Quality of Care and Preventive Screening Use in the CareFirst Patient-Centered Medical Home Program.

Despite their value, comprehensive diabetes care and screening for common cancers remain underutilized. We examined the association between participation in a patient-centered medical home (PCMH) program with strong financial incentives and receipt of preventive care in the first 5 years after program launch. Using multivariate regression analysis, we compared outcomes for adults under the care of participating primary care providers (PCPs) with adults under the care of nonparticipating PCPs. Outcomes were breast, cervical and colorectal cancer screenings, and elements of diabetes care. The analytic sample included 818,623 adults living in Maryland, Virginia, or the District of Columbia, and enrolled with CareFirst for at least 1 year during 2010-2015. By Year 5, enrollees in the intervention group were 7.9 (95% confidence interval [CI]: 2.8-13.0), 6.1 (95% CI: 1.4-10.7), 3.1 (95% CI: 2.1-4.0), and 7.6 (95% CI: 7.0-8.2) percentage points more likely to undergo HbA1c tests, nephropathy examinations, breast, and cervical cancer screenings, respectively. We found no significant change in the propensity to receive colorectal cancer screening or an eye examination. Our study shows that a PCMH program with strong financial incentives can raise the provision of preventive care but could require additional adjustment.

Radical prostatectomy innovation and outcomes at military and civilian institutions.

OBJECTIVES: Limited data are available regarding the impact of the type of healthcare delivery system on technology diffusion and associated clinical outcomes. We assessed the adoption of minimally invasive radical prostatectomy (MIRP), a recent clinical innovation, and whether this adoption altered surgical morbidity for prostate cancer surgery. STUDY DESIGN: Retrospective review of administrative data from TRICARE, the healthcare program of the United States Military Health System. Surgery occurred at military hospitals, supported by federal appropriations, or civilian hospitals, supported by hospital revenue. METHODS: We evaluated TRICARE beneficiaries with prostate cancer (International Classification of Disease, 9th Revision, Clinical Modification [ICD-9-CM] code: 185) who received a radical prostatectomy (60.5) between 2005 and 2009. MIRP was identified based on minimally invasive surgery codes (54.21, 17.42). We assessed yearly MIRP utilization, 30-day postoperative complications (Clavien classification system), length of stay, blood transfusion, and long-term urinary incontinence and erectile dysfunction. RESULTS: A total of 3366 men underwent radical prostatectomy at military hospitals compared with 1716 at civilian hospitals, with minimal clinic-demographic differences. MIRP adoption was 30% greater at civilian hospitals. There were fewer blood transfusions (odds ratio, 0.44; P <.0001) and shorter lengths of stay (incidence risk ratio, 0.85; P <.0001) among civilian hospitals, while 30-day postoperative complications, as well as long-term urinary incontinence and erectile dysfunction rates, were comparable. CONCLUSIONS: Compared with military hospitals, civilian hospitals had a greater MIRP adoption during this timeframe, but had comparable surgical morbidity.

Provider-Induced Demand in the Treatment of Carotid Artery Stenosis: Variation in Treatment Decisions Between Private Sector Fee-for-Service vs Salary-Based Military Physicians.

Importance: Although many factors influence the management of carotid artery stenosis, it is not well understood whether a preference toward procedural management exists when procedural volume and physician compensation are linked in the fee-for-service environment. Objective: To explore evidence for provider-induced demand in the management of carotid artery stenosis. Design, Setting, and Participants: The Department of Defense Military Health System Data Repository was queried for individuals diagnosed with carotid artery stenosis between October 1, 2006, and September 30, 2010. A hierarchical multivariable model evaluated the association of the treatment system (fee-for-service physicians in the private sector vs salary-based military physicians) with the odds of procedural intervention (carotid endarterectomy or carotid artery stenting) compared with medical management. Subanalysis was performed by symptom status at the time of presentation. The association of treatment system and of management strategy with clinical outcomes, including stroke and death, was also evaluated. Data analysis was conducted from August 15, 2015, to August 2, 2016. Main Outcomes and Measures: The odds of procedural intervention based on treatment system was the primary outcome used to indicate the presence and effect of provider-induced demand. Results: Of 10 579 individuals with a diagnosis of carotid artery stenosis (4615 women and 5964 men; mean [SD] age, 65.6 [11.4] years), 1307 (12.4%) underwent at least 1 procedure. After adjusting for demographic and clinical factors, the odds of undergoing procedural management were significantly higher for patients in the fee-for-service system compared with those in the salary-based setting (odds ratio, 1.629; 95% CI, 1.285-2.063; P < .001). This finding remained true when patients were stratified by symptom status at presentation (symptomatic: odds ratio, 2.074; 95% CI, 1.302-3.303; P = .002; and asymptomatic: odds ratio, 1.534; 95% CI, 1.186-1.984; P = .001). Conclusions and Relevance: Individuals treated in a fee-for-service system were significantly more likely to undergo procedural management for carotid stenosis compared with those in the salary-based setting. These findings remained consistent for individuals with and without symptomatic disease.

