High-value Health Research Articles

WITHDRAWN: Revisions to the ICD-10-CM Code Set for Aortic Aneurysms and Dissection Can Advance Clinical Research, Outcomes Reporting, and High-Value Health Care Delivery

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal

Advancing Healthcare Reform: The American Heart Association's 2020 Statement of Principles for Adequate, Accessible, and Affordable Health Care: A Presidential Advisory From the American Heart Association.

The mission of the American Heart Association is to be a relentless force for a world of longer, healthier lives. The American Heart Association has consistently prioritized the needs and perspective of the patient in taking positions on healthcare reform while recognizing the importance of biomedical research, providers, and healthcare delivery systems in advancing the care of patients and the prevention of disease. The American Heart Association's vision for healthcare reform describes the foundational changes needed for the health system to serve the best interests of patients and to achieve health care and coverage that are adequate, accessible, and affordable for everyone living in the United States. The American Heart Association is committed to advancing the dialogue around healthcare reform and has prepared this updated statement of our principles, placed in the context of the advances in coverage and care that have occurred after the passage of the Affordable Care Act, the rapidly changing landscape of healthcare delivery systems, and our evolving recognition that efforts to prevent cardiovascular disease can have synergistic benefit in preventing other diseases and improving overall well-being. These updated principles focus on expanding access to affordable health care and coverage; enhancing the availability of evidence-based preventive services; eliminating disparities that limit the availability and equitable delivery of health care; strengthening the public health infrastructure to respond to social determinants of health; prioritizing and accelerating investments in biomedical research; and growing a diverse, culturally competent health and healthcare workforce prepared to meet the challenges of delivering high-value health care.

Unpacking Medical Students’ Mixed Engagement in Health Systems Science Education

Phenomenon: Medical education is better aligning with the needs of health systems. Health systems science competencies, such as high-value care, population health, and systems thinking, are increasingly being integrated into curricula, but not without challenges. One challenge is mixed receptivity by students, the underlying reasons of which have not been extensively explored. In this qualitative study, we explored the research question: “How do students perceive health systems science curricula across all four years, and how do such perceptions inform the reasons for mixed quality ratings?” Approach: Following large-scale health systems science curricular changes in their medical school, we used students’ open-ended comments obtained from course evaluations related to 1st-, 2nd-, and 4th-year courses and performed a qualitative thematic analysis to explore students’ perceptions. We identified themes, synthesized findings into a conceptual figure, and agreed upon results and quotations. Findings: Five themes were identified: (1) perceived importance and relevance of health systems science education, (2) tension between traditional and evolving health systems science-related professional identity, (3) dissatisfaction with redundancy of topics, (4) competition with basic and clinical science curricula, and, (5) preference for discrete, usable, testable facts over complexity and uncertainty. The relationship between themes is described along a continuum of competing agendas between students’ traditional mindset (which focuses on basic/clinical science) and an emerging medical education approach (which focuses on basic, clinical, and health systems science). Insights: Health systems science education can be viewed by learners as peripheral to their future practice and not aligned with a professional identity that places emphasis on basic and clinical science topics. For some students, this traditional identity limits engagement in health systems science curricula. If health systems science is to achieve its full potential in medical education, further work is required to explore the adoption of new perspectives by students and create activities to accelerate the process.

How to Implement High-Value Health Care Training in Graduate Medical Education.

How to Implement High-Value Health Care Training in Graduate Medical Education.

HIGH-PERFORMING PRIMARY CARE RESIDENCY CLINICS: A COLLABORATION

Primary care is essential to the functioning of a high-value health system. It helps achieve the Triple Aim: improved health care experience, improved health of the population, at decreased overall cost. However, primary care practice is challenging. Many residents and medical students see

Not the Last Word: High-value Health Care and the Assassination of George Washington.

Not the Last Word: High-value Health Care and the Assassination of George Washington.

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.

Lactic Fermentation as a Strategy to Improve the Nutritional and Functional Values of Pseudocereals.

One of the greatest challenges is to reduce malnutrition worldwide while promoting sustainable agricultural and food systems. This is a daunting task due to the constant growth of the population and the increasing demands by consumers for functional foods with higher nutritional values. Cereal grains are the most important dietary energy source globally; wheat, rice, and maize currently provide about half of the dietary energy source of humankind. In addition, the increase of celiac patients worldwide has motivated the development of gluten-free foods using alternative flour types to wheat such as rice, corn, cassava, soybean, and pseudocereals (amaranth, quinoa, and buckwheat). Amaranth and quinoa have been cultivated since ancient times and were two of the major crops of the Pre-Colombian cultures in Latin- America. In recent years and due to their well-known high nutritional value and potential health benefits, these pseudocereals have received much attention as ideal candidates for gluten-free products. The importance of exploiting these grains for the elaboration of healthy and nutritious foods has forced food producers to develop novel adequate strategies for their processing. Fermentation is one of the most antique and economical methods of producing and preserving foods and can be easily employed for cereal processing. The nutritional and functional quality of pseudocereals can be improved by fermentation using Lactic Acid Bacteria (LAB). This review provides an overview on pseudocereal fermentation by LAB emphasizing the capacity of these bacteria to decrease antinutritional factors such as phytic acid, increase the functional value of phytochemicals such as phenolic compounds, and produce nutritional ingredients such as B-group vitamins. The numerous beneficial effects of lactic fermentation of pseudocereals can be exploited to design novel and healthier foods or grain ingredients destined to general population and especially to patients with coeliac disease.

