High-value Health Care Research Articles

Pharmacist Involvement in Population Health Management for a Pediatric Managed Medicaid Accountable Care Organization.

Accountable care organizations (ACOs) have emerged as an effective healthcare delivery model for managing quality and cost at a population level. Within ACOs, pharmacists are critical for the delivery of high-value health care, offering patients and health care providers medication-related training, resources, and guidance that can improve quality of care at lower costs. Partners For Kids (PFK), one of the oldest and largest pediatric ACOs in the country, has successfully leveraged pharmacists to provide population health management and medication management to promote health outcomes for individual patients and the overall population it serves. This review explores how the inclusion of pharmacists in the development and execution of various quality improvement initiatives within PFK has positively impacted outcomes for patients while also lowering overall spend. A catalog of interventions is provided to offer various ways that pharmacists can intersect as providers in the triad of patient/family, payor, and provider. By providing enhanced training and education, on-site guidance, medication management, and population-level data analysis, pharmacists are able to identify and improve inefficiencies in care. Moving forward, ongoing engagement of pharmacists in health care operations will be a necessary feature to maximize health care value.

Patient Reported Outcomes Measures and the Evolving Role of Predictive Analytics in Spine Care

The field of predictive analytics in medicine is constantly expanding, in turn changing the paradigm in which providers and patients experience health care. Machine learning and neural networks are being utilized in diagnosis, individualizing care, and assisting in medical decision making in many fields, including orthopaedics. This technology's utility and accuracy are largely limited by providers’ ability to communicate complex predictions to patients and the input which generates the predictive model including patient reported outcomes (PROs). PROs, classically, are utilized in comparative and cost effectiveness research, but increasingly are being incorporated in patient-provider interactions. However, several limitations in PROs exist including a diverse number of legacy PROs, differing agendas amongst health care systems, providers, and patients, as well as providers’ ability to translate these scores into meaningful information for patients. The Patient Reported Outcome Measurement Information System (PROMIS) is a tool developed by the National Institutes of Health (NIH) to combat some of these limitations. PROMIS is health domain rather than disease specific and therefore can be applied across many fields of medicine or subspecialties within a field. Shared decision making is a framework for patients and physicians to incorporate predictive analytics, PROs, and patient values to make complex medical decisions. Decision aides are utilized to reinforce information provided by physicians to patients. The overarching goal is to maximize patient education, manage expectations and deliver high value health care. As health care systems, providers, and patients generate more data points, the strength of predictive analytic models will improve. These advances will change the way providers deliver health care and present information to patients.

Current Value Frameworks—What's New?

Current Value Frameworks—What's New?

Policy and Ethical Considerations for Widespread Utilization of Generic Orthopedic Implants.

In 2015, the United States spent $3.2 trillion on healthcare, representing 18% of the nation’s gross domestic product [1]. As prices continue to climb, physicians, healthcare policymakers, and industry leaders alike have sought varied means to lower costs while maintaining the quality of care. Coverage expansion, shifts toward bundled care payments, and the implementation of Medicare Payment Reform (Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015 [MACRA]) are indicative of shifting dynamics in the American healthcare system prioritizing outcomes, value, and cost-containment over the fee-for-service model [2], [3]. Orthopedic implant expenditures are considerable in the overall cost of care for surgical patients. The cost of total joint arthroplasty implants between 1996 and 2006 increased an estimated 130%. Implant and medical device costs comprise up to 60% of hospital reimbursements for primary procedures [4]. Most implants are proprietary in nature and vary substantially in their price and features depending on the industry manufacturer [5], [6], [7]. Control of implant costs is thus a necessary focus for cost containment in orthopedic surgery. To that end, as patents on many brand name implants begin to expire, “generic” implants present a unique opportunity to improve the value of orthopedic care. Although generic drugs have been used for decades in the pharmaceutical industry, the use of generic implants has only recently been considered in the field of orthopedic surgery [8], [9], [10]. In the pharmaceutical sector, an estimated $33 billion has been saved by Medicare in the United States through utilization of generic medications [11]. There could be potential for an analogous substantial reduction in healthcare expenditures via the use of generic orthopedic implants. There is some literature describing the favorable economic possibilities for use of generic orthopedic implants [9], [10], [12]. However, the ethical issues, policy implications, and potential unanticipated consequences of such a paradigm shift have not been investigated. This article discusses the pros and cons of generic implant usage from economic, clinical, and ethical perspectives.

