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Sacks GD, Dawes AJ, Tsugawa Y, Brook RH, Russell MM, Ko CY, Maggard-Gibbons M, Ettner SL. The Association Between Risk Aversion of Surgeons and Their Clinical Decision-Making. J Surg Res 2021; 268:232-243. [PMID: 34371282 DOI: 10.1016/j.jss.2021.06.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/02/2021] [Accepted: 06/10/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The extent to which a surgeon's risk aversion influences their clinical decisions remains unknown. We assessed whether a surgeon's attitude toward risk ("risk aversion") influences their surgical decisions and whether the relationship can be explained by differences in surgeons' perception of treatment risks and benefits. MATERIALS AND METHODS We presented a series of detailed clinical vignettes to a national sample of surgeons (n = 1,769; 13.4% adjusted response rate) and asked them to complete an instrument that measured how risk averse they are within their clinical practice (scale 6-36; higher number indicates greater risk aversion). For each vignette, participants rated their likelihood of recommending an operation and judged the likelihood of complications or full recovery. We examined whether differences in perceived likelihood of complications versus recovery could explain why risk-averse surgeons may be less likely to recommend an operation. RESULTS Surgeons varied in their self-reported risk aversion score (median = 25, interquartile range[22,28]). Scores did not differ by level of surgeon experience or gender. Risk-averse surgeons were significantly less likely to recommend an operation for patients with exactly the same condition (65.5% for surgeons in highest quartile of risk aversion versus 62.3% for lowest quartile; P = 0.02). However, after controlling for surgeons' perception of the likelihood of complications versus recovery, there was no longer a significant association between surgeons' risk aversion and the decision to recommend an operation (64.7% versus 64.8%; P = 0.96). CONCLUSIONS Surgeons vary widely in their self-reported risk aversion. Risk-averse surgeons were significantly less likely to recommend an operation, a finding that was explained by a higher perceived probability of post-operative complications than their colleagues.
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Affiliation(s)
- Greg D Sacks
- Department of Surgery, NYU Langone Health, New York, New York.
| | - Aaron J Dawes
- S-SPIRE Center and Department of Surgery, Stanford University, Stanford, California
| | - Yusuke Tsugawa
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Robert H Brook
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California; RAND Corporation, Los Angeles, California
| | - Marcia M Russell
- Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California; VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Clifford Y Ko
- Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California; VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Melinda Maggard-Gibbons
- Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California; VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Susan L Ettner
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California
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Patel AA, Ryan GW, Tisnado D, Chuang E, Walling AM, Saab S, Khemichian S, Sundaram V, Brook RH, Wenger NS. Deficits in Advance Care Planning for Patients With Decompensated Cirrhosis at Liver Transplant Centers. JAMA Intern Med 2021; 181:652-660. [PMID: 33720273 PMCID: PMC7961470 DOI: 10.1001/jamainternmed.2021.0152] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
IMPORTANCE The burden of end-of-life care for patients with cirrhosis is increasing in the US, and most of these patients, many of whom are not candidates for liver transplant, die in institutions receiving aggressive care. Advance care planning (ACP) has been associated with improved end-of-life outcomes for patients with other chronic illnesses, but it has not been well-characterized in patients with decompensated cirrhosis. OBJECTIVE To describe the experience of ACP in patients with decompensated cirrhosis at liver transplant centers. DESIGN, SETTING, AND PARTICIPANTS For this multicenter qualitative study, face-to-face semistructured interviews were conducted between July 1, 2017, and May 30, 2018, with clinicians and patients with decompensated cirrhosis at 3 high-volume transplant centers in California. Patient participants were adults and had a diagnosis of cirrhosis, at least 1 portal hypertension-related complication, and current or previous Model for End-Stage Liver Disease with sodium score of 15 or higher. Clinician participants were health care professionals who provided care during the illness trajectory. MAIN OUTCOMES AND MEASURES Experiences with ACP reported by patients and clinicians. Participants were asked about the context, behaviors, thoughts, and decisions concerning elements of ACP, such as prognosis, health care preferences, values and goals, surrogate decision-making, and documentation. RESULTS The study included 42 patients (mean [SD] age, 58.2 [11.2] years; 28 men [67%]) and 46 clinicians (13 hepatologists [28%], 11 transplant coordinators [24%], 9 hepatobiliary surgeons [20%], 6 social workers [13%], 5 hepatology nurse practitioners [11%], and 2 critical care physicians [4%]). Five themes that represent the experiences of ACP were identified: (1) most patient consideration of values, goals, and preferences occurred outside outpatient visits; (2) optimistic attitudes from transplant teams hindered the discussions about dying; (3) clinicians primarily discussed death as a strategy for encouraging behavioral change; (4) transplant teams avoided discussing nonaggressive treatment options with patients; and (5) surrogate decision makers were unprepared for end-of-life decision-making. CONCLUSIONS AND RELEVANCE This study found that, despite a guarded prognosis, patients with decompensated cirrhosis had inadequate ACP throughout the trajectory of illness until the end of life. This finding may explain excessively aggressive life-sustaining treatment that patients receive at the end of life.
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Affiliation(s)
- Arpan Arun Patel
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles (UCLA), Los Angeles.,Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Gery W Ryan
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Diana Tisnado
- Department of Public Health, California State University, Fullerton
| | - Emmeline Chuang
- School of Social Welfare, University of California, Berkeley, Berkeley.,Department of Health Policy and Management, UCLA Fielding School of Public Health
| | - Anne M Walling
- Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California.,Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA
| | - Sammy Saab
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles (UCLA), Los Angeles.,Division of Liver Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA
| | - Saro Khemichian
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine of University of Southern California, Los Angeles
| | - Vinay Sundaram
- Karsh Division of Gastroenterology and Comprehensive Transplant Center, Cedars Sinai Medical Center, Los Angeles, California
| | - Robert H Brook
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA.,RAND Health Care, Santa Monica, California
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA
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Abstract
OBJECTIVES To determine the public health surveillance severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing volume needed, both for acute infection and seroprevalence. METHODS Required testing volumes were developed using standard statistical methods based on test analytical performance, disease prevalence, desired precision, and population size. RESULTS Widespread testing for individual health management cannot address surveillance needs. The number of people who must be sampled for public health surveillance and decision making, although not trivial, is potentially in the thousands for any given population or subpopulation, not millions. CONCLUSIONS While the contributions of diagnostic testing for SARS-CoV-2 have received considerable attention, concerns abound regarding the availability of sufficient testing capacity to meet demand. Different testing goals require different numbers of tests and different testing strategies; testing strategies for national or local disease surveillance, including monitoring of prevalence, receive less attention. Our clinical laboratory and diagnostic infrastructure are capable of incorporating required volumes for many local, regional, and national public health surveillance studies into their current and projected testing capacity. However, testing for surveillance requires careful design and randomization to provide meaningful insights.
