Value-based Healthcare Models Research Articles

Value-based healthcare analysis of joint replacement surgery for patients with primary hip osteoarthritis

BackgroundA quarter of the population present at least once a year with a musculoskeletal disorder. Primary hip osteoarthritis is a high-volume condition with significant clinical need and population-level costs. There...

Ureteral stenting practices following routine ureteroscopy: an international survey.

Stent omission after routine ureteroscopy (rtURS) is accepted by current guidelines and may result in decreased patient morbidity and treatment costs. In a value-based healthcare model, the added morbidity and cost of routine stent placement may be scrutinized. Furthermore, data are limited on urologist cost knowledge and it is effect on ureteral stent placement. As such, we seek to describe ureteral stenting practices and urologist cost knowledge amongst US and non-US-based urologists. The ureteroscopic practice patterns and cost awareness of members of the Endourological Society were surveyed using an international email listserv. Respondents were grouped by practice location (US vs non-US). Logistic regression was used to evaluate the associations of surgeon practice location with stenting practices. 233 completed responses were received with a response rate of 13.5%. Results revealed that 55% and 71% of respondents reported ureteral stent insertion after rtURS more than 75% of the time for ureteral and renal stones, respectively. Reporting stent insertion following more than 75% of rtURS was more common among US participants for both ureteral and renal stones. Overall, reported cost knowledge was high, but lower among US participants. On multivariable analysis, US respondents were more likely to place ureteral stents after rtURS for ureteral stones more than 75% of the time when compared to those abroad (OR 3.43 p < 0.01). Ureteral stenting after rtURS is over utilized in the US compared to other countries. While this phenomenon is multifactorial in nature, cost knowledge may be under recognized as a determinant of ureteral stent placement following rtURS.

Orthopaedic Trauma Quality Measures for Value-Based Health Care Delivery: A Systematic Review.

To assess the current portfolio of quality measures and candidate quality measures that address orthopaedic trauma surgery. We systematically reviewed the National Quality Forum, the Agency for Healthcare Research and Quality, and the Quality Payment Program for quality measures relevant to fracture surgery. We also searched MEDLINE/PubMed, Embase/Scopus, and Cochrane libraries. Clinical practice guidelines were included as candidate quality measures if their development was in accordance with the Institute of Medicine criteria for development of clinical practice guidelines, were based on consistent clinical evidence including at least one Level I study, and carried the strongest possible recommendation by the developing body. We categorized the measures as structure, process, or outcome domains according to the framework described by Donabedian. From the 3809 articles initially identified and screened, a total of 189 combined quality or candidate quality measures were extracted from our review. With regard to the Donabedian framework, there were a total of 7% (13/189) structure, 52% process (99/189), and 41% (77/189) outcome measures identified. As quality measures progressively inform reimbursement in value-based health care models, quality measures evaluating the care of patients sustaining a fracture will become increasingly relevant to orthopaedic trauma surgeons.

Value-Based Health Care in Inflammatory Bowel Disease.

Inflammatory bowel disease (IBD) is a chronic inflammatory disease associated with significant resource utilization and health care burden. It is emerging as a global disease affecting an increasing proportion of the population. Along with evolving epidemiological trends, the paradigm of managing IBD has also changed. With a burgeoning repertoire of therapeutic options, improved use of health informatics, and emphasis on health care value, the treatment paradigm for IBD has experienced seismic shifts. In this review, we focused on value-based health care (VBHC)-a health care model that emphasizes monitoring outcomes to emphasize patient-centered, cost-effective IBD patient care. Several quality initiatives have been developed worldwide, and successful models of care were created for proper implementation of these initiatives. Although there are significant challenges to scale these models to a national level, it is still possible to successfully implement VBHC models within health systems to improve the quality of care provided to patients with IBD.

Patients Should Define Value in Health Care: A Conceptual Framework.

The main tenet of value-based health care is delivering high-quality care that is centered on the patient, improving health, and minimizing cost. Collaborative decision-making frameworks have been developed to help facilitate delivering care based on patient preferences (patient-centered care). The current value-based health care model, however, focuses on improving population health and overlooks the individuality of patients and their preferences for care. We highlight the importance of eliciting patient preferences in collaborative decision making and describe a conceptual framework that incorporates individual patients' preferences when defining value.

NCCN Conference Addressed Value-Based Healthcare Models, Payer Perspectives, New NCCN Guidelines, and Other Updates in Cancer Care

NCCN Conference Addressed Value-Based Healthcare Models, Payer Perspectives, New NCCN Guidelines, and Other Updates in Cancer Care

Health Policy and Financial Issues Related to New Total Knee Arthroplasty Technology

As demand for knee replacement surgery continues to rise, new technologies continue to be introduced with the hopes of improving total knee arthroplasty outcomes. As new value based health care models are introduced, the ability to pay for these new technologies will likely be impacted. Because of past implant failures and limitations, it will be important for providers to use registries to evaluate both the safety and outcomes of new knee arthroplasty designs.

