Anesthesia, Sterility Measures Contribute To Large Carbon Footprint of Health Care Systems

MedicalResearch.com Interview with:
 <a href="https://www.flickr.com/photos/armymedicine/6127836005">“surgery”</a> by <i> <a href="https://www.flickr.com/people/armymedicine/">Army Medicine</a> </i> is licensed under <a href="https://creativecommons.org/licenses/by/2.0"> CC BY 2.0</a>Andrea MacNeill MD MSc FRCSC

Surgical Oncologist & General Surgeon
University of British Columbia
Vancouver General Hospital
BC Cancer Agency

MedicalResearch.com: What is the background for this study?

Response: Climate change is one of the most pressing public health issues of the present era, responsible for 140,000 deaths annually.  Somewhat paradoxically, the health sector itself has a considerable carbon footprint, as well as other detrimental environmental impacts.  Within the health sector, operating rooms are known to be one of the most resource-intensive areas and have thus been identified as a strategic target for emissions reductions.

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Price Transparency Not Keeping Up With High-Deductible Health Care Plans

MedicalResearch.com Interview with:
“Health Insurance” by Pictures of Money is licensed under CC BY 2.0
Allison Kratka
MD Candidate 2018
Duke University School of Medicine

MedicalResearch.com: What is the background for this study?

Response: As there are increasing numbers of high-deductible plans and those with high rates of co-insurance, patients are increasingly expected to help contain the cost of their health care by being savvy health care consumers. We set out to determine how easy or hard it is to find healthcare prices online.

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Dr. Barbara McAneny, Value-Based Care Pioneer, First Oncologist Named As Incoming AMA President

MedicalResearch.com Interview with:

Barbara L. McAneny MD, CEO New Mexico Oncology Hematology Consultants, Ltd. Albuquerque, NM 87109

Dr. McAneny

Barbara L. McAneny MD, CEO
New Mexico Oncology Hematology Consultants, Ltd.
Albuquerque, NM 87109 

MedicalResearch.com:   What is the meant by value-based care?

Response: There are a lot of people using this term to mean a variety of things, confusion is not surprising.  Generally it means a move to pay more for better patient outcomes and less for worse patient outcomes.  Currently in our Fee for Service system, there are a lot of services for which there are no fees. That deficiency keeps physicians from looking at non face-to-face delivery methods or the use of other health professionals to augment the care they give, because we can’t afford to give services that we aren’t paid to give.

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Penalties for Readmissions Widens Financial Losses At Delta Safety Net Hospitals

MedicalResearch.com Interview with:

Hsueh-Fen Chen, Ph.D. Associate Professor Department of Health Policy and Management College of Public Health University of Arkansas for Medical Sciences Little Rock, AR 72205

Dr. Chen

Hsueh-Fen Chen, Ph.D.
Associate Professor
Department of Health Policy and Management
College of Public Health
University of Arkansas for Medical Sciences
Little Rock, AR 72205

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: The Centers for Medicare and Medicaid Services announced the Hospital Readmissions Reduction Program (HRRP) and Hospital Value-based Purchasing (HVBP) Program in 2011 and implemented the two programs in 2013. These two programs financially motivate hospitals to reduce readmission rates and improve quality of care, efficiency, and patient experience. The Mississippi Delta Region is one of the most impoverished areas in the country, with a high proportion of minorities occupying in the region.  Additionally, these hospitals are  safety-net resources for the poor. It was largely unknown what the financial performance for the hospitals in the Mississippi Delta Region was under the HRRP and HVBP programs.

Dr. Chen and colleagues in the Fay W. Boozman College of Public Health at the University of Arkansas for Medical Sciences compared the financial performance between Delta hospitals and non-Delta hospitals (namely, other hospitals in the nation) from 2008 through 2014 that were covered before and after the implementation of the HRRP and HVBP programs. The financial performance was measured by using the operating margin (profitability from patient care) and total margin (profitability from patient care and non-patient care)

Before the implementation of the HRRP and HVBP programs, Delta hospitals had weaker financial performance than non-Delta hospitals but their differences were not statistically significant. After the implementation of the HRRP and HVBP programs, the gap in financial performance between Delta and non-Delta hospitals became wider and significant. The unadjusted operating margin for Delta hospitals was about -4.0% in 2011 and continuously fell to -10.4% in 2014, while the unadjusted operating margin for non-Delta hospitals was about 0.1% in 2011 and dropped to -1.5% in 2014. The unadjusted total margin for Delta hospitals significantly fell from 3.6% in 2012 to 1.1% in 2013 and reached 0.2% in 2014, while the unadjusted total margin for non-Delta hospitals remained about 5.3% from 2012 through 2014. After adjusting hospital and community characteristics, the difference in financial performance between Delta and non-Delta remained significant.

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Trends in Opioid-Related Inpatient Stays Shifted After Switch to ICD-10 Coding

MedicalResearch.com Interview with:

Anne Elixhauser, Ph.D. Senior Research Scientist Agency for Healthcare Research and Quality Rockville MD 20857

Dr. Elixhauser

Anne Elixhauser, Ph.D.
Senior Research Scientist
Agency for Healthcare Research and Quality
Rockville MD 20857

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Hospital inpatient data began using ICD-10-CM (I-10) codes on October 1, 2015.  We have been doing analysis using the new codeset to determine to what extent we can follow trends crossing the ICD transition—do the trends look consistent when we switch from I-9 to I-10?  Tracking the opioid epidemic is a high priority so we made this one of our first detailed analyses.  We were surprised to find that hospital stays jumped 14% across the transition, compared to a 5% quarterly increase before the transition (under I-9) and a 3.5% quarterly increase after the transition (under I-10).  The largest increase (63.2%) was for adverse effects in therapeutic use (side effects of legal drugs), whereas stays involving opioid abuse decreased 21% and opioid poisoning (overdose) decreased 12.4%.

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Coordination Program Reduced ER Visits and Readmissions in Medicaid Population

MedicalResearch.com Interview with:

Roberta Capp MD Assistant Professor Director for Care Transitions in the Department of Emergency Medicine University of Colorado School of Medicine Medical Director of Colorado Access Medicaid Aurora Colorado

Dr. Capp

Roberta Capp MD
Assistant Professor
Director for Care Transitions in the Department of Emergency Medicine
University of Colorado School of Medicine
Medical Director of Colorado Access Medicaid
Aurora Colorado

 

 

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Medicaid clients are at highest risk for utilizing the hospital system due to barriers in accessing outpatient services and social determinants.

We have found that providing care management services improves primary care utilization, which leads to better chronic disease management and reductions in emergency department use and hospital admissions.

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Financial Incentives to Physicians Did Not Increase Hospital Discharge Follow-Up Visits

MedicalResearch.com Interview with:

Dr. Lauren Lapointe-Shaw, MD Physician at University Health Network Department of Medicine University of Toronto 

Dr. Lapointe-Shaw

Dr. Lauren Lapointe-Shaw, MD
Physician at University Health Network
Department of Medicine
University of Toronto 

MedicalResearch.com: What is the background for this study?

Response: Readmissions after hospital discharge are common and costly. We would like to reduce these as much as possible. Early physician follow-up post hospital discharge is one possible strategy to reduce readmissions. To this end, incentives to outpatient physicians for early follow-up have been introduced in the U.S. and Canada. We studied the effect of such an incentive, introduced to Ontario, Canada, in 2006.

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Arriving Late To Appointment Can Shorten Your Visit With The Doctor

MedicalResearch.com Interview with:
Chester G. Chambers, Ph.D.
Director, Enterprise Risk Management Program, Johns Hopkins Carey Business School
Joint Appointment in Anesthesiology and Critical Care Medicine
Maqbool Dada, Ph.D.
Joint Appointment in Anesthesiology and Critical Care Medicine
John Hopkins Medicine
Kayode Ayodele Williams, M.B.A., M.B.B.S., M.D
Medical Director : Blaustein Pain Treatment Center
Associate Professor of Anesthesiology and Critical Care Medicine
John Hopkins Medicine

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: The result is based on a retrospective analysis of three specialty clinics in the Johns Hopkins System: a private practice low-volume clinic with one physician and no residents; a medium volume clinic that used one attending physician for each clinic session and included residents; and a high-volume clinic with multiple attending physicians and several residents.

