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Purpose: To evaluate billing trends, Medicare reimbursement, and practice setting for Medicare-billing otolaryngologists (ORLs) performing in-office face computerized tomography (CT) scans., Methods: This retrospective study included data on Medicare-billing ORLs from Medicare Part B: Provider Utilization and Payment Datafiles (2012-2018). Number of Medicare-billing ORLs performing in-office CT scans, and total sums and medians for Medicare reimbursements, services performed, and number of patients were gathered along with geographic and practice-type distributions., Results: In 2018, roughly 1 in 7 Medicare-billing ORLs was performing in-office CT scans, an increase from 1 in 10 in 2012 (48.2% growth). From 2012 to 2018, there has been near-linear growth in number of in-office CT scans performed (58.2% growth), and number of Medicare fee-for-service (FFS) patients receiving an in-office CT scan (64.8% growth). However, at the median, the number of in-office CT scans performed and number of Medicare FFS patients receiving an in-office CT, per physician, has remained constant, despite a decline of 42.3% (2012: $227.67; 2018: $131.26) in median Medicare reimbursements., Conclusion: Though sharp declines have been seen in Medicare reimbursement, a greater proportion of Medicare-billing ORLs have been performing in-office face CT scans, while median number of in-office CT scans per ORL has remained constant. Although further investigation is certainly warranted, this analysis suggests that ORLs, at least in the case of the Medicare FFS population, are utilizing in-office CT imaging for preoperative planning, pathologic diagnosis, and patient convenience, rather than increased revenue streams. Future studies should focus on observing these billing trends among private insurers., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background Prenatal diagnosis of congenital heart disease has been associated with early-term delivery and cesarean delivery (CD). We implemented a multi-institutional standardized clinical assessment and management plan (SCAMP) through the University of California Fetal-Maternal Consortium. Our objective was to decrease early-term (37-39 weeks) delivery and CD in pregnancies complicated by fetal congenital heart disease using a SCAMP methodology to improve practice in a high-risk and clinically complex setting. Methods and Results University of California Fetal-Maternal Consortium site-specific management decisions were queried following SCAMP implementation. This contemporary intervention group was compared with a University of California Fetal-Maternal Consortium historical cohort. Primary outcomes were early-term delivery and CD. A total of 496 maternal-fetal dyads with prenatally diagnosed congenital heart disease were identified, 185 and 311 in the historical and intervention cohorts, respectively. Recommendation for later delivery resulted in a later gestational age at delivery (38.9 versus 38.1 weeks, P =0.01). After adjusting for maternal age and site, historical controls were more likely to have a CD (odds ratio [OR],1.8; 95% CI, 2.1-2.8; P =0.004) and more likely (OR, 2.1; 95% CI, 1.4-3.3) to have an early-term delivery than the intervention group. Vaginal delivery was recommended in 77% of the cohort, resulting in 61% vaginal deliveries versus 50% in the control cohort ( P =0.03). Among pregnancies with major cardiac lesions (n=373), vaginal birth increased from 51% to 64% ( P =0.008) and deliveries ≥39 weeks increased from 33% to 48% ( P =0.004). Conclusions Implementation of a SCAMP decreased the rate of early-term deliveries and CD for prenatal congenital heart disease. Development of clinical pathways may help standardize care, decrease maternal risk secondary to CD, improve neonatal outcomes, and reduce healthcare costs.

Background: The iPhone X (Apple, Inc., Cupertino, Calif.) is the first smartphone to be released with a high-fidelity three-dimensional scanner. At present, half of all U.S. smartphone users use an iPhone. Recent data suggest that the majority of these 230 million individuals will upgrade to the iPhone X within 2 years. This represents a profound expansion in access to three-dimensional scanning technology, not only for plastic surgeons but for their patients as well. The purpose of this study was to compare the iPhone X scanner against a popular, portable three-dimensional camera used in plastic surgery (Canfield Vectra H1; Canfield Scientific, Inc., Parsippany, N.J.)., Methods: Sixteen human subjects underwent three-dimensional facial capture with the iPhone X and Canfield Vectra H1. Results were compared using color map analysis and surface distances between key anatomical landmarks. To assess repeatability and precision of the iPhone X three-dimensional scanner, six facial scans of a single participant were obtained and compared using color map analysis. In addition, three-dimensionally-printed facial masks (n = 3) were captured with each device and compared., Results: For the experiments, average root mean square was 0.44 mm following color map analysis and 0.46 mm for surface distance between anatomical landmarks. For repeatability and precision testing, average root mean square difference following color map analysis was 0.35 mm. For the three-dimensionally-printed facial mask comparison, average root mean square difference was 0.28 mm., Conclusions: The iPhone X offers three-dimensional scanning that is accurate and precise to within 0.5 mm when compared to a commonly used, validated, and expensive three-dimensional camera. This represents a significant reduction in the barrier to access to three-dimensional scanning technology for both patients and surgeons.

The Centers for Medicare and Medicade Services (CMS) initiated chronic care management (CCM) codes to reimburse clinicians for coordination activities, but little is known about uptake over time. We find that primary care clinicians drove increasing use over 4 years-a trend that may reflect either new coordination activities or new reimbursements for existing activities. That 5% of chronic care management was denied by Medicare underscores the need for future work evaluating facilitators and barriers to use. Such insight is especially vital given the large number of eligible beneficiaries that have not received chronic care management to date, as well as the limited number of clinicians who currently deliver these services., (© 2020 Annals of Family Medicine, Inc.)

