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Background: Value-based healthcare (VBHC) aims to increase patient outcomes in relation to the costs incurred, with a focus on measuring these outcomes using patient-reported outcome measures (PROMs). The German healthcare system faces the challenge of quality disparities in care amidst rising costs, making VBHC of interest., Objectives: This paper aims to illustrate how VBHC principles are currently being implemented in the field of internal medicine in Germany and to identify the potential that can be derived from VBHC pioneering examples from the Netherlands., Materials and Methods: Selected case studies are presented to illustrate how VBHC principles are already being applied in internal medicine, focusing on where PROMs are utilized and how value-based reimbursement supports VBHC implementation-both in Germany and the Netherlands., Results: In Germany, various cross-provider initiatives and individual providers implement the VBHC element of PROMs measurement. In addition, the Baden-Württemberg selective contract in cardiology demonstrates how financing VBHC elements in regular care was already made possible in Germany. Pioneers such as the Dutch center of excellence Diabeter and the multidisciplinary care network Netherlands Heart Network provide further inspiration for the implementation of VBHC in internal medicine., Conclusion: While various initiatives support the measurement of PROMs in the German context, the use of these results in care practice is not apparent. The utilization of PROMs and strategies identified in Dutch examples could be initial steps toward fostering VBHC in Germany., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Introduction: Interprofessional collaboration in healthcare involves diverse professionals working together to address complex patient needs. Interprofessional training wards offer workplace-based interprofessional education in real healthcare settings, fostering collaborative learning among students. While their educational value is widely recognized, debates persist regarding their cost-effectiveness due to limited research. This study assesses the cost efficiency of the interprofessional training ward Regensburg (A-STAR) within the Department of Internal Medicine I at the University Hospital Regensburg, compared to conventional wards., Methods: From October 2019 to December 2022, 7,244 patient cases were assigned to A-STAR or conventional wards by case managers, with a comprehensive analysis of all associated revenues and costs., Results: A-STAR treated 1,482 patients, whereas conventional wards treated 5,752 patients, with more males and younger patients at A-STAR. A-STAR achieved higher profit per case (€1,508.74) attributed to increased revenues and reduced material costs. It generated an average of €1,366.54 more Diagnosis Related Groups (DRG) revenue per case annually than conventional wards, due to greater medical complexity reflected in a higher case-mix index (CMI: 2.4 vs. 2.2). The increased case complexity led to longer patient stays (9.0 vs. 8.1 days) and fewer cases treated annually at A-STAR (27.4 cases/year vs. 37.8 cases/year). The higher CMI did not result in a higher proportion of patients requiring isolation. A-STAR exhibited a higher capacity utilization rate (87.1% vs. 83.9%). Personnel costs per case at A-STAR were initially elevated due to enhanced observation by the senior physician but were gradually mitigated by expanding A-STAR's bed capacity. Material costs were consistently lower on a per-case basis at A-STAR (€1512.02 vs. €1577.12), particularly in terms of medication expenses, indicating more resource-efficient operations. From the A-STAR graduates, 18 individuals were recruited for permanent positions as doctors or nurses over 2 years., Conclusion: A-STAR demonstrates economic efficiency and stability even during the COVID-19 pandemic. The substantial personnel acquisition is likely influenced by high levels of satisfaction with education and work and is economically relevant in medical staff shortages. These findings provide a compelling rationale for the broader implementation of interprofessional training wards, establishing them as vital platforms for nurturing future professionals., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Schlosser-Hupf, Aichner, Meier, Albaladejo-Fuertes, Mahnke, Ruttmann, Rusch, Michels, Mehrl, Kunst, Schmid and Müller.)