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Affiliation(s)
- Lee H Hilborne
- RAND Corporation, Santa Monica, CA
- Department of Pathology and Laboratory Medicine
- Department of Quest Diagnostics, Secaucus, NJ
| | - Zachary Wagner
- RAND Corporation, Santa Monica, CA
- Department of Pardee RAND Graduate School, Santa Monica, CA
| | | | - Robert H Brook
- RAND Corporation, Santa Monica, CA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
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Brook RH, Wang CJ, Wenger NS. How Community and Unity Can Help Americans Survive. J Gen Intern Med 2020; 35:1879-1880. [PMID: 32291724 PMCID: PMC7155156 DOI: 10.1007/s11606-020-05829-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 03/25/2020] [Accepted: 03/26/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Robert H Brook
- Health Care Services, RAND Corporation, Santa Monica, CA, USA. .,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
| | - C Jason Wang
- Departments of Pediatrics and Medicine, Stanford University, Stanford, CA, USA.,Center for Policy Outcomes and Prevention, Stanford University, Stanford, CA, USA
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Baghdadi JD, Brook RH, Uslan DZ, Needleman J, Bell DS, Cunningham WE, Wong MD. Association of a Care Bundle for Early Sepsis Management With Mortality Among Patients With Hospital-Onset or Community-Onset Sepsis. JAMA Intern Med 2020; 180:707-716. [PMID: 32250412 PMCID: PMC7136852 DOI: 10.1001/jamainternmed.2020.0183] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE The Early Management Bundle for Severe Sepsis/Septic Shock (SEP-1) is a quality metric based on a care bundle for early sepsis management. Published evidence on the association of SEP-1 with mortality is mixed and largely excludes cases of hospital-onset sepsis. OBJECTIVE To assess the association of the SEP-1 bundle with mortality and organ dysfunction in cohorts with hospital-onset or community-onset sepsis. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used data from 4 University of California hospitals from October 1, 2014, to October 1, 2017. Adult inpatients with a diagnosis consistent with sepsis or disseminated infection and laboratory or vital signs meeting the Sepsis-3 (Third International Consensus Definitions for Sepsis and Septic Shock) criteria were divided into community-onset sepsis and hospital-onset sepsis cohorts based on whether time 0 of sepsis occurred after arrival in the emergency department or an inpatient area. Data were analyzed from April to October 2019. Additional analyses were performed from December 2019 to January 2020. EXPOSURES Administration of SEP-1 and 4 individual bundle components (serum lactate level testing, blood culture, broad-spectrum intravenous antibiotic treatment, and intravenous fluid treatment). MAIN OUTCOMES AND MEASURES The primary outcome was in-hospital mortality. The secondary outcome was days requiring vasopressor support, measured as vasopressor days. RESULTS Among the 6404 patient encounters identified (3535 men [55.2%]; mean [SD] age, 64.0 [18.2] years), 2296 patients (35.9%) had hospital-onset sepsis. Among 4108 patients (64.1%) with community-onset sepsis, serum lactate level testing within 3 hours of time 0 was associated with reduced mortality (absolute difference, -7.61%; 95% CI, -14.70% to -0.54%). Blood culture (absolute difference, -1.10 days; 95% CI, -1.85 to -0.34 days) and broad-spectrum intravenous antibiotic treatment (absolute difference, -0.62 days; 95% CI, -1.02 to -0.22 days) were associated with fewer vasopressor days. Among patients with hospital-onset sepsis, broad-spectrum intravenous antibiotic treatment was the only bundle component significantly associated with any improved outcome (mortality difference, -5.20%; 95% CI, -9.84% to -0.56%). Care that was adherent to the complete SEP-1 bundle was associated with increased vasopressor days in patients with community-onset sepsis (absolute difference, 0.31 days; 95% CI, 0.11-0.51 days) but was not significantly associated with reduced mortality in either cohort (absolute difference, -0.07%; 95% CI, -3.02% to 2.88% in community-onset; absolute difference, -0.42%; 95% CI, -6.77% to 5.93% in hospital-onset). CONCLUSIONS AND RELEVANCE SEP-1-adherent care was not associated with improved outcomes of sepsis. Although multiple components of SEP-1 were associated with reduced mortality or decreased days of vasopressor therapy for patients who presented with sepsis in the emergency department, only broad-spectrum intravenous antibiotic treatment was associated with reduced mortality when time 0 occurred in an inpatient unit. Current sepsis quality metrics may need refinement.
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Affiliation(s)
- Jonathan D Baghdadi
- Department of Epidemiology and Public Health, University of Maryland, Baltimore
| | - Robert H Brook
- RAND Corporation, Santa Monica, California.,David Geffen School of Medicine, UCLA (University of California, Los Angeles)
| | | | - Jack Needleman
- Department of Health Policy and Management, Fielding School of Public Health, UCLA
| | | | - William E Cunningham
- Department of Health Policy and Management, Fielding School of Public Health, UCLA.,Division of General Internal Medicine, UCLA
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Affiliation(s)
- C Jason Wang
- Departments of Pediatrics, Medicine, and Health Research and Policy, Stanford University School of Medicine, Stanford, California
- The New School for Leadership in Health Care, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - Chun Y Ng
- The New School for Leadership in Health Care, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - Robert H Brook
- David Geffen School of Medicine, Department of Medicine, University of California, Los Angeles
- The Pardee RAND Graduate School, RAND Corporation, Santa Monica, California
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Caloyeras JP, Kanter MH, Ives NR, Kim CY, Kanzaria HK, Berry SH, Brook RH. Understanding Waste in Health Care: Perceptions of Frontline Physicians Regarding Time Use and Appropriateness of Care They and Others Provide. Perm J 2018; 22:17-176. [PMID: 30010536 DOI: 10.7812/tpp/17-176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Approximately 30% of total US health care spending is thought to be "wasted" on activities like unnecessary and inefficiently delivered services. OBJECTIVES To assess the perceptions of clinic-based physicians regarding their use of time and appropriateness of care provided. DESIGN Cross-sectional online survey of all Southern California Permanente Medical Group partner and associate physicians (N = 1034) who were primarily providing clinic-based care in 1 of 4 geographically and operationally distinct Kaiser Permanente Southern California Medical Centers. MAIN OUTCOME MEASURES The proportion of time spent on direct patient care tasks perceived to require the respondent's clinical/specialty training as a physician or another physician who has similar years of clinical training (vs physicians with fewer years of clinical training, nonphysicians, or automated or computerized systems), and the proportion of care provided by the respondent and by other physicians with whom they are familiar that is perceived to be appropriate (vs equivocal or inappropriate). RESULTS More than 61% of respondents indicated that 15% of their time spent on direct patient care could be shifted to nonphysicians, and between 10% and 16% of care provided was equivocal or inappropriate. DISCUSSION The low proportion of care perceived as equivocal or inappropriate indicates there is little room for reducing such care or that physicians have difficulty assessing care appropriateness. The latter suggests that attempts to reduce or to eliminate inappropriate care may be unsuccessful until physician beliefs, knowledge, or behaviors are better understood and addressed. CONCLUSION On the basis of these findings, it is apparent that within at least one health care system, the opportunity to increase value through task shifting and avoiding inappropriate care is more narrow than commonly perceived on a national level.
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Affiliation(s)
- John P Caloyeras
- Doctoral Fellow at the Pardee RAND Graduate School in Santa Monica, CA when this study was conducted. He is currently a Director of Global Health Economics for Amgen, Inc, in Thousand Oaks, CA.
| | - Michael H Kanter
- Executive Vice President and Chief Quality Officer of The Permanente Federation in Oakland, CA. He is the Regional Medical Director of Quality and Clinical Analysis for the Southern California Permanente Medical Group in Pasadena.
| | - Nicole R Ives
- Group Leader in the Southern California Permanente Medical Group in Pasadena.
| | - Chong Y Kim
- Practice Leader in the Southern California Permanente Medical Group in Pasadena.
| | - Hemal K Kanzaria
- Assistant Professor of Clinical Emergency Medicine at the University of California, San Francisco.
| | - Sandra H Berry
- Senior Behavioral Scientist at the RAND Corporation, where she is Chair of the Human Subjects Protection Committee, Senior Director of the Survey Research Group, and a Professor at the Pardee RAND Graduate School in Santa Monica, CA.
| | - Robert H Brook
- Distinguished Chair in Health Care Services and a Senior Principal Physician Policy Researcher at the RAND Corporation and a Professor at the Pardee RAND Graduate School in Santa Monica.
