Determining variable costs in the acute urolithiasis cycle of care through time-driven activity-based costing

OBJECTIVE

To characterize full cycle of care costs for managing an acute ureteral stone using time-driven activity-based costing.

METHODS

We defined all phases of care for patients presenting with an acute ureteral stone and built an overarching process map. Maps for sub-processes were constructed through interviews with providers and direct observation of clinical spaces. This facilitated calculation of cost per minute for all aspects of care delivery, which were multiplied by associated process times. These were added to consumable costs to determine cost for each specific step and later aggregated to determine total cost for each sub-process. We compared costs of eight common clinical pathways for acute stone management, defining total cycle of care cost as the sum of all sub-processes that comprised each pathway.

RESULTS

Cost per sub-process included $920 for emergency department (ED) care, $1665 for operative stent placement, $2368 for percutaneous nephrostomy tube placement, $106 for urology clinic consultation, $238 for preoperative center visit, $4057 for ureteroscopy with laser lithotripsy (URS), $2923 for extracorporeal shock wave lithotripsy, $169 for clinic stent removal, $197 for abdominal x-ray, and $166 for ultrasound. The lowest cost pathway ($1388) was for medical expulsive therapy, whereas the most expensive pathway ($8002) entailed a repeat ED visit prompting temporizing stent placement and interval URS.

CONCLUSION

We found a high degree of cost variation between care pathways common to management of acute ureteral stone episodes. Reliable cost accounting data and an understanding of variability in clinical pathway costs can inform value-based care redesign as payors move away from pure fee-for-service reimbursement.

Time-Driven Activity-Based Costing in Breast Cancer Care Delivery

BACKGROUND

Accurate measurement of healthcare costs is required to assess and improve the value of oncology care.

OBJECTIVES

We aimed to determine the cost of breast cancer care provision across collaborating health care organizations.

METHODS

We used time-driven activity-based costing (TDABC) to calculate the complete cost of breast cancer care-initial treatment planning, chemotherapy, radiation therapy, surgical resection and reconstruction, and ancillary services (e.g., psychosocial oncology, physical therapy)-across multiple hospital sites. Data were collected between December 2019 and February 2020. TDABC steps involved (1) developing process maps for care delivery pathways; (2) determine capacity cost rates for staff, medical equipment, and hospital space; (3) measure the time required for each process step, both manually through clinic observation and using data from the Real-Time Location System (RTLS); and (4) calculate the total cost of care delivery.

RESULTS

Surgical care costs ranged from $1431 for a lumpectomy to $12,129 for a mastectomy with prepectoral implant reconstruction. Radiation therapy was costed at $1224 for initial simulation and patient education, and $200 for each additional treatment. Base costs for chemotherapy delivery were $382 per visit, with additional costs driven by chemotherapy agent(s) administered. Personnel expenses were the greatest contributor to the cost of surgical care, except in mastectomy with implant reconstruction, where device costs equated to up to 60% of the cost of surgery.

CONCLUSION

The cost of complete breast cancer care depended on (1) treatment protocols; (2) patient choice of reconstruction; and (3) the need for ancillary services (e.g., physical therapy). Understanding the actual costs and cost drivers of breast cancer care delivery may better inform resource utilization to lower the cost and improve the quality of care.

Improving efficiency and reducing costs of MRI-Guided prostate brachytherapy using Time-Driven Activity-Based costing

INTRODUCTION

Integrated quality improvement (QI) and cost reduction strategies can help increase value in cancer care. Time-driven activity-based costing (TDABC) is a bottom-up costing tool that measures resource use over the full care cycle. We applied standard QI and TDABC methods to improve workflow efficiency and reduce costs for MRI-guided prostate brachytherapy.

METHODS AND MATERIALS

We constructed process maps of the baseline prostate brachytherapy workflow from initial consultation through one year after treatment. Process maps reflected resources and time required at each step. TDABC costs were calculated by multiplying each process time by the cost per min of the resource(s) used at that step. We then used plan-do-study-act methodology to identify workflow inefficiencies and implement solutions to reduce resource consumption.

RESULTS

The highest cost components at baseline were the operating room (OR) (40%), imaging (8.7%), and consultation (7.6%). Higher-than-expected costs (3%) were incurred during surgery scheduling. After targeted QI initiatives, OR time was reduced from 90 to 70 min, which reduced overall cost by 5%. Personnel task downshifting reduced costs by 10% at consultation and 77% at surgery scheduling. Re-engineering of follow-up protocols reduced costs by 8.4%. Costs under the new workflow decreased by 18.2%.

CONCLUSIONS

TDABC complements traditional QI initiatives by quantifying the highest cost steps and focusing QI initiatives to reduce costs and improve efficiency. As payment reform evolves toward bundled payments, TDABC and QI initiatives will help providers understand, communicate, and improve the value of cancer care.

Activity-Based Costing of Intensity-Modulated Proton versus Photon Therapy for Oropharyngeal Cancer

PURPOSE

In value-based health care delivery, radiation oncologists need to compare empiric costs of care delivery with advanced technologies, such as intensity-modulated proton therapy (IMPT) and intensity-modulated radiation therapy (IMRT). We used time-driven activity-based costing (TDABC) to compare the costs of delivering IMPT and IMRT in a case-matched pilot study of patients with newly diagnosed oropharyngeal (OPC) cancer.

MATERIALS AND METHODS

We used clinicopathologic factors to match 25 patients with OPC who received IMPT in 2011-12 with 25 patients with OPC treated with IMRT in 2000-09. Process maps were created for each multidisciplinary clinical activity (including chemotherapy and ancillary services) from initial consultation through 1 month of follow-up. Resource costs and times were determined for each activity. Each patient-specific activity was linked with a process map and TDABC over the full cycle of care. All calculated costs were normalized to the lowest-cost IMRT patient.

RESULTS

TDABC costs for IMRT were 1.00 to 3.33 times that of the lowest-cost IMRT patient (mean ± SD: 1.65 ± 0.56), while costs for IMPT were 1.88 to 4.32 times that of the lowest-cost IMRT patient (2.58 ± 0.39) (P < .05). Although single-fraction costs were 2.79 times higher for IMPT than for IMRT (owing to higher equipment costs), average full cycle cost of IMPT was 1.53 times higher than IMRT, suggesting that the initial cost increase is partly mitigated by reductions in costs for other, non-RT supportive health care services.

CONCLUSIONS

In this matched sample, although IMPT was on average more costly than IMRT primarily owing to higher equipment costs, a subset of IMRT patients had similar costs to IMPT patients, owing to greater use of supportive care resources. Multidimensional patient outcomes and TDABC provide vital methodology for defining the value of radiation therapy modalities.