Purpose: In 2019, the Centers for Medicare and Medicaid Services proposed a new radiation oncology alternative payment model aimed at reducing expenditures. We examined changes in aggregate physician Medicare charges allowed per specialty to provide contemporary context to proposed changes and hypothesize that radiation oncology charges remained stable through 2017., Methods and Materials: Medicare physician/supplier utilization, program payments, and balance billing for original Medicare beneficiaries, by physician specialty, were analyzed from 2002 to 2017. Total allowed charges under the physician/supplier fee-for-service program, inflation-adjusted charges, and percent of total charges billed per specialty were examined. We adjusted for inflation using the consumer price index for medical care from the US Bureau of Labor Statistics., Results: Total allowed charges increased from $83 billion in 2002 to $138 billion in 2017. The specialties accounting for the most charges billed to Medicare were internal medicine and ophthalmology. Radiation oncology charges accounted for 1.2%, 1.6%, and 1.4% of total charges allowed by Medicare in 2002, 2012, and 2017, respectively. Radiation oncology charges allowed increased 44% from 2002 to 2012 ($987.6 million to $1.42 billion) but decreased by 19% from 2012 to 2017 ($1.15 billion), adjusted for inflation. Total charges allowed by internal medicine decreased 2% from 2002 to 2012 ($8.53 to $8.36 billion), adjusted for inflation, and decreased 16% from 2012 to 2017 ($7.05 billion). When adjusting for inflation, ophthalmology charges increased 18% from 2002 to 2012 ($4.53 to $5.36 billion) and increased 3% from 2012 to 2017 ($5.5 billion)., Conclusions: Radiation oncology physician charges represent a small fraction of total Medicare expenses and are not a driver for Medicare spending. Aggregate inflation-adjusted charges by radiation oncology have dramatically declined in the past 5 years and represent a stable fraction of total Medicare charges. The need to target radiation oncology with cost-cutting measures may be overstated., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Academic medical centers have expanded their inpatient medicine services with advanced practice clinicians (APCs) or nonteaching hospitalists in response to patient volumes, residency work hour restrictions, and recently, COVID-19. Reports of clinical outcomes, cost, and resource utilization differ among inpatient team structures., Objective: Directly compare outcomes among resident, APC, and solo hospitalist inpatient general medicine teams., Design: Retrospective cohort study using multivariable analysis adjusted for time of admission, interhospital transfer, and comorbidities that compares clinical outcomes, cost, and resource utilization., Subjects: Patients 18 years or older discharged from an inpatient medicine service between July 2015 and July 2018 (N = 12,716)., Main Measures: Length of stay (LOS), 30-day readmission, inpatient mortality, normalized total direct cost, discharge time, and consultation utilization., Key Results: Resident teams admitted fewer patients at night (32.0%; P < .001) than did APC (49.5%) and hospitalist (48.6%) teams. APCs received nearly 4% more outside transfer patients (P = .015). Hospitalists discharged patients 26 minutes earlier than did residents (mean hours after midnight [95% CI], 14.58 [14.44-14.72] vs 15.02 [14.97-15.08]). Adjusted consult utilization was 15% higher for APCs (adjusted mean consults per admission [95% CI], 1.00 [0.96-1.03]) and 8% higher for residents (0.93 [0.90-0.95]) than it was for hospitalists (0.85 [0.80-0.90]). No differences in LOS, readmission, mortality, or cost were observed between the teams., Conclusion: We observed similar costs, LOS, 30-day readmission, and mortality among hospitalist, APC, and resident teams. Our results suggest clinical outcomes are not significantly affected by team structure. The addition of APC or hospitalist teams represent safe and effective alternatives to traditional inpatient resident teams.

Giant cell arteritis (GCA) is the most common vasculitis in adults. However, comprehensive analyses of the healthcare burden are still scarce. The aim of the study is to report the healthcare burden and cost of illness of GCA in the Friuli Venezia Giulia (FVG) region of Italy, based on a data linkage analysis. To this end, a retrospective study was conducted through the integration of many administrative health databases of the FVG region as the source of information. Cases were identified from two verified, partially overlapping sources (the rare disease registry and medical exemption database). From 2001 to 2017, 208 patients with GCA were registered. The prevalence of GCA in the population aged ⩾ 45 years as of December 31, 2017 was 27.2/100,000 inhabitants (95% CI 23.5-31.4). The mean time of observation was 4.5 ± 3.6 years. A total of 3182 visits (338 per 100 patient-years) was recorded. The most frequent specialty visits were rheumatology ( n = 610, 19.2%), followed by internal medicine ( n = 564, 17.7%). A total of 287 hospitalizations (30 per 100 patient-years) were reported. A total of 13,043 prescriptions (1386 per 100 patient-years) were registered. More than half of the patients were prescribed an immunosuppressive agent. The overall estimated direct healthcare cost was €2,234,070, corresponding to €2374 per patient-year. Overall, GCA is a rare disease which implies a high healthcare cost.

Objectives: More than 90% of patients who report a penicillin allergy have the allergy disproved when tested. Unnecessary use of alternative (non-beta-lactam) antibiotics can result in more treatment failures and adverse reactions. We described the prevalence and impact of a reported penicillin allergy in high-cost, high-need (HCHN) patients., Study Design: Retrospective cohort., Methods: We identified HCHN patients in a care management program of an urban academic medical center (January 1, 2014, to December 31, 2016). We used multivariable logistic regression models to determine the association between a reported penicillin allergy and antibiotic use. We used multivariable Poisson regression models to determine the association between a reported penicillin allergy, with or without multiple drug intolerance syndrome (MDIS; ≥3 reported drug allergies), and healthcare resource utilization (HRU)., Results: Of 1870 HCHN patients, 383 (20%) reported penicillin allergy, 835 (45%) had MDIS, and 290 (16%) had both. HCHN patients reporting penicillin allergy had an increased odds of beta-lactam alternative antibiotic use (adjusted odds ratio, 3.84; 95% CI, 2.17-6.80). HRU was significantly higher for patients reporting a penicillin allergy alone (adjusted relative risk [aRR], 1.13; 95% CI, 1.03-1.25) and with concurrent MDIS (aRR, 1.20; 95% CI, 1.08-1.34)., Conclusions: HCHN patients had a high burden of reported drug allergy. A reported penicillin allergy conferred a 4-fold increased odds of beta-lactam alternative antibiotic use. Reporting penicillin allergy, with and without MDIS, was associated with significantly more HRU. HCHN care management programs should consider systematic drug allergy evaluations to optimize antibiotic use in these fragile patients.

