Episodes Of Care Research Articles

Impact of dementia special care units for short-stay nursing home patients.

Improving quality of care provided to short-stay patients with dementia in nursing homes is a policy priority. However, it is unknown whether dementia-focused care strategies are associated with improved clinical outcomes or lower utilization and costs for short-stay dementia patients. We performed a national survey of nursing home administrators in 2020-2021, asking about the presence of three dementia-focused care services used for their short-stay patients: (1) a dementia care unit, (2) cognitive deficiency training for staff, and (3) dementia-specific occupational therapy. Using Medicare claims, we identified short-stay episodes for beneficiaries residing in surveyed skilled nursing facilities (SNFs) with and without dementia. We compared clinical, cost, and utilization outcomes for dementia patients in SNFs, which did and did not offer dementia-focused care services. As a counterfactual control, we compared these differences to those for non-dementia patients in the same facilities. Our primary quantity of interest was an interaction term between a patients' dementia status and the presence of a dementia-focused care tool. The study population included 102,860 Medicare episodes of care from 377 SNF survey respondents in 2018-2019. In adjusted comparisons of the interaction between dementia status and the presence of each dementia-focused care tool, dementia care units were associated with a 1.5-day increase in healthy days at home in the 90 days following discharge (p = 0.01) and a 3.1% decrease in the likelihood of a subsequent SNF admission (p = 0.001). Cognitive deficiency training was also associated with a 2.0% increase in antipsychotics (p = 0.03), whereas dementia-specific occupational therapy was associated with a 1.2% increase in falls (p = 0.01) per patient episode. Self-reported use of dementia care units for short-stay patients was associated with modestly better performance in some, but not all, outcome measures. This provides hypothesis-generating evidence that dementia care units could be a promising mechanism to improve care delivery in nursing homes.

Surgeon idiosyncrasy is a key driver of cost in arthroscopic rotator cuff repair: a time-driven activity-based costing analysis.

Delivering high-value orthopedic care requires optimizing value, defined as health outcomes achieved per dollar spent. Published literature is stippled with inaccurate proxies for cost, including negotiated reimbursement rates, fees paid, or listed prices. Time-driven activity-based costing (TDABC) offers a more robust and accurate approach to calculating cost, including shoulder care. In the present study, we sought to determine the drivers of total cost in arthroscopic rotator cuff repair (aRCR) using TDABC. Consecutive patients undergoing aRCR at multiple sites associated with a large urban health care system between January 2019 and September 2021 were identified. Total cost was determined using TDABC methodology. The episode of care was defined by 3 phases: preoperative, intraoperative, and postoperative care. Patient, procedure, rotator cuff tear morphology, and surgeon characteristics were collected. Bivariate analysis was performed across all characteristics between high-cost (top decile) and all other aRCRs. Multivariable linear regression was used to identify the key cost drivers. In total, 625 aRCRs performed by 24 orthopedic surgeons and 572 aRCRs performed by 13 orthopedic surgeons were included in the bivariate and multivariable linear regression analyses, respectively. By TDABC analysis, total aRCR cost varied 6-fold (5.9×) from least to most costly. Intraoperative costs accounted for 91% of average total cost, followed by preoperative costs and postoperative costs (6% and 3%, respectively). Biologic adjuncts (regression coefficient [RC] 0.54, 95% confidence interval [CI] 0.49-0.58, P<.001) and surgeon idiosyncrasy (RC of highest-cost surgeon 0.50, 95% CI 0.26-0.73, P<.001) were the major cost drivers in aRCR. Patient age, comorbidities, number of rotator cuff tendons torn, and revision surgery were not significantly associated with total cost. The amount of tendon retraction (RC 0.0012, 95% CI 0.000020-0.0024, P=.046), average Goutallier grade (RC 0.029, 95% CI 0.0086-0.049, P=.005), and the number of anchors used (RC 0.039, 95% CI 0.032-0.046, P < .001) were also significantly associated with cost, but with far smaller effect sizes. Episode of care costs vary nearly 6-fold in aRCR and are almost exclusively dictated by the intraoperative phase. Tear morphology and repair technique contribute to cost, although the largest cost drivers of aRCR are the use of biologic adjuncts and surgeon idiosyncrasy, defined as something a surgeon does or does not do that impacts total cost and is not controlled for in the current analysis. Future work should seek to better delineate what these surgeon idiosyncrasies may represent.