Start-ups pursue RNAi for pest control

Three biotech start-ups have plans to produce and manufacture products based on RNA interference that they say can control crop-munching insects better than chemical sprays. RNAi can interrupt a target organism’s ability to produce key proteins. The Donald Danforth Plant Science Center, a not-for-profit research institute based in St. Louis, has spun off a start-up called RNAissance Ag to commercialize RNAi technology developed at the center. TechAccel, a venture development company, provided early-stage financial and technical backing to RNAissance prior to the spin-off. TechAccel is also an investor in GreenLight Biosciences, a Medford, Massachusetts–based biotech firm that raised $50 million in early January. GreenLight is not new—it was founded in 2008—but TechAccel and other investors say the firm’s work on its lower-cost RNAi production platform has opened up pest control markets in addition to the high-value human health care markets it now pursues. TechAccel’s CEO, Michael Helmstetter, says RNAi p...

Choosing Wisely Canada-Top Five List in Hepatology: Official Position Statement of the Canadian Association for the Study of the Liver (CASL) and Choosing Wisely Canada (CWC)

Introduction and aim. The prevalence and incidence of chronic liver disease is increasing resulting, in substantial direct and indirect medical costs. Overuse of investigations, treatments and procedures contribute to rising health care costs and can expose patients to unnecessary harm and delay in receiving care. The Choosing Wisely Canada (CWC) campaign has encouraged professional societies to develop statements that are directly actionable by their members in an effort to promote higher-value health care that will lead to downstream effect on how other practitioners make decisions.Material and methods. The Canadian Association for the Study of the Liver (CASL) established its Choosing Wisely top five list of recommendations using the framework put forward by CWC. CASL convened a task force that developed a list of draft recommendations and shared this with CASL membership electronically with eventual ranking of the top five recommendations by consensus at Canadian Digestives Disease Week (CDDW) 2017. Following revisions, the CASL Executive Committee endorsed the final list, which was disseminated online by CWC (July 2017).Results. The top five recommendations physicians and patients should question include: 1) Don’t order serum ammonia to diagnose or manage hepatic encephalopathy (HE). 2) Don’t routinely transfuse fresh frozen plasma, vitamin K, or platelets to reverse abnormal tests of coagulation in patients with cirrhosis prior to abdominal paracentesis, endoscopic variceal band ligation, or any other minor invasive procedures. 3) Don’t order HFE genotyping based on serum ferritin values alone to diagnose hereditary hemochromatosis. 4) Don’t perform computed tomography (CT) or magnetic resonance imaging (MRI) routinely to monitor benign focal liver lesions. 5) Don’t repeat hepatitis C viral load testing in an individual who has established chronic infection, outside of anti-viral treatment.Conclusion. The Choosing Wisely recommendations will foster patient-physician discussions, reduce unnecessary treatment and testing, avert adverse effects from testing and treatment along with reducing medical expenditure in hepatology.

Cost-effectiveness Analysis of Active Surveillance Strategies for Men with Low-risk Prostate Cancer

BackgroundActive surveillance (AS) has become the recommended management strategy for men with low-risk prostate cancer. However, there is considerable uncertainty about the optimal follow-up schedule in terms of the tests to perform and their frequency. ObjectiveTo assess the costs and benefits of different AS follow-up strategies compared to watchful waiting (WW) or immediate treatment. Design, setting, and participantsA state-transition Markov model was developed to simulate the natural history (ie, no testing or intervention) of prostate cancer for a hypothetical cohort of 50-yr-old men newly diagnosed with low-risk prostate cancer. Following diagnosis, men were hypothetically managed with immediate treatment, watchful waiting, or one of several AS strategies. AS follow-up was performed either with transrectal ultrasound-guided biopsy or magnetic resonance imaging (MRI) which was scheduled annually, biennially, every 3yrs, according to the PRIAS protocol (yrs 1, 4, 7, and 10, and then every 5yr) or every 5yr. Diagnosis of higher-grade or -stage disease while on AS resulted in curative treatment. Outcome measurements and statistical analysisWe measured discounted quality-adjusted life years (QALYs), discounted lifetime medical costs (2017 US$), and incremental cost-effectiveness ratios (ICERs). Results and limitationsCompared to WW, MRI-based surveillance performed every 5yr improved quality-adjusted survival by 4.47 quality-adjusted months and represented high-value health care at the Medicare reimbursement rate using standard cost-effectiveness metrics. Biopsy-based strategies were less effective and less costly than the corresponding MRI-based strategies for each testing interval. MRI-based surveillance at more frequent intervals had ICERs greater than $800000 per QALY and would not be considered cost-effective according to standard metrics. Our results were sensitive to the diagnostic accuracy and costs of both biopsy modes in detecting clinically significant cancer. ConclusionsIncorporation of MRI into surveillance protocols at Medicare reimbursement rates and decreasing the intensity of repeat testing may be cost-effective options for men opting for conservative management of low-risk prostate cancer. Patient summaryOur study modeled outcomes for men with low-risk prostate cancer undergoing watchful waiting, immediate treatment, or active surveillance with different follow-up schedules. We found that conservative management of low-risk disease optimizes health outcomes and costs. Furthermore, we showed that decreasing the intensity of active surveillance follow-up and incorporating magnetic resonance imaging (MRI) into surveillance protocols can be cost-effective, depending on the MRI costs.

