Changes In Reimbursement Policies Research Articles

SOME ADDITIONAL THOUGHTS ON FORTHCOMING AMENDMENTS TO HTA IN POLAND.

In reference to the article A Decade of Health Technology Assessment in Poland by I. Lipska et al. (1), I would like to provide you with some comments and additional information on the changes in reimbursement policies in the Polish healthcare system currently taking place, which is likely to lead to increased number of health technology assessments (HTAs) of medical devices (MDs).

The disproportionate growth of office-based atherectomy

ObjectiveThe purpose of this study was to evaluate the trends in procedure volume, clinical sites of care, and Medicare expenditure for peripheral vascular interventions (PVIs) for lower extremity occlusive disease since the Centers for Medicare and Medicaid Services instituted reimbursement policy changes that broadened payment for procedures performed in physician-owned office-based laboratories (OBLs). MethodsWe analyzed fee-for-service Medicare claims data from 2011 to 2014 to obtain the frequency of use of PVI by type, care setting, and physician specialty. We also assessed changes in the total Medicare cost for PVI by setting. ResultsThere was a 60% increase in atherectomy cases among Medicare beneficiaries between 2011 and 2014. During the same period, OBLs experienced a 298% increase in atherectomy volume vs a 27% increase in hospital outpatient settings and an 11% decrease for inpatient hospital settings. In 2014, OBLs were the most common setting for atherectomy. Nonatherectomy PVIs grew more modestly at just 3% but also experienced site of care shifts. Vascular surgeons and cardiologists accounted for the majority of office-based PVIs in 2014. Total Medicare costs for PVIs increased 18% from 2011 to 2014. Hospital inpatient costs declined 1%, whereas costs for hospital outpatient PVIs increased by 41% and physician office costs increased by 258%. ConclusionsThe migration of revascularization procedures for lower extremity peripheral arterial occlusive disease continues from the inpatient to the outpatient setting and especially to OBLs. Increased use of atherectomy in all segments of the lower extremity arterial system has been observed, particularly in OBLs, without substantial evidence in the literature of increased efficacy compared with standard angioplasty with or without stenting. Generous Medicare reimbursement for in-office atherectomy procedures is likely contributing to the volume shifts observed.

Payment Reform Needed to Address Health Disparities of Undiagnosed Diabetic Retinopathy in the City of Chicago

IntroductionThe Affordable Care Act (ACA) has expanded health coverage for thousands of Illinois residents. Expanded coverage, however, does not guarantee appropriate health care. Diabetes and its ocular complications serve as an example of how providers in underserved urban areas may not be able to keep up with new demand for labor- and technology-intensive health care unless changes in reimbursement policies are instituted.MethodsA retrospective cohort study was conducted using medical encounter information from the Chicago HealthLNK Data Repository (HDR), an assembly of non-duplicated and de-identified patient medical records. We used a method of estimating the geographic distribution of undiagnosed diabetic retinopathy in the city of Chicago to illustrate the magnitude of potentially preventable eye disease. All rates were calculated for all ZIP Codes within Chicago (Cook County), and statistical differences between observed and geographically adjusted expected rates (p < 0.10, p < 0.05, p < 0.01) were highlighted as underserved areas.ResultsThis analysis included 150,661 patients with diabetes identified from a total of nearly two million patients in Chicago. High rates of undetected diabetic retinopathy were found in low-income and minority areas. Within these areas, 37% of the identified diabetics were uninsured, with rates ranging widely from 20% to 68.6%. Among those with insurance, 32.8% were covered by Medicare and only 10% by Medicaid. Most patients with untreated diabetic retinopathy were found to reside in areas where primary health care is provided through Federally Qualified Health Centers.ConclusionsWith 150,661 diabetics identified in the city of Chicago, and this number continuing to rise each year, a manpower approach with ophthalmologist screening for diabetic retinopathy is not realistic. The ability to identify the growing number of diabetic patients with retinopathy in low-income areas will likely require the adoption of cost-effective screening technologies that are currently not funded by Medicare and Medicaid.

