Value-based Healthcare System Research Articles

An Explorative Longitudinal Study on the Five-Year Patient Portal Use among an Underserved Patient Population

The purpose of the study was to identify and assess multiple aspects of patient portal usage behavior in an underserved urban patient population. Given the rise of patient-centered care, patients are required to take active roles to gather health information, make informed health decisions and manage their own healthcare, which behavior were associated with health outcome (Barry & Edgman-Levitan, 2012; Oates, Weston & Jordan, 2000). Patient portals serve as a mean to coordinate patient-centered care by delivering health information to patients (e.g. medical test results), exchanging information with healthcare providers (e.g., messaging providers), and facilitating the delivery of health care services (e.g., scheduling appointments). However, studies often showed that patients in underserved communities did not take full advantages of the patient portals (e.g,. Cazaja et al., 2015, Wallace et al., 2016). These disparities in patient portal usages were associated with many factors, including the complexities of the American healthcare system, lack of internet access, lack of support to navigate through the health systems, and the lack of health literacy among an underserved adult population. To better understand the current use of patient portal of an underserved patient population, we conducted an explorative analysis of portal usage at the University of Illinois Hospitals and Health Sciences System (UIHealth). UIHealth serves throughout the city of Chicago, including areas with high racial segregation (minority population higher than 75%), where patients’ household income is lower than the median of Chicago residents. The majority of patient populations in UIHealth are African Americans (61%) followed by Hispanic/Latino (17%) and White (17%). The study was conducted using a retrospective analysis of Google Analytics portal data from March 2015 to March 2019. User behavior data were extracted to show aspects of usage, including most popular portal functions, language used, time spent on each page, and returning user visits, etc. We used weekly summary data as individual data points (208 data points in total) in the analysis. We found that, over four years, both retuning and new users increased by more than 50%. Regarding the number of users per week, there were local drops in the overall growth which drops were associated with fewer visits to UIHealth during holidays or cold weather. Hence, portal visits were associated with clinic visits. With regards to the most popular functions, writing messages to healthcare providers and viewing medical test results were the most used functions over the years. Results suggested that patients would utilize portal to gather information about their health status (for later discussion with physicians or making informed decisions) and communicate with healthcare providers. Interestingly, we found the dominant devices used to access the portal have shifted from desktop computers (2015-2017) to mobile phones (2017-2019), suggesting the increasing need to present health information in bitable size in smaller screens; and the increasing smartphone adoptions of underserved adults as an alternative solution to get internet access. Overall, improving the accessibility of patient portals remains to be a major issue for empowering patients in contemporary value-based healthcare systems. The explorative study has shed lights on the longitudinal trends of portal usage among an underserved population, which creates practical implications on the design of a more efficient interface between patients and their healthcare providers with the ultimate goal to improve health equity.

Co-producing healthcare in a volume vs. value-based healthcare system: perspective of a parent of a patient and a health professions’ educator

The Institute for Healthcare Improvement’s Triple Aim framework represents an approach to optimizing a health system’s performance by focusing on improving the patient experience of care, improving the health of populations, and reducing healthcare costs. As the US healthcare system undergoes substantial reformation and a shift from fee-for-service payment to value-based models, an approach that emphasizes the co-production of healthcare, our healthcare system must work in concert with the Triple Aim to improve the health experience for patients across multiple environments. Co-production in healthcare means that patients contribute to the provision of health services as partners of professional providers. To highlight how the current healthcare model failed a patient by delaying diagnosis and subsequent care, thus causing undue suffering, the personal experience of one of the author’s children is reported as a narrative. The purpose of communicating this patient experience is to: 1) remind healthcare providers about the importance of not only listening, but hearing the patient and their parent’s concerns; 2) readily admit when a patient’s clinical presentation falls outside of their expertise; and 3) co-produce healthcare by working with the patient and their family. This patient experience serves to reinforce the commitment to co-produce health with patients and their families in a manner that emphasizes the value of care.

The Future of a Data-Driven, Value-Based Health Care System.