Identifying high-cost episodes in lower extremity joint replacement.

To evaluate the ability of claims-based risk adjustment and incremental components of clinical data to identify 90-day episode costs among lower extremity joint replacement (LEJR) patients according to the Centers for Medicare & Medicaid Services (CMS) Comprehensive Care for Joint Replacement (CJR) program provisions. Medicare fee-for-service (FFS) data for qualifying CJR episodes in the United States, and FFS data linked with clinical data from CJR-qualifying LEJR episodes performed at High Value Healthcare Collaborative (HVHC) and Mayo Clinic in 2013. HVHC and Mayo Clinic populations are subsets of the total FFS population to assess the additive value of additional pieces of clinical data in correctly assigning patients to cost groups. Multivariable logistic models identified high-cost episodes. Clinical data from participating health care systems merged with Medicare FFS data. Our three populations consisted of 363621 patients in the CMS population, 4881 in the HVHC population, and 918 in the Mayo population. When modeling per CJR specifications, we observed low to moderate model performance (CMS C-Stat=0.714; HVHC C-Stat=0.628; Mayo C-Stat=0.587). Adding CMS-HCC categories improved identification of patients in the top 20% of episode costs (CMS C-Stat=0.758, HVHC C-Stat=0.692, Mayo C-Stat=0.677). Clinical variables, particularly functional status in the population for which this was available (Mayo C-Stat=0.783), improved ability to identify patients within cost groups. Policy makers could use these findings to improve payment adjustments for bundled LEJR procedures and in consideration of new data elements for reimbursement.

Substituting hospital care with primary care: The evaluation of a cardiology Primary Care Plus intervention

Introduction: To deal with the pressures on the healthcare system, the healthcare system should focus on high-value health care by pursuing the three aims: improving the health of the population, improving the quality of care as experienced by patients and reducing the increase of healthcare costs. In the Netherlands, several initiatives focus on strengthening the primary care and substituting hospital care with primary care in order to keep the health care system sustainable. This study is concentrated on a cardiology primary care plus PC+ centre where cardiologists provide specialist consultations in a primary care setting. This PC+ intervention aims to improve the health of the population and patients’ experience of care while reducing the healthcare costs by decreasing the number of unnecessary referrals to specialist care in the hospital setting. Methods: This is a practice-based study with a longitudinal observational design. The study population consisted of adult patients with non-acute and low-complexity cardiology-related health complaints, who will be referred to the cardiology PC+ centre intervention group or hospital-based outpatient cardiology care control group. Data of the PC+ centre and the hospital were used to investigate the referral and follow-up patterns of intervention group patients compared to the control group. Furthermore, patients were asked to complete questionnaires at three different time points before consultation, directly after consultation, three months after consultation consisting of items about their demographics, health status SF-12, EQ-5D-5L and EQ-VAS and experience of care. Results: The data of the PC+ centre and the hospital consists of 1838 intervention patients and 2155 control patients. Preliminary results show that 27.9 % n= 513 of the intervention group was referred to hospital care after a consultation at the PC+ centre. Moreover, 437 intervention patients and 328 control patients were included in the questionnaire study. In 25 out of 27 items PC+ results in significantly higher levels of patient satisfaction compared to hospital-based outpatient care. The results of the EQ5D-5L indicate no differences in health status between the groups, taking into account the follow-up period of three months F=0.133; P=0.865. Discussion: PC+ is a new concept in the Dutch healthcare system and evidence about its effects is scarce. The findings of this study will fill a gap in knowledge about the effects of PC+ and in particular whether PC+ is able to pursue the Triple Aim outcomes. Conclusion: Whilethis study showed no effects on the health status of the patients, there are promising results looking at the patients’ experience of care and healthcare utilization. Lessons learned: The implementation, as well as the evaluation, of PC+ initiatives is a dynamic process which requires time and continuous interaction with the stakeholders. Limitations: This study does not yet provide insight in the actual effects of PC+ on healthcare costs. Suggestions for future research: Future research, concentrated on PC+, should continue focusing on the Triple Aim outcomes, with a particular focus on healthcare costs.

