sydney, PO Box 123, Broadway, NSW, 2007, Australia
- School of Nursing and Midwifery, Edith Cowan University, Australia, 270 Joondalup Drive, Joondalup, WA, 6027, Australia
| | - Margaret Fry
- Faculty of Health, University of Technology Sydney, PO Box 123, Broadway, NSW, 2007, Australia
- Director Research and Practice Development Nursing and Midwifery Directorate, Northern Sydney Local Health District, Royal North Shore Hospital, Kolling Building, St Leonards, NSW, 2065, Australia
| | - Michael Roche
- Faculty of Health, University of Technology Sydney, PO Box 123, Broadway, NSW, 2007, Australia
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Chandanabhumma PP, Fetters MD, Pagani FD, Malani PN, Hollingsworth JM, Funk RJ, Aaronson KD, Zhang M, Kormos RL, Chenoweth CE, Shore S, Watt TMF, Cabrera L, Likosky DS. Understanding and Addressing Variation in Health Care-Associated Infections After Durable Ventricular Assist Device Therapy: Protocol for a Mixed Methods Study. JMIR Res Protoc 2020; 9:e14701. [PMID: 31909721 PMCID: PMC6996720 DOI: 10.2196/14701] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 09/26/2019] [Accepted: 10/29/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Durable ventricular assist device (VAD) therapy is reserved for patients with advanced heart failure who have a poor estimated 1-year survival. However, despite highly protocolized management processes, patients are at a unique risk for developing a health care-associated infection (HAI). Few studies have examined optimal strategies for HAI prevention after durable VAD implantation, despite variability in rates across centers and their impact on short- and long-term outcomes. OBJECTIVE The objective of this study is to develop recommendations for preventing the most significant HAIs after durable VAD implantation. The study has 3 specific aims: (1) identify determinants of center-level variability in HAI rates, (2) develop comprehensive understanding of barriers and facilitators for achieving low center-level HAI rates, and (3) develop and disseminate a best practices toolkit for preventing HAIs that accommodates various center contexts. METHODS This is a sequential mixed methods study starting with a cross-sectional assessment of current practices. To address aim 1, we will conduct (1) a systematic review of HAI prevention studies and (2) in-depth quantitative analyses using administrative claims, in-depth clinical data, and organizational surveys of VAD centers. For aim 2, we will apply a mixed methods patient tracer assessment framework to conduct semistructured interviews, field observations, and document analysis informed by findings from aim 1 at 5 high-performing (ie, low HAIs) and 5 low-performing (ie, high HAI) centers, which will be examined using a mixed methods case series analysis. For aim 3, we will build upon the findings from the previous aims to develop and field test an HAI preventive toolkit, acquire stakeholder input at an annual cardiac surgical conference, disseminate the final version to VAD centers nationwide, and conduct follow-up surveys to assess the toolkit's adoption. RESULTS The project was funded by the Agency for Healthcare Research and Quality in 2018 and enrollment for the overall project is ongoing. Data analysis is currently under way and the first results are expected to be submitted for publication in 2019. CONCLUSIONS This mixed methods study seeks to quantitatively assess the determinants of HAIs across clinical centers and qualitatively identify the context-specific facilitators and barriers for attaining low HAI rates. The mixed data findings will be used to develop and disseminate a stakeholder-acceptable toolkit of evidence-based HAI prevention recommendations that will accommodate the specific contexts and needs of VAD centers. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/14701.
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Affiliation(s)
- P Paul Chandanabhumma
- Mixed Methods Program, Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Michael D Fetters
- Mixed Methods Program, Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, United States
| | - Preeti N Malani
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | | | - Russell J Funk
- Department of Strategic Management and Entrepreneurship, Carlson School of Management, University of Minnesota, Minneapolis, MN, United States
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Robert L Kormos
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Carol E Chenoweth
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Supriya Shore
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Tessa M F Watt
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, United States
| | - Lourdes Cabrera
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, United States
| | - Donald S Likosky
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, United States