Hospital episode-of-care costs for hip fractures: an activity-based costing analysis.

Despite the large impact of hip fracture care on hospital budgets, accurate episode-of-care costs (EOCC) calculations for this injury remains a challenge. The objective of this article was to assess EOCC for geriatric patients with hip fractures using an activity-based costing methodology and identify intraoperative, perioperative, and patient-specific factors associated with higher EOCC. This is a retrospective cohort study involving a total of 109 consecutive patients with hip fracture treated surgically at a Canadian level-1 trauma center from April 2018 to February 2019. Clinical and demographic data were extracted through the institution's centralized data warehouse. Data acquisition also included direct and indirect costs per episode of care, adverse events, and precise temporal data. The median total EOCC was $13,113 (interquartile range 6658), excluding physician fees. Out of the total cost, 75% was attributed to direct costs, which represented a median expenditure of $9941. The median indirect cost of the EOCC was $3322. Based on the multivariate analysis, patients not operated within the 48 hours guidelines had an increased length of stay by 5.7 days (P = 0.003), representing an increase in EOCC of close to 5000$. Higher American Society of Anesthesiology (ASA) scores were associated with elevated EOCC. The cost of managing a patient with geriatric hip fracture from arrival in the emergency department to discharge from surgical ward represented $13,113. Main factors influencing the EOCC included adherence to the 48-hour benchmark surgical delay and ASA score. High-quality costing data are vital in assessing health care spending, conducting cost effectiveness analyses, and ultimately in guiding policy decisions. Level III (3), retrospective cohort study.

Needs Assessment to Inform Service Delivery Redesign in a Local Tertiary Teaching Clinic

Aims To examine the extent to which physical therapy at a local tertiary teaching clinic enables best practice and to identify priority areas for service redesign. Methods A retrospective file review of clinical records of patients receiving physical therapy ( n = 237) from 2011 to 2015 in Manila, Philippines. Data on clinical diagnosis, interventions, parameters of episode of care, goals and outcome measures were extracted and coded by trained researchers using a standardised form. Results Most patients ( n = 229, 97%) had developmental conditions. Active interventions were employed ( n = 236, 99%) and self-management plans appeared in 161 (68%) records. The duration of the episode of care was variable (median = 16 months, range = 1–139). Almost all patients ( n = 230, 97%) commenced with weekly sessions, with the total number of sessions ranging from 1 to 150 (median = 15). Therapy goals were reported routinely ( n = 236, 99%). Objective measures were recorded in 209 (88%) records at baseline and in 136 (57%) records at follow-up. The time point for outcome assessment was inconsistent (range = &lt;1–36 months). Conclusions Service delivery at the clinic requires more robust longitudinal management procedures, streamlined mechanisms for monitoring and better involvement of the family in decision-making. Some elements of existing practice (active, self-management approaches) suggest the adoption of best practice principles. Results contribute to ‘idea generation’ for service redesign.

FC15: The Baycrest Quick-Response Caregiver Tool TM for Behavioral and Psychological Symptoms of Dementia: Background and mixed methods studies

Goals and Objectives:By the end of the session, participants will be able to: 1.Describe the Baycrest Quick-Response Caregiver Tool2.Describe the role for the Baycrest Quick Response Caregiver Tool in BPSD3.Describe the results of studies to dateObjective:Behavioral and Psychological Symptoms of Dementia (BPSD) are common and are associated with poor outcomes and caregiver burden. A variety of frameworks and tools exist to assess and understand the symptoms and to plan interventions. The Baycrest Quick-Response Caregiver Tool TM (BQRCT) is different than other tools as it assists the caregiver in real time as the BPSD are occurring. A mixed methods feasibility study in family caregivers found favorable results. Scaling up this tool for long term care (LTC) staff can potentially benefit residents living with dementia. The goal of this presentation is for participants to describe this novel tool, its evidence, and its place within the known tools and frameworks for BPSD.Methods:Participants will interactively learn about the BQRCT, how it is applied with caregivers, and how it works with other tools for BPSD. The training videos will be viewed and discussed. The evidence from a mixed methods study of this tool will be presented and compared to evidence for other tools. The methods and preliminary results (if available) for an ongoing study of the BQRCT in the LTC context with be presented.Results:A mixed methods study of family caregivers and health-care providers of persons with dementia and BPSD found that the BQRCT was helpful and participants reported high feasibility ratings. The group of health-care providers found the tool useful and most would recommend it to peers and clients. Participants also provided specific suggestions for improvement, such as including more examples of complex behaviours. The current study in LTC involves the creation of new videos of complex situations in LTC. Participants in LTC homes will complete the online training, and surveys pre/post and at 4 weeks post-intervention. A focus group of a sample of 20 participants will be conducted.Conclusions:The BQRCT complements and works synergistically with existing strategies for managing BPSD. Care teams can use various frameworks and tools flexibly either concurrently or at different times in the episode of care of persons with dementia and BPSD. These tools must address the diversity and personal background of the person with dementia and caregivers.

