Effectiveness and Cost-effectiveness of Mailed FIT in a Safety Net Clinic Population.

BACKGROUND: Mailed fecal immunochemical testing (FIT) can increase colorectal cancer (CRC) screening rates, including for vulnerable patients, but its cost-effectiveness is unclear. OBJECTIVE: We sought to examine the effectiveness and cost-effectiveness of the initial cycle of our mailed FIT program from November 2017 to July 2019 in a federally qualified health center (FQHC) system in Central Texas. DESIGN: Single group intervention and economic analysis PARTICIPANTS: Eligible patients were those ages 50-75 who had been seen recently in a system practice and were not up to date with screening. INTERVENTION: The program mailing packet included an introductory letter in plain language, the FIT itself, easy to read instructions, and a postage-paid lab mailer, supplemented with written and text messaging reminders. MAIN MEASURES: We measured effectiveness based on completion of mailed FIT and cost-effectiveness in terms of cost per person screened. Costs were measured using detailed micro-costing techniques from the perspective of a third-party payer and expressed in 2019 US dollars. Direct costs were based on material supply costs and detailed observations of labor required, valued at the wage rate. KEY RESULTS: Of the 22,838 eligible patients who received program materials, mean age was 59.0, 51.5% were female, and 43.9% were Latino. FIT were successfully completed by 19.2% (4395/22,838) patients at an average direct cost of $5275.70 per 500-patient mailing. Assuming completed tests from the mailed intervention represent incremental screening, the direct cost per patient screened, compared with no intervention, was $54.83. Incorporating start-up and indirect costs increases total costs to $7014.45 and cost per patient screened to $72.90. Alternately, assuming 2.5% and 5% screening without the intervention increased the direct (total) cost per patient screened to $60.03 ($80.80) and $67.05 ($91.47), respectively. CONCLUSIONS: Mailed FIT is an effective and cost-effective population health strategy for CRC screening in vulnerable patients.

Value-based care for the treatment and evaluation of benign prostatic hyperplasia: an analysis of a metropolitan service area claims database.

PURPOSE: With an aging population, cost containment and improved outcomes will be crucial for a sustainable healthcare ecosystem. Current data demonstrate great variation in payments for procedures and diagnostic workup of benign prostatic hyperplasia (BPH). To help determine the best financial value in BPH care, we sought to analyze the major drivers of total payments in BPH. MATERIALS AND METHODS: Commercial and Medicare claims from the Truven Health Analytics Markestscan® database for the Austin, Texas Metropolitan Service Area from 2012 to 2014 were queried for encounters with diagnosis and procedural codes related to BPH. Linear regression was utilized to assess factors related to BPH-related payments. Payments were then compared between surgical patients and patients managed with medication alone. RESULTS: Major drivers of total payments in BPH care were operative, namely transurethral resection of prostate (TURP) [$2778, 95% CI ($2385-$3171), p < 0.001) and photoselective vaporization (PVP) ($3315, 95% CI ($2781-$3849) p < 0.001). Most office procedures were also associated with significantly higher payments, including cystoscopy [$708, 95% CI ($417-$999), p < 0.001], uroflometry [$446, 95% CI ($225-668), p < 0.001], urinalysis [$167, 95% CI ($32-$302), p = 0.02], postvoid residual (PVR) [$245, 95% CI ($83-$407), p < 0.001], and urodynamics [$1251, 95% CI ($405-2097), p < 0.001]. Patients who had surgery had lower payments for their medications compared to patients who had no surgery [$120 (IQR: $0, $550) vs. $532 (IQR: $231, $1852), respectively, p < 0.001]. CONCLUSION: Surgery and office-based procedures are associated with increased payments for BPH treatment. Although payments for surgery were more in total, surgical patients paid significantly less for BPH medications.

Using Interactive Learning Modules to Teach Value-Based Health Care to Health Professions Trainees Across the United States.

PROBLEM: Despite prominent calls to incorporate value-based health care (VBHC) into medical education, there is still a global need for robust programs to teach VBHC concepts throughout health professions training. APPROACH: In June 2017, Dell Medical School released the first collection (three modules) of a set of free interactive online learning modules, which aim to teach the basic foundations of VBHC to health professions learners at any stage of training and can be incorporated across diverse educational settings. These modules were designed by an interprofessional team based on principles of cognitive engagement for active learning. OUTCOMES: From June 2017 to September 2018, the website received 130,098 pageviews from 8,546 unique users (2,072 registered users), representing 45 states in the United States and 10 foreign countries. As of October 15, 2018, 568 (27%) of registered users completed modules 1-3. Five-hundred thirty-five of these users completed a survey (94% response rate). Nearly all (484/535; 90%) reported overall satisfaction with the curriculum, 522/535 (98%) agreed "after completing the modules, I can define value in health care," and 520/535 (97%) agreed "after completing the modules, I can provide examples of low- and high-value care." Second-year Dell Medical School students reported that they have incorporated value into their clinical clerkships (e.g., by discussing VBHC with peers [43/45; 96%]) as a result of completing the modules. NEXT STEPS: Future plans for the curriculum include the release of additional modules, more robust knowledge assessment, and an expanded learning platform that allows for further community engagement.

