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Background Real-time, rapid assessment of barriers to care experienced by patients can be used to inform relevant health care legislation. In recent years, online communities have become a source of support for patients as well as a vehicle for discussion and collaboration among patients, clinicians, advocates, and researchers. The Breast Cancer Social Media (#BCSM) community has hosted weekly Twitter chats since 2011. Topics vary each week, and chats draw a diverse group of participants. Partnering with the #BCSM community, we used Twitter to gather data on barriers to care for patients with metastatic breast cancer and potential policy solutions. Metastatic breast cancer survival rates are low and in large part conditioned by time-sensitive access to care factors that might be improved through policy changes. Objective This study was part of an assessment of the barriers to care for metastatic breast cancer with the goal of offering policy solutions for the legislative session in California. Methods We provided 5 questions for a chat specific to metastatic breast cancer care barriers and potential policy solutions. These were discussed during the course of a #BCSM chat on November 18, 2019. We used Symplur (Symplur LLC) analytics to generate a transcript of tweets and a profile of participants. Responses to the questions are presented in this paper. Results There were 288 tweets from 42 users, generating 2.1 million impressions during the 1-hour chat. Participants included 23 patient advocates (most of whom were patients themselves), 7 doctors, 6 researchers or academics, 3 health care providers (2 nurses, 1 clinical psychologist), and 2 advocacy organizations. Participants noted communication gaps between patient and provider especially as related to the need for individualized medication dosing to minimize side effects and maximize quality of life. Timeliness of insurance company response, for example, to authorize treatments, was also a concern. Chat participants noted that palliative care is not well integrated into metastatic breast cancer care and that insurance company denials of coverage for these services were common. Regarding financial challenges, chat participants mentioned unexpected copays, changes in insurance drug formularies that made it difficult to anticipate drug costs, and limits on the number of physical therapy visits covered by insurance. Last, on the topic of disability benefits, participants expressed frustration about how to access disability benefits. When prompted for input regarding what health system and policy changes are necessary, participants suggested a number of ideas, including expanding the availability of nurse navigation for metastatic breast cancer, developing and offering a guide for the range of treatment and support resources patients with metastatic breast cancer, and improving access to clinical trials. Conclusions Rapid assessments drawing from online community insights may be a critical source of data that can be used to ensure more responsive policy action to improve patient care.

To examine whether changes in food prices are associated with changes in obesity prevalence among women in developing countries, and assess effect modification by individual socioeconomic status (SES). Longitudinal study of country-level food price inflation temporally and geographically linked to anthropometric data on non-pregnant adult women (n = 295,984) in 31 low-income and middle-income countries over the 2000–2014 time period, using separate multivariable multilevel growth models of five SES indicators. Post-estimation analysis computed the relationship between food price inflation and predicted mean probabilities of being obese, by SES. Rising food price inflation was strongly associated with women’s obesity prevalence, and SES consistently modified the relationship. Regardless of indicator used, higher food price inflation was positively associated with obesity among women in top SES categories, but was flat or negative among women in low SES categories, averaging over time. The SES differences were widest across educational strata and were most pronounced when food price inflation was highest. Overall, for every 1-unit increase in food price inflation, predicted mean obesity prevalence was between 0.02 and 0.06 percentage points greater in women of high SES compared to low SES women. There is a strong link between food price inflation and obesity in adult women in developing countries which is clearly modified by individuals’ SES. Greater food price inflation was associated with greater obesity prevalence only among women in higher SES groups, who may be net food buyers most at risk of obesity in low-income and middle-income countries.

Concern is growing in the United States regarding the potential for health insurance benefit designs to discriminate against persons living with HIV as research demonstrates that such practices are occurring. A recent complaint filed against health insurers in seven states alleges that some health insurance companies have been using benefit designs that discourage enrollment of people living with HIV either by not covering essential HIV medications or by requiring cost-sharing for these prohibitively expensive medications. Legislators across the country have reacted by introducing legislation to address these growing problems. This paper describes Assembly Bill 339, legislation passed in California in 2015 and going into effect on 1 January 2017, which provides protection for people living with HIV by requiring coverage for single-tablet regimens to manage HIV while placing a cap on patient cost-sharing. Given California's size and influence, and the uncertainty of the future of the Affordable Care Act, this legislation has the potential to influence the national policy debate.

Objectives. To estimate potential impacts of California Assembly Bill (AB) 1316: a requirement for universal screening and insurance coverage for child blood lead testing. Methods. In April 2017 the California Health Benefits Review Program (Oakland, CA) analyzed AB 1316 for the California legislature, including a systematic review of lead screening effectiveness, commercial insurer surveys regarding screening coverage, and actuarial utilization and cost implication assessments. Results. Universal screening requirements would increase child lead testing by 273%, raise affected populations’ premiums by 0.0043%, and detect an additional 4777 exposed children 1 year after implementation. Conclusions. The evidence for a net societal benefit of universal screening approach is limited and is not supported by prominent medical professional groups. Public Health Implications. California expanded targeted screening to identify additional children at higher risk for lead poisoning on the basis of California-specific risk factors, while mitigating the potential harms of universal screening such as an increase in false positive tests and health care costs.