Objective The hospitalist system is considered successful with respect to the quality of care and cost effectiveness in the United States. Studies have consistently demonstrated an improved clinical efficiency with this system. In Japan, however, the efficacy of the hospitalist system has not yet been examined. As a "super-aged society", Japan has a high number of elderly patients with multiple comorbidities who may theoretically receive better care by the hospitalist system than by the conventional system. This study investigates the impact of the hospitalist system on the quality of care and healthcare economics in a Japanese population. Methods We analyzed 274 patients ≥65 years of age in whom the most resource-consuming diagnosis at admission was aspiration pneumonia over a 1-year period. We categorized patients as those managed by hospitalists and those managed by various departments (control group) and compared the groups. Propensity score matching was used to minimize selection bias. Results For matched pairs, the length of hospital stay in the hospitalist group was shorter than that in the control group. Care by the hospitalist system was associated with significantly lower hospital costs. The quality of care (rate of switching from intravenous to oral antibiotics, duration of antibiotics therapy, number of chest X-rays and blood tests during hospitalization) was also considered to be favorably impacted by the hospitalist system. There was no statistically significant difference in the mortality rate or readmission rate between the groups. Conclusion This study showed that the hospitalist system had a favorable impact on the quality of care and cost effectiveness, suggesting the potential utility of its implementation in the Japanese medical system.

Background: Step therapy policies that require prescribers to follow an ordered protocol for drug choices are widely used by public and private insurers to manage medication costs; however, the perceptions of prescribing physicians regarding these policies have not been studied., Objective: To determine physician attitudes toward step therapy policies and the correlation of these beliefs with physician characteristics., Methods: A sample of clinically active physicians specializing in internal medicine, cardiology, or endocrinology received a survey administered online or via mail. Five-point Likert scale questions assessed physicians' opinions of clinical, economic, and implementation elements of prior authorization policies; physician demographic characteristics; and the extent of their interactions with the pharmaceutical industry., Results: 686 physicians (48%) responded to the survey, which was evenly divided among primary care physicians, endocrinologists, and cardiologists. Many respondents (70%) had interactions with industry, including receipt of meals or gifts and use of medication samples. Physicians reported that step therapy policies could improve the affordability of medication use (55% agree vs. 26% disagree) and its clinical appropriateness (59% agree vs. 19% disagree). By similar margins, however, physicians stated that step therapy policies were implemented inefficiently and inflexibly and often did not incorporate relevant patient-specific information. Physicians in subspecialties, especially endocrinology, and those who had interactions with the pharmaceutical industry were more likely to hold negative views of step therapy policies., Conclusions: Most physicians recognize the potential of step therapy to improve the quality and cost-effectiveness of prescribing, although interactions with industry may affect these opinions. Physician perception of ineffective implementation of these policies, however, undermines their acceptability., Disclosures: The American Board of Internal Medicine (ABIM) funded the survey used in this study. The ABIM had no role in the design and conduct of the study or development and preparation of the manuscript. Survey honoraria was provided by the Consumers Union. Kesselheim and Avorn's work is funded by the Laura and John Arnold Foundation. Kesselheim is also supported by the Harvard-MIT Center for Regulatory Science, Arnold Ventures, and the Engelberg Foundation. Ross is employed by the ABIM. Fischer, Lu, and Tessema have nothing to disclose.

