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Making Sense of Family Medicine Resident Wellness Curricula: A Delphi Study of Content Experts.

Katherine Buck, PhD - Thu, 07/04/2019 - 21:47
Related Articles

Making Sense of Family Medicine Resident Wellness Curricula: A Delphi Study of Content Experts.

Fam Med. 2019 Jul 02;:

Authors: Penwell-Waines L, Runyan C, Kolobova I, Grace A, Brennan J, Buck K, Ross V, Schneiderhan J

Abstract
BACKGROUND AND OBJECTIVES: The Association of Family Medicine Residency Directors (AFMRD) Physician Wellness Task Force released a comprehensive Well-Being Action Plan as a guide to help programs create a culture of wellness. The plan, however, does not offer a recommendation as to which elements may be most important, least resource intensive, or most feasible. This study sought to identify the most essential components of the AFMRD's Well-Being Action Plan, as rated by expert panelists using a modified Delphi technique.
METHODS: Sixty-eight selected experts were asked to participate; after three rounds of surveys, the final sample included 27 participants (7% residents, 38% MD faculty, 54% behavioral science faculty).
RESULTS: Fourteen elements were rated as essential by at least 80% of the participants. These components included interventions at both the system and individual level. Of those elements ranked in the top five by a majority of the panel, all but one do not mention specific curricular content, but rather discusses the nature of a wellness curriculum.
CONCLUSIONS: The expert consensus was that an essential curriculum should begin early, be longitudinal, identify a champion, and provide support for self-disclosure of struggles.

PMID: 31269221 [PubMed - as supplied by publisher]

Family Physician Burnout and Resilience: A Cross-Sectional Analysis.

Katherine Buck, PhD - Thu, 07/04/2019 - 21:47
Related Articles

Family Physician Burnout and Resilience: A Cross-Sectional Analysis.

Fam Med. 2019 Jul 02;:

Authors: Buck K, Williamson M, Ogbeide S, Norberg B

Abstract
BACKGROUND AND OBJECTIVES: Current physician burnout levels are at historically high levels, especially in family medicine, with many factors playing a role. The goal of this study was to understand demographic, psychological, environmental, behavioral, and workplace characteristics that impact physician wellness and burnout, focusing on family medicine physicians and residents.
METHODS: Survey respondents were 295 family medicine residents and faculty members across 11 residency programs within the Residency Research Network of Texas (RRNeT). Subjects completed multiple measures to assess resilience, burnout, psychological flexibility, and workplace stress. Respondents also reported personal wellness practices and demographic information. The primary outcome variables were burnout (depersonalization, emotional exhaustion, and personal achievement) and resilience.
RESULTS: The predictor variables contributed significant variance (depersonalization=27.1%, emotional exhaustion=39%, accomplishment=37.7%, resilience=37%) and resulted in large effect sizes (depersonalization f²=.371, emotional exhaustion f²=.639, accomplishment f²=.605, resilience f²=.587) among the three burnout models and the resilience model for the sample. Similar variance and effect sizes were present for independent resident and program faculty samples, with resilience being the only outcome variable with significant differences in variance between the samples.
CONCLUSIONS: This study demonstrates the roles of both individual and organization change needed to impact provider wellness, with special attention to resilience across faculty and residents. The results of this study may inform workplace policies (ie, organizational practice change) and wellness programming and curricula (ie, individual level) for family medicine residents and program faculty.

PMID: 31269220 [PubMed - as supplied by publisher]

Identifying diverse concepts of discharge failure patients at emergency department in the USA: a large-scale retrospective observational study.

Richard Robinson, MD - Thu, 07/04/2019 - 21:46
Related Articles

Identifying diverse concepts of discharge failure patients at emergency department in the USA: a large-scale retrospective observational study.

BMJ Open. 2019 Jun 27;9(6):e028051

Authors: Schrader CD, Robinson RD, Blair S, Shaikh S, d'Etienne JP, Kirby JJ, Cheeti R, Zenarosa NR, Wang H

Abstract
OBJECTIVES: Identifying patients who are at high risk for discharge failure allows for implementation of interventions to improve their care. However, discharge failure is currently defined in literature with great variability, making targeted interventions more difficult. We aim to derive a screening tool based on the existing diverse discharge failure models.
DESIGN, SETTING AND PARTICIPANTS: This is a single-centre retrospective cohort study in the USA. Data from all patients discharged from the emergency department were collected from 1 January 2015 through 31 December 2017 and followed up within 30 days.
METHODS: Scoring systems were derived using modified Framingham methods. Sensitivity, specificity and area under the receiver operational characteristic (AUC) were calculated and compared using both the broad and restricted discharge failure models.
RESULTS: A total of 227 627 patients were included. The Screening for Healthcare fOllow-Up Tool (SHOUT) scoring system was derived based on the broad and restricted discharge failure models and applied back to the entire study cohort. A sensitivity of 80% and a specificity of 71% were found in SHOUT scores to identify patients with broad discharge failure with AUC of 0.83 (95% CI 0.83 to 0.84). When applied to a 3-day restricted discharge failure model, a sensitivity of 86% and a specificity of 60% were found to identify patients with AUC of 0.79 (95% CI 0.78 to 0.80).
CONCLUSION: The SHOUT scoring system was derived and used to screen and identify patients that would ultimately become discharge failures, especially when using broad definitions of discharge failure. The SHOUT tool was internally validated and can be used to identify patients across a wide spectrum of discharge failure definitions.

