Era Of Value-based Health Care Research Articles

The Rhinoplasty Health Care Monitor: An Update on the Practical and Clinical Benefits after 10 Years of Prospective Outcome Measurements.

The era of value-based health care is characterized by an increasing interest in patient-reported health outcomes. For this purpose we developed the rhinoplasty health care monitor (RHM), a streamlined outcome measurement protocol, including all rhinoplasty patients since 2014. Statistical analyses of patient-reported outcome data are automated and visually presented on a custom web-based dashboard. We describe the clinical and practical benefits of the RHM and discuss how routine prospective outcome measurements have upgraded our care standards. For this prospective study, 979 consecutive patients referred for functional (revision) rhinoplasty from April 2014 to August 2023 were included. Preoperative and 3- and 12-month postoperative scores on the Nasal Obstruction Symptom Evaluation scale (NOSE), Utrecht Questionnaire (UQ), and visual analog scales (VAS) were obtained. Of 979 referred patients, 599 (61.2%) were eligible for rhinoplasty. One year postoperatively, mean NOSE scale sum score improved from 69.1 ± 22.8 to 23.1 ± 23.5 (p < 0.001). Functional VAS scores improved from 4.1 ± 2.8 (left) and 4.1 ± 2.8 (right) to 7.5 ± 1.9 (left) and 7.3 ± 2.0 (right; p < 0.001). Mean UQ sum score improved from 12.0 ± 6.4 to 6.8 ± 3.3 and aesthetic VAS score improved from 4.5 ± 2.5 to 7.4 ± 1.7 (p < 0.001) 1 year postoperatively. Benefits of the outcome routine were improved patient selection, data-driven expectation management and patient empowerment, and targeted critical appraisals of surgical performance. In conclusion, routine, automated, prospective outcome monitoring provides physicians with a response to the increasing demand for data-driven insights in health outcomes. The limited effort that is needed to gather and monitor outcome data is heavily repaid by valuable insights into aspects of care that can be improved.

Comparative Ethics of Modern Payment Models

Comparative Ethics of Modern Payment Models

The treatment choices of abdominal aortic aneurysm patients in China in the era of value-based healthcare.

Endovascular aneurysm repair (EVAR) is often seen as the first choice treatment for patients with abdominal aortic aneurysm (AAA), particularly high-risk patients, yet the long-term survival rate and improvement in quality of life are still unclear. In order to seek the value of EVAR to the entire healthcare field, we conducted a retrospective study to evaluate whether the improvement EVAR can truly bring to the quality of medical care in the era of value-based healthcare. We included AAA patients who underwent surgical treatment in the Department of Vascular Surgery, First Hospital of China Medical University, from January 1, 2004, to December 31, 2019 and evaluated surgery procedure data, short-term and long-term mortality, complications, prognoses, and medical costs. We analyzed 507 patients with AAA who underwent open repair (n = 232) or EVAR (n = 275) over a 15-year period. The operative time, blood loss, blood transfusion rate, and postoperative length of hospital stay of the EVAR group is significantly lower than which of the open repair group. Meanwhile, neither short-term nor long-term mortality rates shows significant differences between the two groups. On the other hand, the complication rate of the EVAR group was significantly higher than that of the open repair group. Lastly, the total cost of EVAR was significantly higher than that of open repair. Existing evidence suggests that EVAR improves neither short-term nor long-term survival rate compared with open surgery. In contrast, the complication rate and the reintervention rate in the EVAR group were higher than those in the open surgery group. Moreover, the cost of EVAR and that paid by medical insurance were higher than those for open surgery. For patients with a long-life expectancy, in order to ensure that patients receive appropriate and effective care, surgeons should choose a suitable method that considers both the quality of medical care as well as the expense accordingly.

Patients' and physicians' gender and perspective on shared decision-making: A cross-sectional study from Dubai.

