Public unawareness of physician reimbursement.

OBJECTIVES: To assess subjects' perception of healthcare costs and physician reimbursement. BACKGROUND: The lack of transparency in healthcare reimbursement leaves patients and physicians unaware of the distribution of health care dollars. METHODS: Anonymous survey-based study by means of convenience sampling. Participants were asked to estimate the total hospital cost and physician fee for one of the six medical procedures (n = 250). RESULTS: On the average for all 6 procedures, patients estimated the total cost was $36,177, ∼1,540% more than the actual Medicare rate of $7,333. Similarly, patients estimated the physician fee was $7,694, 1,474% more the actual Medicare rate of $589. CONCLUSION: Patients' perception of the total cost and physician fee are significantly higher than Medicare rates for all 6 procedures. This lack of insight may have widespread negative implications on the patient-physician relationship, on political trends to reduce physician reimbursement, and on a physician's desire to continue practicing medicine.

Competency based clinical shoulder examination training improves physical exam, confidence, and knowledge in common shoulder conditions.

BACKGROUND: Deficiencies in musculoskeletal knowledge are reported at every stage of learning. Medical programs are looking for effective ways to incorporate competency-based training into musculoskeletal education. AIM: To evaluate the impact of bedside feedback on learner's shoulder examination skills, confidence, and knowledge of common shoulder conditions. SETTING: Four-week musculoskeletal clinic rotation. PARTICIPANTS: UCSD third year medical students and internal medicine residents. PROGRAM DESCRIPTION: Learners completed three baseline evaluations: videotaped shoulder examination, attitude survey, and knowledge test. During the 4-week intervention learners received bedside observation and feedback from musculoskeletal experts while evaluating patients with shoulder conditions. Post-intervention learners repeated the three assessments. PROGRAM EVALUATION: Eighty-nine learners participated. In the primary outcome measure evaluating the pre/post videotaped shoulder examination, significant improvement was seen in 21 of 23 shoulder examination maneuvers. Secondary outcomes include changes in learner confidence and knowledge. Greatest gains in learner confidence were seen in performing the shoulder examination (61.5% improvement) and performing injections (97.1% improvement). Knowledge improved significantly in all categories including anatomy/examination interpretation, diagnosis, and procedures. DISCUSSION: Direct observation and feedback during clinical evaluation of patients with shoulder pain improves shoulder examination competency, provider confidence, and knowledge of common shoulder conditions.

Markov modeling in hepatitis B screening and linkage to care.

BACKGROUND: With up to 240 million people chronically infected with hepatitis B worldwide, including an estimated 2 million in the United States, widespread screening is needed to link the infected to care and decrease the possible consequences of untreated infection, including liver cancer, cirrhosis and death. Screening is currently fraught with challenges in both the developed and developing world. New point-of-care tests may have advantages over standard-of-care tests in terms of cost-effectiveness and linkage to care. Stochastic modeling is applied here for relative utility assessment of point-of-care tests and standard-of-care tests for screening. METHODS: We analyzed effects of point-of-care versus standard-of-care testing using Markov models for disease progression in individual patients. Simulations of large cohorts with distinctly quantified models permitted the assessment of particular screening schemes. The validity of the trends observed is supported by sensitivity analyses for the simulation parameters. RESULTS: Increased utilization of point-of-care screening was shown to decrease hepatitis B-related mortalities and increase life expectancy at low projected expense. CONCLUSIONS: The results suggest that standard-of-care screening should be substituted by point-of-care tests resulting in improved linkage to care and decrease in long-term complications.

Magnetic resonance imaging and liver histology as biomarkers of hepatic steatosis in children with nonalcoholic fatty liver disease.

