Describing the spine surgery learning curve during the first two years of independent practice.

ABSTRACT: Retrospective cohort studyTo characterize the learning curve of a spine surgeon during the first 2 years of independent practice by comparing to an experienced colleague. To stratify learning curves based on procedure to evaluate the effect of experience on surgical complexity.The learning curve for spine surgery is difficult to quantify, but is useful information for hospital administrators/surgical programs/new graduates, so appropriate expectations and accommodations are considered.Data from a retrospective cohort (2014-2016) were analyzed at a quaternary academic institution servicing a geographically-isolated, mostly rural area. Procedures included anterior cervical discectomy and fusion, posterior cervical decompression and stabilization, single and 2-level posterior lumbar interbody fusion, lumbar discectomy, and laminectomy. Data related to patient demographics, after-hours surgery, and revision surgery were collected. Operative time was the primary outcome measure, with secondary measures including cerebrospinal fluid leak and early re-operation. Time periods were stratified into 6 month quarters (quarter [Q] 1-Q4), with STATA software used for statistical analysis.There were 626 patients meeting inclusion criteria. The senior surgeon had similar operative times throughout the study. The new surgeon demonstrated a decrease in operative time from Q1 to Q4 (158 minutes-119 minutes, P < .05); however, the mean operative time was shorter for the senior surgeon at 2 years (91 minutes, P < .05). The senior surgeon performed more revision surgeries (odds ratio [OR] 2.5 [95% confidence interval [CI] 1.7-3.6]; P < .001). Posterior interbody fusion times remained longer for the new surgeon, while laminectomy surgery was similar to the senior surgeon by 2 years. There were no differences in rates of cerebrospinal fluid leak (OR 1.2 [95% CI 0.6-2.5]; P > .05), nor reoperation (OR 1.16 [95% CI 0.7-1.9]; P > .05) between surgeons.A significant learning curve exists starting spine practice and likely extends beyond the first 2 years for elective operations.

Correlates of Burnout in Small Independent Primary Care Practices in an Urban Setting.

BACKGROUND: Little is known about the prevalence and correlates of burnout among providers who work in small independent primary care practices (<5 providers). METHODS: We conducted a cross-sectional analysis by using data collected from 235 providers practicing in 174 small independent primary care practices in New York City. RESULTS: The rate of provider-reported burnout was 13.5%. Using bivariate logistic regression, we found higher adaptive reserve scores were associated with lower odds of burnout (odds ratio, 0.12; 95% CI, 0.02-0.85; P = .034). CONCLUSION: The burnout rate was relatively low among our sample of providers compared with previous surveys that focused primarily on larger practices. The independence and autonomy providers have in these small practices may provide some protection against symptoms of burnout. In addition, the relationship between adaptive reserve and lower rates of burnout point toward potential interventions for reducing burnout that include strengthening primary care practices' learning and development capacity.

Independent practice associations and physician-hospital organizations can improve care management for smaller practices.

Pay-for-performance, public reporting, and accountable care organization programs place pressures on physicians to use health information technology and organized care management processes to improve the care they provide. But physician practices that are not large may lack the resources and size to implement such processes. We used data from a unique national survey of 1,164 practices with fewer than twenty physicians to provide the first information available on the extent to which independent practice associations (IPAs) and physician-hospital organizations (PHOs) might make it possible for these smaller practices to share resources to improve care. Nearly a quarter of the practices participated in an IPA or a PHO that accounted for a significant proportion of their patients. On average, practices participating in these organizations provided nearly three times as many care management processes for patients with chronic conditions as nonparticipating practices did (10.4 versus 3.8). Half of these processes were provided only by IPAs or PHOs. These organizations may provide a way for small and medium-size practices to systematically improve care and participate in accountable care organizations.

Medicare HMO impact on utilization at the end of life.