Background Should health systems invest more in access to care by expanding insurance coverage or in health care services including improving the quality of care? Comparing these options experimentally would shed light on the impact and cost-effectiveness of these strategies. Methods The Quality Improvement Demonstration Study (QIDS) was a randomized policy experiment conducted across 30 districts in the Philippines. The study had a control group and two policy intervention groups intended to improve the health of young children. The demand-side intervention in QIDS was universal health insurance coverage (UHC) for children aged 5 years or younger, and a supply-side intervention, a pay-for-performance (P4P) bonus for all providers who met pre-determined quality levels. In this paper, we compare the impacts of these policies from the QIDS experiment on childhood wasting by calculating DALYs averted per US$spent. Results The direct per capita costs to implement UHC and P4P are US$4.08 and US$1.98 higher, respectively, compared to control. DALYs due to wasting were reduced by 334,862 in UHC and 1,073,185 in P4P. When adjustments are made for the efficiency of higher quality, the DALYS averted per US$ spent is similar in the two arms, 1.56 and 1.58 for UHC and P4P, respectively. Since the P4P quality improvements touches all patients seen by qualifying providers (32% in UHC versus 100% in P4P), there is a larger reduction in DALYs. With similar programmatic costs for either intervention, in this study, each US$spent under P4P yielded 1.52 DALYs averted compared to the standard program, while UHC yielded only a 0.50 DALY reduction. Conclusion P4P had a greater impact and was more cost-effective compared to UHC as measured by DALYs averted. While expanded insurance benefit ceilings affected only those who are covered, P4P incentivizes practice quality improvement regardless of whether children are insured or uninsured.

Background : Misdiagnosis may be a significant and under-recognized quality of care problem. In birthing facilities located in anurban Philippine setting, we investigated the diagnostic accuracy for three obstetric conditions: cephalopelvic disproportion (CPD), post-partum hemorrhage (PPH), and pre-eclampsia. Design : Identical simulated cases were used to measure diagnostic accuracy for every provider ( n =103). We linked misdiagnosis – identified by the simulated cases – to obstetrical complications of the patients at the participating facilities. Patient-level data on health outcomes and costs were obtained from medical records and follow-home in-person interviews. Results : The prevalence of misdiagnosis among obstetric providers was 29.8% overall, 25% for CPD, 33% for PPH, and 31% for pre-eclampsia. Linking provider decision-making to patients, we found those who misdiagnosed the simulated cases were more likely to have patients with a complication (OR 2.96; 95% CI 1.39–3.77) compared with those who did not misdiagnose. Complicated patients were significantly less likely to be referred to a hospital immediately, were more likely to be readmitted to a hospital after delivery, had significantly higher medical costs, and lost more income than non-complicated patients. Conclusion : Diagnosis is arguably the most important task a clinician performs because it determines the subsequent course of evaluation and treatment, with the direct and indirect costs of diagnostic error, placing large financial burdens on the patient. Keywords: misdiagnosis; health outcomes; health costs; Philippines; quality of care; practice variability; obstetrics (Published: 15 December 2016) To access the supplementary material for this article, please see Supplementary files under ‘Article Tools’ Citation: Glob Health Action 2016, 9 : 32672 - http://dx.doi.org/10.3402/gha.v9.32672

Background: Poor clinical outcomes are caused by multiple factors such as disease progression, patient behavior, and structural elements of care. One other important factor that affects outcome is the quality of care delivered by a provider at the bedside. Guidelines and pathways have been developed with the promise of advancing evidence-based practice. Yet, these alone have shown mixed results or fallen short in increasing adherence to quality of care. Thus, effective, novel tools are required for sustainable practice change and raising the quality of care. Methods: The study focused on benchmarking and measuring variation and improving care quality for common types of breast cancer at four sites across the United States, using a set of 12 Clinical Performance and Value ® (CPV ® ) vignettes per site. The vignettes simulated online cases that replicate a typical visit by a patient as the tool to engage breast cancer providers and to identify and assess variation in adherence to evidence-based practice guidelines and pathways. Results: Following multiple rounds of CPV measurement, benchmarking and feedback, we found that scores had increased significantly between the baseline round and the final round (P < 0.001) overall and for all domains. By round 4 of the study, the overall score increased by 14% (P < 0.001), and the diagnosis with treatment plan domain had an increase of 12% (P < 0.001) versus baseline. Conclusion: We found that serially engaging breast cancer providers with a validated clinical practice engagement and measurement tool, the CPVs, markedly increased quality scores and adherence to clinical guidelines in the simulated patients. CPVs were able to measure differences in clinical skill improvement and detect how fast improvements were made. J Clin Med Res. 2016;8(9):633-640 doi: http://dx.doi.org/10.14740/jocmr2620w