Association Between Changes in CMS Reimbursement Policy and Drug Labels for Erythrocyte-Stimulating Agents With Outcomes for Older Patients Undergoing Hemodialysis Covered by Fee-for-Service Medicare

ImportanceIn 2011, the US Centers for Medicare & Medicaid Services (CMS) changed its reimbursement policy for hemodialysis to a bundled comprehensive payment system that included the cost of erythrocyte-stimulating agents (ESAs). Also in 2011, the US Food and Drug Administration revised the drug label for ESAs, recommending more conservative dosing in patients with chronic kidney disease. In response to concerns that these measures could have adverse effects on patient care and outcomes, the CMS and the FDA initiated a collaboration to assess the effect.ObjectiveTo assess the effects of the changes in reimbursement policy and the ESA drug label on patients who underwent incident hemodialysis.Design, Setting, and ParticipantsFor this retrospective cohort study, patients 66 years or older who had undergone incident hemodialysis, and were enrolled in Medicare parts A, B, or D for at least 12 months prior to hemodialysis initiation between January 1, 2008, and December 31, 2013, were recruited from hemodialysis centers across the United States. Patients were divided into 2 cohorts based on their date of hemodialysis initiation and followed: January 1, 2008, to December 31, 2009, for the prepolicy cohort and July 1, 2011, to June 30, 2013, for the postpolicy cohort, with the exclusion of January 1, 2010, to June 30, 2011, as a transition period.InterventionsChanges in CMS reimbursement policy for dialysis and the FDA label for ESAs.Main Outcomes and MeasuresMajor adverse cardiovascular events (MACEs), including acute myocardial infarction (AMI), stroke, and all-cause mortality; hospitalized congestive heart failure (H-CHF); venous thromboembolism; and red blood cell transfusions. Secondary outcomes included evaluating effects on black and other patient subgroups.ResultsBaseline characteristics of the 69 718 incident hemodialysis patients were similar between cohorts. Compared with the prepolicy period, the risk of MACE, death, H-CHF, and venous thromboembolism were similar in the postpolicy period, and the risk of stroke decreased (hazard ratio [HR], 0.77; 95% CI, 0.64-0.93; P = .01); the use of ESAs also decreased, and the rate of blood transfusions increased (HR, 1.09; 95% CI, 1.07-1.12; P < .001). In the post-postpolicy period, black patients had a significant reduction in risk of MACE (HR, 0.82; 95% CI, 0.73-0.92; P < .001) and all-cause mortality (HR, 0.82; 95% CI, 0.73-0.93; P = .002).Conclusions and RelevanceAfter the bundling policy and ESA labeling changes in 2011, the risks of MACE and death for patients 66 years or older and covered by fee-for-service Medicare who had undergone incident hemodialysis did not change; the risk of stroke was reduced, and the rate of blood transfusions modestly increased. Black patients had substantial reductions in the risks of MACE and death.

Impact of rosiglitazone safety alerts on oral antidiabetic sales trends: a countrywide study in Portugal.

Pharmacovigilance systems are important to monitor the safety of on-market drugs after approval. The aim of this study was to assess the impact of rosiglitazone safety alerts on trends in the sale of rosiglitazone and other oral antidiabetic drugs. An ecological study was conducted, using temporally aggregated data and linking safety alerts to countrywide sales of all oral antidiabetic drugs in Portugal from January 2002 to December 2012. Sales figures for oral antidiabetic drugs marketed in Portugal were supplied by IMS Health Portugal with a breakdown by active substance and fixed combinations. The number of defined daily doses per 1000 inhabitants per day (DIDs) of each oral antidiabetic drug sold to the estimated diabetic population using oral antidiabetic drugs in Portugal was calculated. Particular attention was paid to the case of rosiglitazone, with the results being adjusted for changes in rosiglitazone reimbursement policies. A total of four safety alerts were issued about rosiglitazone. Rosiglitazone sales registered an increase of 32.9% (0.202 DIDs; P < 0.001) after the first alert (risk of macular oedema or worsening of pre-existent macular oedema) in January 2006. After subsequent alerts about cardiovascular risks, this trend was not, however, repeated and sales fell. Following the January 2006 and January 2008 safety alerts, rosiglitazone sales described a long-term downward trend, with decreases of 3.75% (-0023 DIDs; P > 0.05) and 0.24% (-0.001 DIDs; P > 0.05), respectively. It is important to promote the dissemination and publication of drug safety alerts.