OBJECTIVE: To estimate the effect of independent practice association (IPA) model HMOs and the Kaiser Foundation Health Plan's group model on inpatient utilization of Medicare beneficiaries in the last 2 years of life, compared with traditional fee-for-service (FFS) coverage. STUDY DESIGN: Data from the Centers for Medicare & Medicaid Services were linked to inpatient discharge data from the California Office of Statewide Health Planning and Development for 1991-2001. A sample of aged Medicare beneficiaries who died between January 1998 and June 2001 and were continuously enrolled during the 2 years before death in (1) FFS (n = 234,498), (2) an IPA (n = 109,577), or (3) Kaiser (n = 29,434) were selected. METHODS: The probability of at least 1 hospitalization, number of inpatient days given at least 1 hospitalization, and total inpatient days per year in the last 2 years of life were estimated for each subgroup. A 2-part regression model, which adjusted for age, sex, Medicaid status, race, ethnicity, and chronic condition associated with the last hospitalization, was applied to determine the HMO-FFS difference in inpatient utilization during the last 2 years of life. RESULTS: During their last 2 years of life, decedents in IPAs and Kaiser used approximately 34% and 51% fewer inpatient days, respectively, than decedents in FFS. CONCLUSIONS: Medicare beneficiaries who died while enrolled in an HMO, particularly Kaiser, had many fewer hospital days during the 2 years before death than beneficiaries who died with FFS coverage.

Correlated physical and mental health summary scores for the SF-36 and SF-12 Health Survey, V.I.

BACKGROUND: The SF-36 and SF-12 summary scores were derived using an uncorrelated (orthogonal) factor solution. We estimate SF-36 and SF-12 summary scores using a correlated (oblique) physical and mental health factor model. METHODS: We administered the SF-36 to 7,093 patients who received medical care from an independent association of 48 physician groups in the western United States. Correlated physical health (PCSc) and mental health (MCSc) scores were constructed by multiplying each SF-36 scale z-score by its respective scoring coefficient from the obliquely rotated two factor solution. PCSc-12 and MCSc-12 scores were estimated using an approach similar to the one used to derive the original SF-12 summary scores. RESULTS: The estimated correlation between SF-36 PCSc and MCSc scores was 0.62. There were far fewer negative factor scoring coefficients for the oblique factor solution compared to the factor scoring coefficients produced by the standard orthogonal factor solution. Similar results were found for PCSc-12, and MCSc-12 summary scores. CONCLUSION: Correlated physical and mental health summary scores for the SF-36 and SF-12 derived from an obliquely rotated factor solution should be used along with the uncorrelated summary scores. The new scoring algorithm can reduce inconsistent results between the SF-36 scale scores and physical and mental health summary scores reported in some prior studies.(Subscripts C = correlated and UC = uncorrelated).

Clinical utilization and cost outcomes from an integrative medicine independent physician association: an additional 3-year update.

OBJECTIVE: Our initial report analyzed clinical and cost utilization data from the years 1999 to 2002 for an integrative medicine independent physician association (IPA) whose primary care physicians (PCPs) were exclusively doctors of chiropractic. This report updates the subsequent utilization data from the IPA for the years 2003 to 2005 and includes first-time comparisons in data points among PCPs of different licensures who were oriented toward complementary and alternative medicine (CAM). METHODS: Independent physician association-incurred claims and stratified random patient surveys were descriptively analyzed for clinical utilization, cost offsets, and member satisfaction compared with conventional medical IPA normative values. Comparisons to our original publication's comparative blinded data, using nonrandom matched comparison groups, were descriptively analyzed for differences in age/sex demographics and disease profiles to examine sample bias. RESULTS: Clinical and cost utilization based on 70,274 member-months over a 7-year period demonstrated decreases of 60.2% in-hospital admissions, 59.0% hospital days, 62.0% outpatient surgeries and procedures, and 85% pharmaceutical costs when compared with conventional medicine IPA performance for the same health maintenance organization product in the same geography and time frame. CONCLUSION: During the past 7 years, and with a larger population than originally reported, the CAM-oriented PCPs using a nonsurgical/nonpharmaceutical approach demonstrated reductions in both clinical and cost utilization when compared with PCPs using conventional medicine alone. Decreased utilization was uniformly achieved by all CAM-oriented PCPs, regardless of their licensure. The validity and generalizability of this observation are guarded given the lack of randomization, lack of statistical analysis possible, and potentially biased data in this population.

