Health Care System Transitions Research Articles

The Pain Intervention & Digital Research Program: an operational report on combining digital research with outpatient chronic disease management.

Chronic pain affects up to 28% of U.S. adults, costing ∼$560 billion each year. Chronic pain is an instantiation of the perennial complexity of how to best assess and treat chronic diseases over time, especially in populations where age, medical comorbidities, and socioeconomic barriers may limit access to care. Chronic disease management poses a particular challenge for the healthcare system's transition from fee-for-service to value and risk-based reimbursement models. Remote, passive real-time data from smartphones could enable more timely interventions and simultaneously manage risk and promote better patient outcomes through predicting and preventing costly adverse outcomes; however, there is limited evidence whether remote monitoring is feasible, especially in the case of older patients with chronic pain. Here, we introduce the Pain Intervention and Digital Research (Pain-IDR) Program as a pilot initiative launched in 2022 that combines outpatient clinical care and digital health research. The Pain-IDR seeks to test whether functional status can be assessed passively, through a smartphone application, in older patients with chronic pain. We discuss two perspectives-a narrative approach that describes the clinical settings and rationale behind changes to the operational design, and a quantitative approach that measures patient recruitment, patient experience, and HERMES data characteristics. Since launch, we have had 77 participants with a mean age of 55.52, of which n = 38 have fully completed the 6 months of data collection necessitated to be considered in the study, with an active data collection rate of 51% and passive data rate of 78%. We further present preliminary operational strategies that we have adopted as we have learned to adapt the Pain-IDR to a productive clinical service. Overall, the Pain-IDR has successfully engaged older patients with chronic pain and presents useful insights for others seeking to implement digital phenotyping in other chronic disease settings.

Benchmark and performance progression: Examining the roles of market competition and focus

AbstractAs the US healthcare system transitions from volume to value, various value‐based programs tie medical reimbursements to hospital performance relative to national top performers (i.e., benchmarks). However, prior studies report very limited results on how such benchmarks affect care delivery and patient outcomes across multiple performance fronts. This study examines how general acute care hospitals progress toward benchmarks measured by performance frontiers in technical efficiency, clinical quality, and patient experience over time, subjecting to external market conditions and internal focuses. Based on a panel dataset comprising hospitals in California from 2012 and 2019, our results find support for competitive‐distance‐driven progression rates, suggesting that hospitals' competitive positions measured by their distances to benchmarks drive performance improvements. Yet, the effect diminishes as they move closer to performance frontiers. In addition, we find that market competition reduces the progression rate of technical efficiency. Finally, our results also suggest that focus improves performance progression rates, yet its effects are curvilinear.

Saudi Arabia's New Care Model and the Transformation of Health Care Kingdom's Vision 2030

"Vision 2030" was the framework adopted by the Kingdom of Saudi Arabia to guide its economic development and foster national expansion. The vision outlined the Kingdom's aspirations to establish itself as a global leader by accomplishing the following three primary objectives: a flourishing economy, a dynamic society, and an ambitious nation. In June 2016, the Kingdom initiated a national transformation program (NTP) in accordance with "Vision 2030" in order to achieve this objective. The transformation of health care is among the NTP's eight themes. Healthcare facilities in the Kingdom have a history of nearly a century. To attain the "vision 2030" objective, the Kingdom must modernize its health care system, despite significant strides in improving the health of its population in recent decades. The objective of this essay is to provide a description of the new Model of Care (MOC) as it pertains to the recent healthcare transformation in Saudi Arabia as outlined in the Kingdom's vision 2030. The MOC concept originated from a desire to comprehend the present condition and amass knowledge. It is predicated on the six systems of care (SOC): preventative care, premeditated interventions, pediatric and maternal care, critical issues, chronic ailments, and end-of-life care. The SOC is segmented across various "service layers" in order to facilitate individuals' recovery and restore their health when necessary. Twenty-seven of the forty-two interventions described in the new MOC are distributed across the six SOC, while the remaining fifteen are distributed across the numerous SOC. The completion of all MOC interventions will facilitate the Saudi health care system's transition to the "vision 2030" of the kingdom.

The mental health burden of racial and ethnic minorities during the COVID-19 pandemic.