Assessing the relationship between fear of cancer recurrence and health care utilization in early-stage breast cancer survivors.

The purpose of this study was to determine whether fear of cancer recurrence (FCR) is associated with greater health care utilization (HCU) in early-stage breast cancer survivors. Three hundred early-stage breast cancer survivors diagnosed within the past 7years reported on FCR as well as calls and visits to oncology providers and primary care providers during the preceding 3months. Participants also reported on use of mental health services and psychotropic medications since diagnosis. Structural equation modeling was used to create a latent FCR factor and evaluate this factor as a predictor of various HCU outcomes controlling for age at diagnosis, years since diagnosis, generalized anxiety, objective risk of recurrence, and number of comorbidities. FCR predicted more visits to both oncology providers (RR = 1.53, p = .002) and primary care providers (RR = 1.31, p = .013), as well as more phone calls to oncology providers (RR = 2.08, p = .007). FCR was not a significant predictor of phone calls to primary care providers (RR = 1.39, p = .054), utilization of mental health treatment (OR = 1.27, p = .362), or use of psychotropic medications (OR = 1.37, p = .178). FCR was associated with increases in some types of HCU, which may reflect excessive medical reassurance-seeking and lead to unnecessary medical costs. FCR is a serious concern that warrants greater attention to reduce distress-related health care utilization. Utilization of mental health services to address FCR may represent higher-value health care.

Optimizing Performance by Preventing Disruptive Behavior in Radiology.

Disruptive behaviors impede delivery of high-value health care by negatively impacting patient outcomes and increasing costs. Health care is brimming with potential triggers of disruptive behavior. Given omnipresent environmental and cultural factors such as constrained resources, stressful environments, commercialization, fatigue, unrealistic expectation of perfectionism, and burdensome documentation, a burnout epidemic is raging, and medical providers are understandably at tremendous risk to succumb and manifest these unprofessional behaviors. Each medical specialty has its own unique challenges. Radiology is not exempt; these issues do not respect specialty or professional boundaries. Unfortunately, preventive measures are too frequently overlooked, provider support programs rarely exist, and often organizations either tolerate or ineffectively manage the downstream disruptive behaviors. This review summarizes the background, key definitions, contributing factors, impact, prevention, and management of disruptive behavior. Every member of the health care team can gain from an improved understanding and awareness of the contributing factors and preventive measures. Application of these principles can foster a just culture of understanding, trust, support, respect, and teamwork balanced with accountability. The authors discuss these general topics along with specific issues for radiologists in the current medical environment. Patients, providers, health care organizations, and society all stand to benefit from better prevention of these behaviors. There is a strong moral, ethical, and business case to address this issue head-on. ©RSNA, 2018.

Improving Value of Care for Older Adults With Advanced Medical Illness and Functional Decline: Cost Analyses of a Home-Based Palliative Care Program

ContextIdentifying high-value health care delivery for patients with clinically complex and high-cost conditions is important for future reimbursement models. ObjectivesThe objective of this study was to assess the Medicare reimbursement savings of an established palliative care homebound program. MethodsThis is a retrospective cohort study involving 50 participants enrolled in a palliative care homebound program and 95 propensity-matched control patients at Mayo Clinic in Rochester, Minnesota, between September 1, 2012, and March 31, 2013. Total Medicare reimbursement was compared in the year before enrollment with the year after enrollment for participants and controls. ResultsNo significant differences were observed in demographic characteristics or prognostic indices between the two groups. Total Medicare reimbursement per program participant the year before program enrollment was $16,429 compared with $14,427 per control patient, resulting in $2004 higher charges per program patient. In 12 months after program enrollment, mean annual payment was $5783 per patient among participants and $22,031 per patient among the matched controls. In the second year, the intervention group had a decrease of $10,646 per patient; the control group had an increase of $7604 per patient. The difference between the participant group and control group was statistically significant (P < 0.001) and favored the palliative care homebound program enrollees by $18,251 (95% CI, $11,268–$25,234). ConclusionThe Mayo Clinic Palliative Care Homebound Program reduced annual Medicare expenditures by $18,251 per program participant compared with matched control patients. This supports the role of home-based palliative medicine in delivering high-value care to high-risk older adults.

