Does Total Ankle Arthroplasty Belong in the Comprehensive Care for Joint Replacement?

The Comprehensive Care for Joint Replacement (CJR) model seeks to lower costs and improve quality for primary lower extremity joint replacements. This includes total ankle arthroplasty (TAA), which is performed far less frequently than total hip (THA) and knee (TKA) arthroplasty. We used the SPARCS database to identify 537 TAA and 239,053 elective primary THA or TKA procedures from 2009 to 2014, excluding hip fractures. Compared with THA and TKA, TAA had a shorter mean length of stay (2.2 versus 3.2 days), greater mean cost ($20,817 versus $17,613), lower rate of disposition to nursing and rehabilitation facilities (17% versus 52%), and lower rate of 90-day readmission (4.9% versus 5.8%). In multivariable-adjusted regression models of TAA versus THA and TKA, length of stay was 30% shorter (p < .001), costs were 14% greater (p < .001), and risk of disposition to nursing and rehabilitation facilities was 86% lower (p < .001), with no significant difference in 90-day readmission (p = .957). Patients undergoing TAA had different patterns of short-term resource usage compared with patients undergoing THA and TKA, most notably higher short-term costs. The economic viability of TAA is threatened by alternative payment models that reimburse hospitals for TAA at the same rate as THA and TKA.

[Quality Assurance using routine data: Overdiagnosis by radiological imaging for back pain]. / Überdiagnostik mit Bildgebung bei Rückenschmerzen.

UNLABELLED: Background and Problem: Acute nonspecific back pain disorders are typically self-limiting. According to the national guideline low back pain, only in case of clinical suspicion of a serious course radiological imaging should take place immediately. Otherwise, the guideline recommends waiting at least six weeks. PATIENTS AND METHODOLOGY: Using Statutory Health Insurance (SHI) routine data of the Techniker Krankenkasse we analyzed how many of the insured persons suffering from acute back pain for the first time with no indication of a serious outcome received a non-indicated diagnostic imaging. RESULTS: In about 10 % diagnostic imaging is conducted after initial diagnosis. If an imaging is carried out, roughly one third of these cases takes place ahead of time or is completely unnecessary. Methodically this is a very conservative estimation, thus it seems likely that the extent of overdiagnosis in actual medical care situation is even larger. CONCLUSIONS: Every third patient who received radiological diagnostics due to first acute nonspecific back pain underwent the procedure more quickly than recommended (less than six weeks). Overdiagnosis is not only economically problematic but also with respect to patient orientation and patient safety. It may cause substantial damage to patients - either by the use of diagnostics itself or by means of therapies initiated after diagnostics.

Rehabilitation - a new approach. Part four: a new paradigm, and its implications.

This editorial proposes changes in healthcare services that should greatly improve the health status of all patients with disability. The main premises are that: rehabilitation usually involves many actions delivered by many people from different organisations over a prolonged period; specific rehabilitation actions cover a wide range of professional activities, with face to face therapy only being one; and the primary patient activity that improves function is practice of personally relevant activities in a safe environment. This editorial argues that: rehabilitation should occur at all times and in all settings, in parallel with medical care in order to maximise recovery and to avoid loss of fitness, skills and confidence associated with rest and being cared for; hospitals and other healthcare settings should adapt the environment to encourage practice of activities at all times; and that measuring rehabilitation, whether in research or for re-imbursement, should not simply consider face-to-face 'therapy time' but must include: all the other important activities undertaken by the team; 'structures' such as the appropriateness of the environment; and a process measure of the time spent by patients undertaking activities.

Truly bold leaders will listen to the evidence.

NHS leaders seeking to cut costs and improve quality should focus on STPs as opposed to reconfiguring acute care.

Triple Aim in Canada: developing capacity to lead to better health, care and cost.