Objective Chronic pain and opioid management are challenging in primary care, especially for trainees with discontinuous ambulatory schedules and less practice experience. The study objective was to improve adherence to quality metrics and office visit utilization in a resident clinic. Design Before-after quality improvement intervention over two Plan-Do-Study-Act cycles. Setting Suburban, university-affiliated Internal Medicine resident clinic. Methods During the 2015-2017 academic years, two sequential interventions were implemented: 1) use of electronic pain and opioid management templates and workflow redesign routing opioid renewals through a registered nurse (RN); 2) RN previsit planning and daily nurse-physician huddles before patient visits. Outcomes included adherence to annual toxicology screening, risk assessment and opioid agreements, opioid dose prescribed, and office visit utilization. Results The template and workflow redesign intervention increased annual toxicology from 53% to 81% (P < 0.0015), annual opioid agreement from 13.8% to 53.5% (P < 0.0001), and risk assessment from 0% to 75.9% (P < 0.0001). Average daily morphine milligram equivalents (MME) decreased from 96.6 MME to 67.7 MME (P < 0.0001), and annual office visits decreased from 11.1 to 8.9 (P = 0.0004). Previsit planning and huddles did not show incremental increases in adherence to quality measures but did improve clinic utilization and maintained high levels of adherence to quality measures. Conclusions Quality improvement interventions can improve adherence to quality measures and clinic utilization. A critical role is served by midlevel nursing providers to provide continuity to patients and trainees. Teaching clinics need to develop sustainable systems of care to moderate quality assurance in opioid prescribing., (© 2018 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Vaccination coverage among adults remains low in the United States. Understanding the barriers to provision of adult vaccination is an important step to increasing vaccination coverage and improving public health. To better understand financial factors that may affect practice decisions about adult vaccination, this study sought to understand how costs compared with payments for adult vaccinations in a sample of U.S. physician practices. We recruited a convenience sample of 19 practices in nine states in 2017. We conducted a time-motion study to assess the time costs of vaccination activities and conducted a survey of practice managers to assess materials, management, and dose costs and payments for vaccination. We received complete cost and payment data from 13 of the 19 practices. We calculated annual income from vaccination services by comparing estimated costs with payments received for vaccine doses and vaccine administration. Median annual total income from vaccination services was $90,343 at family medicine practices (range: $3968-$249,628), $28,267 at internal medicine practices (-$32,659-$141,034) and $2886 at obstetrics and gynecology practices (-$73,451-$23,820). Adult vaccination was profitable at the median of our sample, but there is wide variation in profitability due to differences in costs and payment rates across practices. This study provides evidence on the financial viability of adult vaccination and supports actions for improving financial viability. These results can help inform practices' decisions whether to provide adult vaccines and contribute to keeping adults up-to-date with the recommended vaccination schedule., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Rising out-of-pocket costs are creating a need for cost conversations between patients and physicians., Objective: To understand the factors that influence physicians to discuss and consider cost during a patient encounter., Design: Mixed-methods study using semistructured interviews and a survey., Setting: United States., Participants: 20 internal medicine physicians were interviewed; 621 internal medicine physician members of the American College of Physicians completed the survey., Measurements: Interviews were analyzed by using thematic analysis, and surveys were analyzed by using descriptive statistics., Results: From the interviews, 4 themes were identified: Physicians are 1) aware that patients are struggling to afford medical care; 2) relying on clues from patients that hint at their cost sensitivity; 3) relying on experience to anticipate potentially high-cost treatments; and 4) aware that patients are making financial trade-offs to afford their care. Three quarters (n = 466) of survey respondents stated that they consider out-of-pocket costs when making most clinical decisions. For 31% (n = 191) of participants, there were times in the past year that they wanted to discuss out-of-pocket prescription drug costs with patients but did not. The most influential factors for ordering a test are the desire to be as thorough as possible (71% [n = 422]) and insurance coverage for the test (68% [n = 422])., Limitation: Findings are self-reported, the sample is limited to a single specialty, the survey response rate was low, information on the patient population was limited, and the survey instrument is not validated., Conclusion: Physicians are attuned to the burden of health care costs and are willing to consider alternative options based on a patient's cost sensitivity., Primary Funding Source: Robert Wood Johnson Foundation.

Background: Understanding the most common and costly conditions treated by inpatient general medical services is important for implementing quality improvement, developing health policy, conducting research, and designing medical education., Objective: To determine the prevalence and cost of conditions treated on general internal medicine (GIM) inpatient services., Design: Retrospective cross-sectional study involving 7 hospital sites in Toronto, Canada., Participants: All patients discharged between April 1, 2010 and March 31, 2015 who were admitted to or discharged from an inpatient GIM service., Main Measures: Hospital administrative data were used to identify diagnoses and costs associated with admissions. The primary discharge diagnosis was identified for each admission and categorized into clinically relevant and mutually exclusive categories using the Clinical Classifications Software (CCS) tool., Key Results: Among 148,442 admissions, the most common primary discharge diagnoses were heart failure (5.1%), pneumonia (5.0%), urinary tract infection (4.6%), chronic obstructive pulmonary disease (4.5%), and stroke (4.4%). The prevalence of the 20 most common conditions was significantly correlated across hospitals (correlation coefficients ranging from 0.55 to 0.95, p ≤ 0.01 for all comparisons). No single condition represented more than 5.1% of all admissions or more than 7.9% of admissions at any hospital site. The costliest conditions were stroke (median cost $7122, interquartile range 5587-12,354, total cost $94,199,422, representing 6.0% of all costs) and the group of delirium, dementia, and cognitive disorders (median cost $12,831, IQR 9539-17,509, total cost $77,372,541, representing 4.9% of all costs). The 10 most common conditions accounted for only 36.2% of hospitalizations and 36.8% of total costs. The remaining hospitalizations included 223 different CCS conditions., Conclusions: GIM services care for a markedly heterogeneous population but the most common conditions were similar across 7 hospitals. The diversity of conditions cared for in GIM may be challenging for healthcare delivery and quality improvement. Initiatives that cut across individual diseases to address processes of care, patient experience, and functional outcomes may be more relevant to a greater proportion of the GIM population than disease-specific efforts.