Implementation of the 2011 Reimbursement Act in Poland: Desired and undesired effects of the changes in reimbursement policy

The Act of 12 May 2011 on the Reimbursement of Medicines, Foodstuffs Intended for Particular Nutritional Uses and Medical Devices constitutes a major change of the reimbursement policy in Poland. The main aims of this Act were to rationalize the reimbursement policy and to reduce spending on reimbursed drugs. The Act seems to have met these goals: reimbursement policy (including pricing of reimbursed drugs) was overhauled and the expenditure of the National Health Fund on reimbursed drugs saw a significant decrease in the year following the Act's introduction. The annual savings achieved since then (mainly due to the introduction of risk sharing schemes), have made it possible to include new drugs into the reimbursement list and improve access to innovative drugs. However, at the same time, the decrease in prices of reimbursed drugs, that the Act brought about, led to an uncontrolled outflow of some of these drugs abroad and shortages in Poland. This paper analyses the main changes introduced by the Reimbursement Act and their implications. Since the Act came into force relatively recently, its full impact on the reimbursement policy is not yet possible to assess.

Positive Outcomes for Speech Telepractice as Evidence for Reimbursement Policy Change

Oklahoma has a large population living in rural areas where it is difficult to fill school speech-language pathologist (SLP) positions. To meet this need, telepractice has been used in rural Oklahoma school districts since 1999. Medicaid policies have allowed schools to receive reimbursement for speech therapy provided by onsite therapists; however, reimbursement for speech telepractice was excluded. The current project measured the effectiveness of a speech telepractice program so this policy could be revised. Speech and language skills of 578 children, grades PreK–12, were followed over one of two school years and were rated using Functional Communication Measures (FCM) established by the American Speech Language and Hearing Association (ASHA). Our data show that 67–87% of the children advanced by one or more levels on three common FCM scales. These changes are similar to, or greater than, what was reported in a large sample of students compiled by ASHA's National Outcomes Measurement System (NOMS) with clinicians who worked onsite in schools. Average weekly treatment time was also less in our teletherapy practice than what was reported in the reference database. Therefore, the current study demonstrates that speech telepractice is an effective and efficient method of delivery for the school age population.

Utility of Vertebral Fracture Recognition in Osteoporosis

Vertebral fractures are important because they predict future fractures are associated with increased morbidity and mortality, and because effective therapies exist to prevent them. However, only about 1/3 of vertebral fractures found on imaging are clinically recognized. Therefore, imaging is required for their detection. Yet spine imaging is usually not obtained in the course of management of patients with osteoporosis. Furthermore, even when radiographic images obtained for various clinical indications do include the spine views, vertebral fractures are often not recognized or not reported. In response to this unmet need, Vertebral fracture assessment (VFA, spine image obtained on densitometers) was developed but is still underutilized, at least in part due to problems with reimbursement. Greater awareness of vertebral fractures and their importance among radiologists and clinicians should lead to higher rate of vertebral fracture detection on multiple imaging modalities including spine radiographs and VFA, and also on radiographs, CT and MRI scan of the chest and abdomen obtained for other indications. With appropriate educational efforts and changes in reimbursement policies, it may be possible to improve the rate of detection of vertebral fractures and thus make a diagnosis of osteoporosis (which presence of vertebral fractures signifies) in many patients whose disease is otherwise unrecognized and untreated.

