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2. Patient and Facility Variation in Costs of VA Heart Failure Patients.

Author

Yoon, Jean, Fonarow, Gregg C, Groeneveld, Peter W, Teerlink, John R, Whooley, Mary A, Sahay, Anju, and Heidenreich, Paul A

Subjects
Humans, Substance-Related Disorders, Ambulatory Care, Hospitalization, Mortality, Regression Analysis, Age Factors, Comorbidity, United States Department of Veterans Affairs, Databases, Factual, Aged, Aged, 80 and over, Middle Aged, Medically Uninsured, Health Facilities, Health Care Costs, Medicare, Insurance, Health, United States, Female, Male, Heart Failure, Hispanic or Latino, Black or African American, costs, heart failure, veterans, Cost Effectiveness Research, Clinical Research, Health Services, Heart Disease, Cardiovascular, Good Health and Well Being, Cardiorespiratory Medicine and Haematology
Abstract

ObjectivesThis study sought to determine the variation in annual health care costs among patients with heart failure in the Veterans Affairs (VA) system.BackgroundHeart failure is associated with considerable use of health care resources, but little is known about patterns in patient characteristics related to higher costs.MethodsWe obtained VA utilization and cost records for all patients with a diagnosis of heart failure in fiscal year 2010. We compared total VA costs by patient demographic factors, comorbid conditions, and facility where they were treated in bivariate analyses. We regressed total costs on patient factors alone, VA facility alone, and all factors combined to determine the relative contribution of patient factors and facility to explaining cost differences.ResultsThere were 117,870 patients with heart failure, and their mean annual VA costs were $30,719 (SD 49,180) with more than one-half of their costs from inpatient care. Patients at younger ages, of Hispanic or black race/ethnicity, diagnosed with comorbid drug use disorders, or who died during the year had the highest costs (all p < 0.01). There was variation in costs by facility as mean adjusted costs ranged from approximately $15,000 to $48,000. In adjusted analyses, patient factors alone explained more of the variation in health care costs (R(2) = 0.116) compared with the facility where the patient was treated (R(2) = 0.018).ConclusionsA large variation in costs of heart failure patients was observed across facilities, although this was explained largely by patient factors. Improving the efficiency of VA resource utilization may require increased scrutiny of high-cost patients to determine if adequate value is being delivered to those patients.

Published
2016

14. A critical synthesis of literature on the promoting action on research implementation in health services (PARIHS) framework

Author

Ritchie Mona, Sahay Anju, Daggett Ginger S, Hagedorn Hildi J, Damschroder Laura J, Helfrich Christian D, Damush Teresa, Guihan Marylou, Ullrich Philip M, and Stetler Cheryl B

Subjects
Medicine (General), R5-920
Abstract

Abstract Background The Promoting Action on Research Implementation in Health Services framework, or PARIHS, is a conceptual framework that posits key, interacting elements that influence successful implementation of evidence-based practices. It has been widely cited and used as the basis for empirical work; however, there has not yet been a literature review to examine how the framework has been used in implementation projects and research. The purpose of the present article was to critically review and synthesize the literature on PARIHS to understand how it has been used and operationalized, and to highlight its strengths and limitations. Methods We conducted a qualitative, critical synthesis of peer-reviewed PARIHS literature published through March 2009. We synthesized findings through a three-step process using semi-structured data abstraction tools and group consensus. Results Twenty-four articles met our inclusion criteria: six core concept articles from original PARIHS authors, and eighteen empirical articles ranging from case reports to quantitative studies. Empirical articles generally used PARIHS as an organizing framework for analyses. No studies used PARIHS prospectively to design implementation strategies, and there was generally a lack of detail about how variables were measured or mapped, or how conclusions were derived. Several studies used findings to comment on the framework in ways that could help refine or validate it. The primary issue identified with the framework was a need for greater conceptual clarity regarding the definition of sub-elements and the nature of dynamic relationships. Strengths identified included its flexibility, intuitive appeal, explicit acknowledgement of the outcome of 'successful implementation,' and a more expansive view of what can and should constitute 'evidence.' Conclusions While we found studies reporting empirical support for PARIHS, the single greatest need for this and other implementation models is rigorous, prospective use of the framework to guide implementation projects. There is also need to better explain derived findings and how interventions or measures are mapped to specific PARIHS elements; greater conceptual discrimination among sub-elements may be necessary first. In general, it may be time for the implementation science community to develop consensus guidelines for reporting the use and usefulness of theoretical frameworks within implementation studies.

Published
2010
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