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Funk RJ, Owen-Smith J, Kaufman SA, Nallamothu BK, Hollingsworth JM. Association of Informal Clinical Integration of Physicians With Cardiac Surgery Payments. JAMA Surg 2019; 153:446-453. [PMID: 29282464 DOI: 10.1001/jamasurg.2017.5150] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance To reduce inefficiency and waste associated with care fragmentation, many current programs target greater clinical integration among physicians. However, these programs have led to only modest Medicare spending reductions. Most programs focus on formal integration, which often bears little resemblance to actual physician interaction patterns. Objectives To examine how physician interaction patterns vary between health systems and to assess whether variation in informal integration is associated with care delivery payments. Design, Setting, and Participants National Medicare data from January 1, 2008, through December 31, 2011, identified 253 545 Medicare beneficiaries (aged ≥66 years) from 1186 health systems where Medicare beneficiaries underwent coronary artery bypass grafting (CABG) procedures. Interactions were mapped between all physicians who treated these patients-including primary care physicians and surgical and medical specialists-within a health system during their surgical episode. The level of informal integration was measured in these networks of interacting physicians. Multivariate regression models were fitted to evaluate associations between payments for each surgical episode made on a beneficiary's behalf and the level of informal integration in the health system where the patient was treated. Exposures The informal integration level of a health system. Main Outcomes and Measures Price-standardized total surgical episode and component payments. Results The total 253 545 study participants included 175 520 men (69.2%; mean [SD] age, 74.51 [5.75] years) and 78 024 women (34.3%; 75.67 [5.91] years). One beneficiary of the 253 545 participants did not have sex information. The low level of informal clinical integration included 84 598 patients (33.4%; mean [SD] age, 75.00 [5.93] years); medium level, 84 442 (33.30%; 74.94 [5.87] years); and high level, 84 505 (33.34%; 74.66 [5.72] years) (P < .001). Informal integration levels varied across health systems. After adjusting for patient, health-system, and community factors, higher levels of informal integration were associated with significantly lower total episode and component payments (β coefficients for informal integration were -365.87 [95% CI, -451.08 to -280.67] for total episode payments, -182.63 [-239.80 to -125.46] for index hospitalization, -43.13 [-55.53 to -30.72] for physician services, -74.48 [-103.45 to -45.51] for hospital readmissions, and -62.04 [-88.00 to -36.07] for postacute care; P < .001 for each association). When beneficiaries were treated in health systems with higher informal integration, the greatest savings of lower estimated payments were from hospital readmissions (13.0%) and postacute care services (5.8%). Conclusions and Relevance Informal integration is associated with lower spending. Although most programs that seek to promote clinical integration are focused on health systems' formal structures, policy makers may also want to address informal integration.
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Affiliation(s)
- Russell J Funk
- Strategic Management and Entrepreneurship, Carlson School of Management, University of Minnesota, Minneapolis
| | - Jason Owen-Smith
- Department of Sociology, College of Literature, Sciences, and the Arts, University of Michigan, Ann Arbor
| | - Samuel A Kaufman
- Department of Urology, University of Michigan Medical School, Ann Arbor
| | - Brahmajee K Nallamothu
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor.,Michigan Integrated Center for Health Analytics and Medical Prediction, University of Michigan, Ann Arbor
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Kim D, Funk RJ, Yan P, Nallamothu BK, Zaheer A, Hollingsworth JM. Informal Clinical Integration in Medicare Accountable Care Organizations and Mortality Following Coronary Artery Bypass Graft Surgery. Med Care 2019; 57:194-201. [PMID: 30629017 PMCID: PMC6421077 DOI: 10.1097/mlr.0000000000001052] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Accountable care organizations' (ACOs') focus on formal clinical integration to improve outcomes overlooks actual patterns of provider interactions around shared patients. OBJECTIVE To determine whether such informal clinical integration relates to a health system's performance in an ACO. RESEARCH DESIGN We analyzed national Medicare data (2008-2014), identifying beneficiaries who underwent coronary artery bypass grafting (CABG). After determining which physicians delivered care to them, we aggregated across episodes to construct physician networks for each health system. We used network analysis to measure each system's level of informal clinical integration (defined by cross-specialty ties). We fit regression models to examine the association between a health system's CABG mortality rate and ACO participation, conditional on informal clinical integration. SUBJECTS Beneficiaries age 66 and older undergoing CABG. MEASURES Ninety-day CABG mortality. RESULTS Over the study period, 3385 beneficiaries were treated in 161 ACO-participating health systems. The remaining 49,854 were treated in 875 nonparticipating systems or one of the 161 ACO-participating systems before the ACO start date. ACO systems with higher levels of informal clinical integration had lower CABG mortality rates than nonparticipating ones (2.8% versus 5.5%; P<0.01); however, there was no difference based on ACO participation for health systems with lower to relatively moderate informal clinical integration. Regression results corroborate this finding (coefficient for interaction between ACO participation and informal clinical integration level is -0.25; P=0.01). CONCLUSIONS Formal clinical integration through ACO participation may be insufficient to improve outcomes. Health systems with higher informal clinical integration may benefit more from ACO participation.
