Risk-adjusted Approach Research Articles

The Challenges of Aortic Valve Management After Left Ventricular Assist Device Implantation

BackgroundContinuous retrograde flow across the aortic valve from left ventricular assist device (LVAD) therapy can result in cusp damage and progressive aortic regurgitation, potentially triggering recurrent heart and multiorgan failure. The management of aortic regurgitation after LVAD implantation has not been well defined. MethodsThis study retrospectively reviewed the investigators’ experience with the management of de novo aortic regurgitation requiring intervention in patients with continuous-flow LVAD. ResultsSix patients who had undergone LVAD implantation and who required intervention were identified. Two patients underwent redo sternotomy with bioprosthetic aortic valve replacement, and 4 patients underwent percutaneous management, including Amplatzer device (Abbott) placement and transcatheter aortic valve replacement. All patients had resolution of aortic regurgitation with improved hemodynamics and relief from heart failure. One early and 2 late deaths occurred. Valve function was intact, with all valves opening intermittently without greater than trivial aortic regurgitation. ConclusionsMultiple treatment modalities exist for LVAD-induced aortic valve regurgitation, including open surgical and percutaneous strategies. With a tailored risk-adjusted approach, acceptable results may be achieved.

Time trends of Part D drug expenses and Part D risk adjustment in the Oncology Care Model at a community oncology network.

72 Background: The Oncology Care Model (OCM) was a 6-year Medicare value-based care (VBC) program that rewarded practices for providing high-quality cancer care to Medicare beneficiaries receiving system anti-cancer therapy, while decreasing Total Cost of Care (TCOC) compared to a benchmark price. TCOC in the model was driven by drug expenses and included both physician-administered (Part B) and prescription (Part D) medications. The past decade has seen several novel oral anti-cancer drugs revolutionize cancer treatment. The impact of the shift to oral anti-cancer drugs, the associated costs, and risk adjustments in the OCM is studied here. Methods: Using Medicare episodes data for 15 practices in The US Oncology Network (The Network) participating in the OCM, we evaluated the time trends of Part D drug expenses between July 2016 and June 2022, assessed the risk adjustment for episodes with and without Part D, and studied impacts on TCOC & benchmark prices. Results: Mean per episode spending at The Network practices increased 16.4% (3.4% CAGR) driven by a mean Part D expense per episode increase of 59% (8% CAGR) from 2016 ($5,532) to 2022 ($8,796) for OCM beneficiaries. Much of the increase was led by the approval of new oral cancer medications, cost increases on legacy oral medications, and expanded indications for oral medications in various cancer diagnoses. Mean Part D expenses increased 46.5% for Multiple Myeloma, 68.7% for Chronic Leukemia, and 124.2% for Breast Cancers. The OCM risk adjustment methodology used to determine baseline and benchmark prices includes a Part D risk adjuster that applies to patients with Part D coverage (with and without low-income subsidy eligibility) during the episode. The Part D risk adjuster increased the episode benchmark on an average by 5.1% ($2,112) (range between 2.9% ($850) in 2016, and 6.1% ($2,500) in 2022)), less than the actual increased Part D episode expenses. 81.4% of episodes in the OCM had Part D coverage that ranges between practices: 66% to 88.6%. Variation in Part D coverage between practices translates to variable impact of Part D risk adjustment in the OCM. Conclusions: Novel drugs, cost increases and newer indications for oral anti-cancer medications have translated into higher Part D spending for patients with cancer. Part D risk adjusters alone did not proportionately adjust benchmarks for increased Part D spending, disproportionately affecting those practices with higher Part D coverage. A modified risk adjustment approach for Part D is needed in TCOC VBC programs to account for variations in Part D coverage and increases in Part D expenses.

The reliability and validity of lung cancer and melanoma clinical quality survival measures.