Racial/ethnic minorities have been disproportionately impacted by COVID-19. The effects of COVID-19 on the long-term mental health of minorities remains unclear. To evaluate differences in odds of screening positive for depression and anxiety among various racial and ethnic groups during the latter phase of the COVID-19 pandemic, we performed a cross-sectional analysis of 691,473 participants nested within the prospective smartphone-based COVID Symptom Study in the United States (U.S.) and United Kingdom (U.K). from February 23, 2021 to June 9, 2021. In the U.S. (n=57,187), compared to White participants, the multivariable odds ratios (ORs) for screening positive for depression were 1·16 (95% CI: 1·02 to 1·31) for Black, 1·23 (1·11 to 1·36) for Hispanic, and 1·15 (1·02 to 1·30) for Asian participants, and 1·34 (1·13 to 1·59) for participants reporting more than one race/other even after accounting for personal factors such as prior history of a mental health disorder, COVID-19 infection status, and surrounding lockdown stringency. Rates of screening positive for anxiety were comparable. In the U.K. (n=643,286), racial/ethnic minorities had similarly elevated rates of positive screening for depression and anxiety. These disparities were not fully explained by changes in leisure time activities. Racial/ethnic minorities bore a disproportionate mental health burden during the COVID-19 pandemic. These differences will need to be considered as health care systems transition from prioritizing infection control to mitigating long-term consequences.

Describing the delivery of clinical pharmacy services via telehealth: A systematic review

AbstractIntroductionTelehealth offers a promising opportunity for the delivery of clinical pharmacy services by increasing the accessibility of health care, extending the reach of clinical services, and allowing pharmacists to engage with patients who might otherwise be overlooked. The objectives of the project were to discover effective strategies for the delivery of clinical pharmacy services via telehealth and to identify core components of comprehensive medication management (CMM) that are deliverable via telehealth.MethodsA systematic literature review was performed by searching four databases (Cumulative Index to Nursing and Allied Health Literature [CINAHL], PubMed, Scopus, and Web of Science) for relevant citations using keywords and subject headings relating to telemedicine, clinical pharmacy services, and health conditions. Studies were eligible for inclusion in the review if the interventions they describe involved telehealth technologies and pharmacist care. Blind screening of abstracts and full‐text review was completed by six researchers divided into teams of two. Any discrepancies were resolved by the corresponding author.ResultsFifty‐nine studies met the inclusion criteria, most (n = 53) of which were conducted in the U.S. Five studies (8.5%) reported pharmacist training as an implementation strategy. The telehealth technologies most regularly utilized were telephone‐based interventions (n = 45), videoconferences (n = 13), and web‐based (n = 4) interventions, with five studies using a combination of technologies. Most studies focused on hypertension (n = 22), diabetes (n = 20), or lipid‐related (n = 14) disease state management. Eighteen studies qualified as CMM (n = 18), with most involving all five essential CMM functions.ConclusionThis systematic review study highlights opportunities for pharmacists to deliver clinical pharmacy services using telehealth. The majority of clinical pharmacy services described in the accessed literature was provided via telephone and focused on targeted monitoring of disease states. While studies reporting the use of CMM interventions were limited, there is an opportunity to increase the application of CMM principles as healthcare systems transition to providing more telehealth services.

Institutionalizing value-based healthcare in a service system: a policy and document analysis over three decades

PurposeThis study aims to explore the institutionalization of value-based healthcare (VBHC) in the public healthcare system in the state of Victoria, Australia.Design/methodology/approachThe empirical part of this paper is based on a content analysis of 34 policy and industry-commissioned reports that have guided the development of health-care strategy in Victoria from 1988 to 2020.FindingsThis study sheds light on how VBHC in Victoria has been institutionalized over time, through three key phases (centralization, transitioning and digitalization), how the conceptualization of best value has changed in each phase and the implications each phase has presented for other actors in the health-care system.Practical implicationsThis study highlights the key opportunities and challenges for organizational actors that emerge when a health-care system transitions toward VBHC, and derives implications for vendors, health-care procurement, policymakers and governmental agencies.Originality/valueThis study develops a longitudinal analysis that describes the evolution and institutionalization of a VBHC approach in a complex societal system over three decades and highlights the key implications for other organizational stakeholders.

