Cost-effectiveness of the non-laboratory based Framingham algorithm in primary prevention of cardiovascular disease: A simulated analysis of a cohort of African American adults.

The non-lab Framingham algorithm, which substitute body mass index for lipids in the laboratory based (lab-based) Framingham algorithm, has been validated among African Americans (AAs). However, its cost-effectiveness and economic tradeoffs have not been evaluated. This study examines the incremental cost-effectiveness ratio (ICER) of two cardiovascular disease (CVD) prevention programs guided by the non-lab versus lab-based Framingham algorithm. We simulated the World Health Organization CVD prevention guidelines on a cohort of 2690 AA participants in the Atherosclerosis Risk in Communities (ARIC) cohort. Costs were estimated using Medicare fee schedules (diagnostic tests, drugs & visits), Bureau of Labor Statistics (RN wages), and estimates for managing incident CVD events. Outcomes were assumed to be true positive cases detected at a data driven treatment threshold. Both algorithms had the best balance of sensitivity/specificity at the moderate risk threshold (>10% risk). Over 12years, 82% and 77% of 401 incident CVD events were accurately predicted via the non-lab and lab-based Framingham algorithms, respectively. There were 20 fewer false negative cases in the non-lab approach translating into over $900,000 in savings over 12years. The ICER was -$57,153 for every extra CVD event prevented when using the non-lab algorithm. The approach guided by the non-lab Framingham strategy dominated the lab-based approach with respect to both costs and predictive ability. Consequently, the non-lab Framingham algorithm could potentially provide a highly effective screening tool at lower cost to address the high burden of CVD especially among AA and in resource-constrained settings where lab tests are unavailable.

Results of the Medicare Health Support disease-management pilot program.

BACKGROUND: In the Medicare Modernization Act of 2003, Congress required the Centers for Medicare and Medicaid Services to test the commercial disease-management model in the Medicare fee-for-service program. METHODS: The Medicare Health Support Pilot Program was a large, randomized study of eight commercial programs for disease management that used nurse-based call centers. We randomly assigned patients with heart failure, diabetes, or both to the intervention or to usual care (control) and compared them with the use of a difference-in-differences method to evaluate the effects of the commercial programs on the quality of clinical care, acute care utilization, and Medicare expenditures for Medicare fee-for-service beneficiaries. RESULTS: The study included 242,417 patients (163,107 in the intervention group and 79,310 in the control group). The eight commercial disease-management programs did not reduce hospital admissions or emergency room visits, as compared with usual care. We observed only 14 significant improvements in process-of-care measures out of 40 comparisons. These modest improvements came at substantial cost to the Medicare program in fees paid to the disease-management companies ($400 million), with no demonstrable savings in Medicare expenditures. CONCLUSIONS: In this large study, commercial disease-management programs using nurse-based call centers achieved only modest improvements in quality-of-care measures, with no demonstrable reduction in the utilization of acute care or the costs of care.

Utilization of epidermal growth factor receptor (EGFR) testing in the United States: a case study of T3 translational research.

PURPOSE: We examined hospital use of the epidermal growth factor receptor assay in patients with lung cancer in the United States. Our goal was to inform the development of a model to predict phase 3 translation of guideline-directed molecular diagnostic tests. METHODS: This was a retrospective observational study. Using logistic regression, we analyzed the association between hospitals' institutional and regional characteristics and the likelihood that an epidermal growth factor receptor assay would be ordered. RESULTS: Significant institutional predictors included affiliation with an academic medical center (odds ratio, 1.48; 95% confidence interval, 1.20-1.83), participation in a National Cancer Institute clinical research cooperative group (odds ratio, 2.06, 1.66-2.55), and -availability of positron emission tomography scan (odds ratio, 1.44, 1.07-1.94) and cardiothoracic surgery (odds ratio, 1.90, 1.52-2.37) services. Significant regional predictors included metropolitan county (odds ratio, 2.08, 1.48-2.91), population with above-average education (odds ratio, 1.46, 1.09-1.96), and population with above-average income (odds ratio, 1.46, 1.04-2.05). Distance from a National Cancer Institute cancer center was a negative predictor (odds ratio, 0.996, 0.995-0.998), with a 34% decrease in likelihood for every 100 miles. CONCLUSION: In 2010, only 12% of US acute-care hospitals ordered the epidermal growth factor receptor assay, suggesting that most patients with lung cancer did not have access to this test. This case study illustrated the need for: (i) increased dissemination and implementation research, and (ii) interventions to improve adoption of guideline-directed molecular diagnostic tests by community hospitals.