Value-Based Healthcare in Urology: A Collaborative Review

CONTEXT

In response to growing concerns over rising costs and major variation in quality, improving value for patients has been proposed as a fundamentally new strategy for how healthcare should be delivered, measured, and remunerated.

OBJECTIVE

To systematically review the literature regarding the implementation and impact of value-based healthcare in urology.

EVIDENCE ACQUISITION

A systematic review was performed to identify studies that described the implementation of one or more elements of value-based healthcare in urologic settings and in which the associated change in healthcare value had been measured. Twenty-two publications were selected for inclusion.

EVIDENCE SYNTHESIS

Reorganization of urologic care around medical conditions was associated with increased use of guidelines-compliant care for men with prostate cancer, and improved outcomes for patients with lower urinary tract symptoms. Measuring outcomes for every patient was associated with improved prostate cancer outcomes, while the measurement of costs using time-driven activity-based costing was associated with reduced resource utilization in a pediatric multidisciplinary clinic. Centralization of urologic cancer care in the UK, Denmark, and Canada was associated with overall improved outcomes, although systems integration in the USA yielded mixed results among urologic cancer patients. No studies have yet examined bundled payments for episodes of care, expanding the geographic reach for centers of excellence, or building enabling information technology platforms.

CONCLUSIONS

Few studies have critically assessed the actual or simulated implementation of value-based healthcare in urology, but the available literature suggests promising early results. In order to effectively redesign care, there is a need for further research to both evaluate the potential results of proposed value-based healthcare interventions and measure their effects where already implemented.

PATIENT SUMMARY

While few studies have evaluated the implementation of value-based healthcare in urology, the available literature suggests promising early results.

Utilizing time-driven activity-based costing to determine open radical cystectomy and ileal conduit surgical episode cost drivers

OBJECTIVES

Patients undergoing radical cystectomy represent a particularly resource-intensive patient population. Time-driven activity based costing (TDABC) assigns time to events and then costs are based on the people involved in providing care for specific events. To determine the major cost drivers of radical cystectomy care we used a TDABC analysis for the cystectomy care pathway.

SUBJECTS AND METHODS

We retrospectively reviewed a random sample of 100 patients out of 717 eligible patients undergoing open radical cystectomy and ileal conduit for bladder cancer at our institution between 2012 and 2015. We defined the cycle of care as beginning at the preoperative clinic visit and ending with the 90-day postoperative clinic visit. TDABC was carried out with construction of detailed process maps. Capacity cost rates were calculated and the care cycle was divided into 3 phases: surgical, inpatient, and readmissions. Costs were normalized to the lowest cost driver within the cohort.

RESULTS

The mean length of stay was 6.9 days. Total inpatient care was the main driver of cost for radical cystectomy making up 32% of the total costs. Inpatient costs were mainly driven by inpatient staff care (76%). Readmissions were responsible for 29% of costs. Surgery was 31% of the costs, with the majority derived from operating room staff costs (65%).

CONCLUSION

The major driver of cost in a radical cystectomy pathway is the inpatient stay, closely followed by operating room costs. Surgical costs, inpatient care and readmissions all remain significant sources of expense for cystectomy and efforts to reduce cystectomy costs should be focused in these areas.

Value-Based Health Care in Undergraduate Medical Education

PROBLEM

Value-based health care (VBHC) is an innovative framework for redesigning care delivery to achieve better outcomes for patients and reduce cost; however, providing students with the skills to understand and engage with these topics is a challenge to medical educators.

APPROACH

Here, the authors present a novel, VBHC curriculum integrated into a required course for post-core clerkship students-launched in 2018 at Harvard Medical School and taught in conjunction with Harvard Business School faculty-that highlights key principles of VBHC most relevant to undergraduate medical education. The course integrates VBHC with related health disciplines, including health policy, ethics, epidemiology, and social medicine, using a case-based method. Students practice active decision making while learning key concepts to address value in clinical practice.

OUTCOMES

Since the course's inception in March 2018, 95 students (87%) completed the standardized course evaluation; the majority said VBHC content and pedagogical style (i.e., case-based learning) enhanced their learning. Students' critiques focused on too little integration with other disciplines (e.g., social medicine, ethics), the physical space, and inadequate time for debates about potential tensions between VBHC and other course disciplines.

NEXT STEPS

The authors believe that by exposing medical students to the principles of VBHC, students will fulfill the expectations of graduating physicians by excelling as critical thinkers, collaborative team members, and judicious care providers throughout their residency, clinical practice, and beyond. Future VBHC curricula expansions may include elective coursework, intensive seminar series, and formal dual degrees.

Using Time-Driven Activity-Based Costing to Demonstrate Value in Perioperative Care: Recommendations and Review from the Society for Perioperative Assessment and Quality Improvement (SPAQI)

A shift in healthcare payment models from volume toward value-based incentives will require deliberate input into systems development from both perioperative clinicians and administrators to ensure appropriate recognition of the value of all services provided-particularly ones that are not reimbursable in current fee-for-service payment models. Time-driven activity-based costing (TDABC) methodology identifies cost drivers and reduces inaccurate costing based on siloed budgets. Inaccurate costing also results from the fact that current costing methods use charges and there has been tremendous cost shifting throughout health care. High cost, high variability processes can be identified for process improvement. As payment models inevitably evolve towards value-based metrics, it will be critical to knowledgably participate in the coordination of these changes. This document provides 8 practical Recommendations from the Society for Perioperative Assessment and Quality Improvement (SPAQI) aimed at outlining the principles of TDABC, creating process maps for patient workflows, understanding payment structures, establishing physician alignment across service lines to create integrated practice units to facilitate development of evidence-based pathways for specific patient risk groups, establishing consistent care delivery, minimizing variability between physicians and departments, utilizing data analytics and information technology tools to track progress and obtain actionable data, and using TDABC to create costing transparency.

Development and Feasibility of Bundled Payments for the Multidisciplinary Treatment of Head and Neck Cancer: A Pilot Program

Purpose:

Despite growing interest in bundled payments to reduce the costs of care, this payment method remains largely untested in cancer. This 3-year pilot tested the feasibility of a 1-year bundled payment for the multidisciplinary treatment of head and neck cancers.

Methods:

Four prospective treatment-based bundles were developed for patients with selected head and neck cancers. These risk-adjusted bundles covered 1 year of care that began with primary cancer treatment. Manual processes were developed for patient identification, enrollment, billing, and payment. Patients were prospectively identified and enrolled, and bundled payments were made at treatment start. Operational metrics tracked incremental effort for pilot processes and average payment cycle time compared with fee-for-service (FFS) payments.

