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INTRODUCTION: The healthcare costs for treatment of community-acquired decubitus ulcers accounts for $11.6 billion in the United States annually. Patients with stage 3 and 4 decubitus ulcers are often treated inefficiently prior to reconstructive surgery while physicians attempt to optimize their condition (debridement, fecal/urinary diversion, physical therapy, nutrition, and obtaining durable medical goods). We hypothesized that hospital costs for inpatient optimization of decubitus ulcers would significantly differ from outpatient optimization costs, resulting in significant financial losses to the hospital and that transitioning optimization to an outpatient setting could reduce both total and hospital expenditures. In this study, we analyzed and compared the financial expenditures of optimizing patients with decubitus ulcers in an inpatient setting versus maximizing outpatient utilization of resources prior to reconstruction. METHODS: Encounters of patients with stage 3 or 4 decubitus ulcers over a 5-year period were investigated. These encounters were divided into two groups: Group 1 included patients who were optimized totally inpatient prior to reconstructive surgery; group 2 included patients who were mostly optimized in an outpatient setting and this encounter was a planned admission for their reconstructive surgery. Demographics, comorbidities, paralysis status, and insurance carriers were collected for all patients. Financial charges and reimbursements were compared among the groups. RESULTS: Forty-five encounters met criteria for inclusion. Group 1's average hospital charges were $500,917, while group 2's charges were $134,419. The cost of outpatient therapeutic items for patient optimization prior to wound closure was estimated to be $10,202 monthly. When including an additional debridement admission for group 2 patients (average of $108,031), the maximal charges for total care was $252,652, and hospital reimbursements were similar between group 1 and group 2 ($65,401 vs $50,860 respectively). CONCLUSIONS: The data derived from this investigation strongly suggests that optimizing patients in an outpatient setting prior to decubitus wound closure versus managing the patients totally on an inpatient basis will significantly reduce hospital charges, and hence costs, while minimally affecting reimbursements to the hospital.
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Úlcera por Presión , Humanos , Úlcera por Presión/economía , Úlcera por Presión/terapia , Úlcera por Presión/cirugía , Masculino , Femenino , Persona de Mediana Edad , Anciano , Atención Ambulatoria/economía , Estudios Retrospectivos , Estados Unidos , Costos de la Atención en Salud/estadística & datos numéricos , Costos de Hospital/estadística & datos numéricos , Hospitalización/economía , Procedimientos de Cirugía Plástica/economía , Procedimientos de Cirugía Plástica/métodos , Mejoramiento de la Calidad/economía , Adulto , Anciano de 80 o más AñosRESUMEN
BACKGROUND: Quality improvement (QI) programs require significant financial investment. The authors evaluated the cost-effectiveness of a physician-led, performance-incentivized, QI intervention that increased appropriate peripherally inserted central catheter (PICC) use. METHODS: The authors used an economic evaluation from a health care sector perspective. Implementation costs included incentive payments to hospitals and costs for data abstractors and the coordinating center. Effectiveness was calculated from propensity score-matched observations across two time periods for complications (venous thromboembolism [VTE], central line-associated bloodstream infection [CLABSI], and catheter occlusion): preintervention period (January 2015 through December 2016) and intervention period (January 2017 through December 2021). Cost-effectiveness was presented as the cost-offset per averted complication, reflecting the health care costs avoided due to having lower complication rates. RESULTS: Across 35 hospitals, this study sampled 17,418 PICCs placed preintervention and 26,004 placed during the intervention period. PICC complications decreased significantly following the intervention. CLABSIs decreased from 2.1% to 1.5%, VTEs from 3.2% to 2.3%, and catheter occlusions from 10.8% to 7.0% (all p < 0.01). Estimated number of complications prevented included 871 CLABSIs, 2,535 VTEs, and 8,743 catheter occlusions. Project implementation costs were $31.8 million, and the cost-offset related to avoided complications was $64.4 million. Each participating hospital averaged $932,073 in cost-offset over seven years, and the average cost-offset per complication averted was $2,614 (95% CI [confidence interval] $2,314-$3,003). CONCLUSION: A large-scale, multihospital QI initiative to improve appropriate PICC use yielded substantial return on investment from cost-offset of prevented complications.
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Infecciones Relacionadas con Catéteres , Cateterismo Periférico , Mejoramiento de la Calidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Obstrucción del Catéter , Infecciones Relacionadas con Catéteres/prevención & control , Infecciones Relacionadas con Catéteres/economía , Cateterismo Venoso Central/economía , Cateterismo Venoso Central/efectos adversos , Cateterismo Periférico/economía , Cateterismo Periférico/efectos adversos , Análisis de Costo-Efectividad , Mejoramiento de la Calidad/organización & administración , Mejoramiento de la Calidad/economía , Tromboembolia Venosa/prevención & control , Tromboembolia Venosa/economíaRESUMEN
BACKGROUND: Mohs micrographic surgery efficiently treats skin cancer through staged resection, but surgeons' varying resection rates may lead to higher medical costs. OBJECTIVE: To evaluate the cost savings associated with a quality improvement. MATERIALS AND METHODS: The authors conducted a retrospective cohort study using 100% Medicare fee-for-service claims data to identify the change of mean stages per case for head/neck (HN) and trunk/extremity (TE) lesions before and after the quality improvement intervention from 2016 to 2021. They evaluated surgeon-level change in mean stages per case between the intervention and control groups, as well as the cost savings to Medicare over the same time period. RESULTS: A total of 2,014 surgeons performed Mohs procedures on HN lesions. Among outlier surgeons who were notified, 31 surgeons (94%) for HN and 24 surgeons (89%) for TE reduced their mean stages per case with a median reduction of 0.16 and 0.21 stages, respectively. Reductions were also observed among outlier surgeons who were not notified, reducing their mean stages per case by 0.1 and 0.15 stages, respectively. The associated total 5-year savings after the intervention was 92 million USD. CONCLUSION: The implementation of this physician-led benchmarking model was associated with broad reductions of physician utilization and significant cost savings.
