A budget impact analysis of a digital monitoring solution in patients treated with oral anticancer agents: a medico-economic analysis of the randomized phase 3 CAPRI trial.

BACKGROUND/OBJECTIVES: Remote patient monitoring (RPM) has demonstrated numerous benefits in cancer care, including improved quality of life, overall survival, and reduced medical resource use. This study presents a budget impact analysis of a nurse navigator-led RPM program, based on the CAPRI trial, from the perspective of the French national health insurance (NHI). The study aimed to assess the impact of the program on medical resource utilization and costs. METHODS: Medical resource utilization data were collected from both medico-administrative sources and patient-reported questionnaires. Costs were calculated by applying unit costs to resource utilization and estimating the average monthly cost per patient. Sensitivity analyses were conducted to explore different perspectives and varying resource consumption. RESULTS: The analysis included 559 cancer patients participating in the CAPRI program. From the NHI perspective, the program resulted in average savings of €377 per patient over the 4.58-month follow-up period, mainly due to reduced hospitalizations. The all-payers perspective yielded even greater savings of €504 per patient. Sensitivity analyses supported the robustness of the findings. CONCLUSION: The budget impact analysis demonstrated that the CAPRI RPM program was associated with cost savings from the perspective of the NHI. The program's positive impact on reducing hospitalizations outweighed the additional costs associated with remote monitoring. These findings highlight the potential economic benefits of implementing RPM programs in cancer care. Further research is warranted to assess the long-term cost-effectiveness and scalability of such programs in the real-world settings.

The Ambulatory Medical Assistance (AMA) programme during active-phase treatment in patients with haematological malignancies: A cost-effectiveness analysis.

CONTEXT: The need for patient navigator is growing, and there is a lack of cost evaluation, especially during survivorship. OBJECTIVE: The objective of this study is to evaluate the cost-effectiveness of an Ambulatory Medical Assistance (AMA) programme in patients with haematological malignancies (HM). DESIGN: A cost-effectiveness analysis of the AMA programme was performed compared to a simulated control arm. SETTING: An interventional, single-arm and prospective study was conducted in a French reference haematology-oncology centre between 2016 and 2020. PARTICIPANTS: Adult patients were enrolled with histologically documented malignant haematology, during their active therapy phase, and treated either by intravenous chemotherapy or oral therapy. METHODS: An extrapolation of the effectiveness was derived from a similar nurse monitoring programme (CAPRI study). Cost effectiveness of the programme was evaluated through adverse events of Grade 3 or 4 avoided in different populations. RESULTS: Included patient (n = 797) from the AMA programme were followed during 125 days (IQR: 0-181), and adverse events (Grade 3/4) were observed in 10.1% of patients versus 13.4% in the simulated control arm. The overall cost of AE avoided was estimated to €81,113, leading to an ICER of €864. CONCLUSION: The AMA programme was shown to be cost-effective compared to a simulated control arm with no intervention.

[Entre dynamique d'amélioration de la qualité des soins et conformisme administratif : comportements des établissements de santé français face au paiement à la performance (P4P)].

Le paiement à la performance (P4P) continue de se développer dans les systèmes de santé des pays industrialisés, malgré des preuves encore assez limitées de son efficacité. Cette étude propose de comprendre le comportement des établissements de santé face à ce nouveau mode de paiement en se basant sur l'expérimentation de P4P hospitalier conduite en France. Nous avons, pour cela, combiné une approche quantitative basée sur un questionnaire auprès des établissements participants et une analyse qualitative dans neuf établissements afin de mieux identifier les processus à l'œuvre. L'étude montre que des actions correctives ont été réalisées dans certains établissements mais que les effets du programme sur l'organisation restent en fait assez limités puisqu'ils s'opèrent davantage à la marge. Les comportements semblent être essentiellement le reflet d'une volonté de conformation des organisations aux attentes de la tutelle, sans transformations organisationnelles majeures. Il sera toutefois intéressant de voir comment des perceptions différentes structurent ces comportements sur le long terme.