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Affiliation(s)
- Dennie Kim
- Strategic Management and Entrepreneurship, Carlson School of Management, University of Minnesota, Minneapolis, MN
| | - Russell J Funk
- Strategic Management and Entrepreneurship, Carlson School of Management, University of Minnesota, Minneapolis, MN
| | - Phyllis Yan
- Department of Urology, University of Michigan Medical School
| | - Brahmajee K Nallamothu
- Department of Medicine, University of Michigan Medical School, Michigan Integrated Center for Health Analytics and Medical Prediction
| | - Aks Zaheer
- Strategic Management and Entrepreneurship, Carlson School of Management, University of Minnesota, Minneapolis, MN
| | - John M Hollingsworth
- Department of Urology, Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor, MI
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Lin SC, Regenbogen SE, Hollingsworth JM, Funk R, Adler-Milstein J. Coordination of Care Around Surgery for Colon Cancer: Insights From National Patterns of Physician Encounters With Medicare Beneficiaries. J Oncol Pract 2018; 15:e110-e121. [PMID: 30550373 DOI: 10.1200/jop.18.00228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To improve care coordination for complex cancers, it is critical to establish a more nuanced understanding of the types of providers involved. As the number of provider types increases, strategies to support cancer care coordination must adapt to a greater variety of information needs, communication styles, and treatment strategies. METHODS We categorized providers into 11 types, using National Provider Identifier specialties. Using Medicare claims, we counted the number of unique combinations of provider types billed during preoperative, operative, and postdischarge care for colon cancer surgery and assessed how this count varies across hospitals. The study included 70,567 beneficiaries in fee-for-service Medicare A and B for 6 months before and 60 days after an admission for colectomy for colon cancer between 2008 and 2011. RESULTS We observed 1,554 preoperative provider-type combinations, 975 operative combinations, and 1,571 postdischarge combinations. The three most common combinations in the preoperative phase were general medicine only, other medical specialists only, and general medicine and other medical specialists. In the operative phase, the three most common combinations were primary surgery, anesthesiology, and pathology; general medicine, other medical specialists, radiology, primary surgery, anesthesiology, and pathology; and other medical specialists, radiology, primary surgery, anesthesiology, and pathology. In the postdischarge phase, the three most common combinations were general medicine, general medicine and other medical specialists, and general medicine and oncology. On average, each hospital had 15 preoperative, 11 operative, and 15 postoperative combinations. High-volume, larger, teaching, urban, and noncritical access hospitals had more combinations in all phases. CONCLUSION Many provider-type combinations are involved in colon cancer surgery care. Substantial variation exists across hospitals types, suggesting that certain hospitals need additional resources and more flexible infrastructure to coordinate care.
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Everson J, Adler-Milstein J, Ryan AM, Hollingsworth JM. Hospitals Strengthened Relationships With Close Partners After Joining Accountable Care Organizations. Med Care Res Rev 2018; 77:549-558. [PMID: 30541401 DOI: 10.1177/1077558718818336] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The strategies that hospitals participating in Medicare Accountable Care Organizations (ACOs) use to achieve quality and cost containment goals are poorly understood. One possibility is that participating hospitals could try to influence where their patients receive care. To test this hypothesis, we examined whether a hospital's participation in a Medicare ACO was associated with changes in its patterns of patient sharing with other hospitals. Between 2010 and 2014, patient sharing across hospitals increased 23.3%. After controlling for hospital and regional factors, patient sharing increased 4.4% more at ACO hospitals than non-ACO hospitals (p = .001 for difference). This increase occurred disproportionately among hospitals with which ACO hospitals already shared a high proportion of their patients prior to participation, and among hospitals in ACOs characterized as physician-hospital collaborations. The increased sharing of patients among closely affiliated hospitals may serve to achieve ACO quality and cost containment goals through increased interorganizational coordination.
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Affiliation(s)
- Jordan Everson
- Vanderbilt University School of Medicine, Nashville, TN, USA
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Onnela JP, O’Malley AJ, Keating NL, Landon BE. Comparison of physician networks constructed from thresholded ties versus shared clinical episodes. APPLIED NETWORK SCIENCE 2018; 3:28. [PMID: 30839809 PMCID: PMC6214299 DOI: 10.1007/s41109-018-0084-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 07/13/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To compare standard methods for constructing physician networks from patient-physician encounter data with a new method based on clinical episodes of care. DATA SOURCE We used data on 100% of traditional Medicare beneficiaries from 51 nationally representative geographical regions for the years 2005-2010. STUDY DESIGN We constructed networks of physicians based on their shared patients. In the fixed-threshold networks and adaptive-threshold networks, we included data on all patient-physician encounters to form the physician-physician ties, and then subsequently thresholded some proportion of the strongest ties. In contrast, in the episode-based approach, only those patient-physician encounters that occurred within shared clinical episodes treating specific conditions contributed towards physician-physician ties. DATA COLLECTION/EXTRACTION METHODS We extracted clinical episodes in the Medicare data and investigated structural properties of the patient-sharing networks of physicians, temporal dynamics of their ties, and temporal stability of network communities across the two approaches. PRINCIPAL FINDINGS The episode-based networks accentuated ties between primary care physicians (PCPs) and medical specialists, had ties that were more likely to reappear in the future, and appeared to have more fluid community structure. CONCLUSIONS Constructing physician networks around shared episodes of care is a clinically sound alternative to previous approaches to network construction that does not require arbitrary decisions about thresholding. The resulting networks capture somewhat different aspects of patient-physician encounters.
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Affiliation(s)
- Jukka-Pekka Onnela
- Harvard T.H. Chan School of Public Health, Harvard University, 655 Huntington Avenue, Boston, MA USA
| | - A. James O’Malley
- Department of Biomedical Data Science, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH USA
| | - Nancy L. Keating
- Department of Health Care Policy, Harvard Medical School, Boston, MA USA
- Division of General Internal Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA USA
| | - Bruce E. Landon
- Department of Health Care Policy, Harvard Medical School, Boston, MA USA
- Division of Primary Care and General Internal Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA USA
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