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Ahorro de Costo , Medicare , Cirugía de Mohs , Mejoramiento de la Calidad , Neoplasias Cutáneas , Humanos , Estudios Retrospectivos , Medicare/economía , Estados Unidos , Mejoramiento de la Calidad/economía , Ahorro de Costo/estadística & datos numéricos , Neoplasias Cutáneas/cirugía , Neoplasias Cutáneas/economía , Cirugía de Mohs/economía , Estudios de Seguimiento , Pautas de la Práctica en Medicina/economía , Pautas de la Práctica en Medicina/estadística & datos numéricos , Masculino , Femenino , Cirujanos/economía , Cirujanos/estadística & datos numéricos , Neoplasias de Cabeza y Cuello/cirugía , Neoplasias de Cabeza y Cuello/economíaRESUMEN
Importance: Infections due to multidrug-resistant organisms (MDROs) are associated with increased morbidity, mortality, length of hospitalization, and health care costs. Regional interventions may be advantageous in mitigating MDROs and associated infections. Objective: To evaluate whether implementation of a decolonization collaborative is associated with reduced regional MDRO prevalence, incident clinical cultures, infection-related hospitalizations, costs, and deaths. Design, Setting, and Participants: This quality improvement study was conducted from July 1, 2017, to July 31, 2019, across 35 health care facilities in Orange County, California. Exposures: Chlorhexidine bathing and nasal iodophor antisepsis for residents in long-term care and hospitalized patients in contact precautions (CP). Main Outcomes and Measures: Baseline and end of intervention MDRO point prevalence among participating facilities; incident MDRO (nonscreening) clinical cultures among participating and nonparticipating facilities; and infection-related hospitalizations and associated costs and deaths among residents in participating and nonparticipating nursing homes (NHs). Results: Thirty-five facilities (16 hospitals, 16 NHs, 3 long-term acute care hospitals [LTACHs]) adopted the intervention. Comparing decolonization with baseline periods among participating facilities, the mean (SD) MDRO prevalence decreased from 63.9% (12.2%) to 49.9% (11.3%) among NHs, from 80.0% (7.2%) to 53.3% (13.3%) among LTACHs (odds ratio [OR] for NHs and LTACHs, 0.48; 95% CI, 0.40-0.57), and from 64.1% (8.5%) to 55.4% (13.8%) (OR, 0.75; 95% CI, 0.60-0.93) among hospitalized patients in CP. When comparing decolonization with baseline among NHs, the mean (SD) monthly incident MDRO clinical cultures changed from 2.7 (1.9) to 1.7 (1.1) among participating NHs, from 1.7 (1.4) to 1.5 (1.1) among nonparticipating NHs (group × period interaction reduction, 30.4%; 95% CI, 16.4%-42.1%), from 25.5 (18.6) to 25.0 (15.9) among participating hospitals, from 12.5 (10.1) to 14.3 (10.2) among nonparticipating hospitals (group × period interaction reduction, 12.9%; 95% CI, 3.3%-21.5%), and from 14.8 (8.6) to 8.2 (6.1) among LTACHs (all facilities participating; 22.5% reduction; 95% CI, 4.4%-37.1%). For NHs, the rate of infection-related hospitalizations per 1000 resident-days changed from 2.31 during baseline to 1.94 during intervention among participating NHs, and from 1.90 to 2.03 among nonparticipating NHs (group × period interaction reduction, 26.7%; 95% CI, 19.0%-34.5%). Associated hospitalization costs per 1000 resident-days changed from $64â¯651 to $55â¯149 among participating NHs and from $55â¯151 to $59â¯327 among nonparticipating NHs (group × period interaction reduction, 26.8%; 95% CI, 26.7%-26.9%). Associated hospitalization deaths per 1000 resident-days changed from 0.29 to 0.25 among participating NHs and from 0.23 to 0.24 among nonparticipating NHs (group × period interaction reduction, 23.7%; 95% CI, 4.5%-43.0%). Conclusions and Relevance: A regional collaborative involving universal decolonization in long-term care facilities and targeted decolonization among hospital patients in CP was associated with lower MDRO carriage, infections, hospitalizations, costs, and deaths.
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Antiinfecciosos Locales , Infecciones Bacterianas , Infección Hospitalaria , Farmacorresistencia Bacteriana Múltiple , Instituciones de Salud , Control de Infecciones , Anciano , Humanos , Administración Intranasal , Antiinfecciosos Locales/administración & dosificación , Antiinfecciosos Locales/uso terapéutico , Infecciones Bacterianas/economía , Infecciones Bacterianas/microbiología , Infecciones Bacterianas/mortalidad , Infecciones Bacterianas/prevención & control , Baños/métodos , California/epidemiología , Clorhexidina/administración & dosificación , Clorhexidina/uso terapéutico , Infección Hospitalaria/economía , Infección Hospitalaria/microbiología , Infección Hospitalaria/mortalidad , Infección Hospitalaria/prevención & control , Instituciones de Salud/economía , Instituciones de Salud/normas , Instituciones de Salud/estadística & datos numéricos , Hospitalización/economía , Hospitalización/estadística & datos numéricos , Hospitales/normas , Hospitales/estadística & datos numéricos , Control de Infecciones/métodos , Yodóforos/administración & dosificación , Yodóforos/uso terapéutico , Casas de Salud/economía , Casas de Salud/normas , Casas de Salud/estadística & datos numéricos , Transferencia de Pacientes , Mejoramiento de la Calidad/economía , Mejoramiento de la Calidad/estadística & datos numéricos , Cuidados de la Piel/métodos , Precauciones UniversalesRESUMEN
Importance: US hospitals report data on many health care quality metrics to government and independent health care rating organizations, but the annual cost to acute care hospitals of measuring and reporting quality metric data, independent of resources spent on quality interventions, is not well known. Objective: To evaluate externally reported inpatient quality metrics for adult patients and estimate the cost of data collection and reporting, independent of quality-improvement efforts. Design, Setting, and Participants: Retrospective time-driven activity-based costing study at the Johns Hopkins Hospital (Baltimore, Maryland) with hospital personnel involved in quality metric reporting processes interviewed between January 1, 2019, and June 30, 2019, about quality reporting activities in the 2018 calendar year. Main Outcomes and Measures: Outcomes included the number of metrics, annual person-hours per metric type, and annual personnel cost per metric type. Results: A total of 162 unique metrics were identified, of which 96 (59.3%) were claims-based, 107 (66.0%) were outcome metrics, and 101 (62.3%) were related to patient safety. Preparing and reporting data for these metrics required an estimated 108â¯478 person-hours, with an estimated personnel cost of $5â¯038â¯218.28 (2022 USD) plus an additional $602â¯730.66 in vendor fees. Claims-based (96 metrics; $37â¯553.58 per metric per year) and chart-abstracted (26 metrics; $33â¯871.30 per metric per year) metrics used the most resources per metric, while electronic metrics consumed far less (4 metrics; $1901.58 per metric per year). Conclusions and Relevance: Significant resources are expended exclusively for quality reporting, and some methods of quality assessment are far more expensive than others. Claims-based metrics were unexpectedly found to be the most resource intensive of all metric types. Policy makers should consider reducing the number of metrics and shifting to electronic metrics, when possible, to optimize resources spent in the overall pursuit of higher quality.
