Cost-utility analysis of community-based interventions for hypertension control in Vietnam

Between 2010 and 2011, stakeholders implemented a multi-faceted community-based intervention in response to the escalating issue of uncontrolled hypertension in Hung Yen province, Vietnam. This initiative integrated expanded community health worker services, home blood pressure self-monitoring, and a unique "storytelling intervention" into routine clinical care. From the limited societal perspective, our study evaluates the cost-effectiveness of this intervention using a Markov model with a one-year cycle over a lifetime horizon. The analysis, based on a cohort of 671 patients, reveals a lifetime incremental cost of approximately VND 90.37 million (USD 3,930) per quality-adjusted life year (QALY) gained. With a willingness to pay at three times GDP (VND 259.2 million per QALY), the intervention proves cost-effective 80% of the time. This research underscores the potential of the community-based approach to effectively control hypertension, offering valuable insights into its broader implications for public health.

How much can we trust electronic health record data?

Trust in EHR data is becoming increasingly important as a greater share of clinical and health services research use EHR data. We discuss reasons for distrust and acknowledge limitations. Researchers continue to use EHR data because of strengths including greater clinical detail than sources like administrative billing claims. Further, many limitations are addressable with existing methods including data quality checks and common data frameworks. We discuss how to build greater trust in the use of EHR data for research, including additional transparency and research priority areas that will both enhance existing strengths of the EHR and mitigate its limitations.

Costs of Transforming Established Primary Care Practices to Patient-Centered Medical Homes (PCMHs)

BACKGROUND

The patient-centered medical home (PCMH) shows promise for improving care and reducing costs. We sought to reduce the uncertainty regarding the time and cost of PCMH transformation by quantifying the direct costs of transforming 57 practices in a medical group to National Committee for Quality Assurance (NCQA)-recognized Level III PCMHs.

METHODS

We conducted structured interviews with corporate leaders, and with physicians, practice administrators, and office managers from a representative sample of practices regarding time spent on PCMH transformation and NCQA application, and related purchases. We then developed and sent a survey to all primary care practices (practice-level response rate: initial recognition-44.6%, renewal-35.7%). Direct costs were estimated as time spent multiplied by average hourly wage for the relevant job category, plus observed expenditures.

RESULTS

We estimated HealthTexas' corporate costs for initial NCQA recognition (2010-2012) at $1,508,503; for renewal (2014-2016), $346,617; the Care Coordination resource costs an additional ongoing $390,790/year. A hypothetical 5-physician HealthTexas practice spent another estimated 239.5 hours ($10,669) obtaining, and 110.5 hours ($4,957) renewing, recognition.

CONCLUSION

Centralized PCMH support reduces the burden on practices; however, overall time and cost remains substantial, and should be weighed against the mixed evidence regarding PCMH's impact on quality and costs of care.

Improving diabetes care and outcomes with community health workers

BACKGROUND

Type II diabetes continues to be a major health problem in USA, particularly in minority populations. The Diabetes Equity Project (DEP), a clinic-based diabetes self-management and education program led by community health workers (CHWs), was designed to reduce observed disparities in diabetes care and outcomes in medically underserved, predominantly Hispanic communities.

OBJECTIVE

The purpose of this study was to evaluate the impact of the DEP on patients' clinical outcomes, diabetes knowledge, self-management skills, and quality of life.

METHODS

The DEP was implemented in five community clinics from 2009 to 2013 and 885 patients completed at least two visits with the CHW. Student's paired t-tests were used to compare baseline clinical indicators with indicators obtained from patients' last recorded visit with the CHW and to assess differences in diabetes knowledge, perceived competence in managing diabetes, and quality of life. A mixed-effects model for repeated measures was used to examine the effect of DEP visits on blood glucose (HbA1c), controlling for patient demographics, clinic and enrolment date.

RESULTS

DEP patients experienced significant (P < 0.0001) improvements in HbA1c control, blood pressure, diabetes knowledge, perceived competence in managing diabetes, and quality of life. Mean HbA1c for all DEP patients decreased from 8.3% to 7.4%.

CONCLUSION

Given the increasing prevalence of diabetes in USA and documented disparities in diabetes care and outcomes for minorities, particularly Hispanic patients, new models of care such as the DEP are needed to expand access to and improve the delivery of diabetes care and help patients achieve improved outcomes.