Evaluation of Medicare Health Support chronic disease pilot program.

The Medicare Program is conducting a randomized trial of care management services among fee-for-service (FFS) beneficiaries called the Medicare Health Support (MHS) pilot program. Eight disease management (DM) companies have contracted with CMS to improve clinical quality, increase beneficiary and provider satisfaction, and achieve targeted savings for chronically ill Medicare FFS beneficiaries. In this article, we present 6-month intervention results on beneficiary selection and participation rates, mortality rates, trends in hospitalizations, and success in achieving Medicare cost savings. Results to date indicate limited success in achieving Medicare cost savings or reducing acute care utilization.

Repricing specialty hospital outpatient services using ambulatory surgery center prices.

This article explores whether Medicare pays more for the same outpatient services provided in an acute specialty hospital than in an ambulatory surgery center (ASC). How financially dependent a specialty hospital is on ASC-eligible services is also investigated. Medicare outpatient claims in 43 orthopedic and 12 surgical specialty hospitals in 2004 were repriced using ASC pricing software. Payments for the same surgical procedure were 43 and 64 percent higher in specialty surgical and orthopedic outpatient departments, respectively, compared with simulated ASC payments. Non-ASC-eligible outpatient services were 18-35 percent of all Medicare outpatient payments varying by type of specialty hospital.

Financial gains and risks in pay-for-performance bonus algorithms.

Considerable attention has been given to evidence-based process indicators associated with quality of care, while much less attention has been given to the structure and key parameters of the various pay-for-performance (P4P) bonus and penalty arrangements using such measures. In this article we develop a general model of quality payment arrangements and discuss the advantages and disadvantages of the key parameters. We then conduct simulation analyses of four general P4P payment algorithms by varying seven parameters, including indicator weights, indicator intercorrelation, degree of uncertainty regarding intervention effectiveness, and initial baseline rates. Bonuses averaged over several indicators appear insensitive to weighting, correlation, and the number of indicators. The bonuses are sensitive to disease manager perceptions of intervention effectiveness, facing challenging targets, and the use of actual-to-target quality levels versus rates of improvement over baseline.

Determining the cost-effectiveness of a computer-based smoking cessation intervention in primary care.

PURPOSE: To evaluate the incremental effectiveness and cost-effectiveness of a staged-based, computerized smoking cessation intervention relative to standard care in an urban managed care network of primary care physicians. DESIGN: Decision-analytic model based on results of a randomized clinical trial. METHODOLOGY: Patient outcomes and cost estimates were derived from clinical trial data. Effectiveness was measured in terms of 7-day point-prevalence abstinence at 6 months post-intervention. Quality-adjusted life years (QALYs) and cost-effectiveness (CE) were calculated, with CE measured as cost per patient per life year saved and per quality-adjusted life years saved. CE estimates were adjusted to account for partial behavior change as measured in terms of progression in stage of readiness to quit. Sensitivity analyses were conducted to evaluate the robustness of key model assumptions. PRINCIPAL FINDINGS: Intervention patients were 1.77 times more likely to be smoke-free at 6 months follow-up than those in standard care (p=.078). The intervention generated an additional 3.24 quitters per year. Annualized incremental costs were $5,570 per primary care practice, and $40.83 per smoker. The mean incremental cost-effectiveness ratio was $1,174 per life year saved ($869 per QALY). When the intervention impact on progression in stage of readiness to quit was also considered, the mean incremental cost-effectiveness ratio declined to $999 per life year saved ($739 per QALY). CONCLUSIONS: From a physician's practice perspective, the stage-based computer tailored intervention was cost-effective relative to standard care. Incorporation of partial behavior change into the model further enhanced favorability of the cost-effectiveness ratio.