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Hospitales , Reportes Públicos de Datos en Atención de Salud , Mejoramiento de la Calidad , Calidad de la Atención de Salud , Humanos , Atención a la Salud/economía , Atención a la Salud/normas , Atención a la Salud/estadística & datos numéricos , Hospitales/normas , Hospitales/estadística & datos numéricos , Hospitales/provisión & distribución , Mejoramiento de la Calidad/economía , Mejoramiento de la Calidad/normas , Mejoramiento de la Calidad/estadística & datos numéricos , Calidad de la Atención de Salud/economía , Calidad de la Atención de Salud/estadística & datos numéricos , Estudios Retrospectivos , Adulto , Estados Unidos/epidemiología , Revisión de Utilización de Seguros/economía , Revisión de Utilización de Seguros/normas , Revisión de Utilización de Seguros/estadística & datos numéricos , Seguridad del Paciente/economía , Seguridad del Paciente/normas , Seguridad del Paciente/estadística & datos numéricos , Economía Hospitalaria/estadística & datos numéricosRESUMEN
Importance: Bundled Payments for Care Improvement Advanced (BPCI-A) is a Centers for Medicare & Medicaid Services (CMS) initiative that aims to produce financial savings by incentivizing decreases in clinical spending. Incentives consist of financial bonuses from CMS to hospitals or penalties paid by hospitals to CMS. Objective: To investigate the association of hospital participation in BPCI-A with spending, and to characterize hospitals receiving financial bonuses vs penalties. Design, Setting, and Participants: Difference-in-differences and cross-sectional analyses of 4â¯754â¯139 patient episodes using 2013-2019 US Medicare claims at 694 participating and 2852 nonparticipating hospitals merged with hospital and market characteristics. Exposures: BPCI-A model years 1 and 2 (October 1, 2018, through December 31, 2019). Main Outcomes and Measures: Hospitals' per-episode spending, CMS gross and net spending, and the incentive allocated to each hospital. Results: The study identified 694 participating hospitals. The analysis observed a -$175 change in mean per-episode spending (95% CI, -$378 to $28) and an aggregate spending change of -$75.1 million (95% CI, -$162.1 million to $12.0 million) across the 428â¯670 episodes in BPCI-A model years 1 and 2. However, CMS disbursed $354.3 million (95% CI, $212.0 million to $496.0 million) more in bonuses than it received in penalties. Hospital participation in BPCI-A was associated with a net loss to CMS of $279.2 million (95% CI, $135.0 million to $423.0 million). Hospitals in the lowest quartile of Medicaid days received a mean penalty of $0.41 million; (95% CI, $0.09 million to $0.72 million), while those in the highest quartile received a mean bonus of $1.57 million; (95% CI, $1.09 million to $2.08 million). Similar patterns were observed for hospitals across increasing quartiles of Disproportionate Share Hospital percentage and of patients from racial and ethnic minority groups. Conclusions and Relevance: Among US hospitals measured between 2013 and 2019, participation in BPCI-A was significantly associated with an increase in net CMS spending. Bonuses accrued disproportionately to hospitals providing care for marginalized communities.
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Costos de Hospital , Medicare , Motivación , Paquetes de Atención al Paciente , Mejoramiento de la Calidad , Anciano , Humanos , Estudios Transversales , Etnicidad/estadística & datos numéricos , Hospitales/normas , Hospitales/estadística & datos numéricos , Medicare/economía , Medicare/normas , Grupos Minoritarios/estadística & datos numéricos , Estados Unidos/epidemiología , Paquetes de Atención al Paciente/economía , Paquetes de Atención al Paciente/normas , Paquetes de Atención al Paciente/estadística & datos numéricos , Costos de Hospital/estadística & datos numéricos , Mejoramiento de la Calidad/economía , Mejoramiento de la Calidad/normas , Mejoramiento de la Calidad/estadística & datos numéricos , Marginación SocialRESUMEN
INTRODUCTION: Every year 2.4 million deaths occur worldwide in babies younger than 28 days. Approximately 70% of these deaths occur in low-resource settings because of failure to implement evidence-based interventions. Digital health technologies may offer an implementation solution. Since 2014, we have worked in Bangladesh, Malawi, Zimbabwe and the UK to develop and pilot Neotree: an android app with accompanying data visualisation, linkage and export. Its low-cost hardware and state-of-the-art software are used to improve bedside postnatal care and to provide insights into population health trends, to impact wider policy and practice. METHODS AND ANALYSIS: This is a mixed methods (1) intervention codevelopment and optimisation and (2) pilot implementation evaluation (including economic evaluation) study. Neotree will be implemented in two hospitals in Zimbabwe, and one in Malawi. Over the 2-year study period clinical and demographic newborn data will be collected via Neotree, in addition to behavioural science informed qualitative and quantitative implementation evaluation and measures of cost, newborn care quality and usability. Neotree clinical decision support algorithms will be optimised according to best available evidence and clinical validation studies. ETHICS AND DISSEMINATION: This is a Wellcome Trust funded project (215742_Z_19_Z). Research ethics approvals have been obtained: Malawi College of Medicine Research and Ethics Committee (P.01/20/2909; P.02/19/2613); UCL (17123/001, 6681/001, 5019/004); Medical Research Council Zimbabwe (MRCZ/A/2570), BRTI and JREC institutional review boards (AP155/2020; JREC/327/19), Sally Mugabe Hospital Ethics Committee (071119/64; 250418/48). Results will be disseminated via academic publications and public and policy engagement activities. In this study, the care for an estimated 15 000 babies across three sites will be impacted. TRIAL REGISTRATION NUMBER: NCT0512707; Pre-results.