There is recognition that social protection policies such as raising the minimum wage can favourably impact health, but little evidence links minimum wage increases to child health outcomes. We used multi-year data (2003-2012) on national minimum wages linked to individual-level data from the Demographic and Health Surveys (DHS) from 23 low- and middle-income countries (LMICs) that had least two DHS surveys to establish pre- and post-observation periods. Over a pre- and post-interval ranging from 4 to 8 years, we examined minimum wage growth and four nutritional status outcomes among children under 5 years: stunting, wasting, underweight, and anthropometric failure. Using a differences-in-differences framework with country and time-fixed effects, a 10% increase in minimum wage growth over time was associated with a 0.5 percentage point decline in stunting (-0.054, 95% CI (-0.084,-0.025)), and a 0.3 percentage point decline in failure (-0.031, 95% CI (-0.057,-0.005)). We did not observe statistically significant associations between minimum wage growth and underweight or wasting. We found similar results for the poorest households working in non-agricultural and non-professional jobs, where minimum wage growth may have the most leverage. Modest increases in minimum wage over a 4- to 8-year period might be effective in reducing child undernutrition in LMICs.

Just after dawn, Vivej arrives at the hospital with her newborn under her arm to see you. She is 21 years old, two days postpartum, and exhausted after 36 hours of protracted labor. She is worried because she cannot get her firstborn, Esmile, to breastfeed. You learn that she delivered at a birthing clinic near her home and tells you that, even after her water broke, it took more than a day before the birth attendant could deliver her son. Your examination reveals a dire clinical picture: Esmile is lethargic and hypotonic, he has a poor suck reflex, his temperature is 39.8°C, his pulse is 180, and his breathing is labored. You check his white blood count, confirming leukocytosis. A spinal tap shows pleocytosis. You start him on fluids and antibiotics for neonatal sepsis with likely meningitis and quickly turn your attention to Vivej. Her situation is easier to diagnose but no less urgent: she is febrile and tachycardic, her blood pressure is 85/50. You give her fluids and start her on antibiotics. Ultimately, despite your efforts, both mother and child die.What went wrong? This chapter looks narrowly at these situations—the critical points after access and availability (including affordability) are already accomplished, when patients are in health care facilities that are staffed and equipped with appropriate technology. These are the situations in which the inputs are brought together and it is up to the provider to improve the health of the patient. Simply put, this chapter looks at the decisions and actions of the provider when seeing a patient. It is at this critical moment when we expect the doctor or nurse, or whoever is caring for the patient, to provide the best possible care by skillfully combining the available resources and technologies with the best clinical evidence and professional judgment.Esmile and Vivej received poor-quality care at the time of delivery. Several clinical steps were not taken. The prolonged rupture of membranes was not diagnosed in a timely manner. Vivej needed either to have her labor induced or, failing that, to be referred for a cesarean section. Prophylactic antibiotics should have been administered. Just as important, the provider at the birthing center needed support and professional oversight, with guidelines, supervision, or default referral systems in place to provide a path to the best care possible. The multiple failures in this case led to puerperal and neonatal sepsis. At worst, these conditions have a fatality rate greater than one in four; at best, they lead to protracted care, recovery, and clinical expense that could have been avoided. It is possible, however, to imagine providers in a different setting, with the same physical resources, giving better care and avoiding this tragic scenario.In the next section, we answer the questions raised in this scenario and in countless clinics and hospitals around the world. How much variation is there in the quality of care? How do we measure clinical practice? How and where has quality been systematically improved and practice variation reduced? What elements of care variation can be addressed by policy and what are the costs? Most important, what can be done to elevate the care given by providers in developing country settings? Our focus, therefore, is on the steps that can be taken to optimize the quality of care for patients like Esmile in pediatrics, Vivej in obstetrics, and other patients receiving care for the clinical conditions considered throughout the nine volumes of the third edition of Disease Control Priorities (DCP3).

