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Armstrong AT, Velez-Velez LM, Simpson MC, Massa ST. Trends and Implications of Adjuvant Systemic Therapy for Head and Neck Cancer Without High-Risk Features. Otolaryngol Head Neck Surg 2023; 169:556-569. [PMID: 36939584 DOI: 10.1002/ohn.252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/03/2022] [Accepted: 12/19/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Determine trends and survival implications of adjuvant systemic therapy use for lower risk head and neck cancer. STUDY DESIGN Retrospective cohort study. SETTING US National Cancer Database, 2010 to 2019. METHODS Patients with mucosal head and neck squamous cell carcinoma treated with surgery and postoperative radiation therapy were identified. Adjuvant systemic therapy trends in those with and without extranodal extension or positive margins were assessed as annual percent change by JoinPoint analysis. Factors associated with adjuvant systemic therapy and overall survival were assessed with multivariable models and cox proportional hazard models, respectively. RESULTS From 2010 to 2019, approximately one-third of head and neck cancer patients without extranodal extension or positive margins received adjuvant systemic therapy. This rate decreased throughout the study period, with the highest annual percent change from 2016 to 2019 (12.21%; 95% confidence interval: 3.73%-19.95%). Younger age, male sex, Hispanic ethnicity, community program setting, advanced stage, and lymphovascular invasion increased the odds a patient would receive adjuvant systemic therapy. Adjuvant systemic therapy was associated with inferior overall survival when used in those without extranodal extension or positive margins after controlling for covariates. CONCLUSION Though decreasing, adjuvant systemic therapy use is still common in the absence of extranodal extension and positive margins, and a variety of patient, provider, and oncologic factors may influence its use. The inferior overall survival after adjuvant systemic therapy in the absence of high-risk features suggests any oncologic benefit may not outweigh the costs and morbidity of the therapy.
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Affiliation(s)
- Austin T Armstrong
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University, St. Louis, Missouri, USA
| | - Lisa M Velez-Velez
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University, St. Louis, Missouri, USA
| | - Matt C Simpson
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University, St. Louis, Missouri, USA
| | - Sean T Massa
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University, St. Louis, Missouri, USA
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2
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Snow KK, Patzer RE, Patel SA, Harding JL. County-Level Characteristics Associated with Variation in ESKD Mortality in the United States, 2010-2018. KIDNEY360 2022; 3:891-899. [PMID: 36128479 PMCID: PMC9438422 DOI: 10.34067/kid.0007872021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 02/25/2022] [Indexed: 01/10/2023]
Abstract
Background Geographic and neighborhood-level factors, such as poverty and education, have been associated with an increased risk for incident ESKD, likelihood of receiving pre-ESKD care, and likelihood of receiving a transplant. However, few studies have examined whether these same factors are associated with ESKD mortality. In this study, we examined county-level variation in ESKD mortality and identified county-level characteristics associated with this variation. Methods We identified 1,515,986 individuals (aged 18-84 years) initiating RRT (dialysis or transplant) between 2010 and 2018 using the United States Renal Data System. Among 2781 counties, we estimated county-level, all-cause, age-standardized mortality rates (ASMR) among patients with ESKD. We then identified county-level demographic (e.g., percent female), socioeconomic (e.g., percent unemployed), healthcare (e.g., percent without health insurance), and health behavior (e.g., percent current smokers) characteristics associated with ASMR using multivariable hierarchic linear mixed models and quantified the percentage of ASMR variation explained by county-level characteristics. Results County-level ESKD ASMR ranged from 45 to 1022 per 1000 person-years (PY) (mean, 119 per 1000 PY). ASMRs were highest in counties located in the Tennessee Valley and Appalachia regions, and lowest in counties located in New England, the Pacific Northwest, and Southern California. In fully adjusted models, county-level characteristics significantly associated with higher ESKD mortality included a lower percentage of Black residents (-4.94 per 1000 PY), lower transplant rate (-4.08 per 1000 PY), and higher healthcare expenditures (5.21 per 1000 PY). Overall, county-level characteristics explained 19% of variation in ESKD mortality. Conclusions Counties with high ESKD-related mortality may benefit from targeted and multilevel interventions that combine knowledge from a growing evidence base on the interplay between individual and community-level factors associated with ESKD mortality.
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Affiliation(s)
- Kylie K. Snow
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia,Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Rachel E. Patzer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia,Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Shivani A. Patel
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Jessica L. Harding
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia,Department of Surgery, Emory University School of Medicine, Atlanta, Georgia,Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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3
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Li M, Lakdawalla DN, Goldman DP. Association Between Spending and Outcomes for Patients With Cancer. J Clin Oncol 2020; 38:323-331. [PMID: 31804868 PMCID: PMC6994252 DOI: 10.1200/jco.19.01451] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2019] [Indexed: 12/19/2022] Open
Affiliation(s)
- Meng Li
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA
- Sol Price School of Public Policy, University of Southern California, Los Angeles, CA
| | - Darius N. Lakdawalla
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA
- Sol Price School of Public Policy, University of Southern California, Los Angeles, CA
- School of Pharmacy, University of Southern California, Los Angeles, CA
| | - Dana P. Goldman
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA
- Sol Price School of Public Policy, University of Southern California, Los Angeles, CA
- School of Pharmacy, University of Southern California, Los Angeles, CA
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4
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Crivellaro S, Sofer L, Halgrimson WR, Dobbs RW, Serafini P. Optimized Clinical Decision-making: A Configurable Markov Model for Benign Prostatic Hyperplasia Treatment. Urology 2019; 132:183-188. [DOI: 10.1016/j.urology.2019.06.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 06/12/2019] [Accepted: 06/17/2019] [Indexed: 11/17/2022]
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5
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Schleicher SM, Bach PB, Matsoukas K, Korenstein D. Medication overuse in oncology: current trends and future implications for patients and society. Lancet Oncol 2019; 19:e200-e208. [PMID: 29611528 DOI: 10.1016/s1470-2045(18)30099-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 12/04/2017] [Accepted: 12/05/2017] [Indexed: 01/09/2023]
Abstract
The high cost of cancer care worldwide is largely attributable to rising drugs prices. Despite their high costs and potential toxic effects, anticancer treatments could be subject to overuse, which is defined as the provision of medical services that are more likely to harm than to benefit a patient. We found 30 studies documenting medication overuse in cancer, which included 16 examples of supportive medication overuse and 17 examples of antineoplastic medication overuse in oncology. Few specific agents have been assessed, and no studies investigated overuse of the most toxic or expensive medications currently used in cancer treatment. Although financial, psychological, or physical harms of medication overuse in cancer could be substantial, there is little published evidence addressing these harms, so their magnitude is unclear. Further research is needed to better quantify medication overuse, understand its implications, and help protect patients and the health-care system from overuse.
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Affiliation(s)
- Stephen M Schleicher
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Peter B Bach
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Konstantina Matsoukas
- Information Systems/Medical Library, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Deborah Korenstein
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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6
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Baumgardner J, Shahabi A, Linthicum M, Vine S, Zacker C, Lakdawalla D. Greater Spending Associated with Improved Survival for Some Cancers in OCM-Defined Episodes. J Manag Care Spec Pharm 2018; 24:504-513. [PMID: 29799330 PMCID: PMC10397851 DOI: 10.18553/jmcp.2018.24.6.504] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Previous research finds significant variation in spending and utilization across regions, with little evidence of differences in outcomes. While such findings have been interpreted as evidence that spending can be reduced without compromising patient outcomes, the link between spending variation and outcomes remains a critical question. OBJECTIVE To use evidence from geographic variations in spending and an individual-level survival analysis to test whether spending within oncology care episodes is associated with survival, where episodes are defined as in the Center for Medicare and Medicaid Innovation's Oncology Care Model (OCM). METHODS In this retrospective cohort analysis, patient data from the Surveillance, Epidemiology and End Results Medicare (SEER-Medicare) database for 2007-2013 were linked to hospital referral regions (HRRs) using ZIP codes. Patients in the SEER program are a part of selected population-based cancer registries throughout the United States whose records are linked to Medicare enrollment and claims data (93% of elderly registry patients were successfully linked to Medicare data). Episodes of cancer care were defined as in the OCM: 6 months following a triggering chemotherapy claim. We analyzed episodes of care for 5 tumor types: advanced breast cancer (BC), non-small cell lung cancer (NSCLC), renal cell carcinoma (RCC), multiple myeloma (MM), and chronic myeloid leukemia (CML). We removed the effects of differentials in Medicare payment rates, which were mostly geographic. Regression analysis was then used to calculate standardized spending levels for each HRR, that is, spending adjusted for differences in patient and episode characteristics. To examine the effect of spending during OCM-defined episodes on individual-level survival, we used Cox regression with patient characteristics and standardized HRR spending per episode as covariates. To address concerns that may arise from multiple comparisons across the 5 tumor types, we used the Benjamini-Hochberg procedure to control the false discovery rate. RESULTS Our analysis showed significant differences in standardized spending across HRRs. Compared with spending at the 20th percentile episode, spending at the 80th percentile ranged from 25% higher ($57,392 vs. $45,995 for MM) to 47% higher ($36,920 vs. $24,127 for RCC), indicating practice style variation across regions. The hazard of dying for patients with NSCLC and MM statistically significantly decreased by 7% (HR = 0.93, P = 0.006) and 13% (HR = 0.87, P = 0.019), respectively, for a $10,000 increase in standardized spending (in 2013 U.S. dollars). For the 3 other cancers, spending effects were not statistically significant. After using the Benjamini-Hochberg procedure with a 5% false discovery rate, the effects of increased spending on improved survival for NSCLC and MM remained statistically significant. CONCLUSIONS The association we found between spending and survival suggests caution may be warranted for physicians, pharmacists, other health care professionals, and policymakers involved in efforts to reduce across-the-board spending within OCM-defined episodes for at least 2 of the 5 cancers studied. DISCLOSURES Funding for this research was provided by Novartis Pharmaceuticals to Precision Health Economics in support of research design, analysis, and technical writing services. The funder provided input on study design and comments on the draft report. Baumgardner, Shahabi, and Linthicum are employees of Precision Health Economics (PHE), a health care consultancy to the insurance and life science industries, including firms that market oncology therapies. Vine was an employee of PHE at the time of this research. Zacker is an employee of and shareholder in Novartis Pharmaceuticals. Lakdawalla is a consultant to PHE and holds equity in its parent company, Precision Medicine Group.