Delivering patient-centered care is a declared objective of many health delivery systems globally, especially in an era of value-based health care. It entails the active engagement of the patients in healthcare decisions related to their health, also known as shared decision making (SDM). Little is known about the role of gender in shaping the perspective of patients on their opportunity for engaging in SDM in the Arabian Gulf Region. The aim of this study is to investigate the role of gender in shaping patients' perspectives toward their opportunity for SDM in Dubai, UAE. This study utilized a cross-sectional survey consisting of sociodemographic questions and the 9-item Shared Decision-Making Questionnaire (SDM-Q-9). A total of 50 physicians (25 females and 25 males), practicing at a large private healthcare delivery network in Dubai, were recruited using convenience sampling. Ten patients of every recruited physician (5 male and 5 female) were surveyed (i.e., a total of 500 patients). Statistical analysis assessed the differences in patients' perceptions of physician SDM attitude scores by physicians' and patients' gender using independent t-test, ANOVA-test, and Chi-square analyses. A total of 50 physicians and 500 patients (250 male patients and 250 female patients) participated in this study. The odd of patients agreement was significantly lower for male physicians, compared to their female counterparts, on the following elements of SDM: the doctor precisely explaining the advantages and disadvantages of the treatment (OR = 0.55, 95%CI: 0.34-0.88, p = 0.012); the doctor helping them understand the information (OR = 0.47, 95%CI: 0.23-0.97, p = 0.038), the doctor asking about preferred treatment option (OR = 0.52, 95%CI: 0.35-0.77, p = 0.001), and the doctor thoroughly weighting the different treatment options (OR = 0.60, 95%CI: 0.41-0.90, p = 0.013). No significant associations were observed between patients' gender and their perception of their opportunity for SDM. Likewise, no significant associations were observed between the same or different physician-patient gender and patients' perception of physicians' SDM attitudes. Statistically significant associations were observed between physician-patient gender and preferred treatment option for patients (p = 0.012). Study findings suggest that while there were no differences in patients' perspective on SDM by the gender of patients, significant differences were observed by the gender of physicians. Female physicians, compared to their male counterparts, were more engaged in SDM, with both male and female patients. Male physician-female patient dyad received the lowest scores on SDM. This could be explained by the cultural, social, and religious sensitivities that infiltrate the physician-patient relationship in the Arab contexts. Despite the multi-cultural nature of the country, some female patients may still experience some discomfort in opening up and in discussion preferences with male physicians. For physicians, striking the right balance between assertiveness and SDM is necessary within the cultural context, especially among male providers. Offering targeted learning and development programs on the importance and practice of SDM is also necessary to ensure equitable opportunity for engagement in SDM for all patients irrespective of the gender of their provider.

New Ways to Quantify the Value of Diagnostic Imaging in the Era of Value-Based Health Care.

Health care spending in the United States grew by 4.6% and reached $3.8 trillion in 2019, similar to the 4.7% growth in 2018 [1]. Radiology leaders are under pressure to both reduce costs and provide optimal care for their patients. An ideal care pathway ensures best possible outcomes for patients while keeping costs as low as possible. To achieve this, the value of each step in the care pathway needs to be understood. When the value of a diagnostic imaging test needs to be established in comparison to nonimaging tests or no test at all, a simple comparison on diagnostic accuracy alone is not sufficient.

Patient Reported Outcome Measures: Challenges in the Reporting!

Patient-reported outcome measures are increasingly important in the era of value-based healthcare. We use the example of total joint arthroplasty to demonstrate how current reporting measures may hide poorer outcomes. There is thus a need for a standardized approach in reporting patient-reported outcome measure tied to clinically relevant thresholds.