Our main finding is that physicians adjust face time based on congestion in the clinic, and seem to do this without always knowing they are doing it. Patients who arrive early and whose service begins before their appointment times, tend to get more face-time then other patients. This is similar to other service systems in which first-line providers speed-up when they see long queues at their stations.This is important because most of the prior research in this setting assumed that this never takes place. We verified that it does happen in multiple settings and the changes in processing rates are statistically significant. This means we need to rethink many earlier conclusions about how clinics run.

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Access To Two Different Health Care Systems Can Lead To Dangerous Presciption Combinations

MedicalResearch.com Interview with:

Dr-Joshua-M-Thorpe.jpg

Dr. Joshua Thorpe

Joshua M. Thorpe, PhD, MPH
From the Center for Health Equity Research and Promotion
Veterans Affairs Pittsburgh Healthcare System
Pittsburgh Pennsylvania, and
Center for Health Services Research in Primary Care
Department of Pharmacy and Therapeutics
University of Pittsburgh School of Pharmacy

MedicalResearch.com: What is the background for this study?

Response: Care coordination for persons with dementia is challenging for health care systems under the best of circumstances. These coordination challenges are exacerbated in Medicare-eligible veterans who receive care through both Medicare and the Department of Veterans Affairs (VA). Recent Medicare and VA policy changes (e.g., Medicare Part D, Veteran’s Choice Act) expand veterans’ access to providers outside the VA. While access to care may be improved, seeking care across multiple health systems may disrupt care coordination and increase the risk of unsafe prescribing – particularly in veterans with dementia. To see how expanded access to care outside the VA might influence medication safety for veterans with dementia, we studied prescribing safety in Veterans who qualified for prescriptions through the VA as well as through the Medicare Part D drug benefit.

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Framework for a Systems Thinking Approach to US Population Health

MedicalResearch.com Interview with:

Julie M. Kapp, MPH, PhD, FACE Associate Professor 2014 Baldrige Executive Fellow University of Missouri School of Medicine Department of Health Management and Informatics Columbia, MO 65212

Dr. Julie Kapp

Julie M. Kapp, MPH, PhD, FACE
Associate Professor
2014 Baldrige Executive Fellow
University of Missouri School of Medicine
Department of Health Management and Informatics
Columbia, MO 65212

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: The United States lags behind its high-income peer countries on a number of critical health outcomes, including life expectancy, and this gap has been widening for the last several decades. The 2010 Patient Protection and Affordable Care Act (ACA) created a number of provisions to try to address this, including an emphasis on a systems-engineering approach to health care services. In addition to the ACA, there is a growing movement toward collective impact among community-based organizations. However, despite this focus, U.S. health and health care activities are often uncoordinated and fragmented.

We applied a systems-thinking approach to U.S. population health. We used the Malcolm Baldrige Framework for Performance Excellence as the unifying conceptual systems-thinking approach. In addition to this proposed framework, we make two critical recommendations:

1) the need to drive a strategic outcomes-oriented, rather than action-oriented, approach by creating an evidence-based national reporting dashboard; and

2) improve the operational effectiveness of the workforce.

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What Interventions Can Reduce Epidemic Physician Burnout?

MedicalResearch.com Interview with:

Colin P. West, MD, PhD, FACP  Divisions of General Internal Medicine and Biomedical Statistics and Informatics Departments of Internal Medicine and Health Sciences Research Mayo Clinic

Dr. Colin West

Colin P. West, MD, PhD, FACP
Divisions of General Internal Medicine and Biomedical Statistics and Informatics
Departments of Internal Medicine and Health Sciences Research
Mayo Clinic

MedicalResearch.com: What is the background for this study? What are the main findings? 

Response: Physician burnout has reached epidemic levels, as documented in national studies of both physicians in training and practicing physicians demonstrating burnout rates in excess of 50%. Consequences include negative effects on patient care, professionalism, physicians’ own care and safety, and the viability of health-care systems. We conducted a systematic review and meta-analysis to better understand the quality and outcomes of the literature on approaches to prevent and reduce burnout.

We identified 2617 articles, of which 15 randomized trials including 716 physicians and 37 cohort studies including 2914 physicians met inclusion criteria. Across interventions, overall burnout rates decreased from 54% to 44%, emotional exhaustion score decreased from 23.82 points to 21.17 points, and depersonalization score decreased from 9.05 to 8.41. High emotional exhaustion rates decreased from 38% to 24% and high depersonalization rates decreased from 38% to 34%.

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Medicare Shared Savings Program May Reduce Hospitals’ Propensity To Purchase New CT Machines

MedicalResearch.com Interview with:
Hui Zhang, Ph.D., MBA

Virginia Polytechnic Institute and State University
Blacksburg

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: To promote healthcare coordination and contain the rising costs in the US healthcare system, a variety of payment innovations has been developed and field-tested in both public and private sector. Among them, the Medicare Shared Savings Program (MSSP) for Accountable Care Organizations (ACOs), administered by the Centers for Medicare and Medicaid Services (CMS) has received considerable attention.

Our study took a mathematical modeling approach and comprehensively captured and analyzed the effect of this new payment systems on healthcare stakeholder decisions and system-wide outcomes. Our results provided decision-making insights for payers on how to improve MSSP, for ACOs on how to distribute MSSP incentives among their members, and for hospitals on whether to invest in new CT imaging systems.

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JAMA Study Updates Goals of Cost-Effective Health Care

MedicalResearch.com Interview with:

Gillian D. Sanders-Schmidler Ph.D. Professor of Medicine Duke Evidence Synthesis Group, Director Duke Evidence-based Practice Center, Director Duke Clinical Research Institute Duke University

Dr. Gillian D. Sanders-Schmidler

Gillian D. Sanders-Schmidler Ph.D.
Professor of Medicine
Duke Evidence Synthesis Group, Director
Duke Evidence-based Practice Center, Director
Duke Clinical Research Institute
Duke University

MedicalResearch.com: What is the background for this study?

Response: In 1996, the original panel on cost effectiveness in health and medicine published recommendations for the use of cost effectiveness analysis. During the 20 years since the original panel’s report, the field of cost-effectiveness analysis has advanced in important ways and the need to deliver health care efficiently has only grown. In 2012 the Second Panel on Cost Effectiveness in health and Medicine was formed with a goal of reviewing and updating the recommendations.

This paper summarizes those recommendations. This process provided an opportunity for the Panel to reflect on the evolution of cost-effectiveness analysis and to provide guidance for the next generation of practitioners and consumers.

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Earned Income Tax Credits Linked To Improved Health Parameters

MedicalResearch.com Interview with:

Peter Muennig, MD, MPH Associate Professor Mailman School of Public Health Columbia University New York, NY 10032

Dr. Peter Muennig

Peter Muennig, MD, MPH
Associate Professor
Mailman School of Public Health
Columbia University
New York, NY 10032

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: We looked that the supplemental Earned Income Tax Credit
( EITC ) programs offered by states to determine whether they have health impacts or not.

We found that, on average, folks who live in states that offer supplemental EITC showed improvements in health after EITC was implemented.

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LEAN Methodologies Improved Wait Time In VA Medical Center

MedicalResearch.com Interview with:

Andrew C. Eppstein, MD, FACS Assistant Professor of Clinical Surgery Indiana University School of Medicine Department of Surgery, Division of General Surgery Richard L. Roudebush VA Medical Center Indianapolis, Indiana

Dr. Andrew Eppstein

Andrew C. Eppstein, MD, FACS
Assistant Professor of Clinical Surgery
Indiana University School of Medicine
Department of Surgery, Division of General Surgery
Richard L. Roudebush VA Medical Center
Indianapolis, Indiana

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: A few years ago we encountered long wait times for patients undergoing elective general surgery in our tertiary care VA medical center. Demand had grown and our existing systems were not able to accommodate surgical patients in a timely fashion. By fiscal year (FY) 2012, our wait times averaged 33 days, though patients with malignancies would be moved to the head of the line, pushing more elective cases further back.

To address rising demand and worsening wait times, our Surgery Service convened an analysis of our processes using Lean methodology in collaboration with the Systems Redesign Service. Multidisciplinary meetings were held in 2013 to analyze inefficiencies in the current system and ways to address them to create a streamlined, ideal system. The collaborations included surgeons, nurses, ancillary staff, operating room and sterile processing staff, and hospital administration. Projects were rolled out stepwise in mid-2013 under General Surgery, the busiest surgical service at our institution.