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Salud del Lactante , Atención Posnatal , Mejoramiento de la Calidad , Telemedicina , Algoritmos , Sistemas de Apoyo a Decisiones Clínicas/normas , Recursos en Salud , Humanos , Salud del Lactante/economía , Salud del Lactante/normas , Recién Nacido , Malaui , Aplicaciones Móviles , Proyectos Piloto , Atención Posnatal/economía , Atención Posnatal/métodos , Atención Posnatal/normas , Pobreza , Desarrollo de Programa/economía , Desarrollo de Programa/normas , Mejoramiento de la Calidad/economía , Mejoramiento de la Calidad/normas , Calidad de la Atención de Salud/economía , Calidad de la Atención de Salud/normas , Telemedicina/economía , Telemedicina/métodos , Telemedicina/normas , ZimbabweRESUMEN
Importance: Preoperative optimization is an important clinical strategy for reducing morbidity; however, nearly 25% of persons undergoing elective abdominal hernia repairs are not optimized with respect to weight or substance use. Although the preoperative period represents a unique opportunity to motivate patient health behavior changes, fear of emergent presentation and financial concerns are often cited as clinician barriers to optimization. Objective: To evaluate the feasibility of evidence-based patient optimization before surgery by implementing a low-cost preoperative optimization clinic. Design, Setting, and Participants: This quality improvement study was conducted 1 year after a preoperative optimization clinic was implemented for high-risk patients seeking elective hernia repair. The median (range) follow-up was 197 (39-378) days. A weekly preoperative optimization clinic was implemented in 2019 at a single academic center. Referral occurred for persons seeking elective hernia repair with a body mass index greater than or equal to 40, age 75 years or older, or active tobacco use. Data analysis was performed from February to July 2020. Exposures: Enrolled patients were provided health resources and longitudinal multidisciplinary care. Main Outcomes and Measures: The primary outcomes were safety and eligibility for surgery after participating in the optimization clinic. The hypothesis was that the optimization clinic could preoperatively mitigate patient risk factors, without increasing patient risk. Safety was defined as the occurrence of complications during participation in the optimization clinic. The secondary outcome metric centered on the financial impact of implementing the preoperative optimization program. Results: Of the 165 patients enrolled in the optimization clinic, most were women (90 patients [54.5%]) and White (145 patients [87.9%]). The mean (SD) age was 59.4 (15.8) years. Patients' eligibility for the clinic was distributed across high-risk criteria: 37.0% (61 patients) for weight, 26.1% (43 patients) for tobacco use, and 23.6% (39 patients) for age. Overall, 9.1% of persons (15 patients) were successfully optimized for surgery, and tobacco cessation was achieved in 13.8% of smokers (8 patients). The rate of hernia incarceration requiring emergent surgery was 3.0% (5 patients). Economic evaluation found increased operative yield from surgical clinics, with a 58% increase in hernia-attributed relative value units without altering surgeon workflow. Conclusions and Relevance: In this quality improvement study, a hernia optimization clinic safely improved management of high-risk patients and increased operative yield for the institution. This represents an opportunity to create sustainable and scalable models that provide longitudinal care and optimize patients to improve outcomes of hernia repair.
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Herniorrafia , Complicaciones Posoperatorias/prevención & control , Mejoramiento de la Calidad , Medición de Riesgo/métodos , Adulto , Anciano , Índice de Masa Corporal , Árboles de Decisión , Procedimientos Quirúrgicos Electivos , Femenino , Hernia , Herniorrafia/economía , Humanos , Masculino , Michigan , Persona de Mediana Edad , Obesidad/complicaciones , Mejoramiento de la Calidad/economía , Medición de Riesgo/economía , Factores de Riesgo , Cese del Hábito de Fumar , Resultado del TratamientoRESUMEN
BACKGROUND: Plastic surgeons are evaluated not only by the number of patients served but also by relative value, quantified by the Medicare relative value unit system, which can affect advancement and compensation. Procedures that demand a high operative time without an increase in relative value units are, by definition, inefficient. The purpose of this study was to determine whether the number of relative value units actually corresponds to operative time. METHODS: The National Surgical Quality Improvement Program data sets over a 9-year period were queried for plastic surgery operations. The primary CPT codes representing the 100 most common operations were compared for operative time and total relative value units. RESULTS: A total of 53,701 cases were included. There was a high degree of correlation between operative time and number of relative value units (Pearson correlation coefficient, 0.82). The average efficiency was 10.201 ± 3.386 relative value units per hour. Pressure ulcer excisions and breast reconstruction were among the most efficient (e.g., Excision, sacral pressure ulcer, CPT 19357, generated 20.819 relative value units per hour). Skin excisions, débridements, and flap delays were among the least efficient (e.g., Excision, excessive skin and subcutaneous tissue, CPT 15847, generated 1.752 relative value units per hour). CONCLUSIONS: As a general trend, the most common plastic surgical procedures requiring longer operative times are associated with more relative value units. Cases with higher relative value units assigned tended to be more efficient. For the 100 most common procedures, relative value units and operative time are not evenly distributed. These data suggest modifications to the current relative value unit designation system to more equally allocate these units based on effort and time.