Drivers of Cost Associated With Minimally Invasive Esophagectomy

In this era of value-based healthcare, costs must be measured alongside patient outcomes to prioritize quality improvement and inform performance-based reimbursement strategies. We sought to identify drivers of costs for patients undergoing minimally invasive esophagectomy for esophageal cancer. Patients who underwent minimally invasive esophagectomy for esophageal cancer from December 2008 to March 2020 were included. Our institutional Society of Thoracic Surgeons database was merged with financial data to determine inpatient direct accounting costs in 2020 US dollars for total, operative (surgery and anesthesia), and postoperative (intensive care, floor, radiology, laboratory, etc) services. A supervised machine learning quantitative method, the lasso estimator with 10-fold cross-validation, was applied to identify predictors of costs. In the study cohort (n= 240) most had ≥cT2 pathology (82%), adenocarcinoma histology (90%), and received neoadjuvant therapy (78%). Mean length of stay was 8.00 days (SD, 4.13) with 45% inpatient morbidity rate and no deaths. The largest proportions of cost were from the operating room (30%), inpatient floor (30%), and postanesthesia care/intensive care units (20%). Preoperative predictors of operative costs were age (-5.18% per decade [95% confidence interval {CI}, -9.95 to -0.27], P= .039), body mass index ≥ 30 (+12.9% [95% CI, 0.00-27.5], P= .050), forced expiratory volume in 1 second (-3.24% per 10% forced expiratory volume in 1 second [95% CI, -5.80 to -0.61], P=.017), and year of surgery (+2.55% [95% CI, 0.97-4.15], P= .002). Predictors of postoperative costs were postoperative renal failure (+91.6% [95% CI, 9.93-233.8], P= .022), respiratory failure (+414.6% [95% CI, 158.7-923.6], P<.001), pneumonia (+136.1% [95% CI, 71.1-225.8], P < .001), and reoperation (+60.5% [95% CI, 21.5-111.9], P= .001). Costs associated with minimally invasive esophagectomy are driven by preoperative risk factors and postoperative outcomes. These data enable surgeons and policymakers to reduce cost variation, improve quality through standardization, and ultimately provide greater value to patients.

The Financial Impact of an Inpatient Diabetes Management Service

ContextDiabetes is a leading metabolic disorder with a substantial cost burden, especially in inpatient settings. The complexity of inpatient glycemic management has led to the emergence of inpatient diabetes management service (IDMS), a multidisciplinary team approach to glycemic management.ObjectiveTo review recent literature on the financial and clinical impact of IDMS in hospital settings.MethodsWe searched PubMed using a combination of controlled vocabulary and keyword terms to describe the concept of IDMS and combined the search terms with a comparative effectiveness filter for costs and cost analysis developed by the National Library of Medicine.FindingsIn addition to several improved clinical endpoints such as glycemic management outcomes, IDMS implementation is associated with hospital cost savings through decreased length of stay, preventing hospital readmissions, hypoglycemia reduction, and optimizing resource allocation. There are other downstream potential cost savings in long-term patient health outcomes and avoidance of litigation related to suboptimal glycemic management.ConclusionIDMS may play an important role in helping both academic and community hospitals to improve the quality of diabetes care and reduce costs. Clinicians and policymakers can utilize existing literature to build a compelling business case for IDMS to hospital administrations and state legislatures in the era of value-based healthcare.

Radiology in the Era of Value-based Healthcare: A Multi-Society Expert Statement from the ACR, CAR, ESR, IS3R, RANZCR, and RSNA

Background The Value-Based Healthcare (VBH) concept is designed to improve individual healthcare outcomes without increasing expenditure, and is increasingly being used to determine resourcing of and reimbursement for medical services. Radiology is a major contributor to patient and societal healthcare at many levels. Despite this, some VBH models do not acknowledge radiology's central role; this may have future negative consequences for resource allocation. Methods, findings and interpretation This multi-society paper, representing the views of Radiology Societies in Europe, the USA, Canada, Australia, and New Zealand, describes the place of radiology in VBH models and the health-care value contributions of radiology. Potential steps to objectify and quantify the value contributed by radiology to healthcare are outlined. Published under a CC BY 4.0 license.

Radiology in the era of value-based healthcare: A multi-society expert statement from the ACR, CAR, ESR, IS3R, RANZCR and RSNA.

The value-based healthcare (VBH) concept is designed to improve individual healthcare outcomes without increasing expenditure and is increasingly being used to determine resourcing of and reimbursement for medical services. Radiology is a major contributor to patient and societal healthcare at many levels. Despite this, some VBH models do not acknowledge radiology's central role; this may have future negative consequences for resource allocation. This multi-society paper, representing the views of Radiology Societies in Europe, the USA, Canada, Australia and New Zealand, describes the place of radiology in VBH models and the healthcare value contributions of radiology. Potential steps to objectify and quantify the value contributed by radiology to healthcare are outlined.

