Provider-Induced Demand in the Treatment of Carotid Artery Stenosis: Variation in Treatment Decisions Between Private Sector Fee-for-Service vs Salary-Based Military Physicians

Importance

Although many factors influence the management of carotid artery stenosis, it is not well understood whether a preference toward procedural management exists when procedural volume and physician compensation are linked in the fee-for-service environment.

Objective

To explore evidence for provider-induced demand in the management of carotid artery stenosis.

Design, Setting, and Participants

The Department of Defense Military Health System Data Repository was queried for individuals diagnosed with carotid artery stenosis between October 1, 2006, and September 30, 2010. A hierarchical multivariable model evaluated the association of the treatment system (fee-for-service physicians in the private sector vs salary-based military physicians) with the odds of procedural intervention (carotid endarterectomy or carotid artery stenting) compared with medical management. Subanalysis was performed by symptom status at the time of presentation. The association of treatment system and of management strategy with clinical outcomes, including stroke and death, was also evaluated. Data analysis was conducted from August 15, 2015, to August 2, 2016.

Main Outcomes and Measures

The odds of procedural intervention based on treatment system was the primary outcome used to indicate the presence and effect of provider-induced demand.

Results

Of 10 579 individuals with a diagnosis of carotid artery stenosis (4615 women and 5964 men; mean [SD] age, 65.6 [11.4] years), 1307 (12.4%) underwent at least 1 procedure. After adjusting for demographic and clinical factors, the odds of undergoing procedural management were significantly higher for patients in the fee-for-service system compared with those in the salary-based setting (odds ratio, 1.629; 95% CI, 1.285-2.063; P < .001). This finding remained true when patients were stratified by symptom status at presentation (symptomatic: odds ratio, 2.074; 95% CI, 1.302-3.303; P = .002; and asymptomatic: odds ratio, 1.534; 95% CI, 1.186-1.984; P = .001).

Conclusions and Relevance

Individuals treated in a fee-for-service system were significantly more likely to undergo procedural management for carotid stenosis compared with those in the salary-based setting. These findings remained consistent for individuals with and without symptomatic disease.

Radical prostatectomy innovation and outcomes at military and civilian institutions

OBJECTIVES

Limited data are available regarding the impact of the type of healthcare delivery system on technology diffusion and associated clinical outcomes. We assessed the adoption of minimally invasive radical prostatectomy (MIRP), a recent clinical innovation, and whether this adoption altered surgical morbidity for prostate cancer surgery.

STUDY DESIGN

Retrospective review of administrative data from TRICARE, the healthcare program of the United States Military Health System. Surgery occurred at military hospitals, supported by federal appropriations, or civilian hospitals, supported by hospital revenue.

METHODS

We evaluated TRICARE beneficiaries with prostate cancer (International Classification of Disease, 9th Revision, Clinical Modification [ICD-9-CM] code: 185) who received a radical prostatectomy (60.5) between 2005 and 2009. MIRP was identified based on minimally invasive surgery codes (54.21, 17.42). We assessed yearly MIRP utilization, 30-day postoperative complications (Clavien classification system), length of stay, blood transfusion, and long-term urinary incontinence and erectile dysfunction.

RESULTS

A total of 3366 men underwent radical prostatectomy at military hospitals compared with 1716 at civilian hospitals, with minimal clinic-demographic differences. MIRP adoption was 30% greater at civilian hospitals. There were fewer blood transfusions (odds ratio, 0.44; P <.0001) and shorter lengths of stay (incidence risk ratio, 0.85; P <.0001) among civilian hospitals, while 30-day postoperative complications, as well as long-term urinary incontinence and erectile dysfunction rates, were comparable.

CONCLUSIONS

Compared with military hospitals, civilian hospitals had a greater MIRP adoption during this timeframe, but had comparable surgical morbidity.

Changes in Physician Practice Patterns after Implementation of a Communication-and-Resolution Program

OBJECTIVE

To test if a 2006 communication-and-resolution program to address unexpected adverse outcomes was associated with changes in cost and use trajectories.

