Search

PURPOSE:To improve care coordination for complex cancers, it is critical to establish a more nuanced understanding of the types of providers involved. As the number of provider types increases, strategies to support cancer care coordination must adapt to a greater variety of information needs, communication styles, and treatment strategies. METHODS:We categorized providers into 11 types, using National Provider Identifier specialties. Using Medicare claims, we counted the number of unique combinations of provider types billed during preoperative, operative, and postdischarge care for colon cancer surgery and assessed how this count varies across hospitals. The study included 70,567 beneficiaries in fee-for-service Medicare A and B for 6 months before and 60 days after an admission for colectomy for colon cancer between 2008 and 2011. RESULTS:We observed 1,554 preoperative provider-type combinations, 975 operative combinations, and 1,571 postdischarge combinations. The three most common combinations in the preoperative phase were general medicine only, other medical specialists only, and general medicine and other medical specialists. In the operative phase, the three most common combinations were primary surgery, anesthesiology, and pathology; general medicine, other medical specialists, radiology, primary surgery, anesthesiology, and pathology; and other medical specialists, radiology, primary surgery, anesthesiology, and pathology. In the postdischarge phase, the three most common combinations were general medicine, general medicine and other medical specialists, and general medicine and oncology. On average, each hospital had 15 preoperative, 11 operative, and 15 postoperative combinations. High-volume, larger, teaching, urban, and noncritical access hospitals had more combinations in all phases. CONCLUSION:Many provider-type combinations are involved in colon cancer surgery care. Substantial variation exists across hospitals types, suggesting that certain hospitals need additional resources and more flexible infrastructure to coordinate care.

OBJECTIVES: To understand hospitals' approaches to spending reduction in commercial episode-based payment programs and inform incentive design. STUDY DESIGN: Qualitative arm of an explanatory sequential mixed-methods study involving semistructured interviews with hospital leaders participating in a statewide quality improvement collaborative with novel episode-based incentive payments introduced by the state's largest commercial payer. METHODS: We recruited 21 leaders from 8 purposively selected, diverse hospitals with both high and low performance. Video teleconference--based interviews followed a standardized protocol and addressed 4 domains: choice of clinical condition for evaluation, strategies for episode spending reduction, best practices for success in earning incentives, and barriers to achievement. Rapid qualitative analysis with purposeful data reduction was employed to generate a matrix of key themes within the study domains. RESULTS: Strategies were similar between high- and low-performing hospitals. When selecting conditions, some hospitals focused on areas of underperformance, aiming for improvement opportunities, whereas others chose conditions already achieving highest efficiency. Many tried to synergize with other ongoing improvement initiatives and clinical areas with established leaders and champions. Key strategies included data-driven improvement, care standardization, and protocol dissemination. Best practices for success included readmission prevention and postacute care spending containment. CONCLUSIONS: The findings highlighted hospitals' most common strategies and approaches, providing several insights into optimal design of commercial episode-based incentives: They must be lucrative enough to earn attention or consistent with larger federal programs; hospitals need opportunities to succeed through both improved performance and sustained excellence; and programs may incur malalignment between hospitals and credentialed physicians. [ABSTRACT FROM AUTHOR]

Objective: To assess whether the intensity of family and friend care changes after older individuals enroll in Medicare at age 65. Data Sources: Health and Retirement Study survey data (1998–2018). Study Design: We compared informal care received by patients hospitalized for stroke, heart surgery, or joint surgery and who were stratified into propensity‐weighted pre‐ and post‐Medicare eligibility cohorts. A regression discontinuity design compared the self‐reported likelihood of any care receipt, weekly hours of overall informal care, and intensity of informal care (hours among those receiving any care) at Medicare eligibility. Data Collection: Not applicable. Principal Findings: A total of 2270 individuals were included; 1674 (73.7%) stroke, 240 (10.6%) heart surgery, and 356 (15.7%) joint surgery patients. Mean (SD) care received was 20.0 (42.1) weekly hours. Of the 1214 (53.5%) patients who received informal care, the mean (SD) care receipt was 37.4 (51.7) weekly hours. Mean (SD) overall weekly care received was 23.4 (45.5), 13.9 (35.8), and 7.8 (21.6) for stroke, heart surgery, and joint surgery patients, respectively. The onset of Medicare eligibility was associated with a 13.6 percentage‐point decrease in the probability of informal care received for stroke patients (p = 0.003) but not in the other acute care cohorts. Men had a 16.8 percentage‐point decrease (p = 0.002) in the probability of any care receipt. Conclusions: Medicare coverage was associated with a substantial decrease in family and friend caregiving use for stroke patients. Informal care may substitute for rather than complement restorative care, given that Medicare is known to expand the use of postacute care. The observed spillover effect of Medicare coverage on informal caregiving has implications for patient function and caregiver burden and should be considered in episode‐based reimbursement models that alter professional rehabilitative care intensity. [ABSTRACT FROM AUTHOR]