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Ziaeian B, Kominski GF, Ong MK, Mays VM, Brook RH, Fonarow GC. National Differences in Trends for Heart Failure Hospitalizations by Sex and Race/Ethnicity. Circ Cardiovasc Qual Outcomes 2017; 10:e003552. [PMID: 28655709 PMCID: PMC5540644 DOI: 10.1161/circoutcomes.116.003552] [Citation(s) in RCA: 133] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 05/15/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND National heart failure (HF) hospitalization rates have not been appropriately age standardized by sex or race/ethnicity. Reporting hospital utilization trends by subgroup is important for monitoring population health and developing interventions to eliminate disparities. METHODS AND RESULTS The National Inpatient Sample (NIS) was used to estimate the crude and age-standardized rates of HF hospitalization between 2002 and 2013 by sex and race/ethnicity. Direct standardization was used to age-standardize rates to the 2000 US standard population. Relative differences between subgroups were reported. The national age-adjusted HF hospitalization rate decreased 30.8% from 526.86 to 364.66 per 100 000 between 2002 and 2013. Although hospitalizations decreased for all subgroups, the ratio of the age-standardized rate for men compared with women increased from 20% greater to 39% (P trend=0.002) between 2002 and 2013. Black men had a rate that was 229% (P trend=0.141) and black women, 240% (P trend=0.725) with reference to whites in 2013 with no significant change between 2002 and 2013. Hispanic men had a rate that was 32% greater in 2002 and the difference narrowed to 4% (P trend=0.047) greater in 2013 relative to whites. For Hispanic women, the rate was 55% greater in 2002 and narrowed to 8% greater (P trend=0.004) in 2013 relative to whites. Asian/Pacific Islander men had a 27% lower rate in 2002 that improved to 43% (P trend=0.040) lower in 2013 relative to whites. For Asian/Pacific Islander women, the hospitalization rate was 24% lower in 2002 and improved to 43% (P trend=0.021) lower in 2013 relative to whites. CONCLUSIONS National HF hospitalization rates have decreased steadily during the recent decade. Disparities in HF burden and hospital utilization by sex and race/ethnicity persist. Significant population health interventions are needed to reduce the HF hospitalization burden among blacks. An evaluation of factors explaining the improvements in the HF hospitalization rates among Hispanics and Asian/Pacific Islanders is needed.
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Affiliation(s)
- Boback Ziaeian
- From the Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, CA (B.Z., G.F.K., V.M.M., R.H.B.); Division of Cardiology (B.Z.) and Department of Internal Medicine (M.K.O.), Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA; Division of General Internal Medicine and Health Services Research (M.K.O., R.H.B.) and Division of Cardiology (B.Z., G.C.F.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Psychology, University of California, Los Angeles (V.M.M.); and Ahmanson-UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, CA (G.C.F.)
| | - Gerald F Kominski
- From the Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, CA (B.Z., G.F.K., V.M.M., R.H.B.); Division of Cardiology (B.Z.) and Department of Internal Medicine (M.K.O.), Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA; Division of General Internal Medicine and Health Services Research (M.K.O., R.H.B.) and Division of Cardiology (B.Z., G.C.F.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Psychology, University of California, Los Angeles (V.M.M.); and Ahmanson-UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, CA (G.C.F.)
| | - Michael K Ong
- From the Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, CA (B.Z., G.F.K., V.M.M., R.H.B.); Division of Cardiology (B.Z.) and Department of Internal Medicine (M.K.O.), Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA; Division of General Internal Medicine and Health Services Research (M.K.O., R.H.B.) and Division of Cardiology (B.Z., G.C.F.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Psychology, University of California, Los Angeles (V.M.M.); and Ahmanson-UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, CA (G.C.F.)
| | - Vickie M Mays
- From the Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, CA (B.Z., G.F.K., V.M.M., R.H.B.); Division of Cardiology (B.Z.) and Department of Internal Medicine (M.K.O.), Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA; Division of General Internal Medicine and Health Services Research (M.K.O., R.H.B.) and Division of Cardiology (B.Z., G.C.F.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Psychology, University of California, Los Angeles (V.M.M.); and Ahmanson-UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, CA (G.C.F.)
| | - Robert H Brook
- From the Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, CA (B.Z., G.F.K., V.M.M., R.H.B.); Division of Cardiology (B.Z.) and Department of Internal Medicine (M.K.O.), Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA; Division of General Internal Medicine and Health Services Research (M.K.O., R.H.B.) and Division of Cardiology (B.Z., G.C.F.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Psychology, University of California, Los Angeles (V.M.M.); and Ahmanson-UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, CA (G.C.F.)
| | - Gregg C Fonarow
- From the Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, CA (B.Z., G.F.K., V.M.M., R.H.B.); Division of Cardiology (B.Z.) and Department of Internal Medicine (M.K.O.), Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA; Division of General Internal Medicine and Health Services Research (M.K.O., R.H.B.) and Division of Cardiology (B.Z., G.C.F.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Psychology, University of California, Los Angeles (V.M.M.); and Ahmanson-UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, CA (G.C.F.).
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Liu JL, Brook RH. What is Single-Payer Health Care? A Review of Definitions and Proposals in the U.S. J Gen Intern Med 2017; 32:822-831. [PMID: 28493177 PMCID: PMC5481251 DOI: 10.1007/s11606-017-4063-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 03/13/2017] [Accepted: 04/10/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Single-payer systems have been proposed as a health care reform alternative in the United States. However, there is no consensus on the definition of single-payer. Most definitions characterize single-payer as one entity that collects funds and pays for health care on behalf on an entire population. Increased flexibility for state health care reform may provide opportunities for state-based single-payer systems to be considered. OBJECTIVE To explore the concept of single-payer and to describe the contents of single-payer health care proposals. DESIGN We compared single-payer definitions and proposals. We coded the proposal text for provisions that would change how the health care system functions and could impact health care access, quality, and cost. MAIN MEASURES The share of proposals that include changes to the financing, pooling, purchasing, and delivery of health care; and possible impact on access, quality, and costs. KEY RESULTS We identified 25 proposals for national or state single-payer plans from journal and legislative databases. The proposals typically call for wide-ranging reform; nearly all include changes across the financing, pooling, purchasing, and delivery of health care services. Many provisions aiming to improve access, quality, and cost containment are also included, but the proposals vary in how they plan to achieve these improvements. Common provisions are related to comprehensive benefits, patient choice of providers, little or no cost sharing, the role of private insurance, provider guidelines and standards, periodic reviews of the benefits package, electronic medical records and billing, prescription drug formulary, global budgets, administrative cost thresholds, payment reform and studies, and the authority to implement cost-containment strategies. CONCLUSIONS Single-payer systems are heterogeneous. Acknowledgment of what is considered as single-payer and the characteristics that are variable is important for nuanced policy discussions on specific reform proposals.