AORN JournalVolume 109, Issue 5 p. 565-566 Special Report: Perioperative Leadership Strategies: Spring 2019 The Future of a Data-Driven, Value-Based Health Care System Dave Plank MS, Dave Plank MSSearch for more papers by this author Dave Plank MS, Dave Plank MSSearch for more papers by this author First published: 26 April 2019 https://doi.org/10.1002/aorn.12672Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume109, Issue5Special Focus Issue: Infection PreventionMay 2019Pages 565-566 RelatedInformation

Health Care Resource Utilization and Costs in First-Line Treatments for Patients with Metastatic Melanoma in the United States.

The treatment landscape for patients with metastatic melanoma has changed dramatically with the introduction of novel therapies, such as targeted therapies and immunotherapies, in recent years. Health care resource utilization (HCRU) and cost data are needed to further evaluate these treatments in a value-based health care system. To examine HCRU and total cost of care among U.S. metastatic melanoma patients treated with first-line systemic therapies, including immunotherapies, targeted therapies, and chemotherapy. A retrospective observational study was conducted using a U.S. claims database. Adults with ≥ 2 claims for melanoma and ≥ 1 claim for metastasis between January 1, 2012, and June 30, 2017, were identified. Patients had pharmacy and medical enrollment ≥ 6 months before and ≥ 3 months following first-line treatment start. Per patient per month (PPPM) HCRU and costs were calculated by first-line treatment drug class: PD-1 inhibitors, CTLA-4 inhibitors, CTLA-4 + PD-1 combination, BRAF monotherapy, BRAF + MEK combination, and chemotherapy. Adjusted odds ratios (ORs) for HCRU were estimated by logistic regressions and adjusted costs were estimated by generalized linear models using log-link with gamma distribution to control for differences in patient characteristics across groups. Among 1,599 metastatic melanoma patients (PD-1, n = 255; CTLA-4, n = 555; CTLA-4 + PD-1, n = 88; BRAF, n = 210; BRAF + MEK, n=102; chemotherapy=389), mean age ranged from 59-68 years, and the majority were male (62%). Any hospitalization during first-line treatment was less frequent among PD-1-treated patients (25.9%) compared with 34.7%-45.5% of all other groups (all P < 0.05). PPPM hospitalizations were lowest in PD-1 (0.06) compared with 0.09-0.16 across all other groups (all P < 0.05), and PPPM emergency department (ED) visits were lowest in PD-1 (0.09) compared with 0.13-0.18 across all other groups (all P < 0.05), except for BRAF + MEK (0.14, P = 0.08). CTLA-4, CTLA-4 + PD-1, and BRAF + MEK had increased odds of hospitalization compared to PD-1 (adjusted ORs = 2.10, 2.35, 2.15, respectively; all P < 0.05). Total adjusted PPPM costs were significantly lower for PD-1 ($13,059) compared with CTLA-4 ($25,583), CTLA-4 + PD-1 ($31,310), and BRAF + MEK ($21,517) and higher compared to BRAF ($8,158) and chemotherapy ($6,361). Hospitalizations and ED visits represent important HCRU for metastatic melanoma patients and were lowest among PD-1-treated patients compared with any other systemic therapies (except for ED visits when compared with BRAF + MEK). Total monthly costs varied substantially across first-line regimens and were significantly lower in PD-1-treated patients compared with patients treated with CTLA-4, CTLA-4 + PD-1, and BRAF + MEK. This study was funded by Merck Sharp & Dohme, a subsidiary of Merck & Co. Klink, Feinberg, and Nero are employees of Cardinal Health Specialty Solutions, which received funding from Merck to conduct this study. Chmielsowki is a consultant to Merck but received no funding for the development of this manuscript. Ahsan and Liu are employees of Merck. Chmielowski reports advisory board/speaker fees from Bristol-Myers Squibb, Merck, Genentech/Roche, Iovance Biotherapeutics, HUYA Bioscience International, Compugen, Array BioPharma, Regeneron, Biothera, Janssen, and Novartis. Ahsan has a patent (US20160008380A1) pending.