We noted a sharp decline in patient wait times after initiation of reforms such as improved OR flexibility, scheduling process changes, standardization of work within the department, and improved communication practices. These wait times dropped to 26 days in FY 2013 and further to 12 days in FY 2014, while operating volume and overall outpatient evaluations increased, with decreased no-shows to clinic. Our decreased wait times were sustained through the remainder of the observed period.

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Comparable Diabetes and Heart Disease Care Provided By Physicians and Advanced Care Providers

MedicalResearch.com Interview with:
Salim S. Virani, MD, PhD and
Julia Akeroyd MPH
Health Services Research and Development
Michael E. DeBakey Veterans Affairs Medical Center
Houston

MedicalResearch.com: What is the background for this study?

Response: Given the increase in the number of Americans seeking primary health care due to the Affordable Care Act, combined with current and anticipated physician shortages in the US, there is a growing need to identify other models of primary care delivery to address chronic diseases.

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Safety-Net Hospitals Can Reduce Costs By Shifting Complex Surgery Patients to Other Hospitals

MedicalResearch.com Interview with:

Richard Hoehn, MD Resident in General Surgery College of Medicine University of Cincinnati

Dr. Richard Hoehn

Richard Hoehn, MD
Resident in General Surgery
College of Medicine
University of Cincinnati

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: A recent study from our research group (Hoehn et al, JAMA Surgery, 2015) found that safety-net hospitals perform complex surgery with higher costs compared to other hospitals, and that these higher costs are potentially due to intrinsic differences in hospital performance.

In this analysis, we decided to simulate different policy initiatives that attempt to reduce costs at safety-net hospitals. Using a decision analytic model, we analyzed pancreaticoduodenectomy performed at academic hospitals in the US and tried to reduce costs at safety-net hospitals by either
1) reducing their mortality,
2) reducing their patients’ comorbidities and complications, or
3) sending their patients to non-safety-net hospitals for their surgery.

While reducing mortality had a negligible impact on cost and reducing comorbidities/complications had a noticeable impact on cost, far and away the most successful way to reduce costs at safety-net hospitals, based on our model, was to send patients away from safety-net hospitals for their pancreaticoduodenectomy.

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Specialized Stroke Care Centers Improve Outcomes

MedicalResearch.com Interview with:

Kimon Bekelis, MD Chief Resident Department of Neurosurgery Dartmouth-Hitchcock School of Medicine

Dr. Kimon Bekelis

Kimon Bekelis, MD Chief Resident
Department of Neurosurgery
Dartmouth-Hitchcock School of Medicine

MedicalResearch.com: What is the background for this study?

Response: Physicians often must decide whether to treat acute stroke patients locally, or refer them to a more distant Primary Stroke Center (PSC). There is little evidence on how much the increased risk of prolonged travel time offsets benefits of specialized  Primary Stroke Center care.

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Interventions Involving Patients and Providers Required To Reduce Low-Value Care

Medicalresearch.com Interview with:

Alex Mainor, JD, MPH Research Project Coordinator The Dartmouth Institute for Health Policy and Clinical Practice Lebanon, NH 03756

Alex Mainor

Alex Mainor, JD, MPH
Research Project Coordinator
The Dartmouth Institute for Health Policy and Clinical Practice
Lebanon, NH 03756

Carrie H. Colla, Alexander J. Mainor, Courtney Hargreaves, Thomas Sequist, Nancy Morden

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Waste in the healthcare system is an important concern to healthcare providers, patients, policymakers, and taxpayers, and is estimated to account for 30% of all healthcare costs. Low-value care can expose patients to unnecessary costs for little or no medical benefit, or to potential harm from unnecessary tests and procedures. In recent years, the concept of low-value care has gained wider acknowledgement and acceptance as a pressing concern for the healthcare system, and many interventions have been studied to reduce the use of this wasteful care. However, the landscape of these interventions has not been studied in a systematic and comprehensive way.

In this review, we found that interventions to reduce the use of wasteful medical care are often studied and published selectively. Findings suggest that interventions using clinical decision support, clinician education, patient education, and interventions combining elements from each have strong potential to reduce low-value care.

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Statewide Collaboration Reduced Preventable Hospital Readmissions by 20%

MedicalResearch.com Interview with:

Thomas P. Meehan, MD, MPH Associate Medical Director Harvard Pilgrim Health Care Qualidigm, Wethersfield Quinnipiac University, North Haven CT

Dr. Thomas Meehan

Thomas P. Meehan, MD, MPH
Associate Medical Director
Harvard Pilgrim Health Care
Qualidigm, Wethersfield
Quinnipiac University, North Haven
CT

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: There is a national effort to decrease preventable hospital readmissions in order to improve both the quality and cost of healthcare. Part of this national effort includes local quality improvement projects which are organized and conducted by a variety of organizations working by themselves or with others. We describe one statewide quality improvement project which was led by a Medicare-funded Quality Improvement Organization and conducted with a hospital association and many other collaborators. We document our activities and a relative decrease in the statewide 30-day aggregate readmission rate among fee-for service Medicare beneficiaries of 20.3% over four and a half years. While we are extremely proud of our work and this outcome, we recognize that there are many factors that impacted the outcome and that we can’t claim sole credit.

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Hospital Wide Crew Resource Management Training Improves Communication and Teamwork

MedicalResearch.com Interview with:

Dr. Susan Moffatt-Bruce, MD PhD Cardiothoracic surgeon Associate professor of surgery and assistant professor of molecular virology, immunology and medical genetics The Ohio State University Wexner Medical Center Columbus, OH

Dr. Moffatt-Bruce

Dr. Susan Moffatt-Bruce, MD PhD
Cardiothoracic surgeon
Associate professor of surgery and assistant professor of molecular virology, immunology and medical genetics
The Ohio State University Wexner Medical Center
Columbus, OH

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Crew Resource Management (CRM), a training for all health care providers, including doctors, nurses, staff and students, focusing on team communication, leadership, and decision-making practices, was implemented throughout a large academic health system – across eight departments spanning three hospitals and two campuses. All those in the health system, inclusive of those that took the training, took a survey measuring perceptions of workplace patient safety culture both before CRM implementation and about 2 years after. Safety culture was significantly improved after Crew Resource Management training, with the strongest effects in participant perception of teamwork and communication. This study was the first health-system wide CRM implementation reported in the literature.

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Spending on Cancer Center Advertising Tripled Over 10 Years

MedicalResearch.com Interview with:

Laura B. Vater, MPH MD Candidate 2017 Indiana University School of Medicine

Laura Vater

Laura B. Vater, MPH
MD Candidate 2017
Indiana University School of Medicine

MedicalResearch.com: What is the background for this study?

Response: In the United States, cancer center advertisements are common. Previous research has shown that these ads use emotion-based techniques to influence viewers and omit information about benefits, risks, and costs of cancer treatment. There is a concern that cancer center advertising may increase demand for unnecessary tests and treatments, increase healthcare costs, and provide unrealistic expectations about the benefits of cancer treatment.

In this study, we examined cancer center advertising spending from 2005 to 2014, with particular attention to trends within media (television networks, magazines, newspapers, radio stations, billboards, and the Internet) and by target audience (national versus local).

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Declining Admission Rates and 30-Day Readmissions Linked

MedicalResearch.com Interview with:

Kumar Dharmarajan, MD, MBA Assistant Professor of Medicine (Cardiology) Cardiovascular Medicine: Center for Outcomes Research & Evaluation (CORE) Yale School of Medicine

Dr. Kumar Dharmarajan

Kumar Dharmarajan, MD, MBA
Assistant Professor of Medicine (Cardiology)
Cardiovascular Medicine: Center for Outcomes Research & Evaluation (CORE)
Yale School of Medicine

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Programs from the Centers for Medicare and Medicaid Services simultaneously promote strategies to lower hospital admissions and readmissions. However, there is concern that hospitals in communities that successfully reduce admissions may be penalized, as patients that are ultimately hospitalized may be sicker and at higher risk of readmission. We therefore examined the relationship between changes from 2010 to 2013 in admission rates and thirty-day readmission rates for elderly Medicare beneficiaries.

We found that communities with the greatest decline in admission rates also had the greatest decline in thirty-day readmission rates, even though hospitalized patients did grow sicker as admission rates declined. The relationship between changing admission and readmission rates persisted in models that measured observed readmission rates, risk-standardized readmission rates, and the combined rate of readmission and death.