Radiology in the Era of Value-Based Healthcare: A Multi-Society Expert Statement From the ACR, CAR, ESR, IS3R, RANZCR, and RSNA

Background: The Value-Based Healthcare (VBH) concept is designed to improve individual healthcare outcomes without increasing expenditure, and is increasingly being used to determine resourcing of and reimbursement for medical services. Radiology is a major contributor to patient and societal healthcare at many levels. Despite this, some VBH models do not acknowledge radiology’s central role; this may have future negative consequences for resource allocation. Methods, findings and interpretation: This multi-society paper, representing the views of Radiology Societies in Europe, the USA, Canada, Australia, and New Zealand, describes the place of radiology in VBH models and the health-care value contributions of radiology. Potential steps to objectify and quantify the value contributed by radiology to healthcare are outlined.

Pharmacoeconomic analysis of the management of glaucoma with prostaglandin analogs

Introduction. Prevention and treatment of glaucoma, which threatens the development of blindness, is one of the most important medical and social problems facing modern society in the era of value-based health care. However, against the background of a wide selection of prostaglandin-F2α analogs, which have an approximately similar level of decrease in ophthalmotonus, a clinical and economic argumentation is required for the approach when forming a budget for drug treatment of glaucoma. The aim of the study. To assess the burden on the health budget of the city of Moscow when using the fluorinated prostaglandin-F2α analog as compared to other prostaglandin-F2α analogs for the treatment of adult patients with primary open-angle glaucoma. Material and methods. There was studied data on the population of patients with a diagnosis of «glaucoma» receiving medication from the budgetary funds of the city of Moscow. The direct medical costs of healthcare in Moscow were calculated for preparations of prostaglandin-F2α analogs for the treatment of adult patients with primary open-angle glaucoma in various clinical options for 5 years. Results. The use of the fluorinated prostaglandin-F2α analog drug Tafluprost in patients with primary open-angle glaucoma is economically justified, while budget savings in the 5-year horizon amounted to 196,777,224.60 rubles, 12,295,378.28 rubles in the baseline scenario (default appointment). and 116 084 865.02 rubles, and in alternative scenarios (appointment for adverse events on Latanoprost) - 125 113 646.70 rubles, 43 942 565.04 rubles. and 89,609,415.58 rubles, respectively. Conclusion. The inclusion of the drug Tafluprost in the drug supply programs of the Moscow healthcare system will increase the efficiency of the use of financial resources and increase the availability of drug supply.

Quality Measures to Reduce Opioid Use After Common Soft Tissue Hand and Wrist Procedures

To develop quality measures that are clinically important, feasible, usable, and scientifically acceptable for reducing opioid use after soft tissue procedures of the hand and wrist, and which can be used to evaluate quality in hand surgery. A consortium of 9 fellowship-trained hand/upper-limb surgeons with expertise in quality measure development used the RAND Corporation/University of California Los Angeles Delphi Appropriateness method to evaluate the validity of 2 quality measures for reducing opioid use, based on 4 quality indicators (clinical importance, feasibility, usability, and scientific acceptability). Panelists rated each measure on a scale of 1 (definitely not important/feasible/usable/supported) to 9 (definitely important/feasible/usable/supported) in 2 voting rounds with an intervening face-to-face discussion. Agreement was assessed using predetermined criteria. A measure was considered a valid quality measure if it received a median score of 7 or higher for all 4 indicators with no more than 2 panelists rating outside the range of 7 to9. Panelists achieved agreement on the 4 quality indicators for measuring the proportion of patients undergoing carpal tunnel release, trigger finger release, first dorsal compartment release, or ganglion cyst excision who received structured counseling on opioid use. Panelists also achieved agreement on the 4 quality indicators for measuring the proportion of patients without recent opioid use who did not fill an opioid prescription within 30 days after these procedures. Both candidate quality measures were considered valid. Using a validated consensus-building approach, we developed process and outcome quality measures for reducing opioid use after soft tissue hand surgery that were demonstrated to be valid according to 4 quality indicators. In the era of value-based health care, hand surgeons are assuming increasing responsibility in the prevention of excess opioid prescribing. Quality measures for reducing opioid overprescription can help promote the delivery of evidence-based, high-quality care in hand surgery.