Improving clinical performance using measurement and payment incentives, including pay for performance (or P4P), has, so far, shown modest to no benefit on patient outcomes. Our objective was to assess the impact of a P4P programme on paediatric health outcomes in the Philippines. We used data from the Quality Improvement Demonstration Study. In this study, the P4P intervention, introduced in 2004, was randomly assigned to 10 community district hospitals, which were matched to 10 control sites. At all sites, physician quality was measured using Clinical Performance Vignettes (CPVs) among randomly selected physicians every 6 months over a 36-month period. In the hospitals randomized to the P4P intervention, physicians received bonus payments if they met qualifying scores on the CPV. We measured health outcomes 4-10 weeks after hospital discharge among children 5 years of age and under who had been hospitalized for diarrhoea and pneumonia (the two most common illnesses affecting this age cohort) and had been under the care of physicians participating in the study. Health outcomes data collection was done at baseline/pre-intervention and 2 years post-intervention on the following post-discharge outcomes: (1) age-adjusted wasting, (2) C-reactive protein in blood, (3) haemoglobin level and (4) parental assessment of child's health using general self-reported health (GSRH) measure. To evaluate changes in health outcomes in the control vs intervention sites over time (baseline vs post-intervention), we used a difference-in-difference logistic regression analysis, controlling for potential confounders. We found an improvement of 7 and 9 percentage points in GSRH and wasting over time (post-intervention vs baseline) in the intervention sites relative to the control sites (P ≤ 0.001). The results from this randomized social experiment indicate that the introduction of a performance-based incentive programme, which included measurement and feedback, led to improvements in two important child health outcomes.

Objectives This study examined whether a measurement and feedback system led to improvements in adherence to clinical pathways. Design The M-QURE (Moffitt—Quality, Understanding, Research and Evidence) Initiative was introduced in 2012 to enhance and improve adherence to pathways at Moffitt Cancer Center (MCC) in three broad clinical areas: breast, lung and gastrointestinal (GI) cancers. M-QURE used simulated patient vignettes based on MCC's Clinical Pathways to benchmark clinician adherence and monitor change over three rounds of implementation. Setting MCC, located in Tampa, Florida, a National Cancer Institute Comprehensive Cancer Center. Participants Three non-overlapping cohorts at MCC (one each in breast, lung and GI) totalling 48 providers participated in this study, with each member of the multidisciplinary team (composed of medical oncologists, radiation oncologists, surgeons and advanced practice providers) invited to participate. Interventions Each participant was asked to complete a set of simulated patient vignettes over three rounds within their own cancer specialty. Participants were required to complete all assigned vignettes over each of the three rounds, or they would be excluded from this study. Primary outcome measure Increased domain and overall provider care adherence to clinical pathways, as scored by blinded physician abstractors. Results We found significant improvements in pathway adherence between the third and first rounds of data collection particularly for workup and treatment of cancer cases. By clinical grouping, breast improved by 13.6% (p

In this paper, we present evidence on the health effects of a health insurance intervention targeted to poor children using data from a randomized policy experiment known as the Quality Improvement Demonstration Study. Among study participants, using a difference-in-difference regression model, we estimated a 9–12 and 4–9 percentage point reduction in the likelihood of wasting and having an infection, respectively, as measured by a common biomarker C-reactive Protein. Interestingly, these benefits were not apparent at the time of discharge; the beneficial health effects were manifest several weeks after release from the hospital. Copyright © 2010 John Wiley & Sons, Ltd.

There has been considerable scientific research to understand the potential link between residential and occupational exposures to power-frequency electric and magnetic fields (ELF) and the occurrence of cancer and other diseases. The “limited” association between childhood leukemia and ELF found in epidemiologic studies (evidence from epidemiologic studies is a major force in driving ELF risk assessments), along with “inadequate” animal data, has led to the classification of magnetic fields by the International Agency for Research on Cancer (IARC) as a “possible human carcinogen” (IARC 2002). Because childhood leukemia is the outcome for which the scientific evidence is strongest, it can be regarded as the critical effect in risk assessment and risk evaluation. The combination of the association of childhood leukemia with low-level, chronic exposures on the one hand and the widespread exposures to ELF on the other have made it both necessary and difficult to develop consistent public health policies on ELF exposure. The need for such policies results from the undisputed value of safe, reliable, and economic electricity to society to maintain all the benefits that this provides. Creating effective policy in light of these critical considerations requires an estimate of the potential public health impact and associated uncertainties. The attributable fraction (AF) can be used to inform policies on ELF exposure. The AF, based on an established exposure–disease relationship, is the proportion of the caseload (of disease) that is attributable to the exposure, assuming there is a causal relationship. Hence, the AF can be used to estimate the degree of incidence reduction that would be expected if the observed association were real and if exposure were reduced. In this article we begin with a description of what is known about ELF exposure distributions in various countries. Then, we calculate country-specific and worldwide estimates of AF and attributable cases based on dose–response functions of ELF and childhood leukemia from two major pooled analyses. We conclude with a discussion of the variability and uncertainty in these estimates. Although the causal relationship between magnetic fields and childhood leukemia has not been established (IARC 2002; Kheifets et al. 2005a, 2005b), we present estimates of the possible pubic health impact to provide potentially useful input into policy analysis.

