Optimization-driven framework to understand health care network costs and resource allocation.

In the last several decades, the U.S. Health care industry has undergone a massive consolidation process that has resulted in the formation of large delivery networks. However, the integration of these networks into a unified operational system faces several challenges. Strategic problems, such as ensuring access, allocating resources and capacity efficiently, and defining case-mix in a multi-site network, require the correct modeling of network costs, network trade-offs, and operational constraints. Unfortunately, traditional practices related to cost accounting, specifically the allocation of overhead and labor cost to activities as a way to account for the consumption of resources, are not suitable for addressing these challenges; they confound resource allocation and network building capacity decisions. We develop a general methodological optimization-driven framework based on linear programming that allows us to better understand network costs and provide strategic solutions to the aforementioned problems. We work in collaboration with a network of hospitals to demonstrate our framework applicability and important insights derived from it.

Financial Margins for Prostate Cancer Surgery: Quantifying the Impact of Modifiable Cost Inputs in an Episode Based Reimbursement Model.

PURPOSE: The United States health care system is rapidly moving away from fee for service reimbursement in an effort to improve quality and contain costs. Episode based reimbursement is an increasingly relevant value based payment model of surgical care. We sought to quantify the impact of modifiable cost inputs on institutional financial margins in an episode based payment model for prostate cancer surgery. MATERIALS AND METHODS: A total of 157 consecutive patients underwent robotic radical prostatectomy in 2016 at a tertiary academic medical center. We compiled comprehensive episode costs and reimbursements from the most recent urology consultation for prostate cancer through 90 days postoperatively and benchmarked the episode price as a fixed reimbursement to the median reimbursement of the cohort. We identified 2 sources of modifiable costs with undefined empirical value, including preoperative prostate magnetic resonance imaging and perioperative functional recovery counseling visits, and then calculated the impact on financial margins (reimbursement minus cost) under an episode based payment. RESULTS: Although they comprised a small proportion of the total episode costs, varying the use of preoperative magnetic resonance imaging (33% vs 100% of cases) and functional recovery counseling visits (1 visit in 66% and 2 in 100%) reduced average expected episode financial margins up to 22.6% relative to the margin maximizing scenario in which no patient received these services. CONCLUSIONS: Modifiable cost inputs have a substantial impact on potential operating margins for prostate cancer surgery under an episode based payment model. High cost health systems must develop the capability to analyze individual cost inputs and quantify the contribution to quality to inform value improvement efforts for multiple service lines.

The nature and sources of variability in pediatric surgical case duration.

BACKGROUND: Case time variability confounds surgical scheduling and decreases access to limited operating room resources. Variability arises from many sources and can differ among institutions serving different populations. A rich literature has developed around case time variability in adults, but little in pediatrics. OBJECTIVE: We studied the effect of commonly used patient and procedure factors in driving case time variability in a large, free-standing, academic pediatric hospital. METHODS: We analyzed over 40 000 scheduled surgeries performed over 3 years. Using bootstrapping, we computed descriptive statistics for 249 procedures and reported variability statistics. We then used conditional inference regression trees to identify procedure and patient factors associated with pediatric case time and evaluated their predictive power by comparing prediction errors against current practice. Patient and procedure factors included patient's age and weight, medical status, surgeon identity, and ICU request indicator. RESULTS: Overall variability in pediatric case time, as reflected by standard deviation, was 30% (25.8, 34.7) of the median case time. Relative variability (coefficient of variation), was largest among short cases. For a few procedure types, the regression tree can improve prediction accuracy if extreme behavior cases are preemptively identified. However, for most procedure types, no useful predictive factors were identified and, most notably, surgeon identity was unimportant. CONCLUSIONS: Pediatric case time variability, unlike adult cases, is poorly explained by surgeon effect or other characteristics that are commonly abstracted from electronic records. This largely relates to the 'long-tailed' distribution of pediatric cases and unpredictably long cases. Surgeon-specific scheduling is therefore unnecessary and similar cases may be pooled across surgeons. Future scheduling efforts in pediatrics should focus on prospective identification of patient and procedural specifics that are associated with and predictive of long cases. Until such predictors are identified, daily management of pediatric operating rooms will require compensatory overtime, capacity buffers, schedule flexibility, and cost.

Comparison of automated methods for measurement of 25-hydroxyvitamin D.