Radiology Workload Changes During the COVID-19 Pandemic: Implications for Staff Redeployment

Rationale and ObjectivesQuantify changes in total and by-subspecialty radiology workload due to deferring nonurgent services during the initial COVID-19 pandemic, and describe operational strategies implemented due to shifts in priority.Materials and MethodsThis retrospective, Institutional Review Board-exempt, study was performed between February 3, 2020 and April 19, 2020 at a large academic medical center. During March 9–15 (intervention period), nonurgent outpatient service deferments began. Five-week periods pre- (baseline) and postintervention (COVID) were defined. Primary outcomes were radiology volume (reports per day) overall and in 11 subspecialty divisions. Linear regression assessed relationship between baseline vs. COVID volumes stratified by division. Secondary outcomes included changes in relative value units (RVUs), inpatient and outpatient volumes.ResultsThere were 62,791 baseline reports vs. 23,369 during COVID; a 60% overall precipitous volume decrease (p < 0.001). Mean volume decrease pre- and during-COVID was significant (p < 0.001) amongst all individual divisions. Mean volume decrease differed amongst divisions: Interventional Radiology experienced least disruption (29% volume decrease), 7 divisions experienced 40%–60% decreases, and Musculoskeletal, Breast, and Cardiovascular imaging experienced >75% volume decrease. Total RVUs decreased 60% (71,186 baseline; 28,476 COVID). Both outpatient and inpatient report volumes decreased; 72% (41,115 baseline; 11,326 COVID) and 43% (12,626 baseline vs. 6,845 COVID), respectively. In labor pool tracking data, 21.8% (162/744) total radiology employees were reassigned to other hospital duties during the intervention period.ConclusionPrecipitous radiology workload reductions impacted subspecialty divisions with marked variation. Data-driven operational decisions during COVID-19 assisted workflow and staffing assignment changes. Ongoing adjustments will be needed as healthcare systems transition operations to a “new normal.”

A Path to Resume Aesthetic Care: Executive Summary of Project AesCert Guidance Supplement-Practical Considerations for Aesthetic Medicine Professionals Supporting Clinic Preparedness in Response to the SARS-CoV-2 Outbreak.

A Path to Resume Aesthetic Care: Executive Summary of Project AesCert Guidance Supplement-Practical Considerations for Aesthetic Medicine Professionals Supporting Clinic Preparedness in Response to the SARS-CoV-2 Outbreak.

A PATH TO RESUME AESTHETIC CARE EXECUTIVE SUMMARY OF PROJECT AesCert™ GUIDANCE SUPPLEMENT: PRACTICAL CONSIDERATIONS FOR AESTHETIC MEDICINE PROFESSIONALS SUPPORTING CLINIC PREPAREDNESS IN RESPONSE TO THE SARS-CoV-2 OUTBREAK.

This Project AesCert™ Guidance Supplement ("Guidance Supplement") was developed in partnership with a multi-disciplinary panel of board-certified physician and doctoral experts in the fields of Infectious Disease, Immunology, Public Health Policy, Dermatology, Facial Plastic Surgery and Plastic Surgery. The Guidance Supplement is intended to provide aesthetic medicine physicians and their staffs with a practical guide to safety considerations to support clinic preparedness for patients seeking non-surgical aesthetic treatments and procedures following the return-to-work phase of the COVID-19 pandemic, once such activity is permitted by applicable law. Many federal, state and local governmental authorities, public health agencies and professional medical societies have promulgated COVID-19 orders and advisories applicable to health care practitioners. The Guidance Supplement is intended to provide aesthetic physicians and their staffs with an additional set of practical considerations for delivering aesthetic care safely and generally conducting business responsibly in the new world of COVID-19. Aesthetic providers will face new and unique challenges as government stay-at-home orders and related commercial limitations are eased, and the U.S. economy reopens and healthcare systems transition from providing only urgent and other essential treatment to resuming routine care and elective procedures and services. The medical aesthetic specialties will therefore wish to resume practice in order to ensure high quality, expert care is available, and importantly to help promote patients' positive self-image and sense of well-being following a lengthy and stressful period of quarantine. In a number of areas, this Guidance Supplement exceeds traditional aesthetic office safety precautions, recognizing reduced tolerance in an elective treatment environment for any risk associated with COVID-19's highly variable presentation and unpredictable course. The disease has placed a disturbing number of young, otherwise healthy patients in extremis with severe respiratory and renal failure, stroke, pericarditis, neurologic deficits and other suddenly life-threatening complications, in addition to its pernicious effects on those with pre-existing morbidities and advanced age. Accordingly, the Guidance Supplement seeks to establish an elevated safety profile for providing patient care while reducing, to the greatest extent reasonably possible, the risk of infectious processes to both patients and providers. While the Guidance Supplement cannot foreclose the risk of infection, nor serve to establish or modify any standards of care, it does offer actionable risk-mitigation considerations for general office comportment and for certain non-surgical procedures typically performed in aesthetic medical settings. It is axiomatic that all such considerations are necessarily subject to the ultimate judgment of each individual healthcare professional based on patient situation, procedure details, office environment, staffing constraints, equipment and testing availability, and local legal status and public health conditions.