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Tempo Operativo , Procedimientos de Cirugía Plástica/economía , Escalas de Valor Relativo , Current Procedural Terminology , Conjuntos de Datos como Asunto , Humanos , Mejoramiento de la Calidad/economía , Mejoramiento de la Calidad/normas , Procedimientos de Cirugía Plástica/normas , Cirujanos/economía , Cirujanos/normas , Estados UnidosRESUMEN
BACKGROUND: The Center for Medicare and Medicaid Innovation launched the Medicare Bundled Payments for Care Improvement-Advanced (BPCI-A) program for hospitals in October 2018. Information is needed about the effects of the program on health care utilization and Medicare payments. METHODS: We conducted a modified segmented regression analysis using Medicare claims and including patients with discharge dates from January 2017 through September 2019 to assess differences between BPCI-A participants and two control groups: hospitals that never joined the BPCI-A program (nonjoining hospitals) and hospitals that joined the BPCI-A program in January 2020, after the conclusion of the intervention period (late-joining hospitals). The primary outcomes were the differences in changes in quarterly trends in 90-day per-episode Medicare payments and the percentage of patients with readmission within 90 days after discharge. Secondary outcomes were mortality, volume, and case mix. RESULTS: A total of 826 BPCI-A participant hospitals were compared with 2016 nonjoining hospitals and 334 late-joining hospitals. Among BPCI-A hospitals, the mean baseline 90-day per-episode Medicare payment was $27,315; the change in the quarterly trends in the intervention period as compared with baseline was -$78 per quarter. Among nonjoining hospitals, the mean baseline 90-day per-episode Medicare payment was $25,994; the change in quarterly trends as compared with baseline was -$26 per quarter (difference between nonjoining hospitals and BPCI-A hospitals, $52 [95% confidence interval {CI}, 34 to 70] per quarter; P<0.001; 0.2% of the baseline payment). Among late-joining hospitals, the mean baseline 90-day per-episode Medicare payment was $26,807; the change in the quarterly trends as compared with baseline was $4 per quarter (difference between late-joining hospitals and BPCI-A hospitals, $82 [95% CI, 41 to 122] per quarter; P<0.001; 0.3% of the baseline payment). There were no meaningful differences in the changes with regard to readmission, mortality, volume, or case mix. CONCLUSIONS: The BPCI-A program was associated with small reductions in Medicare payments among participating hospitals as compared with control hospitals. (Funded by the National Heart, Lung, and Blood Institute.).
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Economía Hospitalaria , Medicare/economía , Paquetes de Atención al Paciente/economía , Mejoramiento de la Calidad/economía , Mecanismo de Reembolso , Anciano , Anciano de 80 o más Años , Grupos Diagnósticos Relacionados , Episodio de Atención , Femenino , Insuficiencia Cardíaca/terapia , Hospitales/normas , Hospitales/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Mortalidad , Readmisión del Paciente/estadística & datos numéricos , Análisis de Regresión , Estados UnidosAsunto(s)
Prueba de COVID-19/métodos , COVID-19/diagnóstico , Arquitectura y Construcción de Instituciones de Salud/métodos , Control de Infecciones/métodos , Servicio Ambulatorio en Hospital , Filtros de Aire , Boston , Prueba de COVID-19/economía , Diseño de Equipo , Ergonomía , Arquitectura y Construcción de Instituciones de Salud/economía , Implementación de Plan de Salud , Humanos , Control de Infecciones/economía , Control de Infecciones/normas , Servicio Ambulatorio en Hospital/economía , Equipo de Protección Personal/estadística & datos numéricos , Mejoramiento de la Calidad/economía , Estudios Retrospectivos , SARS-CoV-2RESUMEN
OBJECTIVES: The Quality in Acute Stroke Care (QASC) protocol is a multidisciplinary approach to implement evidence-based treatment after acute stroke that reduces death and disability. This study sought to evaluate the cost-effectiveness of implementing the QASC protocol across Australia, from a healthcare and a societal perspective. MATERIALS AND METHODS: A decision-analytic model was constructed to reflect one-year outcomes post-stroke, aligned with the stroke severity categories of the modified Rankin scale (mRS). Decision analysis compared outcomes following implementation of the QASC protocol versus no implementation. Population data were extracted from Australian databases and data inputs regarding stroke incidence, costs, and utilities were drawn from published sources. The analysis assumed a progressive uptake and efficacy of the QASC protocol over five years. Health benefits and costs were discounted by 5% annually. The cost of each year lived by an Australian, from a societal perspective, was based on the Australian Government's 'value of statistical life year' (AUD 213,000). RESULTS: Over five years, the model predicted 263,722 strokes among the Australian population. The implementation of the QASC protocol was predicted to prevent 1,154 deaths and yield a gain of 876 years of life (0.003 per stroke), and 3,180 quality-adjusted life years (QALYs) (0.012 per stroke). There was an estimated net saving of AUD 65.2 million in healthcare costs (AUD 247 per stroke) and AUD 251.7 million in societal costs (AUD 955 per stroke). CONCLUSIONS: Implementation of the QASC protocol in Australia represents both a dominant (cost-saving) strategy, from a healthcare and a societal perspective.
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Protocolos Clínicos , Costos de la Atención en Salud , Evaluación de Procesos y Resultados en Atención de Salud/economía , Mejoramiento de la Calidad/economía , Indicadores de Calidad de la Atención de Salud/economía , Accidente Cerebrovascular/terapia , Australia/epidemiología , Ahorro de Costo , Análisis Costo-Beneficio , Técnicas de Apoyo para la Decisión , Evaluación de la Discapacidad , Estado Funcional , Humanos , Incidencia , Evaluación de Programas y Proyectos de Salud , Calidad de Vida , Años de Vida Ajustados por Calidad de Vida , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/epidemiología , Factores de Tiempo , Resultado del TratamientoRESUMEN
Patient-reported outcomes (PROs) are elicited directly from patients so they can describe their overall health status, including their symptoms, function, and quality of life. While commonly used as end points in clinical trials, PROs can play an important role in routine clinical care, population health management, and as a means for quantifying the quality of patient care. In this review, we propose that PROs be used to improve patient-centered care in the treatment of cardiovascular diseases given their importance to patients and society and their ability to improve doctor- provider communication. Furthermore, given the current variability in patients' health status across different clinics and the fact that PROs can be improved by titrating therapy, we contend that PROs have a key opportunity to serve as measures of healthcare quality.
