High-value Health Research Articles

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.

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.

Presenting Cost and Efficiency Measures That Support Consumers to Make High-Value Health Care Choices.

To identify approaches to presenting cost and resource use measures that support consumers in selecting high-value hospitals. Survey data were collected from U.S. employees of Analog Devices (n=420). In two online experiments, participants viewed comparative data on four hospitals. In one experiment, participants were randomized to view one of five versions of the same comparative cost data, and in the other experiment they viewed different versions of the same readmissions data. Bivariate and multivariate analyses examined whether presentation approach was related to selecting the high-value hospital. Consumers were approximately 16 percentage points more likely to select a high-value hospital when cost data were presented using actual dollar amounts or using the word "affordable" to describe low-cost hospitals, compared to when the Hospital Compare spending ratio was used. Consumers were 33 points more likely to select the highest performing hospital when readmission performance was shown using word icons rather than percentages. Presenting cost and resource use measures effectively to consumers is challenging. This study suggests using actual dollar amounts for cost, but presenting performance on readmissions using evaluative symbols.

Palliative Care Leadership Centers Are Key To The Diffusion Of Palliative Care Innovation.

Between 2000 and 2015 the proportion of US hospitals with more than fifty beds that had palliative care programs tripled, from 25percent to 75percent. The rapid adoption of this high-value program, which is voluntary and runs counter to the dominant culture in US hospitals, was catalyzed by tens of millions of dollars in philanthropic support for innovation, dissemination, and professionalization in the palliative care field. We describe the dissemination strategies of the Center to Advance Palliative Care in the context of the principles of social entrepreneurship, and we provide an in-depth look at its hallmark training initiative, Palliative Care Leadership Centers. Over 1,240 hospital palliative care teams have trained at the Leadership Centers to date, with 80percent of them instituting palliative care services within two years. We conclude with lessons learned about the role of purposeful technical assistance in promoting the rapid diffusion of high-value health care innovation.

The effects of an activity-based lifestyle intervention on moderate sleep complaints among older adults: study protocol for a randomized controlled trial

BackgroundModerate sleep complaints are major gerontological issue affecting as many as 80% of older adults. More intriguing findings have indicated that moderate sleep complaints were associated with cognitive decline, functional deterioration, clinical depression, and even morbidity and mortality among older adults. The aim of this study is to evaluate the effects of an activity-based lifestyle intervention on moderate sleep complaint among community-dwelling older adults.Methods/DesignThis sequential quantitative–qualitative mixed method study will randomly allocate 224 individuals to receive either the 16-week group-based moderate-intensity stepping exercise or 16-week health education. The exercise group receives three 60-min stepping exercises per week, whereas the education group receives weekly educative talks on health topics other than sleep. The primary outcomes are sleep quality as measured by the Pittsburgh Sleep Quality Index (PSQI) and sleep pattern as measured by the actiwatch. Physical fitness and mood status are measured as mediating variables by using the Rockport walking test and Profile of Mood States. The qualitative part will invite 30 individuals from the exercise group who have different sleep-related treatment responses to participate in individual interviews to explore their overall perception of using stepping exercise as a lifestyle intervention to improve sleep. Mixed effects model with intention-to-treat analysis will be used for quantitative data. Inductive thematic analysis with a prior coding framework will be used for the qualitative data.DiscussionBy investigating the effects and the mediating mechanism of a moderate-intensity exercise program on moderate sleep complaints among older adults, this study will generate evidence of high scientific value and important public health implication. Understanding the sleep-promoting effects and acceptability of exercise informs how to apply lifestyle promotion as a public health practice to improve late-life moderate sleep complaints and forestall its progression to level of clinical severity.Trial registrationClinical Trial Registry Team, Center for Clinical Research and Biostatistics CUHK, CCRB00491. Registered on 1 December 2015.

Reflecting the real value of health care resources in modelling and cost-effectiveness studies-The example of viral load informed differentiated care.