“I think the rose-tinted glasses do just sort of slowly come off”: a grounded theory study on the development of empathy towards people with dementia in healthcare student education.

Background:Globally, dementia prevalence is rising. In the UK, over a million people are expected to be impacted by dementia by 2050. One in four hospital beds are occupied by a person with dementia, and it is inevitable that healthcare professionals will work with people with dementia during their career and across a variety of settings. To deliver effective person-centered care, healthcare professionals need to have the capacity and skills to practice with empathy. Greater empathy can lead to better patient relationships, reduced burnout, and enhanced recognition of personhood. However, people with dementia frequently report episodes of care that lack empathetic approaches. To improve the quality of care, high quality dementia education needs to be provided at undergraduate level. To inform the design and delivery of suitable educational resources, this study aimed to understand the major factors that impact the development of empathy towards people with dementia during undergraduate education.Methods:A constructivist, longitudinal grounded theory study (Charmaz, 2014) was conducted. Data were collected in 2019 using semi-structured interviews with undergraduate nursing, physiotherapy, and medical students (n=30). A second interview was completed with students (n=26) eighteen months later. Emergent findings were informed by simultaneous data collection and analysis using constant comparison techniques, and the use of theoretical memo writing.Results:Preliminary findings suggested that the development of empathy towards people with dementia was impacted by social and emotional exposure during undergraduate years. Data centered on four sub-categories. While there were barriers connecting and understanding people with dementia, students experienced conflicting expectations about empathy more widely. Positive and negative cultural experiences during placement led to emotional changes and a shift in ideals.Conclusion:Environments that promote empathetic practice during clinical placement could impact the development of empathy in undergraduate healthcare education more widely. This study highlights a need for educational design that focuses on both the patient and the environment.

Understanding the uptake of virtual care for first and return outpatient appointments in child and adolescent mental health services: a mixed-methods study

ObjectiveTo describe patterns of virtual and in-person outpatient mental health service use and factors that may influence the choice of modality in a child and adolescent service.DesignA pragmatic mixed-methods approach...

Resource Utilization Groups in transitional home care: validating the RUG-III/HC case-mix system in hospital-to-home care programs

BackgroundTransitional hospital-to-home care programs support safe and timely transition from acute care settings back into the community. Case-mix systems that classify transitional care clients into groups based on their resource utilization can assist with care planning, calculating reimbursement rates in bundled care funding models, and predicting health human resource needs. This study evaluated the fit and relevance of the Resource Utilization Groups version III for Home Care (RUG-III/HC) case-mix classification system in transitional care programs in Ontario, Canada.MethodsWe conducted a retrospective analysis of clinical assessment data and administrative billing records from a cohort of clients (n = 1,680 care episodes) in transitional home care programs in Ontario. We classified care episodes into established RUG-III/HC groups based on clients’ clinical and functional characteristics and calculated four case-mix indices to describe care relative resource utilization in the study sample. Using these indices in linear regression models, we evaluated the degree to which the RUG-III/HC system can be used to predict care resource utilization.ResultsA majority of transitional home care clients are classified as being Clinically complex (41.6%) and having Reduced physical functions (37.8%). The RUG-III/HC groups that account for the largest share of clients are those with the lowest hierarchical ranking, indicating low Activities of Daily Living limitations but a range of Instrumental Activities of Daily Living limitations. There is notable heterogeneity in the distribution of clients in RUG-III/HC groups across transitional care programs. The case-mix indices reflect decreasing hierarchical resource use within but not across RUG-III/HC categories. The RUG-III/HC predicts 23.34% of the variance in resource utilization of combined paid and unpaid care time.ConclusionsThe distribution of clients across RUG-III/HC groups in transitional home care programs is remarkably different from clients in long-stay home care settings. Transitional care programs have a higher proportion of Clinically complex clients and a lower proportion of clients with Reduced physical function. This study contributes to the development of a case-mix system for clients in transitional home care programs which can be used by care managers to inform planning, costing, and resource allocation in these programs.