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Newly Insured Medicaid Patients Not Facing Long Waiting Times For Primary Care Appointments

MedicalResearch.com Interview with:

Renuka Tipirneni, MD, MSc Clinical Lecturer in Internal Medicine University of Michigan Department of Internal Medicine, Division of General Medicine North Campus Research Complex, Bldg 16, Rm 472C Ann Arbor, MI

Dr. Renuka Tipirneni

Renuka Tipirneni, MD, MSc
Clinical Lecturer in Internal Medicine
University of Michigan Department of Internal Medicine, Division of General Medicine
North Campus Research Complex, Bldg 16, Rm 472C
Ann Arbor, MI

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Tipirneni: One year after Medicaid expansion in Michigan, 600,000 individuals had enrolled in the program and there was concern that new enrollees would crowd doctor’s offices and new patients would not be able to get an appointment. We found that the opposite occurred – primary care appointment availability for new Medicaid patients increased.

This study builds on a previous study looking at what happened in the first four months after Medicaid expansion. In the earlier study, we found that appointment availability for new Medicaid patients had increased in the first few months after expansion. Even though the number of enrollees in the Medicaid expansion program doubled since then, the new study found that appointment availability remained increased for new Medicaid patients one year after expansion.

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Medical Tourism Market Booming As Patients Seek Cheaper Prices or More Sophisticated Care

Yan Alicia Hong, Ph.D. Associate Professor Dept of Health Promotion & Community Health Sciences School of Public Health Texas A&M Health Science Center College Station, TX, 77843

Dr. Yan Alicia Hong

MedicalResearch.com Interview with:
Yan Alicia Hong, Ph.D.
Associate Professor
Dept of Health Promotion & Community Health Sciences
School of Public Health
Texas A&M Health Science Center
College Station, TX, 77843

MedicalResearch.com: What is the background for this study and discussion? What are the main findings?

Dr. Hong: Medical tourism has grown rapidly in the past decade, as Internet has greatly facilitated information sharing. A 2013 online survey from US reported that 27% of patients had engaged in some form of medical tourism. The global market of medical tourism is estimated at $439 billion. Traditionally, medical tourists travel from high-income countries to middle- and low-income countries to seek comparable or identical care at a lower price. But in recent years, more and more patients from middle- and low-income countries travel to the high-income countries for better diagnostic capabilities, state-of-the-art medical technologies, and advanced treatment options that may not be available in their home countries. I wrote up this article in response to the opening of a Chinese-American Physicians E-Hospital, a new online service to facilitate Chinese patients seeking medical care in U.S..

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Pegged Software Uses Big Data To Improve Diversification in Health Care Hiring

MedicalResearch.com Interview with:

Mike Rosenbaum Founder and CEO Pegged Software

Pegged Software

Myra Norton
President and COO of Pegged Software

MedicalResearch.com editor’s note: As part of an ongoing series on changes in the health care landscape, we interviewed Ms. Myra Norton, President and COO of Pegged Software. Pegged Software uses an advanced “analytics engine to selecting job candidates based on the actual determinants of high performance”, specifically in the health care field. Ms. Norton has a special interest in gender and hospital hiring practices.

MedicalResearch.com: Given that women earn 78 cents to the dollar in regards to men, can big data improve this pay inequity? If so, how does this happen?

Myra Norton

Myra Norton

Ms. Norton: Big data and predictive analytics alone will not solve the problem of pay inequality. What these tools can do is illuminate talent in a way that removes the biases that undermine equality across gender, ethnicity, socio-economic status and other dimensions. For example, predictive analytics allows organizations to identify candidates with the highest likelihood of improving patient experience, being retained, remaining an engaged employee, lowering thirty day readmissions, and positively impacting other organizational outcomes.

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Only about 25% of Hospital Readmissions are Preventable

MedicalResearch.com Interview with:

Dr. Andrew Auerbach MD Professor of Medicine in Residence Director of Research Division of Hospital Medicine UCSF

Dr. Andrew Auerbach

Dr. Andrew Auerbach MD
Professor of Medicine in Residence
Director of Research Division of Hospital Medicine
UCSF and

Jeffrey L. Schnipper, MD, MPH Associate Physician, Brigham and Women's Hospital Associate Professor of Medicine, Harvard Medical School Department of Medicine Brigham and Women's Hospital

Dr. Jeffrey Scnhipper

Jeffrey L. Schnipper, MD, MPH
Associate Physician, Brigham and Women’s Hospital
Associate Professor of Medicine, Harvard Medical School
Department of Medicine
Brigham and Women’s Hospital

 

 

MedicalResearch.com: What is the background for this study?

Response: The Affordable Care Act required the Department of Health and Human Services to establish a program to reduce what has been dubbed a “revolving door of re-hospitalizations.” Effective October 2012, 1 percent of every Medicare payment was deducted for a hospital that was determined to have excessive readmissions. This percentage has subsequently increased to up to 3 percent. Penalties apply to readmitted Medicare patients with some heart conditions, pneumonia, chronic lung disease, and hip and knee replacements.

Unfortunately, few data exist to guide us in determining how many readmissions are preventable, and in those cases how they might have been prevented.

MedicalResearch.com: What are the main findings?

Response: Our main findings were that 27 percent of readmissions were preventable, and that the most common contributors to readmission were being discharged too soon, poor coordination between inpatient and outpatient care providers, particularly in the Emergency Departments and in arranging post acute care.

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Hospitals Should Engage Patients and Families in Safety Efforts

MedicalResearch.com Interview with:

Dr. Alisa Khan, MD MPH Boston Children's Hospital Boston

Dr. Alisa Khan

Dr. Alisa Khan, MD MPH
Division of General Pediatrics
Boston Children’s Hospital
Department of Pediatrics, Harvard Medical School, Boston, Massachusetts

Medical Research: What is the background for this study? What are the main findings?

Dr. Khan: Medical errors, or mistakes in the process of caring for patients, occur frequently. While methods of detecting errors have improved, parents and families are not typically included in routine hospital safety monitoring systems. We found that nearly 1 in 11 parents reported their child had experienced a safety incident during hospitalization. Most of these reports were confirmed to be medical errors when reviewed by physicians, and many were not otherwise documented in the patient’s medical record.

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Non-Medical Workers and Mobile Technology Can Help Predict Hospital Readmissions

MedicalResearch.com Interview with:

Andrey Ostrovsky, MD CEO | Co-Founder Care at Hand

Dr. Andrey Ostrovsky

Andrey Ostrovsky, MD
CEO | Co-Founder
Care at Hand 

Medical Research: What is the background for this study?

Dr. Ostrovsky: Hospital readmissions are a large source of wasteful healthcare spending, and current care transition models are too expensive to be sustainable. One way to circumvent cost-prohibitive care transition programs is complement nurse-staffed care transition programs with those staffed by less expensive nonmedical workers. A major barrier to utilizing nonmedical workers is determining the appropriate time to escalate care to a clinician with a wider scope of practice. The objective of this study is to show how mobile technology can use the observations of nonmedical workers to stratify patients on the basis of their hospital readmission risk.

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Group Urges Focus on Non-Communicable Diseases in Women

MedicalResearch.com Interview with:

Professor Robyn Norton Principal Director of The George Institute for Global Health Board Member, The George Institute for Global Health Professor of Public Health at the University of Sydney Professor of Global Health at the University of OxfordProfessor Robyn Norton
Principal Director of The George Institute for Global Health
Board Member, The George Institute for Global Health
Professor of Public Health at the University of Sydney
Professor of Global Health at the University of Oxford

Medical Research: What is the background for this study? What are the main findings?

Prof. Norton: The impetus to focus on women’s health, stems from the knowledge that, while noncommunicable diseases (NCDs) are the leading cause of death and disability for women worldwide, this is not sufficiently recognized nor sufficiently resourced. Equally, while there is increasing evidence that we can learn so much more about how to address the burden of disease for women, by collecting and analyzing data on women, separately to that for men, this is not happening.

We are calling for a refocus of the women’s health agenda on NCDs – given that globally and in many countries the focus of women’s health almost exclusively is still on women’s sexual and reproductive health. The fact is that in all but the poorest countries, the greatest health burden, for women, is  noncommunicable diseases and so that if we are to make significant gains in improving women’s health then we must focus on addressing NCDs. The current global burden of disease for women reflects both the significant gains that have been made as a result of addressing maternal mortality and changes that have affected both women and men equally – namely, that populations are living longer, as a consequence of reductions in both infant mortality and communicable diseases, as well as the fact that populations are becoming wealthier and, as a result, are engaging in behaviors that increase the risk of noncommunicable diseases.