Altham proposed Bayesian p-values for the analysis of a 2×2 contingency table that is formed from matched pairs. Using the same Bayesian perspective, we develop an extension of Altham's Bayesian p-values to a 2×2 table from matched pairs with missing data that are missing at random. The approach is applied to a rater agreement study, in which two surgeon–reviewers rated whether or not there was a communication breakdown in malpractice cases. We also use a simulation study to explore the power and type I error rate of the Bayesian p-values. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To evaluate hospital performance and behaviors in the first 2 years of a statewide commercial insurance episode-based incentive pay-for-performance (P4P) program. STUDY DESIGN: Retrospective cohort study of price- and risk-standardized episode-of-care spending from the Michigan Value Collaborative claims data registry. METHODS: Changes in hospital-level episode spending between baseline and performance years were estimated during the program years (PYs) 2018 and 2019. The distribution and hospital characteristics associated with P4P points earned were described for both PYs. A difference-indifferences (DID) analysis compared changes in patient-level episode spending associated with program implementation. RESULTS: Hospital-level episode spending for all conditions declined significantly from the baseline year to the performance year in PY 2018 (-$671; 95% CI, -$1113 to -$230) but was not significantly different for PY 2019 ($177; 95% CI, -$412 to $767). Hospitals earned a mean (SD) total of 6.3 (3.1) of 10 points in PY 2018 and 4.5 (2.9) of 10 points in PY 2019, with few significant differences in P4P points across hospital characteristics. The highest-scoring hospitals were more likely to have changes in case mix index and decreases in spending across the entire episode of care compared with the lowest-scoring hospitals. DID analysis revealed no significant changes in patient-level episode spending associated with program implementation. CONCLUSIONS: There was little evidence for overall reductions in spending associated with the program, but the performance of the hospitals that achieved greatest savings and incentives provides insights into the ongoing design of hospital P4P metrics. [ABSTRACT FROM AUTHOR]

Regional clinical registries provide a unique opportunity for shared learning and population-based analyses of the quality of surgical care. Through the "Michigan Model" of pay for participation in strategic Value Partnerships, exemplified by the Michigan Surgical Quality Collaborative (MSQC), the state's dominant private insurer, Blue Cross Blue Shield of Michigan, has sponsored 20 statewide clinical quality improvement collaboratives. MSQC represents a partnership among 73 Michigan hospitals with a robust data infrastructure and flexible platform for the promulgation of best practices in surgical quality improvement. This article will describe the organizational structure of the MSQC, the contributions the registry has made to quality improvement in colorectal surgery, and how future work will align to improve the reliability of improvement-relevant registry data.

Aim: To summarize the magnitude and time trends of endoscopy-related claims and to compare total malpractice indemnity according to specialty and procedure., Methods: We obtained data from a comprehensive database of closed claims from a trade association of professional liability insurance carriers, representing over 60% of practicing United States physicians. Total payments by procedure and year were calculated, and were adjusted for inflation (using the Consumer Price Index) to 2008 dollars. Time series analysis was performed to assess changes in the total value of claims for each type of procedure over time., Results: There were 1901 endoscopy-related closed claims against all providers from 1985 to 2008. The specialties include: internal medicine (n = 766), gastroenterology (n = 562), general surgery (n = 231), general and family practice (n = 101), colorectal surgery (n = 87), other specialties (n = 132), and unknown (n = 22). Colonoscopy represented the highest frequencies of closed claims (n = 788) and the highest total indemnities ($54 093 000). In terms of mean claims payment, endoscopic retrograde cholangiopancreatography (ERCP) ranked the highest ($374  794) per claim. Internists had the highest number of total claims (n = 766) and total claim payment ($70  730  101). Only total claim payments for colonoscopy and ERCP seem to have increased over time. Indeed, there was an average increase of 15.5% per year for colonoscopy and 21.9% per year for ERCP after adjusting for inflation., Conclusion: There appear to be differences in malpractice coverage costs among specialties and the type of endoscopic procedure. There is also evidence for secular trend in total claim payments, with colonoscopy and ERCP costs rising yearly even after adjusting for inflation.