2208. Ten years of the Irish National Outpatient Parenteral Antimicrobial Therapy (OPAT) Registry Data

Abstract Background The Irish Outpatient Parenteral Antimicrobial Therapy (OPAT) programme, a national centrally administered outpatient antibiotic provision service was established in 2013 within the public hospital system and is operated by the Health Service Executive (HSE). Ireland is relatively unique in having a nationally coordinated OPAT programme with complete summary data since its establishment. Here we describe the programme usage over ten years and show the data can be used to identify important trends in national antimicrobial usage, including stewardship issues, with relevant lessons for other OPAT centres. Methods Using data extracted from the national electronic portal we describe summary statistics from January 2013 to December 2022 (10 years). Results Over the ten-year period 17,559 OPAT episodes were facilitated across 42 healthcare institutions. These episodes represented 14,955 unique care episodes with the remainder being extensions or changes to active episodes. 12388 episodes were home OPAT delivered by a healthcare worker versus 5170 self OPAT where patients were taught to self-administer the antimicrobials. The median OPAT duration of therapy was 14 days with an average of 19.9 days. The median age of a referred patient was 59 years with an average age of 56 years. The top five diagnoses of osteomyelitis, abscesses, cellulitis, bacteraemia, and pyelonephritis accounted for 53% of all referrals. 81.5% of patients were prescribed a single antimicrobial, 17.9% two agents and 0.6% three. Four antibiotics – ceftriaxone, daptomycin, cefazolin and flucloxacillin continuous infusion account of 59% of the 44 different antimicrobials prescribed via the programme. Five of the 42 healthcare institutions accounted for 57.25% of all OPAT prescriptions. The number of beds in a hospital was not the strongest predictor of OPAT usage. The total number of bed days saved in the 10-year period was 292,860. Conclusion Within a health system operating on 11,171 beds available per day, for a population of just over 5 million people, with an average daily running cost of €878 per acute bed, the National OPAT programme has already contributed to significant bed day and consequent financial savings. Starting an infectious diseases clinical service significantly increases OPAT utilisation rates. ID Specialist appointed to centre for first time in 2021 Disclosures All Authors: No reported disclosures

Innovations in Total Hip and Knee Arthroplasty Episodes of Care: Transitioning from Inpatient to Ambulatory Care.

Innovations in Total Hip and Knee Arthroplasty Episodes of Care: Transitioning from Inpatient to Ambulatory Care.

Modern robotics platform associated with reduced 90-day complications in hospital setting

BACKGROUND: Early complications in total knee arthroplasty (TKA) associated with modern robotics platforms integrated with digital balancing technology have not been investigated. OBJECTIVE: The objective was to compare 90-day complication rates between a manual technique and a modern robotic-assisted ligament balancing TKA platform. METHODS: 895 primary TKA procedures from a single surgeon were retrospectively reviewed (614 manual TKA, 281 using a modern robotics platform with an integrated digitally controlled ligament balancing device). Post-operative complications within the 90-day episode of care were recorded by the Michigan Arthroplasty Registry Collaborative Quality Initiative. Differences in complication rates between techniques were further divided into inpatient hospital, outpatient hospital, and ambulatory surgery center (ASC) cohorts. RESULTS: In the pooled hospital cohort and inpatient hospital cohort, ‘Return to OR’ was significantly lower for the robotic assisted group (1.3% vs 5.2% and 0% vs 4.9%, respectively, p&lt; 0.0370). Specifically, the need for manipulation under anesthesia (MUA) was reduced for the robotics group (0.0% vs 2.5%, p= 0.0352). No differences in overall complication rate or cause of complication was found between manual and robotics cases for the hospital outpatient and ASC cohorts (p⩾ 0.68). CONCLUSION: Within the hospital setting, robotic assisted ligament balancing technology was associated with reduced 90-day postoperative complications for ‘Return to OR’ and MUA.