PMID: 31248927 [PubMed - in process]

Identifying diverse concepts of discharge failure patients at emergency department in the USA: a large-scale retrospective observational study.

James d'Etienne, MD - Thu, 07/04/2019 - 21:46
Related Articles

Identifying diverse concepts of discharge failure patients at emergency department in the USA: a large-scale retrospective observational study.

BMJ Open. 2019 Jun 27;9(6):e028051

Authors: Schrader CD, Robinson RD, Blair S, Shaikh S, d'Etienne JP, Kirby JJ, Cheeti R, Zenarosa NR, Wang H

Abstract
OBJECTIVES: Identifying patients who are at high risk for discharge failure allows for implementation of interventions to improve their care. However, discharge failure is currently defined in literature with great variability, making targeted interventions more difficult. We aim to derive a screening tool based on the existing diverse discharge failure models.
DESIGN, SETTING AND PARTICIPANTS: This is a single-centre retrospective cohort study in the USA. Data from all patients discharged from the emergency department were collected from 1 January 2015 through 31 December 2017 and followed up within 30 days.
METHODS: Scoring systems were derived using modified Framingham methods. Sensitivity, specificity and area under the receiver operational characteristic (AUC) were calculated and compared using both the broad and restricted discharge failure models.
RESULTS: A total of 227 627 patients were included. The Screening for Healthcare fOllow-Up Tool (SHOUT) scoring system was derived based on the broad and restricted discharge failure models and applied back to the entire study cohort. A sensitivity of 80% and a specificity of 71% were found in SHOUT scores to identify patients with broad discharge failure with AUC of 0.83 (95% CI 0.83 to 0.84). When applied to a 3-day restricted discharge failure model, a sensitivity of 86% and a specificity of 60% were found to identify patients with AUC of 0.79 (95% CI 0.78 to 0.80).
CONCLUSION: The SHOUT scoring system was derived and used to screen and identify patients that would ultimately become discharge failures, especially when using broad definitions of discharge failure. The SHOUT tool was internally validated and can be used to identify patients across a wide spectrum of discharge failure definitions.

PMID: 31248927 [PubMed - in process]

Identifying diverse concepts of discharge failure patients at emergency department in the USA: a large-scale retrospective observational study.

Hao Wang, MD - Thu, 07/04/2019 - 21:46
Related Articles

Identifying diverse concepts of discharge failure patients at emergency department in the USA: a large-scale retrospective observational study.

BMJ Open. 2019 Jun 27;9(6):e028051

Authors: Schrader CD, Robinson RD, Blair S, Shaikh S, d'Etienne JP, Kirby JJ, Cheeti R, Zenarosa NR, Wang H

Abstract
OBJECTIVES: Identifying patients who are at high risk for discharge failure allows for implementation of interventions to improve their care. However, discharge failure is currently defined in literature with great variability, making targeted interventions more difficult. We aim to derive a screening tool based on the existing diverse discharge failure models.
DESIGN, SETTING AND PARTICIPANTS: This is a single-centre retrospective cohort study in the USA. Data from all patients discharged from the emergency department were collected from 1 January 2015 through 31 December 2017 and followed up within 30 days.
METHODS: Scoring systems were derived using modified Framingham methods. Sensitivity, specificity and area under the receiver operational characteristic (AUC) were calculated and compared using both the broad and restricted discharge failure models.
RESULTS: A total of 227 627 patients were included. The Screening for Healthcare fOllow-Up Tool (SHOUT) scoring system was derived based on the broad and restricted discharge failure models and applied back to the entire study cohort. A sensitivity of 80% and a specificity of 71% were found in SHOUT scores to identify patients with broad discharge failure with AUC of 0.83 (95% CI 0.83 to 0.84). When applied to a 3-day restricted discharge failure model, a sensitivity of 86% and a specificity of 60% were found to identify patients with AUC of 0.79 (95% CI 0.78 to 0.80).
CONCLUSION: The SHOUT scoring system was derived and used to screen and identify patients that would ultimately become discharge failures, especially when using broad definitions of discharge failure. The SHOUT tool was internally validated and can be used to identify patients across a wide spectrum of discharge failure definitions.

PMID: 31248927 [PubMed - in process]

Identifying diverse concepts of discharge failure patients at emergency department in the USA: a large-scale retrospective observational study.

Chet Schrader, MD - Thu, 07/04/2019 - 21:46
Related Articles

Identifying diverse concepts of discharge failure patients at emergency department in the USA: a large-scale retrospective observational study.

