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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