UNLABELLED: Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in children. In order to advance the field of NAFLD, noninvasive imaging methods for measuring liver fat are needed. Advanced magnetic resonance imaging (MRI) has shown great promise for the quantitative assessment of hepatic steatosis but has not been validated in children. Therefore, this study was designed to evaluate the correlation and diagnostic accuracy of MRI-estimated liver proton density fat fraction (PDFF), a biomarker for hepatic steatosis, compared to histologic steatosis grade in children. The study included 174 children with a mean age of 14.0 years. Liver PDFF estimated by MRI was significantly (P < 0.01) correlated (0.725) with steatosis grade. The correlation of MRI-estimated liver PDFF and steatosis grade was influenced by both sex and fibrosis stage. The correlation was significantly (P < 0.01) stronger in girls (0.86) than in boys (0.70). The correlation was significantly (P < 0.01) weaker in children with stage 2-4 fibrosis (0.61) than children with no fibrosis (0.76) or stage 1 fibrosis (0.78). The diagnostic accuracy of commonly used threshold values to distinguish between no steatosis and mild steatosis ranged from 0.69 to 0.82. The overall accuracy of predicting the histologic steatosis grade from MRI-estimated liver PDFF was 56%. No single threshold had sufficient sensitivity and specificity to be considered diagnostic for an individual child. CONCLUSIONS: Advanced magnitude-based MRI can be used to estimate liver PDFF in children, and those PDFF values correlate well with steatosis grade by liver histology. Thus, magnitude-based MRI has the potential for clinical utility in the evaluation of NAFLD, but at this time no single threshold value has sufficient accuracy to be considered diagnostic for an individual child.

A case study of quality improvement methods for complex adaptive systems applied to an academic hepatology program.

Although demands for greater access to hepatology services that are less costly and achieve better outcomes have led to numerous quality improvement initiatives, traditional quality management methods may be inappropriate for hepatology. We empirically tested a model for conducting quality improvement in an academic hepatology program using methods developed to analyze and improve complex adaptive systems. We achieved a 25% increase in volume using 15% more clinical sessions with no change in staff or faculty FTEs, generating a positive margin of 50%. Wait times for next available appointments were reduced from five months to two weeks; unscheduled appointment slots dropped from 7% to less than 1%; "no-show" rates dropped to less than 10%; Press-Ganey scores increased to the 100th percentile. We conclude that framing hepatology as a complex adaptive system may improve our understanding of the complex, interdependent actions required to improve quality of care, patient satisfaction, and cost-effectiveness.

Decoding laboratory test names: a major challenge to appropriate patient care.

Clinical laboratory tests have no value if clinicians cannot quickly order and obtain the results they need. We found that efforts to obtain even the most commonly ordered tests are often derailed by excessively complex nomenclature. Ordering the right laboratory tests is critical to diagnosis and treatment, but existing mechanisms for entering lab orders actively interfere with physicians' efforts to provide good clinical care. Rather than simplifying lab orders, the advent of computerized physician order entry (CPOE) systems-generally programmed by non-clinicians-has introduced new and vexing practical problems. Medical laboratories have filled their test menus, whether paper or electronic, with bewildering nomenclature and abbreviations, and have failed to appreciate the dangers of assigning perilously similar names to different tests. The efficient and efficacious patient care demanded by the quality care initiative requires progress beyond traditional solutions, such as convening naming conventions, to the development of innovative software with intelligent, real-time, clinically driven search functions that will allow these programs to help rather than hinder physicians.

Logistical and fiscal sustainability of a school-based, pharmacist-administered influenza vaccination program.

OBJECTIVE: To assess the fiscal and logistical viability of school-based, pharmacist-administered influenza vaccination programs. DESIGN: Econometric observational study. SETTING: Nine schools in the Rincon Unified School District, Santa Rosa, CA. PARTICIPANTS: Safeway Pharmacies; Rincon Unified School District; California Department of Public Health, Immunization Branch; and University of California, San Diego. INTERVENTION: Assessment of direct workflow observations and administrative data. MAIN OUTCOME MEASURES: Unit costs, productivity, and effectiveness of school-based, pharmacist-administered influenza vaccination programs. RESULTS: The results showed a unit cost of $23.63 (compared with $25.60 for mass vaccination and $39.79 for walk-in shot-only vaccination clinics). The productivity index ($0.88) and efficiency index ($1.12) were better compared with data reported for comparable vaccination programs. CONCLUSION: School-based, pharmacist-administered vaccination programs are fiscally and logistically self-sustaining, viable alternatives to medical office-based or community-based mass vaccination clinics, and may offer a practical strategy for vaccinating children and adolescents.