QUALITY PROBLEM: Many modern health systems strive for 'Triple Aim' (TA)-better health for populations, improved experience of care for patients and lower costs of the system, but note challenges in implementation. Outcomes of applying TA as a quality improvement framework (QI) have started to be realized with early lessons as to why some systems make progress while others do not. INITIAL ASSESSMENT: Limited evidence is available as to how organizations create the capacity and infrastructure required to design, implement, evaluate and sustain TA systems. CHOICE OF SOLUTION: To support embedding TA across Canada, the Canadian Foundation for Healthcare Improvement supported enrolment of nine Canadian teams to participate in the Institute for Healthcare Improvement's TA Improvement Community. IMPLEMENTATION: Structured support for TA design, implementation, evaluation and sustainability was addressed in a collaborative programme of webinars and action periods. Teams were coached to undertake and test small-scale improvements before attempting to scale. EVALUATION: A summative evaluation of the Canadian cohort was undertaken to assess site progress in building TA infrastructure across various healthcare settings. The evaluation explored the process of change, experiences and challenges and strategies for continuous QI. LESSONS LEARNED: Delivering TA requires a sustained and coordinated effort supported by strong leadership and governance, continuous QI, engaged interdisciplinary teams and partnering within and beyond the healthcare sector.

[The influence of framework conditions for integrated care programs on their potential of evaluation]. / Wie beeinflussen die Rahmenbedingungen integrierter Versorgungsprogramme die Möglichkeiten der Evaluation?

AIM AND METHODS: A common justification of the failure to perform scientific evaluations of integrated care programs (in accordance with Sect. 140 SGB V) is the high level of expenditure which is strongly influenced by the conditions of the particular program. Two practical examples will be used to outline frameworks of integrated care programs that may create obstacles to evaluation. If possible, appropriate solutions that may help to avoid or at least reduce these obstacles will be presented. RESULTS: In many programs target groups and program objectives are inaccurately defined. Especially disease-specific programs bear the risk of having too small a sample size to exclude random effects. Only a few integrated care programs include evaluations that have been proactively planned from the outdet. CONCLUSION: In particular, early planning of evaluations plays an important role in avoiding distortions of results and additional expenses. It may also have a positive influence on all other frameworks.

Pursuing the Triple Aim: The First 7 Years.

UNLABELLED: POLICY POINTS: In 2008, researchers at the Institute for Healthcare Improvement (IHI) proposed the Triple Aim, strategic organizing principles for health care organizations and geographic communities that seek, simultaneously, to improve the individual experience of care and the health of populations and to reduce the per capita costs of care for populations. In 2010, the Triple Aim became part of the US national strategy for tackling health care issues, especially in the implementation of the Patient Protection and Affordable Care Act (ACA) of 2010. Since that time, IHI and others have worked together to determine how the implementation of the Triple Aim has progressed. Drawing on our 7 years of experience, we describe 3 major principles that guided the organizations and communities working on this endeavor: creating the right foundation for population management, managing services at scale for the population, and establishing a learning system to drive and sustain the work over time. CONTEXT: In 2008, researchers at the Institute for Healthcare Improvement (IHI) described the Triple Aim as simultaneously "improving the individual experience of care; improving the health of populations; and reducing the per capita costs of care for populations." IHI and its close colleagues had determined that both individual and societal changes were needed. METHODS: In 2007, IHI began recruiting organizations from around the world to participate in a collaborative to implement what became known as the Triple Aim. The 141 participating organizations included health care systems, hospitals, health care insurance companies, and others closely tied to health care. In addition, key groups outside the health care system were represented, such as public health agencies, social services groups, and community coalitions. This collaborative provided a structure for observational research. By noting the contrasts between the contexts and structures of those sites in the collaborative that progressed and those that did not, we were able to develop an ex post theory of what is needed for an organization or community to successfully pursue the Triple Aim. FINDINGS: Drawing on our 7 years of experience, we describe the 3 major principles that guided the organizations and communities working on the Triple Aim: creating the right foundation for population management, managing services at scale for the population, and establishing a learning system to drive and sustain the work over time. CONCLUSIONS: The concept of the Triple Aim is now widely used, because of IHI's work with many organizations and also because of the adoption of the Triple Aim as part of the national strategy for US health care, developed during the implementation of the Patient Protection and Affordable Care Act of 2010. Even those organizations working on the Triple Aim before IHI coined the term found our concept to be useful because it helped them think about all 3 dimensions at once and organize their work around them.

Trace element monitoring in the ICU: quality and economic impact of a change in sampling practice.