Aims: The aim of this study was to analyze the true costs associated with preoperative CT scans performed for robotic-assisted total knee arthroplasty (RATKA) planning and to determine the value of a formal radiologist's report of these studies., Methods: We reviewed 194 CT reports of 176 sequential patients who underwent primary RATKA by a single surgeon at a suburban teaching hospital. CT radiology reports were reviewed for the presence of incidental findings that might change the management of the patient. Payments for the scans, including the technical and professional components, for 330 patients at two hospitals were also recorded and compared., Results: There were 82 incidental findings in 61 CT studies, one of which led to a recommendation for additional testing. Across both institutions, the mean total payment for a preoperative scan was $446 ($8 to $3,870). The mean patient payment was $71 ($0 to $2,690). There was wide variation in payments between the institutions. In Institution A, the mean total payment was $258 ($168 to $264), with a mean patient payment of $57 ($0 to $100). The mean technical payment in this institution was $211 ($8 to $856), while the mean professional payment was $48 ($0 to $66). In Institution B, the mean total payment was $636 ($37 to $3,870), with a mean patient payment of $85 ($0 to $2,690)., Conclusion: The total cost of a CT scan is low and a minimal part of the overall cost of the RATKA. No incidental findings identified on imaging led to a change in management, suggesting that the professional component could be eliminated to reduce costs. Further studies need to take into account the patient perspective and the wide variation in total costs and patient payments across institutions and insurances. Cite this article: Bone Joint J 2020;102-B(6 Supple A):79-84.

Background: The treatment and management of long-term health conditions is the greatest challenge facing health systems around the world today. Innovative approaches to patient care in the community such as Anticipatory Care Planning (ACP), which seek to help with the provision of high-quality comprehensive care to older adults at risk of functional decline, require evaluation. This study will evaluate one approach that will include primary care as the setting for ACP., Methods/design: This study will help to determine the feasibility for a definitive randomised trial to evaluate the implementation and outcomes of an ACP intervention. The intervention will be delivered by specially trained registered nurses in a primary care setting with older adults identified as at risk of functional decline. The intervention will comprise: (a) information collection via patient assessment; (b) facilitated informed dialogue between the patient, family carer, general practitioner and other healthcare practitioners; and, (c) documentation of the agreed support plan and follow-up review dates. Through a structured consultation with patients and their family carers, the nurses will complete a mutually agreed personalised support plan., Discussion: This study will determine the feasibility for a full trial protocol to evaluate the implementation and outcomes of an (ACP) intervention in primary care to assist older adults aged 70 years of age or older and assessed as being at risk of functional decline. The study will be implemented in two jurisdictions on the island of Ireland which employ different health systems but which face similar health challenges. This study will allow us to examine important issues, such as the impact of two different healthcare systems on the health of older people and the influence of different legislative interpretations on undertaking cross jurisdictional research in Ireland., Protocol Version: Version 1, 17 September 2019., Trial Registration: Clinicaltrials.gov, ID: NCT03902743. Registered on 4 April 2019.

Introduction: "Frequent or High Utilizers" are significant stressors to Emergency Departments (EDs) and Inpatient Units across the United States (US). These patients incur higher healthcare costs with ED visits and inpatient admissions. Our aims were to determine whether implementation of individualized care plans (ICPs) could 1) reduce costs, 2) reduce inpatient length of stay (LOS), and 3) reduce ED encounters throughout a large healthcare system., Methods: 13 EDs were included including academic, community, Free-standing and pediatric EDs. Data was collected from January 1, 2014 through December 31, 2017. ICPs were created for high ED utilizers, as recommended by staff input through multidisciplinary care committees at each site. The ICP consisted of 1) specific symptom-related information with approaches in management, 2) recent assessment from specialists, 3) social work summary, and 4) psychiatry summary. A Best Practice Alert was placed in the electronic medical record that could be seen at all hospitals within the system. ICP's were updated annually., Results: 626 ICPs were written; 452 initial ICPs and 174 updates. The 452 ICP patients accounted for 23,705 encounters during the four-year period; on average, an ICP patient visited the ED 52 times (14.75 encounters/year). Overall indirect and direct costs decreased 42% over first 6 months, inpatient LOS improved from 1.9 to 0.97 days/month, and ED encounters decreased from 1.96 to 1.14. All cost and LOS data significantly improved at 24 months post-ICP inception., Conclusion: Implementation of individualized care plan can reduce cost, inpatient LOS, and ED encounters for high utilizers., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Concomitant with the increasing use of cancer care plans has been an increasing awareness of the potential for oncology care to result in long-term financial burdens and financial toxicity. Cancer survivors can benefit from information on support and resources to help them navigate the challenges after acute cancer treatment. While cancer survivorship plans could be a vehicle for patients to receive information on how to mitigate financial toxicity, cancer survivorship plans have typically not dealt with the financial impact of cancer treatment or follow-up care. Embedding information into cancer survivorship plans on how to reduce or avoid financial toxicity presents an opportunity to address a highly prevalent patient need. Patient-centered qualitative studies are needed to assess the type, format, and level of detail of the information provided.

Background: Periprosthetic fractures (PPF) present a common cause for revision surgery after arthroplasty. The choice of performing either an osteosynthesis or revision arthroplasty depends on the orthopedic implant anchored and loosening. Standard diagnostics include x-ray imaging. CT is usually performed to confirm implant loosening in case of ambiguous diagnosis on standard x-ray imaging. This study aimed to examine the role of CT as a diagnostic modality and its implications for treatment planning and outcome., Methods: Patients treated for PPF from January 2010 to February 2018 were included. X-ray and CT reports were analyzed to assess implant loosening. The planning for surgery and the final surgical treatment were evaluated. In addition, patient characteristics were analyzed and compared between patients with and without additional CT as a preoperative diagnostic procedure., Results: Seventy-five patients were eligible for the study. X-ray imaging was performed in 90.7% of cases. CT was performed in 60% of the cases as part of the preoperative diagnostic. A clear statement on implant stability or loosening could not be made in 69.1% after X-ray imaging and in 84.4% following CT imaging. Revision arthroplasty for loosened femoral prosthesis components was necessary in 40% of cases. No difference could be determined comparing patients with X-ray imaging to those with X-ray and additional CT. In both groups, operative treatment did not deviate from the preoperative planning., Discussion: In two thirds of the conventional radiographic findings, no reliable evaluation of implant loosening was possible in femoral PPFs. Intriguingly, additional CT did not improve the evaluation of implant loosening. Nonetheless, CT scans are often performed if loosening assessment is unclear on regular radiographs. This fact can explain the bias CT results in comparison to regular radiography. However, software-supported CT diagnosis could help to adequately answer the question of loosened implants in PPF in the near future. Since the diagnosis of fracture and their morphology assessment is currently adequately performed using X-rays, CT shall not be considered as the gold standard.