Economic profiling of physician specialists: use of outlier treatment and episode attribution rules.

This paper examines the influence of episode attribution methodology and cost outlier methodology on the accuracy of physicians' economic profiles. Four years of claims data from a mixed model HMO were processed using the leading episode grouper software. Episode grouped results then were applied to construct input distributions for a simulation model. For each of four specialties (cardiology, family practice, general surgery, and neurology), we employed sets of 18 simulations to investigate the effects of three alternative episode attribution methodologies and six alternative cost outlier methodologies on sensitivity, specificity, and positive predictive error in classifying cost-efficient and cost-inefficient physicians. For identification of cost-efficient physicians, the most accurate profiling results were obtained when Winsorizing outliers at 2% and 98% of episode-type cost distributions, and attributing responsibility for episode costs to physicians who accounted for at least 30% of associated professional and prescribing fees. No consistent combination of outlier methodology and episode attribution rule was found to be superior for identifying cost-inefficient physicians.

Medicare HMO penetration and mortality outcomes of ischemic stroke.

OBJECTIVE: To examine associations between Medicare health maintenance organization (HMO) penetration and stroke mortality outcomes among older persons. STUDY DESIGN: Panel analysis of nationally representative secondary data from 1993 to 1998. METHODS: The first analysis sample included ischemic stroke hospitalizations among older persons in the Nationwide Inpatient Sample; the second included county-level ischemic stroke deaths in the National Vital Statistics System. The 2 samples were merged with the HMO enrollment data and the 2001 Area Resource File. The 2 outcomes were in hospital death status and county-level population ischemic stroke death rates among older persons; the 2 utilization variables were length of hospital stay for ischemic stroke and proportion of ischemic stroke deaths occurring in hospitals. The 3 key explanatory variables were county-level Medicare total, independent practice association, and nonindependent practice association HMO penetration. Ordinary least squares analysis with hospital or county fixed effects was used in estimation. RESULTS: Medicare HMO penetration was not associated with the 2 ischemic stroke mortality outcomes (P > .05). Increases in Medicare total and independent practice association HMO penetration were associated with a significant shift in a higher proportion of stroke deaths from hospitals to nursing homes or residences (P < .05). Medicare HMO penetration was negatively associated with length of stay, although this was not statistically significant (P > .05). CONCLUSIONS: Increased Medicare HMO penetration was associated with a shift in ischemic stroke deaths from hospitals to nonhospital settings. The effect of Medicare HMO penetration on quality of stroke care needs further research.

The routine use of health risk appraisals: results from a national study of physician organizations.

PURPOSE: To document use of health risk appraisals (HRAs) by U.S. physician organizations as part of their overall approach to health promotion and to identify associated organizational characteristics. METHODS: Telephone survey of 1590 physician organizations in the United States; surveys were conducted in organizations comprising 20 or more physicians and were conducted between September 2000 and September 2001 (70% response rate). Chi-square tests and logistic regression analysis were used to examine the association between organizational characteristics and routine administration of HRAs. RESULTS: Only 22.5% of physician organizations in the United States routinely administer HRAs. External quality incentives, information technology capabilities, and status as a medical group vs. an independent practice association are associated with greater odds of the routine use of HRA. DISCUSSION: Increased use of external quality incentives and information technology in physician organizations may be important in supporting the use of HRAs.

Trust in insurers and access to physicians: associated enrollee behaviors and changes over time.