To develop a risk adjustment approach and test reliability and validity for oncology survival measures. We used the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER)-Medicare data from 2010 to 2013, with mortality data through 2015. We developed 2-year risk-standardized survival rates (RSSR) for melanoma, non-small cell lung cancer (NSCLC), and small cell lung cancer (SCLC). Patients were attributed to group practices based on the plurality of visits. We identified the risk-adjustment variables via bootstrap and calculated the RSSRs. Reliability was tested via three approaches: (1) signal-to-noise ratio (SNR) reliability, (2) split-half, and (3) test-retest using bootstrap. We tested known group validity by stage at diagnosis using Cohen's d. We selected all patients enrolled in Medicare and linked to SEER during the measurement period with an incident first primary diagnosis of stage I-IV melanoma, NSCLC, or SCLC. We excluded patients with missing data on month and/or stage of diagnosis. Results are based on patients with melanoma (n = 4344); NSCLC (n = 16,080); and SCLC (n = 2807) diagnosed between 2012 and 2013. The median (interquartile range) for the RSSRs at the group practice-level were 0.89 (0.83-0.87) for melanoma, 0.37 (0.30-0.43) for NSCLC, and 0.19 (0.11-0.25) for SCLC. C-statistics for the models ranged from 0.725 to 0.825. The reliability varied by approach with median SNR 0.20, 0.25, and 0.13; median test-retest 0.59, 0.57, and 0.56; median split-half reliability 0.21, 0.29, and 0.29 for melanoma, NSCLC, and SCLC, respectively. Cohen's d for stage I-IIIa and IIIb+ was 1.27, 0.86, 0.60 for melanoma, NSCLC, and SCLC, respectively. Our results suggest that these cancer survival measures demonstrated adequate test-retest reliability and expected findings for the known-group validity analysis. If data limitations and feasibility challenges can be addressed, implementation of these quality measures may provide a survival metric used for oncology quality improvement efforts.

Best Current Practice and Research Priorities in Active Surveillance for Prostate Cancer—A Report of a Movember International Consensus Meeting

BackgroundActive surveillance (AS) is recommended for low-risk and some intermediate-risk prostate cancer. Uptake and practice of AS vary significantly across different settings, as does the experience of surveillance—from which tests are offered, and to the levels of psychological support. ObjectiveTo explore the current best practice and determine the most important research priorities in AS for prostate cancer. Design, setting, and participantsA formal consensus process was followed, with an international expert panel of purposively sampled participants across a range of health care professionals and researchers, and those with lived experience of prostate cancer. Statements regarding the practice of AS and potential research priorities spanning the patient journey from surveillance to initiating treatment were developed. Outcome measurements and statistical analysisPanel members scored each statement on a Likert scale. The group median score and measure of consensus were presented to participants prior to discussion and rescoring at panel meetings. Current best practice and future research priorities were identified, agreed upon, and finally ranked by panel members. Results and limitationsThere was consensus agreement that best practice includes the use of high-quality magnetic resonance imaging (MRI), which allows digital rectal examination (DRE) to be omitted, that repeat standard biopsy can be omitted when MRI and prostate-specific antigen (PSA) kinetics are stable, and that changes in PSA or DRE should prompt MRI ± biopsy rather than immediate active treatment. The highest ranked research priority was a dynamic, risk-adjusted AS approach, reducing testing for those at the least risk of progression. Improving the tests used in surveillance, ensuring equity of access and experience across different patients and settings, and improving information and communication between and within clinicians and patients were also high priorities. Limitations include the use of a limited number of panel members for practical reasons. ConclusionsThe current best practice in AS includes the use of high-quality MRI to avoid DRE and as the first assessment for changes in PSA, with omission of repeat standard biopsy when PSA and MRI are stable. Development of a robust, dynamic, risk-adapted approach to surveillance is the highest research priority in AS for prostate cancer. Patient summaryA diverse group of experts in active surveillance, including a broad range of health care professionals and researchers and those with lived experience of prostate cancer, agreed that best practice includes the use of high-quality magnetic resonance imaging, which can allow digital rectal examination and some biopsies to be omitted. The highest research priority in active surveillance research was identified as the development of a dynamic, risk-adjusted approach.

Anatomy of the optic radiations from the white matter fiber dissection perspective: A literature review applied to practical anatomical dissection.