Background: Applications to infectious diseases fellowships have declined nationally; however, the military has not experienced this trend. In the past 6 years, 3 US military programs had 58 applicants for 52 positions. This study examines military resident perceptions to identify potential differences in factors influencing career choice, compared with published data from a nationwide cohort., Methods: An existing survey tool was adapted to include questions unique to the training and practice of military medicine. Program directors from 11 military internal medicine residencies were asked to distribute survey links to their graduating residents from December 2016 to January 2017. Data were categorized by ID interest., Result: The response rate was 51% (n = 68). Of respondents, 7% were ID applicants, 40% considered ID but reconsidered, and 53% were uninterested. Of those who considered ID, 73% changed their mind in their second and third postgraduate years and cited salary (22%), lack of procedures (18%), and training length (18%) as primary deterrents to choosing ID. Active learning styles were used more frequently by ID applicants to learn ID concepts than by those who considered or were uninterested in ID (P = .02)., Conclusions: Despite differences in the context of training and practice among military trainees compared with civilian colleagues, residents cited similar factors affecting career choice. Interest in global health was higher in this cohort. Salary continues to be identified as a deterrent to choosing ID. Differences between military and civilian residents' desire to pursue ID fellowship are likely explained by additional unmeasured factors deserving further study.

Importance: Uninsured and insured but out-of-network emergency department (ED) patients are often billed hospital chargemaster prices, which exceed amounts typically paid by insurers., Objective: To examine the variation in excess charges for services provided by emergency medicine and internal medicine physicians., Design, Setting, and Participants: Retrospective analysis was conducted of professional fee payment claims made by the Centers for Medicare & Medicaid Services for all services provided to Medicare Part B fee-for-service beneficiaries in calendar year 2013. Data analysis was conducted from January 1 to July 31, 2016., Main Outcomes and Measures: Markup ratios for ED and internal medicine professional services, defined as the charges submitted by the hospital divided by the Medicare allowable amount., Results: Our analysis included 12 337 emergency medicine physicians from 2707 hospitals and 57 607 internal medicine physicians from 3669 hospitals in all 50 states. Services provided by emergency medicine physicians had an overall markup ratio of 4.4 (340% excess charges), which was greater than the markup ratio of 2.1 (110% excess charges) for all services performed by internal medicine physicians. Markup ratios for all ED services ranged by hospital from 1.0 to 12.6 (median, 4.2; interquartile range [IQR], 3.3-5.8); markup ratios for all internal medicine services ranged by hospital from 1.0 to 14.1 (median, 2.0; IQR, 1.7-2.5). The median markup ratio by hospital for ED evaluation and management procedure codes varied between 4.0 and 5.0. Among the most common ED services, laceration repair had the highest median markup ratio (7.0); emergency medicine physician review of a head computed tomographic scan had the greatest interhospital variation (range, 1.6-27.7). Across hospitals, markups in the ED were often substantially higher than those in the internal medicine department for the same services. Higher ED markup ratios were associated with hospital for-profit ownership (median, 5.7; IQR, 4.0-7.1), a greater percentage of uninsured patients seen (median, 5.0; IQR, 3.5-6.7 for ≥20% uninsured), and location (median, 5.3; IQR, 3.8-6.8 for the southeastern United States)., Conclusions and Relevance: Across hospitals, there is wide variation in excess charges on ED services, which are often priced higher than internal medicine services. Our results inform policy efforts to protect uninsured and out-of-network patients from highly variable pricing.

Background  There is an ongoing discussion within the German Society of Internal Medicine (DGIM) and the Professional Association of German Internists (BDI) about the appropriate depiction and remuneration of internal medicine in the G-DRG. Method  Therefore, cases with a significantly prolonged length of stay were analyzed in a multicenter study. 124 cases from 6 hospitals were collected for evaluation. Results  The results show that the observed prolongation of hospitalization was mainly due to medical reasons. Discussion  Thus, patients with unclear symptoms and consequently need for a thorough workup could not be identified to cause longer inpatient stay. Instead, treatment complications and comorbidities led to extended hospitalization. The results also reveal prolonged hospitalization as a consequence of unsettled or delayed postdischarge care e. g. in rehabilitation facilities., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

The importance of a specific transition process is recognized by many health organizations. Got Transition, a cooperative endeavor aimed at improving the transition from pediatric to adult health care, developed Six Core Elements defining the basic components of health care transition support. In this article, we review the Six Core Elements by presenting a model that combines resident quality improvement and transition care training. In this Internal Medicine-Pediatrics residency program, ambulatory training for residents takes place in a combined adult and pediatric clinic. Aligned with the Six Core Elements, the program has crafted and disseminated a transition policy for the practice, designed a portable health summary template for the electronic medical record (EMR), created EMR tools for assessing transition readiness and setting transition goals, formed a registry of patients, and audited charts. [Pediatr Ann. 2017;46(5):e203-e206.]., (Copyright 2017, SLACK Incorporated.)