Patterns of Health Care Costs Due to External Ventricular Drain Infections

External ventricular drain (EVD) infections are a significant cause of morbidity among neurosurgical patients and have been correlated with increased length of hospital stay and longer requirements for intensive care. To date, no studies have examined the financial impact of EVD infections. Patients who underwent EVD placement between December 2010 and January 2016 were included in the study. Clinical records were retrospectively reviewed and health care cost data were obtained from the hospital's finance department. Clinical information included patient demographics, details from the hospital course, and outcomes. Total costs, direct/indirect, and fixed/variable costs were analyzed for every patient. Over the 5-year study period, 246 EVDs were placed in 243 patients with an overall infection rate of 9.9% (N= 24). The median EVD duration for infected versus noninfected patients was 19 and 9 days, respectively (P<0.0001). Median length of intensive care unit stay also was increased for patients with EVD infection (30 days vs. 13 days, P < 0.0001). Total health care costs were significantly greater for infected patients (US$ 168,692 vs. US$ 83,919, P < 0.0001). This trend was comparable for all other cost subtypes, including fixed-direct costs, fixed-indirect costs, variable direct costs, and variable-indirect costs. EVD infection has a substantial effect on clinical morbidity and healthcare costs. These results demonstrate the imperative need to improve EVD infection prevention, particularly in the setting of a value-based health care system.

HSR19-095: Healthcare Resource Utilization and Costs in Patients Treated with Systemic Therapies in Metastatic Melanoma

Background: The treatment (tx) landscape for patients (pts) with metastatic melanoma (MM) has changed dramatically from systemic chemotherapy (chemo) to novel therapies, including targeted therapies (TT) and immunotherapies (IO mono- and combination therapy) in recent years. Healthcare resource utilization (HCRU) and cost data are needed to further evaluate tx in a value-based healthcare system. The study aimed to describe HCRU and total cost of care among first line (1L) US MM pts treated with IO, TT, or chemo. Methods: A retrospective observational study was conducted using a U.S. claims database. Adults with ≥2 claims for melanoma and ≥1 claim for metastasis between January 1, 2012 and June 30, 2017 were identified. Pts had pharmacy and medical enrollment ≥6 months pre and ≥3 months post 1L tx start. Per pt per month (PPPM) HCRU and costs were calculated by 1L tx drug class: PD-1, CTLA-4, CTLA-4+PD-1, mono-TT, combo-TT, and chemo. Adjusted odds ratios (OR) for HCRU were estimated by logistic regressions, and adjusted costs were estimated by generalized linear models to control for differences in pt characteristics across groups. Results: Among 1,599 MM pts (255 PD-1, 555 CTLA-4, 88 CTLA-4+PD-1, 210 mono-TT, 102 combo-TT, 389 chemo), mean age ranged from 59–68 years across tx groups, and the majority was male (62%). Any hospitalization during 1L was less frequent among PD-1 (26%) compared to 35%–46% of all other groups (all P&lt;.05). CTLA-4, CTLA-4+PD-1, and combo-TT had increased odds of hospitalization compared to PD-1 (adjusted ORs: 2.10, 2.35, 2.15, respectively; all P&lt;.05). Total adjusted PPPM costs were significantly lower for PD-1 compared to CTLA-4, CTLA-4+PD-1 and combo-TT and higher compared to mono-TT and chemo (Table 1). Conclusions: Hospitalizations represent an important healthcare resource for MM pts and were lowest among PD-1. Total monthly costs varied substantially across 1L regimens and were significantly lower in PD-1 compared to CTLA-4, CTLA-4+PD-1, and combo-TT. HCRU and costs differentiate 1L MM regimens.

AMCP Partnership Forum: Managing Total Cost of Care Through Medical and Pharmacy Data Integration.