UTILIZATION OF COMPLETE VS. LIMITED TRANSTHORACIC ECHOCARDIOGRAPHY: AN OPPORTUNITY FOR COST SAVINGS IN THE ERA OF VALUE BASED CARE

Inpatient transthoracic echocardiography (TTE) is reimbursed as part of “bundled payments” in the current era of value-based healthcare. Thus, targeting TTE resources to impact optimal care is paramount. Limited TTE (L-TTE) shortens sonographer time and lower costs, and may be ideal for repeat

Routine pathology examination in the era of value-based healthcare: the case of haemorrhoids specimens.

Routine pathologic examination of specimens is a common practice with ill-defined value. The present study is the first to investigate the incidence and cost of incidental microscopic lesions in both haemorrhoidectomy and stapled haemorrhoidopexy specimens. Pathological reports of specimens obtained from haemorrhoidectomy and stapled haemorrhoidopexy procedures performed from January 2003 to May 2017 were analysed. Specimens resulting from patients treated for any disease other than haemorrhoids alone were excluded from the study. Unexpected diagnoses in the pathological report were defined as incidental diagnoses. A cost analysis was then performed. In the considered period we performed a total of 3017 procedures complying with our criteria. We found 65 (2.15%) unexpected lesions. Of the incidental diagnosis, 30 (0.99%) altered either the follow-up or the treatment. The incidences of both findings were extremely higher in haemorrhoidectomies specimens (p < 0.0001). We estimated that the cost of 14years of routine pathological examination of haemorrhoids specimens was 133,351.4 euros, each consequential incidental diagnosis costing 4445.03 euros. The incidence of unexpected lesions in routine pathologic examination of haemorrhoidectomy and haemorrhoidopexy specimens is low but not negligible. The vast majority of incidental findings were found among haemorrhoidectomy specimens. Even though the real value of routine pathological examination of haemorrhoids specimens is still uncertain, from a clinical standpoint we were glad to suggest each patients the best follow-up and/or treatment. Future studies should assess preoperative patient's risk stratification and careful intraoperative macroscopic inspection strategies for selective pathology examination of haemorrhoids specimens.

Peak Performance: A Communications-Based Leadership and Teamwork Simulation for Fourth-Year Medical Students.

Background:Medical education has traditionally been rooted in the teaching of health and disease processes, with little attention to the development of teamwork and leadership competencies.Objective:In an era of value-based health care provided by high-functioning teams, new approaches are needed to develop communication, leadership, and teamwork skills for medical students.Design:We designed and piloted a simulation-based educational activity called Peak Performance that linked a workbook, which focused on self-reflection on communication and leadership skills, with professional coaching. The simulation scenario placed students in the role of an upper-level resident on an inpatient service, followed by a small group debrief with students, a clinical faculty member, and a professional executive coach. After the debriefing session, students were invited to complete a self-reflection workbook within 1 week of the initial simulation. The final element of the curriculum was an individualized session with an executive coach. Peak Performance was offered to all fourth-year medical students enrolled in the Social and Health Systems Science required course at the University of North Carolina School of Medicine.Results:Pre-/post-self-assessments of leadership competencies were completed by students. Pre-simulation self-assessment scores ranged from 3.72 to 4.33 on a 5-point scale. The lowest scores were in “Managing Conflict” and “Managing Others.” The highest score was in “Self-Awareness.” The post-simulation scores decreased in every competency, with “Managing Others” dropping significantly from 3.72 pre-simulation to 3.36 post-simulation (0.31, P < .05). Satisfaction with the curriculum was high, as reflected by a Net Promoter Score of 91% (“excellent” > 50%).Conclusions:A novel simulation-based educational activity linked to professional coaching is a feasible and impactful strategy to develop leadership, communication, and teamwork skills in medical students. Student insight and self-awareness increased as evidenced by a decrease in competency self-assessment after guided reflection and individualized coaching.