Wednesday, September 26, 2018 10:35 AM – 12:00 PM Understanding Lumbar Stenosis/Spondylolisthesis: 16. Association of surgical invasiveness with readmission following surgery for lumbar spondylolisthesis

BACKGROUND CONTEXT Surgical treatment for lumbar spondylolisthesis is often considered for those who have failed nonoperative care, especially with persistent or recurrent symptoms, progressive displacement, or worsening functional decline. Criteria for selecting surgical candidates are variable, and decisions about what type of operation to perform is discretionary. Wide heterogeneity in surgical procedure invasiveness reflects a lack of evidence on effectiveness and highlights the need to expand comparative effectiveness research that incorporates patient-reported outcomes. PURPOSE To examine the association of repeat spine operation (1-year), wound problem (90-day), and all-cause re-hospitalization (90-day) with surgical invasiveness in the treatment of lumbar spondylolisthesis. STUDY DESIGN/SETTING Retrospective analysis of spondylolisthesis data from the High Value Healthcare Collaborative, a network of diverse U.S. health systems. PATIENT SAMPLE We included patients (n=884) undergoing decompression or fusion for lumbar spondylolisthesis, excluding those with significant comorbidity or device removal/revision procedures. OUTCOME MEASURES The Surgical Invasiveness Index was calculated using a previously validated method based on Current Procedural Terminology codes. Safety outcomes reported in the High Value Healthcare Collaborative network including rate of repeat lumbar surgery, readmission, and wound problems were also analyzed. METHODS Logistic regression with site-specific robust standard errors were used to identify the association between the surgical invasiveness and safety outcomes, controlling for patient age, sex and Elixhauser (v3.7) comorbidity. RESULTS The adjusted mean adverse event rates were 2.0% for repeat surgery within 1 year, 1.3% for 90-day wound problems, and 4.2% for 90-day readmission. Surgical invasiveness was associated with wound problems (OR 1.10, p CONCLUSIONS Greater use of complex spine operations in treating spondylolisthesis might reflect surgeons’ intention to provide additional stability, even in cases of mild spondylolisthesis. However, we found that greater surgical invasiveness is associated with increased risk for wound problems and readmissions, even after controlling for patient characteristics and comorbidity. Therefore, in planning surgical interventions, surgeons must engage patients in shared decision making, balancing benefits of more complex procedures with these associated increased risks for harm. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Choosing Wisely Canada – Top Five List in Hepatology: Official Position Statement of the Canadian Association for the Study of the Liver (CASL) and Choosing Wisely Canada (CWC)

Introduction and aim: The prevalence and incidence of chronic liver disease is increasing resulting in substantial direct and indirect medical costs. Overuse of investigations, treatments and procedures contribute to rising health care costs and can expose patients to unnecessary harm and delay in receiving care. The Choosing Wisely Canada (CWC) campaign has encouraged professional societies to develop statements that are directly actionable by their members in an effort to promote higher-value health care that will lead to downstream effect on how other practitioners make decisions. Methods: The Canadian Association for the Study of the Liver (CASL) established its Choosing Wisely top five list of recommendations using the framework put forward by CWC. CASL convened a task force that developed a list of draft recommendations and shared this with CASL membership electronically with eventual ranking of the top five recommendations by consensus at Canadian Digestives Disease Week (CDDW) 2017. Following revisions, the CASL Executive Committee endorsed the final list, which was disseminated online by CWC (July 2017). Results: The top five recommendations physicians and patients should question include: (1) Don’t order serum ammonia to diagnose or manage hepatic encephalopathy (HE); (2) Don’t routinely transfuse fresh frozen plasma, vitamin K, or platelets to reverse abnormal tests of coagulation in patients with cirrhosis prior to abdominal paracentesis, endoscopic variceal band ligation, or any other minor invasive procedures; (3) Don’t order HFE genotyping based on serum ferritin values alone to diagnose hereditary hemochromatosis; (4) Don’t perform computed tomography (CT) or magnetic resonance imaging (MRI) routinely to monitor benign focal liver lesions; (5) Don’t repeat hepatitis C viral load testing in an individual who has established chronic infection, outside of antiviral treatment. Conclusion: The Choosing Wisely recommendations will foster patient–physician discussions, reduce unnecessary treatment and testing, adverse effects from testing and treatment, and medical expenditure in hepatology.