Background: Knowledge of the anatomical course of the optic radiations and its relationship to medial temporal lobe structures is of great relevance in preoperative planning for surgery involving the temporal lobe to prevent damage that may result in postsurgical visual field deficits.Methods: In this anatomical study, we reviewed the literature on this topic and applied the information to practical anatomical dissection. The three-dimensional relationship between the course of the optic radiations and structures accessed in the main microneurosurgical approaches to the medial temporal lobe was examined by applying Klingler’s white matter fiber dissection technique to five formalin-fixed human brains. The dissections were performed with an operating microscope at magnifications of ×3–×40. High-resolution images were acquired during dissection for identification of the anatomical structures, focusing on the characterization of the course of the optic radiations in relation to medial temporal lobe structures.Results: In all five dissected brains, we could expose and clearly define the relationship between the optic radiations and medial temporal lobe structures, improving our understanding of these complex structures.Conclusion: The knowledge gained by studying these relationships will help neurosurgeons to develop risk-adjusted approaches to prevent damage to the optic radiations in the medial temporal region, which may result in a disabling visual field deficit.

“This pandemic has changed our daily living”: Young adults’ leisure experiences during the COVID-19 pandemic in South Africa

ABSTRACT The COVID-19 pandemic is a global human ecosystem disruption affecting almost every facet of daily living. South Africa adopted a risk-adjusted approach comprising five-levels to curb the spread of COVID-19. Early in 2020, the country experienced level 5 and 4 restrictions, indicating high COVID-19 spread with low to moderate health system readiness. South Africans were largely confined to their homes. This study explored young adults’ experiences of leisure engagement during the confinement, adaptations made, and the influence on health and well-being. Thirteen occupational therapy student researchers conducted individual qualitative, exploratory-descriptive studies on young adults’ leisure experiences during the level 5 and 4 confinements. The authors used a qualitative meta-analytic approach to review the student researchers’ primary studies and synthesize findings for this paper. The sample comprised 65 participants aged 18 to 32 years (mean age 22.2 years), the majority being either students or employed. Participants were interviewed online or submitted written responses to open-ended questions focusing on their leisure engagement during the confinement. Relevant data were extracted from the primary studies and analyzed thematically. Four themes emerged: 1) disruption, 2) time, 3) adaptations to change, and 4) leisure benefits. Although participants experienced the confinement as disruptive, and restricting their leisure and social engagement, they adapted and developed new leisure occupations, which had a positive influence on their health and well-being. In conclusion, the young adults dealt with the occupational injustices of confinement by adapting their leisure engagement, thus displaying occupational resilience, which positively influenced health and well-being.

Local Instrumental Variable Methods to Address Confounding and Heterogeneity when Using Electronic Health Records: An Application to Emergency Surgery.

BackgroundElectronic health records (EHRs) offer opportunities for comparative effectiveness research to inform decision making. However, to provide useful evidence, these studies must address confounding and treatment effect heterogeneity according to unmeasured prognostic factors. Local instrumental variable (LIV) methods can help studies address these challenges, but have yet to be applied to EHR data. This article critically examines a LIV approach to evaluate the cost-effectiveness of emergency surgery (ES) for common acute conditions from EHRs.MethodsThis article uses hospital episodes statistics (HES) data for emergency hospital admissions with acute appendicitis, diverticular disease, and abdominal wall hernia to 175 acute hospitals in England from 2010 to 2019. For each emergency admission, the instrumental variable for ES receipt was each hospital’s ES rate in the year preceding the emergency admission. The LIV approach provided individual-level estimates of the incremental quality-adjusted life-years, costs and net monetary benefit of ES, which were aggregated to the overall population and subpopulations of interest, and contrasted with those from traditional IV and risk-adjustment approaches.ResultsThe study included 268,144 (appendicitis), 138,869 (diverticular disease), and 106,432 (hernia) patients. The instrument was found to be strong and to minimize covariate imbalance. For diverticular disease, the results differed by method; although the traditional approaches reported that, overall, ES was not cost-effective, the LIV approach reported that ES was cost-effective but with wide statistical uncertainty. For all 3 conditions, the LIV approach found heterogeneity in the cost-effectiveness estimates across population subgroups: in particular, ES was not cost-effective for patients with severe levels of frailty.ConclusionsEHRs can be combined with LIV methods to provide evidence on the cost-effectiveness of routinely provided interventions, while fully recognizing heterogeneity.HighlightsThis article addresses the confounding and heterogeneity that arise when assessing the comparative effectiveness from electronic health records (EHR) data, by applying a local instrumental variable (LIV) approach to evaluate the cost-effectiveness of emergency surgery (ES) versus alternative strategies, for patients with common acute conditions (appendicitis, diverticular disease, and abdominal wall hernia).The instrumental variable, the hospital’s tendency to operate, was found to be strongly associated with ES receipt and to minimize imbalances in baseline characteristics between the comparison groups.The LIV approach found that, for each condition, there was heterogeneity in the estimates of cost-effectiveness according to baseline characteristics.The study illustrates how an LIV approach can be applied to EHR data to provide cost-effectiveness estimates that recognize heterogeneity and can be used to inform decision making as well as to generate hypotheses for further research.