BMJ Open. 2019 Jun 27;9(6):e028051

Authors: Schrader CD, Robinson RD, Blair S, Shaikh S, d'Etienne JP, Kirby JJ, Cheeti R, Zenarosa NR, Wang H

Abstract
OBJECTIVES: Identifying patients who are at high risk for discharge failure allows for implementation of interventions to improve their care. However, discharge failure is currently defined in literature with great variability, making targeted interventions more difficult. We aim to derive a screening tool based on the existing diverse discharge failure models.
DESIGN, SETTING AND PARTICIPANTS: This is a single-centre retrospective cohort study in the USA. Data from all patients discharged from the emergency department were collected from 1 January 2015 through 31 December 2017 and followed up within 30 days.
METHODS: Scoring systems were derived using modified Framingham methods. Sensitivity, specificity and area under the receiver operational characteristic (AUC) were calculated and compared using both the broad and restricted discharge failure models.
RESULTS: A total of 227 627 patients were included. The Screening for Healthcare fOllow-Up Tool (SHOUT) scoring system was derived based on the broad and restricted discharge failure models and applied back to the entire study cohort. A sensitivity of 80% and a specificity of 71% were found in SHOUT scores to identify patients with broad discharge failure with AUC of 0.83 (95% CI 0.83 to 0.84). When applied to a 3-day restricted discharge failure model, a sensitivity of 86% and a specificity of 60% were found to identify patients with AUC of 0.79 (95% CI 0.78 to 0.80).
CONCLUSION: The SHOUT scoring system was derived and used to screen and identify patients that would ultimately become discharge failures, especially when using broad definitions of discharge failure. The SHOUT tool was internally validated and can be used to identify patients across a wide spectrum of discharge failure definitions.

PMID: 31248927 [PubMed - in process]

Making Sense of Family Medicine Resident Wellness Curricula: A Delphi Study of Content Experts.

Making Sense of Family Medicine Resident Wellness Curricula: A Delphi Study of Content Experts.

Fam Med. 2019 Jul 02;:

Authors: Penwell-Waines L, Runyan C, Kolobova I, Grace A, Brennan J, Buck K, Ross V, Schneiderhan J

Abstract
BACKGROUND AND OBJECTIVES: The Association of Family Medicine Residency Directors (AFMRD) Physician Wellness Task Force released a comprehensive Well-Being Action Plan as a guide to help programs create a culture of wellness. The plan, however, does not offer a recommendation as to which elements may be most important, least resource intensive, or most feasible. This study sought to identify the most essential components of the AFMRD's Well-Being Action Plan, as rated by expert panelists using a modified Delphi technique.
METHODS: Sixty-eight selected experts were asked to participate; after three rounds of surveys, the final sample included 27 participants (7% residents, 38% MD faculty, 54% behavioral science faculty).
RESULTS: Fourteen elements were rated as essential by at least 80% of the participants. These components included interventions at both the system and individual level. Of those elements ranked in the top five by a majority of the panel, all but one do not mention specific curricular content, but rather discusses the nature of a wellness curriculum.
CONCLUSIONS: The expert consensus was that an essential curriculum should begin early, be longitudinal, identify a champion, and provide support for self-disclosure of struggles.

PMID: 31269221 [PubMed - as supplied by publisher]

Family Physician Burnout and Resilience: A Cross-Sectional Analysis.

Family Physician Burnout and Resilience: A Cross-Sectional Analysis.

Fam Med. 2019 Jul 02;:

Authors: Buck K, Williamson M, Ogbeide S, Norberg B

Abstract
BACKGROUND AND OBJECTIVES: Current physician burnout levels are at historically high levels, especially in family medicine, with many factors playing a role. The goal of this study was to understand demographic, psychological, environmental, behavioral, and workplace characteristics that impact physician wellness and burnout, focusing on family medicine physicians and residents.
METHODS: Survey respondents were 295 family medicine residents and faculty members across 11 residency programs within the Residency Research Network of Texas (RRNeT). Subjects completed multiple measures to assess resilience, burnout, psychological flexibility, and workplace stress. Respondents also reported personal wellness practices and demographic information. The primary outcome variables were burnout (depersonalization, emotional exhaustion, and personal achievement) and resilience.
RESULTS: The predictor variables contributed significant variance (depersonalization=27.1%, emotional exhaustion=39%, accomplishment=37.7%, resilience=37%) and resulted in large effect sizes (depersonalization f²=.371, emotional exhaustion f²=.639, accomplishment f²=.605, resilience f²=.587) among the three burnout models and the resilience model for the sample. Similar variance and effect sizes were present for independent resident and program faculty samples, with resilience being the only outcome variable with significant differences in variance between the samples.
CONCLUSIONS: This study demonstrates the roles of both individual and organization change needed to impact provider wellness, with special attention to resilience across faculty and residents. The results of this study may inform workplace policies (ie, organizational practice change) and wellness programming and curricula (ie, individual level) for family medicine residents and program faculty.

PMID: 31269220 [PubMed - as supplied by publisher]

Identifying diverse concepts of discharge failure patients at emergency department in the USA: a large-scale retrospective observational study.

Related Articles

Identifying diverse concepts of discharge failure patients at emergency department in the USA: a large-scale retrospective observational study.