What Is the State of Quality Measurement in Spine Surgery?

Value-based healthcare models rely on quality measures to evaluate the efficacy of healthcare delivery and to identify areas for improvement. Quality measure research in other areas of health care has generally shown that there is a limited number of available quality measures and that those that exist disproportionately focus on processes as opposed to outcomes. The purpose of this study was to assess the current state of quality measures and candidate quality measures in spine surgery. (1) How many quality measures and candidate quality measures are currently available? (2) According to Donabedian domains and National Quality Strategy (NQS) priorities, what aspects or domains of care do the present quality measures and candidate quality measures represent? We systematically reviewed the National Quality Forum, the Agency for Healthcare Research and Quality, and the Physician Quality Reporting System for quality measures relevant to spine surgery. A systematic search for candidate quality measures was also performed using MEDLINE/PubMed and Embase as well as publications from the American Academy of Orthopaedic Surgeons, Congress of Neurological Surgeons, and the North American Spine Society. Clinical practice guidelines were included as candidate quality measures if their development was in accordance with Institute of Medicine criteria for the development of clinical practice guidelines, they were based on consistent clinical evidence including at least one Level I study, and they carried the strongest possible recommendation by the developing body. Quality measures and candidate quality measures were then pooled for analysis and categorized by clinical focus, NQS priority, and Donabedian domain. Our initial search yielded a total of 3940 articles, clinical practice guidelines, and quality measures, 74 of which met criteria for inclusion in this study. Of the 74 measures studied, 29 (39%) were quality measures and 45 (61%) were candidate quality measures. Fifty of 74 (68%) were specific to the care of the spine, and 24 of 74 (32%) were related to the general care of spine patients. The majority of the spine-specific measures were process measures (45 [90%]) and focused on the NQS priority of "Effective Clinical Care" (44 [88%]). The majority of the general care measures were also process measures (14 [58%]), the highest portion of which focused on the NQS priority of "Patient Safety" (10 [42%]). Given the large number of pathologies treated by spine surgeons, the limited number of available quality measures and candidate quality measures in spine surgery is inadequate to support the transition to a value-based care model. Additionally, current measures disproportionately focus on certain aspects or domains of care, which may hinder the ability to appropriately judge an episode of care, extract usable data, and improve quality. Physicians can steward the creation of meaningful quality measures by participating in clinical practice guideline development, assisting with the creation and submission of formal quality measures, and conducting the high-quality research on which effective guidelines and quality measures depend.

Where Are the Opportunities for Reducing Health Care Spending Within Alternative Payment Models?

The Oncology Care Model (OCM) is a highly controversial specialty care model developed by the Centers for Medicare & Medicaid aimed to provide higher-quality care at lower cost. Because oncologists will be increasingly held accountable for spending as well as quality within new value-based health care models like the OCM, they need to understand the drivers of total spending for their patients. This retrospective cohort study included patients ≥ 65 years of age with primary fee-for-service Medicare insurance who received antineoplastic therapy at 12 cancer centers in the Southeast from 2012 to 2014. Medicare administrative claims data were used to identify health care spending during the prechemotherapy period (from cancer diagnosis to antineoplastic therapy initiation) and during the OCM episodes of care triggered by antineoplastic treatment. Total health care spending per episode includes all types of services received by a patient, including nononcology services. Spending was further characterized by type of service. Average total health care spending in the three OCM episodes of care was $33,838 (n = 3,427), $23,811 (n = 1,207), and $19,241 (n = 678). Antineoplastic drugs accounted for 27%, 32%, and 36% of total health care spending in the first, second, and third episodes. Ten drugs, used by 31% of patients, contributed 61% to drug spending ($18.8 million) in the first episode. Inpatient spending also substantially contributed to total costs, representing 17% to 20% ($30.5 million) of total health care spending. Health care spending was heavily driven by both antineoplastic drugs and hospital use. Oncologists' ability to affect these types of spending will determine their success under alternative payment models.

Value-Based Healthcare in Residency Training: a Perspective from Singapore

Value-based health care aims to achieve the best outcomes at the lowest cost. Many leading health systems worldwide have already begun to restructure care delivery guided by value-based concepts. Residency training programs will play a key role in the transition to value-based healthcare. However, incorporating value-based healthcare into residency programs has received little attention. This commentary introduces an approach developed in Singapore which encompasses structured teaching, clinical teaching, and evaluations. We elaborate on how educators can use avenues such as quality improvement initiatives and journal clubs to introduce concepts of value-based healthcare to residents. The curriculum is then reinforced by allowing residents to apply value-based concepts in their clinical rounds and multidisciplinary meetings. Lastly, we give examples of how residents can be assessed with a value-based healthcare component in their in-training examinations and posting evaluations. This approach contributes to a well-planned and smoothly executed educational program in value-based healthcare for residents, which will be a keystone in the long-term success of the value-based healthcare model.