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Affiliation(s)
| | - Ahva Shahabi
- 1 Precision Health Economics, Los Angeles, California
| | | | - Seanna Vine
- 1 Precision Health Economics, Los Angeles, California
| | | | - Darius Lakdawalla
- 3 Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles
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Abstract
The economic burden of cancer on the national health expenditure is billions of dollars. The economic cost is measured on direct and indirect medical costs, which vary depending on stage at diagnosis, patient age, type of medical services, and site of service. Costs vary by region, physician behavior, and patient preferences. When analyzing the economic burden of survivors of colon cancer, we cannot forget the societal burden. Post-acute care and readmissions are major economic burdens. People with colon cancer have to be followed for their lifetime. Economic models are being studied to give cost-effective solutions to this problem.
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Affiliation(s)
- Guy R Orangio
- LSU Department of Surgery, 1542 Tulane Avenue, Suite 758, New Orleans, LA 70112, USA.
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8
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Tannenbaum S, Soulos PR, Herrin J, Mougalian S, Long JB, Wang R, Ma X, Gross CP, Xu X. Regional Medicare Expenditures and Survival Among Older Women With Localized Breast Cancer. Med Care 2017; 55:1030-1038. [PMID: 29068906 PMCID: PMC5863278 DOI: 10.1097/mlr.0000000000000822] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite evidence on large variation in breast cancer expenditures across geographic regions, there is little understanding about the association between expenditures and patient outcomes. OBJECTIVES To examine whether Medicare beneficiaries with nonmetastatic breast cancer living in regions with higher cancer-related expenditures had better survival. RESEARCH DESIGN A retrospective cohort study of women with localized breast cancer from the Surveillance, Epidemiology, and End Results-Medicare linked database. Hospital referral regions (HRR) were categorized into quintiles based on risk-standardized per patient Medicare expenditures on initial phase of breast cancer care. Hierarchical generalized linear models were estimated to examine the association between patients' HRR quintile and survival. SUBJECTS In total, 12,610 Medicare beneficiaries diagnosed with stage II-III breast cancer during 2005-2008 who underwent surgery. MEASURES Outcome measures for our analysis were 3- and 5-year overall survival. RESULTS Risk-standardized per patient Medicare expenditures on initial phase of breast cancer care ranged from $13,338 to $26,831 across the HRRs. Unadjusted 3- and 5-year survival varied from 66.7% to 92.2% and 50.0% to 84.0%, respectively, across the HRRs, but there was no significant association between HRR quintile and survival in bivariate analysis (P=0.08 and 0.28, respectively). After adjustment for sociodemographic and clinical characteristics, quintiles of regional cancer expenditures remained unassociated with patients' 3-year (P=0.35) and 5-year survival (P=0.20). Further analysis adjusting for treatment factors (surgery type and receipt of radiation and systemic therapy) and stratifying by cancer stage showed similar results. CONCLUSIONS For Medicare beneficiaries with nonmetastatic breast cancer, residence in regions with higher breast cancer-related expenditures was not associated with better survival. More attention to value in breast cancer care is warranted.
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Affiliation(s)
| | - Pamela R. Soulos
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
- Yale University Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
| | - Jeph Herrin
- Yale University Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
- Division of Cardiology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
- Health Research & Educational Trust, Chicago, IL
| | - Sarah Mougalian
- Yale University Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
- Section of Medical Oncology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Jessica B. Long
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
- Yale University Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
| | - Rong Wang
- Yale University Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Xiaomei Ma
- Yale University Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Cary P. Gross
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
- Yale University Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
| | - Xiao Xu
- Yale University Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT
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9
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Shirk JD, Kwan L, Laviana AA, Chu S, Huen KH, Bergman J. Is More Really Better? An Examination of Services and Payment Patterns among Urologists from the Centers for Medicare & Medicaid Services. UROLOGY PRACTICE 2017; 4:302-307. [PMID: 37592671 DOI: 10.1016/j.urpr.2016.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION We examined provider and regional variation in services provided and payments made to urologists by CMS (Centers for Medicare & Medicaid Services) by linking payments to individual beneficiaries and examining the proportion of submitted charges resulting in payments. METHODS We analyzed Medicare Part B Provider Utilization and Payment Data released by CMS for 2012, the last year of the purely fee-for-service reimbursement model. For each provider we determined the ratio of number of services provided to individual beneficiaries as well as the ratio of total submitted charges-to-total Medicare payments. Each provider was stratified into deciles of total Medicare payments and the mean per decile of total Medicare payment was calculated. Finally, to elucidate the potential association between the ratio of services-to-beneficiaries, we conducted multivariate linear regressions. RESULTS The 20th, 40th, 60th and 80th percentiles for the ratio of number of services per individual beneficiary ratios to total Medicare Part B payments are 2.8, 4.0, 5.2 and 7.4, respectively. Urologists with greater payments received provided more services to individual beneficiaries. Submitted charges exceeded payments by 3:1. Finally, female providers had lower ratios (p <0.01) and there was significant regional variation in the ratio of services per unique beneficiary (p <0.001 for each of the 10 Standard Federal Regions). CONCLUSIONS We found significant variation in services and payment in CMS. Reimbursement models replacing fee-for-service should be tailored to ensure appropriate health care resource utilization.
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Affiliation(s)
- Joseph D Shirk
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Lorna Kwan
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Aaron A Laviana
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Stephanie Chu
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Kathy H Huen
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Jonathan Bergman
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, California
- Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
- Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, California
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10
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McKellar MR, Landrum MB, Gibson TB, Landon BE, Fendrick AM, Chernew ME. Geographic Variation in Quality of Care for Commercially Insured Patients. Health Serv Res 2017; 52:849-862. [PMID: 27140721 PMCID: PMC5346491 DOI: 10.1111/1475-6773.12501] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Extensive evidence documents geographic variation in spending, but limited research assesses geographic variation in quality, particularly among commercially insured enrollees. OBJECTIVE To measure geographic variation in quality measures, correlation among measures, and correlation between measures and spending for commercially insured enrollees. DATA SOURCE Administrative claims from the 2007-2009 Truven MarketScan database. METHODS We calculated variation in, and correlations among, 10 quality measures across 306 Hospital Referral Regions (HRRs), adjusting for beneficiary traits and sample size differences. Further, we created a quality index and correlated it with spending. RESULTS The coefficient of variation of HRR-level performance ranged from 0.04 to 0.38. Correlations among quality measures generally ranged from 0.2 to 0.5. Quality was modestly positively related to spending. CONCLUSION Quality varied across HRRs and there was only a modest geographic "quality footprint."