Does COVID-19 Infection during Pregnancy Increase the Appearance of Congenital Gastrointestinal Malformations in Neonates?

COVID-19 was an infection that was capable of bringing the entire world to a standstill position within a period of days to months. Despite the advancements in the medical sector, the contagion was difficult to control and costed the lives of millions of people worldwide. Many short- and long-term effects are witnessed even to date in people that contracted the disease. Pregnant females had to suffer not only the devastating effects of the virus, but also the psycho-social impact of the lockdown. The impact of COVID-19 infection during pregnancy causing decreased antenatal care or hypoxemic episodes due to severe respiratory distress and whether it could lead to the appearance of congenital gastrointestinal malformation in neonates is still unclear. The aim of our study was to analyze if COVID-19 infection during pregnancy could increase the incidence of gastric malformations in neonates born from these women. We sifted the files of all neonates admitted into our hospital between January 2022 and December 2022, and based on inclusion and exclusion criteria, we included the cases having gastrointestinal congenital malformations during the COVID-19 pandemic. We performed a single-center, retrospective, observational descriptive study. We further divided the patients based on the anatomical location of the malformation. We also took down details of the evolution of pregnancy and whether the mother had contracted a SARS-CoV-2 infection during the pregnancy. Details regarding the Apgar score, days of intensive care admission, sex, and nutrition were the key findings studied. A total of 47 neonates were found to have digestive anomalies, among which, based on the anatomical locations, the number of malformation cases found at the level of the esophagus were 15, while 16 occurred at the level of the pylorus; we found 12 cases of malformation of the duodenum, and four cases had malformation of the rectum. Out of these 47 neonates, 38.3% were females and 61.7% were males. A total of 58% were preemies, among which 9% had intra-uterine growth retardation (IUGR), and 42% were full-term newborns, among which 4% had intra-uterine growth retardation (IUGR). A total of 45% of the births were primiparous pregnancies and 55% were from multiparous females. A total of 14 mothers were found to have tested positive for COVID-19 during the course of pregnancy (p-value = 0.23); many had mild symptoms but were not tested. COVID-19 can affect the wellbeing of the pregnant female and their fetus. Larger studies can help gain extensive knowledge as to whether COVID-19 also has the potential to result in congenital gastrointestinal anomalies in children born from COVID-19 positive mothers. In our study, only a few infants born with this pathology were found to be born from COVID-19 positive mothers. Hence, it is difficult to conclude or exclude a direct correlation between the infection and the congenital malformations.

Clinical assessment, treatment, and referral trends for adolescent runners seeking care at an injured runners' clinic.

Over a 10-year time frame, this study aimed to evaluate diagnosis, treatment, and referral trends for adolescent runners seeking care for running-related injuries (RRIs) at a clinic that specializes in running medicine. This study was a retrospective chart review of 392 adolescent runners (2,326 encounters) who sought care for RRIs between the years 2011 and 2021. Descriptive statistics were used to summarize clinical assessments, referrals, assistive devices, and medications prescribed or administered overall and by injury type. Chi-square analyses were used to compare proportions of services rendered across the 10-year time frame. Patients most frequently received manual evaluations or special tests during clinic visits. Most visits resulted in at least one referral (91%), primarily for physical therapy or gait-training. Assistive devices and medications/supplements were offered at only 18% of patient visits. The majority of assessments (X2 = 69.7, p = 0.002), treatments (X2: 23.6-43.8, p: < 0.001-0.003), and referrals (X2 = 132, p < 0.001) were for shin injuries. Larger proportions of nutrition assessments (X2 = 40.7, p < 0.001), interventions (X2 = 26.8, p = 0.003), and referrals (X2 = 27.5, p = 0.002) were performed in or after the year 2015. Clinic visits for shin injuries required the most clinical resources per episode of care. There were observed shifts in clinical assessment and treatment approaches to include more expanded nutritional and physiologic considerations.

To test or to not test: A retrospective cross-sectional study on potentially inappropriate use of pathology testing in South Australian hospitals.