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ACO Reduced Costs and Maintained Quality In Pediatric Medicaid Population

Dr. Eric W. Christensen, PhD Health Economist Children’s Hospitals and Clinics of Minnesota Minneapolis, MN

Dr. Eric Christensen

MedicalResearch.com Interview with:
Dr. Eric W. Christensen, PhD
Health Economist
Children’s Hospitals and Clinics of Minnesota
Minneapolis, MN

Medical Research: What is the background for this study?

Dr. Christensen: National healthcare expenditures are up from 5.0% of gross domestic product in 1960 to 17.4% in 2013. We must find ways to control cost while maintaining quality. Accountable care organizations (ACOs) were designed to control a population’s health care cost while maintaining or improving quality. This study was an examination of one ACO exclusively covering a pediatric Medicaid population.

Medical Research: What are the main findings?

Dr. Christensen: We found that health care utilization and cost patterns were associated with the length of time patients were attributed to this ACO, where attribution length can be thought of as a proxy for consistent primary care from ACO providers. Specifically, attribution length of 2 or more years was associated with a 40.6% decrease in inpatient days. This decrease was partially offset by increases in outpatient visits (as one would expect with a primary care focus), emergency department visits, and use of pharmaceuticals. Combined these utilization changes resulted in a cost reduction 15.7% for those attributed 2 or more years. These changes were achieved while meeting quality benchmarks.

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Quality Improvement in Colon Cancer Care Linked to Lower Costs

MedicalResearch.com Interview with: Johannes Govaert MD Department of Surgery Leiden University Medical Center Leiden, The Netherlands Medical Research: What is the background for this study? Dr. Govaert: The Value Based Health Care agenda of prof. Porter (Harvard Business School) suggests that focus in healthcare should shift from reducing costs to improving quality: where quality of healthcare improves, cost reduction will follow. One of the cornerstones of potential cost reduction, as mentioned by Porter, could be availability of key clinical data on processes and outcomes of care. Despite the important societal and economical role the healthcare system fulfils, it still lags behind when it comes to standardised reporting processes. With the introduction of the Dutch Surgical Colorectal Audit (DSCA) in 2009, robust quality information became available enabling monitoring, evaluation and improvement of surgical colorectal cancer care in the Netherlands. Since the introduction of the DSCA postoperative morbidity and mortality declined. Primary aim of this study was to investigate whether improving quality of surgical colorectal cancer care, by using a national quality improvement initiative, leads to a reduction of hospital costs. Detailed clinical data was obtained from the 2010-2012 population-based Dutch Surgical Colorectal Audit. Costs at patient-level were measured uniformly in all 29 participating hospitals and based on Time-Driven Activity-Based Costing. Medical Research: What are the main findings? Dr. Govaert: Over three consecutive years (2010-2012) severe complications and mortality after colorectal cancer surgery respectively declined with 20% and 29%. Simultaneously, costs during primary admission decreased with 9% without increase in costs within the first 90 days after discharge. Moreover, an inverse relationship (at hospital level) between severe complication rate and hospital costs was identified among the 29 participating hospitals. Hospitals with increasing severe complication rates (between 2010 and 2012) were associated with increasing costs whereas hospitals with declining severe complication rates were associated with cost reduction. Medical Research: What should clinicians and patients take away from your report? Dr. Govaert: This report presents evidence for simultaneously quality improvement and cost reduction. By participation in a nationwide quality improvement initiative with continuous quality measurement and benchmarked feedback, opportunities for targeted improvements are revealed and therefore bringing the medical field forward in improving value of healthcare delivery. Medical Research: What recommendations do you have for future research as a result of this study? Dr. Govaert: This is the first study outside the United States to describe such inverse relationship based on original financial and clinical data. Our conclusions provide additional evidence for cost reduction by quality improvement programs as seen in the American College of Surgeons National Surgical Quality Improvement Program. Therefore, we believe that our findings should be impetus for healthcare providers to focus on improving quality, which will catalyze costs savings as well. Citation: Nationwide Outcome-Measurement in Colorectal Cancer Surgery: Improving Quality and Reducing Costs Govaert, Johannes A. et al. Journal of the American College of Surgeons DOI: http://dx.doi.org/10.1016/j.jamcollsurg.2015.09.020

Dr. Grovaert

MedicalResearch.com Interview with:
Johannes Govaert MD
Department of Surgery
Leiden University Medical Center
Leiden, The Netherlands

Medical Research: What is the background for this study?

Dr. Govaert: The Value Based Health Care agenda ofPprof. Porter (Harvard Business School) suggests that focus in healthcare should shift from reducing costs to improving quality: where quality of healthcare improves, cost reduction will follow. One of the cornerstones of potential cost reduction, as mentioned by Porter, could be availability of key clinical data on processes and outcomes of care. Despite the important societal and economical role the healthcare system fulfils, it still lags behind when it comes to standardised reporting processes. With the introduction of the Dutch Surgical Colorectal Audit (DSCA) in 2009, robust quality information became available enabling monitoring, evaluation and improvement of surgical colorectal cancer care in the Netherlands. Since the introduction of the DSCA postoperative morbidity and mortality declined.

Primary aim of this study was to investigate whether improving quality of surgical colorectal cancer care, by using a national quality improvement initiative, leads to a reduction of hospital costs. Detailed clinical data was obtained from the 2010-2012 population-based Dutch Surgical Colorectal Audit. Costs at patient-level were measured uniformly in all 29 participating hospitals and based on Time-Driven Activity-Based Costing.

Medical Research: What are the main findings?

Dr. Govaert: Over three consecutive years (2010-2012) severe complications and mortality after colorectal cancer surgery respectively declined with 20% and 29%. Simultaneously, costs during primary admission decreased with 9% without increase in costs within the first 90 days after discharge. Moreover, an inverse relationship (at hospital level) between severe complication rate and hospital costs was identified among the 29 participating hospitals. Hospitals with increasing severe complication rates (between 2010 and 2012) were associated with increasing costs whereas hospitals with declining severe complication rates were associated with cost reduction.

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Skilled Nursing and Readmissions Drive Up Post Hospital Discharge Spending

MedicalResearch.com Interview with:
Anup Das

Medical Scientist Training Program
Department of Health Management and Policy
University of Michigan, Ann Arbor

Medical Research: What is the background for this study? What are the main findings?

Response: The Centers for Medicare & Medicaid Services (CMS) recently added a new measure of episode spending to the Hospital Value Based Purchasing program. Participation in this program allows hospitals to receive a financial bonus if they perform well on the included measures. This is the first spending measure in the program, and this change now incentivizes hospitals to improve their quality as well as their spending. The measure evaluates spending from three days before a hospitalization through 30 days post-discharge.

In this study, we find that while high-cost hospitals had higher spending levels in each of the three components of an episode of care (pre-admission, index admission, and post-discharge), differences in post-discharge spending were the main determinants of hospital performance on this measure. High-cost hospitals spent on average $4,691 more than low-cost hospitals in post-discharge care. The majority of post-discharge spending comes from skilled nursing facility or readmission costs. Similarly, hospitals that did worse on this new measure of spending over time did so because of increases in their post-discharge spending.

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NIHSS Stroke Database is Incomplete and May Have Selection Bias

Mathew J. Reeves BVSc, PhD, FAHA Professor, Department of Epidemiology and Biostatistics, Michigan State University East Lansing, MI 48824

Prof. Reeves

MedicalResearch.com Interview with:
Mathew J. Reeves BVSc, PhD, FAHA
Professor, Department of Epidemiology and Biostatistics,
Michigan State University
East Lansing, MI 48824 

Medical Research: What is the background for this study?

Dr. Reeves: The National Institutes of Health Stroke Scale (NIHSS) is the single most important prognostic factor in predicting outcomes of individual stroke patients. NIHSS data is obviously important at the patient level but also at a hospital level since the case mix of stroke patients are assumed to vary widely across different hospitals and referral centers.

Measuring stroke outcomes at a hospital level is becoming increasingly important as work proceeds in the US to develop integrated stroke systems of care. But it is also very relevant to the new payment models being introduced by CMS which are based on hospital rankings that are developed from statistical risk adjustment models. One would expect that NIHSS would be a major contributor to these models but currently a major limitation is that NIHSS is incompletely documented in clinical registries such as GWTG-Stroke, and is completely absent from administrative data.