Results:

This pilot confirmed the feasibility of a 1-year prospective bundled payment for head and neck cancers. Between November 2014 and October 2016, 88 patients were enrolled successfully with prospective bundled payments. Through September 2017, 94% of patients completed the pilot with 6% still enrolled. Manual pilot processes required more effort than anticipated; claims processing was the most time-consuming activity. The production of a bundle bill took an additional 15 minutes versus FFS billing. The average payment cycle time was 37 days (range, 15 to 141 days) compared with a 15-day average under FFS.

Conclusion:

Prospective bundled payments were successfully implemented in this pilot. Additional pilots should study this payment method in higher-volume cancers. Robust systems are needed to automate patient identification, enrollment, billing, and payment along with policies that reduce administrative burden and allow for the introduction of novel cancer therapies.

Measuring cost in the value equation using time-driven activity-based costing (TDABC) at The University of Texas MD Anderson Cancer Center, Division of Radiation Oncology

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Background: The cost of a full cycle of radiation therapy at MD Anderson Cancer Center has not been determined using a bottom-up measurement approach. Due to the complexity and variation in clinical processes, typical costing strategies do not provide the level of detail necessary to evaluate the value equation, defined as outcomes over cost. To address this limitation, we designed and implemented a practice-wide Time-Driven Activity-Based Costing (TDABC) strategy to capture our total direct cost of care for all treatment modalities within each of 9 disease site-specific services. Methods: Process maps were created for each of the 9 disease site-specific services. Care delivery times were captured by treatment modality for each service as determined by multidisciplinary teams routinely performing each step of the process. The data were entered into a standardized tool, which calculated step costs based upon capacity cost rates for each human resource. The costing tool also calculated total direct labor costs for specific treatment plans based on modality, complexity, and fractionation. Results: The analysis took six months to complete and required the use of approximately 1,000 administrative hours, 250 physician hours, 250 clinical staff hours and 100 medical physics hours. Approximately 17 process maps were created for each of the 9 services with each process map receiving further analysis based upon radiation treatment modality. As a result of observed variation in costs between disease-site services, best practices were identified and 15 standardization opportunities were discovered. Additionally, the cost-benefit analysis between high profile modalities within each disease-site service, such as Proton Therapy and Intensity Modulated Radiation Therapy (IMRT) on the Head and Neck service, were easier to complete. Conclusions: Time-Driven Activity-Based Costing is a valid method for calculating direct costs in a large academic radiation oncology practice. Standardized clinical outcome data can be used to complete the value equation and ultimately provide insight for better clinical and administrative decision making.

Cancer patients' answers to surveys: Incorporation into the electronic health record (EHR) can decrease manual data entry and increase patient-centered information

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Background: Delivery of value-based cancer care has centered on the use of EHR’s and how these applications can document health information, including patient reported outcomes (PRO’s), (1-4). Survey information must be incorporated into the medical record with minimal staff intervention. Our institution, and many cancer centers are currently using “EPIC” as their EHR platform. Although this is a data driven platform, and data can be extracted and reported as desired, certain things need to be done prior to going live in order to ensure this occurs. Surveys must be built using standardized “smart data elements” (SDE’s). If patient data is gathered, but not integrated correctly into the EHR, one will find themselves manually entering data. The goal is to allow patients to answer questions about their health history 1 time, validate answers, incorporate into the EHR, and report data. Methods: We engaged our technology team prior to “go-live” to build patient survey questionnaires. 40 survey questions, were mapped to 72 specific EHR/“EPIC” SDE’s. The SDE’s included cancer diagnoses and past medical history. Patients received and completed the electronic survey via the patient portal. Clinic providers validated patient answers from the surveys and the information was incorporated into the EHR. Results: Patient entered survey data collected, documented, and reported within the EHR. Decreased data entry by providers, efficiently incorporating the patient cancer diagnosis and medical history into the EHR. Data collected for review/reporting/research as needed. Conclusions: EHR’s can gather specific/discrete patient data to benefit both patients and providers. Cancer patients can participate in providing health information easily incorporated and documented by the provider. Data can be updated as needed, and used for patient reported outcomes (PRO’s) and other research endeavors. EHR’s should enhance care by allowing providers to spend more face to face time with patients and providing data that is most important to patients from which they may make informed decisions about their health care.

Communicating Value in Health Care Using Radar Charts: A Case Study of Prostate Cancer

PURPOSE

The transformation from volume to value will require communication of outcomes and costs of therapies; however, outcomes are usually nonstandardized, and cost of therapy differs among stakeholders. We developed a standardized value framework by using radar charts to visualize and communicate a wide range of patient outcomes and cost for three forms of prostate cancer treatment.

MATERIALS AND METHODS

We retrospectively reviewed data from men with low-risk prostate cancer who were treated with low-dose rate brachytherapy (LDR-BT), proton beam therapy, or robotic-assisted prostatectomy. Patient-reported outcomes comprised the Expanded Prostate Cancer Index Composite-50 domains for sexual function, urinary incontinence and/or bother, bowel bother, and vitality 12 months after treatment. Costs were measured by time-driven activity-based costing for the first 12 months of the care cycle. Outcome and cost data were plotted on a single radar chart for each treatment modality.

RESULTS

Outcome and cost data from patients who were treated with robotic-assisted prostatectomy (n = 381), proton beam therapy (n = 165), and LDR-BT (n = 238) were incorporated into the radar chart. LDR-BT seemed to deliver the highest overall value of the three treatment modalities; however, incorporation of patient preferences regarding outcomes may allow other modalities to be considered high-value treatment options.

CONCLUSION

Standardization and visualization of outcome and cost metrics may allow more comprehensive and collaborative discussions about the value of health care services. Communicating the value framework by using radar charts may be an effective method to present total value and the value of all outcomes and costs in a manner that is accessible to all stakeholders. Variations in plotting of costs and outcomes will require future focus group initiatives.

Value-based healthcare: implications for thyroid cancer

Today's delivery of care to thyroid cancer patients is complex, and costly, with uneven outcomes that can be improved. The incidence of thyroid cancer is rising and requires coordinated, multidisciplinary care with high volume centers that is not always available in our current fragmented healthcare system. To address the needs of patients, providers and payers, we believe that thyroid cancer care needs to be reexamined from the perspective of value for the patient, which is defined as the outcomes that matter to patients relative to the cost of delivering them. This paper provides recommendations based on the key principles of the value-based approach to transform the delivery of thyroid cancer care.

Variations in Proton Therapy Coverage in the State of Texas: Defining Medical Necessity for a Safe and Effective Treatment

Purpose

The definition of medical necessity and indications for coverage of proton beam therapy (PBT) for the treatment of cancer can vary greatly among different professional societies (PSs) and payors. Variations in policies introduce substantial inefficiencies and limit access for patients who may clinically benefit from PBT. The purpose of this study was to analyze differences in medical necessity and coverage policies among payors and a PS.