Challenges of Measuring Costs of Care for US Practices.

As the US healthcare system transitions from fee-for-service to value-based purchasing, evaluating physician practice performance on cost is central to driving value. Two measures—Total per Capita Cost (TPCC) and Medicare Spending per Beneficiary (MSPB)—comprise the cost domain in Medicare’s mandatory physician value-based purchasing program: the Merit-based Incentive Payment System (MIPS). Therefore, we sought to describe the feasibility of applying claims-based cost measures included in MIPS to practices nationwide, and to assess whether feasibility varies by practice size or specialty mix.

27. Costs and utility of postdischarge acute inpatient rehabilitation following adult spinal deformity surgery

BACKGROUND CONTEXT As the United States' health care system transitions to a value-based approach, defining costs for entire episodes of care is fundamental to determining value. This is particularly important for adults with spinal deformity (ASD) who undergo surgical intervention. PURPOSE To further the discussion on costs of operative care for ASD, this study aims to evaluate the costs and functional utility of postdischarge acute inpatient rehabilitation after surgery for ASD. STUDY DESIGN/SETTING Single-center, retrospective cohort analysis. PATIENT SAMPLE Adults with spinal deformity (ASD) who underwent operative intervention (>7 levels fused) at a single tertiary care referral center and who were discharged postoperatively to one acute inpatient rehabilitation facility. OUTCOME MEASURES Patient demographics, operative details, direct costs and length of stay for inpatient hospitilization and acute postoperative rehabilitation, and patient function, as assessed by the Functional Independence Measure (FIM) instrument. METHODS Patient demographics, operative details, and costs were obtained for the index operation's inpatient encounter. Data for acute rehabilitation included: direct costs, length of stay, and patient function, as assessed by the Functional Independence Measure (FIM) instrument [scores 18-30 (total assistance), 31-45 (maximal assistance), 46-63 (moderate assistance), 64-80 (minimal assistance), 81-100 (supervision), 101-125 (modified independence), 126 (complete independence)]. Student T-tests and Chi-square tests were used to compared continuous and categorical variables. Pearson's tests were used to assess correlations. p RESULTS Ninety patients (95 episodes of care; average age 70.5±10.6 years; male-31, female-59) were included. After operations, average inpatient length of stay was 8.2±2.6 days (4-16 days). Operative details included: posterior levels fused 13.6±3.6 (7-21 levels), posterior column osteotomies (per patient) 7±3.7 (range, 1-15; n=49 patients), forty-two 3COs (PSO-35, VCR-7), and 11 interbody fusions. Average direct costs were $90,738±$24,166 ($36,521–$141,090) for index inpatient stays and $38,808±$14,752 ($8,679–$100,829) for post-discharge acute rehabilitation (Figure 1). Patients spent an average of 11.7±4.0 days (2-28 days) in acute rehabilitation postdischarge. Average direct cost per day in rehabilitation was $3,338 ±$2,131 ($506-$4,340). Significant improvements in function (FIM) were observed [admit: 66±14 (15–91) vs discharge: 94±14 (54–116); % improvement: 29±14]. CONCLUSIONS Postdischarge inpatient acute rehabilitation following operations for adult spinal deformity is associated with an average direct cost of $38,808 per case. While rehabilitation resulted in significant functional improvements, it came at a very significant economic expense amounting to $3.7 million, which accounted for 30% of the costs for 95 episodes of care. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

It's Time to Wikify Clinical Documentation: How Collaborative Authorship Can Reduce the Burden and Improve the Quality of the Electronic Health Record.