Machine Learning Algorithms in Predicting Hospital Readmissions in Sickle Cell Disease

Background: Sickle cell disease (SCD) is the most common inherited hemoglobinopathy worldwide. The pathophysiology of the disease results in end organ damage which leads to morbidity and mortality. In a subset of patients, SCD-related complications have resulted in prolonged hospitalizations and increased frequency of 30-day hospital readmissions. In the era of value-based health care, hospital quality metrics and reimbursements are generated based on strategic health care utilization. Therefore, being able to identify early unplanned hospital readmissions is critical in managing health care expenditure. Objective: To develop machine learning algorithms for predicting the 30-day unplanned readmission risk of SCD patients and to compare the predictive power of machine learning models against standard hospital readmission scoring systems. Methods: We analyzed retrospective real-world electronic health records (EHR) data for patients with SCD at our institution from January 1, 2013- November 1, 2018. The raw data set contained 2824 unique SCD patients from across 5 hospitals within the University of Pittsburgh Medical Center. After preprocessing using our inclusion criteria, our cohort included 3299 admissions comprising of 446 adult SCD patients. Features extracted from the EHR data were reduced and regrouped using both data-driven methods and clinical knowledge, resulting in 486 unique features. Logistic Regression (LR), Support Vector Machine (SVM), and Random Forest (RF) were applied to predict for 30-day unplanned hospital readmissions in SCD. Prediction performance was evaluated using the area under the receiver operating characteristic curve (AUC), sensitivity and specificity. We compared our results against standard hospital readmission prediction tools such as LACE and HOSPITAL indices. Results: We randomly selected the inpatient admissions incurred by 30 percent of the 195 return patients and 251 nonreturn patients to be included in the testing set (n = 134); the training set contained the inpatient admissions incurred by the remaining 211 patients. Thus, our training and testing sets contained similar demographic information, predictors, and outcomes. The average number of admissions was 7.40 (12.90) for the 446 patients, and 14.47 (16.97) for the 195 patients who had 30-day readmissions. Since the number of samples in our study is comparatively small, our results might be sensitive to the training and testing splits. To address this problem, we performed 100 different training and testing splits and averaged the resulting 100 AUCs. Figure 1 summarizes the two performance metrics of each model. The two benchmark prediction tools, LACE and HOSPITAL, have AUCs of 0.56 (95%CI 0.52-0.60) and 0.63 (95%CI 0.59-0.67), respectively. Notably, all three machine learning algorithms outperformed both benchmarks. The RF was the best machine learning model in prediction of hospital readmissions, as reported in similar machine learning studies (Deschepper et al. 2019), with an AUC of 0.73 (95%CI 0.69-0.76). Table 1 summarizes the sensitivity and specificity of our RF model. Conclusion: Machine learning algorithms outperformed the standard hospital readmission risk scoring systems, LACE and HOSPITAL, by a large margin in a real world data set of SCD patients at a single institution. In particular, machine learning algorithms were able to identify important variables that are underrepresented in the traditional risk scoring systems (Figure 2). The use of machine learning algorithms can be a powerful tool in providing valuable insight towards health care expenditure and resource allocation in high risk patient groups. Disclosures No relevant conflicts of interest to declare.

Patient Reported Outcomes: The Foundation of Value.

As we transition from volume-based to value-based health care, orthopedic surgeons must understand the role of outcomes in measuring value. Patient-reported outcomes (PROs) offer a number of advantages in orthopedic trauma compared with traditional clinical and radiographic results while also being an important indicator of the patient's perception of their condition. Patient-Reported Outcomes Measurement Information System, developed and funded by the National Institutes of Health, has a number of features that make PRO date collection less burdensome for providers and patients. Patient-specific factors, including comorbidities, mental health, social support, and preinjury function need to be accounted for in our assessment, because all of these factors have demonstrated an impact on outcomes. Orthopedic surgeons should be aware of how they can transition their practice in an era of value-based health care in a manner that will benefit their patients and provide insight into their own clinical practice. Prospective collection of PROs is no longer limited to academic surgeons conducting research, and all orthopedic surgeons should consider incorporating PROs into their daily clinical practice. Orthopedic surgeons must maintain an active role in the development of policies and reimbursement models to advocate for and serve our patients.

Patient experiences: a systematic review of quality improvement interventions in a hospital setting.