BackgroundThe WHO HIV Treatment Guidelines suggest routine viral-load monitoring can be used to differentiate antiretroviral therapy (ART) delivery and reduce the frequency of clinic visits for patients stable on ART. This recommendation was informed by economic analysis that showed the approach is very likely to be cost-effective, even in the most resource constrained of settings. The health benefits were shown to be modest but the costs of introducing and scaling up viral load monitoring can be offset by anticipated reductions in the costs of clinic visits, due to these being less frequent for many patients.Key issues for economic evaluationThe cost-effectiveness of introducing viral-load informed differentiated care depends upon whether cost reductions are possible if the number of clinic visits is reduced and/or how freed clinic capacity is used for alternative priorities. Where freed resources, either physical or financial, generate large health gains (e.g. if committed to patients failing ART or to other high value health care interventions), the benefits of differentiated care are expected to be high; if however these freed physical resources are already under-utilized or financial resources are used less efficiently and would not be put to as beneficial an alternative use, the policy may not be cost-effective. The implication is that the use of conventional unit costs to value resources may not well reflect the latter’s value in contributing to health improvement. Analyses intended to inform resource allocated decisions in a number of settings may therefore have to be interpreted with due consideration to local context. In this paper we present methods of how economic analyses can reflect the real value of health care resources rather than simply applying their unit costs. The analyses informing the WHO Guidelines are re-estimated by implementing scenarios using this framework, informing how differentiated care can be prioritized to generate greatest gains in population health.ImplicationsThe findings have important implications for how economic analyses should be undertaken and reported in HIV and other disease areas. Results provide guidance on conditions under which viral load informed differentiated care will more likely prove to be cost effective when implemented.

UPMC's Population Health Management Strategy: A Road Map to High-Value Health Care.

UPMC's Population Health Management Strategy: A Road Map to High-Value Health Care.

Science of health care delivery milestones for undergraduate medical education

BackgroundThe changing healthcare landscape requires physicians to develop new knowledge and skills such as high-value care, systems improvement, population health, and team-based care, which together may be referred to as the Science of Health Care Delivery (SHCD). To engender public trust and confidence, educators must be able to meaningfully assess physicians’ abilities in SHCD. We aimed to develop a novel set of SHCD milestones based on published Accreditation Council for Graduate Medical Education (ACGME) milestones that can be used by medical schools to assess medical students’ competence in SHCD.MethodsWe reviewed all ACGME milestones for 25 specialties available in September 2013. We used an iterative, qualitative process to group the ACGME milestones into SHCD content domains, from which SHCD milestones were derived. The SHCD milestones were categorized within the current ACGME core competencies and were also mapped to Association of American Medical Colleges’ Entrustable Professional Activities (AAMC EPAs).ResultsFifteen SHCD sub-competencies and corresponding milestones are provided, grouped within ACGME core competencies and mapped to multiple AAMC EPAs.ConclusionsThis novel set of milestones, grounded within the existing ACGME competencies, defines fundamental expectations within SHCD that can be used and adapted by medical schools in the assessment of medical students in this emerging curricular area. These milestones provide a blueprint for SHCD content and assessment as ongoing revisions to milestones and curricula occur.

The Medicare Access and CHIP Reauthorization Act: Implications for Nephrology.

In response to rising Medicare costs, Congress passed the Medicare Access and Children's Health Insurance Program Reauthorization Act in 2015. The law fundamentally changes the way that health care providers are reimbursed by implementing a pay for performance system that rewards providers for high-value health care. As of the beginning of 2017, providers will be evaluated on quality and in later years, cost as well. High-quality, cost-efficient providers will receive bonuses in reimbursement, and low-quality, expensive providers will be penalized financially. The Centers for Medicare and Medicaid Services will evaluate provider costs through episodes of care, which are currently in development, and alternative payment models. Although dialysis-specific alternative payment models have already been implemented, current models do not address the transition of patients from CKD to ESRD, a particularly vulnerable time for patients. Nephrology providers have an opportunity to develop cost-efficient ways to care for patients during these transitions. Efforts like these, if successful, will help ensure that Medicare remains solvent in coming years.