The problem of missing NIHSS data plays havoc with the ability to risk adjust stroke outcomes across hospitals. Missing data results is a smaller number of stroke cases being included in the risk adjusted calculations for a given hospital which results in greater uncertainty over what the actual hospital outcomes are. Further there is concern that NIHSS data is not missing at random, and so the NIHSS data that is documented may represent a biased selection of all the cases that a hospital admits. This too could have important consequences for hospital rankings.

To determine the degree of potential bias in the documentation of NIHSS data this study examined trends in and predictors of documentation of NIHSS across 10 years of data (2003-2012) in the GWTG-Stroke program.

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Physician Integration into Hospital Systems Can Raise Outpatient Spending

MedicalResearch.com Interview with:
Hannah Neprash PhD student
Health Policy program
Harvard University.

Medical Research: What is the background for this study?

Response: Hospitals are increasingly employing or purchasing physician practices. This trend started before the Affordable Care Act, as our study documents, but there is a concern that these trends may accelerate as providers reorganize to meet the challenges of new payment models that hold providers accountable for the entire spectrum of patient care, spanning inpatient and outpatient settings. It’s not clear how this change in provider market structure should affect spending. It could lead to lower spending, if care is better coordinated, reducing waste and unnecessary utilization. But, it could also lead to higher spending if larger provider groups have more market power and can negotiate higher prices with insurers.

Medical Research: What are the main findings?

Response: We used Medicare claims to quantify the share of physicians in major metropolitan markets that were owned or employed by a hospital. Most markets saw an increase in physician-hospital integration from 2008 to 2012. The average market saw a 3% increase in physician-hospital integration; the 75th percentile market saw a 5% increase; and the 95th percentile market saw a 15% increase. An increase in physician-hospital integration equivalent to the 75th percentile was associated with a $75 per person (or 3%) increase in annual outpatient spending among a non-elderly commercially insured population. This was driven by price increases – as we found no change in utilization.

We did not find a similar association between physician-hospital integration and inpatient hospital spending. This is likely because hospital markets were already less competitive than physician markets at the beginning of our study period. When a hospital system buys a physician practice, the hospitals might not gain much bargaining power against an insurer in negotiating prices for inpatient care, but the hospital’s bargaining power could be used to negotiate higher fees for the outpatient physician practice.  That is, an insurer may not be persuaded by the threat of excluding the physician practice from its network, but the threat of excluding the entire hospital system from the insurer’s network is likely to carry more weight.

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Short Stay Units May Save Money For Health Care Systems

James Galipeau PhD Ottawa Hospital Research Institute Ottawa, Ontario, Canada

James Galipeau PhD

MedicalResearch.com Interview with:
James Galipeau PhD
Ottawa Hospital Research Institute
Ottawa, Ontario, Canada 

Medical Research: What is the background for this study?

Dr. Galipeau: Overcrowding in emergency departments (EDs) is becoming more and more commonplace in Canada. The issue of overcrowding is complex and multidimensional with three distinct but interdependent components: input, throughput (processing), and output. At the processing level, one solution to overcrowding that has emerged is the establishment of observation/short stay units.

A short-stay unit is a physical location in a hospital, usually in close proximity to the ED. Patients needing treatments or observation that may take several hours to resolve (e.g., blood transfusions, diagnostic testing, arranging social services) can be accommodated in a short-stay unit without occupying ED beds or needing to be admitted. In theory, ED-based short-stay units can lessen ED overcrowding by influencing outcomes such as ED wait times and hospital costs (if patients are moved from the ED to inpatient care).

Although a recent report by the American College of Emergency Physicians recommends pursuing the use of short-stay units to alleviate ED overcrowding, there is a lack of evidence syntheses summarizing their effectiveness, safety, and value for money. Our objective was to conduct a systematic review to evaluate the effectiveness and safety of ED short-stay units compared with care not involving short-stay units.

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Schizophrenia, Chest Pain Top Longest Emergency Department Stays

Ernest Moy, MD, MPH Medical Officer Center for Quality Improvement and Patient Safety Agency for Healthcare Research and QualityMedicalResearch.com Interview with:
Ernest Moy, MD, MPH
Medical Officer
Center for Quality Improvement and Patient Safety
Agency for Healthcare Research and Quality

Medical Research: What is the background for this study?

Dr. Moy: The amount of time that a patient spends in the emergency department (ED) has become increasingly viewed as a quality measure, because length of stay and ED crowding have been linked to quality of care, patient safety, and treatment outcomes. However, current ED length-of-stay measures publicly reported by the Centers for Medicare & Medicaid Services (CMS) combine lengths of stay across all conditions. We suspected that ED length of stay is influenced by the clinical condition of the patient, but didn’t know how disparate times might be. Of course, such stays will certainly be influenced by other factors, which we describe in the paper. Previous studies have helped guide decisions about where to focus resources to improve emergency department services. However, many studies about ED length of stay focus on a single condition, a single or few hospitals, or both, which limits what we can conclude across different conditions.  We were fortunate to find one state, Florida, in the Healthcare Cost and Utilization Project database that provides entry and exit times for a census of emergency department visits for both released and admitted patients to measure length of ED stays by patients’ conditions and dispositions.

Medical Research: What are the main findings?

Dr. Moy: For the 10 most common diagnoses, patients with relatively minor injuries (e.g., sprains and strains, superficial injuries and contusions, skin and subcutaneous tissue infections, open wounds of the extremities) typically required the shortest mean stays (3 hours or less). Conditions involving pain with nonspecific or unclear etiologies (e.g., chest, abdomen, or back pain; headache, including migraine), generally resulted in mean stays of 4 hours or more. However, there were substantial clinical differences among patients released, admitted, and transferred. Conditions resulting in admission or transfer tended to be more serious, resulting in longer stays. Patients requiring the longest stays, by disposition, had discharge diagnoses of nonspecific chest pain (mean 7.4 hours among discharged patients), urinary tract infections (4.8 hours among admissions), and schizophrenia (9.6 hours among transfers) among the top 10 diagnoses.

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Advance Practice Providers Deliver Quality Cardiac Care

Salim S. Virani, M.D., Ph.D Investigator, Health Policy, Quality & Informatics Program, Center for Innovations in Quality, Effectiveness and Safety, Staff Cardiologist, Michael E. DeBakey VA Medical Center Associate Director for Research, Cardiology Fellowship Training Program Associate Professor (tenured), Section of Cardiovascular Research Baylor College of Medicine Houston

Salim S. Virani, M.D., Ph.D

MedicalResearch.com Interview with:
Salim S. Virani, M.D., Ph.D
Investigator, Health Policy, Quality & Informatics Program, Center for Innovations in Quality, Effectiveness and Safety, Staff Cardiologist, Michael E. DeBakey VA Medical Center
Associate Director for Research, Cardiology Fellowship Training Program
Associate Professor (tenured), Section of Cardiovascular Research
Baylor College of Medicine  Houston

Medical Research: What is the background for this study? What are the main findings?

Dr. Virani: The increase in Americans securing health care coverage under the Affordable Care Act, in combination with a projected shortage of specialty and non-specialty physicians, has led to a growing pressure on the existing physician workforce in America.  One proposed solution is to increase the scope of practice for advanced practice providers (APPs) (nurse practitioners [NPs] and physician assistants [PAs].  An important aspect of this discussion is whether the quality of care provided by APPs is comparable to that provided by physicians.

The study utilized data from the American College of Cardiology’s (ACC) National Cardiovascular Data Registry PINNACLE Registry® to examine whether there were clinically meaningful differences in the quality of coronary artery disease (CAD), heart failure (HF), and atrial fibrillation (AF) care delivered by advanced practice providers  versus physicians in a national sample of cardiology practices.

The primary analyses included 883 providers (716 physicians and 167 APPs) in 41 practices who cared for 459,669 patients. The mean number of patients seen by APPs (260.7) was lower compared to that seen by physicians (581.2). Compliance with most CAD, HF, and AF measures was comparable, except for a higher rate of smoking cessation screening and intervention (adjusted rate ratio [RR] 1.14, 95% CI 1.03-1.26) and cardiac rehabilitation referral (RR 1.40, 95% CI 1.16-1.70) among CAD patients receiving care from APPs. Compliance with all eligible CAD measures was low for both (12.1% and 12.2% for APPs and physicians, respectively) with no significant difference. Results were consistent when comparing practices with both physicians and APPs (n = 41) and physician-only practices (n = 49).

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What Explains Hospital Variation In Antibiotic Usage?