Risk-adjusted active tuberculosis case finding strategy in central Ethiopia

BackgroundThe World Health Organization recommends active case finding for tuberculosis (TB). Our study evaluated the targeted screening of household contacts (HHCs) of patients with contagious pulmonary tuberculosis (PTB) in Central Ethiopia. MethodsThe HHCs of patients with microbiologically confirmed PTB were screened for TB symptoms and risk factors for TB transmission. Symptomatic HHCs were subjected to secondary investigation. Antimicrobial resistance was investigated among study participants. ResultsOverall, 112 index patients with TB were included, and 289 HHCs from 89 households were screened. Multidrug-resistant-TB was detected in 2.7% (n=3) of index patients. The routine public health system process did not identify any TB suspects among HHCs. In total, 23.9% (n=69) of HHCs reported ≥1 TB symptom and PTB was confirmed in 2.1% (n=6). Reporting >1 TB symptom (relative risk [RR] 29.4, 95% CI 3.5−245.5, P<0.001) and night sweats (RR 27.1, 95% CI 3.2−226.6, P<0.001) were associated with the greatest relative risk. Regular alcohol consumption was identified as an individual risk factor for TB among HHCs (P=0.022). ConclusionThe MDR-TB rate among our patients was higher than recently reported for Ethiopia. Enhanced contact tracing using a risk-adjusted approach seems feasible and increases the case detection rate among HHCs of confirmed TB cases.

A novel method for handling pre-existing conditions in multivariate prediction model development for COVID-19 death in the Department of Veterans Affairs.

Many mathematical models have been proposed to predict death following the Coronavirus Disease 2019 (COVID-19); all started with comorbidity subsets for this still-little understood disease. Thus, we derived a novel predicted probability of death model (PDeathDx) upon all diagnostic codes documented in the Department of Veterans Affairs. We present the conceptual underpinnings and analytic approach in estimating the independent contribution of pre-existing conditions. This is the largest study to-date following patients with COVID-19 to predict mortality. Cases were identified with at least one positive nucleic acid amplification test. Starting in 1997, we use diagnoses from the first time a patient sought care until 14 days before a positive nucleic acid amplification test. We demonstrate the clear advantage of using an unrestricted set of pre-existing conditions to model COVID-19 mortality, as models using conventional comorbidity indices often assign little weight or usually do not include some of the highest risk conditions; the same is true of conditions associated with COVID-19 severity. Our findings suggest that it is risky to pick comorbidities for analysis without a systematic review of all those experienced by the cohort. Unlike conventional approaches, our comprehensive methodology provides the flexibility that has been advocated for comorbidity indices since 1993; such an approach can be readily adapted for other diseases and outcomes. With our comorbidity risk adjustment approach outperforming conventional indices for predicting COVID-19 mortality, it shows promise for predicting outcomes for other conditions of interest.

Early childhood teachers' and managers' lived experiences of the COVID-19 pandemic in South Africa

The declaration of COVID-19 as a global pandemic by the World Health Organisation in March 2020 brought many changes to the early childhood sector internationally. The South African response is best understood in the context of an under-developed sector with pre-existing vulnerabilities. In this article, we present a contextual understanding of the lived experiences of early childhood development (ECD) teachers and managers during the lockdown and the opening phases of a risk-adjusted approach. Our use of a phenomenological lens together with systems theory provides a reality check through a focus on lived experiences. Data were produced through an online survey with 28 ECD teachers and managers. We conducted semi-structured interviews with a subset of 8 of these participants. Findings show that disruptions of COVID-19 led to entrenching inequities in service provision and early learning opportunities. These intersecting dimensions have implications for building effective ECD systems.