Observation Units as Substitutes for Hospitalization or Home Discharge

Observation unit admissions have been increasing, a trend that will likely continue because of recent changes in reimbursement policies. The purpose of this study is to determine the effect of the availability of observation units on hospitalizations and discharges to home for emergency department (ED) patients. We studied ED visits with a final diagnosis of chest pain in the National Hospital Ambulatory Medical Care Survey from 2007 to 2010. ED visits that resulted in an observation unit admission were propensity-score matched to visits at hospitals without an observation unit. We used logistic regression to develop a prediction model for hospitalization versus discharge home for matched patients treated at nonobservation hospitals. The model was applied to matched observation unit patients to determine the likely alternative disposition had the observation unit not been available. There were 1,325 eligible visits that represented 5,079,154 visits in the United States. Two hundred twenty-seven visits resulted in an observation unit admission. The predictive model for hospitalization had a c statistic of 0.91; variables significantly associated with subsequent hospitalization included age, history of coronary atherosclerosis, systolic blood pressure less than 115 beats/min, and administration of antianginal medications. When the model was applied to matched observation unit patients, 49.9% of them were categorized as discharge home likely. In this study, we estimated that half of ED visits for chest pain that resulted in an observation unit admission were made by patients who may have been discharged home had the observation unit not been available. Increased availability of observation units may result in both decreased hospitalizations and decreased discharges to home.

Causes for 30-Day Readmission following Transsphenoidal Surgery.

The Affordable Care Act Readmissions Reduction Program introduced reimbursement policy changes resulting in penalties for hospitals with higher-than-average readmission rates among several categories, including elective surgical cases. We examined the rate of complications resulting in 30-day readmission following endoscopic transsphenoidal surgery. Case series with chart review. Academic tertiary care center. A database of 466 consecutive patients who underwent endoscopic transsphenoidal surgery at a tertiary care center between April 2006 and July 2014 was reviewed for 30-day causes for readmission, length of stay, level of care required, and average cost. Twenty-nine readmissions were identified within our study period, indicating a 30-day readmission rate of 6.2%. Among all patients, rates of 30-day readmission were 2.1% for epistaxis, 1.5% for hyponatremia, 0.9% for cerebrospinal fluid leak, and 1.7% for other medical conditions. Average cost per readmission ranged from $6011 for hyponatremia to $24,613 for cerebrospinal fluid leak. Overall, the rate of 30-day readmission following endoscopic pituitary surgery is low. However, common causes of readmission do add significant cost to the overall care of this patient population. Special attention to surgical technique to prevent epistaxis and cerebrospinal fluid rhinorrhea, as well as multidisciplinary team management to avoid postoperative endocrine dysfunction, is critical to minimize these complications.

Trends in Anemia Management Practices in Patients Receiving Hemodialysis and Peritoneal Dialysis: A Retrospective Cohort Analysis

Background/Aims: Recent changes in clinical practice guidelines and reimbursement policies may have affected the use of anemia-related medications and red blood cell (RBC) transfusions in peritoneal dialysis (PD) and hemodialysis (HD) patients. We sought to compare patterns of erythropoiesis-stimulating agents (ESA) and intravenous (IV) iron use, achieved hemoglobin levels, and RBC transfusion use in PD and HD patients. Methods: In quarterly cohorts of prevalent dialysis patients receiving persistent therapy (>3 months), 2007-2011, with Medicare Parts A and B coverage, we assessed ESA and IV iron use and dose, RBC transfusions, and hemoglobin levels. Quarterly transfusion rates were calculated. Results: Observable PD and HD patients numbered 14,958 and 221,866 in Q1/2007 and 17,842 and 256,942 in Q4/2011. Adjusted ESA use was lower in PD (71.4-80.1%) than in HD (86.9-92.0%) patients, decreasing from 80.1% (Q1/2010) to 71.4% (Q4/2011) in PD patients, and from 92.0 to 86.9% in HD patients. The mean adjusted ESA dose decreased by 67.5% in PD and 58.4% in HD patients. IV iron use tended to increase, peaking at 39.3% for PD (Q3/2011) and 80.5% for HD (Q2/2011) patients. Adjusted mean hemoglobin levels fell from 11.7 to 10.6 mg/dl in PD and from 12.0 to 10.7 mg/dl in HD ESA users; adjusted transfusion rates increased from 2.4 to 3.0 per 100 patient-months in PD and from 2.6 to 3.3 in HD patients. Conclusions: In patients receiving persistent dialysis, dose and frequency of ESA administrations decreased during the period 2007-2011. Mean hemoglobin levels decreased by more than 1 g/dl, while transfusion rates increased by approximately 25%.