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Affiliation(s)
| | | | | | - Bruce E. Landon
- Department of Health Care PolicyHarvard Medical SchoolBostonMA
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11
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Geographic variation in Medicare treatment costs and outcomes for advanced head and neck cancer. Oral Oncol 2016; 61:83-8. [DOI: 10.1016/j.oraloncology.2016.08.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 08/26/2016] [Accepted: 08/30/2016] [Indexed: 11/30/2022]
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12
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Zeidan AM, Wang R, Davidoff AJ, Ma S, Zhao Y, Gore SD, Gross CP, Ma X. Disease-related costs of care and survival among Medicare-enrolled patients with myelodysplastic syndromes. Cancer 2016; 122:1598-607. [PMID: 26970288 DOI: 10.1002/cncr.29945] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 01/21/2016] [Accepted: 01/28/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND Although newer treatments for myelodysplastic syndromes (MDS), particularly hypomethylating agents (HMAs), are expensive, it is unclear whether MDS-related costs of care are associated with overall survival. This study evaluated the relation between MDS-related costs and survival among Medicare beneficiaries with MDS. METHODS Eligible patients were identified from the Surveillance, Epidemiology, and End Results-Medicare database with codes for MDS from International Classification of Diseases for Oncology, 3rd edition. The patients were diagnosed between January 1, 2005 and December 31, 2011, were 66 years old or older, and were followed through death or the end of study (December 31, 2012). Medicare payments were used to estimate costs. Cumulative costs in a propensity score-matched group of cancer-free Medicare beneficiaries were subtracted from costs in the MDS cohort in each registry to estimate MDS-related costs. Hazard ratios (HRs) and 95% confidence intervals (CIs) were derived from multivariate Cox proportional hazards models adjusted for patient and disease characteristics. RESULTS There were 8580 eligible patients, and 1,267 (14.7%) received HMAs. The overall 2-year survival rate was 48.7%, and the 2-year registry-specific MDS-related cost per patient ranged from $40,793 to $78,156 across 16 registries. The 2-year MDS-related cost was not associated with survival in the overall study population (first tertile, reference; second tertile, HR, 0.96; 95% CI, 0.89-1.04; P = .29; third tertile, HR, 0.98; 95% CI, 0.91-1.06; P = .64) or in subgroups of patients who did or did not receive HMAs. CONCLUSIONS Medicare expenditures for elderly patients with MDS varied across registries but were not associated with survival. A lack of an association between costs and outcomes warrants additional research because it may help to identify potential areas for cost-saving interventions without compromising patient outcomes. Cancer 2016;122:1598-607. © 2016 American Cancer Society.
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Affiliation(s)
- Amer M Zeidan
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.,Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut
| | - Rong Wang
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut.,Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Amy J Davidoff
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut.,Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Shuangge Ma
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Yinjun Zhao
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Steven D Gore
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Cary P Gross
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.,Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut
| | - Xiaomei Ma
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut.,Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
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13
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Keating NL, Landrum MB, Huskamp HA, Kouri EM, Prigerson HG, Schrag D, Maciejewski PK, Hornbrook MC, Haggstrom DA. Dartmouth Atlas Area-Level Estimates of End-of-Life Expenditures: How Well Do They Reflect Expenditures for Prospectively Identified Advanced Lung Cancer Patients? Health Serv Res 2016; 51:1584-94. [PMID: 26799913 DOI: 10.1111/1475-6773.12440] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE Assess validity of the retrospective Dartmouth hospital referral region (HRR) end-of-life spending measures by comparing with health care expenditures from diagnosis to death for prospectively identified advanced lung cancer patients. DATA/SETTING/DESIGN We calculated health care spending from diagnosis (2003-2005) to death or through 2011 for 885 patients aged ≥65 years with advanced lung cancer using Medicare claims. We assessed the association between Dartmouth HRR-level spending in the last 2 years of life and patient-level spending using linear regression with random HRR effects, adjusting for patient characteristics. FINDINGS For each $1 increase in the Dartmouth metric, spending for our cohort increased by $0.74 (p < .001). The Dartmouth spending variable explained 93.4 percent of the HRR-level variance in observed spending. CONCLUSIONS HRR-level spending estimates for deceased patient cohorts reflect area-level care intensity for prospectively identified advanced lung cancer patients.
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Affiliation(s)
- Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, MA.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Mary Beth Landrum
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Haiden A Huskamp
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Elena M Kouri
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Holly G Prigerson
- Center for Research on End-of-Life Care, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY
| | - Deborah Schrag
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA
| | | | - Mark C Hornbrook
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - David A Haggstrom
- VA HSR&D Center for Health Information and Communication, Indiana University School of Medicine, Indianapolis, IN
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14
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Abstract
STUDY DESIGN Retrospective cohort study using medical claims data. OBJECTIVE To document the extent of geographic variation in utilization of magnetic resonance imaging (MRI) for working-age patients early in the course of acute, disabling low back pain (LBP); to identify potential factors associated with the most extreme variations. SUMMARY OF BACKGROUND DATA Although guidelines discourage MRI in acute uncomplicated LBP, this practice is highly prevalent. Geographic variation in radiologic testing is common, and may indicate problems with access or quality of care, yet this has not been studied in working-age patients with LBP (a frequent cause for acute care visits). METHODS All cases of acute, disabling LBP with onset between 1/1/2002 and 12/31/2007 were selected from a large workers' compensation data source. Detailed information from medical bills was used to identify persons who received early MRI (within 30 days of onset), classify cases by LBP severity, and exclude those with concurrent injuries or diseases, and/or prior LBP disability. Individual predictors included age, gender, job tenure, and industry. State-level predictors included economic, physician supply and practice variables, workers compensation system features, and MRI testing location. Generalized linear mixed models were constructed to evaluate within- and between-state variability, selecting the six highest and six lowest MRI utilization states. RESULTS State rates of early MRI scanning varied from 6.0% to 58.4%. In the 12 selected most extreme states, non-hospital MRI sites and lower state median income were associated with higher rates of early MRIs, explaining 84% of between-state variation, and 12.5% of all observed variability. Inter-state differences in MRI rates were greatest for lower-severity cases. Higher severity diagnoses were more common in high utilization states. CONCLUSIONS Between-state inappropriate early MRI variability is largely explained by rate of non-hospital MRI sites and state median income. Potential solutions include efforts to address inappropriate referral patterns based on private MRI facility ownership, and to improve quality of communication with low-income patients. LEVEL OF EVIDENCE 4.
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Tsugawa Y, Hasegawa K, Hiraide A, Jha AK. Regional health expenditure and health outcomes after out-of-hospital cardiac arrest in Japan: an observational study. BMJ Open 2015; 5:e008374. [PMID: 26289451 PMCID: PMC4550714 DOI: 10.1136/bmjopen-2015-008374] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 07/13/2015] [Accepted: 07/20/2015] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVES Japan is considering policies to set the target health expenditure level for each region, a policy approach that has been considered in many other countries. The objective of this study was to examine the relationship between regional health expenditure and health outcomes after out-of-hospital cardiac arrest (OHCA), which incorporates the qualities of prehospital, in-hospital and posthospital care systems. DESIGN We examined the association between prefecture-level per capita health expenditure and patients' health outcomes after OHCA. SETTING We used a nationwide, population-based registry system of OHCAs that captured all cases with OHCA resuscitated by emergency responders in Japan from 2005 to 2011. PARTICIPANTS All patients with OHCA aged 1-100 years were analysed. OUTCOME MEASURES The patients' 1-month survival rate, and favourable neurological outcome (defined as cerebral performance category 1-2) at 1-month. RESULTS Among 618,154 cases with OHCA, the risk-adjusted 1-month survival rate varied from 3.3% (95% CI 2.9% to 3.7%) to 8.4% (95% CI 7.7% to 9.1%) across prefectures. The risk-adjusted probabilities of favourable neurological outcome ranged from 1.6% (95% CI 1.4% to 1.9%) to 3.7% (95% CI 3.4% to 3.9%). Compared with prefectures with lowest tertile health expenditure, 1-month survival rate was significantly higher in medium-spending (adjusted OR 1.31, 95% CI 1.03 to 1.66, p=0.03) and high-spending prefectures (adjusted OR 1.30, 95% CI 1.03 to 1.64, p=0.02), after adjusting for patient characteristics. There was no difference in the survival between medium-spending and high-spending regions. We observed similar patterns for favourable neurological outcome. Additional adjustment for regional per capita income did not affect our overall findings. CONCLUSIONS We observed a wide variation in the health outcomes after OHCA across regions. Low-spending regions had significantly worse health outcomes compared with medium-spending or high-spending regions, but no difference was observed between medium-spending and high-spending regions. Our findings suggest that focusing on the median spending may be the optimum that allows for saving money without compromising patient outcomes.
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Affiliation(s)
- Yusuke Tsugawa
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Atsushi Hiraide
- Department of Acute Medicine, Kinki University Faculty of Medicine, Osaka, Japan
| | - Ashish K Jha
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, USA
- Harvard Global Health Institute, 42 Church Street, Cambridge, MA 02138
- Department of General Internal Medicine, Brigham and Women's Hospital and the Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
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Surgical rehospitalization of the medicare fee-for-service patient: a state-level analysis exploring 30-day readmission factors. Prof Case Manag 2015; 20:130-7; quiz 138-9. [PMID: 25838047 DOI: 10.1097/ncm.0000000000000081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF STUDY Surgical readmissions are a concern to the integrity of the Medicare Trust Fund and gaining attention from policymakers concerned about solvency. This study explores factors associated with variation in surgical readmission rates across the states and provides implications for Medicare Case Management. PRIMARY PRACTICE SETTING(S) Acute inpatient hospital settings. METHODOLOGY AND SAMPLE Fifty state-level data and multivariate regression analysis are used. The dependent variable Surgical Discharge 30-day Readmission Rate is based on the Medicare Fee-For-Service beneficiary population with Medicare Part A and B insurance coverage and age 65 years or older, rehospitalized subsequent to an inpatient surgical procedure, occurring within 30 days of their last discharge. RESULTS Our 2 key explanatory variables-emergency room visit rate and total days of care-are each positively associated with 30-day surgical readmission rate. Age group 65-69 years, native language, physician density, and health care expenditures per capita also influence surgical readmission rate across the states. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE Surgical readmission has an association with many different categories of variables-demographic, clinical process, hospital capacity, and patient need. This strongly suggests that Medicare case managers consider the wide range of elements contributing to surgical readmission and take a multifactorial approach to reducing the rehospitalization rate.