Purpose: In the era of value-based healthcare, one strives for the most optimal outcomes and experiences from the perspective of the patient. So, patient experiences have become a key quality indicator for healthcare. While these are supposed to drive quality improvement (QI), their use and effectiveness for this purpose has been questioned. The aim of this systematic review was to provide insight into QI interventions used in a hospital setting and their effects on improving patient experiences, and possible barriers and promoters for QI work.Methods: Prisma guidelines were used to design this review. International academic literature was searched in Embase, Medline OvidSP, Web of Science, Cochrane Central, PubMed Publisher, Scopus, PsycInfo, and Google Scholar. In total, 3,289 studies were retrieved and independently screened by the first two authors for eligibility and methodological quality. Data was extracted on the study purpose, setting, design, targeted patient experience domains, QI strategies, results of QI, barriers, and promotors for QI.Results: Twenty-one pre–post intervention studies were included for review. The methodological quality of the included studies was assessed using a Critical Appraisal Skills Program (CASP) Tool. QI strategies used were staff education, patient education, audit and feedback, clinician reminders, organizational change, and policy change. Twenty studies reported improvement in patient experience, 14 studies of the 21 included studies reported statistical significance. Most studies (n=17) reported data-related barriers (eg, questionnaire quality), professional, and/or organizational barriers (eg, skepticism among staff), and 14 studies mentioned specific promoters (eg, engaging staff and patients) for QI.Conclusions: Several patient experience domains are targeted for QI using diverse strategies and methodological approaches. Most studies reported at least one improvement and also barriers and promoters that may influence QI work. Future research should address these barriers and promoters in order to enhance methodological quality and improve patient experiences.

(P14) Cost Effectiveness of Radiation and Chemotherapy for High-Risk Low Grade Glioma

The standard of care treatment for maximally resected, high risk (≥ 40 years old or sub-totally resected) low grade glioma (LGG) patients was established by RTOG 9802, which showed an overall survival (OS) of 13.3 years for patients treated with radiotherapy (RT) + PCV (procarbazine, lomustine [CCNU], vincristine) chemotherapy compared to 7.8 years for RT alone. In the era of value-based health care, cost-effectiveness analyses (CEA) have the potential to inform coverage decisions and patient care. To our knowledge, there has been no study assessing the value of RT+PCV as adjuvant therapy for high risk LGG. We sought to analyze the cost-effectiveness of this strategy. The base case comprised patients with high risk LGG after maximal safe resection with indications for adjuvant therapy. A decision tree with an integrated three-state Markov model was created to follow patients treated with RT and RT + PCV. Patients existed in one of 3 health states: stable, progressive, and dead. All patients were assumed to be free of progression at baseline. Survival and freedom from progression were modeled to reflect the results of RTOG 9802 using time-dependent transition probabilities. Health utility values and costs of care were derived from the literature and national registry databases. Starting at initial age of 40 years (median age on RTOG 9802), patients were followed monthly over a maximum time horizon of 60 years after diagnosis (effectively over their remaining lifetimes). Analysis was conducted from the healthcare perspective. Probabilistic sensitivity analysis of modeled parameter distributions was conducted with Monte Carlo simulation of 10,000 samples. Modeled outcomes demonstrated agreement with clinical data in OS, progression free survival (PFS), and expected benefit of addition of PCV to adjuvant RT. In our model, 5-year and 10-year OS rates for RT+PCV vs RT alone were 71.5% vs. 64.8%, and 62.1% vs. 39.2%, respectively; 5-year and 10-year PFS rates for RT+PCV vs RT alone were 61.7% vs. 45.2%, and 50.5% vs. 20.1%, respectively. Patients treated with RT alone accrued 5.17 quality-adjusted life-years (QALYs) (9.63 life-years) at a cost of $139,598. Patients treated with RT+PCV accrued 9.94 QALYs (21.45 life-years) at a cost of $188,234. The addition of PCV to RT yielded an incremental benefit of 4.77 QALYs at an incremental monetary cost of $48,637, leading to an incremental cost-effectiveness ratio of $10,188 per QALY gained. Probabilistic sensitivity analysis demonstrates that cost-effectiveness of RT+PCV was insensitive to variations in modeled distributions of input parameters, with 99.96% probability of cost-effectiveness at a willingness-to-pay threshold of $100,000 per QALY. Based on the impressive benefits in outcomes observed in RTOG 9802, the addition of PCV chemotherapy to RT provides high value for cost in the treatment of patients with high-risk low grade glioma.