Flowering, Fruiting Behavior and Nutritional Quality of Selected Guava Genotypes

Guava is one of the most important commercial fruit crop in Bangladesh due to its high nutrient value, good taste and high health benefits. This study was conducted to investigate the flowering, fruiting behavior and nutritional quality of guava genotype suitable for coastal region of Bangladesh. Fifteen genotypes (PG 01 to PG 15) having satisfactory growth were selected for this study. One branch was randomly selected in each direction (North, South, East and West) to collect field data from each plant. Among the genotypes, the highest percentage (87.62%) of fruit setting and the maximum time (115.8 days) required for fruit maturation were recorded from PG 13 and PG 14, respectively. The PG 12 had the highest fruit weight (312.6 g) and the longest fruit (9.34 cm), whereas the highest diameter (26.28 cm) of fruit was recorded in PG 06. The maximum numbers of seeds (411.20) were counted from PG 10 whereas no seed was obtained in the PG 01 and PG 02. Maximum anthocyanin (0.17 mg/100 g FW), lowest pH (3.31), maximum vitamin C content (91.25 mg/ 100g FW), total sugar (6.56 %) and TSS (5.19 oBrix) were also recorded in the seedless genotype (PG 01). Moreover, the quality characteristics, pulp percentage of seedless genotype (PG 01 and PG 02) was comparatively higher than the other genotypes. The genotypes PG 01 and PG 02 have shown important pomological traits for further study, variety improvement and selection as new variety.

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.

The genomes of pecan and Chinese hickory provide insights into Carya evolution and nut nutrition.

BackgroundPecan (Carya illinoinensis) and Chinese hickory (C. cathayensis) are important commercially cultivated nut trees in the genus Carya (Juglandaceae), with high nutritional value and substantial health benefits.ResultsWe obtained >187.22 and 178.87 gigabases of sequence, and ∼288× and 248× genome coverage, to a pecan cultivar (“Pawnee”) and a domesticated Chinese hickory landrace (ZAFU-1), respectively. The total assembly size is 651.31 megabases (Mb) for pecan and 706.43 Mb for Chinese hickory. Two genome duplication events before the divergence from walnut were found in these species. Gene family analysis highlighted key genes in biotic and abiotic tolerance, oil, polyphenols, essential amino acids, and B vitamins. Further analyses of reduced-coverage genome sequences of 16 Carya and 2 Juglans species provide additional phylogenetic perspective on crop wild relatives.ConclusionsCooperative characterization of these valuable resources provides a window to their evolutionary development and a valuable foundation for future crop improvement.

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.

Olive Oil Effects on Colorectal Cancer.

Colorectal cancer is the fourth cause of cancer-related death worldwide. A Mediterranean diet showed protective action against colorectal cancer due to the intake of different substances. Olive oil is a fundamental component of the Mediterranean diet. Olive oil is rich in high-value health compounds (such as monounsaturated free fatty acids, squalene, phytosterols, and phenols). Phenolic compounds exert favourable effects on free radicals, inflammation, gut microbiota, and carcinogenesis. The interaction between gut microbiota and olive oil consumption could modulate colonic microbial composition or activity, with a possible role in cancer prevention. Gut microbiota is able to degrade some substances found in olive oil, producing active metabolites with chemopreventive action. Further clinical research is needed to clarify the beneficial effects of olive oil and its components. A better knowledge of the compounds found in olive oil could lead to the development of nutritional supplements or chemotherapeutic agents with a potential in the prevention and treatment of colorectal cancer.

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.

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.

Process standardization and development of honey based aonla (Phyllanthus emblica) candy

The present investigation focuses on standardization the process for preparation of aonla candy using honey. Further, sugar was completely replaced with honey. It can be concluded that honey syrup concentration treatments (45°Bx, 50°Bx and 70°Bx) along with 02 per cent alum was found to be suitable to improve the quality of candy. Moreover, cabinet tray drying (60°C) was selected on the basis of chemical composition and organoleptic evaluation for commercial feasibility. Eventually, the prepared candies can be properly stored in standing pouch upto 02 to 03 months without affecting their sensory quality attributes. This honey based aonla candy is nutraceutical rich product that have high energy value and additional health benefits. Therefore, the developed aonla candies can be one of the upcoming value added food products. They may have a good commercial market and subject to catch attention of customers of every age group.

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.