A risk-adjusted approach to monitoring surgery for survival outcomes based on a weighted score test

In programs monitoring surgical quality, risk-adjusted control charts have been used widely to detect changes in surgical performance. Ignoring the survival time may lead to information loss and thus attenuate the monitoring efficiency. However, previous methods based on survival time information only focus on detecting the change in average risk. The stability of surgical performance measured by scale parameters could be of interest in monitoring. In this study, we extend the risk-adjusted monitoring approach to include survival outcomes, in which both the location and scale parameters are monitored simultaneously. Based on the weighted score test for the Cox model, we propose to use an exponentially weighted moving average chart to monitor changes in average surgical risk and the existence of its variance, which could be of interest in practical surgical monitoring programs. Simulation results indicate that the proposed method detects changes in the variance of surgical performance and small shifts in surgical risk more efficiently than existing cumulative sum methods. In addition, the proposed method shows good efficiency for various magnitudes of shift. The proposed chart was applied to a data set from the Surgical Outcome Monitoring and Improvement Program in Hong Kong, identifying an improvement in a hospital's outcomes.

Implementation of a risk-stratified approach to prevent postoperative nausea and vomiting in an institution with high baseline rates of prophylaxis.

Background and Aims:Although a risk-adjusted approach to preventing postoperative nausea and vomiting (PONV) is generally recommended, the successful implementation of such practice without mandated protocols remains elusive. To date, such a strategy has never been adapted to curb high baseline rates of prophylaxis.Material and Methods:We conducted an observational study on a cohort of patients undergoing elective surgery before and after the implementation of a quality improvement initiative including a risk-stratified approach to prevent PONV. The primary outcome was the number of prophylactic interventions administered. Secondary outcome included the repetition of ineffective medications and the need for rescue medication in the post-anesthesia care unit (PACU).Results:A total of 636 patients were included; 325 patients during the control period and 311 after the intervention. The educational program failed to reduce the amount of prophylactic antiemetics administered (2.0 vs. 2.6, P < 0.001) and the repeat administration of ineffective medications for rescue (16% vs. 20%, P = 0.15). More patients in the intervention group required rescue medication compared to the control group (16.9% vs. 9.7%; P = 0.04).Conclusion:Implementation of best practices to combat PONV remains elusive. Our results indicate that difficulties in changing provider behavior also apply to institutions with high prophylactic antiemetic administration rates.

COVID-19 and cardiothoracic surgery: A risk-adjusted approach in the context of a global pandemic

In the face of the novel coronavirus pandemic, the impact of COVID-19 infection has disrupted cardiothoracic surgical services globally. A risk-adjusted approach to restructuring the delivery of cardiothoracic surgical services has been proposed in accordance with international guidance to ensure that the surgical standard of care is maintained in the practice of adult and paediatric cardiac surgery, as well as thoracic surgery. The potential influx of COVID-19 patients with cardio-respiratory complications requiring intensive care management and associated surgical procedures falling within the gamut of the thoracic surgeon, is considered. Finally, the protection of healthcare workers, in particular the surgical team exposed to aerosolising procedures, is outlined.

Risk adjusting for Medicaid participation in Medicare Advantage.

Determining appropriate capitated payments has important access implications for dual-eligible Medicare Advantage (MA) members. In 2017, MA plans began receiving higher capitated payments for beneficiaries with full vs partial Medicaid when payments started being risk adjusted for level of Medicaid benefits instead of any Medicaid participation. This approach could favor MA plans in states with more generous Medicaid programs where more beneficiaries qualify for full Medicaid and thus a higher capitated payment. To understand this issue, we examined adjusted Medicare spending for dual-eligible beneficiaries across states with differing Medicaid eligibility criteria. Retrospective analysis of 2007-2015 traditional Medicare data for dual-eligible beneficiaries 65years and older. We compared predicted per-beneficiary spending levels after adjusting for any Medicaid participation and for level of Medicaid benefits across states with varying Medicaid eligibility requirements. States with the most generous Medicaid requirements had more dual-eligible beneficiaries with full Medicaid compared with the most restrictive states (median, 82% vs 55%). Nationally, Medicare spending levels were 1.3times greater for full vs partial Medicaid participants (range across states, 0.8-1.7). When per-beneficiary spending was adjusted for level of Medicaid benefits, rather than any Medicaid participation, states with more generous Medicaid eligibility had larger gains in predicted spending per dual-eligible beneficiary than states with less generous Medicaid coverage (1.7% vs 1.3% increase). Distinguishing between partial and full Medicaid in MA payments may disproportionately increase MA payments in states that have more full Medicaid beneficiaries due to more generous Medicaid eligibility.