OBJECTIVE: Most studies of trust in the medical arena have focused on trust in physicians rather than trust in health insurers, and have been cross-sectional rather than longitudinal studies. This study examined associations among trust in a managed care insurer, trust in one's primary physician, and subsequent enrollee behaviors relating to source of care. The study also documents changes in trust in the study population following the disclosure of physician incentives. STUDY SETTING: A medium-sized (300,000 member) HMO, located in the southeastern United States. DATA COLLECTION: One to two years after baseline, we randomly resurveyed a quarter (n = 558) of the initial study population of a large intervention study designed to measure the impact of disclosing HMO financial incentives on patient trust. This follow-up study was also designed to measure the effects of trust on source of care. ANALYSES: Multivariate regression analyses of survey data examined associations between baseline levels of trust and subsequent enrollee behaviors such as using a non-PCP physician without a PCP referral, as well as changes in trust since baseline. RESULTS: High baseline insurer trust was associated with a lower probability of a patient seeking care from a non-PCP physician (OR = 0.55, 95 percent CI: 0.33, 0.91). No long-term effects of prior disclosure of financial incentives were observed. Overall, there was a slight increase in overall trust in the insurer (1.8 percent, p < .05) but no change in trust in one's primary physician. The increase in insurer trust was primarily restricted to 23 percent of the enrollees who had changed their PCPs following the baseline survey (6.6 percent, p < .01). In multivariate analyses, changing physicians was the most significant predictor of increased insurer trust (OR = 2.17, 95 percent CI: 1.37, 3.43). CONCLUSIONS. Trust in one's insurer seems to change over time more than trust in one's primary physician, and is predictive of enrollee behaviors such as seeking care from other physicians. The ability to change physicians seems to increase trust in the insurer.

Clinical and cost outcomes of an integrative medicine IPA.

OBJECTIVE: We hypothesized that primary care physicians (PCPs) specializing in a nonpharmaceutical/nonsurgical approach as their primary modality and utilizing a variety of complementary/alternative medicine (CAM) techniques integrated with allopathic medicine would have superior clinical and cost outcomes compared with PCPs utilizing conventional medicine alone. DESIGN: Incurred claims and stratified randomized patient surveys were analyzed for clinical outcomes, cost offsets, and member satisfaction compared with normative values. Comparative blinded data, using nonrandomized matched comparison groups, was analyzed for age/sex demographics and disease profiles to examine sample bias. SETTING: An integrative medicine independent provider association (IPA) contracted with a National Committee for Quality Assurance (NCQA)-accredited health maintenance organization (HMO) in metropolitan Chicago. SUBJECTS: All members enrolled with the integrative medicine IPA from January 1, 1999 through December 31, 2002. RESULTS: Analysis of clinical and cost outcomes on 21,743 member months over a 4-year period demonstrated decreases of 43.0% in hospital admissions per 1000, 58.4% hospital days per 1000, 43.2% outpatient surgeries and procedures per 1000, and 51.8% pharmaceutical cost reductions when compared with normative conventional medicine IPA performance for the same HMO product in the same geography over the same time frame. CONCLUSION: In the limited population studied, PCPs utilizing an integrative medical approach emphasizing a variety of CAM therapies had substantially improved clinical outcomes and cost offsets compared with PCPs utilizing conventional medicine alone. While certainly promising, these initial results may not be consistent on a larger and more diverse population.

Utilization of orthopaedic services for hand and wrist conditions in a capitated population.

BACKGROUND: The utilization of orthopaedic services (office visits and surgery) to treat hand and wrist conditions is not well known. In this study, we report the utilization rates for patients referred for orthopaedic treatment of hand and wrist conditions in a large population of individuals enrolled in a capitated insurance plan. METHODS: The study population consisted of individuals enrolled, between January 1998 and December 2001, in a capitated insurance plan that had an annual average membership of 135,188 during that period. This plan was serviced by an independent physician association of sixty-two orthopaedic surgeons who were responsible for all orthopaedic care. Data were collected prospectively in a centralized database as patients with various hand or wrist conditions were referred for orthopaedic services. Odds ratios were used to compare gender-specific and age-specific utilization rates. RESULTS: Overall utilization rates were 18.06 office visits and 6.47 surgical procedures per 1000 members per year. The most frequent hand or wrist conditions were fractures, carpal tunnel syndrome, tendinitis or tenosynovitis, and ganglion or synovial cysts. These four diagnoses accounted for 70% of all office visits and 71% of all surgical cases. Across all age groups, males had a significantly higher rate of utilization of office visits (p < 0.001). Between the ages of thirty-five and fifty-five years, utilization of office visits and surgery increased approximately linearly with age. CONCLUSIONS: A comparison of these data with those of previous reports indicates that approximately one of every ten patients who are referred for orthopaedic services has a hand or wrist condition, and nearly half will require surgery.