Background: Because of the complex nature of osteocutaneous free flap mandibular reconstruction, modern technologies such as virtual surgical planning have become popularized to refine the procedure. Compared with usual care, virtual surgical planning has been suggested to reduce operative time and improve accuracy of outcomes. The aim of this study was to examine the cost-effectiveness of virtual surgical planning versus usual care in mandibular reconstruction., Methods: A decision-analytic model was constructed to comparatively understand cost-effectiveness of virtual surgical planning and usual care treatments based on additional costs of virtual surgical planning, and costs attributed to probabilities of postoperative complications. Model structure was informed through qualitative clinical interviews from the University of North Carolina, and supported through University of North Carolina clinical data and literature. Costs and complication probabilities were estimated from the literature. Sensitivity analyses of all uncertain model parameters were performed, and distributional parameters were selected based on best practices., Results: Results of base-case analysis indicated that virtual surgical planning was more costly by a difference of $7099 per person and did not reduce the risk of complications or flap loss. Virtual surgical planning cases had an increased incidence of flap loss by 0.6 percent and an increased incidence of mandibular infection by 6.5 percent., Conclusions: Virtual surgical planning has upfront expenses that do not necessarily translate into downstream reduction in complications or improved outcomes. Clinical decision-makers would benefit from future research to identify thresholds whereby virtual surgical planning may result in more cost-savings for particular types of patients.

: media-1vid110.1542/5852348672001PEDS-VA_2017-3562 Video Abstract BACKGROUND AND OBJECTIVES: Multidisciplinary care teams may improve health and control total cost for children with medical complexity (CMC). We aim to quantify the time required to perform nonreimbursed care coordination activities by a multidisciplinary care coordination program for CMC and to estimate the direct salary costs of that time., Methods: From April 2013 to October 2015, program staff tracked time spent in practicably measured nonbilled care coordination efforts. Staff documented the discipline involved, the method used, and the target of the activity. Cost was estimated by multiplying the time spent by the typical salary of the type of personnel performing the activity., Results: Staff logged 53 148 unique nonbilled care coordination activities for 208 CMC. Dietitians accounted for 26% of total time, physicians and nurse practitioners 24%, registered nurses 29%, and social workers 21% (1.8, 2.3, 1.2, and 1.4 hours per CMC per month per full-time provider, respectively). Median time spent in nonreimbursed care coordination was 2.3 hours per child per month (interquartile range 0.8-6.8). Enrollees required substantially greater time in their first program month than thereafter (median 6.7 vs 2.1 hours per CMC per month). Based on 2015 national salary data, the adjusted median estimated cost of documented activities ranged from $145 to $210 per CMC per month., Conclusions: In this multidisciplinary model, care coordination for CMC required substantial staff time, even without accounting for all activities, particularly in the first month of program enrollment. Continued advocacy is warranted for the reimbursement of care coordination activities for CMC., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

Objective: Estimates of the extent of treatment need (defined by the presence of a diagnosis for which there is an effective treatment available) and treatment demand (defined as treatment seeking) are essential parts of effective treatment planning, service provision, and treatment funding. This article reviews the existing literature on approaches to estimating need and demand and the use of models to inform such estimation, and then considers the implications for health planners., Method: A thematic review of the literature was undertaken, with a focus on covering the key concepts and research methods that have been used to date., Results: Both need and demand are important estimates in planning for services but contain many difficulties in moving from the theory of measurement to the practicalities of establishing these figures. Furthermore, the simple quantum of need or demand is limited in its usefulness unless it is matched with consideration of different treatment types and their relative intensity, and/or explored as a function of geography and subpopulation. Modeling can assist with establishing more fine-tuned planning estimates, and is able to take into account both client severity and the various treatment types that might be available., Conclusions: Moving from relatively simplistic estimates of need and demand for treatment, this review has shown that although such estimation can inform national or subnational treatment planning, more sophisticated models are required for alcohol and other drug treatment planning. These can help health planners to determine the appropriate amount and mix of treatments for substance use disorders.

Background: Mandibular and maxillary reconstruction using fibula free transfer is common in many tertiary referral centres. Virtual surgical planning (VSP) is a relatively recent adjunct that allows surgeons to plan resection and reconstruction prior to theatre. This has been shown to reduce operative times and decrease surgeon stress intraoperatively. VSP requires technicians with the appropriate skill set and required materials, software and technology, which is accompanied by a cost that may be prohibitive. Usually, this is outsourced to an external company. We present a preliminary case series of VSP in maxillofacial reconstruction done using our own staff without external resources., Methods: Six patients underwent mandible (n = 5) or maxillary (n = 1) reconstruction with a fibula free flap using in-house VSP. The cases ranged from relatively simple to complex. We present our steps in the planning process and application of this technique., Results and Conclusion: In-house VSP is a feasible process with low cost and turnaround time, making surgery more efficient., (© 2018 Royal Australasian College of Surgeons.)

Background: Hospitals are under increasing pressure to manage costs across multiple episodes of care. Most studies of the financial impact of palliative care have focused on costs during a single hospitalization., Objective: To compare future acute health-care costs and utilization between patients who received inpatient palliative care consultation for goals of care (Palliative Care Service [PCS]) and a propensity-matched cohort of patients who did not receive palliative care consultation (non-PCS) in a single academic medical center., Methods: Data were extracted from the hospital's electronic records for admissions and discharges between July 2014 and October 2016. A stratified propensity score matching was used to account for nonrandom assignment and potential inherent differences between PCS and non-PCS groups using variables of theoretical interest: age, gender, race, diagnosis, risk of mortality, and prior acute care costs., Results: The analytical sample for this study included 41 363 patients (PCS = 1853; non-PCS = 39 510). Future acute care costs were significantly higher in the non-PCS group after propensity score matching (highest tier = US$15 654 vs US$8831; second highest tier = US$12 200 vs US$5496; P = .0001). The non-PCS group also had significantly higher future acute care utilization across all propensity tiers and outcomes including 30-day readmission ( P = .0001), number of future hospital days ( P = .0001), and number of future intensive care unit days ( P = .0001)., Conclusion: Palliative care consultations for goals of care may decrease future health-care utilization with cost savings that persist into future hospitalizations.

