Performance-based Reimbursement Research Articles

Money talks: performance-based reimbursement systems impact on perceived work, health and patient care for physicians in Sweden.

The study aimed to investigate in which way performance-based reimbursement (PBR) systems in Swedish healthcare services (1) subjectively impacted physicians' work and patient care and (2) were associated with the occurrence of stress-induced exhaustion disorders among physicians. The study applied a mixed-method design. Data were collected from a representative sample of Swedish physicians. In the questionnaire, respondents were asked to answer an open-ended question regarding their reflections on PBR. The answers to the open-ended question were analysed using thematic analysis. Respondents were also asked to rate the impact of PBR on their work. The association between PBR and self-rated stress-induced exhaustion disease was analysed with logistic regressions. Stress-induced exhaustion disorder was measured using the Burnout Assessment Scale. Thematic analysis resulted in four themes: (1) Money talks, (2) Patients are affected, (3) Medical morals are challenged, and (4) PBR increase the quantity of illegitimate tasks. Logistic regressions showed that physicians who experienced PBR had an impact on their work and had a two-fold higher risk of stress-induced exhaustion disorder. Our findings suggest that current reimbursement systems in Sweden play an essential role in Swedish healthcare and negatively influence physicians' work and health. Also, current PBR impact patients negatively. No previous study has explored the potentially harmful impact of PBR on how physicians perceive work, health and patient care. Results indicate that policymakers should be encouraged to deeply review PBR systems and focus on ways that they can limit the negative impact on physicians' work and health while meeting future challenges.

AMCP Pay-for-Performance Principles: Performance-Based Reimbursement and Direct and Indirect Remuneration (DIR) Fees.

DISCLOSURE: At the direction of its Board of Directors, the AMCP Public Policy and Professional Practice committees developed these principles for pay-for-performance to promote the use of these arrangements that lead to improved patient outcomes. This document was first released on the AMCP website on December 14, 2021.

Drivers of Cost Associated With Minimally Invasive Esophagectomy

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

PCN205 ATEZOLIZUMAB PAY FOR PERFORMANCE MODEL, FOR THE TREATMENT OF PRIVATE PAYER CHILEAN PATIENTS WITH THE DIAGNOSIS OF NON-SMALL CELL LUNG CANCER (NSCLC) & METASTATIC UROTHERIAL CANCER (MUC)

Design a performance-based reimbursement scheme that could benefit the patient population of NSCLC and mUC to estimate the impact on the private payer access for this treatment in Chile. Based on progression-free survival of pivotal clinical trials (OAK & IMvigor211 studies) we developed a model using the probabilistic analysis to maximize patients’ and payers’ benefits within the riskier period of disease progression. Inclusion and exclusion criteria were defined as minimum requirements to start the program. For 2L NSCLC and mUC, the risk is shared between Roche and payers in a 50% scheme, since 50% of patients would relapse within the first 3 months of treatment (first 4 cycles of treatment), according to clinical trials. For the following cycles (5th onwards) to benefit long-term responders, after three cycles of treatment, a free of charge unit will be provided. Performance-based funding is not a uniform intervention, but rather a range of approaches. Its effects depend on the interaction of several variables, including the design of the intervention and characteristics of the healthcare system. In this case, the financial benefit is for the whole healthcare system, because it reduces the risk during the first 4th cycle of treatment and also benefits long-term responders. This model will be expanded to the Chilean public payer in the future.