Effects of different freshness on the quality of cooked tuna steak

Abstract The variation in quality of yellowfin tuna (Thunnus albacares) steaks of different freshness after cooking were studied by analyzing K value, adenosine triphosphate (ATP)-related compounds content, histamine content, sensory quality, E-nose and E-tongue analysis. The results indicated that when the freshness of raw tuna steak decreased from sashimi grade to cooking grade, IMP content significantly decreased whereas HxR content significantly increased after cooking. With the decrease of freshness, K value of the 4th day sashimi-grade tuna and the 6th day cooking-grade tuna increased from 18% and 24% to 27% and 45% respectively after cooking. The higher histamine content in raw tuna steak, the more significantly increased histamine level of cooked tuna was observed. Raw tuna steaks with sashimi grade have significant variation from those with cooking grade in odor and taste by E-nose and E-tongue analysis after cooking The sensory evaluation showed that the freshness of tuna steak significantly influence the cooking quality (p Industrial relevance Tuna is well appreciated worldwide because of its high nutritional value and potential health benefits. Canned tuna is one of the most widespread and recognized fish commodities in the world. The species utilized commonly for canning are skipjack, yellowfin and albacore tuna. Cooking tuna steak is normally used as semi-manufactured products in canned tuna industry. Control of the cooking unit operation is critically important to producing cooked muscle for tuna industry. However, freshness of raw tuna steak may have close connection with the quality of cooked tuna steak. This research paper presents the effects of different freshness on the cooking quality of tuna steak. Finding in this research showed primary knowledge of mastering the freshness of raw tuna steak for ensuring the quality of cooked tuna steaks in canned tuna industry.

Effect of integrated community neurology on utilization, diagnostic testing, and access.

Background:The primary care medical home (PCMH) aims to promote delivery of high-value health care. However, growing demand for specialists due to increasingly older adults with complicated and chronic disease necessitates development of novel care models that efficiently incorporate specialty expertise while maintaining coordination and continuity with the PCMH. We describe the effect of a model of integrated community neurology (ICN) on health care utilization, diagnostic testing, and access.Methods:This is a retrospective, matched case-control comparison of patients referred to ICN for a face-to-face consultation over a 12-month period. The control group consisted of propensity score–matched patients referred to a non-colocated neurology practice during the study period. Administrative data were used to assess for diagnostic testing, visit utilization, and patient time to appointment.Results:From October 1, 2014, to September 30, 2015, we identified 459 patients evaluated by ICN for a face-to-face visit and 459 matched controls evaluated by the non-colocated neurology practice. The majority of patients were Caucasian and female. ICN patients had lower odds of EMGs ordered (adjusted odds ratio [OR] 0.64; 95% confidence interval [CI] 0.46–0.89; p = 0.009), MRI brain (adjusted OR 0.60; 95% CI 0.45–0.79; p = 0.0004), or subsequent referral to outpatient neurology (adjusted OR 0.62; 95% CI 0.47–0.83; p = 0.001). ICN was not associated with an increase in emergency department visits, hospitalizations, or appointment wait time.Conclusions:The ICN model in a PCMH has the potential to reduce diagnostic testing and utilization.

Value-based care in hepatology.

The migration from legacy fee-for-service reimbursement to payments linked to high-value health care is accelerating in the United States because of new legislation and redesign of payments from the Centers for Medicare and Medicaid Services. Because patients with chronic diseases account for substantial use of health care resources, payers and health systems are focusing on maximizing the value of care for these patients. Because chronic liver diseases impose a major health burden worldwide affecting the health and lives of many individuals and families as well as substantial costs for individuals and payers, hepatologists must understand how they can improve their practices. Hepatologists practice a high-intensity cognitive subspecialty, using complex and costly procedures and medications. High-value patient care requires multidisciplinary coordination, labor-intensive support for critically ill patients, and effective chronic disease management. Under current fee-for-service reimbursement, patient values, medical success, and financial success can all be misaligned. Many current attempts to link health outcomes to reimbursement are based on compliance with process measures, with less emphasis on outcomes that matter most to patients, thus slowing transformation to higher-value team-based care. Outcome measures that reflect the entire cycle of care are needed to assist both clinicians and administrators in improving the quality and value of care. A comprehensive set of outcome measures for liver diseases is not currently available. Numerous researchers now are attempting to fill this gap by devising and testing outcome indicators and patient-reported outcomes for the major liver conditions. These indicators will provide tools to implement a value-based approach for patients with chronic liver diseases to compare results and value of care between referral centers, to perform health technology assessment, and to guide decision-making processes for health authorities. This review sets the groundwork for implementing a value-based, patient-centered approach to chronic liver diseases within a health system. (Hepatology 2017;65:1749-1755).