DATA SOURCE

Records of patients discharged with a principal diagnosis of chest pain from 44 nonfederal general hospitals in Cook County, Illinois, between January 2002 and December 2009.

STUDY DESIGN

Propensity-score matched discharges from the intervention and comparison hospitals before computing difference-in-differences estimates of quarterly growth rates.

DATA COLLECTION METHODS

We used discharge records submitted to a central statewide repository.

PRINCIPAL FINDINGS

Relative to the comparison hospitals and to pre-implementation trends, and consistent with reduced testing at presentation, the intervention hospital recorded an increase in the number of patients with a principal diagnosis of chest pain. Among admitted patients, quarterly growth rates of clinical laboratory and radiology charges at the intervention hospital declined by 3.8 and 6.9 percentage points.

CONCLUSIONS

Among patients with chest pain, the implementation of a comprehensive communication-and-resolution program was associated with substantially reduced growth rates in the use of diagnostic testing and imaging services. Further research is needed to establish to what extent these changes were attributable to the program and clinically appropriate.

The "Seven Pillars" Response to Patient Safety Incidents: Effects on Medical Liability Processes and Outcomes

OBJECTIVE

To determine whether a communication and resolution approach to patient harm is associated with changes in medical liability processes and outcomes.

DATA SOURCES/STUDY SETTING

Administrative, safety, and risk management data from the University of Illinois Hospital and Health Sciences System, from 2002 to 2014.

STUDY DESIGN

Single health system, interrupted time series design. Using Mann-Whitney U tests and segmented regression models, we compared means and trends in incident reports, claims, event analyses, patient communication consults, legal fees, costs per claim, settlements, and self-insurance expenses before and after the implementation of the "Seven Pillars" communication and resolution intervention.

DATA COLLECTION METHODS

Queried databases maintained by Department of Safety and Risk Management and the Department of Administrative Services at UIH. Extracted data from risk module of the Midas incident reporting system.

PRINCIPAL FINDINGS

The intervention nearly doubled the number of incident reports, halved the number of claims, and reduced legal fees and costs as well as total costs per claim, settlement amounts, and self-insurance costs.

CONCLUSIONS

A communication and optimal resolution (CANDOR) approach to adverse events was associated with long-lasting, clinically and financially significant changes in a large set of core medical liability process and outcome measures.

Designing highly reliable adverse-event detection systems to predict subsequent claims

BACKGROUND

To respond proactively to patient safety events, many healthcare organizations have been enhancing and customizing their event reporting systems. Yet an indiscriminate expansion of the range and number of event reports may reduce, rather than raise, risk managers' ability to detect events that warrant a response. To avoid becoming overwhelmed by too many event reports that have little immediate operational value, risk managers therefore require a concurrent and complementary refinement of their data-processing capabilities.

OBJECTIVE

To examine the extent to which adverse event reports can predict subsequent claims.

DATA AND METHODS

The study sample included all adverse event reports and all records of closed claims that related to patient care episodes between July 1, 2006, and May 31, 2009, at a large hospital system in northern Virginia. After matching closed claims to event reports, we fitted multivariate predictive models to identify event report entries that predict future claims.

RESULTS

During the period under study, 20 151 event reports and 94 claims were filed across the health system. We were able to match 60 claims (63.8%) to at least 1 preceding event report, implying that only 0.3% of event reports preceded a subsequent matching claim. The superior prediction model identified 90% of eventual matched claims by retaining only 20% of all event reports.

CONCLUSION

Simple prediction algorithms can supplement expert judgment by screening for reports that are likely to result in a claim, thereby enabling risk managers to evaluate adverse event reports more expeditiously and to identify, and ultimately prevent, serious safety lapses more reliably.