Data envelopment analysis: dynamic possibilities in an academic medical center application.

In a fairly short period of time, data envelopment analysis (DEA) has grown into a powerful quantitative, analytical tool for measuring the relative performance of similar organizations. DEA has been successfully applied to traditional service industries such as universities and hospitals as well as to trades as diverse as banking and manufacturing. To the best of our knowledge, however, DEA has not been applied in the academic medicine healthcare setting. This paper discusses fundamental DEA models and some of their extensions, the arena into which we introduced DEA, and an example from our own institution exploring how DEA can advance the value proposition within an academic healthcare organization.

Introduction of the Balanced Scorecard into an academic department of medicine: creating a road map to success.

In this paper, we describe: 1) the environmental forces driving performance measurement and management in the University of California San Diego Department of Medicine; 2) the systematic process used by the department to implement a Balanced Scorecard; 3) the initial direct and indirect outcomes of this effort; 4) the opportunities and challenges to the Balanced Scorecard as a management directive; and 5) future directions.

Decision support tool for hospital resource allocation during the COVID-19 pandemic.

The SARS-CoV-2 (COVID-19) pandemic has placed unprecedented demands on entire health systems and driven them to their capacity, so that health care professionals have been confronted with the difficult problem of ensuring appropriate staffing and resources to a high number of critically ill patients. In light of such high-demand circumstances, we describe an open web-accessible simulation-based decision support tool for a better use of finite hospital resources. The aim is to explore risk and reward under differing assumptions with a model that diverges from most existing models which focus on epidemic curves and related demand of ward and intensive care beds in general. While maintaining intuitive use, our tool allows randomized "what-if" scenarios which are key for real-time experimentation and analysis of current decisions' down-stream effects on required but finite resources over self-selected time horizons. While the implementation is for COVID-19, the approach generalizes to other diseases and high-demand circumstances.

Opportunities for the use of decision aids in primary care.

BACKGROUND AND OBJECTIVES: Shared decision making (SDM) is part of a larger movement for patient-centered approaches to care. SDM can be facilitated through the use of decision aids (DA), which are evidence-based tools designed to transmit information on topics suitable for SDM. They are intended to facilitate the process of patients arriving at an informed, values-based choice in partnership with physicians. Research indicates that SDM and the use of DA are underutilized. This study evaluated SDM and DA in primary care. METHODS: Adult patients presenting for chronic disease follow-up to one of four participating primary care health centers were recruited over 16 months. Visit discussions were audiorecorded, transcribed, and coded using Davis coding. Discussion comments were coded for type of SDM (with and without DA) and topics matched against two DA registries. RESULTS: Forty-four unique patient visits were recorded. Shared decision activities on 15 topics were found in 34 discussions, across 27 (61%) of the visits. DA use did not occur in any visit. Fifteen (34%) visits included topics with peer-validated, freely available DA. CONCLUSIONS: Even when shared decision making occurs, DAs are rarely used. Research is needed to identify and reduce barriers to using DAs in primary care.

Translating operational research to the medical community: using "guiding measurements" to improve the quality of healthcare delivery.

Despite the ubiquity problems with pay-for-performance and other quality improvement initiatives, there is little in the way of objective evidence that these efforts have improved the quality of care. In part, it may be because the measurements selected are used to "grade" instead of guide improvement efforts. We propose using operational research methods that include how to develop "guiding measurements" to improve care. We show that use of this type of guiding measurements can lead to improved patient understanding, throughput, and satisfaction in a pediatric nephrology ambulatory care clinic, and may have wider applications across the continuum of care.