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Rosenbaum BP, Kshettry VR, Kelly ML, Weil RJ. Diagnoses associated with the greatest years of potential life lost for in-hospital deaths in the United States, 1988-2010. Public Health 2015; 129:173-81. [PMID: 25682904 DOI: 10.1016/j.puhe.2014.11.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 11/07/2014] [Accepted: 11/12/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Premature mortality is a public health concern that can be quantified as years of potential life lost (YPLL). Studying premature mortality from in-hospital mortality can help guide hospital initiatives and resource allocation. This paper identified the diagnosis categories associated with in-hospital deaths that account for the highest YPLL and their trends over time. STUDY DESIGN Retrospective review of the Nationwide Inpatient Sample (NIS), 1988-2010. METHODS Using the NIS, YPLL on patients hospitalized in the United States from 1988 to 2010 was calculated. Hospitalizations were categorized by related principal diagnoses using the Healthcare Cost and Utilization Project (HCUP) single-level Clinical Classification Software (CCS) definitions. RESULTS Between 1988 and 2010, total in-hospital estimated mortality of 20,154,186 people accounted for 198,417,257 YPLL (9.84 YPLL per in-hospital mortality; 8,626,837 estimated annual mean YPLL). The ten highest YPLL diagnosis categories accounted for 51% of the overall YPLL. The liveborn disease category (i.e., in-hospital live births) was the most common principal diagnosis and accounted for the highest YPLL at 1,070,053. The septicemia category accounted for the second highest YPLL at 548,922. The highest in-hospital mortality rate (20.8%) was associated with adult respiratory failure/insufficiency/arrest. The highest estimated in-hospital annual mean deaths occurred in patients with pneumonia at 69,134. For all in-hospital mortality, the inflation adjusted total in-hospital charges per YPLL was highest for acute myocardial infarction at $9292 per YPLL. CONCLUSIONS Using YPLL, a framework has been provided to compare the impact of premature in-hospital mortality from dissimilar diseases. The methodology and results may be used to help guide further investigation of hospital quality initiatives and resource allocation.
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Affiliation(s)
- B P Rosenbaum
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA.
| | - V R Kshettry
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - M L Kelly
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - R J Weil
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
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Nuckols TK. County-level variation in readmission rates: implications for the Hospital Readmission Reduction Program's potential to succeed. Health Serv Res 2015; 50:12-9. [PMID: 25630850 DOI: 10.1111/1475-6773.12268] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
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McWilliams JM, Dalton JB, Landrum MB, Frakt AB, Pizer SD, Keating NL. Geographic variation in cancer-related imaging: Veterans Affairs health care system versus Medicare. Ann Intern Med 2014; 161:794-802. [PMID: 25437407 PMCID: PMC4251705 DOI: 10.7326/m14-0650] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Geographic variations in use of medical services have been interpreted as indirect evidence of wasteful care. Less overuse of services, however, may not be reliably associated with less geographic variation. OBJECTIVE To compare average use and geographic variation in use of cancer-related imaging between fee-for-service Medicare and the Department of Veterans Affairs (VA) health care system. DESIGN Observational analysis of cancer-related imaging from 2003 to 2005 using Medicare and VA utilization data linked to cancer registry data. Multilevel models, adjusted for sociodemographic and tumor characteristics, were used to estimate mean differences in annual imaging use between cohorts of Medicare and VA patients within geographic areas and variation in use across areas for each cohort. SETTING 40 hospital referral regions. PATIENTS Older men with lung, colorectal, or prostate cancer, including 34,475 traditional Medicare beneficiaries (Medicare cohort) and 6835 VA patients (VA cohort). MEASUREMENTS Per-patient count of imaging studies for which lung, colorectal, or prostate cancer was the primary diagnosis (each study weighted by a standardized price), and a direct measure of overuse-advanced imaging for prostate cancer at low risk for metastasis. RESULTS Adjusted annual use of cancer-related imaging was lower in the VA cohort than in the Medicare cohort (price-weighted count, $197 vs. $379 per patient; P < 0.001), as was annual use of advanced imaging for prostate cancer at low risk for metastasis ($41 vs. $117 per patient; P < 0.001). Geographic variation in cancer-related imaging use was similar in magnitude in the VA and Medicare cohorts. LIMITATION Observational study design. CONCLUSION Use of cancer-related imaging was lower in the VA health care system than in fee-for-service Medicare, but lower use was not associated with less geographic variation. Geographic variation in service use may not be a reliable indicator of the extent of overuse. PRIMARY FUNDING SOURCE Doris Duke Charitable Foundation and Department of Veterans Affairs Office of Policy and Planning.
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Colla CH, Goodney PP, Lewis VA, Nallamothu BK, Gottlieb DJ, Meara E. Implementation of a pilot accountable care organization payment model and the use of discretionary and nondiscretionary cardiovascular care. Circulation 2014; 130:1954-61. [PMID: 25421044 DOI: 10.1161/circulationaha.114.011470] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Accountable care organizations (ACOs) seek to reduce growth in healthcare spending while ensuring high-quality care. We hypothesized that accountable care organization implementation would selectively limit the use of discretionary cardiovascular care (defined as care occurring in the absence of indications such as myocardial infarction or stroke), while maintaining high-quality care, such as nondiscretionary cardiovascular imaging and procedures. METHODS AND RESULTS The intervention group was composed of fee-for-service Medicare patients (n=819 779) from 10 groups participating in a Medicare pilot accountable care organization, the Physician Group Practice Demonstration (PGPD). Matched controls were patients (n=934 621) from nonparticipating groups in the same regions. We compared use of cardiovascular care before (2002-2004) and after (2005-2009) PGPD implementation, studying both discretionary and nondiscretionary carotid and coronary imaging and procedures. Our main outcome measure was the difference in the proportion of patients treated with imaging and procedures among patients of PGPD practices compared with patients in control practices, before and after PGPD implementation (difference-in-difference). For discretionary imaging, the difference-in-difference between PGPD practices and controls was not statistically significant for discretionary carotid imaging (0.17%; 95% confidence interval, -0.51% to 0.85%; P=0.595) or discretionary coronary imaging (-0.19%; 95% confidence interval, -0.73% to 0.35%; P=0.468). Similarly, the difference-in-difference was also minimal for discretionary carotid revascularization (0.003%; 95% confidence interval, -0.008% to 0.002%; P=0.705) and coronary revascularization (-0.02%; 95% confidence interval, -0.11% to 0.07%; P=0.06). The difference-in-difference associated with PGPD implementation was also essentially 0 for nondiscretionary cardiovascular imaging or procedures. CONCLUSION Implementation of a pilot accountable care organization did not limit the use of discretionary or nondiscretionary cardiovascular care in 10 large health systems.
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Affiliation(s)
- Carrie H Colla
- From Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH (C.H.C., P.P.G., V.A.L., D.J.G., and E.M.); Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (P.P.G.); Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI (B.K.N.); and National Bureau of Economic Research, Cambridge, MA (E.M.)
| | - Philip P Goodney
- From Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH (C.H.C., P.P.G., V.A.L., D.J.G., and E.M.); Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (P.P.G.); Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI (B.K.N.); and National Bureau of Economic Research, Cambridge, MA (E.M.).
| | - Valerie A Lewis
- From Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH (C.H.C., P.P.G., V.A.L., D.J.G., and E.M.); Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (P.P.G.); Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI (B.K.N.); and National Bureau of Economic Research, Cambridge, MA (E.M.)
| | - Brahmajee K Nallamothu
- From Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH (C.H.C., P.P.G., V.A.L., D.J.G., and E.M.); Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (P.P.G.); Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI (B.K.N.); and National Bureau of Economic Research, Cambridge, MA (E.M.)
| | - Daniel J Gottlieb
- From Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH (C.H.C., P.P.G., V.A.L., D.J.G., and E.M.); Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (P.P.G.); Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI (B.K.N.); and National Bureau of Economic Research, Cambridge, MA (E.M.)
| | - Ellen Meara
- From Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH (C.H.C., P.P.G., V.A.L., D.J.G., and E.M.); Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (P.P.G.); Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI (B.K.N.); and National Bureau of Economic Research, Cambridge, MA (E.M.)