Value-driven health care models that aim to improve patient outcomes while managing total costs of care require better access to integrated health care data. Health care organizations that integrate data from multiple platforms (e.g., pharmacy, medical, electronic medical records, and lab data) can better streamline and guide effective, efficient, and coordinated utilization and care management programs. To address strategies for integrating health care data, the Academy of Managed Care Pharmacy convened a forum in Baltimore, MD, on September 25-26, 2018. The goal of the forum was to develop a roadmap for managed care entities interested in (a) managing medications across the spectrum of health care-regardless of whether the medications are covered by a medical or pharmacy benefit; (b) driving performance improvements in clinical quality with integrated datasets; (c) streamlining care transitions and case management; and (d) facilitating the development of datasets formatted for use in value-based care contracts. Forum deliberations highlighted the need for data integration in value-based health care systems, explored making data actionable through rapid and predictive analytics of integrated datasets, identified the challenges of doing so, and developed a practical roadmap for managing the total cost of care through data integration. Health care leaders representing health plans, integrated delivery systems, pharmacy benefit managers, employers, the federal government, technology companies, data integrators, standards development leaders, and biopharmaceutical companies participated in the forum, which was supported in collaboration with Abbvie, Alkermes, Amgen, Bayer, Boehringer Ingelheim, Genentech, Merck, National Pharmaceutical Council, PhRMA, Takeda, and Xcenda. These proceedings represent common themes and comments from individual participants; they are not necessarily endorsed by all attendees, nor should they be construed as reflecting group consensus. DISCLOSURES: The AMCP Partnership Forum and the development of this proceedings document were supported by Abbvie, Alkermes, Amgen, Bayer, Boehringer Ingelheim, Genentech, Merck, National Pharmaceutical Council, PhRMA, Takeda, and Xcenda.

Constructing a value-based healthcare system for hypertensive patients through changing payment mode: evidence from a comparative study in rural China

Objective: To construct a value-based healthcare system for rural Chinese hypertensive patients through an increasing outpatient care reimbursement ratio.Methods: This comparative study sampled two similar counties, Dangyang County and Zhijiang County, in Hubei Province of China, as the intervention group and the control group, respectively. The Social Health Insurance Fund of the intervention group budgeted 600 yuan per capita per year to insured patients with third stage hypertension to cover their outpatient expenditures, while the outpatient expenditures of the control group were not covered by its Social Health Insurance Fund. The inpatient expenditure reimbursement policies in both groups were not adjusted during the study. Value improvement in this study was defined as reduction in medical costs and improvement in health outcomes within the pilot healthcare system. A propensity score matching model combined with a difference-in-differences model was used to estimate the changes in medical costs and health outcomes.Results: In total, 1,673 pairs of patients were enrolled into statistical analysis after the propensity score matching. The intervention increased per capita annual outpatient expenditure by 81.2 (+31.8%) yuan (p > .05), but decreased the per capita annual inpatient expenditure and total medical expenditure by 475.4 (–40.7%) yuan and 394.2 (–27.7%) yuan, respectively (p < .05). Accordingly, the per capita annual total medical expenditure reimbursement decreased by 192.3 (–28.5%) yuan (p < .05), and the per capita annual total out-of-pocket expenditure by 201.9 (–29.9%) yuan (p < .05). The diastolic blood pressure of the intervention group decreased significantly by 2.9 mmHg (p < .05), but no significant change was found in systolic blood pressure and prevalence of hypertension complications (p > .05).Conclusion: Increasing the outpatient expenditures, the reimbursement ratio was beneficial to the value of the healthcare system for hypertensive patients. Outpatient care for patients with chronic diseases should be prioritized for rural China and healthcare settings with inadequate health insurance funds.

CSM 2019 American Academy of Sports Physical Therapy Poster Presentations (Abstracts SPO1–SPO132)

CSM 2019 American Academy of Sports Physical Therapy Poster Presentations (Abstracts SPO1–SPO132)

Comparison of Surgeon Performance of Rotator Cuff Repair: Risk Adjustment Toward a More Accurate Performance Measure.