The impact of electronic health records on workflow and financial measures in primary care practices

OBJECTIVE

To estimate a commercially available ambulatory electronic health record's (EHR's) impact on workflow and financial measures.

DATA SOURCES/STUDY SETTING

Administrative, payroll, and billing data were collected for 26 primary care practices in a fee-for-service network that rolled out an EHR on a staggered schedule from June 2006 through December 2008.

STUDY DESIGN

An interrupted time series design was used. Staffing, visit intensity, productivity, volume, practice expense, payments received, and net income data were collected monthly for 2004-2009. Changes were evaluated 1-6, 7-12, and >12 months postimplementation.

DATA COLLECTION/EXTRACTION METHODS

Data were accessed through a SQLserver database, transformed into SAS®, and aggregated by practice. Practice-level data were divided by full-time physician equivalents for comparisons across practices by month.

PRINCIPAL FINDINGS

Staffing and practice expenses increased following EHR implementation (3 and 6 percent after 12 months). Productivity, volume, and net income decreased initially but recovered to/close to preimplementation levels after 12 months. Visit intensity did not change significantly, and a secular trend offset the decrease in payments received.

CONCLUSIONS

Expenses increased and productivity decreased following EHR implementation, but not as much or as persistently as might be expected. Longer term effects still need to be examined.

Analysis of the direct cost of surgery for four diagnostic categories of adult spinal deformity

BACKGROUND CONTEXT

Existing literature on adult spinal deformity (ASD) offers little guidance regarding an evidence-based approach to care. To optimize the value of medical treatment, a thorough understanding of the cost of surgical treatment for ASD is required.

PURPOSE

To evaluate four clinically and radiographically distinct groups of ASD and identify and compare the cost of surgical treatment among the groups.

STUDY DESIGN/SETTING

Multicenter retrospective study of consecutive surgeries for ASD.

PATIENT SAMPLE

Three hundred twenty-five consecutive ASD patients treated between 2008 and 2010.

OUTCOME MEASURES

Cost data were collected from hospital administrative records on the direct costs (DCs) incurred for the episode of surgical care, excluding overhead.

METHODS

Based on preoperative radiographs and history, patients were categorized into one of four diagnostic categories of deformity: primary idiopathic scoliosis (PIS), primary degenerative scoliosis (PDS), primary sagittal plane deformity (PSPD), and revision (R). Analysis of variance and generalized linear model regressions were used to analyze the DCs of surgery and to assess differences in costs across the four diagnostic categories considered.

RESULTS

Significant differences were observed in DC of surgery for different categories of ASD, with surgical treatment for PDS the most expensive followed in decreasing order by PSPD, PIS, and R (p<.01). Results further revealed a significant positive relationship between age and DC (p<.01) and a significant positive relationship between length of stay and DC (p<.01). Among PIS patients, for every incremental increase in levels fused, the expected DC increased by $3,997 (p=.00). Fusion to pelvis also significantly increased the DC of surgery for patients aged 18 to 29 years (p<.01) and 30 to 59 years (p<.01) but not for 60 years or more (p=.86).

CONCLUSIONS

There is an increasing DC of surgery with increasing age, length of hospital stay, length of fusion, and fusions to the pelvis. Revision surgery is the least expensive surgery on average and should therefore not preclude its consideration from a pure cost perspective.

The incident user design in comparative effectiveness research

Comparative effectiveness research includes cohort studies and registries of interventions. When investigators design such studies, how important is it to follow patients from the day they initiated treatment with the study interventions? Our article considers this question and related issues to start a dialogue on the value of the incident user design in comparative effectiveness research. By incident user design, we mean a study that sets the cohort's inception date according to patients' new use of an intervention. In contrast, most epidemiologic studies enroll patients who were currently or recently using an intervention when follow-up began. We take the incident user design as a reasonable default strategy because it reduces biases that can impact non-randomized studies, especially when investigators use healthcare databases. We review case studies where investigators have explored the consequences of designing a cohort study by restricting to incident users, but most of the discussion has been informed by expert opinion, not by systematic evidence.