PCN307 IMPROVING PATIENT ACCESS TO PD-(L)1 THERAPIES IN CHINA: POLICY IMPLICATIONS FROM PREVIOUS NRDL NEGOTIATIONS

China National Healthcare Security Administration (former MoHRSS, the Ministry of Human Resources and Social Security) has conducted two rounds of price negotiation of high-price innovative drugs for National Reimbursement Drug List (NRDL) admission (Short for NRDL negotiation). Upon the opening of 3rd NRDL negotiation in 2019, PD-(L)1s (pembrolizumab, nivolumab, Toripalimab, Sintilimab) are lined up for NRDL admission. This study analyzed the policy implications from previous NRDL negotiations and identified the different determinants for PD-(L)1s negotiation in 2019. Through secondary research, we’ve reviewed and analyzed historical policies and price cuts in previous NRDL negotiations to predict the upcoming admission requirements for PD-(L)1s. We’ve also conducted qualitative interviews with China’s Basic Medical Insurance (BMI) payers to gauge the review process and access barriers for PD-(L)1s in 2019. We identified four determinants for PD-(L)1s NRDL negotiation in 2019: 1) Price cut is compulsory as previous oncology products have cut 53% on average to win NRDL admission (46% in 2017 and 56% in 2018). Price cut will be closely related to PAP (Patient Assistance Programs) net price. 2) Price after negotiation is intended to be the lowest among comparable countries/regions. 3) Submission of pharmaco-economic evidence is increasingly important. Cost-effectiveness and budget impact are two major factors reviewed by BMI payers. 4) BMI budget constraint will drive payers to apply payment restrictions on PD-(L)1s. Performance-based reimbursement, patient subgroup restriction and payment capping on treatment duration or expense are potential factors for PD-(L)1s negotiation. In addition, alternative funding is required imminently to sustain the reimbursement of upcoming PD-(L)1s. An over 50% price reduction is anticipated for PD-(L)1s in 2019 NRDL negotiation. BMI payers might apply payment restrictions to maintain the balance between increasing drug access and ensuring funding sustainability. Need for alternative funding is imminent.

Improving First-Case Start Delays in a Tertiary Care Academic Endoscopy Unit

Increasing emphasis on quality of care, as well as performance-based reimbursement have placed the spotlight on improving healthcare efficiency. As demand for GI procedures continues to increase, resources like physical space and personnel remain unchanged. Despite this, the literature is sparse with regard to improving efficiency in the endoscopy unit. First-case start delay is a known endoscopy efficiency metric. In our study, we look at the impact of implementing a patient check-in protocol on first-case start delays in our hospital-based endoscopy unit. A multidisciplinary team, consisting of endoscopists, anesthesiologists, unit manager, and administrators, was created in August 2018 with a focus on improving efficiency. Our initial goal was to improve first-case start delays. Beginning September 1st 2018, specific pre-procedure assessment end times were assigned to the care team for the first case. Fellows completed assessing the patient thirty minutes prior, nursing fifteen minutes prior, anesthesia ten minutes prior, and the endoscopist five minutes prior to the scheduled start time. First-case start delays, defined as the difference between the in-room and scheduled start times, were measured pre- and post-intervention for five GI faculty endoscopists (study group). Delayed cases were defined as any case with a first-case start delay of ≥5 minutes. The control group consisted of private GI endoscopists and colorectal surgeons, who were not part of the protocol. One hundred data points pre-intervention, and all data points for close to 3 months post-intervention, were collected for the study group. Three months of pre- and post-intervention data was collected for the control group. Statistical comparisons were made using a paired t-test (means) and Fisher’s exact test (proportions). A p-value of <0.05 was considered statistically significant. In the study group, the average first-case start delay was 19 minutes pre-intervention. This decreased significantly to 6 minutes post-intervention (p<0.001). In the control group, the average delay was 18 minutes pre-intervention and 19 minutes post-intervention. For the study group, on-time starts increased significantly from 13% to 45%, while delayed cases decreased significantly from 69% to 20% (p<0.001) post-intervention. In the control group, on-time starts remained at 20% pre- and post-intervention, while delayed cases increased from 67.5% to 80%. A standardized pre-procedure process resulted in significant reductions in first-case start delays in our endoscopy unit. This study highlights the use of multidisciplinary teams and the feasibility of implementing simple interventions that can have dramatic effects on endoscopy unit efficiency. It also illustrates the importance of establishing and monitoring reliable efficiency metrics in endoscopy.

Understanding Patient Safety and Quality Outcome Data.

The need for nurses to understand patient safety and quality outcome data is pressing in the current era of data transparency. Health care outcomes data are now publicly reported and readily accessible to consumers, are necessary for performance-based reimbursement, and are required by government and regulatory agencies. In order for nurses at all levels of practice to own their outcomes and be accountable for making improvements, they must possess skills in collecting, analyzing, evaluating, and acting on outcome data. This article provides basic tools and clinical examples for nurses to use in a focused application of outcome data and a structured process for improving nursing care outcomes.