Electronic health records (EHRs) have become ubiquitous tools and represent the standard of care for 96% of hospitals and 86% of ambulatory physicians in the United States. With adoption of EHRs came the promise of improved efficiency, higher-quality care, and lower costs. Unfortunately, some clinicians are now spending twice as much time on documentation as they spend seeing patients, and the documentation paradigm of problem-oriented medical records is contributing to this imbalance. It is time to consider new innovations. The collaborative wiki format offers many opportunities to ease the burden of documentation as well as to increase the usefulness of the recorded clinical data. Wikis support multiple authorship, have built-in features to track edits and changes, allow for contextual linkages (e.g., linking medical problems to their treatment), and support new technologies such as application programming interfaces, which allow for safe and secure exchange of information. In this Perspective, the authors describe the rationale for considering this approach to clinical documentation and propose a pilot to learn about its effectiveness. They believe wiki-based documentation will become increasingly attractive, especially as new legislation and directives from policymakers seek to reduce the crushing documentation burden and as the U.S. health care system transitions from an episode-based payment structure to a value-based, outcomes-focused system.

Assessment of Health Care Utilization and Cost of Targeted Drug Delivery and Conventional Medical Management vs Conventional Medical Management Alone for Patients With Cancer-Related Pain

Targeted drug delivery (TDD) has potential for cost savings compared with conventional medical management (CMM). Despite positive clinical and economic evidence, TDD remains underused to treat cancer pain. To assess the cost of TDD and CMM in treating cancer-related pain. This retrospective economic evaluation using propensity score-matched analysis was conducted using MarketScan commercial claims data on beneficiaries receiving TDD and CMM or CMM only for cancer pain from January 1, 2009, to September 30, 2015. Participants were matched on age, sex, cancer type, comorbidity score, and pre-enrollment characteristics. Data analysis was performed from June 1 to September 30, 2017. Total 2-, 6-, and 12-month costs, number of health care encounters, length of hospital stay, additional components of cost, and health care utilization. A total of 376 TDD and CMM patients (mean [SD] age, 51.88 [9.98] years; 216 [57.5%] female) and 4839 CMM only patients (mean [SD] age, 51.52 [11.16] years; 3005 [62.1%] female) were identified for study inclusion. After matching, 536 patients were included in the study: 268 patients in the TDD and CMM group and 268 in the CMM only group. Compared with CMM only, TDD and CMM was associated with mean total cost savings of $15 142 (95% CI, $3690 to $26 594; P = .01) at 2 months and $63 498 (95% CI, $4620 to $122 376; P = .03) at 12 months; cost savings at 6 months were not statistically different ($19 577; 95% CI, -$12 831 to $51 984; P = .24). The TDD and CMM group had fewer inpatient visits (2-month mean difference [MD], 1.0; 95% CI, 0.8-1.2; P < .001; 6-month MD, 1.3; 95% CI, 0.8-1.7; P < .001; 12-month MD, 2.3; 95% CI, 1.2-3.4; P < .001) and shorter hospital stays (2-month MD, 6.8 days; 95% CI, 5.0-8.7 days; P < .001; 6-month MD, 6.8 days; 95% CI, 3.1-10.5 days; P < .001; 12-month MD, 10.6 days; 95% CI, 2.9-18.3 days; P = .007). Use of CMM only was associated with greater opioid use at 12 months (MD, 3.2; 95% CI, 0.4-6.0; P = .03). Compared with CMM alone, TDD and CMM together were associated with significantly lower cost and health care utilization. The findings suggest that TDD is a cost-saving therapy that should be considered in patients with cancer for whom oral opioids are inadequate or produce intolerable adverse effects and should be expanded as health care systems transition to value-based models.

Drug Treatment Value in a Changing Oncology Landscape: A Literature and Provider Perspective.