BMJ Open. 2019 Jun 27;9(6):e028051

Authors: Schrader CD, Robinson RD, Blair S, Shaikh S, d'Etienne JP, Kirby JJ, Cheeti R, Zenarosa NR, Wang H

Abstract
OBJECTIVES: Identifying patients who are at high risk for discharge failure allows for implementation of interventions to improve their care. However, discharge failure is currently defined in literature with great variability, making targeted interventions more difficult. We aim to derive a screening tool based on the existing diverse discharge failure models.
DESIGN, SETTING AND PARTICIPANTS: This is a single-centre retrospective cohort study in the USA. Data from all patients discharged from the emergency department were collected from 1 January 2015 through 31 December 2017 and followed up within 30 days.
METHODS: Scoring systems were derived using modified Framingham methods. Sensitivity, specificity and area under the receiver operational characteristic (AUC) were calculated and compared using both the broad and restricted discharge failure models.
RESULTS: A total of 227 627 patients were included. The Screening for Healthcare fOllow-Up Tool (SHOUT) scoring system was derived based on the broad and restricted discharge failure models and applied back to the entire study cohort. A sensitivity of 80% and a specificity of 71% were found in SHOUT scores to identify patients with broad discharge failure with AUC of 0.83 (95% CI 0.83 to 0.84). When applied to a 3-day restricted discharge failure model, a sensitivity of 86% and a specificity of 60% were found to identify patients with AUC of 0.79 (95% CI 0.78 to 0.80).
CONCLUSION: The SHOUT scoring system was derived and used to screen and identify patients that would ultimately become discharge failures, especially when using broad definitions of discharge failure. The SHOUT tool was internally validated and can be used to identify patients across a wide spectrum of discharge failure definitions.

PMID: 31248927 [PubMed - in process]

Association Between Empathy and Burnout Among Emergency Medicine Physicians.

Hao Wang, MD - Thu, 06/27/2019 - 19:58
Related Articles

Association Between Empathy and Burnout Among Emergency Medicine Physicians.

J Clin Med Res. 2019 Jul;11(7):532-538

Authors: Wolfshohl JA, Bradley K, Bell C, Bell S, Hodges C, Knowles H, Chaudhari BR, Kirby R, Kline JA, Wang H

Abstract
Background: The association between physician self-reported empathy and burnout has been studied in the past with diverse findings. We aimed to determine the association between empathy and burnout among United States emergency medicine (EM) physicians using a novel combination of tools for validation.
Methods: This was a prospective single-center observational study. Data were collected from EM physicians. From December 1, 2018 to January 31, 2019, we used the Jefferson scale of empathy (JSE) to assess physician empathy and the Copenhagen burnout inventory (CBI) to assess burnout. We divided EM physicians into different groups (residents in each year of training, junior/senior attendings). Empathy, burnout scores and their association were analyzed and compared among these groups.
Results: A total of 33 attending physicians and 35 EM residents participated in this study. Median self-reported empathy scores were 113 (interquartile range (IQR): 105 - 117) in post-graduate year (PGY)-1, 112 (90 - 115) in PGY-2, 106 (93 - 118) in PGY-3 EM residents, 112 (105 - 116) in junior and 114 (101 - 125) in senior attending physicians. Overall burnout scores were 43 (33 - 50) in PGY-1, 51 (29 - 56) in PGY-2, 43 (42 - 53) in PGY-3 EM residents, 33 (24 - 47) in junior attending and 25 (22 - 53) in senior attending physicians separately. The Spearman correlation (ρ) was -0.11 and β-weight was -0.23 between empathy and patient-related burnout scores.
Conclusion: Self-reported empathy declines over the course of EM residency training and improves after graduation. Overall high burnout occurs among EM residents and improves after graduation. Our analysis showed a weak negative correlation between self-reported empathy and patient-related burnout among EM physicians.

PMID: 31236173 [PubMed]

Initiation of the ABCD3-I algorithm for expediated evaluation of transient ischemic attack patients in an emergency department.

Hao Wang, MD - Thu, 06/27/2019 - 19:58
Related Articles

Initiation of the ABCD3-I algorithm for expediated evaluation of transient ischemic attack patients in an emergency department.

Am J Emerg Med. 2019 Jun 10;:

Authors: Dahlquist RT, Young JM, Reyner K, Farzad A, Moleno RB, Gandham G, Ho AF, Wang H