BACKGROUND: The objective of the study was to compare the analytical performance of three automated immunoassays for the determination of serum 25-hydroxyvitamin D. METHODS: Quantitative determination of serum 25(OH)D were performed by "Vitamin D total" (n = 131) and "Vitamin D3(25-OH)" (n = 77) assays (Roche Diagnostics) on a Cobas e411 and by "25-OH Vitamin D" (n = 131) assay (Abbott Laboratories) on an Architect. The inter-assay precision was calculated and methods were compared by the Passing Bablok regression and Bland-Altman analysis. RESULTS: The "Vitamin D total" demonstrated stronger correlation (r = 0.863) and better agreement (bias = -7.89 nmol/L) with the "25-OH Vitamin D" than with the "Vitamin D3(25-OH)" (r = 0.716; bias = +18.6 nmol/L). The inter-assay precision (% CV) for the "Vitamin D total" and "25-OH Vitamin D" assays, were respectively 3.47 to 6.14 and 4.27 to 8.56. CONCLUSIONS: The results of this study demonstrate that Abbott "25-OH Vitamin D" and Roche "Vitamin D total" are rapid and precise methods for 25(OH)D serum measurement over a wide reportable range on automated immunoassay platforms. The Abbott assay exhibited better correlation and agreement with the new Roche assay than the "Vitamin D3(25-OH)" Roche assay. Between method differences observed in this study still indicates the need for standardization of 25(OH)D assays.

Modeling financial outcomes and quantifying risk in episode-based payment models.

OBJECTIVES: Health systems and provider groups currently lack a systematic mechanism to evaluate the financial implications of value-based alternative payments. We sought to develop a method to prospectively quantify the financial implications, including risk and uncertainty of (1) transitioning from a fee-for-service to an episode-based payment model and (2) modifying episode-specific clinical cost drivers. Finally, we highlight practical applications for the model to help facilitate stakeholder engagement in the transition to value-based payment models. STUDY DESIGN: We created a financial simulation from empirical data to demonstrate the feasibility and potential use cases within the context of a hypothetical episode-based payment model for prostate cancer surgery (prostatectomy). METHODS: We used Monte Carlo simulation methods to predict financial outcomes under various clinical and payment model scenarios for our pilot prostatectomy episode use case. We input patient-level empirical cost, reimbursement, and clinical data for a cohort of 157 patients at our institution into our model to quantify expected financial outcomes (payments, financial margins) and financial risk for stakeholders (payer, hospital, providers) under an episode-based payment model. RESULTS: Compared with the status quo, there is a range of expected financial outcomes for various stakeholders depending on the financial parameters (episode price, shared savings, downside risk, stop-loss) in an episode-based payment model. Modifying clinical cost drivers has a profound impact on these outcomes. Uncertainty is high due to the small number of episodes. CONCLUSIONS: The simulation demonstrates that both financial parameters and clinical cost drivers significantly affect the expected financial outcomes for stakeholders in value-based payment models.

Liver transplantation and anemia in familial amyloidosis ATTR V30M.

Familial amyloid polyneuropathy type I (FAP-I) is caused by a mutant transthyretin (TTR V30M) produced by liver, and orthotopic liver transplantation (OLT) is a widely accepted treatment for stopping the major production of TTR V30M. Anemia affects 24.8% of symptomatic FAP-I patients with low erythropoietin (Epo) levels, suggesting a blockage of Epo-producing cells by local or circulating factors. To evaluate the putative toxicity effect of the mutant protein on Epo-producing cells and consequent Epo production, clinical and laboratory parameters of 20 FAP patients were collected before and after liver transplantation, analyzed and compared. Following OLT, the prevalence of anemia increased, with a significant decrease in transferrin saturation, but without significant change in ferritin. Serum Epo levels remained low after OLT and the observed to expected (O/E) Epo level ratio decreased even further after OLT (O/E < 0.8 rose to 70%). Despite the decrease in creatinine clearance (95.1 to 66.9 ml/min, p < 0.001), a similar median O/E Epo level was observed, independently of the presence of renal failure, excluding an important impact of renal failure on Epo production. The increase of anemia after OLT and the maintenance of a defective endogenous Epo production after liver transplantation excluded an inhibitory effect of the circulating TTR V30M on the Epo-producing cells.

Peritoneal membrane evaluation in routine clinical practice.