The U.S. health care system's transition to a value-based reimbursement model holds important implications for medical innovation, care delivery, and value-based assessments of therapeutic interventions. This transition has been especially noteworthy in oncology, with substantial ongoing changes to payer reimbursement and the provider landscape, as well as the introduction of value frameworks to guide drug treatment decision making. The implications of these changes for provider assessments of drug value and evidence needs remain unclear. To understand provider perspectives on drug value assessment and the utility of existing oncology value frameworks by identifying (a) key value-based trends in the evolving oncology landscape, (b) provider definitions of drug value, (c) the role of existing value frameworks in provider decision making, and (d) future provider evidence needs for making value-based treatment decisions. We conducted a literature review to identify existing oncology value frameworks and definitions of drug treatment value in oncology. Using a structured discussion guide informed by this literature review, we conducted 12 telephone-based in-depth interviews in November and December 2017 with U.S. oncology providers involved in organizational drug treatment and formulary decision making within their practices. Responses to interview questions were analyzed and reported as averages and percentages across participants. Of 293 publications identified by keyword searches, 35 relevant articles were identified. Among these, the literature review identified no common definition for providers to assess drug value. Interview research participants described large ongoing changes in the oncology provider landscape, with economic pressures from payers as the foremost leading factor. Although 5 value frameworks were found in the literature, interviews found that in practice few providers consider these value frameworks to be key influences when evaluating treatment or formulary decisions. Furthermore, while 83% of participants' organizations employed some form of internal clinical pathways, only the minority (25%) with pathways integrated in their electronic medical record (EMR) systems saw these pathways as significantly affecting clinicians' drug treatment decision making. To aid the ongoing shift from volume-based to value-based care, we found that, rather than value frameworks, providers are looking for patient-level tools to make more appropriate drug decisions. Payer reimbursement pressures are leading to radical changes in the oncology provider landscape, and there is a need for improved guidance for providers in assessing drug value. In particular, this study identifies the need for a timely and multifaceted summary of information required to assess the value of alternative treatment options for a given patient. Manufacturers also need to make significant strides to help generate and improve the dissemination of evidence to support the value of their therapies. Funding for this work was provided by Novartis Pharmaceuticals. The study sponsor was involved in study design, data interpretation, and data review. All authors contributed to the development of the manuscript and maintained control over the final content. Sasane, Howe, Wong, and Zacker were employees of Novartis at the time of this study. Frois, Jarvis, and Grice are or have been employed by Analysis Group, which received a grant from Novartis for this research. At the time of this study, Analysis Group received funding from multiple manufacturers with oncology products in their portfolio during this time period, including, but not limited to, Astellas and Genentech.

Measuring Value in the Provision of Lower-Limb Prostheses

ABSTRACT As modern health care systems transition from fee-for-service to fee-for-value structures, it is increasingly relevant for the field of prosthetic rehabilitation to understand modern economic science. Health care economics can be approached through a range of analyses in which the costs of health care services are compared against subsequent cost savings, consequences observed with the intervention, the effectiveness of the intervention with regard to a range of outcomes valued by the patient, payer, and provider, or widely used global utility measures. Although examples of economic science are limited in current prosthetic literature, available examples are cited to describe various approaches to economic analysis. An understanding of economic science clarifies the need for the continued identification, creation, and adoption of outcome measures sensitive enough to discriminate between prosthetic interventions and valued collectively by patients, payers, and providers. Future clinical trials should collect and report upon the associated costs as well as meaningful outcome measures to expand the current body of economic evidence in the prosthetic literature.

Promoting and Sustaining Positive Personal Health Behaviors - Putting the Person First.

Amidst the national debate on the future of health care, there must be a focus on how individuals, communities, and the system need to change to promote and sustain health rather than reactively treat sickness and disability. To transition from a health care system to a "System for Health", we need to move from a patient-focused to a person-focused position. A system that focuses on improving personal decisions related to activity, nutrition, sleep, and tobacco-free living could have a profound impact on health and well-being. The delivery of health, instead of just health care, entails more than just preventing sickness and disability; it requires focusing on building personal wellness, resilience, and endurance. Engaging the individual person to embrace a healthier lifestyle through education, incentives, and technology we can have a positive impact on reducing costs and improving health outcomes. The purpose of this commentary is three-fold: (1) to address the need to implement prescriptions for health, (2) advocate for the need for a person-centric model to help our health care system transition to a system for health, and (3) demonstrate how simple behavior changes can help drive the change to health.

PMD6 - Real-World Data Analysis of Confirmatory Biopsy Utilization in Suspected Prostate Cancer Patients

As the US healthcare system transitions away from volume-based delivery to one that is focused on quality and value, there is a continued focus on understanding the drivers of cost, especially in oncology. Over one million prostate biopsies are performed annually, with many newly diagnosed cases being patients who may never die of the disease. Potential cost savings exist in identifying patients for which biopsy is unnecessary. In this study, we quantify the use of biopsy procedure in the diagnosis of prostate cancer. We utilized a chart pull survey methodology to identify 1,000 patients who had undergone traditional sextant prostate biopsy for suspected prostate cancer. Patient chart surveys were collected from 11 community urology sites varying in practice size and geographic representation from across the US. Patients were separated into research cohorts by whether they had received molecular testing prior to biopsy. Our research found that among the 1,000 patients who received a prostate biopsy, the most common reason for biopsy was elevated prostate-specific antigen (PSA), followed by abnormal digital rectal exam (DRE). Only 80 patients (8%) received a molecular test (4Kscore, PHI, PCA3, SelectMDx) prior to biopsy. Among the 1,000 patients who received a biopsy, 530 (53%) were confirmed to have prostate cancer. Among the 80 patients who had molecular testing prior to biopsy, 41 (51%) were confirmed to have prostate cancer. This result represents no significant difference in the rate of patients confirmed to have prostate cancer following biopsy (p=0.74), with or without prior molecular testing. Our results demonstrated that use of molecular testing did not improve the rate of prostate cancer confirmation through biopsy. They also highlighted the need for more accurate biomarkers for molecular testing to determine which patients should be biopsied among those suspected of having prostate cancer.