Does size matter? The impact of caseload and expertise concentration on AMI 30-day mortality-A comparison across 10 OECD countries.

OBJECTIVE: To examine the variability of hospital performance within and across countries, using 30-day acute myocardial infarction (AMI) mortality, and to study the impact of hospital characteristics on performance. STUDY SETTING: Hospital-level adjusted risk standardized mortality rates (RSMR) and hospital characteristics were collected from 10 OECD and two collaborating countries including 1,163 hospitals. STUDY DESIGN: Associations between RSMR and hospital characteristics were studied using univariate and multivariate linear regressions. Clusters of hospitals were created using hierarchical clustering and mortality compared using linear regression. FINDINGS: Wide variation between countries was found for RSMR and hospital characteristics. Regression models showed large country effects. A high volume of AMI admission was associated with lower RSMR in a model using a restricted number of hospital characteristics (-0.83, p < 0.001) but not in a model using all characteristics (-1.03, p = 0.06). Analysis within countries supported this association. Hospital clusters showed clear differences in characteristic distributions but no difference in RSMR. CONCLUSIONS: The effect of volume may support policies toward a concentration of services within the hospital sector. The effect of other hospital characteristics was inconclusive and suggests the importance of system-wide characteristics or pathways of care (i.e. timeliness and nature of initial response and during transportation to a hospital, transfers between hospitals, post-discharge organization) in explaining variation.

[New modes of payment for the process of care]. / Nouveaux modes de rémunération pour la prise en charge médicale.

NEW MODES OF PAYMENT FOR THE PROCESS OF CARE. Paying for quality and bundled payment appear in France, and in other countries, as complements to existing payments that have encouraged the volume of activity. Quality payment has already been implemented for several years while bundled payment is more recent, in an experimental phase, mainly in the frame of the Article 51 of the Sécurité sociale financing act for 2019. This article describes the main principles of these payments, provides a critical analysis, and lays the foundations for a coherent strategy of their developments. While these payments can improve quality and reduce costs, they require evaluation studies for a better understanding of their effectiveness, and should not represent objectives in themselves, but means to improve the organization of the continuum of care.

NOUVEAUX MODES DE RÉMUNÉRATION POUR LA PRISE EN CHARGE MÉDICALE. Les modes de rémunération à la qualité et au parcours apparaissent en France, et ailleurs, comme des compléments aux rémunérations existantes qui ont principalement incité à augmenter l'activité. Le paiement à la qualité est déjà implanté depuis plusieurs années tant en ville qu'à l'hôpital alors que le paiement au parcours est plus récent, en phase expérimentale, principalement dans le cadre de l'article 51 de la loi de financement de la Sécurité sociale pour 2019. Cet article décrit les grands principes de ces nouveaux modes de rémunération, porte une analyse critique, et jette les bases d'un emploi cohérent. Si ces paiements peuvent inciter à une amélioration de la qualité et à des parcours coordonnés (avec des conséquences aussi en matière de réduction des gaspillages), ils nécessitent de nombreux travaux d'évaluation afin d'optimiser leur impact, et ne doivent pas perdre de vue qu'ils ne sont pas des objectifs en eux-mêmes, mais des moyens au service d'une meilleure organisation des parcours de patients.

Toward Customized Care Comment on "(Re) Making the Procrustean Bed? Standardization and Customization as Competing Logics in Healthcare".

Patients want their personal needs to be taken into account. Accordingly, the management of care has long involved some degree of personalization. In recent times, patients' wishes have become more pressing in a moving context. As the population ages, the number of patients requiring sophisticated combinations of longterm care is rising. Moreover, we are witnessing previously unvoiced demands, preferences and expectations (eg, demand for information about treatment, for care complying with religious practices, or for choice of appointment dates). In view of the escalating costs and the concerns about quality of care, the time has now come to rethink healthcare delivery. Part of this reorganization can be related to customization: what is needed is a customized business model that is effective and sustainable. Such business model exists in different service sectors, the customization being defined as the development of tailored services to meet consumers' diverse and changing needs at near mass production prices. Therefore, its application to the healthcare sector needs to be seriously considered.