Cost-Minimization Analysis of Open and Endoscopic Carpal Tunnel Release.

Carpal tunnel release is the most common upper-limb surgical procedure performed annually in the U.S. There are 2 surgical methods of carpal tunnel release: open or endoscopic. Currently, there is no clear clinical or economic evidence supporting the use of one procedure over the other. We completed a cost-minimization analysis of open and endoscopic carpal tunnel release, testing the null hypothesis that there is no difference between the procedures in terms of cost. We conducted a retrospective review using a private-payer and Medicare Advantage database composed of 16 million patient records from 2007 to 2014. The cohort consisted of records with an ICD-9 (International Classification of Diseases, Ninth Revision) diagnosis of carpal tunnel syndrome and a CPT (Current Procedural Terminology) code for carpal tunnel release. Payer fees were used to define cost. We also assessed other associated costs of care, including those of electrodiagnostic studies and occupational therapy. Bivariate comparisons were performed using the chi-square test and the Student t test. Data showed that 86% of the patients underwent open carpal tunnel release. Reimbursement fees for endoscopic release were significantly higher than for open release. Facility fees were responsible for most of the difference between the procedures in reimbursement: facility fees averaged $1,884 for endoscopic release compared with $1,080 for open release (p < 0.0001). Endoscopic release also demonstrated significantly higher physician fees than open release (an average of $555 compared with $428; p < 0.0001). Occupational therapy fees associated with endoscopic release were less than those associated with open release (an average of $237 per session compared with $272; p = 0.07). The total average annual reimbursement per patient for endoscopic release (facility, surgeon, and occupational therapy fees) was significantly higher than for open release ($2,602 compared with $1,751; p < 0.0001). Our data showed that the total average fees per patient for endoscopic release were significantly higher than those for open release, although there currently is no strong evidence supporting better clinical outcomes of either technique. Value-based health-care models that favor delivering high-quality care and improving patient health, while also minimizing costs, may favor open carpal tunnel release.

Value-based procurement: Canada's healthcare imperative.

Value-based healthcare models are being adopted globally to maximize value for patients. Given that procurement is at the heart of purchasing value, value-based procurement goes hand in hand with value-based healthcare. Shifting procurement's traditional focus on short-term cost savings to a more holistic objective that includes health system performance and patient outcomes, giving preference to longer-term cost efficiencies, and working with suppliers to identify opportunities to develop more innovative products and services, is proving successful in leading jurisdictions. This article presents an overview of value within healthcare systems and how healthcare value-based procurement is being implemented across various jurisdictions.

Quality of Life and General Health After Elective Surgery for Cervical Spine Pathologies: Determining a Valid and Responsive Metric of Health State Utility.

As part of the Affordable Care Act, health utility metrics are being investigated to define a cost-effective, value-based health care model. EuroQOL-5D (EQ-5D) and Short Form-6D (SF-6D) are commonly used quality-of-life instruments. Domains in the EQ-5D questionnaire are thought to be less responsive in measuring quality of life after cervical surgery. To evaluate the validity and responsiveness of SF-6D and EQ-5D in determining health and quality of life after elective cervical spine surgery. A total of 420 patients undergoing elective cervical spine surgery over a period of 2 years were enrolled in a prospective longitudinal registry. Patient-reported outcomes Neck Disability Index (NDI), EQ-5D, and SF-12 were recorded. Based on previously published equations, SF-6D was calculated using NDI and SF-12 scores. Patients were asked whether "surgery met their expectations" (meaningful improvement). The validity and relative responsiveness of SF-6D (NDI), SF-6D (SF-12), and EQ-5D to discriminate between meaningful and nonmeaningful improvement were calculated. Sixty-six percent of patients (277) reported a level of improvement after surgery that met their expectations (meaningful improvement). SF-6D (NDI) (area under the curve [AUC] = 0.69) was a more valid discriminator of meaningful improvement compared with the SF-6D (SF-12) (AUC = 0.65) and EQ-5D (AUC = 0.62). SF-6D (NDI) was also a more responsive measure compared with SF-6D (SF-12) and EQ-5D (standardized response mean difference: 0.66, 0.48, and 0.44, respectively). SF-6D is a more valid and responsive measure of general health and quality of life compared with EQ-5D. SF-6D derived from disease-specific disability scores was more valid and responsive than that derived from the generic preference-based SF-12. Cost-effective studies should use SF-6D as a measure of QALY after cervical spine surgery.