Children with medical complexity (CMC) have multiple chronic conditions and require an array of medical- and community-based providers. Dedicated care coordination is increasingly seen as key to addressing the fragmented care that CMC often encounter. Often conceptually misunderstood, care coordination is a team-driven activity that organizes and drives service integration. In this article, we examine models of care coordination and clarify related terms such as care integration and case management. The location of care coordination resources for CMC may range from direct practice provision to external organizations such as hospitals and accountable care organizations. We discuss the need for infrastructure building, design and implementation leadership, use of care coordination tools and training modules, and appropriate resource allocation under new payment models., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Importance: Cancer care is expensive. Cancer care provided by practice organizations varies in total spending incurred by patients and payers during treatment episodes and in quality of care, and this unnecessary variation contributes to the high cost., Objective: To use the variation in total spending and quality of care to assess oncology practice attributes distinguishing "high value" that may be tested and adopted by others to produce similar results., Design, Setting, and Participants: "Positive deviance" was used in this exploratory mixed-methods (quantitative and qualitative) analysis of interview results. To quantify value, oncology practices located near the US Pacific Northwest and Midwest with low mean insurer-allowed spending were identified. Among those, practices with high quality were selected. A team then conducted site visits to interview practice personnel from June 2, 2015, through October 3, 2015, and to probe for attributes of high-value care. A qualitative analysis of their interview results was performed, and a panel of experienced oncologists was convened to review attributes occurring uniquely or frequently in low-spending practices for their contribution to value improvement and ease of implementation. Four positive deviant (ie, low-spending) oncology practices and 3 oncology practices that ranked near the middle of the spending distribution were studied., Main Outcomes and Measures: Thematic saturation in a qualitative analysis of high-value care attributes., Results: From the 7 oncology practices studied, 13 attributes within the following 5 themes emerged: treatment planning and goal setting, services supporting the patient journey, technical support and physical layout, care team organization and function, and external context. Five attributes (ie, conservative use of imaging, early discussion of treatment limitations and consequences, single point of contact, maximal use of registered nurses for interventions, and a multicomponent health care system) most sharply distinguished the high-value practice sites. The expert oncologist panel judged 3 attributes (ie, early and normalized palliative care, ambulatory rapid response, and early discussion of treatment limitations and consequences) to carry the highest immediate potential for lowering spending without compromising the quality of care., Conclusions and Relevance: Oncology practice attributes warranting further testing were identified that may lower total spending for high-quality oncology care.

Background: Brief interventions (BIs) delivered in primary care have shown potential to increase physical activity levels and may be cost-effective, at least in the short-term, when compared with usual care. Nevertheless, there is limited evidence on their longer term costs and health benefits., Objectives: To estimate the cost-effectiveness of BIs to promote physical activity in primary care and to guide future research priorities using value of information analysis., Methods: A decision model was used to compare the cost-effectiveness of three classes of BIs that have been used, or could be used, to promote physical activity in primary care: 1) pedometer interventions, 2) advice/counseling on physical activity, and (3) action planning interventions. Published risk equations and data from the available literature or routine data sources were used to inform model parameters. Uncertainty was investigated with probabilistic sensitivity analysis, and value of information analysis was conducted to estimate the value of undertaking further research., Results: In the base-case, pedometer interventions yielded the highest expected net benefit at a willingness to pay of £20,000 per quality-adjusted life-year. There was, however, a great deal of decision uncertainty: the expected value of perfect information surrounding the decision problem for the National Health Service Health Check population was estimated at £1.85 billion., Conclusions: Our analysis suggests that the use of pedometer BIs is the most cost-effective strategy to promote physical activity in primary care, and that there is potential value in further research into the cost-effectiveness of brief (i.e., <30 minutes) and very brief (i.e., <5 minutes) pedometer interventions in this setting., (Copyright © 2018 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.)

Objectives: We evaluated a pilot quality improvement intervention implemented in an urban academic medical center emergency department (ED) to improve care coordination and reduce ED visits and hospitalizations among frequent ED users., Study Design: Randomized controlled trial., Methods: We identified the most frequent ED users in both the 30 days prior to the intervention and the 12 months prior to the intervention. We randomized the top 72 patients to receive either our pilot intervention or usual care. The intervention consisted of a community health worker who assisted patients with navigating care and identifying unmet social needs and an ED-based clinical team that developed interdisciplinary acute care plans for eligible patients. After 7 months, we analyzed ED visits, hospitalizations, and costs for the intervention and control groups., Results: We randomized 72 patients to the intervention (n = 36) and control (n = 36) groups. Patients randomized to the intervention group had 35% fewer ED visits (P = .10) and 31% fewer admissions from the ED (P = .20) compared with the control group. Average ED direct costs per patient were 15% lower and average inpatient direct costs per patient were 8% lower for intervention patients compared with control patients., Conclusions: ED-based care coordination is a promising approach to reduce ED use and hospitalizations among frequent ED users. Our program also demonstrated a decrease in costs per patient. Future efforts to promote population health and control costs may benefit from incorporating similar programs into acute care delivery systems.

