How to Identify Team-based Primary Care in the United States Using Medicare Data.

BACKGROUND: Studying team-based primary care using 100% national outpatient Medicare data is not feasible, due to limitations in the availability of this dataset to researchers. METHODS: We assessed whether analyses using different sets of Medicare data can produce results similar to those from analyses using 100% data from an entire state, in identifying primary care teams through social network analysis. First, we used data from 100% Medicare beneficiaries, restricted to those within a primary care services area (PCSA), to identify primary care teams. Second, we used data from a 20% sample of Medicare beneficiaries and defined shared care by 2 providers using 2 different cutoffs for the minimum required number of shared patients, to identify primary care teams. RESULTS: The team practices identified with social network analysis using the 20% sample and a cutoff of 6 patients shared between 2 primary care providers had good agreement with team practices identified using statewide data (F measure: 90.9%). Use of 100% data within a small area geographic boundary, such as PCSAs, had an F measure of 83.4%. The percent of practices identified from these datasets that coincided with practices identified from statewide data were 86% versus 100%, respectively. CONCLUSIONS: Depending on specific study purposes, researchers could use either 100% data from Medicare beneficiaries in randomly selected PCSAs, or data from a 20% national sample of Medicare beneficiaries to study team-based primary care in the United States.

A multidisciplinary approach to vascular surgery procedure coding improves coding accuracy, work relative value unit assignment, and reimbursement.

BACKGROUND: Vascular surgery procedural reimbursement depends on accurate procedural coding and documentation. Despite the critical importance of correct coding, there has been a paucity of research focused on the effect of direct physician involvement. We hypothesize that direct physician involvement in procedural coding will lead to improved coding accuracy, increased work relative value unit (wRVU) assignment, and increased physician reimbursement. METHODS: This prospective observational cohort study evaluated procedural coding accuracy of fistulograms at an academic medical institution (January-June 2014). All fistulograms were coded by institutional coders (traditional coding) and by a single vascular surgeon whose codes were verified by two institution coders (multidisciplinary coding). The coding methods were compared, and differences were translated into revenue and wRVUs using the Medicare Physician Fee Schedule. Comparison between traditional and multidisciplinary coding was performed for three discrete study periods: baseline (period 1), after a coding education session for physicians and coders (period 2), and after a coding education session with implementation of an operative dictation template (period 3). The accuracy of surgeon operative dictations during each study period was also assessed. An external validation at a second academic institution was performed during period 1 to assess and compare coding accuracy. RESULTS: During period 1, traditional coding resulted in a 4.4% (P = .004) loss in reimbursement and a 5.4% (P = .01) loss in wRVUs compared with multidisciplinary coding. During period 2, no significant difference was found between traditional and multidisciplinary coding in reimbursement (1.3% loss; P = .24) or wRVUs (1.8% loss; P = .20). During period 3, traditional coding yielded a higher overall reimbursement (1.3% gain; P = .26) than multidisciplinary coding. This increase, however, was due to errors by institution coders, with six inappropriately used codes resulting in a higher overall reimbursement that was subsequently corrected. Assessment of physician documentation showed improvement, with decreased documentation errors at each period (11% vs 3.1% vs 0.6%; P = .02). Overall, between period 1 and period 3, multidisciplinary coding resulted in a significant increase in additional reimbursement ($17.63 per procedure; P = .004) and wRVUs (0.50 per procedure; P = .01). External validation at a second academic institution was performed to assess coding accuracy during period 1. Similar to institution 1, traditional coding revealed an 11% loss in reimbursement ($13,178 vs $14,630; P = .007) and a 12% loss in wRVU (293 vs 329; P = .01) compared with multidisciplinary coding. CONCLUSIONS: Physician involvement in the coding of endovascular procedures leads to improved procedural coding accuracy, increased wRVU assignments, and increased physician reimbursement.

Interprofessional healthcare: a common taxonomy to assist with understanding.

Implementation of models of interprofessional healthcare can be a difficult process. One of the contributing factors is that different professionals use different terminology when addressing the same concepts. This paper proposes a common taxonomy for models of interprofessional care in order to facilitate understanding of these models regardless of the health professions involved. Three basic models are described with specific examples: the Physician Extender Model, Triage Model, and Parallel Model.

Clinical examination of pregnant women by paramedical and medical personnel: an assessment of consistency of findings in a field study.

BACKGROUND: As a part of a project to improve the maternal and child health services in 4 primary health centres (PHCs) in Bellary and Raichur districts of Karnataka, we assessed the consistency in recording symptoms, signs and some clinical observations of pregnant women by three examiners-the junior health assistant, medical officer of the PHC and a private medical practitioner. METHODS: One hundred seventy-four pregnant women were examined independently by the three examiners on the same day for 4 symptoms reported by the women themselves, 4 signs assessed by the examining person and 9 simple clinical observations. Agreement rates in each examiner pair for each parameter were assessed. RESULTS: We found poor rates of agreement in assesment of various parameters by each observer pair. The disagreement rates were lower between the two doctors compared with those between the junior health assistant and each doctor. CONCLUSION: The agreement rates between various healthcare personnel in assessing pregnant women are low. There is a need for measures to correct this situation.