Materials and Methods

Peer-reviewed references and coverage decisions were abstracted from the coverage policies of each of the major payors in the state of Texas (Aetna-TX, UnitedHealthcare-TX, Blue Cross Blue Shield-TX) as well as from a representative PS, the Particle Therapy Cooperative Group. Differences in number and quality of references as well as coverage decisions were analyzed with descriptive statistics.

Results

Proton beam therapy coverage in the state of Texas varied among payors and the PS for several disease sites, including the central nervous system, eyes, and prostate. The PS cited more references and higher levels of evidence than payor policies (P < .01). Levels of evidence were inconsistent between policies. Interestingly, only 18% to 29% of cited references overlapped between policies.

Conclusions

Payors and PSs have independent and nonstandardized processes for determining PBT coverage, which result in variations in both coverage and evidence cited. These differences can lead to clinical inefficiencies and may reduce access to PBT based on payor status rather than clinical utility. A collaborative approach among all stakeholders would help create a more consistent, equitable, and patient-centered PBT policy that could identify areas for further evidence development.

Value-Based Breast Cancer Care: A Multidisciplinary Approach for Defining Patient-Centered Outcomes

PURPOSE

Value in healthcare-i.e., patient-centered outcomes achieved per healthcare dollar spent-can define quality and unify performance improvement goals with health outcomes of importance to patients across the entire cycle of care. We describe the process through which value-based measures for breast cancer patients and dynamic capture of these metrics via our new electronic health record (EHR) were developed at our institution.

METHODS

Contemporary breast cancer literature on treatment options, expected outcomes, and potential complications was extensively reviewed. Patient perspective was obtained via focus groups. Multidisciplinary physician teams met to inform a 3-phase process of (1) concept development, (2) measure specification, and (3) implementation via EHR integration.

RESULTS

Outcomes were divided into 3 tiers that reflect the entire cycle of care: (1) health status achieved, (2) process of recovery, and (3) sustainability of health. Within these tiers, 22 patient-centered outcomes were defined with inclusion/exclusion criteria and specifications for reporting. Patient data sources will include the Epic Systems EHR and validated patient-reported outcome questionnaires administered via our institution's patient portal.

CONCLUSIONS

As healthcare costs continue to rise in the United States and around the world, a value-based approach with explicit, transparently reported patient outcomes will not only create opportunities for performance improvement but will also enable benchmarking across providers, healthcare systems, and even countries. Similar value-based breast cancer care frameworks are also being pursued internationally.

Measuring value in bundled payments for head and neck cancer

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Background: Value, defined as outcomes relative to costs, cannot be improved without rigorous long-term measurement. To assess value within a bundled payment pilot for head and neck cancer, we aim to generate timely, patient-centered outcomes and robust, near-real time financial tracking (Porter and Teisberg, Redefining health care. Creating value-based competition on results; Harvard Business School Press, 2006). Methods: Clinical and quality experts created an outcome measure set for head and neck cancer, using a three-tiered outcomes hierarchy from Michael Porter of Harvard Business School as a framework. Process measures were identified to evaluate compliance with standards of care. Data sources were verified and patient-reported outcomes were collected via a patient portal. A REDCap database was created to aggregate all longitudinal outcomes. The project managers and financial leaders identified key financial metrics to be tracked for enrolled patients. Outcomes and financial data were built into a dashboard to deliver timely, actionable information on value. Patients will be tracked for 2 years post-treatment completion. Results: 22 outcome measures and 6 process measures are being collected for all enrolled patients. Financial indicators, such as cumulative costs and fee-for-service payment vs. bundled payment, are being tracked for each patient. Currently, most outcomes and financial data are extracted manually. Implementation of a new electronic health record (EHR) should alleviate much of this administrative burden (Table). Conclusions: The project demonstrates the feasibility of value measurement for bundled payment. With provider and patient input, the outcome measures direct attention to what is important to patients and is actionable by clinicians. Additionally, near real-time financial tracking offers insights into the financial implications of this alternative payment model for cancer care. With automation via the EHR, this value measurement methodology can be scaled for other disease sites and additional payers. [Table: see text]

Evaluation of resource utilization using time-derived, activity-based costing (TDABC) to result in more effective processes and cost reduction

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Background: Current changes in health care economics have led to a focus on value-based health care. TDABC is a systematic method to assess personnel utilization and the associated cost in the delivery of medical care. Based on baseline process maps and cost estimates in our outpatient center, cancer surveillance visits (CSV) were identified as inefficient, lengthy and high cost. The purpose of this study was to determine if reallocation of personnel was feasible, resulted in decrease cost and better value care. Methods: In 2014, a multidisciplinary team developed process maps for each visit type in the outpatient center. Maps included each step of clinical care from registration to check out and the personnel associated with that care. Total personnel costs were based on the estimated time spent with each patient and the average salary of the care provider. In 9/2014, we instituted an advanced practice provider (APP) independent practice initiative where CSV were done by either faculty or APP, no longer both. Billing codes were used to determine the % of CSV seen by APPs only. Patient and staff satisfaction were assessed pre- and post-implementation with validated measures. Results: At baseline, the estimated patient time and personnel cost for a CSV was 98 min and $380.79. The estimated patient time and personnel cost for an APP only CSV was 53 min and $132.60.; resulting in a potential savings of $249/CSV. Prior to 9/14 less than 21% were seen by APP’s only. After implementation of the initiative, the number of APP only visits increased each quarter to Q1 27%, Q2 38%, Q3 40% and Q4 41%. The estimated cost savings based on 4000 CSV/year was $354,000. Patient satisfaction remained the same (Press-Ganey). APP and physician engagement/satisfaction increased by 30% (Gallup Employee Survey). Conclusions: Evaluation of our outpatient clinic using TDABC allowed us to identify low efficiency, high cost processes. After implementation of a new process, patient wait times and personnel costs were significantly reduced resulting in better value care and improved provider satisfaction.