Changes in Physician Practice Patterns after Implementation of a Communication-and-Resolution Program.

OBJECTIVE: To test if a 2006 communication-and-resolution program to address unexpected adverse outcomes was associated with changes in cost and use trajectories. DATA SOURCE: Records of patients discharged with a principal diagnosis of chest pain from 44 nonfederal general hospitals in Cook County, Illinois, between January 2002 and December 2009. STUDY DESIGN: Propensity-score matched discharges from the intervention and comparison hospitals before computing difference-in-differences estimates of quarterly growth rates. DATA COLLECTION METHODS: We used discharge records submitted to a central statewide repository. PRINCIPAL FINDINGS: Relative to the comparison hospitals and to pre-implementation trends, and consistent with reduced testing at presentation, the intervention hospital recorded an increase in the number of patients with a principal diagnosis of chest pain. Among admitted patients, quarterly growth rates of clinical laboratory and radiology charges at the intervention hospital declined by 3.8 and 6.9 percentage points. CONCLUSIONS: Among patients with chest pain, the implementation of a comprehensive communication-and-resolution program was associated with substantially reduced growth rates in the use of diagnostic testing and imaging services. Further research is needed to establish to what extent these changes were attributable to the program and clinically appropriate.

Racial disparities in emergency general surgery: Do differences in outcomes persist among universally insured military patients?

BACKGROUND: Racial disparities in surgical care are well described. As many minority patients are also uninsured, increasing access to care is thought to be a viable solution to mitigate inequities. The objectives of this study were to determine whether racial disparities in 30-/90-/180- day outcomes exist within a universally insured population of military-/civilian-dependent emergency general surgery (EGS) patients and ascertain whether differences in outcomes differentially persist in care received at military versus civilian hospitals and among sponsors who are enlisted service members versus officers. It also considered longer-term outcomes of EGS care. METHODS: Five years (2006-2010) of TRICARE data, which provides insurance to active/reserve/retired members of the US Armed Services and dependents, were queried for adults (≥18 years) with primary EGS conditions, defined by the AAST. Risk-adjusted survival analyses assessed race-associated differences in mortality, major acute care surgery-related morbidity, and readmission at 30/90/180 days. Models accounted for clustering within hospitals and possible biases associated with missing race using reweighted estimating equations. Subanalyses considered restricted effects among operative interventions, EGS diagnostic categories, and effect modification related to rank and military- versus civilian-hospital care. RESULTS: A total of 101,011 patients were included: 73.5% white, 14.5% black, 4.4% Asian, and 7.7% other. Risk-adjusted survival analyses reported a lack of worse mortality and readmission outcomes among minority patients at 30, 90, and 180 days. Major morbidity was higher among black versus white patients (hazard ratio [95% confidence interval): 30 days, 1.23 [1.13-1.35]; 90 days, 1.18 [1.09-1.28]; and 180 days, 1.15 [1.07-1.24], a finding seemingly driven by appendiceal disorders (hazard ratio, 1.69-1.70). No other diagnostic categories were significant. Variations in military- versus civilian-managed care and in outcomes for families of enlisted service members versus officers altered associations, to some extent, between outcomes and race. CONCLUSIONS: While an imperfect proxy of interventions is directly applicable to the broader United States, the contrast between military observations and reported racial disparities among civilian EGS patients merits consideration. Apparent mitigation of disparities among military-/civilian-dependent patients provides an example for which we as a nation and collective of providers all need to strive. The data will help to inform policy within the Department of Defense and development of disparities interventions nationwide, attesting to important differences potentially related to insurance, access to care, and military culture and values. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.

Designing highly reliable adverse-event detection systems to predict subsequent claims.

BACKGROUND: To respond proactively to patient safety events, many healthcare organizations have been enhancing and customizing their event reporting systems. Yet an indiscriminate expansion of the range and number of event reports may reduce, rather than raise, risk managers' ability to detect events that warrant a response. To avoid becoming overwhelmed by too many event reports that have little immediate operational value, risk managers therefore require a concurrent and complementary refinement of their data-processing capabilities. OBJECTIVE: To examine the extent to which adverse event reports can predict subsequent claims. DATA AND METHODS: The study sample included all adverse event reports and all records of closed claims that related to patient care episodes between July 1, 2006, and May 31, 2009, at a large hospital system in northern Virginia. After matching closed claims to event reports, we fitted multivariate predictive models to identify event report entries that predict future claims. RESULTS: During the period under study, 20 151 event reports and 94 claims were filed across the health system. We were able to match 60 claims (63.8%) to at least 1 preceding event report, implying that only 0.3% of event reports preceded a subsequent matching claim. The superior prediction model identified 90% of eventual matched claims by retaining only 20% of all event reports. CONCLUSION: Simple prediction algorithms can supplement expert judgment by screening for reports that are likely to result in a claim, thereby enabling risk managers to evaluate adverse event reports more expeditiously and to identify, and ultimately prevent, serious safety lapses more reliably.