Background: Treatment planning especially liver resection in cholangiocarcinoma (CCA) depends on the extension of tumor and lymph node metastasis which is included as a key criterion for operability. Magnetic resonance imaging (MRI) offers a rapid and powerful tool for the detection of lymph node metastasis (LNM) and in the current manuscript is assessed as a critical tool in the preoperative protocol for liver resection for treatment of CCA. However, the accuracy of MRI to detect LNM from CCA had yet to be comprehensively evaluated., Methods: The accuracy of MRI to detect LNM was assessed in a cohort of individuals with CCA from the Cholangiocarcinoma Screening and Care Program (CASCAP), a screening program designed to reduce CCA in Northeastern Thailand by community-based ultrasound (US) for CCA. CCA-positive individuals are referred to one of the nine tertiary centers in the study to undergo a preoperative protocol that included enhanced imaging by MRI. Additionally, these individuals also underwent lymph node biopsies for histological confirmation of LNM (the "gold standard") to determine the accuracy of the MRI results., Results: MRI accurately detected the presence or absence of LNM in only 29 out of the 51 CCA cases (56.9%, 95% CI 42.2-70.7), resulting in a sensitivity of 57.1% (95% CI 34.0-78.2) and specificity of 56.7% (95% CI 37.4-74.5), with positive and negative predictive values of 48.0% (95% CI 27.8-68.7) and 65.4% (95% CI 44.3-82.8), respectively. The positive likelihood ratio was 1.32 (95% CI 0.76-2.29), and the negative likelihood ratio was 0.76 (95% CI 0.42-1.36)., Conclusions: MRI showed limited sensitivity and a poor positive predictive value for the diagnosis of LNM for CCA, which is of particular concern in this resource-limited setting, where simpler detection methods could be utilized that are more cost-effective in this region of Thailand. Therefore, the inclusion of MRI, a costly imaging method, should be reconsidered as part of protocol for treatment planning of CCA, given the number of false positives, especially as it is critical in determining the operability for CCA subjects.

Purpose: The free osteomyocutaneous fibular flap has become one of the primary options for mandibular reconstruction, because of the later introduction and development of virtual surgical planning (VSP). However, VSP is associated with high additional pre-operative effort and costs. Therefore, the purpose of the study was to develop a new individual cost-effective pre-operative planning concept for free fibula mandible reconstruction and to compare it with VSP regarding clinical parameters and post-operative outcome., Materials and Methods: 31 patients undergoing mandibular reconstruction with a microvascular free fibular flap were divided into two groups and retrospectively reviewed. For the first group A (18 of 31 patients), an individual method with stererolithographic (STL) models, silicon templates and hand-made cutting guides was used (about 250 € planning costs/patient). For the second group B (13 of 31 patients), VSP including pre-fabricated cutting guides was used (about 2500 € planning costs/patient)., Results: We found no statistically significant differences with respect to intra-operative time of mandibular reconstruction, duration of hospitalisation or post-operative complications between the two groups (p ≥ 0.05)., Conclusion: The surgical outcomes and operative efficiency of this individual and cost-effective planning concept are comparable with the much more expensive complete VSP concept., (Copyright © 2017 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Introduction: High-need, high-cost (HNHC) patients can over-use acute care services, a pattern of behavior associated with many poor outcomes that disproportionately contributes to increased U.S. healthcare cost. Our objective was to reduce healthcare cost and improve outcomes by optimizing the system of care. We targeted HNHC patients and identified root causes of frequent healthcare utilization. We developed a cross-continuum intervention process and a succinct tool called a Complex Care Map (CCM)© that addresses fragmentation in the system and links providers to a comprehensive individualized analysis of the patient story and causes for frequent access to health services., Methods: Using a pre-/post-test design in which each subject served as his/her own historical control, this quality improvement project focused on determining if the interdisciplinary intervention called CCM© had an impact on healthcare utilization and costs for HNHC patients. We conducted the analysis between November 2012 and December 2015 at Mercy Health Saint Mary's, a Midwestern urban hospital with greater than 80,000 annual emergency department (ED) visits. All referred patients with three or more hospital visits (ED or inpatient [IP]) in the 12 months prior to initiation of a CCM© (n=339) were included in the study. Individualized CCMs© were created and made available in the electronic medical record (EMR) to all healthcare providers. We compared utilization, cost, social, and healthcare access variables from the EMR and cost-accounting system for 12 months before and after CCMs© implementation. We used both descriptive and limited inferential statistics., Results: ED mean visits decreased 43% (p<0.001), inpatient mean admissions decreased 44% (p<0.001), outpatient mean visits decreased 17% (p<0.001), computed tomography mean scans decreased 62% (p<0.001), and OBS/IP length of stay mean days decreased 41% (p<0.001). Gross charges decreased 45% (p<0.001), direct expenses decreased 47% (p<0.001), contribution margin improved by 11% (p=0.002), and operating margin improved by 73% (p<0.001). Patients with housing increased 14% (p<0.001), those with primary care increased 15% (p<0.001), and those with insurance increased 16% (p<0.001)., Conclusion: Individualized CCMs© for a select group of patients are associated with decreased healthcare system overutilization and cost of care., Competing Interests: Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. This work is supported by an internal Innovation Grant funded by Trinity Health. The funding organization had no role in the design and conduct of the QI analysis; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript. The authors have no financial stake in the sales or marketing of this tool. The copyright was assigned to prevent others from selling or marketing the tool. It was intended to be shared with appropriate permissions.

Background: To help the growing number of cancer survivors deal with the challenges of cancer survivorship, survivorship care plans (SCPs) were recommended by the Institute of Medicine (IOM) in 2006. The SCP is a formal document that contains both a tailored treatment summary and a follow-up care plan. Since the IOM recommendation 10 years ago, the implementation in daily clinical practice is minimal. Several studies have investigated the effects of SCPs on patient-reported outcomes and oncology and primary care providers (PCPs), but the quantity and quality of these studies are limited., Results: The first four randomized trials comparing SCP delivery with usual care failed to show a positive effect on satisfaction with information provision, satisfaction with care, distress or quality of life. SCPs did improve the amount of information provided and communication of PCPs with medical specialists and patients. A recent small trial that changed the focus from SCP as primarily an information delivery intervention to a behavioral intervention did observe positive effects on self-reported health, lower social role limitations and a trend towards greater self-efficacy. Gaps in knowledge about SCPs include uncertainty about content and length of the SCP; whether it should be delivered online or on paper; the timing and frequency of delivery; which health care provide should deliver SCP care. Finally, cost-effectiveness of SCP interventions has received limited attention., Conclusion: Currently, there is not enough evidence to warrant large-scale implementation of SCPs, or to abandon SCPs altogether. Emphasis on the SCP process and survivor engagement, supporting self-management may be an important way forward in SCP delivery. Whether this is beneficial and cost-effective on the long term and among different groups of cancer survivors needs further investigation.