Abstract
BACKGROUND: The use of ABCD3-I score for Transient ischemic attack (TIA) evaluation has not been widely investigated in the ED. We aim to determine the performance and cost-effectiveness of an ABCD3-I based pathway for expedited evaluation of TIA patients in the ED.
METHODS: We conducted a single-center, pre- and post-intervention study among ED patients with possible TIA. Accrual occurred for seven months before (Oct. 2016-April 2017) and after (Oct. 2017-April 2018) implementing the ABCD3-I algorithm with a five-month wash-in period (May-Sept. 2017). Total ED length of stay (LOS), admissions to the hospital, healthcare cost, and 90-day ED returns with subsequent stroke were analyzed and compared.
RESULTS: Pre-implementation and post-implementation cohorts included 143 and 118 patients respectively. A total of 132 (92%) patients were admitted to the hospital in the pre-implementation cohort in comparison to 28 (24%) patients admitted in the post-implementation cohort (p < 0.001) with similar 90-day post-discharge stroke occurrence (2 in pre-implementation versus 1 in post-implementation groups, p > 0.05). The mean ABCD2 scores were 4.5 (1.4) in pre- and 4.1 (1.3) in post-implementation cohorts (p = 0.01). The mean ABCD3-I scores were 4.5 (1.8) in post-implementation cohorts. Total ED LOS was 310 min (201, 420) in pre- and 275 min (222, 342) in post-implementation cohorts (p > 0.05). Utilization of the ABCD3-I algorithm saved an average of over 40% of total healthcare cost per patient in the post-implementation cohort.
CONCLUSIONS: The initiation of an ABCD3-I based pathway for TIA evaluation in the ED significantly decreased hospital admissions and cost with similar 90-day neurological outcomes.

PMID: 31230922 [PubMed - as supplied by publisher]

Association Between Empathy and Burnout Among Emergency Medicine Physicians.

Related Articles

Association Between Empathy and Burnout Among Emergency Medicine Physicians.

J Clin Med Res. 2019 Jul;11(7):532-538

Authors: Wolfshohl JA, Bradley K, Bell C, Bell S, Hodges C, Knowles H, Chaudhari BR, Kirby R, Kline JA, Wang H

Abstract
Background: The association between physician self-reported empathy and burnout has been studied in the past with diverse findings. We aimed to determine the association between empathy and burnout among United States emergency medicine (EM) physicians using a novel combination of tools for validation.
Methods: This was a prospective single-center observational study. Data were collected from EM physicians. From December 1, 2018 to January 31, 2019, we used the Jefferson scale of empathy (JSE) to assess physician empathy and the Copenhagen burnout inventory (CBI) to assess burnout. We divided EM physicians into different groups (residents in each year of training, junior/senior attendings). Empathy, burnout scores and their association were analyzed and compared among these groups.
Results: A total of 33 attending physicians and 35 EM residents participated in this study. Median self-reported empathy scores were 113 (interquartile range (IQR): 105 - 117) in post-graduate year (PGY)-1, 112 (90 - 115) in PGY-2, 106 (93 - 118) in PGY-3 EM residents, 112 (105 - 116) in junior and 114 (101 - 125) in senior attending physicians. Overall burnout scores were 43 (33 - 50) in PGY-1, 51 (29 - 56) in PGY-2, 43 (42 - 53) in PGY-3 EM residents, 33 (24 - 47) in junior attending and 25 (22 - 53) in senior attending physicians separately. The Spearman correlation (ρ) was -0.11 and β-weight was -0.23 between empathy and patient-related burnout scores.
Conclusion: Self-reported empathy declines over the course of EM residency training and improves after graduation. Overall high burnout occurs among EM residents and improves after graduation. Our analysis showed a weak negative correlation between self-reported empathy and patient-related burnout among EM physicians.

PMID: 31236173 [PubMed]

Initiation of the ABCD3-I algorithm for expediated evaluation of transient ischemic attack patients in an emergency department.

Related Articles

Initiation of the ABCD3-I algorithm for expediated evaluation of transient ischemic attack patients in an emergency department.

Am J Emerg Med. 2019 Jun 10;:

Authors: Dahlquist RT, Young JM, Reyner K, Farzad A, Moleno RB, Gandham G, Ho AF, Wang H

Abstract
BACKGROUND: The use of ABCD3-I score for Transient ischemic attack (TIA) evaluation has not been widely investigated in the ED. We aim to determine the performance and cost-effectiveness of an ABCD3-I based pathway for expedited evaluation of TIA patients in the ED.
METHODS: We conducted a single-center, pre- and post-intervention study among ED patients with possible TIA. Accrual occurred for seven months before (Oct. 2016-April 2017) and after (Oct. 2017-April 2018) implementing the ABCD3-I algorithm with a five-month wash-in period (May-Sept. 2017). Total ED length of stay (LOS), admissions to the hospital, healthcare cost, and 90-day ED returns with subsequent stroke were analyzed and compared.
RESULTS: Pre-implementation and post-implementation cohorts included 143 and 118 patients respectively. A total of 132 (92%) patients were admitted to the hospital in the pre-implementation cohort in comparison to 28 (24%) patients admitted in the post-implementation cohort (p < 0.001) with similar 90-day post-discharge stroke occurrence (2 in pre-implementation versus 1 in post-implementation groups, p > 0.05). The mean ABCD2 scores were 4.5 (1.4) in pre- and 4.1 (1.3) in post-implementation cohorts (p = 0.01). The mean ABCD3-I scores were 4.5 (1.8) in post-implementation cohorts. Total ED LOS was 310 min (201, 420) in pre- and 275 min (222, 342) in post-implementation cohorts (p > 0.05). Utilization of the ABCD3-I algorithm saved an average of over 40% of total healthcare cost per patient in the post-implementation cohort.
CONCLUSIONS: The initiation of an ABCD3-I based pathway for TIA evaluation in the ED significantly decreased hospital admissions and cost with similar 90-day neurological outcomes.