Effective strategies to improve the management of diabetes: case illustration from the diabetes health and wellness institute

Many patients with diabetes do not have access to clinical care or medications, resulting in cases of undiagnosed diabetes or uncontrolled diabetes, especially in patients of low socioeconomic status. Given these considerations, new strategies are needed to control the rampant growth of diabetes and prevent new cases. This article discusses effective strategies for improving the management of diabetes in underserved populations, with special reference to the Juanita J. Craft Diabetes Health and Wellness Institute, a unique partnership between a large, urban integrated health care system, the City of Dallas, and a South Dallas community.

The effectiveness of implementing an electronic health record on diabetes care and outcomes

OBJECTIVE

To assess the impact of electronic health record (EHR) implementation on primary care diabetes care.

DATA SOURCES

Charts were abstracted semi-annually for 14,051 diabetes patients seen in 34 primary care practices in a large, fee-for-service network from January 1, 2005 to December 31, 2010. The study sample was limited to patients aged 40 years or older.

STUDY DESIGN

A naturalistic experiment in which GE Centricity Physician Office-EMR 2005 was rolled out over a staggered 3-year schedule.

DATA COLLECTION

Chart audits were conducted using the AMA/Physician Consortium Adult Diabetes Measure set. The primary outcome was the HealthPartners' "optimal care" measure: HbA1c ≤ 8 percent; LDL cholesterol < 100 mg/dl; blood pressure < 130/80 mmHg; not smoking; and documented aspirin use in patients ≥ 40 years of age.

PRINCIPAL FINDINGS

After adjusting for patient age, sex, and insulin use, patients exposed to the EHR were significantly more likely to receive "optimal care" when compared with unexposed patients (p < .001), with an estimated difference of 9.20 percent (95% CI: 6.08, 12.33) in the final year between exposed patients and patients never exposed. Components of the optimal care bundle showing positive improvement after adjustment were systolic blood pressure <80 mmHg, diastolic blood pressure <130 mmHg, aspirin prescription, and smoking cessation. Among patients exposed to EHR, all process and outcome measures except HbA1c and lipid control showed significant improvement.

CONCLUSION

Implementation of a commercially available EHR in primary care practice may improve diabetes care and clinical outcomes.

Initial and subsequent therapy for newly diagnosed type 2 diabetes patients treated in primary care using data from a vendor-based electronic health record

BACKGROUND

Diabetes is a leading cause of death and disability, and its prevalence is increasing. When diet fails, patients with type 2 diabetes mellitus (T2DM) are prescribed oral hypoglycemics for glycemic control. Few studies have explored initial use or change from initial oral hypoglycemic therapy in the primary care setting. We aimed to describe the utilization of initial oral hypoglycemics among newly diagnosed patients with diabetes from 1998-2009 and changes from initial to subsequent therapy among patients prescribed older oral hypoglycemic agents using electronic health records.

METHODS

This observational cohort study used electronic health records from newly diagnosed patients with T2DM between 1 January 1998 and 31 March 2009 at two large health systems in the USA. Oral hypoglycemics included older (biguanide, sulfonylurea, and thiazolidinedione) and newer agents (incretin mimetic agents, alpha-glucosidase inhibitors, and D-phenylalanine derivatives). Multinomial regression models were fit to evaluate initial older oral hypoglycemic medication. We used incidence density sampling and conditional logistic regression models to evaluate predictors of regimen change.

RESULTS

Most patients were treated from the biguanide class of oral hypoglycemics (67%), but there were differences in initial prescribing by age and race. HbA1c (Odds Ratio for HbA1c 7.0-8.9 vs < 7.0, 5.87 [95% Confidence Interval: 3.62-9.52]; Odds Ratio for HbA1c ≥ 9 vs < 7.0, 20.25 [95% Confidence Interval: 8.32-49.29] and Black people (Odds Ratio, 0.29 [95% Confidence Interval: 0.14, 0.60]) versus White people were associated with regimen change in the adjusted analysis.

CONCLUSIONS

Clinical and demographic characteristics influence choice and duration of initial oral hypoglycemic treatment as well as regimen changes.