[Development of a guideline for rehabilitation of patients with low back pain-- phase 2: analysis of data of the classification of therapeutic procedures]. / Leitlinienentwicklung in der Rehabilitation bei Rückenschmerzpatienten--Phase 2: Ergebnisse einer Analyse von KTL-Daten.

Initiated by the Federal Insurance Institute for Salaried Employees (BfA, Bundesversicherungsanstalt für Angestellte), the project is aimed at developing an evidence-based guideline for rehabilitation of patients with low back pain (LBP). Guideline development will be based on a systematic review of the literature, an analysis of the treatment procedures currently employed in rehabilitation, inclusion of the patients' perspectives as well as consultation of experts' panels of clinically experienced physicians and therapists. Formulation of the guideline will then be carried out in a structured consensus building process. This article is focused on analysing the present situation with regard to the treatments received by patients insured by the BfA, using data from routine documentation according to the Classification of Therapeutic Procedures (KTL, Klassifikation Therapeutischer Leistungen). The analysis is intended to provide indications of a basic need to implement a common guideline as well as, simultaneously, to explore possible deficits in present treatment practices, hence to define priorities requiring special attention in the framework of guideline development. As a result of a systematic literature review, the KTL-defined therapeutic procedures that had emerged as relevant in the rehabilitation of LBP patients were aggregated into so-called therapeutic modules which then formed the basis of the analysis. In all, more than 46,000 KTL-data of 2438 patients with a diagnosis of "low back pain" (M54.5 ICD-10) were included. In the rehab centres investigated, rehabilitation of patients with LBP follows a multidimensional, multiprofessional therapeutic strategy. More than 90 % of all patients receive treatments from the modules "medical training therapy", "health education", "physiotherapy", and "physical therapy". Treatments provided to a majority of the patients are massage (78 %), electrotherapy (67 %) as well as psychotherapy (68 %). Women more frequently than men receive therapies belonging to the "psychological treatments" and "occupational therapies" modules; younger patients receive more of the "training therapies", and more often. When treatments are compared across centres, a large variability in the therapeutic procedures provided becomes apparent. This high degree of variability suggests that development and implementation of a common clinical practice guideline for rehabilitation of patients with chronic low back pain should receive priority attention.

[Classification of social medical products provided by the German Medical Services of the Statutory Health Insurance in Hessen]. / Zur Klassifikation sozialmedizinischer Leistungen des Medizinischen Dienstes der Krankenversicherung in Hessen nach Produktgruppen1.

Based on agreements presented by a task force the German Medical Services of the Statutory Health Insurance in Hessen developed its own classification of social medical assignments. According to economic systematics they were arranged in groups of external and internal products reflecting providing services in form of medical expertises and fulfilment of legal obligations. Further typologisation of the products can be achieved by relational marks. Documentation based on this classification as a part of social medical controlling supports modern planning and management concepts. This way practical sociomedicine as an applied health science makes its contribution to economic efficiency of the statutory health care system.

The organization and delivery of craniofacial health services: the state of the art.

The dominant organizational structure providing care for cleft palate and other craniofacial conditions is the health care team. Various types of health care team organization are profiled, including intradisciplinary, multidisciplinary, and interdisciplinary teams. Effective team-based care delivery has the ability to address the fragmentation and dehumanization that can result when a variety of specialists and disciplines are required to provide assessment and technical care. A team's leadership and its hierarchy of professional authority can be expected to affect its ability to function effectively. Health reform and managed care are considered for their impact on the team and on the doctor-patient relationship. Trends in team regionalization, quality assurance, outcomes research, and consumer advocacy are reviewed. The cleft palate and craniofacial team is profiled as an organizational model that is being affected by the forces of health system change.

Desenvolvimento da sexualidade e da relacao materno-filial em gestantes adolescentes / Development of teenager's sexuality and mother-child relationship

O presente trabalho e o produto de uma das atividades do "Programa Integrado de Assitencia e Educacao a Adolescente Gravida" (PIAEGA) do Ambulatorio de Obstetricia do HC da FMUSP. Uma das dificuldades enfrentadas no trabalho com gestantes adolescentes e o desenvolvimento da maternidade e a constituicao do casal adolescente como um nucleo familiar. Este trabalho descreve o desenvolvimento da relacao materno-filial durante o periodo gestacional. Foram entrevistadas 91 gestantes, que frequentaram o PIAEGA de 1991 a 1994. Nas entrevistas investigava-se dados sociais, psicologicos e corporais: escolaridade, condicoes de habitacao e de trabalho; nucleo familiar, relacionamento afetivo do casal, desenvolvimento da adolescencia e da gravidez; percepcoes corporais da adolescencia e da gravidez...

Equipo de trabajo multidisciplinario en salud / Multidisciplinary working-team in health

Hoy en enfermería y en general en salud buscamos el mejoramiento de la calidad de la atención brindada, resurge el trabajo en equipo como una de las estrategias fundamentales para el logro de la calidad total. En el presente artículo se dan a conocer el concepto de trabajo en equipo, se describe el proceso de formación de un equipo de trabajo y se analizan aspectos que facilitan, así como las dificultades para un trabajo en equipo (multidisciplinario) en salud