Improving physician involvement in care management programs.

Care management delivered by interdisciplinary teams has been demonstrated to be a successful method for treating diseases such as asthma, hypertension, diabetes, and heart failure. Two models have emerged: (1) office-based programs, in which most services are delivered directly from the practice; and (2) insurer-run or purchased (external) programs delivered by third parties. Physician involvement and coordination of patient care with both programs is felt to be advantageous, yet physician involvement has been found to be sporadic. The issues surrounding physician noninvolvement have not been delineated, as the few studies conducted have tended to be descriptive, and they have not provided a model that could inform policy makers how to improve collaborative relationships. The purpose of this study was to construct such a model.

Systems approach to assessing and improving local human research Institutional Review Board performance.

OBJECTIVE: To quantifying the interdependency within the regulatory environment governing human subject research, including Institutional Review Boards (IRBs), federally mandated Medicare coverage analysis and contract negotiations. METHODS: Over 8000 IRB, coverage analysis and contract applications initiated between 2013 and 2016 were analyzed using traditional and machine learning analytics for a quality improvement effort to improve the time required to authorize the start of human research studies. RESULTS: Staffing ratios, study characteristics such as the number of arms, source of funding and number and type of ancillary reviews significantly influenced the timelines. Using key variables, a predictive algorithm identified outliers for a workflow distinct from the standard process. Improved communication between regulatory units, integration of common functions, and education outreach improved the regulatory approval process. CONCLUSIONS: Understanding and improving the interdependencies between IRB, coverage analysis and contract negotiation offices requires a systems approach and might benefit from predictive analytics.

Development of a game-based learning tool for applied team science communication in a virtual clinical trial.

Educational tools for application of team science competencies in clinical research are needed. Our interdisciplinary group developed and evaluated acceptability of a virtual world game-based learning tool simulating a multisite clinical trial; performance hinges on effective intrateam communication. Initial implementation with clinical research trainees (n=40) indicates high satisfaction and perceived relevance to team science and research career goals. Game-based learning may play an important role in team science training.

Should we measure the individual or the system? Operational factors affecting compliance with treatment.

Chronic kidney disease requires a complex array of treatment interventions, including dietary and fluid restriction, medications, and self-monitoring of blood pressure. Patient well-being is directly linked to adhering to physician recommendations and treatment schedules. While considerable efforts have been directed to understanding the contribution of patient characteristics, burden of treatment, and patient-provider relations, little study has been conducted on the "system" requirements that support good patient-provider communication. This study examines how operational characteristics occurring at the time of an encounter affect the likelihood a patient will "hear" provider recommendations.

A multisite study of performance drivers among institutional review boards.

INTRODUCTION: The time required to obtain Institutional Review Board (IRB) approval is a frequent subject of efforts to reduce unnecessary delays in initiating clinical trials. This study was conducted by and for IRB directors to better understand factors affecting approval times as a first step in developing a quality improvement framework. METHODS: 807 IRB-approved clinical trials from 5 University of California campuses were analyzed to identify operational and clinical trial characteristics influencing IRB approval times. RESULTS: High workloads, low staff ratios, limited training, and the number and types of ancillary reviews resulted in longer approval times. Biosafety reviews and the need for billing coverage analysis were ancillary reviews that contributed to the longest delays. Federally funded and multisite clinical trials had shorter approval times. Variability in between individual committees at each institution reviewing phase 3 multisite clinical trials also contributed to delays for some protocols. Accreditation was not associated with shorter approval times. CONCLUSIONS: Reducing unnecessary delays in obtaining IRB approval will require a quality improvement framework that considers operational and study characteristics as well as the larger institutional regulatory environment.