Implementing value-based cancer care: A multidisciplinary approach to defining breast cancer outcomes

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Background: Value in healthcare (patient-centered outcomes achieved per dollar spent) unifies performance improvement goals with health outcomes of importance to patients. We describe the process through which value-based measures for breast cancer patients and dynamic capture of these metrics via our new electronic health record (EHR) were developed at our institution. Methods: A review of the breast cancer literature was conducted on treatment options as well as expected outcomes and potential treatment complications. Patient perspective was obtained via focus groups. Multidisciplinary teams met to inform a 3-phase process of (1) concept development, (2) measure specification, and (3) implementation via EHR integration, planned for spring 2016. Results: Outcomes were divided into 3 previously defined tiers (NEJM 2010; 363:2477-2481) that reflect the entire cycle of care (Table).Within these tiers, 22 patient-centered outcomes were defined with inclusion/exclusion criteria, specifications for reporting, and sources for data including the EHR and validated patient-reported outcome questionnaires (e.g., FACT-B+4) administered via our patient portal. Conclusions: A value-based approach to cancer care with transparently reported patient outcomes not only creates opportunity for performance improvement but also enables benchmarking within and across providers, healthcare systems, and even countries. Our value-based framework for breast cancer is the first of its kind in the United States, with a similar model being pursued internationally as well. [Table: see text]

Assessing the cost of cancer care delivery using a time-driven, activity-based costing software

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Background: Poor costing systems and measurement have led to cross-subsidies and cost-shifting in health care. A large academic cancer center has adopted Robert Kaplan’s bottom-up cost accounting methodology called time-driven, activity-based costing (TDABC). TDABC in health care has been proven to be an effective cost accounting tool to measure and improve care delivery by standardizing and creating transparency around patient care processes. The project aims to process map and identify event triggers associated with each process map, use a software applications to compute the costs and resource capacities. Methods: Information technology and financial subject-matter experts integrated clinical, resource, and financial data from the institution’s enterprise information warehouse, general ledger, resource and asset management systems into the software application. Clinical business managers, nurse managers and other clinical content experts helped identify patient-level care processes. Results: The institution deployed a project team to integrate data from the institution’s enterprise information warehouse and aid in the process mapping across three multidisciplinary care centers. The team was able to successfully cost both direct and overhead costs associated with 69 head and neck, 18 endocrine, and 15-20 proton therapy patient-level processes over 7 different business department within 7 months. The resource capacity analysis was the most difficult to analyze due of the lack of transparency around resource’s clinical, administrative, and research responsibilities. Dashboards are currently being developed to help assess changes in patient care processes, cost or resource utilization. Conclusions: This methodology can be used across all health care organizations in all countries to analyze the true cost of care delivery.

Using Quality Improvement Methods and Time-Driven Activity-Based Costing to Improve Value-Based Cancer Care Delivery at a Cancer Genetics Clinic

Purpose:

To meet increasing demand for cancer genetic testing and improve value-based cancer care delivery, National Cancer Centre Singapore restructured the Cancer Genetics Service in 2014. Care delivery processes were redesigned. We sought to improve access by increasing the clinic capacity of the Cancer Genetics Service by 100% within 1 year without increasing direct personnel costs.

Methods:

Process mapping and plan-do-study-act (PDSA) cycles were used in a quality improvement project for the Cancer Genetics Service clinic. The impact of interventions was evaluated by tracking the weekly number of patient consultations and access times for appointments between April 2014 and May 2015. The cost impact of implemented process changes was calculated using the time-driven activity-based costing method.

Results:

Our study completed two PDSA cycles. An important outcome was achieved after the first cycle: The inclusion of a genetic counselor increased clinic capacity by 350%. The number of patients seen per week increased from two in April 2014 (range, zero to four patients) to seven in November 2014 (range, four to 10 patients). Our second PDSA cycle showed that manual preappointment reminder calls reduced the variation in the nonattendance rate and contributed to a further increase in patients seen per week to 10 in May 2015 (range, seven to 13 patients). There was a concomitant decrease in costs of the patient care cycle by 18% after both PDSA cycles.

Conclusion:

This study shows how quality improvement methods can be combined with time-driven activity-based costing to increase value. In this paper, we demonstrate how we improved access while reducing costs of care delivery.

Defining the value framework for prostate brachytherapy using patient-centered outcome metrics and time-driven activity-based costing

PURPOSE

Value, defined as outcomes over costs, has been proposed as a measure to evaluate prostate cancer (PCa) treatments. We analyzed standardized outcomes and time-driven activity-based costing (TDABC) for prostate brachytherapy (PBT) to define a value framework.

METHODS AND MATERIALS

Patients with low-risk PCa treated with low-dose-rate PBT between 1998 and 2009 were included. Outcomes were recorded according to the International Consortium for Health Outcomes Measurement standard set, which includes acute toxicity, patient-reported outcomes, and recurrence and survival outcomes. Patient-level costs to 1 year after PBT were collected using TDABC. Process mapping and radar chart analyses were conducted to visualize this value framework.

RESULTS

A total of 238 men were eligible for analysis. Median age was 64 (range, 46-81). Median followup was 5 years (0.5-12.1). There were no acute Grade 3-5 complications. Expanded Prostate Cancer Index Composite 50 scores were favorable, with no clinically significant changes from baseline to last followup at 48 months for urinary incontinence/bother, bowel bother, sexual function, and vitality. Ten-year outcomes were favorable, including biochemical failure-free survival of 84.1%, metastasis-free survival 99.6%, PCa-specific survival 100%, and overall survival 88.6%. TDABC analysis demonstrated low resource utilization for PBT, with 41% and 10% of costs occurring in the operating room and with the MRI scan, respectively. The radar chart allowed direct visualization of outcomes and costs.

CONCLUSIONS

We successfully created a visual framework to define the value of PBT using the International Consortium for Health Outcomes Measurement standard set and TDABC costs. PBT is associated with excellent outcomes and low costs. Widespread adoption of this methodology will enable value comparisons across providers, institutions, and treatment modalities.

A cross-sectional analysis of symptom burden among adult cancer patients in a Filipino tertiary care cancer center

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Background: Palliative and supportive care has been shown to improve quality of life (QOL) and survival and reduce caregiver burden and costs, but remains poorly integrated into cancer care in the Philippines. Understanding symptom burden profile among patients will guide policy-making in a limited/moderate resource setting. Methods: This cross-sectional study was conducted among adult Filipino cancer patients. Demographic and clinical data were collected from medical records and patient interviews. Symptom severity and interference were assessed using the M.D. Anderson Symptom Inventory. Symptom prevalence and mean severity scores were determined. Pearson correlation analysis was used to examine relationships between symptom severity and interference. Results: Participants (n = 251)were aged 18-80 years; the majority were aged < 60, females, or with good performance status (PS). Breast, head-and-neck and gastrointestinal primaries were most common; 45% had advanced disease. Moderate and severe symptoms were prevalent across stages. Fatigue (65%), pain (62%), sadness (62%), and anxiety/distress (58%) were the most prevalent, most severe and most interfering. In metastatic disease, sadness was most prevalent, and fatigue, most serious; among those with poor PS, disturbed sleep was most prevalent and most serious. Pain was more disabling among females, and fatigue and sadness, among the elderly. Conclusions: This is the first study to describe symptom burden among adult Filipino cancer patients. The clinical impact of symptoms is determined by their concurrence and the patient’s demographic and clinical profile. Symptom burden is highest for fatigue, pain, sadness, and anxiety/distress. Comprehensive symptom evaluation and tailored approach to care is necessary for optimal management. While a clinical practice guideline (CPG) has been adopted for use at our institute, effective CPGs for the screening, assessment and management of fatigue, depression and anxiety/distress have yet to be identified and implemented.