PMID: 31230922 [PubMed - as supplied by publisher]

Where Are the Opportunities for Reducing Health Care Spending Within Alternative Payment Models?

Related Articles

Where Are the Opportunities for Reducing Health Care Spending Within Alternative Payment Models?

J Oncol Pract. 2018 06;14(6):e375-e383

Authors: Rocque GB, Williams CP, Kenzik KM, Jackson BE, Halilova KI, Sullivan MM, Rocconi RP, Azuero A, Kvale EA, Huh WK, Partridge EE, Pisu M

Abstract
PURPOSE: The Oncology Care Model (OCM) is a highly controversial specialty care model developed by the Centers for Medicare & Medicaid aimed to provide higher-quality care at lower cost. Because oncologists will be increasingly held accountable for spending as well as quality within new value-based health care models like the OCM, they need to understand the drivers of total spending for their patients.
METHODS: This retrospective cohort study included patients ≥ 65 years of age with primary fee-for-service Medicare insurance who received antineoplastic therapy at 12 cancer centers in the Southeast from 2012 to 2014. Medicare administrative claims data were used to identify health care spending during the prechemotherapy period (from cancer diagnosis to antineoplastic therapy initiation) and during the OCM episodes of care triggered by antineoplastic treatment. Total health care spending per episode includes all types of services received by a patient, including nononcology services. Spending was further characterized by type of service.
RESULTS: Average total health care spending in the three OCM episodes of care was $33,838 (n = 3,427), $23,811 (n = 1,207), and $19,241 (n = 678). Antineoplastic drugs accounted for 27%, 32%, and 36% of total health care spending in the first, second, and third episodes. Ten drugs, used by 31% of patients, contributed 61% to drug spending ($18.8 million) in the first episode. Inpatient spending also substantially contributed to total costs, representing 17% to 20% ($30.5 million) of total health care spending.
CONCLUSION: Health care spending was heavily driven by both antineoplastic drugs and hospital use. Oncologists' ability to affect these types of spending will determine their success under alternative payment models.

PMID: 28981388 [PubMed - indexed for MEDLINE]

Affordable Care Act and cancer stage at diagnosis in an underserved population.

Bassam Ghabach, MD - Thu, 06/20/2019 - 18:53
Related Articles

Affordable Care Act and cancer stage at diagnosis in an underserved population.

Prev Med. 2019 Jun 10;:

Authors: Lu Y, Jackson BE, Gehr AW, Cross D, Neerukonda L, Tanna B, Ghabach B, Ojha RP

Abstract
The Patient Protection and Affordable Care Act (ACA) has increased insurance coverage among underserved individuals, but the effect of ACA on cancer diagnosis is currently debated, particularly in Medicaid non-expansion states. Therefore, we aimed to assess the effect of ACA implementation on stage at diagnosis among underserved cancer patients in Texas, a Medicaid non-expansion state. We used data from the institutional registry of the JPS Center for Cancer Care, which serves an urban population of underserved cancer patients. Eligible individuals were aged 18 to 64 years and diagnosed with a first primary invasive solid tumor between 2008 and 2015. We used a natural experiment framework and interrupted time-series analysis to assess level (i.e. immediate) and slope (over time) changes in insurance coverage and cancer stage at diagnosis between pre- and post-ACA periods. Our study population comprised 4808 underserved cancer patients, of whom 51% were racial/ethnic minorities. The prevalence of uninsured cancer patients did not immediately change after ACA implementation but modestly decreased over time (PR = 0.94; 95% CL: 0.90, 0.98). The prevalence of early- and advanced-stage diagnosis did not appreciably change overall or when stratified by screen-detectable cancers. Our results suggest that ACA implementation decreased the prevalence of uninsured cancer patients but had little effect on cancer stage at diagnosis in an underserved population. Given that Texas is a Medicaid non-expansion state, Medicaid expansion and alternative approaches may need to be further explored to improve earlier cancer diagnosis among underserved individuals.

PMID: 31195020 [PubMed - as supplied by publisher]

Rethinking the definition of major trauma: The Need For Trauma Intervention outperforms Injury Severity Score and Revised Trauma Score in 38 adult and pediatric trauma centers.

Related Articles

Rethinking the definition of major trauma: The Need For Trauma Intervention outperforms Injury Severity Score and Revised Trauma Score in 38 adult and pediatric trauma centers.