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Affiliation(s)
- Jodi L Liu
- RAND Corporation, 1776 Main Street, P.O. Box 2138, Santa Monica, CA, 90407-2138, USA.
| | - Robert H Brook
- RAND Corporation, 1776 Main Street, P.O. Box 2138, Santa Monica, CA, 90407-2138, USA.,University of California, Los Angeles, Los Angeles, CA, USA
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Hochman M, Briggs-Malonson M, Wilkes E, Bergman J, Daskivich LP, Moin T, Brook I, Ryan GW, Brook RH, Mangione CM. Fostering a Commitment to Quality: Best Practices in Safety-net Hospitals. J Health Care Poor Underserved 2016; 27:293-307. [PMID: 27763471 DOI: 10.1353/hpu.2016.0008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In 2007, the Martin Luther King, Jr.-Harbor Hospital (MLK-Harbor), which served a large safety-net population in South Los Angeles, closed due to quality challenges. Shortly thereafter, an agreement was made to establish a new hospital, Martin Luther King, Jr. Community Hospital (MLKCH), to serve the unmet needs of the community. To assist the newly appointed MLKCH Board of Directors in building a culture of quality, we conducted a series of interviews with five high-performing hospital systems. In this report, we describe our findings. The hospitals we interviewed achieved a culture of quality by: 1) developing guiding principles that foster quality; 2) hiring and retaining personnel who are stewards of quality; 3) promoting efficient resource utilization; 4) developing a well-organized quality improvement infrastructure; and 5) cultivating integrated, patient-centric care. The institutions highlighted in this report provide important lessons for MLKCH and other safety-net institutions.
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Robinson MT, Vickrey BG, Holloway RG, Chong K, Williams LS, Brook RH, Leng M, Parikh P, Zingmond DS. The lack of documentation of preferences in a cohort of adults who died after ischemic stroke. Neurology 2016; 86:2056-62. [PMID: 27060165 DOI: 10.1212/wnl.0000000000002625] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 02/04/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To measure the extent and timing of physicians' documentation of communication with patients and families regarding limitations on life-sustaining interventions, in a population cohort of adults who died within 30 days after hospitalization for ischemic stroke. METHODS We used the California Office of Statewide Health Planning and Development Patient Discharge Database to identify a retrospective cohort of adults with ischemic strokes at all California acute care hospitals from December 2006 to November 2007. Of 326 eligible hospitals, a representative sample of 39 was selected, stratified by stroke volume and mortality. Medical records of 981 admissions were abstracted, oversampled on mortality and tissue plasminogen activator receipt. Among 198 patients who died by 30 days postadmission, overall proportions and timing of documented preferences were calculated; factors associated with documentation were explored. RESULTS Of the 198 decedents, mean age was 80 years, 78% were admitted from home, 19% had mild strokes, 11% received tissue plasminogen activator, and 42% died during the index hospitalization. Preferences about at least one life-sustaining intervention were recorded on 39% of patients: cardiopulmonary resuscitation 34%, mechanical ventilation 23%, nasogastric tube feeding 10%, and percutaneous enteral feeding 6%. Most discussions occurred within 5 days of death. Greater stroke severity was associated with increased in-hospital documentation of preferences (p < 0.05). CONCLUSIONS Documented discussions about limitations on life-sustaining interventions during hospitalization were low, even though this cohort died within 30 days poststroke. Improving the documentation of preferences may be difficult given the 2015 Centers for Medicare and Medicaid 30-day stroke mortality hospital performance measure that is unadjusted for patient preferences regarding life-sustaining interventions.
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Affiliation(s)
- Maisha T Robinson
- From the Department of Neurology (M.T.R.), Mayo Clinic, Jacksonville, FL; Department of Neurology (B.G.V.), David Geffen UCLA School of Medicine (R.H.B.), and Department of Medicine, Division of General Internal Medicine and Health Services Research (M.L., P.P., D.S.Z.), University of California, Los Angeles; Icahn School of Medicine at Mount Sinai (B.G.V.), New York; Department of Neurology (R.G.H.), University of Rochester, New York, NY; University of New Mexico School of Medicine (K.C.); Veterans Affairs HSR&D Center for Health Information and Communication (L.S.W.); Department of Neurology, Indiana University (L.S.W.); Regenstrief Institute, Inc. (L.S.W.); RAND Corporation (R.H.B.); Jonathan and Karin Fielding School of Public Health (R.H.B.); and Veterans Affairs Greater Los Angeles Healthcare System (D.S.Z.).
| | - Barbara G Vickrey
- From the Department of Neurology (M.T.R.), Mayo Clinic, Jacksonville, FL; Department of Neurology (B.G.V.), David Geffen UCLA School of Medicine (R.H.B.), and Department of Medicine, Division of General Internal Medicine and Health Services Research (M.L., P.P., D.S.Z.), University of California, Los Angeles; Icahn School of Medicine at Mount Sinai (B.G.V.), New York; Department of Neurology (R.G.H.), University of Rochester, New York, NY; University of New Mexico School of Medicine (K.C.); Veterans Affairs HSR&D Center for Health Information and Communication (L.S.W.); Department of Neurology, Indiana University (L.S.W.); Regenstrief Institute, Inc. (L.S.W.); RAND Corporation (R.H.B.); Jonathan and Karin Fielding School of Public Health (R.H.B.); and Veterans Affairs Greater Los Angeles Healthcare System (D.S.Z.)
| | - Robert G Holloway
- From the Department of Neurology (M.T.R.), Mayo Clinic, Jacksonville, FL; Department of Neurology (B.G.V.), David Geffen UCLA School of Medicine (R.H.B.), and Department of Medicine, Division of General Internal Medicine and Health Services Research (M.L., P.P., D.S.Z.), University of California, Los Angeles; Icahn School of Medicine at Mount Sinai (B.G.V.), New York; Department of Neurology (R.G.H.), University of Rochester, New York, NY; University of New Mexico School of Medicine (K.C.); Veterans Affairs HSR&D Center for Health Information and Communication (L.S.W.); Department of Neurology, Indiana University (L.S.W.); Regenstrief Institute, Inc. (L.S.W.); RAND Corporation (R.H.B.); Jonathan and Karin Fielding School of Public Health (R.H.B.); and Veterans Affairs Greater Los Angeles Healthcare System (D.S.Z.)
| | - Kelly Chong
- From the Department of Neurology (M.T.R.), Mayo Clinic, Jacksonville, FL; Department of Neurology (B.G.V.), David Geffen UCLA School of Medicine (R.H.B.), and Department of Medicine, Division of General Internal Medicine and Health Services Research (M.L., P.P., D.S.Z.), University of California, Los Angeles; Icahn School of Medicine at Mount Sinai (B.G.V.), New York; Department of Neurology (R.G.H.), University of Rochester, New York, NY; University of New Mexico School of Medicine (K.C.); Veterans Affairs HSR&D Center for Health Information and Communication (L.S.W.); Department of Neurology, Indiana University (L.S.W.); Regenstrief Institute, Inc. (L.S.W.); RAND Corporation (R.H.B.); Jonathan and Karin Fielding School of Public Health (R.H.B.); and Veterans Affairs Greater Los Angeles Healthcare System (D.S.Z.)
| | - Linda S Williams
- From the Department of Neurology (M.T.R.), Mayo Clinic, Jacksonville, FL; Department of Neurology (B.G.V.), David Geffen UCLA School of Medicine (R.H.B.), and Department of Medicine, Division of General Internal Medicine and Health Services Research (M.L., P.P., D.S.Z.), University of California, Los Angeles; Icahn School of Medicine at Mount Sinai (B.G.V.), New York; Department of Neurology (R.G.H.), University of Rochester, New York, NY; University of New Mexico School of Medicine (K.C.); Veterans Affairs HSR&D Center for Health Information and Communication (L.S.W.); Department of Neurology, Indiana University (L.S.W.); Regenstrief Institute, Inc. (L.S.W.); RAND Corporation (R.H.B.); Jonathan and Karin Fielding School of Public Health (R.H.B.); and Veterans Affairs Greater Los Angeles Healthcare System (D.S.Z.)