BACKGROUND/AIMS: Establishment of reference values for small solute transport, sodium sieving and effluent CA125 with 3.86% (4 h) peritoneal equilibration test (PET), and comparison with fast-fast PET with regard to small solute transport categories. METHODS: Cross-sectional study; 69 prevalent patients. Sodium sieving corrected for sodium diffusion with a formula applicable to the PET. CA125 appearance rate (AR) was measured. Expected and observed 60 min D/P(creatinine) were compared by Bland and Altman. RESULTS: Means (95% CI): D/P(creatinine) 0.73 (0.70-0.76), MTAC(creatinine) 9.6 (8.4-10.9) ml/min, D/D0 glucose 0.30 (0.28-0.31), corrected dip 0.17 (0.15-0.18), CA125 150 (125-176) U/min. Both corrected and uncorrected sodium sieving were informative. Peritoneal transport was faster at 60 min dwell. UFF patients presented very low corrected dip and CA125 AR. CONCLUSION: 3.86% (4 h) PET provided results similar to those from SPA. Correction for diffusion of sodium sieving is dispensable for simple clinical evaluations. D/P(creatinine) at 60 min overestimated small solute transport rate. Effluent CA125 was consistently lower in UFF patients.

The soluble transferrin receptor as a marker of iron homeostasis in normal subjects and in HFE-related hemochromatosis.

BACKGROUND AND OBJECTIVES: The soluble transferrin receptor (sTfR) is a clinical marker of erythropoietic activity, also used in the diagnosis of iron deficiency. In the present paper we explore the meaning of this parameter in normal physiological conditions of iron homeostasis and in the setting of iron overload due to hereditary hemochromatosis (HH). DESIGN AND METHODS: Reference values for sTfR were established in a population of 42 apparently healthy subjects, analyzed in relation to other hematologic parameters, namely, hemoglobin (Hb), mean corpuscular volume (MCV), transferrin saturation (TfSat) and serum ferritin. The same analysis was done in a group of 45 patients with HH who were homozygous for the C282Y mutation of HFE and had a wide range of TfSat values. In addition, individual serial profiles were analyzed in three patients. RESULTS: In normal subjects circulating sTfR correlated significantly with the TfSat level, reflecting the systemic effect of iron availability on the erythropoietic activity in a normal physiological steady state. A TfSat of 25% appeared as a threshold value, below which there was a progressive increase in sTfR; this increase in sTfR occurred concomitantly with a decrease in Hb, MCV and serum ferritin. In HH patients the up-regulation of sTfR started at TfSat values as high as 50%. INTERPRETATION AND CONCLUSIONS: The fact that sTfR up-regulation started at higher TfSat values in HH patients suggests that the recognition of systemic iron available for erythropoiesis is altered in this condition. Based on these results, a new hypothesis is advanced, proposing that the HFE protein in involved as a sensor of systemic iron availability, via the soluble transferrin receptor.

Contando e encantando histórias de vida em um centro de atenção psicossocial / Contando y encantando historias de vida en un centro de atención psicosocial / Telling and enchanting lifestories in a psychosocial care center

A Reforma Psiquiátrica tem provocado inúmeras mudanças na atenção ao portador de sofrimento mental, ampliando as formas de intervenção junto a essa população. Este trabalho teve por objetivo relatar a experiência de criação de um grupo de contação de histórias em um Centro de Atenção Psicossocial (CAPS). Nesse grupo, por meio da apropriação de contos milenares, histórias do cotidiano e experiências de vida dos próprios participantes, é criado um espaço no qual cada um pode se aproximar de suas emoções, fantasias, pensamentos e medos de maneira metafórica e lúdica, potencializando possibilidades de compreensão do funcionamento psíquico. O grupo ocorre semanalmente, com 20 usuários de ambos os sexos, com duração de uma hora e vinte minutos. Nesse espaço de escuta, acolhimento, lembranças e ressignificação de sentidos, os participantes podem experimentar a si mesmos em outras possibilidades do existir, escrevendo também mais um capítulo da história de vida do próprio grupo.

La Reforma Psiquiátrica ha provocado diversos cambios en la atención al portador de sufrimiento mental, ampliando las formas de intervención junto a esta población. Este trabajo tuvo como objetivo relatar la experiencia de creación de un grupo de contadores de historias en un Centro de Atención Psicosocial (CAPS). En este grupo, a través de la apropiación de cuentos milenarios, historias cotidianas y experiencias de vida de los propios participantes, se crea un espacio en el cual ellos pueden aproximarse a sus emociones, fantasías, pensamientos y miedos de una forma metafórica y lúdica, potencializando posibilidades de comprensión del funcionamiento psíquico. El grupo funciona semanalmente, con 20 usuarios de ambos sexos, con duración de una hora y veinte minutos. En ese espacio de escucha, acogida, recuerdos y resignificación de sentidos, los participantes pueden probar a sí mismos en otras posibilidades del existir, escribiendo también más un capítulo de la historia de vida del propio grupo.