James Baggs, PhD Division of Healthcare Quality Promotion Centers for Disease Control and Prevention Atlanta, GA

Dr. James Baggs, PhD

MedicalResearch.com Interview with:
James Baggs, PhD
Division of Healthcare Quality Promotion
Centers for Disease Control and Prevention
Atlanta, GA

Medical Research: What is the background for this study?

Dr. Baggs: The National Action Plan for Combating Antibiotic Resistance Bacteria calls for annual reporting of antibiotic use in inpatient settings as well as the identification of variations at the provider or patient level that can assist in developing interventions. Antibiotic use varies among hospitals, but some portion of that variability is related to the type of patients admitted to the hospital and other hospital characteristics. We evaluated factors in a large cohort of US hospitals that may account for inter-facility variability in antibiotic use, so that we can more appropriately monitor antibiotic use in hospitals.

Medical Research: What are the main findings?

Dr. Baggs: We utilized data from the Truven Health MarketScan Hospital Drug Database (HDD), which contains detailed administrative records, including inpatient drug utilization data based on billing records, for all patients discharged from a convenience sample of over 500 US hospitals. We retrospectively estimated days of therapy (DOT)/1,000 patient days (PDs) by year from 2006-2012, and created a multivariable model that adjusts for hospital-specific location of antibiotic use (ICU vs. other), average patient age, average patient co-morbidity score, number of hospital beds, teaching status, urban or rural location, proportion of discharges with a surgical diagnosis related code, case mix index, and proportion of patient days with an infectious disease primary ICD-9-CM discharge code. We observed that DOT varied significantly between hospitals; the 10th to 90th percentile values for hospital days of therapy ranged from 546 to 998/1,000 PDs. The variables included in our model accounted for 47-53% of the inter-facility variability, depending on year. However, nearly all of this variability was explained by two predictors: proportion of PDs with an infectious disease diagnosis code and hospital location (ICU vs. other). 

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Many Academic Medical Professors Serve on Health Care Company Boards

Timothy Anderson, M.D. Chief medical resident University of Pittsburgh’s Department of Internal MedicineMedicalResearch.com Interview with:
Timothy Anderson, M.D.
Chief medical resident
Department of Internal Medicine
University of Pittsburgh

Medical Research: What is the background for this study? What are the main findings?

Dr. Anderson: My coauthors and I analyzed the public disclosures of all publicly traded U.S. health care companies listed on the NASDAQ exchange and New York Stock Exchange in January 2014 that specialized in pharmaceuticals, biotechnology, medical equipment and providing health care services.  Of the 442 companies with publicly accessible disclosures on boards of directors, 180 – or 41 percent – had one or more academically affiliated directors in 2013. These individuals included chief executive officers, vice presidents, presidents, provosts, chancellors, medical school deans, professors and trustees from 85 non-profit academic research and health care institutions. These individuals received compensation and stock shares from companies which far exceeds payment for other relationships such as consulting. In some cases compensation approaches or exceeds average professor and physician salaries.

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No Clear Standard For Measuring Health Care Quality Improvement Interventions

Megan Colleen McHugh, PhD Research Assistant Professor Center for Healthcare Studies Institute for Public Health and Medicine and Emergency Medicine Northwestern UniversityMedicalResearch.com Interview with:
Megan Colleen McHugh, PhD
Research Assistant Professor
Center for Healthcare Studies
Feinberg Institute for Public Health and Medicine and Emergency Medicine
Northwestern University
 

Medical Research: What is the background for this study? What are the main findings?

Dr. McHugh: There have been many large efforts to improve the delivery of health care in the U.S., for example, the Robert Wood Johnson Foundation’s Aligning Forces for Quality Program and the Institute for Healthcare Improvement’s 100,000 Lives Campaign.  One of the challenges to understanding whether these programs work is that the intervention “dose” – the quality and quantity of the intervention – often varies across different participating sites.

As evaluators of multi-site quality improvement programs, we want to better understand how to measure the dose of a quality improvement intervention at participating sites.  We identified four different approaches to measuring dose.  These approaches resulted in different conclusions about which sites are “low dose” and “high dose” intervention sites.

Medical Research: What should clinicians and patients take away from your report?

Dr. McHugh: The main audience for this paper is program evaluators.  They should take away the following:

1) Variation in dose scores across intervention sites suggests that dose may be a contributor to the effectiveness of a quality improvement intervention.

2) It is feasible to measure the dose of a quality improvement intervention, but measuring QI dose presents many challenges, including subjective decisions about which approach to measurement to use and the need for extensive data collection.

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Data-Driven Model Can Help Predict Hospital Discharges

Dr. Sean Barnes Ph.D. Department of Decision, Operations & Information Technologies Robert H. Smith School of Business University of Maryland, College Park, MD

MedicalResearch.com Interview with:
Dr. Sean Barnes Ph.D.
Department of Decision, Operations & Information Technologies
Robert H. Smith School of Business
University of Maryland, College Park, MD

 

Medical Research: What is the background for this study? What are the main findings?

Dr. Barnes: Hospitals are continually being challenged to provide timely and efficient care in the face of increasingly constrained resources. One recent approach to help improve patient flow in hospitals is Real-Time Demand and Capacity Management, by which clinicians huddle each morning to predict the number of patients they expect to discharge on a given day (and hence the number of beds that will become available to potentially utilize for newly admitted patients). We proposed a data-driven method for predicting discharges–either on an individual or aggregate basis–and demonstrated that we could match or exceed the predictive accuracy of clinicians. In addition, we showed (with moderate success) that we could use this model to rank patients in order of their expected discharge times, which could be used to prioritize the remaining care tasks for specific subsets of patients.

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Health Care Organizations Require Different Tactics To Implement Change

MedicaIngrid Nembhard, PhD, MS Associate Professor, Yale School of Public Health & Yale School of Management Associate Director, Health Care Management Program YalelResearch.com Interview with:
Ingrid M. Nembhard PhD MS
Yale University
New Haven, CT

Medical Research: What is the background for this study? What are the main findings?

Dr. Nembhard: Many health care organizations (hospital, medical groups,  etc.) have sought to address well-documented quality problems by implementing evidence-based innovations, that is, practices, policies, or technologies that have been proven to work in other organizations. The benefits of these innovations are often not realized because adopting organizations experience implementation failure—lack of skillful and consistent use of innovations by intended users (e.g., clinicians). Past research estimates that implementation failure occurs at rates greater than 50% in health care. The past work also shows organizational factors expected to be facilitators of implementation are not always helpful.

In this work, we examined a possible explanation for the mixed results: different innovation types have distinct enabling factors. Based on observation and statistical analyses, we differentiated role-changing innovations, altering what workers do, from time-changing innovations, altering when tasks are performed or for how long. We then examined our hypothesis that the degree to which access to groups that can alter organizational learning—staff, management, and external network— facilitates implementation depends on innovation type. Our longitudinal study of 517 hospitals’ implementation of evidence-based practices for treating heart attack confirmed our thesis for factors granting access to each group: improvement team’s representativeness (of affected staff), senior management engagement, and network membership. Although team representativeness and network membership were positively associated with implementing role-changing practices, senior management engagement was not. In contrast, senior management engagement was positively associated with implementing time-changing practices, whereas team representativeness was not, and network membership was not unless there was limited management engagement.

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Mexican Study Links Health System Delays and Later Stage Of Breast Cancer Diagnosis

MedicalResearch.com Interview with:
Dr. Karla Unger-Saldaña
Unit of Epidemiology
Instituto Nacional de Cancerología
Mexico City, Mexico.

Medical Research: What is the background for this study?

Dr. Unger-Saldaña: Even though Breast Cancer is most common in the developed world, most cancer deaths actually occur in developing regions. This is mainly because patients are diagnosed in advanced stages, with poor chances of survival. Most studies have shown that long times between symptom discovery and treatment start (total delay) are associated with advanced clinical stage. Like total delay, patient delay -a prolonged time between symptom discovery and the first medical consultation- has also shown to be associated with advanced clinical stage. But the impact of health system delay -the time between the first clinical consultation and the start of cancer treatment- is less clear. Studies have shown contradictory findings. For example, studies in developed countries have found the reverse association: advanced stages associated with short times between first medical consultation and treatment start. This has been attributed to the ability of doctors to quickly identify patients with advanced cancer and somehow accelerate their care.

Medical Research: What are the main findings?