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Hassett MJ, Neville BA, Weeks JC. The Relationship Between Quality, Spending, and Outcomes Among Women With Breast Cancer. ACTA ACUST UNITED AC 2014; 106:dju242. [DOI: 10.1093/jnci/dju242] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Chang TS, Huang KY, Chang CM, Lin CH, Su YC, Lee CC. The association of hospital spending intensity and cancer outcomes: a population-based study in an Asian country. Oncologist 2014; 19:990-8. [PMID: 25117067 DOI: 10.1634/theoncologist.2014-0013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Different results are reported for the relationship between regional variation in medical spending and disease prognosis for acute illness and for cancer. Our objective was to investigate the association between hospital medical care spending intensity and mortality rates in cancer patients. METHODS A total of 80,597 patients with incident cancer diagnosed in 2002 were identified from the National Health Insurance Research Database of Taiwan, Republic of China. The Cox proportional hazards model was used to compare the 5-year survival rates of patients treated at hospitals with different spending intensities after adjusting for possible confounding and risk factors. RESULTS After adjustment for patient characteristics, treatment modality, and hospital volume, an association was found between lower hospital spending intensity and poorer survival rates. The 5-year survival rate expressed by hazard ratios was 1.36 (95% confidence interval [CI]: 1.30-1.43, p < .001) for colorectal cancer, 1.18 (95% CI: 1.08-1.29, p < .001) for lung cancer, 1.13 (95% CI: 1.05-1.22, p = .002) for hepatoma, 1.16 (95% CI: 1.07-1.26, p < .001) for breast cancer, and 1.23 (95% CI: 1.10-1.39, p = .001) for prostate cancer. CONCLUSION Our preliminary findings indicate that higher hospital spending intensity was associated with lower mortality rates in patients being treated for lung cancer, breast cancer, colorectal cancer, prostate cancer, hepatoma, or head and neck cancer. The cancer stages were unavailable in this series, and more research linked with the primary data may be necessary to clearly address this issue.
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Affiliation(s)
- Ting-Shou Chang
- Department of Otolaryngology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China; National Defense Medical Center, Taipei, Taiwan, Republic of China; Institute of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan, Republic of China; Division of Rheumatology, Department of Internal Medicine, Department of Surgery, Department of Medical Research, Division of Hematology-Oncology, Department of Internal Medicine, Department of Otolaryngology, Center for Clinical Epidemiology and Biostatistics, and Cancer Center, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan, Republic of China; School of Medicine, Tzu Chi University, Hualian, Taiwan, Republic of China; Department of Life Science and Institute of Molecular Biology, National Chung Cheung University, Chiayi, Taiwan, Republic of China
| | - Kuang-Yung Huang
- Department of Otolaryngology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China; National Defense Medical Center, Taipei, Taiwan, Republic of China; Institute of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan, Republic of China; Division of Rheumatology, Department of Internal Medicine, Department of Surgery, Department of Medical Research, Division of Hematology-Oncology, Department of Internal Medicine, Department of Otolaryngology, Center for Clinical Epidemiology and Biostatistics, and Cancer Center, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan, Republic of China; School of Medicine, Tzu Chi University, Hualian, Taiwan, Republic of China; Department of Life Science and Institute of Molecular Biology, National Chung Cheung University, Chiayi, Taiwan, Republic of China
| | - Chun-Ming Chang
- Department of Otolaryngology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China; National Defense Medical Center, Taipei, Taiwan, Republic of China; Institute of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan, Republic of China; Division of Rheumatology, Department of Internal Medicine, Department of Surgery, Department of Medical Research, Division of Hematology-Oncology, Department of Internal Medicine, Department of Otolaryngology, Center for Clinical Epidemiology and Biostatistics, and Cancer Center, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan, Republic of China; School of Medicine, Tzu Chi University, Hualian, Taiwan, Republic of China; Department of Life Science and Institute of Molecular Biology, National Chung Cheung University, Chiayi, Taiwan, Republic of China
| | - Chun-Hsuan Lin
- Department of Otolaryngology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China; National Defense Medical Center, Taipei, Taiwan, Republic of China; Institute of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan, Republic of China; Division of Rheumatology, Department of Internal Medicine, Department of Surgery, Department of Medical Research, Division of Hematology-Oncology, Department of Internal Medicine, Department of Otolaryngology, Center for Clinical Epidemiology and Biostatistics, and Cancer Center, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan, Republic of China; School of Medicine, Tzu Chi University, Hualian, Taiwan, Republic of China; Department of Life Science and Institute of Molecular Biology, National Chung Cheung University, Chiayi, Taiwan, Republic of China
| | - Yu-Chieh Su
- Department of Otolaryngology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China; National Defense Medical Center, Taipei, Taiwan, Republic of China; Institute of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan, Republic of China; Division of Rheumatology, Department of Internal Medicine, Department of Surgery, Department of Medical Research, Division of Hematology-Oncology, Department of Internal Medicine, Department of Otolaryngology, Center for Clinical Epidemiology and Biostatistics, and Cancer Center, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan, Republic of China; School of Medicine, Tzu Chi University, Hualian, Taiwan, Republic of China; Department of Life Science and Institute of Molecular Biology, National Chung Cheung University, Chiayi, Taiwan, Republic of China
| | - Ching-Chih Lee
- Department of Otolaryngology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China; National Defense Medical Center, Taipei, Taiwan, Republic of China; Institute of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan, Republic of China; Division of Rheumatology, Department of Internal Medicine, Department of Surgery, Department of Medical Research, Division of Hematology-Oncology, Department of Internal Medicine, Department of Otolaryngology, Center for Clinical Epidemiology and Biostatistics, and Cancer Center, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan, Republic of China; School of Medicine, Tzu Chi University, Hualian, Taiwan, Republic of China; Department of Life Science and Institute of Molecular Biology, National Chung Cheung University, Chiayi, Taiwan, Republic of China
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Tak HJ, Hougham GW, Ruhnke A, Ruhnke GW. The effect of in-office waiting time on physician visit frequency among working-age adults. Soc Sci Med 2014; 118:43-51. [PMID: 25089963 DOI: 10.1016/j.socscimed.2014.07.053] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 07/16/2014] [Accepted: 07/23/2014] [Indexed: 10/25/2022]
Abstract
Disparities in unmet health care demand resulting from socioeconomic, racial, and financial factors have received a great deal of attention in the United States. However, out-of-pocket costs alone do not fully reflect the total opportunity cost that patients must consider as they seek medical attention. While there is an extensive literature on the price elasticity of demand for health care, empirical evidence regarding the effect of waiting time on utilization is sparse. Using the nationally representative 2003 Community Tracking Study Household Survey, the most recent iteration containing respondents' physician office visit frequency and estimated in-office waiting time in the United States (N = 23,484), we investigated the association between waiting time and calculated time cost with the number of physician visits among a sample of working-age adults. To avoid the bias that literature suggests would result from excluding respondents with zero physician visits, we imputed waiting time for the essential inclusion of such individuals. On average, respondents visited physician offices 3.55 times, during which time they waited 28.7 min. The estimates from a negative binomial model indicated that a doubling of waiting time was associated with a 7.7 percent decrease (p-value < 0.001) in physician visit frequency. For women and unemployed respondents, who visited physicians more frequently, the decrease was even larger, suggesting a stronger response to greater waiting times. We believe this finding reflects the discretionary nature of incremental visits in these groups, and a consequent lower perceived marginal benefit of additional visits. The results suggest that in-office waiting time may have a substantial influence on patients' propensity to seek medical attention. Although there is a belief that expansions in health insurance coverage increase health care utilization by reducing financial barriers to access, our results suggest that unintended consequences may arise if in-office waiting time increases.
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Affiliation(s)
- Hyo Jung Tak
- Department of Health Management and Policy, University of North Texas Health Science Center, 3500 Camp Bowie Boulevard, EAD 601R, Fort Worth, TX 76107, USA.
| | - Gavin W Hougham
- Section of Hospital Medicine, Department of Medicine, University of Chicago, 5841 South Maryland Avenue, MC 5000, Chicago, IL 60637, USA; The Center for Health and the Social Sciences, University of Chicago, 5841 South Maryland Avenue, MC 1000, Chicago, IL 60637, USA.
| | | | - Gregory W Ruhnke
- Section of Hospital Medicine, Department of Medicine, University of Chicago, 5841 South Maryland Avenue, MC 5000, Chicago, IL 60637, USA.