Validation of the nonlaboratory-based Framingham cardiovascular disease risk assessment algorithm in the Atherosclerosis Risk in Communities dataset.

BACKGROUND: Nonlaboratory-based (non-LB) algorithms have been developed to facilitate absolute cardiovascular risk assessment in resource-constrained settings. The non-LB Framingham algorithm, which substitute BMI for lipids in laboratory-based Framingham, exhibits best performance among non-LB algorithms. However, its external validity has not been evaluated. AIM: To examine the validity of non-LB Framingham algorithm in Atherosclerosis Risk in Communities dataset, and contrast performance with the laboratory-based Framingham algorithm. METHODS: We developed Cox regression models including non-LB and laboratory-based Framingham covariates in Atherosclerosis Risk in Communities dataset. Discrimination was assessed via C-statistic, calibration via goodness-of-fit, and marginal discrimination value of BMI vis-à-vis lipids vis-à-vis waist-hip ratio via net reclassification improvement (NRI). Both models were compared via area under receiver operating characteristic. RESULTS: Among 11 601 participants (mean age 54 years, 55% women, 23% black), non-LB vs. laboratory-based Framingham performed as follows: C-statistic 0.75 vs. 0.76 among women and 0.67 vs. 0.68 among men; goodness-of-fit 14.2 vs. 10.5 among women and 25.8 vs. 21.8 among men. Overall area under receiver operating characteristic was 0.706 vs. 0.710, respectively, with no racial differences in discrimination or calibration. BMI and total cholesterol had no impact on NRI. Incremental predictive value of HDL was comparable with waist-hip ratio (category-less NRI = 0.34 vs. 0.31; categorical NRI = 0.06 vs. 0.05, P < 0.01). CONCLUSION: These results demonstrate the validity and limitations of the non-LB Framingham algorithm in a biracial cohort. Substituting BMI with a central adiposity metric such as waist-hip ratio or waist circumference could make the algorithm better or at par with the laboratory-based Framingham algorithm.

Patient casemix classification for medicare psychiatric prospective payment.

OBJECTIVE: For a proposed Medicare prospective payment system for inpatient psychiatric facility treatment, the authors developed a casemix classification to capture differences in patients' real daily resource use. METHOD: Primary data on patient characteristics and daily time spent in various activities were collected in a survey of 696 patients from 40 inpatient psychiatric facilities. Survey data were combined with Medicare claims data to estimate intensity-adjusted daily cost. Classification and Regression Trees (CART) analysis of average daily routine and ancillary costs yielded several hierarchical classification groupings. Regression analysis was used to control for facility and day-of-stay effects in order to compare hierarchical models with models based on the recently proposed payment system of the Centers for Medicare & Medicaid Services. RESULTS: CART analysis identified a small set of patient characteristics strongly associated with higher daily costs, including age, psychiatric diagnosis, deficits in daily living activities, and detox or ECT use. A parsimonious, 16-group, fully interactive model that used five major DSM-IV categories and stratified by age, illness severity, deficits in daily living activities, dangerousness, and use of ECT explained 40% (out of a possible 76%) of daily cost variation not attributable to idiosyncratic daily changes within patients. A noninteractive model based on diagnosis-related groups, age, and medical comorbidity had explanatory power of only 32%. CONCLUSIONS: A regression model with 16 casemix groups restricted to using "appropriate" payment variables (i.e., those with clinical face validity and low administrative burden that are easily validated and provide proper care incentives) produced more efficient and equitable payments than did a noninteractive system based on diagnosis-related groups.

Specialty versus community hospitals: referrals, quality, and community benefits.

In this paper we compare physician referral patterns, quality, patient satisfaction, and community benefits of physician-owned specialty versus peer competitor hospitals. Our results are based on evidence gathered from site visits to six markets, 2003 Medicare claims, patient focus groups, and Internal Revenue Service data. Although physician-owners are more likely than others to refer to their own facilities and treat a healthier population, there are rationales for these patterns aside from motives for profit. Specialty hospitals provide generally high-quality care to satisfied patients. Uncompensated care plus specialty hospitals' taxes represent a greater burden, in percentage terms, than community benefits provided by nonprofit providers.