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Enfermedades Cardiovasculares/terapia , Evaluación de Procesos y Resultados en Atención de Salud/normas , Medición de Resultados Informados por el Paciente , Atención Dirigida al Paciente/normas , Mejoramiento de la Calidad/normas , Indicadores de Calidad de la Atención de Salud/normas , Enfermedades Cardiovasculares/diagnóstico , Enfermedades Cardiovasculares/economía , Análisis Costo-Beneficio , Estado Funcional , Costos de la Atención en Salud , Humanos , Evaluación de Procesos y Resultados en Atención de Salud/economía , Atención Dirigida al Paciente/economía , Psicometría , Mejoramiento de la Calidad/economía , Indicadores de Calidad de la Atención de Salud/economía , Calidad de Vida , Resultado del TratamientoRESUMEN
OBJECTIVE: Accurate documentation of patient care and acuity is essential to determine appropriate reimbursement as well as accuracy of key publicly reported quality metrics. We sought to investigate the impact of standardized note templates by inpatient advanced practice providers (APPs) on evaluation and management (E/M) charge capture, including outside of the global surgical package (GSP), and quality metrics including case mix index (CMI) and mortality index (MI). We hypothesized this clinical documentation initiative as well as improved coding of E/M services would result in increased reimbursement and quality metrics. METHODS: A documentation and coding initiative on the heart and vascular service line was initiated in 2016 with focus on improving inpatient E/M capture by APPs outside the GSP. Comprehensive training sessions and standardized documentation templates were created and implemented in the electronic medical record. Subsequent hospital care E/M (current procedural terminology codes 99231, 99232, 99233) from the years 2015 to 2017 were audited and analyzed for charge capture rates, collections, work relative value units (wRVUs), and billing complexity. Data were compared over time by standardizing CMS values and reimbursement rates. In addition, overall CMI and MI were calculated each year. RESULTS: One year following the documentation initiative, E/M charges on the vascular surgery service line increased by 78.5% with a corresponding increase in APP charges from 0.4% of billable E/M services to 70.4% when compared with pre-initiative data. The charge capture of E/M services among all inpatients rose from 21.4% to 37.9%. Additionally, reimbursement from CMS increased by 65% as total work relative value units generated from E/M services rose by 78.4% (797 to 1422). The MI decreased over the study period by 25.4%. Additionally, there was a corresponding 5.6% increase in the cohort CMI. Distribution of E/M encounter charges did not vary significantly. Meanwhile, the prevalence of 14 clinical comorbidities in our cohort as well as length of stay (P = .88) remained non-statistically different throughout the study period. CONCLUSIONS: Accurate clinical documentation of E/M care and ultimately inpatient acuity is critical in determining quality metrics that serve as important measures of overall hospital quality for CMS value-based payments and rankings. A system-based documentation initiative and expanded role of inpatient APPs on vascular surgery teams significantly improved charge capture and reimbursement outside the GSP as well as CMI and MI in a consistently complex patient population.
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Técnicos Medios en Salud/economía , Documentación/economía , Costos de la Atención en Salud , Reembolso de Seguro de Salud/economía , Gravedad del Paciente , Manejo de Atención al Paciente/economía , Garantía de la Calidad de Atención de Salud/economía , Indicadores de Calidad de la Atención de Salud/economía , Procedimientos Quirúrgicos Vasculares/economía , Anciano , Anciano de 80 o más Años , Técnicos Medios en Salud/normas , Documentación/normas , Femenino , Costos de la Atención en Salud/normas , Humanos , Reembolso de Seguro de Salud/normas , Masculino , Persona de Mediana Edad , Manejo de Atención al Paciente/normas , Garantía de la Calidad de Atención de Salud/normas , Mejoramiento de la Calidad/economía , Mejoramiento de la Calidad/normas , Indicadores de Calidad de la Atención de Salud/normas , Estudios Retrospectivos , Estados Unidos , Procedimientos Quirúrgicos Vasculares/normasRESUMEN
OBJECTIVES: To experiment with new approaches of collaboration in healthcare delivery, local authorities implement new models of care. Regarding the local decision context of these models, multi-criteria decision analysis (MCDA) may be of added value to cost-utility analysis (CUA), because it covers a wider range of outcomes. This study compares the 2 methods using a side-by-side application. METHODS: A new Dutch model of care, Primary Care Plus (PC+), was used as a case study to compare the results of CUA and MCDA. Data of patients referred to PC+ or care-as-usual were retrieved by questionnaires and administrative databases with a 3-month follow-up. Propensity score matching together with generalized linear regression models was used to reduce confounding. Univariate and probabilistic sensitivity analyses were performed to explore uncertainty in the results. RESULTS: Although both methods indicated PC+ as the dominant alternative, complementary differences were observed. MCDA provided additional evidence that PC+ improved access to care (standardized performance score of 0.742 vs 0.670) and that improvement in health-related quality of life was driven by the psychological well-being component (standardized performance score of 0.710 vs 0.704). Furthermore, MCDA estimated the budget required for PC+ to be affordable in addition to preferable (521.42 per patient). Additionally, MCDA was less sensitive to the utility measures used. CONCLUSIONS: MCDA may facilitate an auditable and transparent evaluation of new models of care by providing additional information on a wider range of outcomes and incorporating affordability. However, more effort is needed to increase the usability of MCDA among local decision makers.