PHP364 - HOW TO USE RWE TO OPTIMIZE P&R OF NEW HEALTH TECHNOLOGIES

Utilizing real world evidence (RWE) of disease burden and performance of technologies in clinical practice settings is increasingly a focus of the healthcare industry. However, the willingness and ability to use RWE in reimbursement decision-making varies significantly. This research aims to classify major national payers into archetypes based on their use of RWE in decision-making. Publically-available information on payer processes were screened from the relevant websites for UK (NICE), Germany (G-BA), France (HAS), Sweden (TLV), Australia (PBAC), Canada (CADTH) and Italy (AIFA) alongside a targeted search of appraisal outcomes for how RWE has been used. RWE has been used by payers to quantify the unmet need (all), support economic modelling (NICE, TLV, PBAC, CADTH) and/or validate the clinical benefit of a new technology. Some markets have regular HTA re-assessments (HAS) or produce time-limited outcomes (G-BA and NICE[CDF]) where local RWE on clinical benefits can be submitted. Reimbursement can also be linked to patient outcomes using RWE (AIFA [Onco registry], NICE [complex PASs] and PBAC [Managed Entry Schemes]). Few specific examples were identified where RWE directly supported favourable P&R outcomes. No RWE had been used in G-BA assessments, no HAS re-assessments using RWE had increased its ASMR, no drugs have completed the CDF [NICE] and MES [PBAC] processes, and a recent report of AIFA performance-based reimbursement concluded it only produced drug budget savings of 3%. Evidence of RWE directly supporting favorable reimbursement is limited to date. However, payer systems are evolving to better facilitate this. Utilizing RWE to support optimal reimbursement will necessitate a global evidence generation strategy as well as specific local implementation tactics to navigate local requirements. However, archetyping payers by RWE demands can enable a better-focused evidence generation strategy to optimize commercial success.

PHP219 - Commercialising Regenerative Medicines in the US – What Lessons can We Learn from Europe?

In November 2017, the Food and Drugs Administration (FDA) announced a new regulatory framework for Regenerative Medicine Advanced Therapies (RMATs). In Europe, a similar regulatory framework has existed for Advanced Therapy Medicinal Products (ATMPs) since 2007. This research assesses the regulatory and commercial success of ATMPs and discusses their implications for RMATs in USA. European Commission (EC)-approved ATMPs were identified alongside their current FDA/EMA regulatory and reimbursement status in UK, Italy, and Germany from relevant regulatory/Health Technology Assessment (HTA) websites plus a targeted review of relevant company press releases (to 12/21/2017). Nine ATMPs have received EC-approvals but only 3/9 were FDA-approved (one [Provenge®] subsequently withdrawn). The first four EC-approved ATMPs (ChondroCelect®, Glybera®, MACI®, Provenge®) have all been withdrawn for commercial reasons after an average of 3.5 years on market (range: 1-7 years). Most notably, Glybera®, the first EC-approved gene therapy (2012) priced at >€1 million/patient, was withdrawn in 2017 having reported only one commercial sale in 2016. Five others (Holoclar®, Imlygic®, Strimvelis®, Zalmoxis®, Spherox®) have been EC-approved since 2015. There are limited HTA appraisals of these to date, only Strimvelis® (the second EC-approved gene therapy) receiving >1 positive appraisal (AIFA and NICE). Nevertheless, only in March 2017, did Strimvelis® receive its first commercial sale, despite being EC-approved since May 2016 with a 100% refund performance-based reimbursement scheme. Only nine ATMPs have EC-approved in the decade since this regulatory framework was introduced but most of these approved therapies did not achieve FDA-approval. Nevertheless, the first four EC-approved ATMPs have been withdrawn from market for commercial reasons. Although in the US, regulatory approval typically forms the primary hurdle to patient access (unlike Europe where it is reimbursement) the FDA-withdrawal of Provenge® for commercial reasons, emphasizes the magnitude of the commercial challenges facing such therapies in the US.

Stakeholder perspectives regarding transfer of free maternity services to National Health Insurance Fund in Kenya: Implications for universal health coverage.

Kenya is developing strategies to finance health care through prepayment to achieve universal health coverage (UHC). Plans to transfer free maternity services (FMS) from the Ministry of Health to the National Health Insurance Fund (NHIF) are a step towards UHC. We examined views of health workers and women regarding the transition of FMS to NHIF to inform the process. In-depth interviews among 14 facility-level managers and providers, 11 county-level managers, and 21 focus group discussions with women who gave birth before and after the introduction of FMS. Data were analyzed thematically. The transfer is a mechanism of achieving UHC, eliminating dependency on free services, and encouraging people to take responsibility of their health. However, skepticism regarding the efficiency of NHIF may limit support. Diverse and robust systems were recommended for enrollment of clients while standardization of services through accreditation and quality assurance linked to performance-based reimbursement would improve greater predictability in the payment schedule and better coverage of referrals and complications. Transitioning FMS to NHIF provides an opportunity for the Ministry of Health to sharpen its role as policymaker and develop a comprehensive health care financing strategy for the country towards achieving UHC.