Purpose: Because benign biopsies resulting from false-positive mammographic findings are a known harm of breast cancer screening, physicians and test manufacturers are searching for ways to reduce their frequency. The aim of this study was to estimate potential costs and consequences associated with using an adjunct diagnostic test for triaging women with suspicious mammographic findings before biopsy., Methods: A decision model was developed to compare the use of an adjunct test before biopsy to the current standard of care for suspicious mammographic findings. The decision analysis was performed from the perspective of a national health payer, with a 1-year time horizon among women representative of the US screening population aged 40 to 79 years. Three primary outcomes were assessed: (1) incremental costs, (2) number of benign biopsies avoided, and (3) number of missed opportunities for diagnosing cancer per million women screened. Input parameters were obtained from the medical literature and expert opinion. Sensitivity analyses were performed to evaluate the effects of uncertainty in parameter estimates., Results: The base-case analysis demonstrated that the use of an adjunct diagnostic test with 95% sensitivity, 75% specificity, and a cost of $1,000 would eliminate 8,127 unnecessary breast biopsies per million women screened. However, this would cost the US health care system an additional $6,462,977 and result in 255 missed opportunities for diagnosing cancer per million women screened., Conclusions: The addition of an adjunct test for triaging women for breast biopsy after abnormal findings on screening mammography would likely eliminate many unnecessary biopsies but also increase overall health care costs. This exploratory analysis highlights the fact that mammography remains a relatively inexpensive and effective breast cancer screening and diagnostic modality., (Copyright © 2013 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: Virtual surgical planning (VSP) and 3-dimensional printing of surgical splints are becoming the standard of care for orthognathic surgery, but costs have not been thoroughly evaluated. The purpose of this study was to compare the cost of VSP and 3-dimensional printing of splints ("VSP") versus that of 2-dimensional cephalometric evaluation, model surgery, and manual splint fabrication ("standard planning")., Materials and Methods: This is a retrospective cohort study including patients planned for bimaxillary surgery from January 2014 to January 2015 at Massachusetts General Hospital. Patients were divided into 3 groups by case type: symmetric, nonsegmental (group 1); asymmetric (group 2); and segmental (group 3). All cases underwent both VSP and standard planning with times for all activities recorded. The primary and secondary predictor variables were method of treatment planning and case type, respectively. Time-driven activity-based micro-costing analysis was used to quantify the differences in cost. Results were analyzed using a paired t test and analysis of variance., Results: The sample included 43 patients (19 in group 1, 17 in group 2, and 7 in group 3). The average times and costs were 194 ± 14.1 minutes and $2,765.94, respectively, for VSP and 540.9 ± 99.5 minutes and $3,519.18, respectively, for standard planning. For the symmetric, nonsegmental group, the average times and costs were 188 ± 17.8 minutes and $2,700.52, respectively, for VSP and 524.4 ± 86.1 minutes and $3,380.17, respectively, for standard planning. For the asymmetric group, the average times and costs were 187.4 ± 10.9 minutes and $2,713.69, respectively, for VSP and 556.1 ± 94.1 minutes and $3,640.00, respectively, for standard planning. For the segmental group, the average times and costs were 208.8 ± 13.5 minutes and $2,883.62, respectively, for VSP and 542.3 ± 118.4 minutes and $3,537.37, respectively, for standard planning. All time and cost differences were statistically significant (P < .001)., Conclusions: The results of this study indicate that VSP for bimaxillary orthognathic surgery takes significantly less time and is less expensive than standard planning for the 3 types of cases analyzed., (Copyright © 2016 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Modern total knee arthroplasty is effective at treating the pain and disability associated with osteoarthritis. The number of total knee replacements done in the USA continues to increase. Despite the great care taken during all of these procedures, some patients remain dissatisfied with their outcome. While this dissatisfaction is likely multifactorial, malalignment of the prosthetic components is a major cause of postoperative complications. A neutral mechanical axis plus or minus 3° is felt to have a positive impact on the survivorship of the prosthesis. Conventional instrumentation has been shown to have a significant number of total knee replacements that lie well outside a neutral coronal alignment. With that in mind, significant effort has been placed into the development of technology to improve the overall alignment of the prosthesis. In order to reduce the number of outliers, several companies have developed cost-effective systems to aid the surgeon in achieving a more predictably aligned prosthesis in all three planes. We will review the literature that is available regarding several of these tools to examine if navigation or custom guides improve outcomes in total knee arthroplasty. Our review supports that while both navigation and custom implants guides seem to be a cost effective way to achieve a predictable mechanical alignment of a total knee prosthesis therefore reducing the number of outliers, the cost may be increased operative times with no perceived difference in patient satisfaction with navigation custom guides.

Polypharmacy is an increasing problem in the care of multimorbide patients, and increases morbidity, mortality, hospitalization rates and costs. A promising intervention against polypharmacy is the systematic listing of all drugs taken by the patient with critical appraisal of indication, side effects, dosage and alternatives of every single drug. It is necessary to consider and to discuss priorities and preferences of patients in regard to treatment goals. A clear medication plan is needed after shared decision making with the patient. We present some helpful tools for this purpose. Further challenges besides an empathic communication with the patient are finding enough time in the clinical encounter, the integration of other health professionals and computer-assisted solutions in primary care practices and hospitals.

The Triple Aim has become the guiding light and benchmark by which healthcare organizations plan their future efforts. It has been adopted into healthcare policies with little regard for including the skill sets of compassion and emotional intelligence. The multiple increasing demands on providers of healthcare are unsustainable and will cripple the system, resulting in outcomes that are counter to the Triple Aim goals. Patient engagement with shared decision-making should become the primary focus of care delivery. New delivery models and care plans are unaffordable to far too many patients and payers, despite the efforts of futurists who seek to advance quality and lower costs. Clinical care delivery and patient engagement efforts must be drastically redirected to innovative and sustainable value-based delivery models that support the goals of the Triple Aim.

