The role of patient-reported outcomes in evaluating the quality of oncology care.
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The science of oncology care is rapidly developing, resulting in considerable variation in treatment patterns and disparity in the quality of care. Efforts are under way to evaluate and improve the quality of oncology care, because the goals of care have progressed beyond reducing morbidity and mortality to include maximizing functional and cognitive status, improving health-related quality of life, and preserving productivity. Traditional indicators of quality of care were based on survival outcomes or the processes of care. Although these remain important, they are inadequate for evaluating the multidimensional goals of care. Although not commonly included, patient-reported outcomes (PROs) would enhance the evaluation of the quality of care by including a patient perspective. A model for measuring quality of care that incorporates outcomes, structures, and processes of care as well as patient characteristics is proposed. Methodology including PROs that are valid, reliable, sensitive, and feasible, as well as rigorous risk adjustment methods, is critical to quality of care studies that appropriately inform decision makers. (+info)
Medicaid managed care payment methods and capitation rates in 2001.
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We present results from a survey of Medicaid managed care payment methods and rates in 2001 for AFDC/TANF and poverty-related Medicaid populations, updating a similar survey of 1998 rates. Rates were adjusted for differences in age-sex groupings, maternity payments, and service carve-outs. A twofold variation in Medicaid capitation rates remains, although there was a change in the composition of states at the top and bottom. The data also show that the growth in Medicaid capitation rates between 1998 and 2001 averaged 18 percent, considerably more than the increase in Medicare+Choice rates. (+info)
Healthcare use by veterans treated for diabetes mellitus in the Veterans Affairs medical care system.
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OBJECTIVES: To estimate the burden of comorbid conditions and to describe patterns of inpatient and outpatient service use by veterans with diabetes mellitus. STUDY DESIGN: Retrospective cohort study of 33,481 veterans conducted by means of secondary analysis of Department of Veterans Affairs (VA) healthcare utilization databases. PATIENTS AND METHODS: The cohort was constructed by enrolling all veterans treated in the VA medical care system who had their initial VA hospitalization for diabetes mellitus between 1992 and 1997. To estimate the typical annual pattern of service use for diabetes mellitus, 1997 utilization rates per person-year were analyzed based on cohort members surviving into 1997. Data on comorbid conditions were obtained from outpatient and inpatient contacts. RESULTS: The 3 most prevalent coexisting conditions were hypertension (73.4%), ischemic heart disease (35.2%), and alcohol or drug abuse disorders (29.5%). In 1997, the typical cohort member followed for 12 months had 6 primary care visits, 16 other visits for tests or consultations, and 1.3 unscheduled visits for emergency or urgent care and spent approximately 8 days in the hospital. One-year survival was 94.0%. CONCLUSIONS: In the VA medical care system, beneficiaries with diabetes mellitus have an extremely heavy burden of comorbidities, face a significant risk of dying in a given year (approximately 6% in this population), and are heavy users of hospital and outpatient services. (+info)
Risk-adjusted sequential probability ratio tests and longitudinal surveillance methods.
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Regardless of the exact method employed, the application of statistical process controL SPRTs, or related longitudinal analysis methods can significantly improve the ability to monitor clinical processes and outcomes. Incorporation and adaptation of risk-adjustment and rare events into these methods represent important contributions to their use in health care. Fostering greater and more widespread use of these methods, however, remains a significant challenge. Hopefully studies such as those by Spiegelhalter et al. will lead to more awareness of their value for contributing to a safer health care system. (+info)
Risk-adjusted sequential probability ratio tests: applications to Bristol, Shipman and adult cardiac surgery.