Value based care and bundled payments: Anesthesia care costs for outpatient oncology surgery using time-driven activity-based costing

BACKGROUND

With the movement towards bundled payments, stakeholders should know the true cost of the care they deliver. Time-driven activity-based costing (TDABC) can be used to estimate costs for each episode of care. In this analysis, TDABC is used to both estimate the costs of anesthesia care and identify the primary drivers of those costs of 11 common oncologic outpatient surgical procedures.

METHODS

Personnel cost were calculated by determining the hourly cost of each provider and the associated process time of the 11 surgical procedures. Using the anesthesia record, drugs, supplies and equipment costs were identified and calculated. The current staffing model was used to determine baseline personnel costs for each procedure. Using the costs identified through TDABC analysis, the effect of different staffing ratios on anesthesia costs could be predicted.

RESULTS

Costs for each of the procedures were determined. Process time and costs are linearly related. Personnel represented 79% of overall cost while drugs, supplies and equipment represented the remaining 21%. Changing staffing ratios shows potential savings between 13% and 28% across the 11 procedures.

CONCLUSIONS

TDABC can be used to estimate the costs of anesthesia care. This costing information is critical to assessing the anesthesiology component in a bundled payment. It can also be used to identify areas of cost savings and model costs of anesthesia care. CRNA to anesthesiologist staffing ratios profoundly influence the cost of care. This methodology could be applied to other medical specialties to help determine costs in the setting of bundled payments.

Improving the quality of cancer care in America

Thomas Feeley is the Helen Shafer Fly Distinguished Professor of Anesthesiology, and the Head of the Institute for Cancer Care Innovation at the University of Texas MD Anderson Cancer Center (TX, USA), which he has led since its formation in 2008. He received his undergraduate degree and M.D. from Boston University (MA, USA) and trained in anesthesiology and critical care medicine at Harvard’s Beth Israel Hospital in Boston. He was a faculty member at Stanford University (CA, USA) for 19 years prior to moving to The University of Texas MD Anderson Cancer Center in 1997 to lead the then newly created Division of Anesthesiology and Critical Care. Dr Feeley served on the Institute of Medicine’s Committee on Improving the Quality of Cancer Care: Addressing the Challenges of an Aging Population that published its report in September of 2013. He was recently appointed by Texas Governor Rick Perry to the board of directors of the Texas Institute for Health Care Quality and Efficiency. In addition to his research and administrative roles, Dr Feeley provides patient care services in the delivery of anesthesia.

Using time-driven activity-based costing to identify value improvement opportunities in healthcare

As healthcare providers cope with pricing pressures and increased accountability for performance, they should be rededicating themselves to improving the value they deliver to their patients: better outcomes and lower costs. Time-driven activity-based costing offers the potential for clinicians to redesign their care processes toward that end. This costing approach, however, is new to healthcare and has not yet been systematically implemented and evaluated. This article describes early time-driven activity-based costing work at several leading healthcare organizations in the United States and Europe. It identifies the opportunities they found to improve value for patients and demonstrates how this costing method can serve as the foundation for new bundled payment reimbursement approaches.

A patient-centered outcome measurement approach for bundled payments in cancer care

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Background: The project aims are to: 1) apply a patient-centered approach to evaluate quality of care in a bundled payment pilot for head & neck cancer; and, 2) measure quality at the condition-level; and, 3) incorporate patient-reported outcomes (PRO) in routine quality assessments. A three-tiered outcomes hierarchy developed by Michael Porter of Harvard Business School is used to define outcome measures, to be used for quality improvement and reporting during the pilot. Porter’s model evaluates outcomes over the full cycle of care, examining: (1) health status achieved/retained; (2) recovery process; and, (3) health sustainability. [Porter, M.E. (2010). What is value in health care? N Engl J Med, 363(26), 2477-2481. doi: 10.1056/NEJMp1011024.] Methods: An 11-member team of clinical, quality, data, and IT experts identified measure concepts, developed measure specifications, and implemented reporting. The project lead interviewed clinical experts to gain consensus around a focused set of measures and benchmarks. Measures were evaluated for importance to patients using feedback from patient focus groups. The team defined the measure specifications (numerator, denominator, etc.), selected a validated PRO instrument, and developed the work flow and tools for data collection and reporting. Process maps were created for training and reference purposes, and clinic staff trained. Testing was completed prior to implementation, with periodic process checks and additional staff training, as needed. Results: Measure development and implementation were completed using a streamlined approach over a 6-month period and required 12 team meetings before implementation. The project leveraged existing data streams, where possible, and IT development focused on quick-turnaround solutions. Conclusions: The project demonstrated that patient-centered outcomes measures can be developed and implemented in a compressed time frame. With provider and patient input, the measures focused on outcomes that are important to patients and actionable by clinicians. This created a scalable framework to be implemented in other disease sites and integrated into our EHR.

Proof-of-concept: A working demonstration of real-time patient tracking using time-driven activity-based costing

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Background: Historically, hospital costs are based on a cost-to-charge ratio. The current cost system determines when a charge is filed and a bill is created, which can be days following the patient visit. This time lag between the patient visit and the billed charges can be problematic. In preparation for episode-based payments, it is essential to know the true cost of care at the time of delivery. To accomplish this goal, the University of Texas MD Anderson Cancer Center (MDACC) leveraged existing time-driven activity-based costing (TDABC) process maps to track the true costs of the patient care cycle. Methods: The first steps were to understand the patient care cycle through process mapping. Next, data sources were identified to capture patient volumes. Process maps were adjusted to capture the data sources and provide a more accurate cost. Trigger logic models were created to link data sources and the TDABC process maps to the true cost for each patient appointment. Lastly, we developed a SAS software program to compute the real-time TDABC costs for 50 patients in the Head & Neck Center. Results: Our existing data sources capture information relevant to TDABC on a regular basis. Patient appointment data provided the patient visit, and billing and time data provided approximations of the amount of time spent in the encounter and the number of resources involved in the patient visit. Out of 219 process maps, 148 (70%) were matched to existing patient appointment and charge data using the trigger logic. This allowed us to track 4,980 patient appointments for 50 patients in fifteen minutes. Conclusions: As data are collected throughout the institution, it is realized that multiple data sources are needed to reconcile the patient’s experience and to match the TDABC process maps to existing data sources. Since our data sources are updated daily and are based on a patient’s date of service, we can capture our costs of delivering care close to real-time. This process is continually refined as additional data sources are made available and as process maps are developed in other parts of MDACC.