PCPI Helps Organizations Produce Clinically Valid Quality Measures

PCPI Helps Organizations Produce Clinically Valid Quality Measures

Establishing the cost of implementing a performance-based, managed entry agreement for a hypothetical CAR T-cell therapy

ABSTRACTBackground: Market access stakeholders consider the adoption of Managed Entry Agreements (MEAs), however a clearly described methodology to quantify their implementation burden is not available in the public domain.Objective: To quantify the cost of implementing a performance-based MEA at the hospital level.Methods: The analysis involved a hypothetical one-off therapy targeting Acute Lymphoblastic Leukaemia. Data collection from five NHS Hospital Trusts in England captured costs by task, job band, personnel time and capital investment. We compared the administrative burden of the standard of care (SoC) to that of adopting the therapy with or without an MEA over 10 years.Findings: The 10-year cost for the activities required to support hospital payments for the target patient population in England varied as follows: for the SoC was £447,353, compared to £1,117,024 for the novel therapy with MEA, and £245,317 without MEA.Conclusions: The higher cost associated with the SoC compared to the novel therapy without an MEA, arises from the higher frequency of infusions requiring payments and the associated mandatory data capturing requirements for oncology therapies. The novel therapy with MEA presents the greatest burden due to increased frequency of monitoring in year one to compensate for the greater uncertainty in clinical data and to inform the performance-based reimbursement.

Innovative Pricing and Reimbursement Schemes – The What, Why, Which, and How

We are at the advent of a new era of therapies which offer potential transformative/curative patient benefits in areas of severe unmet need after a single treatment (e.g. CAR-T cell and gene therapies). These offer the potential for significant healthcare system savings through reduced medium/long-term costs of patient care, but are likely to come at a substantial acquisition cost (per patient costs estimated to exceed $500,000). In the traditional approach for medicine reimbursement, payers are purchasing health care (e.g. treatment for disease) rather than health (e.g. extended life expectancy). For such transformative therapies this would mean a substantial upfront investment from healthcare payers alongside the significant risk that real-world patients do not obtain the expected benefits, especially as many will likely be approved on early clinical data through expedited regulatory pathways. Therefore, there has been a move towards exploring innovative types of reimbursement, including leasing, performance-based reimbursement, budgetary caps and dynamic pricing. These schemes can offer means for payers and manufacturers to agree coverage by sharing risks and managing affordability but they also involve additional complexity and costs in terms of management and administration. Each of these schemes offers distinct opportunities and risks for both manufacturers and payers with the simpler ones (e.g. budgetary caps) being cruder in how they manage risk/payment but being relatively simple to administer and the more complex ones (e.g. performance-based reimbursement and leasing) being potentially fairer in managing risk/payment but this may be outweighed by the associated complexities/costs. Indeed, there have been some notable examples of where such complexities have fatally undermined such schemes (the UK Multiple Sclerosis Risk Sharing Scheme and Conditional Financing in the Netherlands). There will not likely be a best-in-class scheme but different ones will be utilised depending on the health system infrastructure and the specific therapy, manufacturer and patient population.

An Analysis of Quality Measures in Diagnostic Radiology with Suggestions for Future Advancement

Radiology in the United States of America is evolving from a fee-for-service to a value-based, “pay-for-performance” system. Such a system requires objective measures, termed metrics, to grade performance. Current grading systems in health care, not designed with the unique nature of radiology in mind, often emphasize patient outcomes; this can be a challenge for measuring and grading performance in radiology, which is often several steps removed from patient outcome. At the present, while there are hundreds of individual radiology-specific metrics, there is no widely accepted overall standard for quality or value in diagnostic radiology services. This article analyzes the current system of radiology metrics and suggests a new direction for performance-based reimbursement in diagnostic radiology, focusing on a limited number of reasonably measurable outcomes-related factors that are specific to radiology.

Influence of Patient Goals of Care on Performance Measures in Patients Hospitalized for Heart Failure: An Analysis of the Enhanced Feedback For Effective Cardiac Treatment (EFFECT) Registry.