Background: The treatment of patients with dementia in acute care hospitals is becoming increasingly more important. The aim of this study was to investigate and demonstrate aspects of the healthcare situation and resource consumption of dementia patients during their hospital stay in a ward for internal medicine., Material and Methods: Secondary data from a ward of internal medicine were analyzed on a retrospective and case-related basis. For 100 patients a diagnosis of dementia by a general practitioner before hospitalization was identified. The control group was selected by age and sex from the other patients in the ward (n = 100). The costs were calculated on the basis of the German diagnosis-related groups (G-DRG) flat rate case classification. The relationship between dementia, deviation from the average length of stay and costs was investigated under the control of comorbidities using multivariate regression analysis., Results: Patients with dementia had poorer health at admission with respect to functionality and orientation and a higher risk of falls and pressure ulcers. During hospitalization patients with dementia fell more frequently than patients without dementia (12 % versus 3 %, p = 0.029). Regarding the average length of stay, according to the G‑DRG catalogue patients with dementia stayed 1.4 days longer in hospital than patients without dementia and caused excess costs of 19 %., Conclusion: Patients with dementia are a highly vulnerable patient group with a higher consumption of resources than patients without dementia. The results demonstrate the care-related and economic consequences, which the increasing number of patients with dementia could have in the future.

In order to provide high quality, cost-efficient care, it is critical to understand drivers of the cost of care. Therefore, we sought to identify clinical variables associated with high utilization (cost) in patients admitted to medical services and to develop a robust model to identify high utilization patients. In this case-control analysis, cases were identified as the 200 most costly patients admitted to internal medicine/internal medicine subspecialty services using our institution's computerized clinical data warehouse over a 7-month time period (November 1, 2012-May 31, 2013). 400 patients admitted in the same time period were randomly selected to serve as controls. The mean cost for the highest utilization patients was $126,343, while that for randomly matched patients was $15,575. In a multivariable regression model, the following variables were associated with high utilization of resources: African American race, age 35-44, admission through the emergency department, primary service of hematology-oncology, a history of heart failure or paralysis, a diagnosis of HIV, cancer, collagen vascular diseases and/or coagulopathy, a reduced albumin, and/or an elevated creatinine. The in hospital mortality rate for high utilization patients was 19%, compared to 8% for controls (p=0.0002). A predictive model using 14 different readily available clinical variables predicted high utilization with an area under the curve of 0.85. The data suggest that high utilization patients share similar demographic and clinical features. We speculate that a predictive model using commonly known patient characteristics should be able to predict high utilization patients., (Copyright © 2016 American Federation for Medical Research.)

Background: Rates of preventable admissions will soon be publicly reported and used in calculating performance-based payments. The current method of assessing preventable admissions, the Agency of Healthcare Research and Quality (AHRQ) Preventable Quality Indicators (PQI) rate, is drawn from claims data and was originally designed to assess population-level access to care., Objective: To identify the prevalence and causes of preventable admissions by attending physician review and to compare its performance with the PQI tool in identifying preventable admissions., Design: Cross-sectional survey., Setting: General medicine service at an academic medical center., Participants: Consecutive inpatient admissions from December 1-15, 2013., Main Measures: Survey of inpatient attending physicians regarding the preventability of the admissions, primary contributing factors and feasibility of prevention. For the same patients, the PQI tool was applied to determine the claims-derived preventable admission rate., Key Results: Physicians rated all 322 admissions and classified 122 (38 %) as preventable, of which 31 (25 %) were readmissions. Readmissions were more likely to be rated preventable than other admissions (49 % vs. 35 %, p = 0.04). Application of the AHRQ PQI methodology identified 75 (23 %) preventable admissions. Thirty-one admissions (10 %) were classified as preventable by both methods, and the majority of admissions considered preventable by the AHRQ PQI method (44/78) were not considered preventable by physician assessment (K = 0.04). Of the preventable admissions, physicians assigned patient factors in 54 (44 %), clinician factors in 36 (30 %) and system factors in 32 (26 %)., Conclusions: A large proportion of admissions to a general medicine service appeared preventable, but AHRQ's PQI tool was unable to identify these admissions. Before initiation of the PQI rate for use in pay-for-performance programs, further study is warranted.