Health impact assessment (HIA), a systematic assessment of potential health impacts of proposed public polices, programs, and projects, offers a means to advance population health by bringing public health research to bear on questions of public policy. The United States has been slow to adopt HIA, but considerable strides have been made in many other countries, and under the auspices of the World Health Organization and World Bank. Varied applications in these diverse milieu have given rise to diverse approaches to HIA—quantitative/analytic, participatory, and procedural—each with distinct disciplinary foundations, goals, and methodologies. Suitability of these approaches for different applications and their challenges are highlighted, along with areas in which methodologic work is most needed and most likely to advance the field from theory and infrequent application to more routine practice in the United States.

All populations are exposed to varying degrees of electromagnetic fields (EMF); in this study we consider only extremely low frequency (ELF) and radio frequency (RF) fields. After the first study of ELF and childhood leukemia in 1979, intensive epidemiologic investigation has sought to shed light on the potential relation between EMF and childhood leukemia. Consistent associations from epidemiologic studies and two pooled analyses have been the basis for the classification of ELF as a possible carcinogen by the International Agency for Research on Cancer (IARC). The study of RF is still in its infancy and little is known about residential RF exposure or its potential effects on childhood leukemia. The purpose of this study, presented at the WHO Workshop on Sensitivity of Children to EMF in Istanbul, Turkey in June 2004, is to review and critically assess the epidemiologic evidence on EMF and childhood leukemia.

Background Variability exists in the assessment of disease activity in rheumatoid arthritis (RA) patients that may affect quality of care. Objectives To measure the impact on quality of care of a Multi-Biomarker Disease Activity (MBDA) test that quantitatively assesses RA disease activity. Methods Board-certified rheumatologists without prior experience with the MBDA test (N = 81) were randomized into an intervention or control group as part of a longitudinal randomized-control study. All physicians were asked to care for three simulated RA patients, using Clinical Performance and Value (CPV™) vignettes, in a before and after design. CPV™ vignettes have been validated to assess the quality of clinical practice and identify variation in care. The vignettes covered all domains of a regular patient visit; scores were determined as a percentage of explicit predefined criteria completed. Three vignettes, representing typical RA cases, were administered each round. In the first round, no physician received information about the MBDA test. In the second round, only physicians in the intervention group were given educational materials about the test and hypothetical test results for each of the simulated patients. The outcome measures were the overall quality of care, disease assessment and treatment. Results The overall quality scores in the intervention group improved by 3 percent (p = 0.02) post-intervention compared with baseline, versus no change in the control group. The greatest benefit in the intervention group was to the quality of disease activity assessment and treatment decisions, which improved by 12 percent (p

e18173Background: One important factor that affects clinical outcome is the quality of care delivered by a provider at the bedside. Evidence-based guidelines and pathways have been developed to low...

Background: Improving the quality of inpatient hospital care is increasingly attainable in a variety of settings. However, the relationship between rising quality and costs is unclear; similarly the relationship between varying levels of quality and a patient's satisfaction remains poorly defined. Methods: We use data from the Quality Improvement Demonstration Study (QIDS) based in 30 district hospitals in the Philippines. There were 974 children in the study; these children were cared for by 43 physicians. To measure quality of care, the physicians completed vignettes, a valid and inexpensive measure. Patient exit surveys were given to parents of children on the day of discharge, collecting information on services and hospital charges for the inpatient stay, payment sources for the hospitalization, and the Patient Satisfaction Survey (PSQ-18). Results: We found a nonlinear relationship between quality and hospital charges: at low levels of quality improvements are linked to lower hospital charges. However, as quality improves further, these changes lead to higher charges. Higher quality also demonstrated a similar nonlinear relationship with patient satisfaction. Conclusions: The U-shaped association between quality and hospital charges suggests that targeting the lowest quality providers may decrease costs. The similar relationship between patient-reported satisfaction and quality improvement suggests that investments in quality will raise satisfaction, perhaps even when charges are increased.

Background. Factors that increase likelihood of readmission or mortality postdischarge from diarrhea and pneumonia cases among children is less understood. Methods. This study investigated the deaths of 24 children from a cohort of 3275. Using logistic regression, the authors compared data from those who survived with those who died to estimate the determinants of mortality in the study population. The authors also analyzed the hospital charts and completed mortality interviews with families of the deceased children. Results. Poor quality of care significantly increased the likelihood of mortality. Sicker children, those born to less-educated mothers, and those who had longer lengths of stay also had a higher likelihood of mortality. Hospital charts corroborated findings from clinical vignettes. The mortality interviews revealed delays in seeking care from onset of symptoms. Conclusion. Quality of care contributes to postdischarge mortality and that clinical vignettes are an effective means to identify where quality can be improved.

