Using Behavioral Economics to Design Physician Incentives That Deliver High-Value Care.

Behavioral economics provides insights about the development of effective incentives for physicians to deliver high-value care. It suggests that the structure and delivery of incentives can shape behavior, as can thoughtful design of the decision-making environment. This article discusses several principles of behavioral economics, including inertia, loss aversion, choice overload, and relative social ranking. Whereas these principles have been applied to motivate personal health decisions, retirement planning, and savings behavior, they have been largely ignored in the design of physician incentive programs. Applying these principles to physician incentives can improve their effectiveness through better alignment with performance goals. Anecdotal examples of successful incentive programs that apply behavioral economics principles are provided, even as the authors recognize that its application to the design of physician incentives is largely untested, and many outstanding questions exist. Application and rigorous evaluation of infrastructure changes and incentives are needed to design payment systems that incentivize high-quality, cost-conscious care.

U.S. healthcare failing in cost, quality, safety; together we can cure what's ailing our system.

The American healthcare system is headed toward a cliff, and the fall will be long and painful. Healthcare consumes 18% of our nation's gross domestic product, almost 50% more than the second highest-spending nation. High-deductible health plans are the new norm for one-third of insured patients. Out-of-pocket costs are increasingly unaffordable for many.

Lifestyle Medicine: Overcoming Systemic and Cultural Barriers to Better, More Affordable Care.

The 6 pillars of lifestyle medicine have strong scientific backing and plenty of supportive evidence to validate their integration into routine clinical practice. However, two barriers stand in the way of their widespread adoption: the system of healthcare and the culture of medicine. This article describes changes necessary to overcome these systemic and cultural obstacles and outlines steps necessary to achieve what traditional healthcare has so-far failed to deliver: higher quality, lower costs, and greater access to care.

Burnout among urologists linked to status and hierarchy.

This article includes partial excerpts from Dr. Robert Pearl's upcoming book, "Uncaring: How The Culture Of Medicine Kills Doctors And Patients." This book contains specific and detailed solutions for reforming both the system and culture of healthcare. See online sellers for preorder information. All profits from the book will be donated to Doctors Without Borders.

Infection Rates for Open Distal Phalangeal Fractures Treated with Kirschner Wire: A UK Regional Hand Centre Experience.

Background: Phalangeal fractures are common in hand injuries which: comprising of 23% of all hand and forearm fractures. The current consensus is that focus of treatment should be on prompt irrigation and debridement to reduce infection risk. These infections are significant as they can lead to serious sequelae including osteomyelitis. The aim of this study was to determine the incidence of infection amongst patients with open fracture of distal phalanx who had been treated with K-wire fixation and the timing of their operative management compared to the UK national guideline. Methods: We performed a retrospective case-note analysis of the patients treated for open distal phalangeal fractures at a regional hands centre over the period of 12 months, and compared with the national guidelines. Data collected included patient demographics, mechanism of injury, length of time taken from injury to first washout, length of time K-wire remains in situ, and infection rate. Results: Half of the patients (n = 19) met the guideline and were treated with washout within the first 24 hours. Infection rates in this group was 11%. This compared with 26% in those patients that did not receive washout within 24 hours. Conclusions: This study demonstrates the difficulty in always meeting national guidelines and suggests key reasons for this. The authors propose a set of local, easily-achieved interventions to raise awareness and compliance with the national guidelines and reduce infection. Furthermore, it highlights the importance of carefully selecting cases that required percutaneous K-wire fixation.

Fulminant necrotizing fasciitis to the hand in a patient on high-dose steroids: A case report of successful limb salvage.

Glucocorticoids are commonly used in the management of patients with brain Tumour for reducing peritumoral and vasogenic edema. However, they may lead to development of limb and life-threatening conditions such as necrotizing fasciitis (NF). NF is a rare but potentially lethal condition. Early detection and aggressive treatment may lead to decreased mortality and limb salvage. The diagnosis is predominately clinical but may be supported by laboratory and radiological investigations. Chronic steroid use not only predisposes to the development of NF but also may mask early features delaying presentation and diagnosis. Clinicians should have a high index of suspicion especially in patients on chronic steroid therapy as this may aid in early detection and treatment. We present a case report of a successful limb salvage that exemplifies these points.

Exophiala campbellii causing a subcutaneous palmar cyst in an otherwise healthy UK resident.

Exophiala is a ubiquitous genus encompassing more than forty species, a number of which have been associated with superficial or systemic infections in humans, and other hot- or cold-blooded animals. Here we report a human case of subcutaneous mycotic cyst caused by Exophiala campbellii. To our knowledge, this is only the third reported human infection caused by E. campbellii, all three of which involved subcutaneous nodules in patients who had resided in the United Kingdom.

Association of Anxiety With High-Cost Health Care Use Among Individuals With Type 2 Diabetes.

OBJECTIVE: People with type 2 diabetes vary greatly in their use of high-cost health care resources. We examined the association of anxiety with high-cost use after accounting for depression and medical comorbidity. RESEARCH DESIGN AND METHODS: Using electronic health record data, we assessed past anxiety diagnosis, health care use and costs, demographics, comorbidities, and diabetes control status and complications during 2008-2012 for 143,573 adult members of an integrated health care system with type 2 diabetes. Multivariable regression models estimated associations between anxiety and emergency department (ED) use, total hospitalization costs, and high-cost status (i.e., incurring total health care costs in the top 20% among all system members). RESULTS: During 2008-2011, 12.9% of participants received a diagnosis of anxiety, of whom 52.9% also had received a depression diagnosis. After adjustment for covariates including depression, anxiety was positively related to the number of ED visits in 2012 (incidence rate ratio 1.27; 95% CI 1.21, 1.34), the likelihood of visiting the ED on a chronic, frequent basis during 2010-2012 (odds ratio 2.55; 95% CI 1.90, 3.44), and high-cost status in 2012 (odds ratio 1.29; 95% CI 1.23, 1.36), but anxiety was not related to total hospitalization costs in 2012 (relative cost ratio 1.06; 95% CI 0.94, 1.21; P = 0.33). CONCLUSIONS: Anxiety is highly comorbid with depression among individuals with type 2 diabetes and is independently associated with high-cost resource use. Strategies to improve anxiety management among people with diabetes hold the potential to also reduce health care costs.