| | - Robert H Brook
- From the Department of Neurology (M.T.R.), Mayo Clinic, Jacksonville, FL; Department of Neurology (B.G.V.), David Geffen UCLA School of Medicine (R.H.B.), and Department of Medicine, Division of General Internal Medicine and Health Services Research (M.L., P.P., D.S.Z.), University of California, Los Angeles; Icahn School of Medicine at Mount Sinai (B.G.V.), New York; Department of Neurology (R.G.H.), University of Rochester, New York, NY; University of New Mexico School of Medicine (K.C.); Veterans Affairs HSR&D Center for Health Information and Communication (L.S.W.); Department of Neurology, Indiana University (L.S.W.); Regenstrief Institute, Inc. (L.S.W.); RAND Corporation (R.H.B.); Jonathan and Karin Fielding School of Public Health (R.H.B.); and Veterans Affairs Greater Los Angeles Healthcare System (D.S.Z.)
| | - Mei Leng
- From the Department of Neurology (M.T.R.), Mayo Clinic, Jacksonville, FL; Department of Neurology (B.G.V.), David Geffen UCLA School of Medicine (R.H.B.), and Department of Medicine, Division of General Internal Medicine and Health Services Research (M.L., P.P., D.S.Z.), University of California, Los Angeles; Icahn School of Medicine at Mount Sinai (B.G.V.), New York; Department of Neurology (R.G.H.), University of Rochester, New York, NY; University of New Mexico School of Medicine (K.C.); Veterans Affairs HSR&D Center for Health Information and Communication (L.S.W.); Department of Neurology, Indiana University (L.S.W.); Regenstrief Institute, Inc. (L.S.W.); RAND Corporation (R.H.B.); Jonathan and Karin Fielding School of Public Health (R.H.B.); and Veterans Affairs Greater Los Angeles Healthcare System (D.S.Z.)
| | - Punam Parikh
- From the Department of Neurology (M.T.R.), Mayo Clinic, Jacksonville, FL; Department of Neurology (B.G.V.), David Geffen UCLA School of Medicine (R.H.B.), and Department of Medicine, Division of General Internal Medicine and Health Services Research (M.L., P.P., D.S.Z.), University of California, Los Angeles; Icahn School of Medicine at Mount Sinai (B.G.V.), New York; Department of Neurology (R.G.H.), University of Rochester, New York, NY; University of New Mexico School of Medicine (K.C.); Veterans Affairs HSR&D Center for Health Information and Communication (L.S.W.); Department of Neurology, Indiana University (L.S.W.); Regenstrief Institute, Inc. (L.S.W.); RAND Corporation (R.H.B.); Jonathan and Karin Fielding School of Public Health (R.H.B.); and Veterans Affairs Greater Los Angeles Healthcare System (D.S.Z.)
| | - David S Zingmond
- From the Department of Neurology (M.T.R.), Mayo Clinic, Jacksonville, FL; Department of Neurology (B.G.V.), David Geffen UCLA School of Medicine (R.H.B.), and Department of Medicine, Division of General Internal Medicine and Health Services Research (M.L., P.P., D.S.Z.), University of California, Los Angeles; Icahn School of Medicine at Mount Sinai (B.G.V.), New York; Department of Neurology (R.G.H.), University of Rochester, New York, NY; University of New Mexico School of Medicine (K.C.); Veterans Affairs HSR&D Center for Health Information and Communication (L.S.W.); Department of Neurology, Indiana University (L.S.W.); Regenstrief Institute, Inc. (L.S.W.); RAND Corporation (R.H.B.); Jonathan and Karin Fielding School of Public Health (R.H.B.); and Veterans Affairs Greater Los Angeles Healthcare System (D.S.Z.)
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Caloyeras JP, Kanter M, Ives N, Kim CY, Kanzaria HK, Berry SH, Brook RH. Physician Professional Satisfaction and Area of Clinical Practice: Evidence from an Integrated Health Care Delivery System. Perm J 2016; 20:35-41. [PMID: 27057819 DOI: 10.7812/tpp/15-163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
CONTEXT For health care reform to succeed, health care systems need a professionally satisfied primary care workforce. Evidence suggests that primary care physicians are less satisfied than those in other medical specialties. OBJECTIVE To assess three domains of physician satisfaction by area of clinical practice among physicians practicing in an established integrated health system. DESIGN Cross-sectional online survey of all Southern California Permanente Medical Group (SCPMG) partner and associate physicians (N = 1034) who were primarily providing clinic-based care in 1 of 4 geographically and operationally distinct Kaiser Permanente Southern California Medical Centers. MAIN OUTCOME MEASURES Primary measure was satisfaction with one's day-to-day professional life as a physician. Secondary measures were satisfaction with quality of care and income. RESULTS Of the 636 physicians responding to the survey (61.5% response rate), on average, 8 in 10 SCPMG physicians reported satisfaction with their day-to-day professional life as a physician. Primary care physicians were only minimally less likely to report being satisfied (difference of 8.2-9.5 percentage points; p < 0.05) than were other physicians. Nearly all physicians (98.2%) were satisfied with the quality of care they are able to provide. Roughly 8 in 10 physicians reported satisfaction with their income. No differences were found between primary care physicians and those in other clinical practice areas regarding satisfaction with quality of care or income. CONCLUSION It is possible to create practice settings, such as SCPMG, in which most physicians, including those in primary care, experience high levels of professional satisfaction.
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Affiliation(s)
- John P Caloyeras
- Doctoral Fellow at the Pardee RAND Graduate School in Santa Monica, an Assistant Policy Analyst for RAND Corporation in Santa Monica, and a Senior Manager for Global Health Economics for Amgen, Inc, in Thousand Oaks, CA.
| | - Michael Kanter
- Medical Director of Quality and Clinical Analysis for the Southern California Permanente Medical Group in Pasadena, CA.
| | - Nicole Ives
- Senior Consultant for the Southern California Permanente Medical Group in Pasadena, CA.
| | - Chong Y Kim
- Senior Consultant for the Southern California Permanente Medical Group in Pasadena, CA.
| | - Hemal K Kanzaria
- Assistant Professor of Clinical Emergency Medicine at the University of California, San Francisco, an Emergency Physician at San Francisco General Hospital, and a Natural Scientist for the RAND Corporation in Santa Monica.
| | - Sandra H Berry
- Senior Behavioral Scientist for the RAND Corporation and a Professor at the Pardee RAND Graduate School in Santa Monica, CA.
| | - Robert H Brook
- Distinguished Chair in Health Care Services for the RAND Corporation, a Professor at the Pardee RAND Corporation in Santa Monica, a Professor at the David Geffen School of Medicine and at the Fielding School of Public Health at the University of California, Los Angeles.
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Mattke S, Mengistu T, Klautzer L, Sloss EM, Brook RH. Improving Care for Chronic Conditions: Current Practices and Future Trends in Health Plan Programs. Rand Health Q 2015; 5:3. [PMID: 28083379 PMCID: PMC5158283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The need for better management of chronic conditions is urgent. About 141 million people in the United States were living with one or more chronic conditions in 2010, and this number is projected to increase to 171 million by 2030. To address this challenge, many health plans have piloted and rolled out innovative approaches to improving care for their members with chronic conditions. This article documents the current range of chronic care management services, identifies best practices and industry trends, and examines factors in the plans' operating environment that limit their ability to optimize chronic care programs. The authors conducted telephone surveys with a representative sample of health plans and made in-depth case studies of six plans. All plans in the sample provide a wide range of products and services around chronic care, including wellness/lifestyle management programs for healthy members, disease management for members with common chronic conditions, and case management for high-risk members regardless of their underlying condition. Health plans view these programs as a "win-win" situation and believe that they improve care for their most vulnerable members and reduce cost of coverage. Plans are making their existing programs more patient-centric and are integrating disease and case management, and sometimes lifestyle management and behavioral health, into a consolidated chronic care management program, believing that this will increase patient engagement and prevent duplication of services and missed opportunities.