Factors Associated With the Cost of Care for the Most Common Atraumatic Painful Upper Extremity Conditions.

PURPOSE: To help strategize efforts to optimize value (relative improvement in health for resources invested), we analyzed the factors associated with the cost of care and use of resources for painful, nontraumatic conditions of the upper extremity. METHODS: The following were the most common upper extremity diagnoses in the Truven Health MarketScan database: shoulder pain and rotator cuff tendinopathy, shoulder stiffness, shoulder arthritis, lateral epicondylitis, hand arthritis, trigger finger, wrist pain, and hand pain. Multivariable generalized linear regression models were constructed accounting for sex, age, employment status, enrollment year, payer type, emergency room visit, joint injection, magnetic resonance imaging (MRI), physical or occupational therapy, outpatient and inpatient surgery, and insurance type. In addition, we assessed the use of the following 4 diagnostic and treatment interventions: joint injection, surgery, MRI, and physical or occupational therapy. RESULTS: Inpatient and outpatient surgery are the largest contributors to the total amount paid for most diagnoses. Older patients had more injections for the majority of conditions. CONCLUSIONS: Efforts to improve the value of care for nontraumatic upper extremity pain can focus on the relative benefits of surgery compared with other treatments and interventions to lower the costs of surgery (eg, office surgery and limited draping for minor hand surgery). TYPE OF STUDY/LEVEL OF EVIDENCE: Economic II.

And Now, Please Sign on the Dotted Line: Teaching Residents About Professional Life After Residency.

OBJECTIVES: Despite possible long-term repercussions, few training programs teach their residents about the business of medicine. In particular, certain contractual issues can adversely affect a young physician's career mobility. METHODS: We designed a business-of-medicine curriculum and used a survey to determine whether the curriculum satisfied attendees' perceived knowledge gaps about the topics covered in the course, which included four key contractual matters: physician employment contracts (including restrictive covenants), malpractice insurance, job search, and interviewing skills. We used a postsurvey in 2015 and added a presurvey for the course in 2016. The same content was delivered in a 1-hour conference to internal medicine residents attending a regular noon conference series in 2015 and a regional academic meeting in 2016. Survey data are presented in terms of descriptive statistics. We used χ2 tests for comparisons of pre- and post-Likert scale survey data. RESULTS: Of 108 residents, 50 returned the surveys for an overall response rate of 46% across the 2 years of the course. Overwhelmingly, residents found the conference to be beneficial to the understanding of the four key contractual matters, with each topic having a statistically significant difference in perceived knowledge between the pre- and postconference questionnaires (P < 0.001). The majority of the residents indicated that they wanted to learn more about business-of-medicine topics, in particular financial challenges (76%) and job opportunities (68%). CONCLUSIONS: Our results confirm that our curriculum is effective in increasing the residents' perceived understanding of restrictive covenants, malpractice insurance, negotiating skills, and job search. Our results also demonstrate that residents have a desire to learn more about job searches; negotiating skills; and contractual issues, including restrictive covenants and malpractice insurance.

Caring Wisely: A Program to Support Frontline Clinicians and Staff in Improving Healthcare Delivery and Reducing Costs.

We describe a program called "Caring Wisely"®, developed by the University of California, San Francisco's (UCSF), Center for Healthcare Value, to increase the value of services provided at UCSF Health. The overarching goal of the Caring Wisely® program is to catalyze and advance delivery system redesign and innovations that reduce costs, enhance healthcare quality, and improve health outcomes. The program is designed to engage frontline clinicians and staff-aided by experienced implementation scientists-to develop and implement interventions specifically designed to address overuse, underuse, or misuse of services. Financial savings of the program are intended to cover the program costs. The theoretical underpinnings for the design of the Caring Wisely® program emphasize the importance of stakeholder engagement, behavior change theory, market (target audience) segmentation, and process measurement and feedback. The Caring Wisely® program provides an institutional model for using crowdsourcing to identify "hot spot" areas of low-value care, inefficiency and waste, and for implementing robust interventions to address these areas.