Oxygen therapy use in older adults with chronic obstructive pulmonary disease.

RationaleOxygen therapy improves survival and function in severely hypoxemic chronic obstructive pulmonary disease (COPD) patients based on two landmark studies conducted over 40 years ago. We hypothesize that oxygen users in the current era may be very different. We examined trends and subject characteristics associated with oxygen therapy use from 2001–2010 in the United States.MethodsWe examined Medicare beneficiaries with COPD who received oxygen from 2001 to 2010. COPD subjects were identified by: 1) ≥2 outpatient visits >30 days apart within one year with an encounter diagnosis of COPD; or 2) an acute care hospitalization with COPD as the primary or secondary discharge diagnosis. Oxygen therapy and sustained oxygen therapy were defined as ≥1 and ≥11 claims for oxygen, respectively, in the durable medical equipment file in a calendar year. Primary outcome measures were factors associated with oxygen therapy and sustained oxygen therapy over the study period.ResultsOxygen therapy increased from 33.7% in 2001 to 40.5% in 2010 (p-value of trend <0.001). Sustained oxygen therapy use increased from 19.5% in 2001, peaked in 2008 to 26.9% and declined to 18.5% in 2010. The majority of subjects receiving oxygen therapy and sustained oxygen therapy were female. Besides gender, factors associated with any oxygen use or sustained oxygen therapy were non-Hispanic white race, low socioeconomic status and ≥2 comorbidities.ConclusionsAny oxygen use among fee-for service Medicare beneficiaries with COPD is high. Current users of oxygen are older females with multiple comorbidities. Decline in sustained oxygen therapy use after 2008 may be related to reimbursement policy change.

Higher Adherence During Reimbursement of Pharmacological Smoking Cessation Treatments.

In the Netherlands, pharmacologic Smoking Cessation Treatments (pSCTs) were reimbursed in 2011. In 2012 the reimbursement was discontinued. As of 2013, pSCTs were again reimbursed, provided they are accompanied by behavioral counseling. The aim of this article is to assess the impact of changes in reimbursement policy on use of-and adherence to-pSCTs. A retrospective dispensing database analysis was performed on real-world observational data (2010-2013) from the Netherlands. Data on use and adherence was collected, in patients who were dispensed bupropion or varenicline in community pharmacies for the first time. Using the InterActionDataBase (iadb.nl), adherence per patient that initiated varenicline or bupropion was calculated by adding up all dispenses between initiation of the therapy and the 120 days thereafter. Good adherence was defined as using minimal 80% of the recommended duration and intensity of use. The prevalence of patients initiating pSCTs was stable at 0.4 per 1000 inhabitants per quarter during 2010. In 2011, the prevalence was on average 0.7, with peaks in the first (0.8 per 1000) and fourth (1.0 per 1000) quarters of 2011. In 2012, the prevalence was stable again at 0.3. In 2013, prevalence was on average 0.4, with a small peak in the first quarter. Adherence was 15.4% in 2010 versus 20.1% in 2011 (P = .002). In 2012, adherence was 13.9%, compared with 18.9% in 2013 (P = .008). Not only the likelihood of initiating pSCTs, but also the extent of adherence to these treatments, although generally low, seems higher during reimbursement.