The relationship of care coordination activities and outcomes to resource utilization and personnel costs has been evaluated for a number of pediatric medical home practices. One of the first tools designed to evaluate the activities and outcomes for pediatric care coordination is the Care Coordination Measurement Tool (CCMT). It has become widely used as an instrument for health care providers in both primary and subspecialty care settings. This tool enables the user to stratify patients based on acuity and complexity while documenting the activities and outcomes of care coordination. We tested the feasibility of adapting the CCMT to a pediatric surgical population at Boston Children's Hospital. The tool was used to assess the preoperative care coordination activities. Care coordination activities were tracked during the interval from the date the patient was scheduled for a surgical or interventional procedure through the day of the procedure. A care coordination encounter was defined as any task, whether face to face or not, supporting the development or implementation of a plan of care. Data were collected to enable analysis of 5675 care coordination encounters supporting the care provided to 3406 individual surgical cases (patients). The outcomes of care coordination, as documented by the preoperative nursing staff, included the elaboration of the care plan through patient-focused communication among specialist, facilities, perioperative team, and primary care physicians in 80.5% of cases. The average time spent on care coordination activities increased incrementally by 30 minutes with each additional care coordination encounter for a surgical case. Surgical cases with 1 care coordination encounter took an average of 35.7 minutes of preoperative care coordination, whereas those with ≥4 care coordination encounters reported an average of 121.6 minutes. We successfully adapted and implemented the CCMT for a pediatric surgical population and measured nonface-to-face, nonbillable encounters performed by perioperative nursing staff. The care coordination activities integrated into the preoperative process include elaboration of care plans and identification and remediation of discrepancies. Capturing the activities and outcomes of care coordination for preoperative care provides a framework for quality improvement and enables documentation of the value of nonface-to-face perioperative nursing encounters that comprise care coordination.

Objective: The aim of this study was to assess the impact of a new workers' compensation medical assessment model on loss of earnings (LOE) benefits duration., Methods: A medical assessment model was introduced incorporating return to work planning and inclusion of the worker's treating physician. Impact of the program on LOE benefit duration was assessed using a quasi-experimental pre-post study design. Cox PH multivariable regression was adjusted for age, gender, injury severity, time to referral, and industry., Results: The study population comprised 3146 workers: 1794 assessed pre-intervention and 1574 assessed after introduction of the new model. There was a significant reduction in LOE benefit duration for workers assessed in the new model (hazard ratio 1.33, 95% confidence interval 1.23-1.43)., Conclusions: The probability of being off LOE benefits for workers assessed in the new program was 33% greater than for workers assessed in the prior program.

Background: The SwissDRG prospective payment system is known to inadequately account for nursing intensity due to the DRG group criteria insufficiently describing the variability of nursing intensity within individual diagnosis-related groups. In order to allow for appropriate reimbursement and resource allocation, nursing intensity must be able to be explicitly quantified and accounted for. The aim of this project was to develop a set of nursing-sensitive indicators intended to reduce the variation within individual diagnosis-related groups, supplementary to existing SwissDRG group criteria., Methods: The approach comprised a variety of methods. A systematic literature review, input from an advisory board and an expert panel, as well as three focus group interviews with nurses and nurse managers formed the basis for the synthesis of data and information gathered from these sources., Results: A set of 14 nursing-sensitive indicators was developed. The indicators are intended to improve the homogeneity of nursing intensity within SwissDRG diagnosis-related groups. Before these nursing indicators can be adopted as group criteria, they must be formulated to conform with SwissDRG and tested empirically., Conclusion: This set of indicators can be seen at as a first step towards nursing intensity being adequately represented in SwissDRG diagnosis-related groups. The next challenge to be met is operationalising the indicators in codable form.

Background: An essential element of mental health service scale up relates to an assessment of resource requirements and cost implications., Aims: To assess the expected resource needs of scaling up services in five districts in sub-Saharan Africa and south Asia., Method: The resource quantities associated with each site's specified care package were identified and subsequently costed, both at current and target levels of coverage., Results: The cost of the care package at target coverage ranged from US$0.21 to 0.56 per head of population in four of the districts (in the higher-income context of South Africa, it was US$1.86). In all districts, the additional amount needed each year to reach target coverage goals after 10 years was below $0.10 per head of population., Conclusions: Estimation of resource needs and costs for district-level mental health services provides relevant information concerning the financial feasibility of locally developed plans for successful scale up., (© The Royal College of Psychiatrists 2016.)

Background: older people often experience complex problems. Because of multiple problems, care for older people in general practice needs to shift from a 'problem-based, disease-oriented' care aiming at improvement of outcomes per disease to a 'goal-oriented care', aiming at improvement of functioning and personal quality of life, integrating all healthcare providers. Feasibility and cost-effectiveness of this proactive and integrated way of working are not yet established., Design: cluster randomised trial., Participants: all persons aged ≥75 in 59 general practices (30 intervention, 29 control), with a combination of problems, as identified with a structured postal questionnaire with 21 questions on four health domains., Intervention: for participants with problems on ≥3 domains, general practitioners (GPs) made an integrated care plan using a functional geriatric approach. Control practices: care as usual., Outcome Measures: (i) quality of life (QoL), (ii) activities of daily living, (iii) satisfaction with delivered health care and (iv) cost-effectiveness of the intervention at 1-year follow-up., Trial Registration: Netherlands trial register, NTR1946., Results: of the 11,476 registered eligible older persons, 7,285 (63%) participated in the screening. One thousand nine hundred and twenty-one (26%) had problems on ≥3 health domains. For 225 randomly chosen persons, a care plan was made. No beneficial effects were found on QoL, patients' functioning or healthcare use/costs. GPs experienced better overview of the care and stability, e.g. less unexpected demands, in the care., Conclusions: GPs prefer proactive integrated care. 'Horizontal' care using care plans for older people with complex problems can be a valuable tool in general practice. However, no direct beneficial effect was found for older persons., (© The Author 2016. Published by Oxford University Press on behalf of the British Geriatrics Society.)