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Técnicas de Apoyo para la Decisión , Atención a la Salud/economía , Costos de la Atención en Salud , Modelos Económicos , Atención Primaria de Salud/economía , Regionalización/economía , Adulto , Anciano , Conducta de Elección , Investigación sobre la Eficacia Comparativa , Análisis Costo-Beneficio , Femenino , Accesibilidad a los Servicios de Salud/economía , Humanos , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Países Bajos , Satisfacción del Paciente/economía , Estudios Prospectivos , Mejoramiento de la Calidad/economía , Indicadores de Calidad de la Atención de Salud/economía , Participación de los InteresadosRESUMEN
BACKGROUND: In 2015, a quality improvement project of childbirth care called Adequate Childbirth Project ("Projeto Parto Adequado"- PPA) was implemented in Brazilian public and private hospitals, aiming to improve the quality of childbirth care and to reduce caesarean sections without clinical indications. The objective of this study is to conduct an economic analysis of two models of care existing in a private Brazilian hospital-the model following the recommendations of the PPA and the standard of care model-in reducing the proportion of caesarean sections. METHODS: We conducted a cost-effectiveness analysis using data from one of the private hospitals included in the PPA project. The main outcome was the proportion of caesarean section. We used total cost of hospitalization for women and newborns, from the health care sector perspective, during the length of the observed hospital stay. We did not apply discount rates and inflation rate adjustments due to the short time horizon. We conducted univariate sensitivity analysis using the minimum and maximum costs observed in hospitalizations and variation in the probabilities of caesarean section and of maternal and neonatal complications. RESULTS: 238 puerperal women were included in this analysis. The PPA model of care resulted in a 56.9 percentage point reduction in the caesarean section probability (88.6% vs 31.7%, p < 0.001) with an incremental cost-effectiveness ratio of US$1,237.40 per avoided caesarean section. Women in the PPA model of care also had a higher proportion of spontaneous and induced labor and a lower proportion of early term births. There were no maternal, fetal or neonatal deaths and no significant differences in cases of maternal and neonatal near miss. The cost of uncomplicated vaginal births and caesarean sections was the parameter with the greatest impact on the cost-effectiveness ratio of the PPA model of care. CONCLUSION: The PPA model of care was cost-effective in reducing caesarean sections in women assisted in a Brazilian private hospital. Moreover, it reduced the frequency of early term births and did not increase the occurrence of severe negative maternal and neonatal outcomes.
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Cesárea/estadística & datos numéricos , Hospitales Privados/estadística & datos numéricos , Mejoramiento de la Calidad/economía , Brasil , Análisis Costo-Beneficio , Femenino , Humanos , Recién Nacido , EmbarazoRESUMEN
BACKGROUND: There is growing interest in paying for performance (P4P) as a means to align the incentives of healthcare providers with public health goals. Rigorous evidence on the effectiveness of these strategies in improving health care and health in low- and middle-income countries (LMICs) is lacking; this is an update of the 2012 review on this topic. OBJECTIVES: To assess the effects of paying for performance on the provision of health care and health outcomes in low- and middle-income countries. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, and 10 other databases between April and June 2018. We also searched two trial registries, websites, online resources of international agencies, organizations and universities, and contacted experts in the field. Studies identified from rerunning searches in 2020 are under 'Studies awaiting classification.' SELECTION CRITERIA: We included randomized or non-randomized trials, controlled before-after studies, or interrupted time series studies conducted in LMICs (as defined by the World Bank in 2018). P4P refers to the transfer of money or material goods conditional on taking a measurable action or achieving a predetermined performance target. To be included, a study had to report at least one of the following outcomes: patient health outcomes, changes in targeted measures of provider performance (such as the delivery of healthcare services), unintended effects, or changes in resource use. DATA COLLECTION AND ANALYSIS: We extracted data as per original review protocol and narratively synthesised findings. We used standard methodological procedures expected by Cochrane. Given diversity and variability in intervention types, patient populations, analyses and outcome reporting, we deemed meta-analysis inappropriate. We noted the range of effects associated with P4P against each outcome of interest. Based on intervention descriptions provided in documents, we classified design schemes and explored variation in effect by scheme design. MAIN RESULTS: We included 59 studies: controlled before-after studies (19), non-randomized (16) or cluster randomized trials (14); and interrupted time-series studies (9). One study included both an interrupted time series and a controlled before-after study. Studies focused on a wide range of P4P interventions, including target payments and payment for outputs as modified by quality (or quality and equity assessments). Only one study assessed results-based aid. Many schemes were funded by national governments (23 studies) with the World Bank funding most externally funded schemes (11 studies). Targeted services varied; however, most interventions focused on reproductive, maternal and child health indicators. Participants were predominantly located in public or in a mix of public, non-governmental and faith-based facilities (54 studies). P4P was assessed predominantly at health facility level, though districts and other levels were also involved. Most studies assessed the effects of P4P against a status quo control (49 studies); however, some studies assessed effects against comparator interventions (predominantly enhanced financing intended to match P4P funds (17 studies)). Four studies reported intervention effects against both comparator and status quo. Controlled before-after studies were at higher risk of bias than other study designs. However, some randomised trials were also downgraded due to risk of bias. The interrupted time-series studies provided insufficient information on other concurrent changes in the study context. P4P compared to a status quo control For health services that are specifically targeted, P4P may slightly improve health outcomes (low certainty evidence), but few studies assessed this. P4P may also improve service quality overall (low certainty evidence); and probably increases the availability of health workers, medicines and well-functioning infrastructure and equipment (moderate certainty evidence). P4P may have mixed effects on the delivery and use of services (low certainty evidence) and may have few or no distorting unintended effects on outcomes that were not targeted (low-certainty evidence), but few studies assessed these. For secondary outcomes, P4P may make little or no difference to provider absenteeism, motivation or satisfaction (low certainty evidence); but may improve patient satisfaction and acceptability (low certainty evidence); and may positively affect facility managerial autonomy (low certainty evidence). P4P probably makes little to no difference to management quality or facility governance (low certainty evidence). Impacts on equity were mixed (low certainty evidence). For health services that are untargeted, P4P probably improves some health outcomes (moderate certainty evidence); may improve the delivery, use and quality of some health services but may make little or no difference to others (low certainty evidence); and may have few or no distorting unintended effects (low certainty evidence). The effects of P4P on the availability of medicines and other resources are uncertain (very low certainty evidence). P4P compared to other strategies For health outcomes and services that are specifically targeted, P4P may make little or no difference to health outcomes (low certainty evidence), but few studies assessed this. P4P may improve service quality (low certainty evidence); and may have mixed effects on the delivery and use of health services and on the availability of equipment and medicines (low certainty evidence). For health outcomes and services that are untargeted, P4P may make little or no difference to health outcomes and to the delivery and use of health services (low certainty evidence). The effects of P4P on service quality, resource availability and unintended effects are uncertain (very low certainty evidence). Findings of subgroup analyses Results-based aid, and schemes using payment per output adjusted for service quality, appeared to yield the greatest positive effects on outcomes. However, only one study evaluated results-based aid, so the effects may be spurious. Overall, schemes adjusting both for quality of service and rewarding equitable delivery of services appeared to perform best in relation to service utilization outcomes. AUTHORS' CONCLUSIONS: The evidence base on the impacts of P4P schemes has grown considerably, with study quality gradually increasing. P4P schemes may have mixed effects on outcomes of interest, and there is high heterogeneity in the types of schemes implemented and evaluations conducted. P4P 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 (e.g., who receives payments ), the amount of additional funding, ancillary components (such as technical support) and contextual factors (including organizational context).