Monotherapy Ot Polypharmacy ? Prevalent Prescription Patterns in a Big General Hospital

Introduction In general, monotherapy is advocated. However, a proportion of the treatment regimens contains two or more drugs from the same class (i.e. polypharmacy) or a combination of drugs from different classes. Objectives To investigate the prevalence of prescription patterns of psychotropic drugs to our outpatients with schizophrenia, unipolar depression or bipolar disorder. Methods Files of 510 outpatients were studied. A retrograde examination was done spanning for 6 months. Demographics, details of diagnosis, hospitalizations and a chart of the drugs administered were collected. A comparison was done between various characteristics of patients under polypharmacy and monotherapy. Results Polypharmacy as well as combination therapy was more prevalent than monotherapy in all groups. Patients with a history of previous hospitalizations were not prone to be under polypharmacy, excluding depressives . Antidepressant prescription in schizophrenics was unusually high reflecting the easiness of use of new agents for negative symptomatology . The most commonly prescribed antipsychotics were quetiapine, olanzapine and risperidone. Classical antipsychotics had medium proportion of the treatment, mainly as combined therapy. Mirtazapine, Venlafaxine and Sertraline were the most commonly prescribed antidepressants Tricyclics were prescribed also Conclusions .. Greek clinicians' attitude for polypharmacy, regardless of the diagnosis, is prevalent. The recent changes in reimbursement policies of the healthcare System in Greece, did little to affect antipsychotics, but had an effect in the prescribing patterns of antidepressants

Biological therapy in inflammatory bowel diseases: access in Central and Eastern Europe.

Biological drugs opened up new horizons in the management of inflammatory bowel diseases (IBD). This study focuses on access to biological therapy in IBD patients across 9 selected Central and Eastern European (CEE) countries, namely Bulgaria, the Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Romania and Slovakia. Literature data on the epidemiology and disease burden of IBD in CEE countries was systematically reviewed. Moreover, we provide an estimation on prevalence of IBD as well as biological treatment rates. In all countries with the exception of Romania, lower biological treatment rates were observed in ulcerative colitis (UC) compared to Crohn's disease despite the higher prevalence of UC. Great heterogeneity (up to 96-fold) was found in access to biologicals across the CEE countries. Poland, Bulgaria, Romania and the Baltic States are lagging behind Hungary, Slovakia and the Czech Republic in their access to biologicals. Variations of reimbursement policy may be one of the factors explaining the differences to a certain extent in Bulgaria, Latvia, Lithuania, and Poland, but association with other possible determinants (differences in prevalence and incidence, price of biologicals, total expenditure on health, geographical access, and cost-effectiveness results) was not proven. We assume, nevertheless, that health deterioration linked to IBD might be valued differently against other systemic inflammatory conditions in distinct countries and which may contribute to the immense diversity in the utilization of biological drugs for IBD. In conclusion, access to biologicals varies widely among CEE countries and this difference cannot be explained by epidemiological factors, drug prices or total health expenditure. Changes in reimbursement policy could contribute to better access to biologicals in some countries.

PRS86 - Sustainable Policy: Higher Medication Use & Adherence During Reimbursement of Pharmacologic Smoking Cessation Treatments