Objectives Measuring and monitoring health system performance is important albeit controversial. Technical, logistic and financial challenges are formidable. We introduced a system of measurement, which we call Q*, to measure the quality of hospital clinical performance across a range of facilities. This paper describes how Q* was developed, implemented in hospitals in the Philippines and how it compares with typical measures. Methods Q* consists of measures of clinical performance, patient satisfaction and volume of physician services. We evaluate Q* using experimental data from the Quality Improvement Demonstration Study (QIDS), a randomized policy experiment. We determined its responsiveness over time and to changes in structural measures such as staffing and supplies. We also examined the operational costs of implementing Q*. Results Q* was sustainable, minimally disruptive and readily grafted into existing routines in 30 hospitals in 10 provinces semi-annually for a period of 2½ years. We found Q* to be more responsive to immediate impacts of policy change than standard structural measures. The operational costs totalled US$2133 or US$305 per assessment per site. Conclusion Q* appears to be an achievable assessment tool that is a comprehensive and responsive measure of system level quality at a limited cost in resource-poor settings.

It is unclear whether health provider accreditation ensures or promotes quality of care. Using baseline data from the Quality Improvement Demonstration Study (QIDS) in the Philippines we measured the quality of pediatric care provided by private and public doctors working at the district hospital level in the country’s central region. We found that national level accreditation by a national insurance programme influences quality of care. However, our data also show that insurance payments have a similar, strong impact on quality of care. These results suggest that accreditation alone may not be sufficient to promote high quality of care. Further improvements may be achieved with properly monitored and well-designed payment or incentive schemes.

Background Many developing countries promote social health insurance as a means to eliminate unmet health needs. However, this strategy may be ineffective if there are barriers to fully utilizing insurance. Methods We analyzed the utilization of social health insurance in 30 hospital districts in the central regions of the Philippines between 2003 and 2007. Data for the study came from the Quality Improvement Demonstration Study (QIDS) and included detailed patient information from exit interviews of children under 5 years of age conducted in seven waves among public hospital districts located in the four central regions of the Philippines. These data were used to estimate and identify predictors of underutilization of insurance benefits - defined as the likelihood of not filing claims despite having legitimate insurance coverage - using logistic regression. Results Multivariate analyses using QIDS data from 2004 to 2007 reveal that underutilization averaged about 15% throughout the study period. Underutilization, however, declined over time. Among insured hospitalized children, increasing length of stay in the hospital and mother's education, were associated with less underutilization. Being in a QIDS intervention site was also associated with less underutilization and partially accounts for the downward trend in underutilization over time. Discussion The surprisingly high level of insurance underutilization by insured patients in the QIDS sites undermines the potentially positive impact of social health insurance on the health of the marginalized. In the Philippines, where the largest burden of health care spending falls on households, underutilization suggests ineffective distribution of public funds, failing to reach a significant proportion of households which are by and large poor. Interventions that improve benefit awareness may combat the problem of underutilization and should be the focus of further research in this area.

e17622 Background: Standardizing the care of cancer patients around best evidence has proven remarkably intransigent to traditional education efforts and incentives. The failure of these efforts is...

There has been considerable scientific effort to understand the potential link between exposures to power-frequency electric and magnetic fields (EMF) and the occurrence of cancer and other diseases. The combination of widespread exposures, established biological effects from acute, high-level exposures, and the possibility of leukemia in children from low-level, chronic exposures has made it both necessary and difficult to develop consistent public health policies. In this article we review the basis of both numeric standards and precautionary-based approaches. While we believe that policies regarding EMF should indeed be precautionary, this does not require or imply adoption of numeric exposure standards. We argue that cutpoints from epidemiologic studies, which are arbitrarily chosen, should not be used as the basis for making exposure limits due to a number of uncertainties. Establishment of arbitrary numeric exposure limits undermines the value of both the science-based numeric EMF exposure standards for acute exposures and precautionary approaches. The World Health Organization's draft Precautionary Framework provides guidance for establishing appropriate public health policies for power-frequency EMF.

To provide a multidisciplinary and comprehensive analysis on the impact of tuberculosis (TB) in a high incidence country.Data from several large scale surveys, carried out between 1997 and 2001 in the Philippines, were used to: (1) perform a burden of disease (BoD) analysis, (2) model the economic costs to society due to lost wages, and (3) determine the clinical outcomes, including the costs of care, for a hypothetical cohort of TB cases.Over 500 000 disability-adjusted life years (DALYs) are lost due to illness and premature mortality from TB in the Philippines annually. This is equal to 9% of all years of life lost (YLL) in the Philippines. The combined economic losses due to premature mortality and morbidity total PhP 8 billion (approximately USD $145 million). Clinically, only 28% of patients with incident active TB are diagnosed and successfully treated, while 20% of patients will die without ever being diagnosed and 6% more will die after they are diagnosed because they do not receive adequate care. The costs of treating all expected cases requires between PhP 475-1625 million (approximately USD $8-29 million) annually.The high burden of disease from TB, large economic losses from mortality and morbidity from TB and the poor clinical outcomes all suggest that there is an urgent need for an increased investment in TB control. The costs of providing this treatment appear to be significantly lower than the current economic losses.