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Abstract
IMPORTANCE Despite the importance of identifying and reducing wasteful health care use, few direct measures of overuse have been developed. Direct measures are appealing because they identify specific services to limit and can characterize low-value care even among the most efficient providers. OBJECTIVES To develop claims-based measures of low-value services, examine service use (and associated spending) detected by these measures in Medicare, and determine whether patterns of use are related across different types of low-value services. DESIGN, SETTING, AND PARTICIPANTS Drawing from evidence-based lists of services that provide minimal clinical benefit, we developed 26 claims-based measures of low-value services. Using 2009 claims for 1,360,908 Medicare beneficiaries, we assessed the proportion of beneficiaries receiving these services, mean per-beneficiary service use, and the proportion of total spending devoted to these services. We compared the amount of use and spending detected by versions of these measures with different sensitivity and specificity. We also estimated correlations between use of different services within geographic areas, adjusting for beneficiaries' sociodemographic and clinical characteristics. MAIN OUTCOMES AND MEASURES Use and spending detected by 26 measures of low-value services in 6 categories: low-value cancer screening, low-value diagnostic and preventive testing, low-value preoperative testing, low-value imaging, low-value cardiovascular testing and procedures, and other low-value surgical procedures. RESULTS Services detected by more sensitive versions of measures affected 42% of beneficiaries and constituted 2.7% of overall annual spending. Services detected by more specific versions of measures affected 25% of beneficiaries and constituted 0.6% of overall spending. In adjusted analyses, low-value spending detected in geographic regions at the 5th percentile of the regional distribution of low-value spending ($227 per beneficiary) exceeded the difference in detected low-value spending between regions at the 5th and 95th percentiles ($189 per beneficiary). Adjusted regional use was positively correlated among 5 of 6 categories of low-value services (mean r for pairwise, between-category correlations, 0.33; range, 0.14-0.54; P ≤ .01). CONCLUSIONS AND RELEVANCE Services detected by a limited number of measures of low-value care constituted modest proportions of overall spending but affected substantial proportions of beneficiaries and may be reflective of overuse more broadly. Performance of claims-based measures in supporting targeted payment or coverage policies to reduce overuse may depend heavily on how the measures are defined.
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Affiliation(s)
- Aaron L Schwartz
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Bruce E Landon
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts2Division of General Internal Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Adam G Elshaug
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts3The Commonwealth Fund, New York, New York4Menzies Centre for Health Policy, The University of Sydney, Sydney, New South Wales, Australia5Lown Institute, Boston, Massachusetts
| | - Michael E Chernew
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - J Michael McWilliams
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts6Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Chen LM, Norton EC, Langa KM, Le S, Epstein AM. Geographic variation in out-of-pocket expenditures of elderly Medicare beneficiaries. J Am Geriatr Soc 2014; 62:1097-104. [PMID: 24852182 DOI: 10.1111/jgs.12834] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To examine whether out-of-pocket expenditures (OOPEs) exhibit the same geographic variation as Medicare claims, given wide variation in the costs of U.S. health care, but no information on how that translates into OOPEs or financial burden for older Americans. DESIGN Retrospective cohort study. SETTING Data from the Health and Retirement Study linked to Medicare claims. PARTICIPANTS A nationally representative cohort of 4,657 noninstitutionalized, community-dwelling, fee-for-service elderly Medicare beneficiaries interviewed in 2006 and 2008. MEASUREMENTS The primary predictor was per capita Medicare spending quintile according to hospital referral region. The primary outcome was a self-reported, validated measure of annual OOPEs excluding premiums. RESULTS Mean and median adjusted per capita Medicare payments were $5,916 and $2,635, respectively; mean and median adjusted OOPEs were $1,525 and $779, respectively. Adjusted median Medicare payments were $3,474 in the highest cost quintile and $1,942 in the lowest cost quintile (ratio 1.79, P < .001 for difference). In contrast, adjusted median OOPEs were not higher in the highest than in the lowest Medicare cost quintile ($795 vs $764 for a Q5:Q1 ratio of 1.04, P = .42). The Q5:Q1 ratio was 1.48 for adjusted mean Medicare payments and 1.04 for adjusted mean OOPEs (both P < .001). CONCLUSION Medicare payments vary widely between high- and low-cost regions, but OOPEs do not.
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Affiliation(s)
- Lena M Chen
- Division of General Medicine, Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
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Hadley J, Reschovsky JD, O’Malley JA, Landon BE. Factors associated with geographic variation in cost per episode of care for three medical conditions. HEALTH ECONOMICS REVIEW 2014; 4:8. [PMID: 24949281 PMCID: PMC4052668 DOI: 10.1186/s13561-014-0008-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 03/21/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To identify associations between market factors, especially relative reimbursement rates, and the probability of surgery and cost per episode for three medical conditions (cataract, benign prostatic neoplasm, and knee degeneration) with multiple treatment options. METHODS We use 2004-2006 Medicare claims data for elderly beneficiaries from sixty nationally representative communities to estimate multivariate models for the probability of surgery and cost per episode of care as a function local market factors, including Medicare physician reimbursement for surgical versus non-surgical treatment and the availability of primary care and specialty physicians. We used Symmetry's Episode Treatment Groups (ETG) software to group claims into episodes for the three conditions (n = 540,874 episodes). RESULTS Higher Medicare reimbursement for surgical episodes and greater availability of the relevant specialists are significantly associated with more surgery and higher cost per episode for all three conditions, while greater availability of primary care physicians is significantly associated with less frequent surgery and lower cost per episode. CONCLUSION Relative Medicare reimbursement rates for surgical vs. non-surgical treatments and the availability of both primary care physicians and relevant specialists are associated with the likelihood of surgery and cost per episode.
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Affiliation(s)
- Jack Hadley
- Department of Health Administration and Policy, George Mason University, 4400 University Drive, MS 2G7 Fairfax, VA 22030, USA
| | - James D Reschovsky
- Mathematica Policy Research, 1100 1st Street, NE, 12th Floor, Washington, DC 20002-4221, USA
| | - James A O’Malley
- The Dartmouth Institute and Geisel Medical School at Dartmouth, Dartmouth University, Lebanon, NH 03766, USA
| | - Bruce E Landon
- Department of Health Care Policy, Harvard University School of Medicine, 180 Longwood Avenue, Boston, Massachusetts 02115, USA
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Hassett MJ, Elkin EB. What does breast cancer treatment cost and what is it worth? Hematol Oncol Clin North Am 2014; 27:829-41, ix. [PMID: 23915747 DOI: 10.1016/j.hoc.2013.05.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The costs of breast cancer care are substantial and growing, and they extend across the spectrum of care. Medical therapies and hospitalizations account for a significant proportion of these costs. Cost-effectiveness analysis (CEA) is the preferred method for assessing the health benefits of medical interventions relative to their costs. Although many CEAs have been conducted for a wide range of breast cancer treatments, these analyses are not used routinely to guide coverage or utilization decisions in the United States. Currently, patients and providers may not consider costs when making most treatment decisions; this is likely to change as payment reform spreads.
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Affiliation(s)
- Michael J Hassett
- Department of Medicine, Harvard Medical School, 250 Longwood Avenue, Boston, MA 02115, USA.
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Brooks GA, Li L, Sharma DB, Weeks JC, Hassett MJ, Yabroff KR, Schrag D. Regional variation in spending and survival for older adults with advanced cancer. J Natl Cancer Inst 2013; 105:634-42. [PMID: 23482657 DOI: 10.1093/jnci/djt025] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Medicare spending varies substantially across the United States. We evaluated the association between mean regional spending and survival in advanced cancer. METHODS We identified 116 523 subjects with advanced cancer from 2002 to 2007, using Surveillance, Epidemiology and End Results (SEER)-Medicare linked data. Subjects were aged 65 years and older with non-small cell lung, colon, breast, prostate, or pancreas cancer. Of these subjects, 61 083 had incident advanced-stage cancer (incident cohort) and 98 935 had death from cancer (decedent cohort); 37% of subjects were included in both cohorts. Subjects were linked to one of 80 hospital referral regions within SEER areas. We estimated mean regional spending in both cohorts. We assessed the primary outcome, survival, in the incident cohort; the exposure measure was the quintile of regional spending in the decedent cohort. Survival in quintiles 2 through 5 was compared with that in quintile 1 (lowest spending quintile) using Cox regression models. RESULTS From quintile 1 to 5, mean regional spending increased by 32% and 41% in the incident and decedent cohorts (incident cohort: $28 854 to $37 971; decedent cohort: $27 446 to $38 630). The association between spending and survival varied by cancer site and quintile; hazard ratios ranged from 0.92 (95% confidence interval [CI] = 0.82 to 1.04, pancreas cancer quintile 5) to 1.24 (95% CI = 1.11 to 1.39, breast cancer quintile 3). In most cases, differences in survival between quintile 1 and quintiles 2 through 5 were not statistically significant. CONCLUSION There is substantial regional variation in Medicare spending for advanced cancer, yet no consistent association between mean regional spending and survival.
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Affiliation(s)
- Gabriel A Brooks
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA.