Movement toward a value-based health-care system necessitates the development of performance measures to compare physicians, hospitals, and health-care systems. Patient-reported outcomes (PROs) are a potential metric. However, valid use of PROs hinges on the ability to risk-adjust for baseline patient differences across a surgeon's panel of patients. The purpose of this study was to propose an approach for baseline risk adjustment and evaluate the importance of risk adjustment when comparing surgeons' performance of rotator cuff repair. Patients (n = 995) treated with arthroscopic rotator cuff repair by 34 surgeons from 2010 to 2017 were identified from a large sports medicine clinical data registry. A linear regression model was used to adjust for baseline PROs, patient demographics, and clinical characteristics to predict American Shoulder and Elbow Surgeons (ASES) change scores for each surgeon. A risk-adjusted performance measure was calculated as the difference between the average unadjusted ASES change scores and the risk-adjusted predicted ASES change scores across all patients treated by a surgeon. The differences between unadjusted and risk-adjusted performance scores varied widely across surgeons (range, -13.8 to 10.3 ASES points). Use of the risk-adjusted performance scores resulted in a dramatic change in the relative ranking of surgeons, compared with the ranking based on the observed ASES change scores, with 31 of the 34 surgeons' rank changing following risk adjustment. On average, the observed ASES scores improved from 49.5 ± 17.5 at baseline to 78.0 ± 22.5 at 6 months across all surgeons. In the risk-adjustment model (R = 0.44), male sex, Workers' Compensation status, higher scores on the Veterans RAND 12-item Health Survey (VR-12), lower baseline ASES scores, fair and poor tendon quality, and night pain all had a significant effect on the predicted ASES change scores (p < 0.05). Our results show wide variation of nearly 25 points in the risk-adjusted 6-month ASES performance difference from the highest to the lowest-performing surgeons. Additionally, 91% of surgeons' rank changed following risk adjustment. This suggests that performance measurement that does not account for baseline patient characteristics would likely result in incorrect conclusions about a surgeon's relative performance based on PROs. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Weighing benefits and risks in aspects of security, privacy and adoption of technology in a value-based healthcare system

BackgroundTechnology can potentially enable the implementation of a value-based healthcare system, where the impact of quality of care is offered at optimised cost for maximised patient benefit. Technology can deliver value by aiding in data collection to evaluate outcomes and measure costs on a patient and population level. Healthcare organisations, however, face several challenges and risks that result almost exclusively from the use of these technologies.DiscussionSome challenges associated with healthcare technology include their unsustainability, due to lack of scale-up plans and timely evaluations. Other risks include noncompliance with data protection policies, inadequate data governance, and overestimated expectations resulting from the rapid introduction of new technologies.ConclusionOrganisations need to consider the risks and challenges associated with the use of technology and develop comprehensive strategies that mitigate factors leading to non-adoption and to realise benefits for achieving a value-based healthcare system.

Leadership’s role in accountable care success

Accountable care is a model of health-care delivery that stresses prevention, efficiency, quality and outcomes. It is considered an important step in moving to a value-based healthcare system. Leadership must be willing and able to articulate the message, understand the roadblocks to success and navigate a path forward. This requires a specific skill set not previously stressed in healthcare leadership. This paper reviews the accountable care organisation (ACO) model, examines why it is important and discusses how to succeed.

Relationship Between the Patient-Reported Outcome Measurement Information System and Traditional Patient-Reported Outcomes for Osteoarthritis

BackgroundIncorporating patient-reported outcomes (PROs) is paramount to the creation of a value-based healthcare system that prioritizes patient-centered care in total joint arthroplasty. The relationship between global assessment PROs such as Patient-Reported Outcome Measurement Information System (PROMIS) and joint-specific PROs for hip and knee, such as short form variations of Knee Injury and Osteoarthritis Outcome Score (KOOS-JR) and Hip Injury and Osteoarthritis Outcome Score (HOOS-JR), has yet to be assessed. MethodsA retrospective analysis was conducted to assess PRO measurements for knee-related and hip-related complaints. The KOOS-JR and HOOS-JR were compared to the PROMIS computerized adaptive test (CAT) short forms (physical function, pain interference, and pain intensity) to assess their relationship. ResultsA total of 3644 patients completed 4609 questionnaires. A modest to strong correlation was observed between the KOOS-JR and the PROMIS CAT (ranging from r = 0.56 to −0.71, P < .05). A modest to strong correlation was also found between the HOOS-JR and the PROMIS CAT (r = 0.59 to −0.79, P < .05). ConclusionPROMIS CATs demonstrated a modest to strong correlation with KOOS-JR or HOOS-JR. Future studies should further investigate the limitations of global assessment health surveys in capturing disease-specific changes following total joint arthroplasty.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P100. Cervical laminoplasty: timing of postoperative complications