The discussion on the reimbursement of Smoking Cessation Treatment (SCT) has known many stages in The Netherlands. From January 2011, SCTs were reimbursed, until January 2012 when the reimbursement of nicotine replacement therapies (NRTs) and pharmacotherapeutic SCT (pSCT) was discontinued. As of 2013, NRTs and pSCTs were again reimbursed for a maximum of one attempt per calendar year, provided they are accompanied by behavioural counselling. To assess the impact of changes in reimbursement policy of pSCT on use and adherence. A retrospective dispensing database analysis was performed on real-world observational data from the years 2010-2013 in The Netherlands. Data on use and adherence was collected, in patients who were dispensed bupropion or varenicline in community pharmacies for the first time. Adherence was defined a using minimal 80% of the in guidelines recommended duration and intensity of use. The study cohort consisted of 4,412 users of pSCT. The number of prescriptions was stable at 0.5 prescriptions per 1,000 inhabitants (dispensing prevalence, dp) during 2010. The prevalence was on average 0.8 dp, with peaks in the the 1st and 4th quarters of 2011. In 2012, the prevalence was stable at 0.4 dp. In 2013 was on average 0.5 dp, with a small peak in the 1st quarter. Adherence was 18% in 2010 and 2012 (non-reimbursement period), and 21% in 2011 and 2013 (reimbursement period). Not only the likelihood of starting smoking cessation, but also the extent of adherence to pharmacologic smoking cessation is higher during reimbursement. Increasing the awareness of health care providers on adherence issues is warranted.

Applying clinical process analysis in patient access.

214 Background: Patient access is the entry point for new and established patient registration and scheduling process. It serves as the doorway in aligning the need of the patients to the vision of the organization, ensuring financial viability of all parties involved. The increasing demands for regulatory requirements, changes in reimbursement policies, technological and medical advancement, and steep competition, patient access becomes a vital improvement initiative in many healthcare organizations. In FY 2013, our group, the Clinical Process Analysis (CPA) team was tasked to assess the patient access work processes of our clinic areas. Methods: Through a series of structured group interview meetings, the interdisciplinary team (frontline staff, clinical leadership and financial teams) reflects and articulates their current work processes. These work processes are translated into an electronic process map, inclusive of the activities, job roles, estimated times, probabilities, and opportunities for improvement (OFIs). With these elements, CPA delivers a visual display of current work processes which can be utilized for onboarding, visualization of OFIs, and calculation of direct labor cost. A completion of a facilitated PDSA project further infuses the science of improvement. Results: Six centers completed the CPA projects since September 2013. 98 OFIs identified with 91% identified as efficiency and timely issues. 10 PDSA projects initiated, 50% reached completion and 50% are in progress. Clinical teams continue to work on the improvement projects even after the facilitation were completed. Conclusions: Drawing from system thinking and Time-Driven Activity-Based Costing (TDABC) methodology, CPA provides a comprehensive analysis of the current work flow. This allows for both a clinic specific and institutional comparative analysis for identification, implementation and improvement plan. Through facilitation of an interdisciplinary team, from frontline to leadership, process realities are visualized and work-list of opportunities for improvement are identified and worked on. This enables a quality improvement culture of providers and staff to drive quality and financial improvement.

Outcomes of pancreaticoduodenectomy: where should we focus our efforts on improving outcomes?

Changes in health care reimbursement policy have led to an era in which hospitals are motivated to improve quality of care while simultaneously reducing costs. Research demonstrating the most efficient means to target costs may have a positive effect on patient quality of life and the overburdened health care system. To evaluate the effect of hospital length of stay (LOS) and the occurrence of postoperative complications on total charges in patients undergoing elective pancreaticoduodenectomy. We performed a retrospective review of 89 cases identified in an institutional database of patients who underwent elective pancreaticoduodenectomy at an academic tertiary care center from December 1, 2007, through May 31, 2012. Occurrence of postoperative and inpatient complications, LOS, incidence of readmission within 60 days of discharge, and hospital charges from initial postoperative hospitalization. Linear regression analysis was performed comparing LOS with hospital charges. Thirty-four of 89 patients (38%) developed postoperative complications. Mean and median LOSs were 12 and 8 days, respectively. The LOS was significantly related to postoperative complications. Of the 34 patients who developed complications, the mean LOS was 19 days compared with 7 days for those patients not developing complications (P < .001). Only 2 of 55 patients (4%) without complications were readmitted to the hospital, whereas 13 of 34 patients (38%) with complications required readmission. Perioperative hospital charges were significantly related to LOS (R² = 0.840, R = 0.917). For those patients without complications, linear regression demonstrated a daily hospital charge of $11,612 (R² = 0.923, R = 0.961). However, for those patients with complications, the optimal relationship between LOS and hospital charges was exponential (R² = 0.832). Prolonged LOS is associated with increased total charges, but given the exponential increase in charges, the complication itself has an effect on increased charges above and beyond that of a prolonged hospitalization. The drive to reduce LOS after pancreaticoduodenectomy has minimal effect on overall charges to the patient. Efforts should be directed instead at reducing complications because this has a much more significant effect on financial outcomes.