Study objective: To estimate the relative health effects of the income and health insurance provisions of the Los Angeles City living wage ordinance. Setting and participants: About 10 000 employees of city contractors are subject to the Los Angeles City living wage ordinance, which establishes an annually adjusted minimum wage ($7.99 per hour in July 2002) and requires employers to contribute $1.25 per hour worked towards employees' health insurance, or, if health insurance is not provided, to add this amount to wages. Design: As part of a comprehensive health impact assessment (HIA), we used estimates of the effects of health insurance and income on mortality from the published literature to construct a model to estimate and compare potential reductions in mortality attributable to the increases in wage and changes in health insurance status among workers covered by the Los Angeles City living wage ordinance. Results: The model predicts that the ordinance currently reduces mortality by 1.4 deaths per year per 10 000 workers at a cost of $27.5 million per death prevented. If the ordinance were modified so that all uninsured workers received health insurance, mortality would be reduced by eight deaths per year per 10 000 workers at a cost of $3.4 million per death prevented. Conclusions: The health insurance provisions of the ordinance have the potential to benefit the health of covered workers far more cost effectively than the wage provisions of the ordinance. This analytical model can be adapted and used in other health impact assessments of related policy actions that might affect either income or access to health insurance in the affected population.

49 Background: Before entering into risk bearing contracts with payors, ACOs are challenged to find a basis for forming partnerships. Specialty ACO networks, in particular, must find ways to provide a common, high standard of care among a typically varied set of partners. The Moffitt Oncology Network (MON) Initiative demonstrates a possible solution to forming a value based ACO network across a broad geographical area that is based upon using clinical pathways. Methods: Moffitt Cancer Center (MCC) has developed more than 24 different disease specific pathways. The MCC pathways translate evidence-based guidelines into personalized cancer care throughout the continuum of care from evaluation to treatment. MCC is using these pathways with other hospital systems and physician groups throughout the MON. To enhance the use of pathways in the MON, MCC uses Clinical Performance and Value (CPV) Vignettes. CPV’s, are virtual patient cases related to the specific clinical pathways. The report herein is on pathway implementation in several disease areas (breast, lung and gastrointestinal (GI) cancers) across multiple sites: Lehigh Valley Hospital (Pennsylvania), Norton Cancer Institute (Kentucky), and Space Coast Cancer Center (Florida). Results: Pathway based clinical care was measured at baseline using CPVs across disease and site (Table). A total of 67 breast cancer providers took 131 breast cancer vignettes; 35 lung cancer providers took 104 lung cancer vignettes; and to date 27 GI cancer providers have taken 54 GI vignettes. There is statistically significant variation in performance among providers and between sites. This is manifest in pathway-specified areas of work-up, diagnosis, and treatment. Conclusions: Fostering adoption of clinical pathways is a practical objective that can help guide the formation of an ACO oncology network. This may be useful for forming specialty ACOs that establish a standard of care and set the stage for adopting new payment models with payors. [Table: see text]

e17689 Background: The era of the Accountable Care Organization has pushed providers to form networks and consolidate referral streams to avoid loss of market share. In 2012, Moffitt launched an in...

While we welcome a scientific discourse on developing policy for electromagnetic fields (EMF) and on setting guideline limits, the letter by Kundi has a number of inaccuracies. The author appears not to understand the basis for the International Commission on Non-Ionizing Radiation Protection (ICNIRP, 1998), EMF guidelines, or the use of precautionary measures suggested by the World Health Organization (WHO). Two of our authors (MR and LK) were instrumental in the development of the draft WHO framework and our views are “not at odds,” but rather consistent, with it. First, the ICNIRP low-frequency EMF guideline limits are based on established adverse health consequences, namely, acute short-term effects on excitable tissues (nerve and muscle cells). The scientific evidence on the association between childhood leukemia and ELF magnetic fields is noted by ICNIRP, but is considered insufficient for guideline formulation. Second, the author’s assertion on relationships between EMF and “cardiovascular diseases, Alzheimer’s disease, amyotrophic lateral sclerosis, childhood and adult brain cancer, male and female breast cancer, and adverse pregnancy outcomes” is not supported by current scientific knowledge. A recent comprehensive health risk assessment by the WHO ELF Task Group (for publication as an Environmental Health Criteria monograph) forms the basis for our understanding of the scientific literature. It found, for example, that the evidence “does not support an association between ELF exposure and cardiovascular disease” (WHO, in press). The evidence