Automated detection of retinal disease

Nearly 4 in 10 Americans with diabetes currently fail to undergo recommended annual retinal exams, resulting in tens of thousands of cases of blindness that could have been prevented. Advances in automated retinal disease detection could greatly reduce the burden of labor-intensive dilated retinal examinations by ophthalmologists and optometrists and deliver diagnostic services at lower cost. As the current availability of ophthalmologists and optometrists is inadequate to screen all patients at risk every year, automated screening systems deployed in primary care settings and even in patients' homes could fill the current gap in supply. Expanding screens to all patients at risk by switching to automated detection systems would in turn yield significantly higher rates of detecting and treating diabetic retinopathy per dilated retinal examination. Fewer diabetic patients would develop complications such as blindness, while ophthalmologists could focus on more complex cases.

The nature of surgeon human capital depreciation

To test how practice interruptions affect worker productivity, we estimate how temporal breaks affect surgeons' performance of coronary artery bypass grafting (CABG). Examining 188 surgeons who performed 56,315 CABG surgeries in Pennsylvania between 2006 and 2010, we find that a surgeon's additional day away from the operating room raised patients' inpatient mortality by up to 0.067 percentage points (2.4% relative effect) but reduced total hospitalization costs by up to 0.59 percentage points. Among emergent patients treated by high-volume providers, where temporal distance is most plausibly exogenous, an additional day away raised mortality risk by 0.398 percentage points (11.4% relative effect) but reduced cost by up to 1.4 percentage points. This is consistent with the hypothesis that as temporal distance increases, surgeons are less likely to recognize and address life-threatening complications. Our estimates imply additional intraprocedural treatment intensity has a cost per life-year preserved of $7871-18,500, well within conventional cost-effectiveness cutoffs.

Do hospitals cross-subsidize?

Despite its salience as a regulatory tool to ensure the delivery of unprofitable medical services, cross-subsidization of services within hospital systems has been notoriously difficult to detect and quantify. We use repeated shocks to a profitable service in the market for hospital-based medical care to test for cross-subsidization of unprofitable services. Using patient-level data from general short-term hospitals in Arizona and Colorado before and after entry by cardiac specialty hospitals, we study how incumbent hospitals adjusted their provision of three uncontested services that are widely considered to be unprofitable. We estimate that the hospitals most exposed to entry reduced their provision of psychiatric, substance-abuse, and trauma care services at a rate of about one uncontested-service admission for every four cardiac admissions they stood to lose. Although entry by single-specialty hospitals may adversely affect the provision of unprofitable uncontested services, these findings warrant further evaluation of service-line cross-subsidization as a means to finance them.

Integrating Patient Incentives with Episode-Based Payment

To rein in cost, payers are exploring bundled payment, which aggregates fees for a range of services into a single prospective payment. While under bundled payment providers would have incentives to reduce cost, they might also withhold more expensive care that patients prefer. We explore how bundled payment could be aligned with a benefit design that would encourage patients' consideration of cost without jeopardizing access to the most expensive treatments. Least-costly-alternative approaches allow patient choice but might deter patients from choosing more expensive care by exposing them to potentially large out-of-pocket payments. A novel "shared-savings supplement" would reward patients for choosing the least costly alternative with a supplemental cash disbursement and thus allow them to share in any cost savings. This cash incentive for the least-costly-alternative allows a reduction of the out-of-pocket payment for the expensive alternative. Thus, patients would still have the option of the more expensive therapy while facing only a modest out-of-pocket cost. Such benefit modifications could be aligned with bundled payment by splitting the responsibility for the incremental cost of more expensive care between patients and their providers.

How sensitive is physician performance to alternative compensation schedules? Evidence from a large network of primary care clinics

Despite its centrality for the provision of health care, physician compensation remains understudied, and existing studies either fail to control for time trends, cover small samples from highly particular settings, or examine empirically negligible changes in reward levels. Using a four-year sample of 59 physicians and 1.1 million encounters, we study how physicians at a network of primary care clinics responded when their salaried compensation plan was replaced with a lower salary plus substantial piece rates for encounters and select procedures. Although patient characteristics remained unchanged, physicians increased encounters by 11 to 61%, both by increasing encounters per day and days worked at the network, and increased procedures to the maximum reimbursable level.