Wealth and the health of older Black women in the United States.

Public health scholars and policy-makers are concerned that the United States continues to experience unmanageable health care costs while struggling with issues surrounding access and equity. To addresses these and other key issues, the National Academy of Medicine held a public symposium, Vital Directions for Health and Health Care: A National Conversation during September 2016, with the goal of identifying clear priorities for high-value health care and improved well-being. One important area was addressing social determinants of health. This article contributes to this objective by investigating the impact of wealth on older Black women's health. Employing the 2008/2010 waves of the RAND Health and Retirement Study on a sample of 906 older Black women, this panel study examined self-assessed health ratings of very good/good/fair/poor within a relaxed random effects framework, thereby controlling for both (i) observed and (ii) unobserved individual-level heterogeneity. This analysis did not find a statistically significant association with wealth despite a difference of approximately $75 000 in its valuation from very good to poor health. This also occurred after wealth was (i) readjusted for outliers and (ii) reformulated as negative, no change or positive change from 2008. This finding suggests that wealth may not play as integral a role. However, the outcome was significant for earnings and education, particularly higher levels of education. Scholars should further this inquiry to better understand how earnings/education/wealth operate as social determinants of health for minority populations.

How Do We Teach High-Value Radiology?

The healthcare environment is under tremendous flux and the rate of change is continuously increasing. Calls have been made and efforts are underway to transform medical education. In this article, trends, key drivers, and resources for both global medical education and some specific to radiology are discussed. Great strides have been made to begin shifting focus towards high-value healthcare delivery through both non-traditional methods and innovation. We are not alone in this journey; resources are readily offered by instrumental key drivers of medical education with collaboration and sharing as valuable tools at our disposal. Despite initial progress, barriers persist to achieving meaningful and sustainable changes in medical education. We must commit our resources and empower our current and future medical providers to lead the way in providing high-value healthcare for our patients. An awareness of trends and driving forces in healthcare and medical education is necessary for radiologists to be relevant and vital contributors to the healthcare team.

Transitioning to a High-Value Health Care Model: Academic Accountability

Health care spending in the United States has increased to unprecedented levels, and these costs have broken medical providers' promise to do no harm. Medical debt is the leading contributor to U.S. personal bankruptcy, more than 50% of household foreclosures are secondary to medical debt and illness, and patients are choosing to avoid necessary care because of its cost. Evidence that the health care delivery model is contributing to patient hardship is a call to action for the profession to transition to a high-value model, one that delivers the highest health care quality and safety at the lowest personal and financial cost to patients. As such, value improvement work is being done at academic medical centers across the country. To promote measurable improvements in practice on a national scale, academic institutions need to align efforts and create a new model for collaboration, one that transcends cross-institutional competition, specialty divisions, and geographical constraints. Academic institutions are particularly accountable because of the importance of research and education in driving this transition. Investigations that elucidate effective implementation methodologies and evaluate safety outcomes data can facilitate transformation. Engaging trainees in quality improvement initiatives will instill high-value care into their practice. This article charges academic institutions to go beyond dissemination of best practice guidelines and demonstrate accountability for high-value quality improvement implementation. By effectively transitioning to a high-value health care system, medical providers will convincingly demonstrate that patients are their most important priority.

Use of a Surgical Debriefing Checklist to Achieve Higher Value Health Care.