Patient-centeredness and timeliness in a primary care network: baseline analysis and power assessment for detection of the effects of an electronic health record

Electronic health records are expected to improve all six dimensions of quality care identified by the Institute of Medicine (safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness). HealthTexas Provider Network, the ambulatory care network affiliated with the Baylor Health Care System in Dallas-Fort Worth, Texas, is implementing a networkwide ambulatory electronic health record (AEHR). To evaluate the quality of care and financial impact of the AEHR implementation, we examined the available indicators for quantitatively measuring performance in each dimension of quality. For patient-centeredness, the primary data source available is the patient satisfaction survey. To achieve a broad view of patient-centeredness, we identified two measures of satisfaction (overall satisfaction with the physician and willingness to refer the physician) to be examined individually and used additional survey items to construct physician interaction and organizational scales. These scales showed good reliability (Cronbach alpha = 0.95 and 0.89, respectively) and predictive ability ranging from 77% to 93% when applied to the overall satisfaction measures. Data from September 2003 to June 2006 showed mean pre-AEHR implementation baseline performance of 22.9 (±3.3) on the 25-point physician interaction scale and 38.0 (±5.8) on the 45-point organizational scale; 70.9% of patients reported excellent satisfaction with their physician, and 97.6% of patients reported willingness to refer. Timeliness data were collected using the same survey. Baseline performance showed that 43.4% of patients waited <2 days between making and keeping an appointment, and 50.6% of patients waited <5 minutes past appointment time. However, 12.5% waited >30 days between making and keeping an appointment, and 14.0% waited >30 minutes past appointment time. The power to detect changes in the patient-centeredness and timeliness measures in the 3-year multiple time series evaluation of the quality and financial impact of the AEHR was investigated and showed that even small changes in these measures will be detectable.

The financial and nonfinancial costs of implementing electronic health records in primary care practices

The incentives in the American Recovery and Reinvestment Act to expand the "meaningful use" of electronic health record systems have many health care professionals searching for information about the cost and staff resources that such systems require. We report the cost of implementing an electronic health record system in twenty-six primary care practices in a physician network in north Texas, taking into account hardware and software costs, as well as the time and effort invested in implementation. For an average five-physician practice, implementation cost an estimated $162,000, with $85,500 in maintenance expenses during the first year. We also estimate that the HealthTexas network implementation team and the practice implementation team needed 611 hours, on average, to prepare for and implement the electronic health record system, and that "end users"-physicians, other clinical staff, and nonclinical staff-needed 134 hours per physician, on average, to prepare for use of the record system in clinical encounters.

Impact of a standardized heart failure order set on mortality, readmission, and quality and costs of care

OBJECTIVE

To determine the impact of a standardized heart failure order set on mortality, readmission, and quality and costs of care.

DESIGN

Observational study.

SETTING

Eight acute care hospitals and two specialty heart hospitals.

PARTICIPANTS

All adults (>18 years) discharged from one of the included hospitals between December 2007 and March 2009 with a diagnosis of heart failure, who had not undergone heart transplant, did not have a left ventricular assistive device, and with a length of stay of 120 or less days.

INTERVENTIONS

A standardized heart failure order set was developed internally, with content driven by the prevailing American College of Cardiology/American Heart Association clinical practice guidelines, and deployed systemwide via an intranet physician portal.

MAIN OUTCOME MEASURES

Publicly reported process of care measures, in-patient mortality, 30-day mortality, 30-day readmission, length of stay, and direct cost of care were compared for heart failure patients treated with and without the order set.

RESULTS

Order set used reached 73.1% in March 2009. After propensity score adjustment, order set use was associated with significantly increased core measures compliance [odds ratio (95% confidence interval) = 1.51(1.08; 2.12)] and reduced in-patient mortality [odds ratio (95% confidence interval) = 0.49(0.28; 0.88)]. Reductions in 30-day mortality and readmission approached significance. Direct cost for initial admissions alone and in combination with readmissions were significantly lower with order set use.

CONCLUSIONS

Implementing an evidence-based standardized order set may help improve outcomes, reduce costs of care and increase adherence to evidence-based processes of care.

Finding the ROI in EMRs

There are five common pitfalls in using clinical studies to calculate the ROI of electronic medical records (EMRs): Imputing value to minutes of time saved when staffing is not reduced. Imputing or estimating cost savings that can't be measured. Ignoring the revenue impact of reduced resource utilization. Ignoring baseline performance in extrapolating benefits. Using fixed costs in financial savings analyses.

Applying total quality management (TQM) to health care administration

Author Neil S. Fleming, Ph.D., ASQC, C.Q.E., approaches quality management from a more theoretical perspective, relating it to dimensions of predictability and responsiveness. He couples these with achieving the optimal balance between prevention, appraisal and failure with the goal of producing the lowest possible total quality costs.