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Neuhausen K, Davis AC, Needleman J, Brook RH, Zingmond D, Roby DH. Disproportionate-share hospital payment reductions may threaten the financial stability of safety-net hospitals. Health Aff (Millwood) 2015; 33:988-96. [PMID: 24889948 DOI: 10.1377/hlthaff.2013.1222] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Safety-net hospitals rely on disproportionate-share hospital (DSH) payments to help cover uncompensated care costs and underpayments by Medicaid (known as Medicaid shortfalls). The Affordable Care Act (ACA) anticipates that insurance expansion will increase safety-net hospitals' revenues and will reduce DSH payments accordingly. We examined the impact of the ACA's Medicaid DSH reductions on California public hospitals' financial stability by estimating how total DSH costs (uncompensated care costs and Medicaid shortfalls) will change as a result of insurance expansion and the offsetting DSH reductions. Decreases in uncompensated care costs resulting from the ACA insurance expansion may not match the act's DSH reductions because of the high number of people who will remain uninsured, low Medicaid reimbursement rates, and medical cost inflation. Taking these three factors into account, we estimate that California public hospitals' total DSH costs will increase from $2.044 billion in 2010 to $2.363-$2.503 billion in 2019, with unmet DSH costs of $1.381-$1.537 billion.
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Affiliation(s)
- Katherine Neuhausen
- Katherine Neuhausen is director of delivery system reform in the Office of Health Innovation and a clinical assistant professor in the Department of Family Medicine and Population Health, Virginia Commonwealth University, in Richmond
| | - Anna C Davis
- Anna C. Davis is a PhD student in the Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles (UCLA)
| | - Jack Needleman
- Jack Needleman is a professor in the Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health, UCLA
| | - Robert H Brook
- Robert H. Brook is a professor of medicine and public health in the David Geffen School of Medicine and the Jonathan and Karin Fielding School of Public Health and codirector of the Robert Wood Johnson Foundation Clinical Scholars Program, UCLA. He is also the distinguished chair in health services at RAND and a professor in the Pardee RAND Graduate School
| | - David Zingmond
- David Zingmond is an assistant professor in residence in the Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, UCLA
| | - Dylan H Roby
- Dylan H. Roby is an assistant professor in the Department of Health Policy and Management and director of health economics and evaluation research at the Center for Health Policy Research, both in the Jonathan and Karin Fielding School of Public Health, UCLA
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Sacks GD, Dawes AJ, Russell MM, Brook RH, Ettner SL, Fox CR, Ko CY, Gibbons MM. Does Use of the American College of Surgeons NSQIP Calculator Change a Surgeon’s Decision to Operate? A Randomized Trial. J Am Coll Surg 2015. [DOI: 10.1016/j.jamcollsurg.2015.07.293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Brook RH, Vaiana ME. Using the Knowledge Base of Health Services Research to Redefine Health Care Systems. J Gen Intern Med 2015; 30:1547-56. [PMID: 25840780 PMCID: PMC4579238 DOI: 10.1007/s11606-015-3298-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 02/23/2015] [Accepted: 03/16/2015] [Indexed: 10/23/2022]
Abstract
This Perspective discusses 12 key facts derived from 50 years of health services research and argues that this knowledge base can stimulate innovative thinking about how to make health care systems safer, more efficient, more cost effective, and more patient centered, even as they respond to the needs of diverse communities.
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Affiliation(s)
- Robert H Brook
- RAND Corporation, Santa Monica, CA, USA.
- David Geffen UCLA School of Medicine, UCLA Fielding School of Public Health, Los Angeles, CA, USA.
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Sacks GD, Dawes AJ, Gibbons MM, Brook RH, Ettner SL, Fox CR, Ko CY, Russell MM. Do Surgeons’ Perceptions of Treatment Risks and Benefits Influence Their Decision to Operate? J Am Coll Surg 2015. [DOI: 10.1016/j.jamcollsurg.2015.07.292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kanzaria HK, Brook RH, Probst MA, Harris D, Berry SH, Hoffman JR. Emergency physician perceptions of shared decision-making. Acad Emerg Med 2015; 22:399-405. [PMID: 25807995 DOI: 10.1111/acem.12627] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 10/10/2014] [Accepted: 10/22/2014] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Despite the potential benefits of shared decision-making (SDM), its integration into emergency care is challenging. Emergency physician (EP) perceptions about the frequency with which they use SDM, its potential to reduce medically unnecessary diagnostic testing, and the barriers to employing SDM in the emergency department (ED) were investigated. METHODS As part of a larger project examining beliefs on overtesting, questions were posed to EPs about SDM. Qualitative analysis of two multispecialty focus groups was done exploring decision-making around resource use to generate survey items. The survey was then pilot-tested and revised to focus on advanced diagnostic imaging and SDM. The final survey was administered to EPs recruited at four emergency medicine (EM) conferences and 15 ED group meetings. This report addresses responses regarding SDM. RESULTS A purposive sample of 478 EPs from 29 states were approached, of whom 435 (91%) completed the survey. EPs estimated that, on average, multiple reasonable management options exist in over 50% of their patients and reported employing SDM with 58% of such patients. Respondents perceived SDM as a promising solution to reduce overtesting. However, despite existing research to the contrary, respondents also commonly cited beliefs that 1) "many patients prefer that the physician decides," 2) "when offered a choice, many patients opt for more aggressive care than they need," and 3) "it is too complicated for patients to know how to choose." CONCLUSIONS Most surveyed EPs believe SDM is a potential high-yield solution to overtesting, but many perceive patient-related barriers to its successful implementation.
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Affiliation(s)
- Hemal K. Kanzaria
- Robert Wood Johnson Foundation Clinical Scholars program; University of California Los Angeles; Los Angeles CA
- U.S. Department of Veterans Affairs; University of California Los Angeles; Los Angeles CA
| | - Robert H. Brook
- David Geffen School of Medicine; University of California Los Angeles; Los Angeles CA
- Jonathan and Karin Fielding School of Public Health; University of California Los Angeles; Los Angeles CA
- RAND Corporation; Santa Monica CA
| | - Marc A. Probst
- The Department of Emergency Medicine; Mount Sinai Medical Center; New York NY
| | - Dustin Harris
- David Geffen School of Medicine; University of California Los Angeles; Los Angeles CA
| | | | - Jerome R. Hoffman
- Emergency Medicine Center; University of California Los Angeles; Los Angeles CA
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Kanzaria HK, Hoffman JR, Probst MA, Caloyeras JP, Berry SH, Brook RH. Emergency physician perceptions of medically unnecessary advanced diagnostic imaging. Acad Emerg Med 2015; 22:390-8. [PMID: 25807868 DOI: 10.1111/acem.12625] [Citation(s) in RCA: 128] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 10/07/2014] [Accepted: 10/22/2014] [Indexed: 12/26/2022]
Abstract
OBJECTIVES The objective was to determine emergency physician (EP) perceptions regarding 1) the extent to which they order medically unnecessary advanced diagnostic imaging, 2) factors that contribute to this behavior, and 3) proposed solutions for curbing this practice. METHODS As part of a larger study to engage physicians in the delivery of high-value health care, two multispecialty focus groups were conducted to explore the topic of decision-making around resource utilization, after which qualitative analysis was used to generate survey questions. The survey was extensively pilot-tested and refined for emergency medicine (EM) to focus on advanced diagnostic imaging (i.e., computed tomography [CT] or magnetic resonance imaging [MRI]). The survey was then administered to a national, purposive sample of EPs and EM trainees. Simple descriptive statistics to summarize physician responses are presented. RESULTS In this study, 478 EPs were approached, of whom 435 (91%) completed the survey; 68% of respondents were board-certified, and roughly half worked in academic emergency departments (EDs). Over 85% of respondents believe too many diagnostic tests are ordered in their own EDs, and 97% said at least some (mean = 22%) of the advanced imaging studies they personally order are medically unnecessary. The main perceived contributors were fear of missing a low-probability diagnosis and fear of litigation. Solutions most commonly felt to be "extremely" or "very" helpful for reducing unnecessary imaging included malpractice reform (79%), increased patient involvement through education (70%) and shared decision-making (56%), feedback to physicians on test-ordering metrics (55%), and improved education of physicians on diagnostic testing (50%). CONCLUSIONS Overordering of advanced imaging may be a systemic problem, as many EPs believe a substantial proportion of such studies, including some they personally order, are medically unnecessary. Respondents cited multiple complex factors with several potential high-yield solutions that must be addressed simultaneously to curb overimaging.