Association of behavioral health factors and social determinants of health with high and persistently high healthcare costs.

A high proportion of U.S. health care costs are attributable to a relatively small proportion of patients. Understanding behavioral and social factors that predict initial and persistent high costs for these "high utilizers" is critical for health policy-makers. This prospective observational study was conducted at Kaiser Permanente Northern California (KPNC), an integrated healthcare delivery system with 4.1 million members. A stratified random sample of high-cost vs. non-high-cost adult KPNC members matched by age, gender, race/ethnicity, type of health insurance, and medical severity (N = 378) was interviewed between 3/14/2013 and 3/20/2014. Data on health care costs and clinical diagnoses between 1/1/2008 and 12/31/2012 were derived from the electronic health record (EHR). Social-economic status, depression symptoms, adverse childhood experiences (ACEs), interpersonal violence, financial stressors, neighborhood environment, transportation access, and patient activation and engagement were obtained through telephone interviews. Initial and subsequent high-cost status were defined as being classified in top 20% cost levels over 1/1/2009-12/31/2011 and 1/1/2012-12/31/2012, respectively. Psychiatric diagnosis (OR 2.55, 95% CI 1.52-4.29, p < 0.001), financial stressors (OR 1.97, 95% CI 1.19-3.26, p = 0.009), and ACEs (OR 1.10, 95% CI 1.00-1.20, p = 0.051) predicted initial high-cost status. ACEs alone predicted persistent high-cost status in the subsequent year (OR 1.12, 95% CI 1.00-1.25, p = 0.050). Non-medical factors such as psychiatric problems, financial stressors and adverse childhood experiences contribute significantly to the likelihood of high medical utilization and cost. Efforts to predict and reduce high utilization must include measuring and potentially addressing these factors.

Kaiser Permanente Northern California: current experiences with internet, mobile, and video technologies.

The US health care system has been slow to adopt Internet, mobile, and video technologies, which have the capability to engage patients in their own care, increase patients' access to providers, and possibly improve the quality of care while reducing costs. Nevertheless, there are some pockets of progress, including Kaiser Permanente Northern California (KPNC). In 2008 KPNC implemented an inpatient and ambulatory care electronic health record system for its 3.4 million members and developed a suite of patient-friendly Internet, mobile, and video tools. KPNC has achieved many successes. For example, the number of virtual "visits" grew from 4.1 million in 2008 to an estimated 10.5 million in 2013. This article describes KPNC's experience with Internet, mobile, and video technologies and the obstacles faced by other health care providers interested in embracing them. The obstacles include the predominant fee-for-service payment model, which does not reimburse for virtual visits; the considerable investment needed to deploy these technologies; and physician buy-in.

The safety of autologous fat transfer in breast cancer: lessons from stem cell biology.

Autologous fat grafting is versatile tool in plastic surgery and is increasing used for reconstruction following breast conserving surgery for breast cancer. Part of the reconstructive qualities of the transferred fat may be due to the presence of adipose derived mesenchymal stem cells (ADMSC) playing an angiogenic and an adipogenic role. In this context it must be considered if autologously engrafted fat tissue could contribute to carcinogenesis following breast conserving surgery. In this article we review the current stem cell biology evidence on engraftment, transdifferentiation and potential carcinogenic contribution in the breast and other solid organ stem cell niches in an attempt to highlight possible areas of concern.

Reconstruction following traumatic partial amputation of the ear.

BACKGROUND: Reconstruction following traumatic amputation of the external ear remains a unique challenge to the plastic surgeon. The authors report a series of ear reconstructions with autologous costal cartilage in patients following traumatic partial amputation of the ear. Technical points regarding the carving of the cartilage framework and methods of skin coverage are discussed. METHODS: Fifty partial ear reconstructions with autologous costal cartilage were performed over a 4-year period. All patients had suffered previous traumatic amputation of part of the external auricle due to bite injuries (n = 36), road traffic accidents (n = 6), burns (n = 5), or torture (n = 3). A two-stage technique of reconstruction with autologous cartilage graft was used based on Nagata's adaptations of Brent's original technique. In nine cases, skin shortage or extensive scarring required preoperative tissue expansion (n = 4) or a temporoparietal fascial flap (n = 5) to provide adequate coverage of the cartilage framework. RESULTS: Forty-seven patients had a successful surgical outcome without complication. Two patients developed small areas of skin necrosis resulting in exposure of the cartilage framework. These healed with conservative management with minor loss of definition. One case of wound infection resulted in significant loss of definition of the construct, which required a further surgical procedure with additional costal cartilage graft. CONCLUSION: Reconstruction of the external ear with autologous costal cartilage following traumatic amputation can produce high-quality auricles consistently and is becoming the treatment of choice for such injuries, given access to a specialist center with exposure to a high volume of cases.

A case of large sporadic neurofibroma of the hand.

We report the case of a large sporadic neurofibroma arising in the palm of the 40 year old nurse. Isolated neurofibroma in the hand are rare and pose both diagnostic and treatment challenges for the surgeon. Preoperative imaging can be useful to delineate the anatomical relationships of a soft tissue lesion but is not always diagnostic. The key points in the management of these tumours are discussed.