Financing the Primary Care Behavioral Health Model.

The PCBH model of integrated care blends behavioral health professionals into the primary care team, thereby enhancing the scope of primary care and expanding the range of services provided to the patient. Despite promising evidence in support of the model and a growing number of advocates and practitioners of PCBH integration, current reimbursement policies are not always favorable. As the nation's healthcare system transitions to value-based payment models, new financing strategies are emerging which will further support the viability of PCBH integration. This article provides an overview of the infrastructure necessary to support PCBH practice; reviews the current PCBH funding landscape; discusses how emerging trends in healthcare financing are impacting the model; and provides a vision for the viability of the PCBH model within the value-based financing of our healthcare system in the future.

Assessing Health-Related Quality of Life in Patients With Diabetic Foot Disease: Why Is It Important and How Can We Improve? The 2017 Roger E. Pecoraro Award Lecture.

Patient-reported outcomes (PROs) have become an important subject in the area of diabetes-related foot complications. Self-reported health-related quality of life (HRQOL) surveys can provide a generic measure of overall health (global) and can be disease specific (i.e., diabetes) or even region specific (i.e., lower-extremity function). Analysis of PRO measures utilizing validated instruments allows health care providers to determine whether medical and surgical treatments are providing patients with the highest level of outcome possible and are actually improving HRQOL. The 36-item Short Form (SF-36), EuroQol five-dimension questionnaire (EQ-5D-5L), and Foot and Ankle Ability Measure (FAAM) are examples of commonly used HRQOL surveys. Low HRQOL has been associated with higher rates of hospital admission and mortality in patients with diabetes. Previous studies have demonstrated that patients with diabetes-related foot disease have low self-reported physical quality of life but do not typically report low mental quality of life. The impact of mental quality of life may be underestimated in these patients using the SF-36. In this article, we will discuss several widely used outcome instruments used to measure patient HRQOL and the impact of diabetic foot disease on HRQOL. As health care providers, we must continue to adjust and modify our treatments to achieve the best patient outcomes and associated high quality of life. Assessing PROs will become increasingly important as health care systems transition from a volume-based reimbursement model to a value-based model.

Real-World Data Analysis of Cancer Treatment Cost Drivers By Type and Place of Service

As the US healthcare system transitions from one of volume based delivery to one focused on quality and value there is a continued focus on understanding the drivers of cost, especially in oncology. Cancer drug costs have been a focus of much debate and this study analyzes real world data from two large volume cancer centers in the US to quantify drivers of cancer treatment costs. Integra Connect utilized Medicare claims data from two large cancer treatment centers in the US with over 60,000 cancer patients treated in the last 12 months. Overall treatment costs were categorized into 9 cost buckets (including Part B drug costs, Part D drug costs, Inpatient, E&M, Lab testing, Imaging, Emergency visits, etc.). Treatment costs were based on amounts paid by CMS from July 2016 through August 2016. Secondary research included a review of previously published studies on cost drivers of cancer care for comparison to current results. Our research found that prescription drug costs from both Part B and Part D paid Medicare claims accounted for 47% (site 1) and 51% (site 2) of total cancer treatment costs. Second to cancer treatment costs, inpatient hospitalization related costs accounted for 20% (site 1) and 17% (site 2) of overall costs. These results contrast previously published research that found cancer drug costs to be a smaller proportion of overall treatment costs (18% of overall costs attributed to chemotherapy and other cancer drugs)1. This real-world data analysis highlights the variability in cancer treatment costs and the continued need for cancer treatments to demonstrate value and savings among other areas that drive overall cost. 1“Cost Drivers of Cancer Care: A Retrospective Analysis of Medicare and Commercially Insured Population Claim Data 2004-2014”, Milliman