To measure rates of potentially inappropriate pathology testing in the hospital setting. Retrospective cross-sectional study in hospital setting from July 2021 to December 2021. We examined 3 potentially inappropriate uses: overordering, selection errors, and unnecessary repeat testing. Overordering included vitamin D and lipids (rarely required in acute hospital care). Selection error was the ratio of iron studies to standalone ferritin requests. Unnecessary repeats included any repeat vitamin D, lipids, iron, or ferritin in an episode of care or C-reactive protein (CRP) repeated within 3 days and N-terminal pro-brain natriuretic peptide (NT-proBNP) within 7 days and repeated previously abnormal CRP and NT-proBNP tests. Costs of inappropriate tests were estimated using the Australian Medicare Benefits Schedules. Among 55,904 test requests, 15% (n = 8120) were potentially inappropriate. Vitamin D was frequently ordered (n = 4498), as were lipids (n = 2872). Ratio of iron studies to standalone ferritin was 36. Of 19,233 repeat CRPs, 36% (n = 6947) were within 3 days and 62% (n = 179) of repeat NT-proBNPs were within 7 days of the first test. For initially abnormal tests, 89% of CRPs and 97% of NT-proBNPs remained abnormal. Inappropriate test costs accounted for 12% to 30% of costs. Frequent potential inappropriate use and selection of pathology tests was observed in South Australian hospitals.

Symptom and problem clusters in German specialist palliative home care - a factor analysis of non-oncological and oncological patients’ symptom burden

BackgroundSpecialist palliative home care (SPHC) aims to maintain and improve patients’ quality of life in the community setting. Symptom burden may differ between oncological and non-oncological patients. However, little is known about diagnosis-related differences of SPHC patients. This study aims to describe the prevalence of physical symptom burden and psychosocial problems of adult patients in SPHC, and to evaluate diagnosis-related symptom clusters.MethodsSecondary analysis of data from a prospective, cross-sectional, multi-centre study on complexity of patients, registered at the German Register for Clinical Studies (DRKS trial registration number: DRKS00020517, 12/10/2020). Descriptive statistics on physical symptom burden and psychosocial problems at the beginning of care episodes. Exploratory and confirmatory factor analyses to identify symptom and problem clusters.ResultsSeven hundred seventy-eight episodes from nine SPHC teams were included, average age was 75 years, mean duration of episode 18.6 days (SD 19.4). 212/778 (27.2%) had a non-oncological diagnosis. Main burden in non-oncological episodes was due to poor mobility (194/211; 91.9%) with significant diagnosis-related differences (χ² = 8.145, df = 1, p = .004; oncological: 472/562; 84.0%), and due to weakness (522/565; 92.4%) in oncological episodes. Two symptom clusters (psychosocial and physical) for non-oncological and three clusters (psychosocial, physical and communicational/practical) for oncological groups were identified. More patients in the non-oncological group compared to the oncological group showed at least one symptom cluster (83/212; 39.2% vs. 172/566; 30.4%).ConclusionPatients with non-oncological diseases had shorter episode durations and were more affected by symptom clusters, whereas patients with oncological diseases showed an additional communicational/practical cluster. Our findings indicate the high relevance of care planning as an important part of SPHC to facilitate anticipatory symptom control in both groups.

The Impact of Biosimilar Use on Total Cost of Care and Provider Financial Performance in the Medicare Oncology Care Model: A Population-Based Simulation Study.

Payment for oncology care is increasingly moving from fee-for-service to value-based payment (VBP). VBPs are agreements in which providers are held accountable for total cost of care (TCOC) through risk-sharing arrangements with payers that tie reimbursement levels to TCOC benchmarks. Oncology biosimilars may play an important role in managing financial risk in the VBPs like Medicare's Oncology Care Model (OCM), but there has been limited research in this area. The objective of this study is to estimate the impact of biosimilar adoption on TCOC and oncology provider financial performance under the terms of the Medicare OCM. We conducted a population-based simulation study using the Medicare Limited Data Set (LDS) and the methodology of Medicare's OCM. The primary outcome was the simulated average change in TCOC per 6-month episode of care attributable to use of biosimilars as an alternative to reference products. The study population consisted of episodes of care in 2020 and using the reference product or corresponding biosimilar for bevacizumab, rituximab, trastuzumab, epoetin alfa, filgrastim, or pegfilgrastim. TCOC was calculated for each episode of care with use of reference products only and compared with TCOC with corresponding biosimilars. The simulation calculated TCOC outcomes in cohorts of 100 episodes sampled from the Medicare LDS study population using a Monte Carlo simulation with 10,000 iterations. Among the total of 8281 6-month oncology care episodes identified in the study period (initiating January 2020 to July 2020) in Medicare claims, 1586 (19.2%) episodes met OCM and study criteria and were included. Applying the simulation methods to these observed episodes, biosimilar substitution reduced mean TCOC per episode by $1193 (95%CI $583-1840). The cost reduction from biosimilars represented 2.4% of the average TCOC benchmark and led to a 15% reduction in the risk of providers needing to pay recoupments to Medicare for exceeding TCOC benchmarks. On the basis of our simulation study using observed Medicare claims and OCM criteria, we found that biosimilar substitution for reference products can significantly lower episode TCOC and improve provider financial performance under the terms of the largest value-based payment model implemented to date.

