Author Interviews, Cost of Health Care, Health Care Systems, Hospital Readmissions / 20.07.2016

MedicalResearch.com Interview with: [caption id="attachment_26313" align="alignleft" width="150"]Thomas P. Meehan, MD, MPH Associate Medical Director Harvard Pilgrim Health Care Qualidigm, Wethersfield Quinnipiac University, North Haven CT Dr. Thomas Meehan[/caption] 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.
Author Interviews, Education, Health Care Systems, Outcomes & Safety / 15.07.2016

MedicalResearch.com Interview with: [caption id="attachment_26186" align="alignleft" width="142"]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[/caption] 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.
Author Interviews, Cancer Research, Cost of Health Care, Health Care Systems, JAMA / 11.07.2016

MedicalResearch.com Interview with: [caption id="attachment_25955" align="alignleft" width="160"]Laura B. Vater, MPH MD Candidate 2017 Indiana University School of Medicine Laura Vater[/caption] 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).
Author Interviews, Health Care Systems, Hospital Readmissions, Yale / 09.07.2016

MedicalResearch.com Interview with: [caption id="attachment_25938" align="alignleft" width="183"]Kumar Dharmarajan, MD, MBA Assistant Professor of Medicine (Cardiology) Cardiovascular Medicine: Center for Outcomes Research & Evaluation (CORE) Yale School of Medicine Dr. Kumar Dharmarajan[/caption] 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.
Author Interviews, Health Care Systems / 20.06.2016

MedicalResearch.com Interview with: [caption id="attachment_25305" align="alignleft" width="108"]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[/caption] 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.
Author Interviews, Global Health, Health Care Systems / 07.06.2016

[caption id="attachment_25009" align="alignleft" width="151"]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[/caption] 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..
Author Interviews, Health Care Systems / 06.06.2016

MedicalResearch.com Interview with: [caption id="attachment_24504" align="alignleft" width="336"]Mike Rosenbaum Founder and CEO Pegged Software Pegged Software[/caption] 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? [caption id="attachment_24967" align="alignleft" width="173"]Myra Norton Myra Norton[/caption] 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.
Author Interviews, Brigham & Women's - Harvard, Cost of Health Care, Hand Washing, Health Care Systems, JAMA, UCSF / 07.03.2016

MedicalResearch.com Interview with: [caption id="attachment_22366" align="alignleft" width="133"]Dr. Andrew Auerbach MD Professor of Medicine in Residence Director of Research Division of Hospital Medicine UCSF Dr. Andrew Auerbach[/caption] Dr. Andrew Auerbach MD Professor of Medicine in Residence Director of Research Division of Hospital Medicine UCSF and [caption id="attachment_22367" align="alignleft" width="100"]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[/caption] 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.
Author Interviews, Health Care Systems, JAMA, Outcomes & Safety / 29.02.2016

MedicalResearch.com Interview with: [caption id="attachment_22185" align="alignleft" width="180"]Dr. Alisa Khan, MD MPH Boston Children's Hospital Boston Dr. Alisa Khan[/caption] 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.
Author Interviews, Cost of Health Care, Health Care Systems, Hospital Readmissions, Technology / 25.02.2016

MedicalResearch.com Interview with: [caption id="attachment_22021" align="alignleft" width="200"]Andrey Ostrovsky, MD CEO | Co-Founder Care at Hand Dr. Andrey Ostrovsky[/caption] 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.
Author Interviews, Gender Differences, Health Care Systems, Women's Heart Health / 22.02.2016

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.
Author Interviews, Cost of Health Care, Health Care Systems, Pediatrics / 14.12.2015

[caption id="attachment_20068" align="alignleft" width="261"]Dr. Eric W. Christensen, PhD Health Economist Children’s Hospitals and Clinics of Minnesota Minneapolis, MN Dr. Eric Christensen[/caption] 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.
Author Interviews, Colon Cancer, Cost of Health Care, Health Care Systems, Outcomes & Safety, Surgical Research / 06.12.2015

[caption id="attachment_19860" align="alignleft" width="200"]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[/caption] 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.
Author Interviews, Cost of Health Care, Health Care Systems, JAMA, Outcomes & Safety / 25.11.2015

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.
AHA Journals, Author Interviews, Health Care Systems, Outcomes & Safety, Stroke / 29.10.2015

[caption id="attachment_18912" align="alignleft" width="169"]Mathew J. Reeves BVSc, PhD, FAHA Professor, Department of Epidemiology and Biostatistics, Michigan State University East Lansing, MI 48824 Prof. Reeves[/caption] 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.
Author Interviews, Brigham & Women's - Harvard, Cost of Health Care, Health Care Systems, JAMA / 20.10.2015

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.
Author Interviews, Cost of Health Care, Emergency Care, Health Care Systems / 17.10.2015

[caption id="attachment_18476" align="alignleft" width="200"]James Galipeau PhD Ottawa Hospital Research Institute Ottawa, Ontario, Canada James Galipeau PhD[/caption] 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.
AHRQ, Author Interviews, Emergency Care, Health Care Systems / 15.10.2015

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.
Author Interviews, Baylor College of Medicine Houston, Health Care Systems, Heart Disease, JACC / 14.10.2015

[caption id="attachment_18369" align="alignleft" width="120"]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[/caption] 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).
Author Interviews, CDC, Health Care Systems, Infections, Outcomes & Safety / 12.10.2015

[caption id="attachment_18299" align="alignleft" width="180"]James Baggs, PhD Division of Healthcare Quality Promotion Centers for Disease Control and Prevention Atlanta, GA Dr. James Baggs, PhD[/caption] 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). 
Author Interviews, BMJ, Cost of Health Care, Education, Health Care Systems, University of Pittsburgh / 30.09.2015

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.
Author Interviews, Health Care Systems, Outcomes & Safety / 12.09.2015

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.
Author Interviews, Health Care Systems / 01.09.2015

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.
Author Interviews, Health Care Systems, Yale / 01.07.2015

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.
Breast Cancer, Health Care Systems / 06.04.2015

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%.
Author Interviews, Cost of Health Care, Health Care Systems / 04.03.2015

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).
Author Interviews, Health Care Systems, Medicare / 02.03.2015

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.
Author Interviews, General Medicine, Health Care Systems, Johns Hopkins / 29.10.2014

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.
Author Interviews, Cost of Health Care, Health Care Systems / 28.10.2014

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.
Author Interviews, Health Care Systems / 23.10.2014

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.