BACKGROUND CONTEXT Understanding the timing of adverse event onset is a critical component of post-surgical care and discharge planning. As health-care systems continue to evolve toward rewarding quality of care through episode and bundled payments, spine surgeons face increasing pressure to minimize hospital length of stay following common yet costly procedures such as cervical laminoplasty. Although prior studies outline the incidence and predictors of postoperative complications following cervical laminoplasty, the time elapsed between surgery and adverse event onset remains unknown. PURPOSE To characterize the timing of postoperative complications following cervical laminoplasty. STUDY DESIGN/SETTING Retrospective cohort analysis using the 2012-2015 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. PATIENT SAMPLE The study included 1,243 patients undergoing cervical laminoplasty. OUTCOME MEASURES Outcome measures were rate and timing of postoperative complications, readmission, and reoperation. METHODS A retrospective cohort analysis of the NSQIP database for 2012-2015 was performed. Data from patients undergoing cervical laminoplasty was extracted with 12 outcomes selected a priori: stroke or CVA, MI,pneumonia, pulmonary embolism, UTI, deep vein thrombosis requiring therapy, sepsis, superficial SSI, deep SSI, organ space SSI, unplanned reoperation, and hospital readmission. Analysis was done to determine rate of adverse events, timing to adverse events, 30-day readmission rates and timing, and 30-day unplanned reoperation rates and timing. RESULTS A total of 1,243 patients undergoing cervical laminoplasty were identified for this study. The median day of diagnosis (lower quartile-upper quartile) for myocardial infarction was 2days (1–7 days), for pneumonia 4days (1–6 days), for pulmonary embolism 4days (3–13 days), for stroke or CVA 8 (4–14 days), unplanned reoperation 9.5 (4–16 days), urinary tract infection 10.5 (4–14.5 days), readmission 14 (6.5–18.5 days), deep incisional surgical site infection 16.5 (12–19 days), organ or space surgical site infection 18 (15–21 days), sepsis 18 (8–21 days), and superficial incisional surgical site infection 24 (20–26 days). CONCLUSIONS A value-based health-care system requires that physicians optimize patient outcomes while containing costs wherever possible. Decreasing postoperative length of stay has been a major focus of hospital systems and surgeons in their response to emerging alternative payment models. However, outcome-based reimbursement and penalties for hospital readmissions necessitate that surgeons not discharge a patient prematurely. The results of this study can help improve clinical decision-making by identifying the typical time frame during which adverse events develop following cervical laminoplasty.

Moving Organizational Culture from Volume to Value: A Qualitative Analysis of Private Sector Accountable Care Organization Development.

The concept of shifting from volume (i.e., billing for as many patients and services as possible) to value (i.e., reducing costs while improving quality) has been a key underpinning of the development of accountable care organizations (ACOs), yet the cultural change necessary to make this shift has been previously unexplored. Primary data collected through site visits to four private sector ACOs. Cross-sectional, semi-structured interview study with analysis done at the ACO level to learn about ACO development. One hundred and forty-eight interviews recorded and transcribed verbatim followed by rigorous qualitative analysis using a grounded theory approach. The importance of shifting organizational culture from volume to value was emphasized across sites and interviewees, particularly when defining an ACO; describing the shift in organizational focus to value; and discussing how to create value by emphasizing quality over volume. Value was viewed as more than cost-benefit, but rather encapsulated a paradigmatic cultural change in the way care is provided. We found that moving from volume to value is central to the culture change required of an ACO. Our findings can inform future efforts that aim to create a more effective value-based health care system.