Objective: With aging and obesity trends, the incidence and prevalence of osteoarthritis (OA) is expected to rise in Canada, increasing the demand for health resources. Resource planning to meet this increasing need requires estimates of the anticipated number of OA patients. Using administrative data from Alberta, we estimated OA incidence and prevalence rates and examined their sensitivity to alternative case definitions., Methods: We identified cases in a linked data set spanning 1993 to 2010 (population registry, Discharge Abstract Database, physician claims, Ambulatory Care Classification System, and prescription drug data) using diagnostic codes and drug identification numbers. In the base case, incident cases were captured for patients with an OA diagnostic code for at least 2 physician visits within 2 years or any hospital admission. Seven alternative case definitions were applied and compared., Results: Age- and sex-standardized incidence and prevalence rates were estimated to be 8.6 and 80.3 cases per 1,000 population, respectively, in the base case. Physician claims data alone captured 88% of OA cases. Prevalence rate estimates required 15 years of longitudinal data to plateau. Compared to the base case, estimates are sensitive to alternative case definitions., Conclusion: Administrative databases are a key source for estimating the burden and epidemiologic trends of chronic diseases such as OA in Canada. Despite their limitations, these data provide valuable information for estimating disease burden and planning health services. Estimates of OA are mostly defined through physician claims data and require a long period of longitudinal data., (© 2015, American College of Rheumatology.)

The year is quickly coming to an end and your schedule is wide open, plus the goals for practice productivity have not been achieved, which naturally means the collections are behind too. You know that all year long you have informed patients of the dentistry they need, the decay they have, the fractured teeth, the broken cusps, etc., and they still haven't gone forward with their care. You have asked the business team to call all of these patients and they say they have without much success.

Background: Involving service users in planning their care is at the centre of policy initiatives to improve mental health care quality in England. Whilst users value care planning and want to be more involved in their own care, there is substantial empirical evidence that the majority of users are not fully involved in the care planning process. Our aim is to evaluate the effectiveness and cost-effectiveness of training for mental health professionals in improving user involvement with the care planning processes., Methods/design: This is a cluster randomised controlled trial of community mental health teams in NHS Trusts in England allocated either to a training intervention to improve user and carer involvement in care planning or control (no training and care planning as usual). We will evaluate the effectiveness of the training intervention using a mixed design, including a 'cluster cohort' sample, a 'cluster cross-sectional' sample and process evaluation. Service users will be recruited from the caseloads of care co-ordinators. The primary outcome will be change in self-reported involvement in care planning as measured by the validated Health Care Climate Questionnaire. Secondary outcomes include involvement in care planning, satisfaction with services, medication side-effects, recovery and hope, mental health symptoms, alliance/engagement, well-being and quality of life. Cost- effectiveness will also be measured. A process evaluation informed by implementation theory will be undertaken to assess the extent to which the training was implemented and to gauge sustainability beyond the time-frame of the trial., Discussion: It is hoped that the trial will generate data to inform mental health care policy and practice on care planning., Trial Registration Number: ISRCTN16488358 (14 May 2014).

Background: Virtual surgical planning using three-dimensional (3D) printing technology has improved surgical efficiency and precision. A limitation to this technology is that production of 3D surgical models requires a third-party source, leading to increased costs (up to $4000) and prolonged assembly times (averaging 2-3 weeks). The purpose of this study is to evaluate the feasibility, cost, and production time of customized skull models created by an "in-office" 3D printer for craniofacial reconstruction., Methods: Two patients underwent craniofacial reconstruction with the assistance of "in-office" 3D printing technology. Three-dimensional skull models were created from a bioplastic filament with a 3D printer using computed tomography (CT) image data. The cost and production time for each model were measured., Results: For both patients, a customized 3D surgical model was used preoperatively to plan split calvarial bone grafting and intraoperatively to more efficiently and precisely perform the craniofacial reconstruction. The average cost for surgical model production with the "in-office" 3D printer was $25 (cost of bioplastic materials used to create surgical model) and the average production time was 14  hours., Conclusions: Virtual surgical planning using "in office" 3D printing is feasible and allows for a more cost-effective and less time consuming method for creating surgical models and guides. By bringing 3D printing to the office setting, we hope to improve intraoperative efficiency, surgical precision, and overall cost for various types of craniofacial and reconstructive surgery.

Background: Recently we developed and validated generic quality indicators that define 'appropriate antibiotic use' in hospitalized adults treated for a (suspected) bacterial infection. Previous studies have shown that with appropriate antibiotic use a reduction of 13% of length of hospital stay can be achieved. Our main objective in this project is to provide hospitals with an antibiotic checklist based on these quality indicators, and to evaluate the introduction of this checklist in terms of (cost-) effectiveness., Methods/design: The checklist applies to hospitalized adults with a suspected bacterial infection for whom antibiotic therapy is initiated, at first via the intravenous route. A stepped wedge study design will be used, comparing outcomes before and after introduction of the checklist in nine hospitals in the Netherlands. At least 810 patients will be included in both the control and the intervention group. The primary endpoint is length of hospital stay. Secondary endpoints are appropriate antibiotic use measured by the quality indicators, admission to and duration of intensive care unit stay, readmission within 30 days, mortality, total antibiotic use, and costs associated with implementation and hospital stay. Differences in numerical endpoints between the two periods will be evaluated with mixed linear models; for dichotomous outcomes generalized estimating equation models will be used. A process evaluation will be performed to evaluate the professionals' compliance with use of the checklist. The key question for the economic evaluation is whether the benefits of the checklist, which include reduced antibiotic use, reduced length of stay and associated costs, justify the costs associated with implementation activities as well as daily use of the checklist., Discussion: If (cost-) effective, the AB-checklist will provide physicians with a tool to support appropriate antibiotic use in adult hospitalized patients who start with intravenous antibiotics., Trial Registration: Dutch trial registry: NTR4872.