Cognitive and adaptive outcome in low-grade pediatric cerebellar astrocytomas: evidence of diminished cognitive and adaptive functioning in National Collaborative Research Studies (CCG 9891/POG 9130).

PURPOSE: Clinicians often assume that children with posterior fossa tumors are at minimal risk for cognitive or adaptive deficits if they do not undergo cranial irradiation. However, small case series have called that assumption into question, and have also suggested that nonirradiated cerebellar tumors can cause location-specific cognitive and adaptive impairment. This study (1) assessed whether resected but not irradiated pediatric cerebellar tumors are associated with cognitive and adaptive functioning deficits, and (2) examined the effect of tumor location and medical complications on cognitive and adaptive functioning. PATIENTS AND METHODS: The sample was composed of 103 children aged 3 to 18 years with low-grade cerebellar astrocytomas, who underwent only surgical treatment as part of Children's Cancer Group protocol 9891 or Pediatric Oncology Group protocol 9130. The sample was divided into three groups based on primary tumor location: vermis, left hemisphere, or right hemisphere. Data were collected prospectively on intelligence, academic achievement, adaptive skills, behavioral functioning, and pre-, peri-, and postsurgical medical complications. RESULTS: The sample as a whole displayed an elevated risk for cognitive and adaptive impairment that was not associated consistently with medical complications. Within this group of children with cerebellar tumors, tumor location had little effect on cognitive, adaptive, or medical outcome. CONCLUSION: We did not replicate previous findings of location-specific effects on cognitive or adaptive outcome. However, the elevated risk of deficits in this population runs contrary to clinical lore, and suggests that clinicians should attend to the functional outcomes of children who undergo only surgical treatment for cerebellar tumors.

Mass vaccination clinics versus appointments.

Influenza vaccine is a safe, effective, and cost-effective intervention that can prevent serious disease in adults. Opinions differ as to the most effective method for delivering the vaccine to the greatest number of high-risk adults. The objective of this article is to compare immunization delivery of influenza vaccine to high-risk adults during two types of clinic visits: routine scheduled appointments versus mass clinics. Data was collected at 15 ambulatory care settings on 599 patients 50 years and over from October 23, 2001, to January 31, 2002. Immunizations given at either routine scheduled visits or at mass influenza immunization clinics were compared for costs and resource requirements (productivity), and completeness of delivery of quality visit components (efficiency). The two visit types presented significantly different strengths on key clinical functions. Routine scheduled appointments promoted more review of patient health history and more of the contact information necessary for reminder/recall and audit functions. In mass immunization clinics, patients were more likely to be vaccinated, with far less time spent in either direct services or in waiting, and it was more likely that the required vaccination information statements (VIS) would be provided. Mass vaccination clinics and routine scheduled appointments are both viable service strategies for delivering influenza vaccines. This study suggests the greatest advantage occurs when both strategies are used in a coordinated manner.

Life expectancy and health expenditure evolution in Eastern Europe-DiD and DEA analysis.

BACKGROUND: Exploration of long-term health expenditure and longevity trends across three major sub-regions of Eastern Europe since 1989. METHODS: 24 countries were classified as EU 2004, CIS, or SEE. European Health for All Database (HFA-DB) 1989-2012 data were processed using difference-in-difference (DiD) and data envelopment analysis (DEA). RESULTS: The strongest expenditure growth was recorded in EU 2004 followed by SEE and the CIS. A surprisingly similar longevity increase was present in SEE and EU 2004. In 1989, countries that joined EU in 2004 were relatively inefficient in the number of life-years gained yet had a lower life expectancy than the SEE region and was only slightly higher than the CIS region (DEA). By 2012 the revenue spent was roughly linear to additional life-year expectancies. CONCLUSION: EU 2004 members were the best performers in terms of balanced longevity increase followed by health expenditure growth. The SEE economies' longevity gains were lagging slightly behind at a far lower cost. An extrapolated CIS expenditure to longevity increase ratio has the fastest-growing long-term promise.