Into the unknown: the anticipation and experience of membership of independent practitioner associations.

AIMS: To understand why general practitioners (GPs) joined independent practitioner associations (IPAs), their concerns on joining, and the extent to which both positive and negative expectations have been realised. METHODS: A self-complete postal questionnaire to a sample of IPA rank-and-file members invited their views on their decision to join, their satisfaction with leadership, and the experience of being in an IPA. RESULTS: The most popular reasons for joining were related to the uncertainties of the health sector environment, including the prospect of contracting and the place of general practice within the health sector. Aspirations on joining were largely realised, although at a general rather than specific level. Concerns over joining related mostly to day-to-day operation and practitioner autonomy, but were less strongly held and less likely than aspirations to be realised. Satisfaction with IPA leadership was quite high and associated with practitioner involvement in IPA activities. CONCLUSIONS: Results are consistent with the international literature, with importance attached by practitioners to both 'personal' and 'system' level aspirations. Research also suggests that where management remains 'connected' with rank-and-file clinicians then perceived threats to autonomy are likely to be minimised. In moving towards primary health organisations, care needs to be taken not to undermine this 'connectedness' and therefore pose risks to the effective management of primary care.

What are we without risk? The physician organization at a crossroads.

The managed care market in Chicago is experiencing rapid change. As health maintenance organization (HMO) enrollment flattens or even declines, and capitation becomes less sustainable for many, physician organizations are reevaluating their continued participation in risk-based contracts and are struggling to define their future roles. Physician organizations are looking for new ways to provide value to their physician members. Physician hospital organizations (PHOs) in particular are reassessing how the organization can continue to serve the interests of both the physicians and their hospital partners. To better understand the concerns of physician organizations, The Lowell Group surveyed Chicago area provider executives on their top issues. Three major concerns emerged: (1) protecting the financial health of the organization; (2) predicting the future of the managed care industry; and (3) evolving the physician organization to meet changing market conditions. Ultimately, physician organizations must make business decisions that support their true goals-serving patients and purchasers of care, physician members, and the organization's owners.

How are health plans supporting physician practice? The physician perspective.

IPA-model HMOs are now the dominant organizational structures for delivering "managed care" in the United States. Are they taking advantage of opportunities to support physician practices in ways that arguably could improve care? In this paper we report the findings from a survey of generalist and specialist physicians in nineteen health plans. Not surprisingly, we found that generalists are much more likely than specialists are to be the target of health plans' efforts to support care delivery. However, our survey data indicate that these opportunities generally are not being fully exploited; also, efforts that plans do make to provide information to support care often are not seen as useful by physicians.

On being new to an insurance plan: health care use associated with the first years in a health insurance plan.

BACKGROUND: We wanted to compare health care utilization and costs in the first year of being in a health insurance plan with those of subsequent years. METHODS: We used claims data from an independent practitioner association (IPA)-style managed care organization in the Rochester, NY, metropolitan area from 1996 through 1999. Cross-sectional and panel analyses of up to 4 years of claims data were conducted, involving 335,547 adult patients assigned to the panels of 687 primary care physicians (internists and family physicians). Multivariate analyses, adjusting for age, sex, case mix, and socioeconomic status derived from ZIP codes, examined the relationship between the first year of health insurance and Papanicolaou tests, mammograms in women older than 40 years, physician use, avoidable hospitalization, and expenditures. RESULTS: After multivariate adjustment, the first year of insurance was associated with a higher risk of not getting a mammogram, a higher risk of avoidable hospitalization, greater likelihood of visiting a physician, and higher expenditures, especially for testing. There was no relationship, however, between Papanicolaou test compliance and year of enrollment. CONCLUSIONS: The findings suggest there might be adverse clinical and financial implications associated with changing insurance.