Association Between Surgeon Scorecard Use and Operating Room Costs.

Importance: Despite the significant contribution of surgical spending to health care costs, most surgeons are unaware of their operating room costs. Objective: To examine the association between providing surgeons with individualized cost feedback and surgical supply costs in the operating room. Design, Setting, and Participants: The OR Surgical Cost Reduction (OR SCORE) project was a single-health system, multihospital, multidepartmental prospective controlled study in an urban academic setting. Intervention participants were attending surgeons in orthopedic surgery, otolaryngology-head and neck surgery, and neurological surgery (n = 63). Control participants were attending surgeons in cardiothoracic surgery, general surgery, vascular surgery, pediatric surgery, obstetrics/gynecology, ophthalmology, and urology (n = 186). Interventions: From January 1 to December 31, 2015, each surgeon in the intervention group received standardized monthly scorecards showing the median surgical supply direct cost for each procedure type performed in the prior month compared with the surgeon's baseline (July 1, 2012, to November 30, 2014) and compared with all surgeons at the institution performing the same procedure at baseline. All surgical departments were eligible for a financial incentive if they met a 5% cost reduction goal. Main Outcomes and Measures: The primary outcome was each group's median surgical supply cost per case. Secondary outcome measures included total departmental surgical supply costs, case mix index-adjusted median surgical supply costs, patient outcomes (30-day readmission, 30-day mortality, and discharge status), and surgeon responses to a postintervention study-specific health care value survey. Results: The median surgical supply direct costs per case decreased 6.54% in the intervention group, from $1398 (interquartile range [IQR], $316-$5181) (10 637 cases) in 2014 to $1307 (IQR, $319-$5037) (11 820 cases) in 2015. In contrast, the median surgical supply direct cost increased 7.42% in the control group, from $712 (IQR, $202-$1602) (16 441 cases) in 2014 to $765 (IQR, $233-$1719) (17 227 cases) in 2015. This decrease represents a total savings of $836 147 in the intervention group during the 1-year study. After controlling for surgeon, department, patient demographics, and clinical indicators in a mixed-effects model, there was a 9.95% (95% CI, 3.55%-15.93%; P = .003) surgical supply cost decrease in the intervention group over 1 year. Patient outcomes were equivalent or improved after the intervention, and surgeons who received scorecards reported higher levels of cost awareness on the health care value survey compared with controls. Conclusions and Relevance: Cost feedback to surgeons, combined with a small departmental financial incentive, was associated with significantly reduced surgical supply costs, without negatively affecting patient outcomes.

Development of a high-value care culture survey: a modified Delphi process and psychometric evaluation.

BACKGROUND: Organisational culture affects physician behaviours. Patient safety culture surveys have previously been used to drive care improvements, but no comparable survey of high-value care culture currently exists. We aimed to develop a High-Value Care Culture Survey (HVCCS) for use by healthcare leaders and training programmes to target future improvements in value-based care. METHODS: We conducted a two-phase national modified Delphi process among 28 physicians and nurse experts with diverse backgrounds. We then administered a cross-sectional survey at two large academic medical centres in 2015 among 162 internal medicine residents and 91 hospitalists for psychometric evaluation. RESULTS: Twenty-six (93%) experts completed the first phase and 22 (85%) experts completed the second phase of the modified Delphi process. Thirty-eight items achieved ≥70% consensus and were included in the survey. One hundred and forty-one residents (83%) and 73 (73%) hospitalists completed the survey. From exploratory factor analyses, four factors emerged with strong reliability: (1) leadership and health system messaging (α=0.94); (2) data transparency and access (α=0.80); (3) comfort with cost conversations (α=0.70); and (4) blame-free environment (α=0.70). In confirmatory factor analysis, this four-factor model fit the data well (Bentler-Bonett Normed Fit Index 0.976 and root mean square residual 0.056). The leadership and health system messaging (r=0.56, p<0.001), data transparency and access (r=0.15, p<0.001) and blame-free environment (r=0.37, p<0.001) domains differed significantly between institutions and positively correlated with Value-Based Purchasing Scores. CONCLUSIONS: Our results provide support for the reliability and validity of the HVCCS to assess high-value care culture among front-line clinicians. HVCCS may be used by healthcare groups to identify target areas for improvements and to monitor the effects of high-value care initiatives.

Operating room waste: disposable supply utilization in neurosurgical procedures.