Validation of physician survey estimates of surgical time using operating room logs.

The Medicare Physician Fee Schedule (MFS) is based on relative value units that represent the costliness of a particular service compared to all other services. Comparison of current surgical time estimates show systematically longer times than those obtained in the original Harvard study more than a decade ago. Any bias in surgical time estimates is likely to distort MFS payments across specialties. This study is the first to use objectively collected intraservice surgical time to validate estimates of time collected from small-group physician surveys. Median intraservice time estimates are significantly longer than intraservice times from operative logs. The average difference across 60 procedures is 31 minutes; the range is from a few minutes to almost 2 hours. Given that half of the studied surgical procedures is a subset of services that anchors the MFS, surgical times for other related services are likely to be overstated as well.

Validating CPT typical times for Medicare office evaluation and management (E/M) services.

Every 5 years, the federal government reviews the Medicare Fee Schedule for changes in the work effort physicians personally devote to office visits. Using physician face-to-face times reported in the Centers for Disease Control and Prevention's National Ambulatory Care Survey (NAMCS), guideline office visit times associated with the 1997-1998 mix of Medicare claims averaged 9 percent longer versus NAMCS; Medicare billed visits with new patients were 32 percent longer. Surgeons and dermatologists had the largest discrepancies in Medicare versus NAMCS times. If CPT guideline times currently in use are now overstated, then intraservice work effort is likely overstated given the high correlation of time with work effort, and Medicare payment levels need to be reduced. Upcoding visit content to higher paid CPT visit codes may also explain seemingly longer Medicare billed times and call for payment reductions as well.

BBA impacts on hospital residents, finances, and Medicare subsidies.

Concern over rapidly rising Medicare expenditures prompted Congress to pass the 1997 Balanced Budget Act (BBA) that included provisions reducing graduate medical education (GME) payments and capped the growth in residents for payment purposes. Using Medicare cost reports through 2001, we find that both actual and capped residents continued to grow post-BBA. While teaching hospital total margins declined, GME payment reductions of approximately 17 percent had minimal impact on revenue growth (-0.5 percent annually). Four years after BBA, residents remained a substantial line of business for nearly one-half of teaching hospitals with Medicare effective marginal subsidies exceeding resident stipends by nearly $50,000 on average. Coupled with an estimated replacement cost of over $100,000 per resident, it is not surprising that hospitals accepted nearly 4,000 residents beyond their allowable payment caps in just 4 years post-BBA.

Economic grand rounds: Variation in staffing and activities in psychiatric inpatient units.

In 1999 the Balanced Budget Refinement Act mandated the development of a per diem prospective payment for all psychiatric inpatients. To assist Medicare in developing a per diem patient-based payment system, this study surveyed a representative sample of psychiatric inpatient units in 40 facilities for one week in 2001 through 2003 to determine how units are staffed and how staff members spend their time caring for patients. On general adult units, psychiatric staff averaged ten hours per patient per 24-hour day, roughly 55 percent of staff time was involved in psychiatric care, medical-related nursing and personal care accounted for 10 percent of staff time, and milieu time took up 34 percent of staff time. Small general adult and geriatric units required 50 percent more staff time per patient than large units. More research is needed to determine how recent changes in the method of payment affect these facilities.

Variation in patient routine costliness in U.S. psychiatric facilities.