Second-Opinion Pathologic Review Is a Patient Safety Mechanism That Helps Reduce Error and Decrease Waste

Second review of a patient's outside pathology by a subspecialist pathologist demonstrates the value of multidisciplinary cancer care in a high-volume comprehensive cancer center.

Delivering High-Quality Cancer Care: The Critical Role of Quality Measurement

In 1999, the Institute of Medicine (IOM) published Ensuring Quality Cancer Care, an influential report that described an ideal cancer care system and issued ten recommendations to address pervasive gaps in the understanding and delivery of quality cancer care. Despite generating much fervor, the report's recommendations-including two recommendations related to quality measurement-remain largely unfulfilled. Amidst continuing concerns regarding increasing costs and questionable quality of care, the IOM charged a new committee with revisiting the 1999 report and with reassessing national cancer care, with a focus on the aging US population. The committee identified high-quality patient-clinician relationships and interactions as central drivers of quality and attributed existing quality gaps, in part, to the nation's inability to measure and improve cancer care delivery in a systematic way. In 2013, the committee published its findings in Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis, which included two recommendations that emphasize coordinated, patient-centered quality measurement and information technology enhancements: Develop a national quality reporting program for cancer care as part of a learning health care system; and,Develop an ethically sound learning health care information technology system for cancer that enables real-time analysis of data from cancer patients in a variety of care settings. These recommendations underscore the need for independent national oversight, public-private collaboration, and substantial funding to create robust, patient-centered quality measurement and learning enterprises to improve the quality, accessibility, and affordability of cancer care in America.

Improving the quality of cancer care in America through health information technology

A recent report from the Institute of Medicine titled Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis, identifies improvement in information technology (IT) as essential to improving the quality of cancer care in America. The report calls for implementation of a learning healthcare IT system: a system that supports patient-clinician interactions by providing patients and clinicians with the information and tools necessary to make well informed medical decisions and to support quality measurement and improvement. While some elements needed for a learning healthcare system are already in place for cancer, they are incompletely implemented, have functional deficiencies, and are not integrated in a way that creates a true learning healthcare system. To achieve the goal of a learning cancer care delivery system, clinicians, professional organizations, government, and the IT industry will have to partner, develop, and incentivize participation.

Measuring cost savings of process improvement

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Background: The aim of the project was to use anesthesia providers in a cancer center to lead process improvements using time-driven activity-based costing (TDABC), a system of measuring process and capacity costs. Methods: The process improvement objectives were centered on eliminating unnecessary patient care processes and improving patient flow. Teams were tasked with planning, process mapping, improving processes, and measuring costs. Projects were done in four anesthesia sites: ambulatory surgery, bone marrow aspiration, pediatric CT and XRT, and cardiopulmonary areas. Results: Process mapping identified areas for improvement and costs before and after the improvement. The Table highlights four project areas’ average total cost and time savings per patient using TDABC methodology. Conclusions: TDABC is a costing methodology that measures the costs of care utilizing process maps. Anesthesia providers had front-line insight in improving process flow and found the process mapping useful to improve processes and measure the cost savings of the improvement. In each area there was improvement or no adverse effect on patient outcomes. This project demonstrates that TDABC illustrates inefficiencies and provides a method to evaluate the cost savings of process improvements. As cancer care reimbursement evolves, the ability to control costs while providing value-based care is essential. [Table: see text]

Patients as partners in defining outcomes

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Background: The aim of this project was to develop an understanding of how patients conceptualize the term “outcomes” as it relates to their cancer experience and to determine patient preference for receiving and using outcomes-related information. When asked to rank cancer outcomes, most health care professionals suggest survival is the most significant outcome metric. We sought to determine if patients felt the same way. Methods: Focus group methodology was used in cancer patients with one of five major disease sites: breast, colon, lung, prostate, and head and neck. Participants were diverse with respect to age, ethnicity, income level, education level, and gender. Participants received semi-structured questions intended to elicit the patient’s personal conceptualization and use of outcomes information during their cancer continuum. Results: Patients identified a range of phenomena as their preferred definition of outcome and were sometimes confused by the term. Participants reported finding it difficult to interpret survival data without a basis for comparison or medical knowledge. Results of the focus groups will be presented and will address the wide variety of outcome definitions defined by patient participants. Conclusions: We found a large disconnect between what providers consider important and what patients consider important. We are continuing to evaluate patient perceptions of outcomes information by conducting further focus groups, and these qualitative findings will be used to develop a rigorous survey tool that can be administered to a greater number and wider variety of patients. Ultimately, the finding from these focus groups will allow for the creation of useful tools that educate patients and empower them to be full partners in their care.

Time-driven activity-based costing and the impact on cost measurement in the face of health reform

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Background: In 2010, the Institute for Cancer Care Innovation (ICCI) began measuring the true cost of cancer care delivery by following the patient treatment cycle from initial referral to survivorship or supportive care. The project was prompted by both internal and external concerns about the rising costs of health care, the ability to demonstrate value for services provided, and potential changes in reimbursement. Hospital cost accounting systems are historically charge-based and are inherently skewed to shift costs towards procedures or encounters that are higher volume and well-reimbursed. However, these systems do not accurately reflect the actual acquisition costs of the resources providing care. Methods: In order to more accurately and transparently capture costs, the ICCI piloted the use of the time-driven activity-based costing (TDABC) methodology. This methodology allowed the team to map the entire patient experience of care while also capturing costs and capacity associated with each activity in the care delivery cycle. Results: To date, the team has created over 150 maps made up of over 6,500 unique activities with associated cost and capacity rates, which make up various costing equations. Actual clinical volumes are then run through the model to produce cost and capacity results. Initial results provided an unexpected view of the costs of various processes occurring within the care delivery cycle with the ability to rank the processes from most to least costly. This provided a unique opportunity to target specific areas for improvement. Additionally, transparency of the costing equations allows for precise modeling of episode-based bundles of care for different diseases and treatments. Conclusions: TDABC provides a more accurate and transparent approach to developing cost and capacity rates for cancer care delivery to aid in identifying the greatest opportunities for improvement, as well as providing a mechanism for creating episode-based bundles of care that are reflective of actual treatment being provided.

Depressive symptoms among cancer patients in a Philippine tertiary hospital: prevalence, factors, and influence on health-related quality of life

BACKGROUND

The World Health Organization recognizes depression as one of the most burdensome diseases in the world. Among cancer patients, depression is significantly associated with shorter survival, independent of the influence of biomedical prognostic factors. Although cancer is the third leading cause of morbidity and mortality among Filipinos, little is known about depressive symptoms and their influence on health-related quality of life in this population. We assessed the prevalence of, and factors associated with, depressive symptoms and their influence on health-related quality of life in Filipino patients with cancer.