OBJECTIVE Disposable supplies constitute a large portion of operating room (OR) costs and are often left over at the end of a surgical case. Despite financial and environmental implications of such waste, there has been little evaluation of OR supply utilization. The goal of this study was to quantify the utilization of disposable supplies and the costs associated with opened but unused items (i.e., "waste") in neurosurgical procedures. METHODS Every disposable supply that was unused at the end of surgery was quantified through direct observation of 58 neurosurgical cases at the University of California, San Francisco, in August 2015. Item costs (in US dollars) were determined from the authors' supply catalog, and statistical analyses were performed. RESULTS Across 58 procedures (36 cranial, 22 spinal), the average cost of unused supplies was $653 (range $89-$3640, median $448, interquartile range $230-$810), or 13.1% of total surgical supply cost. Univariate analyses revealed that case type (cranial versus spinal), case category (vascular, tumor, functional, instrumented, and noninstrumented spine), and surgeon were important predictors of the percentage of unused surgical supply cost. Case length and years of surgical training did not affect the percentage of unused supply cost. Accounting for the different case distribution in the 58 selected cases, the authors estimate approximately $968 of OR waste per case, $242,968 per month, and $2.9 million per year, for their neurosurgical department. CONCLUSIONS This study shows a large variation and significant magnitude of OR waste in neurosurgical procedures. At the authors' institution, they recommend price transparency, education about OR waste to surgeons and nurses, preference card reviews, and clarification of supplies that should be opened versus available as needed to reduce waste.

Predictors of Variation in Neurosurgical Supply Costs and Outcomes Across 4904 Surgeries at a Single Institution.

BACKGROUND: There is high variability in neurosurgical costs, and surgical supplies constitute a significant portion of cost. Anecdotally, surgeons use different supplies for various reasons, but there is little understanding of how supply choices affect outcomes. Our goal is to evaluate the effect of patient, procedural, and provider factors on supply cost and to determine if supply cost is associated with patient outcomes. METHODS: We obtained patient information (age, gender, payor, case mix index [CMI], body mass index, admission source), procedural data (procedure type, length, date), provider information (name, case volume), and total surgical supply cost for all inpatient neurosurgical procedures from 2013 to 2014 at our institution (n = 4904). We created mixed-effect models to examine the effect of each factor on surgical supply cost, 30-day readmission, and 30-day mortality. RESULTS: There was significant variation in surgical supply cost between and within procedure types. Older age, female gender, higher CMI, routine/elective admission, longer procedure, and larger surgeon volume were associated with higher surgical supply costs (P < 0.05). Routine/elective admission and higher surgeon volume were associated with lower readmission rates (odds ratio, 0.707, 0.998; P < 0.01). Only patient factors of older age, male gender, private insurance, higher CMI, and emergency admission were associated with higher mortality (odds ratio, 1.029, 1.700, 1.692, 1.080, 2.809). There was no association between surgical supply cost and readmission or mortality (P = 0.307, 0.548). CONCLUSIONS: A combination of patient, procedural, and provider factors underlie the significant variation in neurosurgical supply costs at our institution. Surgical supply costs are not correlated with 30-day readmission or mortality.

Study of Tomography Of Nephrolithiasis Evaluation (STONE): methodology, approach and rationale.

BACKGROUND: Urolithiasis (kidney stones) is a common reason for Emergency Department (ED) visits, accounting for nearly 1% of all visits in the United States. Computed tomography (CT) has become the most common imaging test for these patients but there are few comparative effectiveness data to support its use in comparison to ultrasound. This paper describes the rationale and methods of STONE (Study of Tomography Of Nephrolithiasis Evaluation), a pragmatic randomized comparative effectiveness trial comparing different imaging strategies for patients with suspected urolithiasis. METHODS: STONE is a multi-center, non-blinded pragmatic randomized comparative effectiveness trial of patients between ages 18 and 75 with suspected nephrolithiasis seen in an ED setting. Patients were randomized to one of three initial imaging examinations: point-of-care ultrasound, ultrasound performed by a radiologist or CT. Participants then received diagnosis and treatment per usual care. The primary aim is to compare the rate of severe SAEs (Serious Adverse Events) between the three arms. In addition, a broad range of secondary outcomes was assessed at baseline and regularly for six months post-baseline using phone, email and mail questionnaires. RESULTS: Excluding 17 patients who withdrew after randomization, a total of 2759 patients were randomized and completed a baseline questionnaire (n=908, 893 and 958 in the point-of-care ultrasound, radiology ultrasound and radiology CT arms, respectively). Follow-up is complete, and full or partial outcomes were assessed on over 90% of participants. CONCLUSIONS: The detailed methodology of STONE will provide a roadmap for comparative effectiveness studies of diagnostic imaging conducted in an ED setting.