Ranking hospitals when performance and risk factors are correlated: A simulation-based comparison of risk adjustment approaches for binary outcomes.

BackgroundThe conceptualization of hospital quality indicators usually includes some form of risk adjustment to account for hospital differences in case mix. For binary outcome variables like in-hospital mortality, frequently utilized risk adjusted measures include the standardized mortality ratio (SMR), the risk standardized mortality rate (RSMR), and excess risk (ER). All of these measures require the estimation of expected hospital mortality, which is often based on logistic regression models. In this context, an issue that is often neglected is correlation between hospital performance (e.g. care quality) and patient-specific risk factors. The objective of this study was to investigate the impact of such correlation on the adequacy of hospital rankings based on different measures and methods.MethodsUsing Monte Carlo simulation, the impact of correlation between hospital care quality and patient-specific risk factors on the adequacy of hospital rankings was assessed for SMR/RSMR, and ER based on logistic regression and random effects logistic regression. As an alternative method, fixed effects logistic regression with Firth correction was considered. The adequacies of the resulting hospital rankings were assessed by the shares of hospitals correctly classified into quintiles according to their true (unobserved) care qualities.ResultsThe performance of risk adjustment approaches based on logistic regression and random effects logistic regression declined when correlation between care quality and a risk factor was induced. In contrast, fixed-effects-based estimations proved to be more robust. This was particularly true for fixed-effects-logistic-regression-based ER. In the absence of correlation between risk factors and care quality, all approaches showed similar performance.ConclusionsCorrelation between risk factors and hospital performance may severely bias hospital rankings based on logistic regression and random effects logistic regression. ER based on fixed effects logistic regression with Firth correction should be considered as an alternative approach to assess hospital performance.

Visualizing Delivery Catchment Area for Severe Maternal Morbidity in Harris County, Texas, 2016 [25T

INTRODUCTION: Severe maternal morbidity (SMM) reflects complex, multi-level factors. In Texas, the SMM rate was 17.0 per 1,000 deliveries in 2016. In this exploratory case study, we describe SMM by ZIP Code for select hospitals in the Texas county with the highest delivery volume, to highlight differences in SMM at a granular level. METHODS: Using Texas all-payer inpatient hospitalization data for 2011-2016, delivery-related hospitalizations were classified as SMM based on 21 ICD-10-CM diagnosis and procedure codes. Using ArcGIS Desktop, SMM was mapped at (1) maternal residence ZIP Code for Harris County, and (2) maternal residence ZIP Code and hospital level for two hospitals with the lowest and two hospitals with the highest SMM rates. RESULTS: SMM remained consistent during 2011-2016 in Harris County (15.4-23.4 per 1,000 deliveries, P>.05). Among the 125 ZIP Codes with at least 100 deliveries in 2016, over one-third had SMM higher than the state rate. In the four hospitals included in this study, the SMM rate ranged from 1.9 to 33.8 per 1,000 deliveries. The hospital with the highest SMM rate included deliveries from a wide catchment area, while the other three hospitals had a relatively concentrated delivery catchment area. CONCLUSION: In this exploratory study, we observed differences in SMM across hospital and community settings, which reflects complex factors, including patient preexisting conditions, hospital quality of care and community characteristics. Our findings can help generate additional research to gain in-depth understanding of the relative contribution of these multi-level factors to SMM and inform development of risk adjustment approaches for SMM.