METHODS

The Patient Health Questionnaire (PHQ)-8 and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 were administered to all inpatients and outpatients, age >=18 years presenting for cancer treatment.

RESULTS

Twenty-two percent (n=53/247) were categorized as depressed, using a PHQ-8 cutoff of ≥10. Depressed patients scored lower on cognitive, emotional, role, physical, and social functioning than those who scored PHQ<10 (all P<0.001). Depression varied by disease status, performance status and marital status (all P<0.001). However, only performance status (OR [odds ratio]=2.20; 95% CI=1.60, 3.00) and disease status (OR=2.4; 95% CI=1.13, 5.22) were significantly associated with depression in the multivariable model.

CONCLUSIONS

Depression is prevalent in Filipino cancer patients. The findings provide empirical support for the development of mental health services in this understudied population. This study, the first to assess the prevalence of and factors associated with depression in Filipino cancer patients, needs further validation.

Measuring the value of process improvement initiatives in a preoperative assessment center using time-driven activity-based costing

BACKGROUND

The value and impact of process improvement initiatives are difficult to quantify. We describe the use of time-driven activity-based costing (TDABC) in a clinical setting to quantify the value of process improvements in terms of cost, time and personnel resources.

PROBLEM

Difficulty in identifying and measuring the cost savings of process improvement initiatives in a Preoperative Assessment Center (PAC).

GOALS

Use TDABC to measure the value of process improvement initiatives that reduce the costs of performing a preoperative assessment while maintaining the quality of the assessment.

STRATEGY

Apply the principles of TDABC in a PAC to measure the value, from baseline, of two phases of performance improvement initiatives and determine the impact of each implementation in terms of cost, time and efficiency.

RESULTS

Through two rounds of performance improvements, we quantified an overall reduction in time spent by patient and personnel of 33% that resulted in a 46% reduction in the costs of providing care in the center. The performance improvements resulted in a 17% decrease in the total number of full time equivalents (FTE's) needed to staff the center and a 19% increase in the numbers of patients assessed in the center. Quality of care, as assessed by the rate of cancellations on the day of surgery, was not adversely impacted by the process improvements.

Developing a system to track meaningful outcome measures in head and neck cancer treatment

BACKGROUND

The health care industry, including consumers, providers, and payers of health care, recognize the importance of developing meaningful, patient-centered measures. This article describes our experience using an existing electronic medical record largely based on free text formats without structured documentation, in conjunction with tumor registry abstraction techniques, to obtain and analyze data for use in clinical improvement and public reporting.

METHODS

We performed a retrospective analysis of 2467 previously untreated patients treated with curative intent who presented with laryngeal, pharyngeal, or oral cavity cancer in order to develop a system to monitor and report meaningful outcome metrics of head and neck cancer treatment. Patients treated between 1995 and 2006 were analyzed for the primary outcomes of survival at 1 and 2 years, the ability to speak at 1 year posttreatment, and the ability to swallow at 1 year posttreatment.

RESULTS

We encountered significant limitations in clinical documentation because of the lack of standardization of meaningful measures, as well limitations with data abstraction using a retrospective approach to reporting measures. Almost 5000 person-hours were required for data abstraction, quality review, and reporting, at a cost of approximately $134,000. Our multidisciplinary teams document extensive patient information; however, data is not stored in easily accessible formats for measurement, comparison, and reporting.

CONCLUSION

We recommend identifying measures meaningful to patients, providers, and payers to be documented throughout the patients' entire treatment cycle, and significant investment in the improvements to electronic medical records and tumor registry reporting in order to provide meaningful quality measures for the future.

Epidural versus ON-Q local anesthetic-infiltrating catheter for post-thoracotomy pain control

OBJECTIVE

The authors compared thoracic epidural with ON-Q infiltrating catheters in patients having open thoracotomy to determine whether one method better relieves postoperative pain and would allow earlier discharge from the hospital and, hence, cost savings.

DESIGN

Retrospective chart review.

SETTING

University hospital.

PARTICIPANTS

Fifty adult patients (24 to 81 years old) undergoing open thoracotomy by one surgeon.

INTERVENTIONS

One group had thoracic epidural catheters placed by an anesthesiologist and then managed by the acute pain service. The other group had intraoperative ON-Q (ON-Q; I-Flow; Lake Forest, California) infiltrating catheters placed by the surgeon, wound infiltration with a local anesthetic, plus patient-controlled analgesia with an intravenous opioid.

MEASUREMENTS AND MAIN RESULTS

The authors measured and compared average daily pain rating, maximum pain rating, time to discharge from the hospital, and total bill for hospital stay. Patients who received epidural analgesia had lower average pain scores on day 2 than did patients in the ON-Q group. Patients in the ON-Q group reported higher maximum pain scores on days 1 and 2 and at the time of discharge. Patients in the ON-Q group were discharged an average of 1 day earlier; hence, their average total bill was lower.

CONCLUSIONS

Even though the maximum pain score was higher in the ON-Q group, patients were comfortable enough to be discharged earlier, resulting in cost savings. ON-Q infiltrating catheters present a good option for providing postoperative analgesia to patients having an open thoracotomy.

Ensuring quality cancer care: a follow-up review of the Institute of Medicine's 10 recommendations for improving the quality of cancer care in America

Responding to growing concerns regarding the safety, quality, and efficacy of cancer care in the United States, the Institute of Medicine (IOM) of the National Academy of Sciences commissioned a comprehensive review of cancer care delivery in the US health care system in the late 1990s. The National Cancer Policy Board (NCPB), a 20-member board with broad representation, performed this review. In its review, the NCPB focused on the state of cancer care delivery at that time, its shortcomings, and ways to measure and improve the quality of cancer care. The NCPB described an ideal cancer care system in which patients would have equitable access to coordinated, guideline-based care and novel therapies throughout the course of their disease. In 1999, the IOM published the results of this review in its influential report, Ensuring Quality Cancer Care. The report outlined 10 recommendations, which, when implemented, would: 1) improve the quality of cancer care, 2) increase the current understanding of quality cancer care, and 3) reduce or eliminate access barriers to quality cancer care. Despite the fervor generated by this report, there are lingering doubts regarding the safety and quality of cancer care in the United States today. Increased awareness of medical errors and barriers to quality care, coupled with escalating health care costs, has prompted national efforts to reform the health care system. These efforts by health care providers and policymakers should bridge the gap between the ideal state described in Ensuring Quality Cancer Care and the current state of cancer care in the United States.