Development of a 'ready-to-use' tool that includes preventability, for the assessment of adverse drug events in oncology.

Background Adverse drug events (ADEs) occur frequently in oncology and justify continuous assessment and monitoring. There are several methods for detecting them, but the trigger tool method seems the most appropriate. Although a generic tool exists, its use for ADEs in oncology has not been convincing. The development of a focused version is therefore necessary. Objective To provide an oncology-focused trigger tool that evaluates the prevalence, harm, and preventability in a standardised method for pragmatic use in ADE surveillance. Setting Hospitals with cancer care in France. Method The tool has been constructed in two steps: (1) constitution of an oncology-centred list of ADEs; 30 pharmacists/practitioners in cancer care from nine hospitals selected a list of ADEs using a method of agreement adapted from the RAND/UCLA Appropriateness Method; and (2) construction of three standardised dimensions for the characterisation of each ADE (including causality, severity, and preventability). Main outcome measure The main outcome measure was validation of the tool, including preventability criteria. Results The tool is composed of a final list of 15 ADEs. For each ADE, a 'reviewer form' has been designed and validated by the panel. It comprises (1) the trigger(s), (2) flowcharts to guide the reviewer, (3) criteria for grading harm, and (4) a standardised assessment of preventability with 6-14 closed sentences for each ADE in terms of therapeutic management and/or prevention of side-effects. Conclusion A complete 'ready-to-use' tool for ADE monitoring in oncology has been developed that allows the assessment of three standardised dimensions.

Evaluation of the effects of the French pay-for-performance program-IFAQ pilot study.

OBJECTIVE: Most studies showed no or little effect of pay-for-performance (P4P) programs on different outcomes. In France, the P4P program IFAQ was generalized to all acute care hospitals in 2016. A pilot study was launched in 2012 to design, implement and assess this program. This article aims to assess the immediate impact of the 2012-14 pilot study. DESIGN AND SETTING: From nine process quality indicators (QIs), an aggregated score was constructed as the weighted average, taking into account both achievement and improvement. Among 426 eligible volunteer hospitals, 222 were selected to participate. Eligibility depended on documentation of QIs and results of hospital accreditation. Hospitals with scores above the median received a financial reward based on their ranking and budget. Several characteristics known to have an influence on P4P results (patient age, socioeconomic status, hospital activity, casemix and location) were used to adjust the models. INTERVENTION: To assess the effect of the program, comparison between the 185 eligible selected hospitals and the 192 eligible not selected volunteers were done using the difference-in-differences method. RESULTS: Whereas all hospitals improved from 2012 to 2014, the difference-in-differences effect was positive but not significant both in the crude (2.89, P = 0.29) and adjusted models (4.07, P = 0.12). CONCLUSION: These results could be explained by several reasons: low level of financial incentives, unattainable goals, too short study period. However, the lack of impact for the first year should not undermine the implementation of other P4P programs. Indeed, the pilot study helped to improve the final model used for generalization.

Implementing hospital pay-for-performance: Lessons learned from the French pilot program.