Background: Traditional productivity-based compensation models do not align well with newer population-based approaches to primary care. There are few published examples of academic general internal medicine compensation models that explicitly reward population health management, including care for patients between visits., Objective: To describe the development and implementation of an academic general internal medicine compensation plan based upon actual work performed, compare satisfaction across primary care specialties, and evaluate work-related outcomes., Design: Observational study., Participants: Forty-seven general internists who practice in affiliated academic and community clinics., Main Measures: Clinician satisfaction with compensation plan, workforce stability, panel data, and productivity., Key Results: The compensation plan change was associated with higher provider satisfaction. Sixty-five percent (31/47) of participants within general internal medicine reported being satisfied or very satisfied, as compared to 24 % (22/90 participants) for family medicine and 22 % (5/23 participants) for general pediatrics (p < 0.05). In the first 4 years of the compensation plan change, no general internists left to join other local groups. General internal medicine increased its number of physicians by 19 %. The number of established general internists accepting new patients increased from 17 to 48 %, while the relative value units per full-time equivalent declined by 3 %., Conclusions: An equitable compensation model that aligns with population management goals and work performed outside the clinical visit can lead to improved satisfaction and retention of faculty in an academic general internal medicine division, along with improved access for the patient population.

Background: Combined internal medicine and pediatrics (medicine-pediatrics) residencies were Accreditation Council for Graduate Medical Education (ACGME) accredited separately from their corresponding categorical residencies in June 2006., Objective: We investigated how ACGME accreditation of medicine-pediatrics programs has affected the levels of support (both financial and personnel), the National Resident Matching Program (NRMP) match rate, performance on the board examination, and other graduate outcomes., Methods: From 2009 through 2013 we sent an annual SurveyMonkey online survey to members of the Medicine-Pediatrics Program Directors Association. Questions pertained to program characteristics, program director support, recruitment, ambulatory training, and graduate data. More than 79% of responders completed the entire survey for each year (sample size was 60 program directors)., Results: Compared to the time prior to accreditation of the specialty, there was an increase in program directors who are dually trained (89% versus 93%), an increase in program director salary ($134,000 before accreditation versus $185,000 in 2013, P < .05), and an increase in the average full-time equivalent support (0.32 before accreditation versus 0.42 in 2013, P < .05). There was also an increase in programs with associate program directors (35% versus 78%), programs with chief residents (71% versus 91%), and an increase in program budgets controlled by program directors (52% versus 69%). The 2013 NRMP match rates increased compared to those of 2005 (99% versus 49%). Performance on the American Board of Pediatrics examination was comparable to that for pediatrics residents. Since accreditation, a larger number of residents are choosing careers in hospital medicine., Conclusions: Our data show widespread improved support for medicine-pediatrics programs since the 2006 start of ACGME accreditation.

Purpose: To examine the perceived likelihood of sustaining new residency positions funded by five-year (2010-2015) Primary Care Residency Expansion (PCRE) grants from the Health Resources and Services Administration, which aimed to increase training output to address primary care workforce issues., Method: During September-December 2013, the authors administered an online or telephone survey to program directors whose residency programs received PCRE grants. The main outcome measure was perceived likelihood of sustaining the expanded residency positions beyond the expiration of the grant, in the outlying years of 2016 and 2017 (when the positions will be partially supported) and after 2017 (when the positions will be unsupported)., Results: Of 78 eligible program directors, 62 responded (response rate = 79.5%). Twenty-eight (45.1%; 95% CI 32.9%-57.9%) reported that their programs were unlikely to, very unlikely to, or not planning to continue the expanded positions after the PCRE grant expires. Overall, 14 (22.5%) reported having secured full funding to support the expanded positions beyond 2017. Family medicine and pediatrics program directors were significantly less likely than internal medicine program directors to report having secured funding for the outlying years (P = .02)., Conclusions: This study suggests that an approach to primary care residency training expansion that relies on time-limited grants is unlikely to produce sustainable growth of the primary care pipeline. Policy makers should instead implement systemic reform of graduate medical education (GME) financing and designate reliable sources of funding, such as Medicare and Medicaid GME funds, for new primary care residency positions.

Provisions of the Affordable Care Act (ACA) allow millions more Americans to obtain health insurance. However, a sizable number of people remain uninsured because they live in states that have not expanded Medicaid coverage or because they feel that Marketplace coverage is not affordable. Using data from a ten-state telephone survey in which callers posed as patients, we examined prices for primary care visits offered by physician offices to new uninsured patients in 2012-13, prior to ACA insurance expansions. Patients were quoted a mean price of $160. Significantly lower prices for the uninsured were offered by family practice offices compared to general internists, in offices participating in Medicaid managed care plans, and in federally qualified health centers. Prices were also lower for offices in ZIP codes with higher poverty rates. Only 18 percent of uninsured callers were told that they could bring less than the full amount to the visit and arrange to pay the rest later. ACA insurance expansions could greatly decrease out-of-pocket spending for low-income adults seeking primary care. However, benefits of health reform are likely to be greater in states expanding Medicaid eligibility., (Project HOPE—The People-to-People Health Foundation, Inc.)