BACKGROUND & AIMS: Trace elements (TE) are involved in the immune and antioxidant defences which are of particular importance during critical illness. Determining plasma TE levels is costly. The present quality control study aimed at assessing the economic impact of a computer reminded blood sampling versus a risk guided on-demand monitoring of plasma concentrations of selenium, copper, and zinc. METHODS: Retrospective analysis of 2 cohorts of patients admitted during 6 months periods in 2006 and 2009 to the ICU of a University hospital. INCLUSION CRITERIA: to receive intravenous micronutrient supplements and/or to have a TE sampling during ICU stay. The TE samplings were triggered by computerized reminder in 2006 versus guided by nutritionists in 2009. RESULTS: During the 2 periods 636 patients met the inclusion criteria out of 2406 consecutive admissions, representing 29.7% and 24.9% respectively of the periods' admissions. The 2009 patients had higher SAPS2 scores (p = 0.02) and lower BMI compared to 2006 (p = 0.007). The number of laboratory determinations was drastically reduced in 2009, particularly during the first week, despite the higher severity of the cohort, resulting in à 55% cost reduction. CONCLUSIONS: The monitoring of TE concentrations guided by a nutritionist resulted in a reduction of the sampling frequency, and targeting on the sickest high risk patients, requiring a nutritional prescription adaptation. This control leads to cost reduction compared to an automated sampling prescription.

[Concept for a department of intensive care]. / Konzept einer Klinik für Intensivmedizin.

BACKGROUND: Demographic change and increasing complexity are among the reasons for high-tech critical care playing a major and increasing role in today's hospitals. At the same time, intensive care is one of the most cost-intensive departments in the hospital. PREREQUISITES: To guarantee high-quality care, close cooperation of specialised intensive care staff with specialists of all other medical areas is essential. A network of the intensive care units within the hospital may lead to synergistic effects concerning quality of care, simultaneously optimizing the use of human and technical resources. GOAL: Notwithstanding any organisational concepts, development and maintenance of the highest possible quality of care should be of overriding importance.

The costs of accessible quality assured syphilis diagnostics: informing quality systems for rapid syphilis tests in a Tanzanian setting.

OBJECTIVES: To determine the costs of Rapid Syphilis Test (RSTs) as compared with rapid plasma reagin (RPR) when implemented in a Tanzanian setting, and to determine the relative impact of a quality assurance (QA) system on the cost of RST implementation. METHODS: The incremental costs for RPR and RST screening programmes in existing antenatal care settings in Geita District, Tanzania were collected for 9 months in subsequent years from nine health facilities that varied in size, remoteness and scope of antenatal services. The costs per woman tested and treated were estimated for each facility. A sensitivity analysis was constructed to determine the impact of parameter and model uncertainty. FINDINGS: In surveyed facilities, a total of 6362 women were tested with RSTs compared with 224 tested with RPR. The range of unit costs was $1.76-$3.13 per woman screened and $12.88-$32.67 per woman treated. Unit costs for the QA system came to $0.51 per woman tested, of which 50% were attributed to salaries and transport for project personnel. CONCLUSIONS: Our results suggest that rapid syphilis diagnostics are very inexpensive in this setting and can overcome some critical barriers to ensuring universal access to syphilis testing and treatment. The additional costs for implementation of a quality system were found to be relatively small, and could be reduced through alterations to the programme design. Given the potential for a quality system to improve quality of diagnosis and care, we recommend that QA activities be incorporated into RST roll-out.

[Is there adequate care for patients with psychosomatic disorders in Austria? Analysis of the need and a proposal for a model of quality assurance in Austrian psychosomatic medicine]. / Werden in Osterreich Patienten mit psychosomatischen Storungen ausreichend versorgt? Eine Bedarfserhebung mit Losungsvorschlag zur Qualitats-sicherung fur die Psychosomatische Medizin in Osterreich.