Despite a wide implementation of pay-for-performance (P4P) programs, evidence on their impact in hospitals is still limited. Our objective was to assess the implementation of the French P4P pilot program (IFAQ1) across 222 hospitals. The study consisted of a questionnaire among four leaders in each enrolled hospital, combined with a qualitative analysis based on 33 semi-structured interviews conducted with staff in four participating hospitals. For the questionnaire results, descriptive statistics were performed and responses were analyzed by job title. For the interviews, transcripts were analysed using coding techniques. Survey results showed that leaders were mostly positive about the program and reported a good level of awareness, in contrast to the frontline staff, who remained mostly unaware of the program's existence. The main barriers were attributed to lack of clarity in program rules, and to time constraints. Different strategies were then suggested by leaders. The qualitative results added further explanations for low program adoption among hospital staff, so far. Ultimately, although paying for quality is still an intuitive approach; gaps in program awareness within enrolled hospitals may pose an important challenge to P4P efficacy. Implementation evaluations are therefore necessary for policymakers to better understand P4P adoption processes among hospitals.

Impacts of a navigation program based on health information technology for patients receiving oral anticancer therapy: the CAPRI randomized controlled trial.

BACKGROUND: The emergence of oral delivery in cancer therapeutics is expected to result in an increased need for better coordination between all treatment stakeholders, mainly to ensure adequate treatment delivery to the patient. There is significant interest in the nurse navigation program's potential to improve transitions of care by improving communication between treatment stakeholders and by providing personalized organizational assistance to patients. The use of health information technology is another strategy aimed at improving cancer care coordination that can be combined with the NN program to improve remote patient follow-up. However, the potential of these two strategies combined to improve oral treatment delivery is limited by a lack of rigorous evidence of actual impact. METHODS/DESIGN: We are conducting a large scale randomized controlled trial designed to assess the impact of a navigation program denoted CAPRI that is based on two Nurse Navigators and a web portal ensuring coordination between community and hospital as well as between patients and navigators, versus routine delivery of oral anticancer therapy. The primary research aim is to assess the impact of the program on treatment delivery for patients with metastatic cancer, as measured by Relative Dose Intensity. The trial involves a number of other outcomes, including tumor response, survival, toxic side effects, patient quality of life and patient experience An economic evaluation adopting a societal perspective will be conducted, in order to estimate those health. care resources' used. A parallel process evaluation will be conducted to describe implementation of the intervention. DISCUSSION: If the CAPRI program does improve treatment delivery, the evidence on its economic impact will offer important knowledge for health decision-makers, helping develop new follow-up services for patients receiving oral chemotherapy and/or targeted therapy. The process evaluation will determine the best conditions in which such a program might be implemented. TRIAL REGISTRATION: NCT 02828462 . Registered 29 June 2016.

Evaluating iatrogenic prescribing: development of an oncology-focused trigger tool.

BACKGROUND: Drug-related iatrogenic effects are common in oncology because chemotherapy is toxic. The evaluation of the application of the guidelines may be a way to understand the occurrence of adverse drug-related event (ADE). There is no specific method for identifying ADEs and measuring harm to patients in oncology. OBJECTIVE: Our objective was to develop and test an Oncology Trigger Tool (OTT) for ADEs and to describe ADE characteristics and incidence. METHODS: A clinical advisory panel identified situations at high risk of ADE occurrence and built 22 triggers with, in each case, an analysis flowchart to confirm or refute occurrence. The OTT was used to review 288 random admissions (Oct. 2010-Sept. 2011) and measure ADE incidence and severity (CTCAE 4.03 - Common Terminology Criteria for Adverse Events). Tool feasibility (time required), inter-rater (IR) reproducibility and positive predictive value (PPV) were measured. RESULTS: Overall, 884 triggers were detected and 122 ADEs, with 42.4 ADEs/100 admissions or 46.0 ADEs/1000 patient-days, and a 31.1% rate of severe ADEs. The most common ADEs were hyperglycaemia (14.5%), unplanned drug-related admission within 30 days (13.7%) and opiate-induced constipation (12.1%). Unplanned drug-related admission was the most serious (82.4% incidence of severe harm). Mean time for OTT implementation was 21.8 min; IR reproducibility was high (κ=0.965 (trigger); κ=0.935 (ADE); κ=0.853 (harm)); PPV 22-trigger version was 20.7%. CONCLUSIONS: ADE analysis flowcharts coupled with standardised grading of harm considerably reduced IR variability, thus providing a robust oncology-focused trigger tool for use in ADE audits and hospital comparisons. The involvement of a clinical advisory panel in tool development should help drive changes for improving practice. Further research on the OTT is warranted.