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Geographic variation of chronic opioid use in fibromyalgia. Clin Ther 2013; 35:303-11. [PMID: 23485077 DOI: 10.1016/j.clinthera.2013.02.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Revised: 02/01/2013] [Accepted: 02/05/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND Opioid use for the treatment of chronic nonmalignant pain has increased drastically over the past decade. Although no evidence of efficacy exists supporting the treatment of fibromyalgia (FM) with chronic opioid therapy, a large number of patients are receiving this therapy. Geographic variation in the use of opioids has been demonstrated in the past, but there are no studies examining variation of chronic opioid use. OBJECTIVE This study examines both the extent of geographic variation and the factors associated with variation across states of chronic opioid use among patients with FM. METHODS Using a large, nationally representative dataset of commercially insured individuals, the following characteristics were examined: sex, disease prevalence, physician prevalence, illicit drug use, and the prescence of a prescription monitoring program. Other contextual and structural characteristics were also assessed. RESULTS The analysis included 245,758 patients with FM; 11.3% received chronic opioid therapy during the study period. There was a 5-fold difference between the states with the lowest rate of use (~4%) and those with the highest (~20%). The weighted %CV was 36.2%. Percent female and previous illicit opioid use rates were associated with higher rates of chronic opioid use, and FM prevalence and physician prevalence were associated with lower rates. The presence of a prescription monitoring program was not significantly correlated. CONCLUSIONS Geographic variation in chronic opioid use among patients with FM exists at rates similar to those seen in other studies examining opioid use. This large level of geographic variation suggests that the prescribing decision is not based solely on physician-patient interaction but also on contextual and structural factors at the state level. The level of physician and condition prevalence suggest that information dissemination and peer-to-peer interaction may play a key role in adopting evidence-based medicine for the treatment of patients suffering from FM and related conditions. Level of diagnosis prevalence as a predictor of evidence-based practice has not been reported in the literature and is an important contribution to research on geographic variation.
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Abstract
BACKGROUND Although there is broad policy consensus that both cost containment and quality improvement are critical, the association between costs and quality is poorly understood. PURPOSE To systematically review evidence of the association between health care quality and cost. DATA SOURCES Electronic literature search of PubMed, EconLit, and EMBASE databases for U.S.-based studies published between 1990 and 2012. STUDY SELECTION Title, abstract, and full-text review to identify relevant studies. DATA EXTRACTION Two reviewers independently abstracted data with differences reconciled by consensus. Studies were categorized by level of analysis, type of quality measure, type of cost measure, and method of addressing confounders. DATA SYNTHESIS Of 61 included studies, 21 (34%) reported a positive or mixed-positive association (higher cost associated with higher quality); 18 (30%) reported a negative or mixed-negative association; and 22 (36%) reported no difference, an imprecise or indeterminate association, or a mixed association. The associations were of low to moderate clinical significance in many studies. Of 9 studies using instrumental variables analysis to address confounding by unobserved patient health status, 7 (78%) reported a positive association, but other characteristics of these studies may have affected their findings. LIMITATIONS Studies used widely heterogeneous methods and measures. The review is limited by the quality of underlying studies. CONCLUSION Evidence of the direction of association between health care cost and quality is inconsistent. Most studies have found that the association between cost and quality is small to moderate, regardless of whether the direction is positive or negative. Future studies should focus on what types of spending are most effective in improving quality and what types of spending represent waste. PRIMARY FUNDING SOURCE Robert Wood Johnson Foundation.
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Makarov DV, Desai R, Yu JB, Sharma R, Abraham N, Albertsen PC, Krumholz HM, Penson DF, Gross CP. Appropriate and inappropriate imaging rates for prostate cancer go hand in hand by region, as if set by thermostat. Health Aff (Millwood) 2012; 31:730-40. [PMID: 22492890 DOI: 10.1377/hlthaff.2011.0336] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Policy makers interested in containing health care costs are targeting regional variation in utilization, including the use of advanced imaging. However, bluntly decreasing utilization among the highest-utilization regions may have negative consequences. In a cross-sectional study of prostate cancer patients from 2004 to 2005, we found that regions with lower rates of inappropriate imaging also had lower rates of appropriate imaging. Similarly, regions with higher overall imaging rates tended to have not only higher rates of inappropriate imaging, but also higher rates of appropriate imaging. In fact, men with high-risk prostate cancer were more likely to receive appropriate imaging if they resided in areas with higher rates of inappropriate imaging. This "thermostat model" of regional health care utilization suggests that poorly designed policies aimed at reducing inappropriate imaging could limit access to appropriate imaging for high-risk patients. Health care organizations need clearly defined quality metrics and supportive systems to encourage appropriate treatment for patients and to ensure that cost containment does not occur at the expense of quality.
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The relationship between geographic variations and overuse of healthcare services: a systematic review. Med Care 2012; 50:257-61. [PMID: 22329997 DOI: 10.1097/mlr.0b013e3182422b0f] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the relationship between overuse of healthcare services and geographic variations in medical care. DESIGN Systematic Review. DATA SOURCES Articles published in Medline between 1978, the year of publication of the first framework to measure quality, and January 1, 2009. STUDY SELECTION Four investigators screened 114,830 titles and 2 investigators screened all selected abstracts and articles for possible inclusion and extracted all data. DATA EXTRACTION We extracted data on rates of overuse in different geographic areas. We also extracted data on underuse, if available, for the same population in which overuse was measured. RESULTS Five papers examined the relationship between geographic variations and overuse of healthcare services. One study in 2008 compared the appropriateness of coronary angiography (CA) for acute myocardial infarction in high-cost areas versus low cost areas in the Medicare population and found largely similar rates of inappropriateness (12.2% vs. 16.2%). A study in 2000 using national data concluded that overuse of CA explained little of the geographic variations in the use of this procedure in the Medicare program. An older study of Medicare patients found similar rates of inappropriate use of CA (15% to 17% vs. 18%), endoscopy (15% vs. 18% 19%), and carotid endarterectomy (29% vs. 30%) in low-use and high-use regions. A small area reanalysis of data from this study of 3 procedures found no evidence of a relationship between inappropriate use of procedures and volume in 23 adjacent counties of California. Another 2008 study found that inappropriate chemotherapy for stage I cancer was less common in low-cost areas compared with high-cost areas (3.1% vs. 6.3%). CONCLUSIONS The limited available evidence does not lend support to the hypothesis that inappropriate use of procedures is a major source of geographic variations in intensity and/or costs of care. More research is needed to improve our understanding of the relationship between geographic variations and the quality of care.
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Stukel TA, Fisher ES, Alter DA, Guttmann A, Ko DT, Fung K, Wodchis WP, Baxter NN, Earle CC, Lee DS. Association of hospital spending intensity with mortality and readmission rates in Ontario hospitals. JAMA 2012; 307:1037-45. [PMID: 22416099 PMCID: PMC3339410 DOI: 10.1001/jama.2012.265] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
CONTEXT The extent to which better spending produces higher-quality care and better patient outcomes in a universal health care system with selective access to medical technology is unknown. OBJECTIVE To assess whether acute care patients admitted to higher-spending hospitals have lower mortality and readmissions. DESIGN, SETTING, AND PATIENTS The study population comprised adults (>18 years) in Ontario, Canada, with a first admission for acute myocardial infarction (AMI) (n = 179,139), congestive heart failure (CHF) (n = 92,377), hip fracture (n = 90,046), or colon cancer (n = 26,195) during 1998-2008, with follow-up to 1 year. The exposure measure was the index hospital's end-of-life expenditure index for hospital, physician, and emergency department services. MAIN OUTCOME MEASURES The primary outcomes were 30-day and 1-year mortality and readmissions and major cardiac events (readmissions for AMI, angina, CHF, or death) for AMI and CHF. RESULTS Patients' baseline health status was similar across hospital expenditure groups. Patients admitted to hospitals in the highest- vs lowest-spending intensity terciles had lower rates of all adverse outcomes. In the highest- vs lowest-spending hospitals, respectively, the age- and sex-adjusted 30-day mortality rate was 12.7% vs 12.8% for AMI, 10.2% vs 12.4% for CHF, 7.7% vs 9.7% for hip fracture, and 3.3% vs 3.9% for CHF; fully adjusted relative 30-day mortality rates were 0.93 (95% CI, 0.89-0.98) for AMI, 0.81 (95% CI, 0.76-0.86) for CHF, 0.74 (95% CI, 0.68-0.80) for hip fracture, and 0.78 (95% CI, 0.66-0.91) for colon cancer. Results for 1-year mortality, readmissions, and major cardiac events were similar. Higher-spending hospitals had higher nursing staff ratios, and their patients received more inpatient medical specialist visits, interventional (AMI cohort) and medical (AMI and CHF cohorts) cardiac therapies, preoperative specialty care (colon cancer cohort), and postdischarge collaborative care with a cardiologist and primary care physician (AMI and CHF cohorts). CONCLUSION Among Ontario hospitals, higher spending intensity was associated with lower mortality, readmissions, and cardiac event rates.
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Affiliation(s)
- Therese A Stukel
- Institute for Clinical Evaluative Sciences, G106-2075 Bayview Ave, Toronto, ON M4N 3M5, Canada.