Using expletives to enhance therapeutic outcomes: A case report.

Swearing deserves attention in the physical therapy setting due to its potential positive effects on pain, physical performance, and therapeutic alliance. The purpose of this case report is to describe the strategic use of swearing in the clinical setting. A 44-year-old female completed an episode of physical therapy after undergoing patellofemoral arthroplasty. Swearing was formally included into the plan of care, and the patient swore out loud during the most challenging and painful interventions. The patient reported that repeating a swear word was funny, distracted the patient, and made the patient feel more confident. The patient and physical therapist self-reported a strong therapeutic alliance. There is evidence repeating a swear word out loud can strengthen the therapeutic alliance, improve physical performance, and decrease pain. This is, to our knowledge, the first report of a patient swearing during an episode of physical therapy care.

Midwives' and obstetricians' practice, perspectives and experiences in relation to altered fetal movement: A focused ethnographic study

BackgroundReducing avoidable stillbirth is a global priority. The stillbirth rate in England compares unfavourably to that of some other high-income countries. Poorly-managed episodes of altered fetal movement have been highlighted as a key contributor to avoidable stillbirth, and strategies introduced in England in 2016 to reduce perinatal mortality included recommendations for the management of reduced fetal movement. Despite a downward trend in stillbirth rates across the UK, the effects of policies promoting awareness of fetal movement remain uncertain. ObjectiveTo provide in-depth knowledge of how practice and clinical guidance relating to altered fetal movement are perceived, enacted and experienced by midwives and obstetricians, and explore the relationship between recommended fetal movement care and actual fetal movement care. DesignA focused ethnographic approach comprising over 180 h of observation, 15 interviews, and document analysis was used to explore practice at two contrasting UK maternity units. SettingsAntenatal services at two UK maternity units, one in the Midlands and one in the North of England. ParticipantsThirty-six midwives, obstetricians and sonographers and 40 pregnant women participated in the study across 52 observed care episodes and relevant unit activity. Twelve midwives and three obstetricians additionally participated in formal semi-structured interviews. MethodsFieldnotes, interview transcripts, policy documents, maternity notes and clinical guidelines were analysed using a modified constant comparison method to identify important themes. Resultsfetal movement practice was mostly consistent and in line with guideline recommendations. Notwithstanding, most midwives and obstetricians had concerns about this area of care, including challenges in diagnosis, conflicting evidence about activity, heightened maternal anxiety, and high rates of monitoring and intervention in otherwise low-risk pregnancies. To address these issues, midwives spent considerable time reassuring women through information and regular monitoring, and coaching them to perceive fetal movement more accurately. ConclusionsPractice relating to altered fetal movement might be more uniform than in the past. However, a heightened focus on fetal movement is associated by some midwives and obstetricians with potential harms, including increased anxiety in pregnancy, and high rates of monitoring and intervention in pregnancies where there are no ‘objective concerns’. Challenges in diagnosing a significant change in fetal movement with accuracy might mean that interventions and resources are not being directed towards those pregnancies most at risk. More research is needed to determine how healthcare professionals can engage in conversations about fetal movement and stillbirth to support safe outcomes and positive experiences in pregnancy and birth. RegistrationNot registered. Tweetable abstractMidwives and obstetricians take #reducedfetalmovement seriously but worry this ‘unreliable’ symptom increases anxiety, monitoring and intervention in many ‘low risk’ pregnancies.