Efforts to improve surgical care by using checklists have been inconsistent in results and not reproducible at scale. The ideal manner for using checklists, along with the time horizon for achieving meaningful and measurable benefits, has been unclear. This article describes a novel process for utilizing debriefing checklists to improve value in surgical care. Debriefings of 54 003 consecutive surgical cases and subsequent analysis of 4523 defects in care by multidisciplinary teams led to rapid-cycle iterative changes in care design and processes. Four dimensions of health care value were achieved: debrief-driven improvements reduced the proportion of surgical cases with reported defects, was associated with a significant reduction in the 30-day unadjusted surgical mortality, lowered costs by substantial gains in efficiency and productivity, and led to a better workforce safety climate. Meaningful and sustained improvements required consistent broad-based teamwork over multiple years, an evidence-based data-driven approach, and senior leader and governance engagement.

UPMC’s blueprint for BuILDing a high-value health care system

National-level demonstration projects and real-world studies continue to inform health care transformation efforts and catalyze implementation of value-based service delivery and payment models, though evidence generation and diffusion of learnings often occurs at a relatively slow pace. Rapid-cycle learning models, however, can help individual organizations to more quickly adapt health care innovations to meet the challenges and demands of a rapidly changing health care landscape. Integrated delivery and financing systems (IDFSs) offer a unique platform for rapid-cycle learning and innovation. Since both the provider and payer benefit from delivering care that enhances the patient experience, improves quality, and reduces cost, incentives are aligned to experiment with value-based models, enhance learning about what works and why, and contribute to solutions that can accelerate transformation. In this article, we describe how the UPMC Insurance Services Division, as part of a large IDFS, uses its Business, Innovation, Learning, and Dissemination (BuILD) model to prioritize, design, test, and refine health care innovations and accelerate learning. We provide examples of how the BuILD model offers an approach for quickly assessing the impact and value of health care transformation efforts. Lessons learned through the BuILD process will offer insights and guidance for a wide range of stakeholders whether an IDFS or independent payer-provider collaborators.

The effects of tiered healthcare service delivery on the cost control and quality improvement in rural China: an interrupted time series analysis

Introduction: Worldwide, many countries have established their own gatekeeper system. Tertiary hospitals in China have experienced explosive growth both in the quantity and quality since 2009. However, the healthcare delivery system in China is fragmented for its weak coordination between different faculties. And it was not well prepared for the tremendous and complex needs, especially the grassroots healthcare faculties whittled by the tertiary hospitals. Moreover, it has caused the increasing of total health expenditure and occurrence of catastrophic health expenditure.Policy context and objective: To deal the unreasonable resources distribution among the tertiary-grassroots faculties and urban-rural areas, and establish a high-value healthcare delivery system. In January 2013, the tiered healthcare service delivery was first implemented among Qinghai and Hubei province. Given emerging problems might influence the current policy analysis from different perspective may achieve contrasting results, it is necessary to evaluate the secular effects of the previous pilots and synthesis its experience for the following programs with the similar contextual settings.Targeted population: The New Rural Cooperative Medical System enrollee in the Dangyang.Highlights: A quasi-natural experiment was designed in Dangyang, Hubei province. And the policy were piloted in October 2014, policies related to this reform and claim data from January 2011 to December 2015 were collected from the New Cooperative Medical Scheme (NCMS) enrollees. First, the patients are motivated to take the grassroots faculties for the initial treatment-seeking, with different reimbursement ratio settings varied with the delivery system levels. Second, all the county-level hospitals have to establish the integrated delivery system with more than township faculties. Third, all community healthcare centers should carry out the family doctors system and the grassroots faculties in rural areas should be equipped with a physician good at the Traditional Chinese Medicine.The outcomes indicated the changes in cost and patients flow were included to evaluate its effects and calculated monthly based on the claim data. Policy analysis and interrupted time series analysis model were designed to estimate the before-after changes in the indicators with Stata version 13.0. All the cost data was adjusted according the 2016 China Health Statistics Yearbook.The actual reimburstment ratio and the proportion of total medical expenses in township hospitals increased significantly in the first month of the implementation of the tired medical system policies, and has reversed the orginal downward trend. Meanwhile, the upward trend and level of out-of-pocket has significantly declined. However, the level and trend of proportion of health expenditure and patient visits in health care facilities outside Dangyang did not decreased significantly, so does the average length of stay and average total cost. The proportion of total patient visits in township hospitals increased at first, but not reversed significantly in the long term.Conclusions: Although this policy has not achieved all its expected outcomes temporarily, it has reduce the out-of-pocket cost for patients and improve the effectiveness of the grassroots facilities. Further studies should focus on the more comprehensive evaluation of health system and an appropriate control group should be found.