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Affiliation(s)
- Hemal K. Kanzaria
- The Robert Wood Johnson Foundation Clinical Scholars Program; Los Angeles CA
- U.S. Department of Veterans Affairs; Los Angeles CA
- University of California Los Angeles; Los Angeles CA
| | - Jerome R. Hoffman
- The Emergency Medicine Center; Los Angeles CA
- University of California Los Angeles; Los Angeles CA
| | - Marc A. Probst
- The Department of Emergency Medicine; Mount Sinai Medical Center; New York NY
| | - John P. Caloyeras
- RAND Corporation; Santa Monica CA
- Pardee RAND Graduate School; Santa Monica CA
| | | | - Robert H. Brook
- RAND Corporation; Santa Monica CA
- The David Geffen School of Medicine; Los Angeles CA
- Jonathan and Karin Fielding School of Public Health; Los Angeles CA
- University of California Los Angeles; Los Angeles CA
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Affiliation(s)
- Hemal K Kanzaria
- Veterans Affairs/Robert Wood Johnson Clinical Scholars Program, University of California, Los Angeles
| | | | - Alissa A Detz
- Department of Medicine, University of California, Los Angeles
| | - Robert H Brook
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
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Stey AM, Brook RH, Needleman J, Hall BL, Zingmond DS, Lawson EH, Ko CY. Hospital costs by cost center of inpatient hospitalization for medicare patients undergoing major abdominal surgery. J Am Coll Surg 2014; 220:207-17.e11. [PMID: 25529900 DOI: 10.1016/j.jamcollsurg.2014.10.021] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Revised: 10/27/2014] [Accepted: 10/29/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND This study aims to describe the magnitude of hospital costs among patients undergoing elective colectomy, cholecystectomy, and pancreatectomy, determine whether these costs relate as expected to duration of care, patient case-mix severity and comorbidities, and whether risk-adjusted costs vary significantly by hospital. Correctly estimating the cost of production of surgical care may help decision makers design mechanisms to improve the efficiency of surgical care. STUDY DESIGN Patient data from 202 hospitals in the ACS-NSQIP were linked to Medicare inpatient claims. Patient charges were mapped to cost center cost-to-charge ratios in the Medicare cost reports to estimate costs. The association of patient case-mix severity and comorbidities with cost was analyzed using mixed effects multivariate regression. Cost variation among hospitals was quantified by estimating risk-adjusted hospital cost ratios and 95% confidence intervals from the mixed effects multivariate regression. RESULTS There were 21,923 patients from 202 hospitals who underwent an elective colectomy (n = 13,945), cholecystectomy (n = 5,569), or pancreatectomy (n = 2,409). Median cost was lowest for cholecystectomy ($15,651) and highest for pancreatectomy ($37,745). Room and board costs accounted for the largest proportion (49%) of costs and were correlated with length of stay, R = 0.89, p < 0.001. The patient case-mix severity and comorbidity variables most associated with cost were American Society of Anesthesiologists (ASA) class IV (estimate 1.72, 95% CI 1.57 to 1.87) and fully dependent functional status (estimate 1.63, 95% CI 1.53 to 1.74). After risk-adjustment, 66 hospitals had significantly lower costs than the average hospital and 57 hospitals had significantly higher costs. CONCLUSIONS The hospital costs estimates appear to be consistent with clinical expectations of hospital resource use and differ significantly among 202 hospitals after risk-adjustment for preoperative patient characteristics and procedure type.
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Affiliation(s)
- Anne M Stey
- Icahn School of Medicine at Mount Sinai Medical Center, NY, NY; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA.
| | - Robert H Brook
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA; RAND Corporation, Santa Monica, CA
| | - Jack Needleman
- Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA
| | - Bruce L Hall
- American College of Surgeons, Chicago, IL; Washington University in Saint Louis Department of Surgery, Olin Business School, and Center for Health Policy; St Louis VA Medical Center; BJC Healthcare Saint Louis, St Louis, MO
| | - David S Zingmond
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Elise H Lawson
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Clifford Y Ko
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA; American College of Surgeons, Chicago, IL
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Friedberg MW, Chen PG, Van Busum KR, Aunon F, Pham C, Caloyeras J, Mattke S, Pitchforth E, Quigley DD, Brook RH, Crosson FJ, Tutty M. Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. Rand Health Q 2014. [PMID: 28083306 DOI: 10.7249/rb9740] [Citation(s) in RCA: 130] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
The American Medical Association asked RAND Health to characterize the factors that affect physician professional satisfaction. RAND researchers sought to identify high-priority determinants of professional satisfaction by gathering data from 30 physician practices in six states, using a combination of surveys and semistructured interviews. This article presents the results of the subsequent analysis.
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Lesser LI, Kayekjian KC, Velasquez P, Tseng CH, Brook RH, Cohen DA. Adolescent Purchasing Behavior at McDonald's and Subway. J Adolesc Health 2013; 53:441-5. [PMID: 23660412 DOI: 10.1016/j.jadohealth.2013.02.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 02/15/2013] [Accepted: 02/15/2013] [Indexed: 11/19/2022]
Abstract
PURPOSE To assess whether adolescents purchasing food at a restaurant marketed as "healthy" (Subway) purchase fewer calories than at a competing chain (McDonald's). METHODS We studied 97 adolescents who purchased a meal at both restaurants on different days, using each participant as his or her control. We compared the difference in calories purchased by adolescents at McDonald's and Subway in a diverse area of Los Angeles, CA. RESULTS Adolescents purchased an average of 1,038 calories (standard error of the mean [SEM]: 41) at McDonald's and 955 calories (SEM 39) at Subway. The difference of 83 calories (95% confidence interval [CI]: -20 to 186) was not statistically significant (p = .11). At McDonald's, participants purchased significantly more calories from drinks (151 vs. 61, p < .01) and from side dishes (i.e., French fries or potato chips; 201 at McDonald's vs. 35 at Subway, p < .01). In contrast, they purchased fewer cups of vegetables at McDonald's (.15 vs. .57 cups, p < .01). CONCLUSIONS We found that, despite being marketed as "healthy," adolescents purchasing a meal at Subway order just as many calories as at McDonald's. Although Subway meals had more vegetables, meals from both restaurants are likely to contribute to overeating.
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Affiliation(s)
- Lenard I Lesser
- Palo Alto Medical Foundation Research Institute, Palo Alto, California.
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Affiliation(s)
- Jonathan Bergman
- Department of Urology, University of California, Los Angeles 90095-1738, USA.