The Psychiatric Reform has caused numerous changes in care to patients with mental disorder, widening the forms and scope of treatments. This study aimed to present an experience report of the creation of a storytelling group at a Psychosocial Care Center (CAPS). In this group, through the world of ancient tales and participants' own daily stories and life experiences, patients can approach their emotions, fantasies, thoughts and fears in a metaphoric and ludic way, thus improving their chances of gaining a better understanding of their own psychic performance. The group has 20 participants of both genders, and meets weekly for one hour and twenty minutes. In this environment of listening, embracement, memories and review of meanings, participants are able to experience themselves in other possibilities of being. At the same time they write another chapter of the life story of the group itself.

Familial ATTR amyloidosis: microalbuminuria as a predictor of symptomatic disease and clinical nephropathy.

BACKGROUND: Portuguese type familial amyloid polyneuropathy (FAP) is a neuropathic amyloidosis caused by a mutant transthyretin (TTR). Varying degrees of renal involvement have been reported. Our aim was to assess the value of microalbuminuria (MA) for predicting clinical neurological disease and overt nephropathy in TTR-related amyloidosis. METHODS: All subjects had the TTR Val30Met mutation, and were recruited between 1993 and 1999. We have prospectively evaluated 22 asymptomatic gene carriers (7 male, 15 female; mean age 41.6+/-9.6 years) and 32 patients with neuropathy (14 male, 18 female; 36.8+/-8.8 years, on average, 33.0+/-9.3 years at the onset of neuropathy). We measured urinary albumin excretion every year, if asymptomatic, or every 6 months if already affected. Kidney biopsies were performed in patients with normal urinary albumin excretion, MA, and overt nephropathy, respectively. RESULTS: In asymptomatic carriers, persistent MA was detected in eight (36%) subjects. The presence of MA in asymptomatic gene carriers, compared with those having normal urinary albumin excretion, conferred a 4.8-fold risk of developing neuropathy, usually within the subsequent 3 years. Once neurological signs appeared, nephropathy, manifested as MA, progressed to overt nephropathy in one-half of subjects. In patients with neuropathy, 24 (75%) had MA during follow-up: evolution towards clinical renal disease occurred in 14 (58%) and renal failure occurred in five (21%), always after a course of MA. Proteinuria or renal failure without prior persistent MA were never observed in the present patient cohort. Histopathological evaluation did not reveal glomerular lesions other than amyloid deposits to explain abnormal urinary albumin excretion. The amount of mesangial and vascular-pole amyloid deposits was correlated with the degree of albuminuria. CONCLUSIONS: Microalbuminuria represents the first stage of clinical TTR amyloid nephropathy and is premonitory of neuropathy. Its presence identifies a subgroup of patients who are more prone to develop overt nephropathy. Screening of MA may be important to assess disease onset and to recommend liver transplantation in individuals at risk.

Kidney and anemia in familial amyloidosis type I.

BACKGROUND: Familial amyloid polyneuropathy (FAP) type I is caused by a mutated transthyretin (TTR V30M) and characterized by a sensorimotor and autonomic neuropathy. Renal, cardiac, and ocular abnormalities can also occur. Anemia has been described in previous reports, but its prevalence in Portuguese FAP patients is not precisely known. The aim of this study was to estimate the prevalence of anemia in FAP type I Portuguese patients and to evaluate the contribution of erythropoietin (Epo) to its genesis. METHODS: A retrospective cross-sectional study was undertaken to determinate the prevalence and characteristics of anemia in 165 FAP patients. For comparison analysis, 3 control groups were also evaluated, 1 group of 46 apparently healthy subjects, 1 group of 17 asymptomatic carriers of FAP-trait, and a group of 14 non-FAP patients with chronic renal insufficiency. Serum Epo levels were analyzed in all groups. RESULTS: Anemia was present in 24.8% of symptomatic FAP patients. Iron stores, B12 vitamin, and serum folate levels were normal. FAP patients presented significantly lower serum Epo levels than healthy controls (P= 0.003). Epo levels were found lower than expected for the degree of anemia and in 17.5% were undetectable. Low Epo values were observed independently of the presence of renal failure or anemia, and sometimes preceded clinical disease. CONCLUSION: Anemia in FAP type I is a common manifestation. The results clearly suggest a defective endogenous Epo production in the genesis of the anemia.