The nature of surgeon human capital depreciation.

To test how practice interruptions affect worker productivity, we estimate how temporal breaks affect surgeons' performance of coronary artery bypass grafting (CABG). Examining 188 surgeons who performed 56,315 CABG surgeries in Pennsylvania between 2006 and 2010, we find that a surgeon's additional day away from the operating room raised patients' inpatient mortality by up to 0.067 percentage points (2.4% relative effect) but reduced total hospitalization costs by up to 0.59 percentage points. Among emergent patients treated by high-volume providers, where temporal distance is most plausibly exogenous, an additional day away raised mortality risk by 0.398 percentage points (11.4% relative effect) but reduced cost by up to 1.4 percentage points. This is consistent with the hypothesis that as temporal distance increases, surgeons are less likely to recognize and address life-threatening complications. Our estimates imply additional intraprocedural treatment intensity has a cost per life-year preserved of $7871-18,500, well within conventional cost-effectiveness cutoffs.

Automated detection of retinal disease.

Nearly 4 in 10 Americans with diabetes currently fail to undergo recommended annual retinal exams, resulting in tens of thousands of cases of blindness that could have been prevented. Advances in automated retinal disease detection could greatly reduce the burden of labor-intensive dilated retinal examinations by ophthalmologists and optometrists and deliver diagnostic services at lower cost. As the current availability of ophthalmologists and optometrists is inadequate to screen all patients at risk every year, automated screening systems deployed in primary care settings and even in patients' homes could fill the current gap in supply. Expanding screens to all patients at risk by switching to automated detection systems would in turn yield significantly higher rates of detecting and treating diabetic retinopathy per dilated retinal examination. Fewer diabetic patients would develop complications such as blindness, while ophthalmologists could focus on more complex cases.

Strategic response by providers to specialty hospitals, ambulatory surgery centers, and retail clinics.

Radical innovation and disruptive technologies are frequently heralded as a solution to delivering higher quality, lower cost health care. According to the literature on disruption, local hospitals and physicians (incumbent providers) may be unable to competitively respond to such "creative destruction" and alter their business models for a host of reasons, thus threatening their future survival. However, strategic management theory and research suggest that, under certain conditions, incumbent providers may be able to weather the discontinuities posed by the disrupters. This article analyzes 3 disruptive innovations in service delivery: single-specialty hospitals, ambulatory surgical centers, and retail clinics. We first discuss the features of these innovations to assess how disruptive they are. We then draw on the literature on strategic adaptation to suggest how incumbents develop competitive responses to these disruptive innovations that assure their continued survival. These arguments are then evaluated in a field study of several urban markets based on interviews with both incumbents and entrants. The interviews indicate that entrants have failed to disrupt incumbent providers primarily as a result of strategies pursued by the incumbents. The findings cast doubt on the prospects for these disruptive innovations to transform health care.

How does routine disclosure of medical error affect patients' propensity to sue and their assessment of provider quality? Evidence from survey data.

BACKGROUND: Although strongly favored by patients and ethically imperative for providers, the disclosure of medical errors to patients remains rare because providers fear that it will trigger lawsuits and jeopardize their reputation. To date little is known how patients might respond to their providers' disclosure of a medical error even when paired with an offer of remediation. RESEARCH DESIGN: A representative sample of Illinois residents was surveyed in 2008 about their knowledge about medical errors, their confidence that their providers would disclose medical errors to them, and their propensity to sue and recommend providers that disclose medical errors and offer to remedy them. We report the response patterns to these questions. As robustness checks, we also estimate the covariate-adjusted distributions and test the associations among these dimensions of medical-error disclosure. RESULTS: Of the 1018 respondents, 27% would sue and 38% would recommend the hospital after medical error disclosure with an accompanying offer of remediation. Compared with the least confident respondents, those who were more confident in their providers' commitment to disclose were not likely to sue but significantly and substantially more likely to recommend their provider. CONCLUSIONS: Patients who are confident in their providers' commitment to disclose medical errors are not more litigious and far more forgiving than patients who have no faith in their providers' commitment to disclose.

Does advanced medical technology encourage hospitalist use and their direct employment by hospitals?

In the United States, inpatient medical care increasingly encompasses the use of expensive medical technology and, at the same time, is coordinated and supervised more and more by a rapidly growing number of inpatient-dedicated physicians (hospitalists). In the production of inpatient care services, Hospitalist services can be viewed as complementary to sophisticated and expensive medical equipment in the provision of inpatient medical care. We investigate the causal relationship between a hospital's access to three types of sophisticated diagnostic and therapeutic medical equipment - intensity-modulated radiation therapy, gamma knife, and multi-slice computed tomography - and its likelihood of using hospitalists. To rule out omitted variables bias and reverse causality, we use technology-specific Certificate of Need regulation to predict technology use. We find a strong positive association, yet no causal link between access to medical technology and hospitalist use. We also study the choice of employment modality among hospitals that use hospitalists, and find that access to expensive medical technology reduces the hospital's propensity to employ hospitalists directly.