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Países en Desarrollo , Mejoramiento de la Calidad/economía , Reembolso de Incentivo , Sesgo , Estudios Controlados Antes y Después , Humanos , Análisis de Series de Tiempo Interrumpido , Ensayos Clínicos Controlados no Aleatorios como Asunto , Mejoramiento de la Calidad/normas , Calidad de la Atención de Salud/economía , Calidad de la Atención de Salud/normasRESUMEN
OBJECTIVE. The purpose of this study was to describe the results of an ongoing program implemented in an academic radiology department to support the execution of small- to medium-size improvement projects led by frontline staff and leaders. MATERIALS AND METHODS. Staff members were assigned a coach, were instructed in improvement methods, were given time to work on the project, and presented progress to department leaders in weekly 30-minute reports. Estimated costs and outcomes were calculated for each project and aggregated. An anonymous survey was administered to participants at the end of the first year. RESULTS. A total of 73 participants completed 102 projects in the first 2 years of the program. The project type mix included 25 quality improvement projects, 22 patient satisfaction projects, 14 staff engagement projects, 27 efficiency improvement projects, and 14 regulatory compliance and readiness projects. Estimated annualized outcomes included approximately 4500 labor hours saved, $315K in supply cost savings, $42.2M in potential increased revenues, 8- and 2-point increase in top-box patient experience scores at two clinics, and a 60-incident reduction in near-miss safety events. Participant time equated to approximately 0.35 full-time equivalent positions per year. Approximately 0.4 full-time equivalent was required to support the program. Survey results indicated that the participants generally viewed the program favorably. CONCLUSION. The program was successful in providing a platform for simultaneously solving a large number of organizational problems while also providing a positive experience to frontline personnel.
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Centros Médicos Académicos , Eficiencia Organizacional/estadística & datos numéricos , Encuestas de Atención de la Salud/métodos , Evaluación de Programas y Proyectos de Salud/métodos , Mejoramiento de la Calidad/estadística & datos numéricos , Servicio de Radiología en Hospital/estadística & datos numéricos , Encuestas de Atención de la Salud/estadística & datos numéricos , Humanos , Mejoramiento de la Calidad/economía , Servicio de Radiología en Hospital/economíaRESUMEN
A recent analysis highlights waste and missed opportunities to improve outcomes.
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Gastos en Salud/estadística & datos numéricos , Instituciones de Salud/economía , Instituciones de Salud/estadística & datos numéricos , Salud Poblacional/estadística & datos numéricos , Mejoramiento de la Calidad/economía , Mejoramiento de la Calidad/estadística & datos numéricos , Humanos , Estados UnidosRESUMEN
OBJECTIVE: The prevailing approaches to selecting multiple sclerosis (MS) disease modifying therapies (DMTs) have contributed to exponential increases in societal expenditures and out-of-pocket expenses, without compelling evidence of improved outcomes. Guidance is lacking regarding when and in whom the benefits of preventing MS-related disability likely outweighs the risks of highly effective DMTs (HET) and when it is appropriate to consider DMT costs. Our objective was to develop a standardized approach to improve the quality, affordability and equity of MS care. METHODS: MS experts partnered with health plan pharmacists to develop an ethical, risk-stratified, cost-sensitive treatment algorithm. We developed a risk-stratification schema to classify patients with relapsing forms of MS as high, intermediate or low risk of disability based on the best available evidence and, when the evidence was poor or lacking, by consensus. DMTs are grouped as highly, modestly or low/uncertain effectiveness and preferentially ranked within groups by safety based on pre-specified criteria. We reviewed FDA documents and the published literature. When efficacy and safety are equivalent, the lower cost DMT is preferred. RESULTS: Assignment to the high-risk group prompts treatment with preferred HETs early in the disease course. For persons in the intermediate- or low-risk groups with cost or health care access barriers, we incorporated induction therapy with an affordable B-cell depleting agent. Based on more favorable safety profiles, our preferred approach prioritizes use of rituximab and natalizumab among HETs and interferon-betas or glatiramer acetate among modestly effective agents. INTERPRETATION: The risk-stratified treatment approach we recommend provides clear, measurable guidance in whom and when to prescribe HETs, when to prioritize lower cost DMTs and how to accommodate persons with MS with cost or other barriers to DMT use. It can be adapted to other cost structures and updated quickly as new information emerges. We recommend that physician groups partner with health insurance plans to adapt our approach to their settings, particularly in the United States. Future studies are needed to resolve the considerable uncertainty about how much variability in prognosis specific risk factors explain.