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Affiliation(s)
- Robert H. Brook
- />RAND Corporation, 1776 Main Street, Santa Monica, CA 90401 USA
- />David Geffen UCLA School of Medicine, Los Angeles, CA USA
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Affiliation(s)
- Lenard I Lesser
- Palo Alto Medical Foundation Research Institute, 795 El Camion Real Ames Bldg, Palo Alto, CA 94306, USA.
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Affiliation(s)
- Robert H Brook
- RAND Corporation, 1776 Main St, Santa Monica, CA 90401, USA.
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Clarke RMA, Tseng CH, Brook RH, Brown AF. Tool used to assess how well community health centers function as medical homes may be flawed. Health Aff (Millwood) 2012; 31:627-35. [PMID: 22345663 DOI: 10.1377/hlthaff.2011.0908] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The patient-centered medical home model holds the potential for reducing disease complications and improving health, and the federal government is now promoting the adoption of the model within federally qualified community health centers. In a group of Los Angeles community health centers, we found that all would have qualified as patient-centered medical homes under a widely used assessment tool developed by the National Committee for Quality Assurance and endorsed by the federal government for the community health center program. However, we also found that there was no significant relationship between how well these centers performed on the assessment and whether they achieved a range of process or outcome measures for diabetes care. These findings suggest that the federal government is promoting medical home redesign that may not be sensitive to, or inclusive of, services that will actually improve diabetes care for low-income patients. Therefore, additional methods are required for measuring and improving the capabilities of community health centers to function as medical homes and to deliver the scope of services that impoverished patients genuinely need.
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Affiliation(s)
- Robin M A Clarke
- David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA.
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Affiliation(s)
- Robert H Brook
- RAND Corporation and David Geffen UCLA School of Medicine, Santa Monica, CA 90401, USA.
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Lesser LI, Hunnes DE, Reyes P, Arab L, Ryan GW, Brook RH, Cohen DA. Assessment of food offerings and marketing strategies in the food-service venues at California Children's Hospitals. Acad Pediatr 2012; 12:62-7. [PMID: 22136808 DOI: 10.1016/j.acap.2011.09.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Revised: 09/13/2011] [Accepted: 09/17/2011] [Indexed: 10/14/2022]
Abstract
OBJECTIVE Marketing strategies and food offerings in hospital cafeterias can impact dietary choices. Using a survey adapted to assess food environments, the purpose of this study was to assess the food environment available to patients, staff, and visitors at the food-service venues in all 14 California children's hospitals. METHODS We modified a widely-used tool to create the Nutritional Environment Measures Survey for Cafeterias (NEMS-C) by partnering with a hospital wellness committee. The NEMS-C summarizes the number of healthy items offered, whether calorie labeling is present, if there is signage promoting healthy or unhealthy foods, pricing structure, and the presence of unhealthy combination meals. The range of possible scores is zero (unhealthy) to 37 (healthy). We directly observed the food-service venues at all 14 tertiary care children's hospitals in California and scored them. RESULTS Inter-rater reliability showed 89% agreement on the assessed items. For the 14 hospitals, the mean score was 19.1 (SD = 4.2; range, 13-30). Analysis revealed that nearly all hospitals offered diet drinks, low-fat milk, and fruit. Fewer than one-third had nutrition information at the point of purchase and 30% had signs promoting healthy eating. Most venues displayed high calorie impulse items such as cookies and ice cream at the registers. Seven percent (7%) of the 384 entrees served were classified as healthy according to NEMS criteria. CONCLUSIONS Most children's hospitals' food venues received a mid-range score, demonstrating there is considerable room for improvement. Many inexpensive options are underused, such as providing nutritional information, incorporating signage that promotes healthy choices, and not presenting unhealthy impulse items at the register.
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Affiliation(s)
- Lenard I Lesser
- Robert Wood Johnson Foundation Clinical Scholars Program and Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.
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Affiliation(s)
- Robert H Brook
- RAND Corporation, 1776 Main St, Santa Monica, CA 90401, USA.
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Affiliation(s)
- Robert H Brook
- RAND Corporation and David Geffen University of California Los Angeles School of Medicine, 1776 Main St, Santa Monica, CA 90401, USA.
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Affiliation(s)
- Robert H Brook
- RAND Corporation and David Geffen UCLA School of Medicine, 1776 Main St, Santa Monica, CA 90401, USA.
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Affiliation(s)
- Robert H Brook
- RAND Corporation, 1776 Main St, Santa Monica, CA 90401, USA.
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Affiliation(s)
- Robert H Brook
- RAND Corporation, PO Box 2138, Santa Monica, CA 90407, USA.
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Affiliation(s)
- Robert H Brook
- RAND Health, 1776 Main St, PO Box 2138, Santa Monica, CA 90407, USA.
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Affiliation(s)
- Robert H Brook
- RAND Corporation, 1776 Main St, Santa Monica, CA 90407, USA.
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Affiliation(s)
- Robert H Brook
- RAND Corporation, 1776 Main St, Santa Monica, CA 90401, USA.
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Affiliation(s)
- Robert H Brook
- RAND Health, 1776 Main St, PO Box 2138, Santa Monica, CA 90401, USA.
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Affiliation(s)
- Robert H Brook
- RAND Corporation, 1776 Main St, Santa Monica, CA 90407, USA.
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Affiliation(s)
- Robert H Brook
- RAND Corporation, 1776 Main St, Santa Monica, CA 90407, USA.
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Tseng CW, Brook RH, Alexander GC, Hixon AL, Keeler EB, Mangione CM, Chen R, Jackson EA, Dudley RA. Health information technology and physicians' knowledge of drug costs. Am J Manag Care 2010; 16:e105-e110. [PMID: 20370310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To examine whether physicians' use of information technology (IT) was associated with better knowledge of drug costs. STUDY DESIGN/METHODS A 2007 statewide survey of 247 primary care physicians in Hawaii regarding IT use and self-reported knowledge of formularies, copayments, and retail prices. RESULTS Approximately 8 in 10 physicians regularly used IT in clinical care: 60% Internet, 54% e-prescribing, 43% electronic health records (EHRs), and 37% personal digital assistants (PDAs). However, fewer than 1 in 5 often knew drug costs when prescribing, and more than 90% said lack of knowledge of formularies and copayments remained a barrier to considering drug costs for patients. In multivariate analyses adjusting for sex, practice size, years in practice, number of formularies, and use of clinical resources (eg, pharmacists), use of the Internet -- but not e-prescribing, EHRs, or PDAs -- was associated with physicians reporting slightly better knowledge of copayments (adjusted predicted percentage of 23% vs 11%; P = .04). No type of IT was associated with better knowledge of formularies or retail prices. CONCLUSIONS Despite high rates of IT use, there was only a modest association between physicians' use of IT and better knowledge of drug costs. Future investments in health IT should consider how IT design can be improved to make it easier for physicians to access cost information at the point of care.
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Affiliation(s)
- Chien-Wen Tseng
- Department of Family Medicine and Community Health, University of Hawaii, Honolulu, 96789, USA.
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Affiliation(s)
- Robert H Brook
- RAND Health, 1776 Main St, PO Box 2138, Santa Monica, CA 90407, USA.
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Affiliation(s)
- Robert H Brook
- RAND Corporation, 1776 Main St, PO Box 2138, Santa Monica, CA 90407, USA.
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Affiliation(s)
- Robert H Brook
- RAND Health, 1776 Main St, PO Box 2138, Santa Monica, CA 90407, USA.
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Affiliation(s)
- Robert H Brook
- RAND Corporation, 1776 Main St, Santa Monica, CA 90407, USA.
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