Managing customization in health care: a framework derived from the services sector literature.

Organizations that provide health services are increasingly in need of systems and approaches that will enable them to be more responsive to the needs and wishes of their clients. Two recent trends, namely, patient-centered care (PCC) and personalized medicine, are first steps in the customization of care. PCC shifts the focus away from the disease to the patient. Personalized medicine, which relies heavily on genetics, promises significant improvements in the quality of healthcare through the development of tailored and targeted drugs. We need to understand how these two trends can be related to customization in healthcare delivery and, because customization often entails extra costs, to define new business models. This article analyze how customization of the care process can be developed and managed in healthcare. Drawing on relevant literature from various services sectors, we have developed a framework for the implementation of customization by the hospital managers and caregivers involved in care pathways.

Relationship between longitudinal continuity of primary care and likelihood of death: analysis of national insurance data.

BACKGROUND: Continuity of care (COC) is a widely accepted core principle of primary care and has been associated with patient satisfaction, healthcare utilization and mortality in many, albeit small, studies. OBJECTIVE: To assess the relationship between longitudinal continuity with a primary care physician (PCP) and likelihood of death in the French general population. DESIGN: Observational study based on reimbursement claims from the French national health insurance (NHI) database for salaried workers (2007-2010). SETTING: Primary care. PATIENTS: We extracted data on the number and pattern of visits made to a PCP and excluded all patients who did not visit a PCP at least twice within 6 months. We recorded age, gender, comorbidities, social status, and deaths. MAIN OUTCOME MEASURES: The primary endpoint was death by all causes. We measured longitudinal continuity of care (COC) with a PCP twice a year between 2007 and 2010, using the COC index developed by Bice and Boxerman. We introduced the COC index as time-dependent variables in a survival analysis after adjustment for age, gender and stratifying on comorbidities and social status. RESULTS: A total of 325 742 patients were included in the analysis. The average COC index ranged from 0.74 (SD: 0.35) to 0.76 (0.35) (where 1.0 is perfect continuity). Likelihood of death was lower in patients with higher continuity (hazard ratio for an increase in 0.1 of continuity, adjusted for age, sex, and stratified on comorbidities and social status: 0.96 [0.95-0.96]). CONCLUSION: Higher longitudinal continuity was associated with a reduced likelihood of death.

Designing adverse event prevention programs using quality management methods: the case of falls in hospital.

OBJECTIVE: From a public health perspective, the effectiveness of any prevention program depends on integrated medical and managerial strategies. In this way, quality management methods drawn from organization and business management can help design prevention programs. The aim of this study was to analyze the potential value of these methods in the specific context of preventing falls in hospital. SETTING: Medical and Rehabilitation Care Unit of Saint-Maurice National Hospital (France). DESIGN: In phase 1, two surveys assessed the context in which falls occurred. The first survey (1995) quantified adverse events during a 1-year period (n = 564) and the second (1996-1997) documented the reasons for falls (n = 53). In phase 2, a set of recommendations to prevent falls was elaborated and implemented throughout the hospital. RESULTS: The fall frequency in this unit was 18.3% in 1995. Analysis showed organizational causes in 35 (66%) of the 53 documented falls; 24 of them were associated with individual factors. Even though the two categories of causes are interdependent, their distinction enables specific recommendations. The proposed organizational management changes recommended do not aim to achieve an illusory objective of 'zero falls', but are designed to reduce the number of avoidable falls and to limit the negative consequences of unavoidable falls. CONCLUSION: Quality improvement methods shed new light on how to prevent falls. An unexploited potential for prevention lies in organization and management of care for hospitalized patients.