Engaging telehealth to drive value-based urology

Telehealth, or the remote delivery of healthcare services using telecommunications technology, has the potential to revolutionize the delivery of healthcare and contribute to ongoing efforts to provide high-value care. We discuss several categories of telehealth that have been applied to healthcare. Several of these approaches, in particular video visits and teleconsultations, have promising early data demonstrating the significant benefits of telehealth technology with respect to the quality of care, access, cost savings, and patient experience. Nonetheless, considerable knowledge gaps still exist regarding how and for which patients and diseases telehealth modalities should be applied. Finally, we discuss the barriers to widespread adoption at the institutional, state, and federal levels. Maximizing the value of healthcare is an important goal for hospitals, physicians, and policymakers. Telehealth leverages advances in technology and the widespread availability of telecommunications devices to make healthcare communication more available, more convenient, and more efficient for patients and providers. With appropriate policies and incentives, telehealth initiatives can improve the value of urologic care and smooth the transition to a value-based healthcare system.

Modeling and simulation framework for value-based healthcare systems

Regardless of the coordination of its activities, a healthcare system is composed of a large number of distributed components that are interrelated by complex processes. Understanding the behavior of the overall system is becoming a major concern among healthcare managers and decision-makers. This paper presents a modeling and simulation framework to support a holistic analysis of healthcare systems through a stratification of the levels of abstraction into multiple perspectives and their integration in a common simulation framework. In each of the perspectives, models of different components of a healthcare system can be developed and coupled together. Concerns from other perspectives are abstracted as parameters, that is, we reflect the parameter values of other perspectives through explicit assumptions and simplifications in such models. Consequently, the resulting top model within each perspective can be coupled with its experimental frame to run simulations and derive results. Components of the various perspectives are integrated to provide a holistic view of the healthcare problem and system under study. The resulting global model can be coupled with a holistic experimental frame to derive results that cannot be accurately addressed in any of the perspectives taken alone. Furthermore, as we endeavored to allow perspective-specific experts to contribute to the modeling process, we took benefit of results originating from research efforts that Norbert Giambiasi initiated in the 2000s, which his PhD students further developed with their own PhD students.

The technological imperative for value-based health care.

The overarching principle of a value-based health-care strategy is to provide higher quality care at a lower cost. To achieve the goals of a value-based healthcare system is highly dependent on the availability and the effective use of technologies. This article explores the potential for the use of technology to enable value and the key design factors associated with their implementation in a value-based health-care system.

Primary and secondary care integration in delivery of value-based health-care systems.

The Five Year Forward View ( NHS England, 2014 ) endorses outcomes-based approaches and integrated care systems. This article looks at the role and functions of hospitals in value-based health-care systems, following Porter's value-based health-care framework. Changes will be required not only in the way health care is organized within a hospital in the form of so-called integrated practice units, but more importantly primary and secondary care will have to work together to realize value for patients across the health-care pathway and system. It will be necessary to build an enabling IT platform that facilitates an integrated dataset across primary and secondary care to measure outcomes and costs across patient pathways. Finally, new payment models will be required to remove current barriers and allow clinicians to do the right things for their patients without organizations being penalized. The final section describes current maturity of the system, opportunities and challenges in the UK.

Spinal cord injured women's treatment of breast carcinoma: alert to complications.

Women with spinal cord injury (SCI) and who develop breast cancer are a vulnerable and potentially overlooked population. They experience risk factors owing to decreased mobility and are at risk for unique complications from their oncologic treatment. A 54-year-old woman who suffered a T6 AIS A traumatic SCI in 1981, who was diagnosed 32 years later with estrogen receptor and progesterone receptor positive and human epidermal growth factor receptor 2-negative invasive ductal carcinoma. During the course of her chemotherapy, she experienced several complications, including reflexive diaphoresis, urinary tract infection, leukopenia, anemia, dehydration, and weakness. These contributed to the development of a stage 4 ischial pressure sore, which required complex treatment. There is a paucity of literature examining the complications of chemotherapy that may be unique to those with SCI. Physiatrists will be seeing more women undergoing oncologic care, as this population of patients ages. A multidisciplinary approach that takes into account the pathophysiologic changes associated with SCI is crucial to understand and prevent complications that could affect their outcomes and contribute to increased cost in a value-based health-care system.