Background Assessment of disease activity in patients with RA includes patient and physician reported measures and differs by rheumatologist and practice, resulting in variability in treatment decisions and quality of care. Given multiple and often-expensive therapies with significant potential adverse effects, a more uniform assessment of disease activity may benefit treatment selection and patient care. Objectives The study estimated the impact of a novel Multi-Biomarker Disease Activity (MBDA) test, Vectra™ DA, on the overall quality of RA patient care and on the assessment of disease activity and treatment decisions. Methods This was a randomized controlled study. Eighty-one Board-certified rheumatologists were recruited and then randomized into an intervention and a control group. Quality was measured using Clinical Performance and Value (CPV™) vignettes, on-line simulations of clinical cases. CPV™ vignettes have been validated to assess the quality of clinical practice and identify inherent variation in care. To evaluate the impact of the MBDA test, three types of vignettes, representing typical RA cases, were used. Case type A comprised two RA cases that were insufficiently controlled and required the addition of or change in non-biologic DMARDs; Case type B comprised two cases inadequately controlled that required addition of combination or biologic DMARDs; and Case type C comprised two cases adequately treated with DMARDs but with a worsening co-morbidity. The open-ended responses were scored in five domains: taking a history, performing an examination, ordering laboratory and imaging tests, assessing disease activity and prescribing treatment. Scores were the percentage of physician answers that matched explicit evidence-based criteria and expert opinion. Rheumatologists randomly completed two of each of the three case types, one at baseline and one after the intervention, for a total of six vignettes. Before completing the second round of vignettes, the intervention group was given educational materials about the MBDA test. The intervention group also received simulated MBDA test results as part of their second round cases. The outcome measures were the overall quality of care, the quality of disease assessment and treatment and the secondary outcome measures: appropriate use of biologic and/or combination DMARDs, laboratory and imaging tests, and overall resource use. Results The overall quality scores in the intervention group improved by 3% (p=0.02) post-intervention compared with baseline, versus no change in the control group. The greatest benefit in the intervention group was to the quality of disease activity assessment and treatment, which improved by 12% (p Conclusions In this study, use of the MBDA test in simulated cases improved the overall quality and the assessment of disease activity and subsequent treatment decisions for RA patients. New assessment technologies appear to be an effective means for improving quality of care in RA and should prove useful for rheumatologists in daily practice. Disclosure of Interest J. Peabody Consultant for: Crescendo Bioscience, V. Strand: None Declared, R. Shimkhada: None Declared, D. Chernoff Employee of: Crescendo Bioscience, R. Lee: None Declared

Objective To examine whether delays in seeking care are associated with worse health outcomes or increased treatment costs in children, and then assess whether insurance coverage reduces these delays. Study design We use data on 4070 children younger than 5 years from the Quality Improvement Demonstration Study, a randomized controlled experiment assessing the effects of increasing insurance coverage. We examined whether delay in care, defined as greater than 2 days between the onset of symptoms and admission to the study district hospitals, is associated with wasting or having positive C-reactive protein levels on discharge, and with total charge for hospital admission; we also evaluated whether increased benefit coverage and enrollment reduced the likelihood of delay. Results Delay is associated with 4.2% and 11.2% percentage point increases in the likelihood of wasting ( P = .08) and having positive C-reactive protein levels ( P = .03), respectively, at discharge. On average, hospitalization costs were 1.9% higher with delay ( P = .04). Insurance intervention results in 5 additional children in 100 not delaying going to the hospital ( P = .02). Conclusions In this population, delayed care is associated with worse health outcomes and higher costs. Access to insurance reduced delays; thus insurance interventions may have positive effects on health outcomes.

253 Background: New payment models, such as accountable care organizations (ACOs), bundled payments and global budgets will shift some financial risk from payers to providers. The first step in creating a cancer ACO will be to partner with payers to understand aggregate costs over time. Methods: Moffitt Cancer Center (MCC) is partnering with Florida Blue in (BCBS of FL) in developing a specialty ACO strategy for cancer. As an initial step, we created an analytical framework to group and estimate the total costs of cancer care for newly diagnosed breast cancer (BC) and malignant hematology (MH) patients. We used HIPPA-compliant Florida Blue claims billings from 2010-2012 to capture all episodes of care within each calendar year. BC and MH patients were attributed to MCC if they had at least 3 annual visits. Claims from attributed patients were grouped into 7 categories. We calculated the annual costs and the costs by category to generate a Per Member Per Year (PMPY) cost and determine the stability and/or trends in these costs. Results: The PMPY data for the three years (2010, 2011, 2012) were stable over time. Important trends, however, were noted: outpatient (OP) costs, which include infusion chemotherapy, rose similarly (16 and 13%, respectively), inpatient (IP) costs for BC increased 10%, compared to an 8% decrease in IP cost for MH over the 3 years. Physician costs remained stable, consistent with other reports. Conclusions: Moving away from volume-based reimbursement requires building partnerships between payers and providers. We created disease-based cost groupers for two cancer conditions as a first step. Cost trends were stable over time. These findings will give payers and partners confidence to explore ways to improve quality and reducing cost as they consider new arrangements such as a specialty ACO. [Table: see text]