INTRODUCTION: Quality assurance in psychosomatic medicine in Austria is currently based on a voluntary continuing medical education programme in psychosocial, psychosomatic and psychotherapeutic medicine. It is questionable whether psychosomatic care can be sufficiently provided in this manner. In addition, a broadly based proposal to create a subspecialty in psychosomatic medicine in order to facilitate quality assurance, is investigated. METHODS: The necessity to reorganize psychosomatic care was explored through semi-structured qualitative interviews with experts. Data-based analyses probed the labour market of the proposed subspecialty, and the literature was reviewed to look into the cost-benefit ratio of psychosomatic treatment. RESULTS: All experts expressed a need to restructure psychosomatic care in Austria. Examples exist for psychosomatic treatment with an efficient cost-benefit relation in diverse medical settings. CONCLUSION: Establishing a subspecialty in Psychosomatic Medicine seems feasible and could contribute to increased quality assurance and the nationwide provision of psychosomatic care.

What is the present situation of vascular surgery? Considerations and reflections based on real practice.

"For the best vascular care to every patient, every day" is the goal of our practice, but is it a possible goal? Where are we now? The general idea is that we are pursuing the right way. The evolution of our discipline in the last two decades has been extraordinary and we reaffirm that we are the leaders in diagnose and treatment of the arterial pathology. Unfortunately, we can find some cases in which reality has to be faced as hardly as it can be, remembering us that we still have to go further with our job. The delay in the diagnose and treatment could lead to a permanent deficit and a money loss for the national health system due to prolonged hospitalization, multiple re-hospitalizations, loss of working capacity. This must be avoided. We strongly suggest that a vascular surgeon should be present in all the Emergency Room and should be routinely involved in the management of patients. The routine use of dedicated interdisciplinary protocols should be strongly advocated. Vascular surgery, as medical specialty, should be recognized as single specialty in all countries and as "peculiar" by the National Authority as well as Neurosurgery and Cardiac Surgery.

Structured care of diabetes in general practice: a qualitative study of the barriers and facilitators.

This qualitative study explored general practitioner's and practice nurse's perceptions of barriers and facilitators to the proposed transfer of diabetes care to general practice. Qualitative data were collected through five focus groups. Participants included GPs (n = 55) and practice nurses (n = 11) representing urban (44%), rural (29%) and mixed (27%) practices, in the Irish Mid-West region. Barriers and facilitators were mentioned 631 times (100%). Barriers were mentioned 461 times (73%), facilitators 170 times (27%). The most frequently identified barriers were lack of financial incentive (119/631; 19%), lack of access to secondary resources (93/631; 15%), lack of staff and increased workload (59/631; 9%) and time constraints (52/631; 8%). Identified facilitators were access to secondary care (49/631;7.8%), the holistic nature of general practice and continuity of care (48/631;7.6%). Although many are enthusiastic, there remains significant reluctance among GPs and practice nurses to take responsibility for diabetes care without addressing these barriers.

Healthcare system effects of pay-for-performance for smoking status documentation.

OBJECTIVES: To evaluate the impact on smoking status documentation of a payer-sponsored pay-for-performance (P4P) incentive that targeted a minority of an integrated healthcare delivery system's patients. STUDY DESIGN: Three commercial insurers simultaneously adopted P4P incentives to document smoking status of their members with 3 chronic diseases. The healthcare system responded by adding a smoking status reminder to all patients' electronic health records (EHRs). We measured change in smoking status documentation before (2008-2009) and after (2010-2011) P4P implementation by patient P4P eligibility. METHODS: The P4P-eligible patients were compared primarily with a subset of non-P4P-eligible patients who resembled P4P-eligible patients and also with all non-P4P-eligible patients. Multivariate models adjusted for patient and provider characteristics and accounted for provider-level clustering and preimplementation trends. RESULTS: Documentation increased from 48% of 207,471 patients before P4P to 71% of 227,574 patients after P4P. Improvement from 56% to 83% occurred among P4P-eligible patients (adjusted odds ratio [AOR], 3.6; 95% confidence interval [CI], 2.9-4.5) and from 56% to 80% among the comparable subset of non-P4P-eligible patients (AOR, 3.0; 95% CI, 2.3-3.9). The difference in improvement between groups was significant (AOR, 1.3; 95% CI, 1.1-1.4; P = .009). CONCLUSIONS: A P4P incentive targeting a minority of a healthcare system's patients stimulated adoption of a system wide EHR reminder and improved smoking status documentation overall. Combining a P4P incentive with an EHR reminder might help healthcare systems improve treatment delivery for smokers and meet "meaningful use" standards for EHRs.