A risk adjustment approach to estimating the burden of skin disease in the United States

Direct insurance claims tabulation and risk adjustment statistical methods can be used to estimate health care costs associated with various diseases. In this third manuscript derived from the new national Burden of Skin Disease Report from the American Academy of Dermatology, a risk adjustment method that was based on modeling the average annual costs of individuals with or without specific diseases, and specifically tailored for 24 skin disease categories, was used to estimate the economic burden of skin disease. The results were compared with the claims tabulation method used in the first 2 parts of this project. The risk adjustment method estimated the direct health care costs of skin diseases to be $46 billion in 2013, approximately $15 billion less than estimates using claims tabulation. For individual skin diseases, the risk adjustment cost estimates ranged from 11% to 297% of those obtained using claims tabulation forthe 10 most costly skin disease categories. Although either method may be used for purposes of estimating the costs of skin disease, the choice of method will affect the end result. These findings serve as an important reference for future discussions about the method chosen in health care payment models to estimate both the cost of skin disease and the potential cost impact of care changes.

Defining Team Effort Involved in Patient Care from the Primary Care Physician's Perspective.

A better understanding of the attributes of patients who require more effort to manage may improve risk adjustment approaches and lead to more efficient resource allocation, improved patient care and health outcomes, and reduced burnout in primary care clinicians. To identify and characterize high-effort patients from the physician's perspective. Cohort study. Ninety-nine primary care physicians in an academic primary care network. From a list of 100 randomly selected patients in their panels, PCPs identified patients who required a high level of team-based effort and patients they considered complex. For high-effort patients, PCPs indicated which factors influenced their decision: medical/care coordination, behavioral health, and/or socioeconomic factors. We examined differences in patient characteristics based on PCP-defined effort and complexity. Among 9594 eligible patients, PCPs classified 2277 (23.7%) as high-effort and 2676 (27.9%) as complex. Behavioral health issues were the major driver of effort in younger patients, while medical/care coordination issues predominated in older patients. Compared to low-effort patients, high-effort patients were significantly (P < 0.01 for all) more likely to have higher rates of medical (e.g. 23.2% vs. 6.3% for diabetes) and behavioral health problems (e.g. 9.8% vs. 2.9% for substance use disorder), more frequent primary care visits (10.9 vs. 6.0 visits), and higher acute care utilization rates (25.8% vs. 7.7% for emergency department [ED] visits and 15.0% vs. 3.9% for hospitalization). Almost one in five (18%) patients who were considered high-effort were not deemed complex by the same PCPs. Patients defined as high-effort by their primary care physicians, not all of whom were medically complex, appear to have a high burden of psychosocial issues that may not be accounted for in current chronic disease-focused risk adjustment approaches.

Failure of Risk-Adjustment by Test Method for C. difficile Laboratory-Identified Event Reporting

Using an algorithm including both enzyme immunoassay (EIA) and nucleic acid amplification (NAAT) for Clostridium difficile infection (CDI) diagnosis, we found that the use of NAAT versus EIA almost doubled our hospital-onset CDI laboratory-identified (LabID) event standardized infection ratio (SIR). We recommend that the current risk adjustment approach be modified. Infect Control Hosp Epidemiol 2016:1-3.

Effect of Hashimoto thyroiditis on low-dose radioactive-iodine remnant ablation.

Radioactive-iodine remnant ablation is an integral part of the papillary thyroid carcinoma (PTC) treatment. Although a minimum dose is usually recommended, there is controversy as to whether the low-dose (1100 MBq) radioactive-iodine remnant ablation is adequate for selected patients. A retrospective cohort study was conducted on 691 patients. Patients with no remnant thyroid on the follow-up whole body scan and low stimulated thyroglobulin (sTg) level (<2.0 ng/mL) were deemed as successful treatment cases. Initial low-dose radioactive-iodine remnant ablation was successful in 431 patients (62.3%). Multivariate analysis demonstrated a negative correlation between successful radioactive-iodine remnant ablation and coexisting Hashimoto thyroiditis based on histopathology diagnosis (odds ratio [OR] = 3.23; p < .001) as well as elevated preablation sTg (OR = 1.24; p < .001). Our data suggest that coexisting Hashimoto thyroiditis and elevated sTg are negative predictive factors for successful low-dose radioactive-iodine remnant ablation treatment. An appropriate risk-adjusted approach may improve the efficacy of radioactive-iodine remnant ablation treatment. © 2015 Wiley Periodicals, Inc. Head Neck 38: E730-E735, 2016.