J Trauma Acute Care Surg. 2019 Jun 13;:

Authors: Roden-Foreman JW, Rapier NR, Foreman ML, Zagel AL, Sexton KW, Beck WC, McGraw C, Coniglio RA, Blackmore AR, Holzmacher J, Sarani B, Hess JC, Greenwell C, Adams CA, Lueckel SN, Weaver M, Agrawal V, Amos JD, Workman CF, Milia DJ, Bertelson A, Dorlac W, Warne MJ, Cull J, Lyell CA, Regner JL, McGonigal MD, Flohr SD, Steen S, Nance ML, Campbell M, Putty B, Sherar D, Schroeppel TJ

Abstract
BACKGROUND: Patients' trauma burdens are a combination of anatomic damage, physiologic derangement, and the resultant depletion of reserve. Typically, Injury Severity Score (ISS) >15 defines major anatomic injury and Revised Trauma Score (RTS) <7.84 defines major physiologic derangement, but there is no standard definition for reserve. The Need For Trauma Intervention (NFTI) identifies severely depleted reserves (NFTI+) with emergent interventions and/or early mortality. We hypothesized NFTI would have stronger associations with outcomes and better model fit than ISS and RTS.
METHODS: Thirty-eight adult and pediatric U.S. trauma centers submitted data for 88,488 encounters. Mixed models tested ISS >15, RTS <7.84, and NFTI's associations with complications, survivors' discharge to continuing care, and survivors' length of stay (LOS).
RESULTS: NFTI had stronger associations with complications and LOS than ISS and RTS (odds ratios (99.5% CI): NFTI = 9.44 (8.46, 10.53), ISS = 5.94 (5.36, 6.60), RTS = 4.79 (4.29, 5.34); LOS incidence rate ratios (99.5% CI): NFTI = 3.15 (3.08, 3.22), ISS = 2.87 (2.80, 2.94), RTS = 2.37 (2.30, 2.45)). NFTI was more strongly associated with continuing care discharge but not significantly more than ISS (relative risk (99.5% CI): NFTI = 2.59 (2.52, 2.66), ISS = 2.51 (2.44, 2.59), RTS = 2.37 (2.28, 2.46)). Cross-validation revealed that in all cases NFTI's model provided a much better fit than ISS>15 or RTS<7.84.
CONCLUSIONS: In this multicenter study, NFTI had better model fit and stronger associations with the outcomes than ISS and RTS. By determining depletion of reserve via resource consumption, NFTI+ may be a better definition of major trauma than the standard definitions of ISS >15 and RTS <7.84. Using NFTI may improve retrospective triage monitoring and statistical risk adjustments.
LEVEL OF EVIDENCE: III, Therapeutic.

PMID: 31205214 [PubMed - as supplied by publisher]

Affordable Care Act and cancer stage at diagnosis in an underserved population.

Affordable Care Act and cancer stage at diagnosis in an underserved population.

Prev Med. 2019 Jun 10;:

Authors: Lu Y, Jackson BE, Gehr AW, Cross D, Neerukonda L, Tanna B, Ghabach B, Ojha RP

Abstract
The Patient Protection and Affordable Care Act (ACA) has increased insurance coverage among underserved individuals, but the effect of ACA on cancer diagnosis is currently debated, particularly in Medicaid non-expansion states. Therefore, we aimed to assess the effect of ACA implementation on stage at diagnosis among underserved cancer patients in Texas, a Medicaid non-expansion state. We used data from the institutional registry of the JPS Center for Cancer Care, which serves an urban population of underserved cancer patients. Eligible individuals were aged 18 to 64 years and diagnosed with a first primary invasive solid tumor between 2008 and 2015. We used a natural experiment framework and interrupted time-series analysis to assess level (i.e. immediate) and slope (over time) changes in insurance coverage and cancer stage at diagnosis between pre- and post-ACA periods. Our study population comprised 4808 underserved cancer patients, of whom 51% were racial/ethnic minorities. The prevalence of uninsured cancer patients did not immediately change after ACA implementation but modestly decreased over time (PR = 0.94; 95% CL: 0.90, 0.98). The prevalence of early- and advanced-stage diagnosis did not appreciably change overall or when stratified by screen-detectable cancers. Our results suggest that ACA implementation decreased the prevalence of uninsured cancer patients but had little effect on cancer stage at diagnosis in an underserved population. Given that Texas is a Medicaid non-expansion state, Medicaid expansion and alternative approaches may need to be further explored to improve earlier cancer diagnosis among underserved individuals.

PMID: 31195020 [PubMed - as supplied by publisher]

Radiation therapy utilization in Medicare beneficiaries with early-stage breast cancer.

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Radiation therapy utilization in Medicare beneficiaries with early-stage breast cancer.

Cancer. 2018 02 01;124(3):475-481

Authors: Wallace AS, Keene KS, Williams CP, Jackson BE, Pisu M, Partridge EE, Rocque GB

Abstract
BACKGROUND: There is increasing evidence that radiation therapy (RT) can be omitted for select older patients who are compliant with hormonal blockade, but there is no recent claim-based analysis for determining patterns of care and guiding possible treatment recommendations.
METHODS: Medicare beneficiaries who were 65 years old or older and were diagnosed with breast cancer at 1 of 12 cancer centers affiliated with an academic center in the southeastern United States were analyzed. Stage 0 or I patients treated with lumpectomy from 2012 to 2014 were identified. Patient, treatment, and center characteristics were analyzed for the utilization of RT.
RESULTS: Among 800 women treated with lumpectomy, 64% received adjuvant radiation. The median age was 74 years. The omission of RT was more likely in older patients, stage 0 patients, and patients with more comorbidities (P < .01). Hormonal blockade was used in 41% of the patients who did not receive RT. The utilization of hormonal blockade with the omission of RT was more likely in patients with fewer comorbidities (P < .01).
CONCLUSIONS: In an older cohort of patients who otherwise would have qualified for the omission of radiation, two-thirds were treated with radiation. Future guideline recommendations should address omission in the context of hormonal blockade compliance because only 41% of the patients used hormonal blockade when radiation was not delivered. Cancer 2018;124:475-81. © 2017 American Cancer Society.