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OBJECTIVE: To investigate the use of the risk-adjusted sequential probability ratio test in monitoring the cumulative occurrence of adverse clinical outcomes. DESIGN: Retrospective analysis of three longitudinal datasets. SUBJECTS: Patients aged 65 years and over under the care of Harold Shipman between 1979 and 1997, patients under 1 year of age undergoing paediatric heart surgery in Bristol Royal Infirmary between 1984 and 1995, adult patients receiving cardiac surgery from a team of cardiac surgeons in London,UK. MAIN OUTCOME MEASURE: Annual and 30-day mortality rates. RESULTS: Using reasonable boundaries, the procedure could have indicated an 'alarm' in Bristol after publication of the 1991 Cardiac Surgical Register, and in 1985 or 1997 for Harold Shipman depending on the data source and the comparator. The cardiac surgeons showed no significant deviation from expected performance. CONCLUSIONS: The risk-adjusted sequential probability test is simple to implement, can be applied in a variety of contexts, and might have been useful to detect specific instances of past divergent performance. The use of this and related techniques deserves further attention in the context of prospectively monitoring adverse clinical outcomes. (+info)
How does the employer contribution for the federal employees health benefits program influence plan selection?
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Market reform of health insurance is proposed to increase coverage and reduce growth in spending by providing an incentive to choose low-cost plans. However, having a choice of plans could result in risk segmentation. Risk-adjusted payments have been proposed to address risk segmentation but are criticized as ineffective. An alternative to risk adjustment is to subsidize premiums, as in the Federal Employees Health Benefits Program (FEHBP). Subsidizing premiums may also increase total premium spending. We find that there is little risk segmentation in the FEHBP and that reducing the premium subsidy would lower government premium spending and slightly increase risk segmentation. (+info)
Validity of the risk adjustment approach to compare outcomes.
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This paper focuses on the issue of the extent to which the present mainstream risk adjustment (RA) methodology for measuring outcomes is a valid and useful tool for quality-improvement activities. The method's predictive and attributional validity are discussed, considering the confounding and effect modification produced by medical care over risk variables' effect. For this purpose, the sufficient-cause model and the counterfactual approach to effect and interaction are tentatively applied to the relationships between risk (prognostic) variables, medical technology, and quality of care. The main conclusions are that quality of care modifies the antagonistic interaction between medical technologies and risk variables, related to different types of responders, as well as the confounding of the effect of risk variables produced by related medical technologies. Thus, confounding of risk factors in the RA method, which limits the latter's predictive validity, is related to the efficacy and complexity of associated medical technologies and to the quality mix of services. Attributional validity depends on the validity of the probabilities estimated for each subgroup of risk (predictive validity) and the percentage of higher-risk patients at each service. (+info)
Reducing costs and improving outcomes of percutaneous coronary interventions.
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OBJECTIVE: To describe cost reduction and quality improvement efforts in our percutaneous coronary intervention (PCI) program and how risk adjustment was used to assess the effects of these changes. STUDY DESIGN: Single center registry analysis. PATIENTS AND METHODS: Data were collected on 2158 PCIs performed between July 1, 1994, and June 30, 1997. Of these, 1126 PCIs reflected care provided after implementation of competitive bidding for catheterization lab supplies, and efforts to reduce the use of postprocedure heparin and to implement early arterial sheaths removal (postbidding period). Hospital costs were estimated using a microcost accounting method. In-hospital mortality rates during the 2 time periods were compared using standardized mortality ratio estimated with a previously validated risk adjustment model for in-hospital mortality. RESULTS: Compared with the prebidding period, the postbidding period was characterized by a significantly higher utilization of new technology (coronary stents and atherectomy devices 46% vs 25%; abciximab 19.1% vs 3.7, P<.01), and an overall increase in case complexity. Despite these changes, the average and median postbidding cost per case was dollars 1223 and dollars 1444 lower, respectively, than in the prebidding period. After adjustment for comorbidities, procedure variables, complications, and length of hospital stay, multivariate regression modeling identified the postbidding period as an independent predictor of lower hospital costs (P<.001) with an estimated adjusted cost savings of dollars 460. These cost savings were associated with trends toward a lower observed mortality rate, a higher predicted mortality rate, and a significantly lower standardized mortality ratio (SMR .71; 95% CI 0.48-0.9; P<.05). CONCLUSION: Despite an increase in case complexity and utilization of new technology, cost reductions can be achieved through competitive bidding for supplies and modifications of periprocedure care. Risk adjustment appears to be a valid tool for assessing the effectiveness of these efforts independently from changes in case mix. (+info)