Dr. Unger-Saldaña: In this study, done among 886 patients, we found that the majority started cancer treatment in advanced stages, with only 15% being diagnosed in stages 0 and I. Also, we found long delays for breast cancer diagnosis and treatment in most cases. The median time between symptom discovery and cancer treatment start was 7 months. The longest subinterval was that between the first medical consultation and diagnosis confirmation, which had a median of 4 months. The most relevant result was that not only was patient delay associated with advanced stage, but also health system delay. For every additional month of health system delay, the probability of starting treatment in advanced stage was increased by 1%.

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NHS Sees Reductions In Low-Value Procedures

MedicalResearch.com Interview with:
Sophie Coronini-Cronberg

Honorary research Fellow
Department of Primary Care and Public Health, Imperial College London
Consultant in public health
Centre Medical Directorate with Bupa, United Kingdom.

Medical Research: What is the background for this study? What are the main findings?

Dr. Coronini-Cronberg: From April 2011, England’s National Health Service (NHS) was challenged to find £20 billion of efficiency savings over four years, in part by reducing the use of ineffective, overused or inappropriate procedures. However, there was no clear instruction as to which procedures are of ‘limited clinical value’ and also under which circumstances they should be reduced. We looked at hospital admissions statistics for six procedures that appear on local and/or unofficial lists to see which had been affected and whether cuts were applied consistently across commissioners in the first year of the savings programme.

We found a significant drop in three procedures considered potentially ‘low value’ compared to the underlying time trend: removal of cataracts, hysterectomy for heavy menstrual bleeding, and myringotomy to relieve eardrum pressure. There was no significant change in three other ‘low-value’ procedures: spinal surgery for lower back pain, inguinal hernia repair, and primary hip replacement, or in two ‘benchmark’ procedures (coronary revascularisation, gall bladder removal).

Myringotomy, a procedure to relieve pressure in the ear which is considered relatively ineffective, declined by 11.4 per cent overall. Two procedures considered only effective in certain circumstances also fell overall. Hysterectomy for heavy menstrual bleeding declined by 10.7 per cent overall, and cataract removal declined by 4.8 per cent.ý

ýWe also found the reductions were inconsistently applied by commissioning groups (so-called Primary Care Trusts).

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Medicare RAC Audits Fraught With Delays, High Costs and Lack of Transparency

Ann M. Sheehy, M.D., M.S. Associate Professor Division Head, Hospital Medicine University of Wisconsin Department of MedicineMedicalResearch.com Interview with:
Ann M. Sheehy, M.D., M.S.

Associate Professor
Division Head, Hospital Medicine
University of Wisconsin Department of Medicine

MedicalResearch: What is the background for this study? What are the main findings?

Dr. Sheehy: Outpatient (observation) and inpatient status determinations are important for hospitalized Medicare beneficiaries. The Recovery Audit program, more commonly known as the RACs (Recovery Audit Contractors), is charged with surveillance and enforcement of such status determinations. Surveillance in the Medicare program is necessary, and Medicare fraud and abuse should not be tolerated. However, there are increasing concerns regarding RAC accuracy, auditor financial incentives, and the volume of audits and overpayment determinations auditors allege. We therefore studied Complex Medicare Part A RAC audits at 3 academic medical centers, the University of Wisconsin, the University of Utah, and Johns Hopkins, to determine the impact and trends of such audits.

There was a nearly 300% increase in RAC overpayment determinations in just 2 years at the study hospitals. Each year, the hospitals won a greater percent of contested cases, winning 68.0% of cases with decisions in 2013. Two-thirds of all favorable decisions for the hospitals occurred in the discussion period. Because discussion is not considered part of the formal appeals process, this is omitted from reports of RAC accuracy. None of the overpayment determinations contested the need for the care delivered, rather contested the billing location, outpatient or inpatient. The hospitals averaged 5 FTE each to manage the audit and appeals process. Claims still in appeals had been in process for a mean of 555 days without decisions.

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Leftover US Hospital Supplies Can Have Lifesaving Impact Overseas

MedicalResearch.com Interview with:
Eric Wan BS and Miceile Barrett BS

Johns Hopkins University School of Medicine
Baltimore, MD

Medical Research: What is the background for this study? What are the main findings?

Answer: Access to surgery is limited in resource-poor settings and low-and-middle income countries (LMICs) due to a lack of human and material resources. In contrast, academic hospitals in high-income countries often generate significant amounts of unused and clean medical supplies that cannot be re-used in the operating rooms of high-income countries. Programs such as Supporting Hospitals Abroad with Resources and Equipment (SHARE) provide an avenue for recovery of these supplies and donation to resource-poor hospitals in LMICs. From data collected from SHARE supplies donated by Johns Hopkins, we found that the nationwide impact for these programs to be $15.4 million among US academic hospitals, which accounts for only 19 categories of commonly recovered supplies. When we tracked our donated supplies to hospitals in Ecuador serving the poor, we found that the cost-effectiveness of these donations was US $2.14 per disability-adjusted life-year prevented.
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How To Quickly Disseminate Best Practices To Doctors

Luís A. Nunes Amaral PhD HHMI Early Career Scientist Professor of Chemical & Biological Eng. Professor of Medicine Howard Hughes Medical Institute Northwestern University, Evanston, IllinoisMedicalResearch.com Interview with:
Luís A. Nunes Amaral PhD
HHMI Early Career Scientist
Professor of Chemical & Biological Eng.
Professor of Medicine
Howard Hughes Medical Institute
Northwestern University, Evanston, Illinois

Medical Research: What is the background for this study? What are the main findings?

Dr. Amaral: There is a well known difficulty in promoting the rapid adoption of best practices by physicians.  Because of their work load and because of the inability to figure out when some result is a true advance or just hype, doctors tend to stick to what they believe works. Unfortunately, as a 15 year old Institute of Medicine study shows, this lack of adoption of best practices costs society hundreds of thousands of lives a year in the US alone.

The typical process for informing doctors of what best practices are (such as continual medical education and other broadcasting approaches) do not work well. We believe that a weakness of typical approaches is that they have a one talking to the many style, and they are out of a medical practice context.  Our hypothesis was that by seeding a few doctors with desired knowledge, one could have spread of the adoption through one-on-one contacts between physicians in the context of treating patients.  We found that this approach has the potential to be very effective.
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Physicians Frustrated By Administrative Burdens of Medical Practice

Dr. Steffie Woolhandler MD MPH Professor of Public Health and City University of New York, Lecturer (formerly Professor of Medicine) at Harvard Medical School Primary Care Physician Practicing in the South BronxMedicalResearch.com Interview with:
Dr. Steffie Woolhandler MD MPH
Professor of Public Health and City University of
New York, Lecturer (formerly Professor of
Medicine) at Harvard Medical School
Primary Care Physician Practicing in the South Bronx

Medical Research: What is the background for this study?

Dr. Woolhandler: Physicians like myself are extremely frustrated
by the administrative burdens of medical
practice. Many hours of physicians’ time each
week go to administrative work completely
unrelated to good patient care, but mandated by
private insurers and other payers. Colleagues
often tell me that they love seeing patients but
are getting burned out by the paperwork.
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Bundled Payment Orthopedic Pilot Program A Bust In California

M. Susan Ridgely, JD Senior Policy Analyst RAND Corporation Santa Monica, CaliforniaMedicalResearch.com: Interview with:
M. Susan Ridgely, JD
Senior Policy Analyst
RAND Corporation
Santa Monica, California

 

Medical Research: What are the main findings of the study?

Answer: We evaluated a three-year effort, coordinated by the Integrated Healthcare Association, to determine whether bundled payment could be an effective payment model for California. The pilot focused on bundled payment for orthopedic procedures for commercially insured adults under age 65. Bundled payment is a much-touted strategy that pays doctors and hospitals one fee for performing a procedure or caring for an illness. The strategy is seen as one of the most-promising ways to curb health care spending. Unfortunately, the project failed to meet its goals, succumbing to recruitment challenges, regulatory uncertainty, administrative burden and concerns about financial risk.

At the outset of the project, participants included six of the state’s largest health plans, eight hospitals and an independent practice association. Eventually, two insurers dropped out because they believed the bundled payment model in this project would not lead to a redesign of care or lower costs. Another decided that bundled payment was incompatible with its primary type of business (health maintenance organization). Just two hospitals eventually signed contracts with the three remaining health plans to use bundled payments. Hospitals that dropped out cited concerns about the time and effort involved.

The project was hurt by a lack of consensus about what types of cases to include and which services belonged in the bundle. In the end, most stakeholders agreed that the bundle definitions were probably too narrow to capture enough procedures to make bundled payment viable.

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