BACKGROUND: The Balanced Budget Refinement Act of 1999 included a Congressional mandate to develop a patient-level case mix prospective payment system (PPS) for all Medicare beneficiaries treated in PPS-exempt psychiatric facilities. Payment levels by case mix category have been proposed by the government based on claims and facility cost reports. Because of claims data limitations, these levels do not account for patient-specific staffing costs within a facility's routine units, nor are certain key patient characteristics considered for higher payment. AIMS OF THE STUDY: This study uses novel primary data to quantify heretofore unmeasured differences in daily staffing intensity on routine units among Medicare patients. The data are used to test for compression (or narrowing) in case mix payment weights that would result from using only Medicare claims and facility cost reports to quantify daily routine costliness. METHODS: Primary data on patient and staff times in over 20 activities were collected from 40 psychiatric facilities and 66 psychiatric units, nation-wide. Patient times were reported on all inpatients on each shift over a 7-day study period. A resource intensity measure (in Registered Nurse (RN)-equivalent minutes) was constructed on a daily basis for 4,149 Medicare and 4,667 non-Medicare patient days. The routine measure is converted into daily cost using cost report per diems and ancillary costs added using submitted claims. Descriptive tables isolate key cost drivers for Medicare patients. Classification and Regression Trees (CART) clustering identifies 16 potential case mix groups. Multivariate regression is used to compare case mix, day-of-stay, and facility effects using 4 alternative measures of daily routine and ancillary costs. RESULTS: Patient daily routine intensity of care is found to vary by a factor of 3 or more between the top and bottom 10% of days. Medicare patient days were 12.5% more staff intensive than non-Medicare days, which may have been due to age and other differences. Older dementia and "residual diagnosis" patients are more intensive while schizophrenia and substance-related patients are less intensive. Age, psychiatric and medical severity, deficits in Activities in Daily Living (ADLs), dangerous behaviors, and electroconvulsive therapy (ECT) also contribute substantially to higher staffing intensity. Other patient characteristics were insignificant within broad diagnostic groups. Routine costs based on a single facility per diem produced narrower case mix cost differences--often by a factor of 2 or more--for 10 of 12 groups with significantly higher costs. Adding patient-specific ancillary to uniform per diem costs only marginally decompressed costs. Day of-stay costs were similarly compressed when using only cost reports. DISCUSSION: Claims-based costing using Medicare cost reports unduly compresses (narrows) estimates of inter-group case mix cost differences. Also, by not capturing ADL deficits and dangerous behaviors, administrative data sets fail to identify small, but very resource intensive, patient groups. ECT treatment regimens, although rare, significantly increase costs on a daily basis. IMPLICATIONS FOR HEALTH POLICIES: Medicare's recently proposed prospective payment system for psychiatric inpatients uses claims-based costing methods based on widely available administrative data. Consequently, fewer high cost groups are identified due to non-reported patient characteristics such as ADL deficits. Moreover, inter-group relative cost differences are likely understated. It is also possible that any standardized dollar amount applied to group relative weights is understated because Medicare patients appear more intensive per day on routine units. IMPLICATIONS FOR FUTURE RESEARCH: Larger primary samples of special psychiatric units (e.g., med-psych, child/adolescent) could improve estimates of daily routine costliness. Larger samples could also support stronger tests of case mix and cost differences by facility type and teaching status. Medical records information on non-Medicare patients could quantify any systematic differences in average daily costs holding case mix constant. Similar primary studies of psychiatric patients treated outside PPS-exempt units in acute general hospitals could result in a fully integrated payment system for all mentally ill Medicare patients, thereby avoiding payment inefficiencies and inequities.

Racial Disparities in Health-Related Quality of Life After Lung Cancer Surgery: Findings From the Cancer Care Outcomes Research and Surveillance Consortium.

INTRODUCTION: This study investigated racial disparities in postsurgical health-related quality of life (HRQOL) among patients with non-small-cell lung cancer (NSCLC). METHODS: Data were collected by the Cancer Care Outcomes Research and Surveillance Consortium. Inclusion criteria were greater than or equal to 21 years of age, NSCLC, and receipt of surgery. HRQOL data were available from patients' surveys, and complete medical record abstraction was performed to obtain clinical data. HRQOL was assessed by the physical/mental component summary scores (PCS/MCS) of the 12-item Short-Form Health Survey at two time points. Mean time between surgery and the initial assessment (time 1) after surgery was 4.1 (SD 2.2) months and between surgery and second assessment (time 2) was 12.7 (SD 3.8) months. Multivariable linear regression models were used to examine associations between race and HRQOL. RESULTS: Of 650 patients, 80.5% were White, 8.8% Black, and 10.7% other races. At second assessment, Blacks reported lower MCS than Whites (47.4 versus 52.6, p = 0.002). In multivariable analysis, Blacks had lower MCS compared with Whites. No difference was found between Whites and Blacks on PCS. Those with less than high school education reported lower MCSs. Older age and receipt of adjuvant chemotherapy after surgery were associated with gain in MCS. Male, less than college education, and comorbidities were associated with impaired PCS. Older age was associated with improved PCS. CONCLUSION: Racial disparities exist in postoperative mental HRQOL. Results highlight the need for interventions after lung cancer surgery to improve mental health in Black and younger patients.