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Medicare spending, mortality rates, and quality of care. ACTA ACUST UNITED AC 2012; 12:87-105. [PMID: 22399369 DOI: 10.1007/s10754-012-9107-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Accepted: 02/21/2012] [Indexed: 10/28/2022]
Abstract
We applied instrumental variable analysis to a sample of 388,690 Medicare beneficiaries predicted to be high-cost cases to estimate the effects of medical care use on the relative odds of death or experiencing an avoidable hospitalization in 2006. Contrary to conclusions from the observational geographic variations literature, the results suggest that greater medical care use is associated with statistically significant and quantitatively meaningful health improvements: a 10% increase in medical care use is associated with a 8.4% decrease in the mortality rate and a 3.8% decrease in the rate of avoidable hospitalizations.
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Sirovich BE, Woloshin S, Schwartz LM. Too Little? Too Much? Primary care physicians' views on US health care: a brief report. ACTA ACUST UNITED AC 2011; 171:1582-5. [PMID: 21949169 DOI: 10.1001/archinternmed.2011.437] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Some believe that a substantial amount of US health care is unnecessary, suggesting that it would be possible to control costs without rationing effective services. The views of primary care physicians-the frontline of health care delivery-are not known. METHODS Between June and December 2009, we conducted a nationally representative mail survey of US primary care physicians (general internal medicine and family practice) randomly selected from the American Medical Association Physician Masterfile (response rate, 70%; n=627). RESULTS Forty-two percent of US primary care physicians believe that patients in their own practice are receiving too much care; only 6% said they were receiving too little. The most important factors physicians identified as leading them to practice more aggressively were malpractice concerns (76%), clinical performance measures (52%), and inadequate time to spend with patients (40%). Physicians also believe that financial incentives encourage aggressive practice: 62% said diagnostic testing would be reduced if it did not generate revenue for medical subspecialists (39% for primary care physicians). Almost all physicians (95%) believe that physicians vary in what they would do for identical patients; 76% are interested in learning how aggressive or conservative their own practice style is compared with that of other physicians in their community. CONCLUSIONS Many US primary care physicians believe that their own patients are receiving too much medical care. Malpractice reform, realignment of financial incentives, and more time with patients could remove pressure on physicians to do more than they feel is needed. Physicians are interested in feedback on their practice style, suggesting they may be receptive to change. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00853918.
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Affiliation(s)
- Brenda E Sirovich
- VA Outcomes Group, 111B, Veterans Affairs Medical Center, 215 N Main St, White River Junction, VT 05009, USA.
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Jennings B, Morrissey MB. Health care costs in end-of-life and palliative care: the quest for ethical reform. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2011; 7:300-317. [PMID: 22150176 DOI: 10.1080/15524256.2011.623458] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Health reform in the United States must address both access to medical services and universal insurance coverage, as well as health care cost containment. Uncontrolled health care costs will undermine improvements in access and coverage in the long-run, and will also be detrimental to other important social programs and goals. Accordingly, the authors offer an ethical perspective on health care cost control in the context of end-of-life and palliative care, an area considered by many to be a principal candidate for cost containment. However, the policy and ethical challenges may be more difficult in end-of-life care than in other areas of medicine. Here we discuss barriers to developing high quality, cost effective, and beneficial end-of-life care, and barriers to maintaining a system of decision making that respects the wishes and values of dying patients, their families, and caregivers. The authors also consider improvements in present policy and practice-such as increased timely access and referral to hospice and palliative care; improved organizational incentives and cultural attitudes to reduce the use of ineffective treatments; and improved communication among health professionals, patients, and families in the end-of-life care planning and decision-making process.
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Affiliation(s)
- Bruce Jennings
- Center for Humans and Nature, Dobbs Ferry, New York 10522, USA.
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Causes and Consequences of Regional Variations in Health Care11This chapter was written for the Handbook of Health Economics (Vol. 2). My greatest debt is to John E. Wennberg for introducing me to the study of regional variations. I am also grateful to Handbook authors Elliott Fisher, Joseph Newhouse, Douglas Staiger, Amitabh Chandra, and especially Mark Pauly for insightful comments, and to the National Institute on Aging (PO1 AG19783) for financial support. HANDBOOK OF HEALTH ECONOMICS 2011. [DOI: 10.1016/b978-0-444-53592-4.00002-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
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Affiliation(s)
- Milton C Weinstein
- Department of Health Policy and Management, Harvard School of Public Health, Boston, USA
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Quality of End‐of‐Life Care Between Medical Oncologists and Other Physician Specialists for Taiwanese Cancer Decedents, 2001–2006. Oncologist 2009; 14:1232-41. [DOI: 10.1634/theoncologist.2009-0095] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Webster BS, Cifuentes M, Verma S, Pransky G. Geographic variation in opioid prescribing for acute, work-related, low back pain and associated factors: a multilevel analysis. Am J Ind Med 2009; 52:162-71. [PMID: 19016267 DOI: 10.1002/ajim.20655] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Given reports about variation in opioid prescribing, concerns about increasing opioid use and its associated negative consequences make understanding the sources of variability important. The aims of the study were to assess the extent of and factors associated with geographic variation in early opioid prescribing for acute, work-related, low back pain (LBP). METHODS Cases were selected from workers compensation administrative data filed between January 1, 2002 and December 31, 2003 and included claims from states with more than 40 cases. Early opioid prescribing (one or more prescriptions within first 15 days) was the outcome. Weighted coefficient of variation (wCOV) estimated geographic variation, and multilevel models measured variability controlling for individual and contextual factors. RESULTS Of the 8,262 claimants, 21.3% received at least one early opioid prescription. Significant between-state variation was found (wCOV = 53%), from 5.7% (Massachusetts) to 52.9% (South Carolina). Seventy-nine percent of the between-state variation was explained by three contextual factors: state household income inequality (prevalence ratio [PR] 1.06, 95% confidence interval [CI] = 1.01, 1.12), number of physicians per capita (PR 0.99, 95% CI = 0.98, 0.99), and workers compensation cost containment effort score (PR 1.12, 95% CI = 1.02, 1.24). Individual-level factors, including severity, explained only a small portion of the geographic variability. CONCLUSION Geographic variation of early opioid prescribing for acute LBP is important and almost fully explained by state-level contextual factors. The study suggests that clinician and patient interaction and the subsequent decision to use opioids are substantially framed by social conditions and control systems. Am. J. Ind. Med. 52:162-171, 2009. (c) 2008 Wiley-Liss, Inc.
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Affiliation(s)
- Barbara S Webster
- Liberty Mutual Research Institute for Safety, Center for Disability Research, Hopkinton, Massachusetts, USA.
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Fowler FJ, Gallagher PM, Anthony DL, Larsen K, Skinner JS. Relationship between regional per capita Medicare expenditures and patient perceptions of quality of care. JAMA 2008; 299:2406-12. [PMID: 18505950 PMCID: PMC2438036 DOI: 10.1001/jama.299.20.2406] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Wide variations in Medicare expenditures exist across regions, but little is known about whether beneficiaries residing in low-expenditure regions perceive receiving lower-quality care than those in high-expenditure regions. OBJECTIVE To evaluate how Medicare beneficiaries' perceptions of their health care are related to per capita expenditure in the areas where they live. DESIGN, SETTING, AND RESPONDENTS: A probability sample of Medicare beneficiaries living in households in the United States was surveyed by a combination of mail and telephone in 2005. Each respondent was allocated to 1 of 5 quintiles, depending on mean age-, sex-, and race-adjusted per capita Medicare expenditures based on Centers for Medicare & Medicaid Services claims data. MAIN OUTCOME MEASURES The survey included 3 questions about perceived unmet need for care, 4 questions about the perceived quality of ambulatory care, and 3 questions rating the perceived quality of overall care. RESULTS Of 4000 Medicare beneficiaries sampled, 160 (4%) were ascertained to have died or to be living in a long-term care facility. Of the remaining 3840 potentially eligible beneficiaries, 2515 (65%) responded. Per capita expenditures were highly related to receiving more medical care, such as mean number of ambulatory visits to physicians in the past year (range from lowest to highest expenditure quintile, 3.4-3.9; P < .001 for linear trend) and more cardiac tests (respondents reporting receiving tests in past year, 158/387 [40.1%] to 468/739 [63.5%]; P < .001 for linear trend). However, 7 of the 10 measures of perceived quality, including perceived unmet needs for tests and treatment (respondents reporting unmet needs, 15/387 [3.9%] to 37/739 [5.0%]; P = .25 for linear trend) and spending enough time with physicians (respondents reporting adequate time, 311/387 [88.7%] to 603/739 [87.0%]; P = .94 for linear trend), were unrelated to expenditures, while the overall rating of perceived quality of care was higher in the lower-expenditure areas (respondents reporting overall care rating of 9 or 10, 242/387 [63.3%] to 404/739 [55.4%]; P = .008 for linear trend). CONCLUSION In this representative sample of Medicare beneficiaries, no consistent association was observed between the mean per capita expenditure in a geographic area and the perceptions of the quality of medical care of the people who live in those areas.
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Affiliation(s)
- Floyd J Fowler
- Center for Survey Research, University of Massachusetts Boston, Boston, MA 02125, USA.
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