Five Organizational Strategies to Deliver High-Value Health Care

Five Organizational Strategies to Deliver High-Value Health Care

Levers for addressing medical underuse and overuse: achieving high-value health care

Levers for addressing medical underuse and overuse: achieving high-value health care

We Can Teach How to Bend the Cost Curve: Lessons in Pediatric High-Value Health Care.

* Abbreviations: PPI — : Prepare, Process, Initiate SOAP-V — : Subjective, Objective, Assessment, Plan, Value “We have really good data that show when you take patients and you really inform them about their choices, patients make more frugal choices. They pick more efficient choices than the health care system does.” Donald Berwick, MD In continuing the series of articles by the Council on Medical Student Education in Pediatrics, we focus on the great clinical teacher’s responsibility to both deliver and explicitly teach about high-value health care. Medical students entering clinical rotations have been introduced to the concept of “too much care” in their coursework, including overdiagnosis, overtreatment, excessive testing, and poor care coordination and communication.1,2 As pediatricians committed to eliminating practices and associated expenditures that are not evidence-based and that lack direct patient benefit, we can improve our clinical teaching skills by making our role-modeling of such behaviors explicit. This paper reviews ways to incorporate teaching about common examples of pediatric care of limited or no value by using accessible teaching tools, such as the Choosing Wisely lists.3 We also introduce 2 efficient teaching aids to help learners incorporate the concept of value into their clinical reasoning and presentations: Prepare, Process, Initiate (PPI), and Subjective, Objective, Assessment, Plan, Value (SOAP-V).4 Despite the modest deceleration in the … Address correspondence to Alison Volpe Holmes, MD, MPH, 1 Medical Center Dr, Rubin 525, Lebanon, NH 03756. E-mail: alison.v.holmes{at}hitchcock.org

Better Evidence to Guide Payment Reforms

While considerable uncertainty exists about the future of health care reform in the United States, interest continues to grow in benefit and payment reforms that support models of care that control costs and improve quality. Despite the large number of reforms being implemented, such as bundled episode payments and per-beneficiary payments to primary care groups and integrated health care organizations, evidence on the effectiveness of these “value-based” financing reforms is mixed and limited,1 leading to ongoing questions about how such reforms affect outcomes and costs in various contexts. This makes it difficult to know which initiatives should be scaled up and which need further refinement or replacement to support a more efficient, high-value health care system.

Costing in Radiology and Health Care: Rationale, Relativity, Rudiments, and Realities.

Costs direct decisions that influence the effectiveness of radiology in the care of patients on a daily basis. Yet many radiologists struggle to harness the power of cost measurement and cost management as a critical path toward establishing their value in patient care. When radiologists cannot articulate their value, they risk losing control over how imaging is delivered and supported. In the United States, recent payment trends directing value-based payments for bundles of care advance the imperative for radiology providers to articulate their value. This begins with the development of an understanding of the providers' own costs, as well as the complex interrelationships and imaging-associated costs of other participants across the imaging value chain. Controlling the costs of imaging necessitates understanding them at a procedural level and quantifying the costs of delivering specific imaging services. Effective product-level costing is dependent on a bottom-up approach, which is supported through recent innovations in time-dependent activity-based costing. Once the costs are understood, they can be managed. Within the high fixed cost and high overhead cost environment of health care provider organizations, stakeholders must understand the implications of misaligned top-down cost management approaches that can both paradoxically shift effort from low-cost workers to much costlier professionals and allocate overhead costs counterproductively. Radiology's engagement across a broad spectrum of care provides an excellent opportunity for radiology providers to take a leading role within the health care organizations to enhance value and margin through principled and effective cost management. Following a discussion of the rationale for measuring costs, this review contextualizes costs from the perspectives of a variety of stakeholders (relativity), discusses core concepts in how costs are classified (rudiments), presents common and improved methods for measuring costs in health care, and discusses how cost management strategies can either improve or hinder high-value health care (realities). © RSNA, 2017 Online supplemental material is available for this article.