Background: Care for many chronic health conditions is delivered by both specialists and generalists. Differences in patients' quality of care and management between generalists and specialists have been well documented for asthma, whereas a few studies for COPD reported no differences., Objective: The objective of this study is to compare consistency with Global initiative for chronic Obstructive Lung Disease guidelines, as well as rate, health care utilization, and hospital outcomes of severe acute exacerbation (AE) of COPD patients managed by pulmonologists and internists., Materials and Methods: This is a 12-month prospective, comparative observational study among 208 COPD patients who were regularly managed by pulmonologists (Group A) and internists (Group B). Clinical data, health care utilization, and hospital outcomes of the two groups were statistically compared., Results: Out of 208 enrolled patients, 137 (Group A) and 71 (Group B) were managed by pulmonologists and internists, respectively. Pharmacological treatment corresponding to disease severity stages between the two groups was not statistically different. Group A received care consistent with guidelines in terms of annual influenza vaccination (31.4% vs 9.9%, P<0.001) and pulmonary rehabilitation (24.1% vs 0%, P<0.001) greater than Group B. Group A had reduced rates (12.4% vs 23.9%, P=0.033) and numbers of severe AE (0.20±0.63 person-years vs 0.41±0.80 person-years, P=0.029). Among patients with severe AE requiring mechanical ventilation, Group A had reduced mechanical ventilator duration (1.5 [1-7] days vs 5 [3-29] days, P=0.005), hospital length of stay (3.5 [1-20] days vs 16 [6-29] days, P=0.012), and total hospital cost ($863 [247-2,496] vs $2,095 [763-6,792], P=0.049) as compared with Group B., Conclusion: This study demonstrated that pulmonologists followed national COPD guidelines more closely than internists. The rates and frequencies of severe AE were significantly lower in patients managed by pulmonologists, and length of hospital stay and cost were significantly lower among the patients with severe AE who required mechanical ventilation.

Importance: Graduate medical education training may imprint young physicians with skills and experiences, but few studies have evaluated imprinting on physician spending patterns., Objective: To examine the relationship between spending patterns in the region of a physician's graduate medical education training and subsequent mean Medicare spending per beneficiary., Design, Setting, and Participants: Secondary multilevel multivariable analysis of 2011 Medicare claims data (Part A hospital and Part B physician) for a random, nationally representative sample of family medicine and internal medicine physicians completing residency between 1992 and 2010 with Medicare patient panels of 40 or more patients (2851 physicians providing care to 491,948 Medicare beneficiaries)., Exposures: Locations of practice and residency training were matched with Dartmouth Atlas Hospital Referral Region (HRR) files. Training and practice HRRs were categorized into low-, average-, and high-spending groups, with approximately equal distribution of beneficiary numbers. There were 674 physicians in low-spending training and low-spending practice HRRs, 180 in average-spending training/low-spending practice, 178 in high-spending training/low-spending practice, 253 in low-spending training/average-spending practice, 417 in average-spending training/average-spending practice, 210 in high-spending training/average-spending practice, 97 in low-spending training/high-spending practice, 275 in average-spending training/high-spending practice, and 567 in high-spending training/high-spending practice., Main Outcomes and Measures: Mean physician spending per Medicare beneficiary., Results: For physicians practicing in high-spending regions, those trained in high-spending regions had a mean spending per beneficiary per year $1926 higher (95% CI, $889-$2963) than those trained in low-spending regions. For practice in average-spending HRRs, mean spending was $897 higher (95% CI, $71-$1723) for physicians trained in high- vs low-spending regions. For practice in low-spending HRRs, the difference across training HRR levels was not significant ($533; 95% CI, -$46 to $1112). After controlling for patient, community, and physician characteristics, there was a 7% difference (95% CI, 2%-12%) in patient expenditures between low- and high-spending training HRRs. Across all practice HRRs, this corresponded to an estimated $522 difference (95% CI, $146-$919) between low- and high-spending training regions. For physicians 1 to 7 years in practice, there was a 29% difference ($2434; 95% CI, $1004-$4111) in spending between those trained in low- and high-spending regions; however, after 16 to 19 years, there was no significant difference., Conclusions and Relevance: Among general internists and family physicians who completed residency training between 1992 and 2010, the spending patterns in the HRR in which their residency program was located were associated with expenditures for subsequent care they provided as practicing physicians for Medicare beneficiaries. Interventions during residency training may have the potential to help control future health care spending.