Pay for performance programs compare metrics that are risk-adjusted, but goals of care are not considered in current models. We conducted this study to explore the associations between do not resuscitate (DNR) designations, quality of care, and outcomes. Retrospective cohort study with chart review for inpatient quality metrics, 30 day mortality, and readmissions or death within 30 days of discharge in 96 Ontario hospitals participating in the Enhanced Feedback For Effective Cardiac Treatment (EFFECT) study in 2004/05. Of 8339 patients (mean age 77 years) with new heart failure, 1220 (15%) had DNR documented at admission (admission DNR, varying from 0% to 36% between hospitals) and 892 (11%) were switched from full resuscitation to DNR during their index hospitalization (later DNR). Death at 30 days was more common in patients with admission DNR (27%) or later DNR (35%) than full resuscitation (3%)-admission DNR was a stronger predictor (adjusted OR 8.6, 95% confidence interval 6.8-10.7) than any of the variables currently included in heart failure 30 day mortality risk models. Hospital-level rankings differed considerably if DNR patients were excluded: 22 of the 39 EFFECT hospitals in the top and bottom quintiles for 30 day mortality rates (the usual thresholds for rewards/penalties in current performance-based reimbursement schemes) would not have been in those same quintiles if admission DNR patients were excluded. Alternate goals of care are frequent and important confounders in heart failure comparative studies. Philosophy of care discussions should be considered for inclusion as a potential quality of care indicator.

Crowd-Sourced Assessment of Technical Skills: Differentiating Animate Surgical Skill Through the Wisdom of Crowds.

Objective quantification of surgical skill is imperative as we enter a healthcare environment of quality improvement and performance-based reimbursement. The gold standard tools are infrequently used due to time-intensiveness, cost inefficiency, and lack of standard practices. We hypothesized that valid performance scores of surgical skill can be obtained through crowdsourcing. Twelve surgeons of varying robotic surgical experience performed live porcine robot-assisted urinary bladder closures. Blinded video-recorded performances were scored by expert surgeon graders and by Amazon's Mechanical Turk crowdsourcing crowd workers using the Global Evaluative Assessment of Robotic Skills tool assessing five technical skills domains. Seven expert graders and 50 unique Mechanical Turkers (each paid $0.75/survey) evaluated each video. Global assessment scores were analyzed for correlation and agreement. Six hundred Mechanical Turkers completed the surveys in less than 5 hours, while seven surgeon graders took 14 days. The duration of video clips ranged from 2 to 11 minutes. The correlation coefficient between the Turkers' and expert graders' scores was 0.95 and Cronbach's Alpha was 0.93. Inter-rater reliability among the surgeon graders was 0.89. Crowdsourcing surgical skills assessment yielded rapid inexpensive agreement with global performance scores given by expert surgeon graders. The crowdsourcing method may provide surgical educators and medical institutions with a boundless number of procedural skills assessors to efficiently quantify technical skills for use in trainee advancement and hospital quality improvement.

Cost-Quality Tradeoff in Healthcare: Does it Affect Patient Experience?

This study empirically investigates the effect of cost and average length of stay on experiential quality in healthcare. The author uses aggregate level data from 245 acute care hospitals operating in the state of California and performs ordinary least squares regression to test his hypotheses. Supporting the classic theory on cost-quality tradeoff, results show that hospitals do have a tradeoff between cost efficiency and experiential quality. Further, the author finds that hospitals with a higher average length of stay rate have, on average, lower experiential quality. In light of the recent move by Medicare to performance-based reimbursement, the author's results provide key insights to hospital administrators regarding cost-quality tradeoff and the tradeoff between achieving clinical quality and experiential quality outcomes.

Patient characteristics associated with multiple pharmacy use in the U.S. population: Findings from the Medical Expenditure Panel Survey.