PMID: 29053170 [PubMed - indexed for MEDLINE]

Role of Empiric Anti-Fungal Therapy in the Treatment of Perforated Peptic Ulcer Disease: Review of the Evidence and Future Directions.

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Role of Empiric Anti-Fungal Therapy in the Treatment of Perforated Peptic Ulcer Disease: Review of the Evidence and Future Directions.

Surg Infect (Larchmt). 2019 Jun 12;:

Authors: Huston JM, Kreiner L, Ho VP, Sanders JM, Duane TM

Abstract
Background: Peptic ulcer disease (PUD) affects four million people worldwide. Perforated peptic ulcer (PPU) occurs in less than 15% of cases but is associated with significant morbidity and mortality rates. Administration of antibiotics is standard treatment for gastrointestinal perforations, including PPU. Although fungal growth is common in peritoneal fluid cultures from patients with PPU, current data suggest empiric anti-fungal therapy fails to improve outcomes. To examine the role of anti-fungal agents in the treatment of PPU, the Surgical Infection Society hosted an Update Symposium at its 37th Annual Meeting. Here, we provide a synopsis of the symposium's findings and a brief review of prospective and retrospective reports on the subject. Methods: A search of Pubmed/MEDLINE, EMBASE, and the Cochrane Library was performed between January 1, 2000, and November 1, 2018, comparing outcomes of PPU following empiric anti-fungal treatment versus no anti-fungal therapy. We used the search terms "perforated peptic ulcer," "gastroduodenal ulcer," "anti-fungal," and "perforated" or "perforation." Results: There are no randomized clinical trials comparing outcomes specifically for patients with PPU treated with or without empiric anti-fungal therapy. We identified one randomized multi-center trial evaluating outcomes for patients with intra-abdominal perforations, including PPU, that were treated with or without empiric anti-fungal therapy. We identified one single-center prospective series and three additional retrospective studies comparing outcomes for patients with PPU treated with or without empiric anti-fungal therapy. Conclusion: The current evidence reviewed here does not demonstrate efficacy of anti-fungal agents in improving outcomes in patients with PPU. As such, we caution against the routine use of empiric anti-fungal agents in these patients. Further studies should help identify specific subpopulations of patients who might derive benefit from anti-fungal therapy and help define appropriate treatment regimens and durations that minimize the risk of resistance, adverse events, and cost.

PMID: 31188069 [PubMed - as supplied by publisher]

Accuracy of point-of-care ultrasound and radiology-performed ultrasound for intussusception: A systematic review and meta-analysis.

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Accuracy of point-of-care ultrasound and radiology-performed ultrasound for intussusception: A systematic review and meta-analysis.

Am J Emerg Med. 2019 Jun 04;:

Authors: Tsou PY, Wang YH, Ma YK, Deanehan JK, Gillon J, Chou EH, Hsu TC, Huang YC, Lin J, Lee CC

Abstract
OBJECTIVE: It is unclear whether point-of-care ultrasound (POCUS) by emergency medicine physicians is as accurate as radiology-performed ultrasound (RADUS). We aim to summarize the diagnostic accuracy of ultrasonography for intussusception and to compare the performance between POCUS and RADUS.
METHODS: Databases were searched from inception through February 2018 using pre-defined index terms. Peer-reviewed primary studies that investigated the diagnostic accuracy of ultrasound for intussusception in children were included. The study is reported using Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies (PRISMA-DTA). Meta-analysis of the diagnostic accuracy of ultrasound for intussusception was conducted using the random-effects bivariate model. Subgroup analysis (POCUS vs RADUS) was also performed. Meta-regression was utilized to determine if the diagnostic accuracy between POCUS and RADUS was significantly different.
RESULTS: Thirty studies (n = 5249) were included in the meta-analysis. Ultrasonography for intussusception has a sensitivity: 0.98 (95% CI: 0.96-0.98), specificity: 0.98 (95% CI: 0.95-0.99), positive likelihood ratio: 43.8 (95% CI: 18.0-106.7) and negative likelihood ratio: 0.03 (95% CI: 0.02-0.04), with an area under ROC (AUROC) curve of 0.99 (95% CI: 0.98-1.00). Meta-regression suggested no significant difference in the diagnostic accuracy for intussusception between POCUS and RADUS (AUROC: 0.95 vs 1.00, p = 0.128).
CONCLUSIONS: Current evidence suggested POCUS has a high diagnostic accuracy for intussusception not significantly different from that of RADUS.

PMID: 31182360 [PubMed - as supplied by publisher]

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