Physician payment reform: how will medical specialties fare under the new Medicare fee schedule?

In 1989, the federal government legislated a major overhaul of the Medicare payment system for physician services, to be implemented beginning in January 1992. Under the new plan, payments will be set according to a national fee schedule based primarily on a "resource-based relative value scale." This article summarizes the development of the new payment system and explores the likely impact of its implementation on medical and surgical specialties.

The impact of the Texas 1989 motorcycle helmet law on total and head-related fatalities, severe injuries, and overall injuries

The State of Texas implemented a mandatory total motorcycle helmet law for all operators and passengers, effective September 1, 1989. In this study the impact of this intervention on frequency of both total and head-related fatalities, severe injuries, and overall injuries for operators during the subsequent year was quantified. This quantification is important because 26 states in the United States fail to have strict, mandatory helmet laws. The Box-Tiao time-series intervention methodology is used to estimate secular trends before and changes after the implementation of the law, analyzing Department of Public Safety monthly injury accident data for a period of 6 years collected from traffic accident reports filed for each motorcycle injury accident. Trends in fatalities and injuries (except for head-related deaths) estimated before implementation of the law approximated the 9.4% average annual decline in motorcycle registrations. Additional declines of 12.6% and 57.0%, respectively, were estimated for total and head-related fatalities during the year after the law was implemented. Declines of 13.1% and 54.6% were estimated for severe injuries for total and head-related accidents. Declines of 12.3% and 52.9% were found for total and head-related injuries overall.

The erosion of physician-patient privilege and patient confidentiality

With the proliferation of third party payers for health care who exercise utilization management, there has been an erosion of the physician-patient privilege and patient confidentiality. The kinds of medical information obtained by third party payers under the guise of claims administration violate the spirit if not the actual laws pertaining to physician-patient communication. It presents three episodes involving the first author in which that communication was violated by third parties administering health care benefits. Recommendations are made to protect that confidentiality in this era of increasing cost management.

Approaches to primary care. Physician capitation

The first author, as a consultant to the Office of Prepaid Health Care, reviewed the financial status of nine IPAs for federal qualification in 1987. He found little to suggest any methodology being used for constructing primary care physician (PCP) capitation reimbursement systems. This article draws upon statistical theory and presents hypothetical examples to structure better financial arrangements based on five criteria: stop-loss reinsurance deductible levels, capitation of services related to physician practice, minimum panel size (number of patients) for capitation, stratified capitation, and inclusion of all PCPs in the capitation arrangement.

Sociodemographic differences in access to vision care among adults in the United States, 1974-1975

Access to refractive care is examined by comparing uncorrected and corrected (with eyeglasses or contact lenses) distance visual acuity across eight race-sex-economic status groups. Of those with less than 20/20 uncorrected distance visual acuity, the age-adjusted proportion using corrective lenses is examined across these sociodemographic groups to assess unmet need in vision care. Measurements of distance visual acuity were obtained for 2,828 adults aged 25-74 years from the national probability sample selected for the 1974-1975 National Health and Nutrition Examination Augmentation Survey. Questionnaire responses were collected on usual correction. Individuals were classified by race, sex, and economic status. Weighted least squares categoric data analysis showed that blacks, males, and nonpoor persons have a higher proportion with 20/20 uncorrected distance vision than whites, females, and poor persons. Individuals who are white, male, and nonpoor are more likely to have 20/20 corrected distance vision than their counterparts.

The impact of outpatient department and emergency room use on costs in the Texas Medicaid Program

Medicaid claims data for a 35% random sample (n = 146,167) of persons receiving benefits from Aid to Families with Dependent Children, and who were eligible for Medicaid in Texas in 1980 are used to examine the impact of outpatient department (OPD)/emergency room (ER) care. Average cost is estimated for OPD/ER and private physician (MD) visits. Persons are also classified by primary source of care. Data on age, race, sex, residence, and months eligible in 1980 permitted prediction of statistically adjusted differences between OPD- and MD-oriented persons for number of ambulatory visits, probability of hospitalization, 1980 total costs, and both hospital episode institutional amount paid and length of stay. OPD/ER visits were found to be $23 more expensive than MD visits. OPD-oriented persons had fewer ambulatory visits, slightly more hospitalizations, greater total and episode costs, and longer lengths of stay than did MD-oriented persons. Potential cost savings are projected.