Americans Support Price Shopping For Health Care, But Few Actually Seek Out Price Information.

The growing awareness of the wide variation in health care prices, increased availability of price data, and increased patient cost sharing are expected to drive patients to shop for lower-cost medical services. We conducted a nationally representative survey of 2,996 nonelderly US adults who had received medical care in the previous twelve months to assess how frequently patients are price shopping for care and the barriers they face in doing so. Only 13 percent of respondents who had some out-of-pocket spending in their last health care encounter had sought information about their expected spending before receiving care, and just 3 percent had compared costs across providers before receiving care. The low rates of price shopping do not appear to be driven by opposition to the idea: The majority of respondents believed that price shopping for care is important and did not believe that higher-cost providers were of higher quality. Common barriers to shopping included difficulty obtaining price information and a desire not to disrupt existing provider relationships.

Challenges in adapting existing clinical natural language processing systems to multiple, diverse health care settings.

OBJECTIVE: Widespread application of clinical natural language processing (NLP) systems requires taking existing NLP systems and adapting them to diverse and heterogeneous settings. We describe the challenges faced and lessons learned in adapting an existing NLP system for measuring colonoscopy quality. MATERIALS AND METHODS: Colonoscopy and pathology reports from 4 settings during 2013-2015, varying by geographic location, practice type, compensation structure, and electronic health record. RESULTS: Though successful, adaptation required considerably more time and effort than anticipated. Typical NLP challenges in assembling corpora, diverse report structures, and idiosyncratic linguistic content were greatly magnified. DISCUSSION: Strategies for addressing adaptation challenges include assessing site-specific diversity, setting realistic timelines, leveraging local electronic health record expertise, and undertaking extensive iterative development. More research is needed on how to make it easier to adapt NLP systems to new clinical settings. CONCLUSIONS: A key challenge in widespread application of NLP is adapting existing systems to new clinical settings.

Preliminary Data on a Care Coordination Program for Home Care Recipients.

Home care recipients are often hospitalized for potentially avoidable reasons. A pilot program (Intervention in Home Care to Improve Health Outcomes (In-Home)) was designed to help home care providers identify acute clinical changes in condition and then manage the condition in the home and thereby avoid a costly hospitalization. Caregivers answer simple questions about the care recipient's condition during a telephone-based "clock-out" at the end of each shift. Responses are electronically captured in the agency management software that caregivers use to "clock-in," manage care, and "clock-out" on every shift. These are transmitted to the agency's care manager, who follows up on the change in condition and escalates appropriately. A description of the In-Home model is presented, and pilot data from 22 home care offices are reported. In the pilot, caregivers reported a change in condition after 2% of all shifts, representing an average of 1.9 changes per care recipient in a 6-month period. Changes in behavior and skin condition were the most frequently recorded domains. Interviews with participating caregivers and care managers suggested positive attitudes regarding the intervention; challenges included resistance to change on the part of home care staff and difficulties in applying a uniform intervention to individuals with varying needs in home care offices with varying capacities. In an ongoing randomized trial, the success of the overall program will be measured primarily according to the potential reduction in avoidable hospitalizations of home care recipients and the effect this potential reduction has on spending and healthcare outcomes.

Integrated Payment And Delivery Models Offer Opportunities And Challenges For Residential Care Facilities.

Under health care reform, new financing and delivery models are being piloted to integrate health and long-term care services for older adults. Programs using these models generally have not included residential care facilities. Instead, most of them have focused on long-term care recipients in the community or the nursing home. Our analyses indicate that individuals living in residential care facilities have similarly high rates of chronic illness and Medicare utilization when compared with matched individuals in the community and nursing home, and rates of functional dependency that fall between those of their counterparts in the other two settings. These results suggest that the residential care facility population could benefit greatly from models that coordinated health and long-term care services. However, few providers have invested in the infrastructure needed to support integrated delivery models. Challenges to greater care integration include the private-pay basis for residential care facility services, which precludes shared savings from reduced Medicare costs, and residents' preference for living in a home-like, noninstitutional environment.

The impact of exclusion criteria on a physician's adenoma detection rate.

BACKGROUND: The adenoma detection rate (ADR) is a validated and widely used measure of colonoscopy quality. There is uncertainty in the published literature as to which colonoscopy examinations should be excluded when measuring a physician's ADR. OBJECTIVE: To examine the impact of varying the colonoscopy exclusion criteria on physician ADR. DESIGN: We applied different exclusion criteria used in 30 previous studies to a dataset of endoscopy and pathology reports. Under each exclusion criterion, we calculated physician ADR. SETTING: A private practice colonoscopy center affiliated with the University of Illinois College of Medicine. PATIENTS: Data on 20,040 colonoscopy examinations performed by 11 gastroenterologists from July 2009 to May 2013 and associated pathology notes. MAIN OUTCOME MEASUREMENTS: ADRs across all colonoscopy examinations, each physician's ADR, and ADR ranking. RESULTS: There were 28 different exclusion criteria used when measuring the ADR. Each study used a different combination of these exclusion criteria. The proportion of all colonoscopy examinations in the dataset excluded under these combinations of exclusion criteria ranged from 0% to 92.2%. The mean ADR across all colonoscopy examinations was 39.1%. The change in mean ADR after applying the 28 exclusion criteria ranged from -5.5 to +3.0 percentage points. However, the exclusion criteria affected each physician's ADR relatively equally, and therefore physicians' rankings via the ADR were stable. LIMITATIONS: ADR assessment was limited to a single private endoscopy center. CONCLUSION: There is wide variation in the exclusion criteria used when measuring the ADR. Although these exclusion criteria can affect overall ADRs, the relative rankings of physicians by ADR were stable. A consensus definition of which exclusion criteria are applied when measuring ADR is needed.