Expansion of Medicare's definition of post-acute care transfers.

In October 1998, the definition of a transfer in Medicare's hospital prospective payment system was expanded to include several post-acute care (PAC) providers in 10 high-volume PAC diagnosis-related groups (DRGs). In this methodological article, the authors respond to a congressional mandate to consider more DRGs in the definition. Empirical results support expansion to many more DRGs that are split in ways that understate total PAC volumes, including 25 DRG pairs (with/without complications) and DRG bundles (e.g., infections) that together exhibit high PAC volumes. By contrast, some DRGs (e.g., craniotomy) are questionable PAC candidates because of their heterogenous procedure mix.

Characteristics of high staff intensive Medicare psychiatric inpatients.

Previous analyses of the costs of Medicare psychiatric inpatients have been limited by the use of claims and provider cost reports that fail to quantify differences in patient characteristics and routine costs. This article uses new primary data from 66 psychiatric inpatient units in 40 facilities nationwide to measure the times staff spend in therapeutic and other activities caring for Medicare patients. Patient days are divided into two groups of very high and low staff intensity and patient characteristics compared in each group. Results identify key patient characteristics associated with high staffing days, including old age, dementia and cognitive impairment, severe psychiatric diagnosis, deficits in activities of daily living (ADLs), and assaultive or agitated behaviors. Policy implications and suggested enhancements are made with regard to the proposed CMS case-mix classification system based on claims data alone.

Hopelessness and complementary therapy use in patients with ovarian cancer.

BACKGROUND: Hopelessness negatively affects ovarian cancer patients' quality of life (QOL). Research validating the effects of complementary and alternative medicine (CAM) use on QOL and hope is scarce, even though QOL and hope are reasons that patients cite for using CAM therapy. Clinicians need effective, evidence-based interventions to improve QOL and reduce hopelessness. OBJECTIVE: The objectives of this study were to examine factors influencing hopelessness in patients with newly diagnosed disease, long-term survivors, and patients experiencing ovarian cancer recurrence and to examine the effects of CAM on hopelessness in the same population. METHODS: Surveys of ovarian cancer patients (N = 219) undergoing treatment at a comprehensive cancer center in the United States were analyzed. Descriptive, correlation, and multivariate analyses described variables and demonstrated the effects of sociodemographics, disease state, psychological distress, QOL, CAM use, and faith on hopelessness. RESULTS: Patients ages 65 years or older (-0.95, P = .03), with strong faith (-0.28, P = .00), and good QOL (0.11, P = .00) directly reduced hopelessness scores (mean, 3.37). Massage therapy substantially reduced hopelessness scores (-1.07, P = .02); holding age constant, employed patients were twice as likely to use massage (odds ratio, 2.09; P = .04). Patients who had newly diagnosed and recurrent ovarian cancer were more hopeless because of greater distress from symptoms and adverse effects of treatment. CONCLUSION: Patients who used massage therapy were significantly less hopeless, as were those with strong faith and well-controlled disease symptoms and treatment for adverse effects. IMPLICATIONS FOR PRACTICE: Support of spiritual needs and symptom management are important interventions to prevent and/or reduce hopelessness, especially for patients with newly diagnosed and recurrent ovarian cancer. Further research testing the positive effect of massage interventions on hopelessness is needed.

No harm found when nurse anesthetists work without supervision by physicians.

In 2001 the Centers for Medicare and Medicaid Services (CMS) allowed states to opt out of the requirement for reimbursement that a surgeon or anesthesiologist oversee the provision of anesthesia by certified registered nurse anesthetists. By 2005, fourteen states had exercised this option. An analysis of Medicare data for 1999-2005 finds no evidence that opting out of the oversight requirement resulted in increased inpatient deaths or complications. Based on our findings, we recommend that CMS allow certified registered nurse anesthetists in every state to work without the supervision of a surgeon or anesthesiologist.