Dosage of angiotensin-II receptor blockers in heart failure patients following changes in Danish drug reimbursement policies.

National reimbursement policies in Denmark were changed in November 2010 favouring a shift in angiotensin-II receptor blocker (ARB) treatment to generic losartan for heart failure (HF) patients. We examined how changes in reimbursement policies affected the fraction of HF patients up-titrated to optimal or suboptimal ARB dosage. A historical cohort study was performed including HF patients with at least one prescription of ARB in the months of May-Jul 2010 (baseline). Patients were considered up-titrated at doses 100, 16 or 160 mg for losartan, valsartan and candesartan, respectively. Individual-level linkage of nationwide registries of hospitalization and drug dispensing in Denmark was used to describe patterns of ARB prescriptions and estimate dosage before and after November 2010. Logistic regression models were used to assess the probability for being up-titrated in the period. Of 6036 individuals included (mean age 73.5 [standard deviation 11.2] years; 51% males), 3346 (55.4%) used losartan, 541 (9.0%) valsartan and 2149 (35.6%) candesartan at inclusion, respectively. 2887 (47.8%) were up-titrated at baseline (May-Jul 2010), followed by 2878 (48.2%) in the three months before the policy change (Aug-Oct 2010), and 2492 (43.7%) in the first months after the policy change (Feb-Apr 2011). Odds ratios for being up-titrated according to time period were 1.02 [0.95-1.09] in Aug-Oct 2010 (before policy change) and 0.84 [0.78-0.90] in Feb-Apr 2011 (after policy change), compared with May-Jul 2010 (reference). Probability of being up-titrated in ARB treatment was reduced 20% following changes in drug reimbursement policies.

Impact of changes to reimbursement of fixed combinations of inhaled corticosteroids and long-acting β₂ -agonists in obstructive lung diseases: a population-based, observational study.

BackgroundIn 2010, the Icelandic government introduced a new cost-saving policy that limited reimbursement of fixed inhaled corticosteroid/long-acting β2-agonist (ICS/LABA) combinations.MethodsThis population-based, retrospective, observational study assessed the effects of this policy change by linking specialist/primary care medical records with data from the Icelandic Pharmaceutical Database. The policy change took effect on 1 January 2010 (index date); data for the year preceding and following this date were analysed in 8241 patients with controlled/partly controlled asthma and/or chronic obstructive pulmonary disease (COPD) who had been dispensed an ICS/LABA during 2009. Oral corticosteroid (OCS) and short-acting β2-agonist (SABA) use, and healthcare visits, were assessed pre- and post-index.ResultsThe ICS/LABA reimbursement policy change led to 47.8% fewer fixed ICS/LABA combinations being dispensed during the post-index period among patients whose asthma and/or COPD was controlled/partly controlled during the pre-index period. Fewer ICS monocomponents were also dispensed. A total of 48.6% of patients were no longer receiving any respiratory medications after the policy change. This was associated with reduced disease control, as demonstrated by more healthcare visits (44.0%), and more OCS (76.3%) and SABA (51.2%) dispensations.ConclusionsOverall, these findings demonstrate that changes in healthcare policy and medication reimbursement can directly impact medication use and, consequently, clinical outcomes and should, therefore, be made cautiously.