Socioeconomic status and post-covid illness trajectory

Abstract Background The associations between deprivation and illness trajectory after hospitalisation for coronavirus disease-19 (COVID-19) are uncertain. Methods A prospective, multicentre, longitudinal, cohort study involving post-COVID-19 patients enrolled in-hospital or early post-discharge (visit 1) and re-evaluated at 28-60 days post-discharge (visit 2) and in the longer term. Serial research blood tests (biomarkers), digital electrocardiography, and patient-reported outcome measures were obtained at both visits. Novel, multisystem imaging, including chest computed tomography (CT) with pulmonary and coronary angiography, cardiovascular and renal magnetic resonance imaging, was acquired at visit 2. The analysis of primary and secondary outcomes by socioeconomic status was prespecified. The Scottish Index of Multiple Deprivation (SIMD), a small-area measure of social deprivation based on domiciled post code reflecting seven factors including income, employment, education, health, access to services, crime, and housing, and categorized into general population quintiles, was used to measure social deprivation. The EQ-5D-5L, Brief Illness Perception Questionnaire (BIPQ), Patient Health Questionnaire-4 (PHQ-4) for Anxiety and Depression, and the Duke Activity Status Index (DASI) were used to assess health status. Follow-up of clinical outcomes was undertaken using electronic health records. Results Two hundred and fifty-two patients (mean±SD age 55.0 ±12.0 years, body mass index (BMI) 31.3 ±6.9 kg/m2,101 (40%) female, and 59 (23%) with diabetes) were enrolled and had follow-up completed at a median 428 (IQR 385, 538) days. Deprivation status was positively associated with BMI (p=0.0444) and diabetes (p=0.0239). One hundred and eighty-six (74%) patients reattended for investigation 28-60 days post-discharge. Lung ground glass opacity and/or consolidation (p=0.0085), obstructive coronary artery disease (p=0.0128) and renal inflammation (p=0.0421) were associated with deprivation. At 28-60 days post-discharge (n=184), health-related quality of life (EQ-5D-5L utility score, p=0.0084), illness perception, (BIPQ, p=0.0004), anxiety and depression (PHQ-4 score, p=0.0038), physical activity (DASI, p=0.002) and estimated peak oxygen consumption (ml/min/kg) (p=0.002) were worse with greater deprivation. At 3 months (n=252), deprivation status was associated with more referrals to secondary care because of ongoing COVID-19 symptoms (p=0.0438). Clinical outcomes did not associate with deprivation. Conclusion In a post-hospital COVID-19 population, socioeconomic deprivation was associated with impaired health status and secondary care episodes. Deprivation influences illness trajectory after COVID-19.

Has pharmaceutical innovation reduced the average cost of U.S. health care episodes?

A number of authors have argued that technological innovation has increased U.S. health care spending. We investigate the impact that pharmaceutical innovation had on the average cost of U.S. health care episodes during the period 2000-2014, using data from the Bureau of Economic Analysis' Health Care Satellite Account and other sources. We analyze the relationship across approximately 200 diseases between the growth in the number of drugs that have been approved to treat the disease and the subsequent growth in the mean amount spent per episode of care, controlling for the growth in the number of episodes and other factors. Our estimates indicate that mean episode cost is not significantly related to the number of drugs ever approved 0-4years before, but it is significantly inversely related to the number of drugs ever approved 5-20years before. This delay is consistent with the fact (which we document) that utilization of a drug is relatively low during the first few years after it was approved, and that some drugs may have to be consumed for several years to have their maximum impact on treatment cost. Our estimates of the effect of pharmaceutical innovation on the average cost of health care episodes are quite insensitive to the weights used and to whether we control for 3 covariates. Our most conservative estimates imply that the drugs approved during 1986-1999 reduced mean episode cost by 4.7%, and that the drugs approved during 1996-2009 reduced mean episode cost by 2.1%. If drug approvals did not affect the number of episodes, the drugs approved during 1986-1999 would have reduced 2014 medical expenditure by about $93 billion. However, drug approvals may have affected the number, as well as the average cost, of episodes. We also estimate models of hospital utilization. The number of hospital days is significantly inversely related to the number of drugs ever approved 10-19years before, controlling for the number of disease episodes. Our estimates imply that the drugs approved during 1984-1997 reduced the number of hospital days by 10.5%. The hospital cost reduction was larger than expenditure on the drugs.