Multiple pharmacy use (MPU) is an important safety and quality issue, as it results in fragmented patient care. However, few studies have examined patient characteristics predicting the use of multiple pharmacies, and the findings have been inconsistent. To identify patient characteristics associated with MPU using national data. Data were obtained from the 2011 U.S. Medical Expenditure Panel Survey. The dependent variable was MPU, or the use of more than one pharmacy. The Andersen Behavioral Model of Health Service Use was used to guide the selection of independent variables, which were categorized as predisposing, enabling, and medical need related characteristics. Multivariable logistic regression analysis was conducted to identify the relationships between predisposing, enabling, and need variables and MPU in a hierarchical fashion. Point estimates were weighted to the U.S. non-institutionalized population, and to adjust standard errors to account for the complex survey design. MPU was common, with a national prevalence of 41.3%. Individuals aged 40-64 and adults 65 and older were significantly less likely to use multiple pharmacies as patients aged 18-39 years (40-64 years OR: 0.67, CI: 0.58-0.77; ≥65 years OR: 0.49, CI: 0.41-0.58). Females were significantly more likely to use multiple pharmacies than males (OR: 1.16, CI: 1.05-1.29). Individuals lacking health insurance were more likely to use multiple pharmacies as individuals with private health insurance (OR: 1.42, CI: 1.16-1.73); in contrast, individuals having drug insurance were more likely to use multiple pharmacies (OR: 1.25, CI: 1.06-1.47) relative to those without drug insurance. Any mail order use was the strongest predictor of MPU (OR: 6.94, CI: 5.90-8.18). Pharmacists and other health care providers need to be aware that their patients may be using multiple pharmacies, especially younger patients, those lacking access to health insurance, or those using mail order pharmacies. The findings from this study can be used to identify patients that may need additional monitoring to ensure safe and appropriate drug therapy, and has important implications as health care continues to shift toward performance-based reimbursement and quality ratings.

Project BOOST: Effectiveness of a multihospital effort to reduce rehospitalization

Rehospitalization is a prominent target for healthcare quality improvement and performance-based reimbursement. The generalizability of existing evidence on best practices is unknown. To determine the effect of Project BOOST (Better Outcomes for Older adults through Safe Transitions) on rehospitalization rates and length of stay. Semicontrolled pre-post study. Volunteer sample of 11 hospitals varying in geography, size, and academic affiliation. Hospitals implemented Project BOOST-recommended tools supported by an external quality improvement physician mentor. Pre-post changes in readmission rates and length of stay within BOOST units, and between BOOST units and site-designated control units. The average rate of 30-day rehospitalization in BOOST units was 14.7% prior to implementation and 12.7% 12 months later (P = 0.010), reflecting an absolute reduction of 2% and a relative reduction of 13.6%. Rehospitalization rates for matched control units were 14.0% in the preintervention period and 14.1% in the postintervention period (P = 0.831). The mean absolute reduction in readmission rates in BOOST units compared to control units was 2.0% (P = 0.054 for signed rank test comparing differences in readmission rate reduction in BOOST units compared to site-matched control units). Participation in Project BOOST appeared to be associated with a decrease in readmission rates.

Reducing 30-Day Rehospitalization

Letters7 February 2012Reducing 30-Day RehospitalizationLuke O. Hansen, MD, MHS and Mark V. Williams, MDLuke O. Hansen, MD, MHSFrom Northwestern University Feinberg School of Medicine, Chicago, IL 60611.Search for more papers by this author and Mark V. Williams, MDFrom Northwestern University Feinberg School of Medicine, Chicago, IL 60611.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-156-3-201202070-00027 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail IN RESPONSE:We agree with Dr. Sandy that thoughtful attention to care transitions will often result in lower readmission rates, with process change supported by some of the interventions we reviewed as well as a culture shift to more safety awareness at discharge. However, these improvements are unlikely to be experienced by all hospitals. The key question for performance-based reimbursement tied to the readmission outcome is whether hospitals that demonstrate themselves to be laggards fall short because of factors that are or are not under their control.Many of the reports of success are observational, and we lack a robust ...Reference1. Kansagara D, Englander H, Salanitro A, Kagen D, Theobald C, Freeman M, et al. Risk prediction models for hospital readmission: a systematic review. JAMA. 2011;306:1688-98. [PMID: 22009101] CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAffiliations: From Northwestern University Feinberg School of Medicine, Chicago, IL 60611.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-1422. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoInterventions to Reduce 30-Day Rehospitalization: A Systematic Review Luke O. Hansen , Robert S. Young , Keiki Hinami , Alicia Leung , and Mark V. Williams Reducing 30-Day Rehospitalization Lewis G. Sandy Reducing 30-Day Rehospitalization Azeem Majeed Metrics 7 February 2012Volume 156, Issue 3Page: 252KeywordsFearHealth careInpatientsMedicareMotivationOutpatientsPrevention, policy, and public healthResearch fundingSafetySocial welfare ePublished: 7 February 2012 Issue Published: 7 February 2012 Copyright & PermissionsCopyright © 2012 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...