Responding to patient safety incidents: the "seven pillars"

BACKGROUND

Although acknowledged to be an ethical imperative for providers, disclosure following patient safety incidents remains the exception. The appropriate response to a patient safety incident and the disclosure of medical errors are neither easy nor obvious. An inadequate response to patient harm or an inappropriate disclosure may frustrate practitioners, dent their professional reputation, and alienate patients.

METHODS

The authors have presented a descriptive study on the comprehensive process for responding to patient safety incidents, including the disclosure of medical errors adopted at a large, urban tertiary care centre in the United States.

RESULTS

In the first two years post-implementation, the "seven pillars" process has led to more than 2,000 incident reports annually, prompted more than 100 investigations with root cause analysis, translated into close to 200 system improvements and served as the foundation of almost 106 disclosure conversations and 20 full disclosures of inappropriate or unreasonable care causing harm to patients.

CONCLUSIONS

Adopting a policy of transparency represents a major shift in organisational focus and may take several years to implement. In our experience, the ability to rapidly learn from, respond to, and modify practices based on investigation to improve the safety and quality of patient care is grounded in transparency.

Does advanced medical technology encourage hospitalist use and their direct employment by hospitals?

In the United States, inpatient medical care increasingly encompasses the use of expensive medical technology and, at the same time, is coordinated and supervised more and more by a rapidly growing number of inpatient-dedicated physicians (hospitalists). In the production of inpatient care services, Hospitalist services can be viewed as complementary to sophisticated and expensive medical equipment in the provision of inpatient medical care. We investigate the causal relationship between a hospital's access to three types of sophisticated diagnostic and therapeutic medical equipment - intensity-modulated radiation therapy, gamma knife, and multi-slice computed tomography - and its likelihood of using hospitalists. To rule out omitted variables bias and reverse causality, we use technology-specific Certificate of Need regulation to predict technology use. We find a strong positive association, yet no causal link between access to medical technology and hospitalist use. We also study the choice of employment modality among hospitals that use hospitalists, and find that access to expensive medical technology reduces the hospital's propensity to employ hospitalists directly.

Economics of health and mortality special feature: race, infection, and arteriosclerosis in the past

We document racial trends in chronic conditions among older men between 1910 and 2004. The 1910 black arteriosclerosis rate was six times higher than the white 2004 rate and more than two times higher than the 2004 black rate. We argue that blacks' greater lifelong burden of infection led to high arteriosclerosis rates in 1910. Infectious disease, especially respiratory infections at older ages and rheumatic fever and syphilis at younger ages, predicted arteriosclerosis in 1910, suggesting that arteriosclerosis has an infectious cause. Additional risk factors for arteriosclerosis were being born in the second relative to the fourth quarter, consistent with studies implying that atherogenesis begins in utero, and a low body mass index, consistent with an infectious disease origin of arteriosclerosis.

Changes in the distribution of body mass index of white US men, 1890-2000

OBJECTIVE

The study aimed to describe changes in the distribution of body mass index (BMI) among white non-Hispanic US men aged 40-69 years throughout the 20th century.

SUBJECTS

The subjects were 12 312 randomly drawn Union Army veterans examined between 1890 and 1900, and 4059 NHANES (National Health and Nutrition Examination Survey) participants examined between 1976 and 2000.

METHOD

The study compared descriptive statistics of the age- and year-specific distributions of BMI.

RESULTS

Between 1890 and 2000, median BMI of men aged 50-59 years increased by 5.7 kg/m(2) (25%), while the standard deviation almost doubled. In this age group, the current distribution of BMI is less right-skewed than in the earlier cohort. Obesity prevalence increased from 3.4% to 35%. In 1890-1894, median BMI declined with age, but by 2000 the age pattern had been reversed. The average annual growth rate of median BMI was lowest between 1900 and 1976 and has been rising to 0.5% per annum between 1988 and 2000.

CONCLUSIONS

The increase in median BMI accounts for 75% of the rise in obesity prevalence between 1890 and 2000. The remainder must be attributed to changes in other features of the distribution, most notably the increased variance of BMI.