No date for the PROM: the association between patient-reported health events and clinical coding in primary car

Journal of Patient-Reported Outcomes

Paul J. Barr , Scott A. Berry , Wendolyn S. Gozansky , Deanna B. McQuillan , Colleen Ross , Don Carmichael, Andrea M. Austin , Travis D. Satterlund , Karen E. Schifferdecker , Lora Council , Michelle D. Dannenberg , Ariel T. Wampler , Eugene C. Nelson and Jonathan Skinner

Objective: It is unclear whether data from patient-reported outcome measures (PROMs) are captured and used by clinicians despite policy initiatives. We examined the extent to which fall risk and urinary incontinence (UI) reported on PROMS and provided to clinicians prior to a patient visit are subsequently captured in the electronic medical record (EMR). Additionally, we aimed to determine whether the use of PROMs and EMR documentation is higher for visits where PROM data was provided to clinicians.

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Use of Advance Care Planning Billing Codes for Hospitalized Older Adults at High Risk of Dying: A National Observational Study

Journal of Hospital Medicine

Amber E Barnato, MD, MPH, MS; A James O’Malley, PhD; Jonathan S Skinner, PhD; John D Birkmeyer, MD

Advance care planning (ACP) is the process where- in patients, in discussions with their healthcare providers, family members, and other loved ones, make individual decisions about their fu- ture healthcare or prepare proxies to guide future medical treatment decisions.1,2 In 2016, the Centers for Medicare and Medicaid Services (CMS) began paying providers for ACP by using billing codes 99497 (first 30 min of ACP) and 99498 (additional 30 min of ACP). According to the CMS, during the first year after the billing codes were introduced, 22,864 providers billed for ACP conversations with 574,621 patients.3 While all adults are eligible, common triggers for ACP in- clude advanced age, serious illness, and functional status changes that confer an increased risk of dying. We explored the early uptake of the ACP billing code in a large national physician practice that provided mandatory education in use of the ACP billing code, offered a small financial incentive for ACP documentation, and primed physicians to reflect on the patient’s risk of dying in the next year at the time of hospital admission.

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Residential Setting and the Cumulative Financial Burden of Dementia in the 7  Years Before Death

Journal of the American Geriatric Society
Kelley AS, McGarry K, Bollens-Lund E, Rahman OK, Husain M, Ferreira KB, Skinner JS.

Care for older adults with dementia during the final years of life is costly, and families shoulder much of this burden. We aimed to assess the financial burden of care for those with and without dementia, and to explore differences across residential settings. Using the Health and Retirement Study (HRS) and linked claims, we examined total healthcare spending and proportion by payer-Medicare, Medicaid, out-of-pocket, and calculated costs of informal caregiving-over the last 7 years of life, comparing those with and without dementia and stratifying by residential setting. We found that, consistent with prior studies, people with dementia experience significantly higher costs, with a disproportionate share falling on patients and families. This pattern is most striking among community residents with dementia, whose families shoulder 64% of total expenditures (including $176,180 informal caregiving costs and $55,550 out-of-pocket costs), compared with 43% for people with dementia residing in nursing homes ($60,320 informal caregiving costs and $105,590 out-of-pocket costs). These findings demonstrate disparities in financial burden shouldered by families of those with dementia, particularly among those residing in the community. They highlight the importance of considering the residential setting in research, programs, and policies.

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Measuring racial segregation in health system networks using the dissimilarity index

Social Science & Medicine
Austin AM, Carmichael DQ, Bynum JPW, Skinner JS.

Racial disparities in the end-of-life treatment of patients are a well observed fact of the U.S. healthcare system. Less is known about how the physicians treating patients at the end-of-life influence the care received. Social networks have been widely used to study interactions with the healthcare system using physician patient-sharing networks. In this paper, we propose an extension of the dissimilarity index (DI), classically used to study geographic racial segregation, to study differences in patient care patterns in the healthcare system. Using the proposed measure, we quantify the unevenness of referrals (sharing) by physicians in a given region by their patients' race and how this relates to the treatments they receive at the end-of-life in a cohort of Medicare fee-for-service patients with Alzheimer's disease and related dementias. We apply the measure nationwide to physician patient-sharing networks, and in a sub-study comparing four regions with similar racial distribution, Washington, DC, Greenville, NC, Columbus, GA, and Meridian, MS. We show that among regions with similar racial distribution, a large dissimilarity index in a region (Washington, DC DI = 0.86 vs. Meridian, MS DI = 0.55), which corresponds to more distinct referral networks for black and white patients by the same physician, is correlated with black patients with Alzheimer's disease and related dementias receiving more aggressive care at the end-of-life (including ICU and ventilator use), and less aggressive quality care (early hospice care).

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Chronic Condition Measurement Requires Engagement, Not Measurement Alone.

The Journal of Ambulatory Care Management
Austin AM1, Carmichael D, Berry S, Gozansky WS, Nelson EC, Skinner JS, Barr PJ.

Patient-reported outcome measures (PROMs) have great promise, but evidence of success is mixed. This study uses data from Dartmouth-Hitchcock Medical Center and Kaiser-Permanente Colorado to evaluate providing PROMs directly to the primary care physician. We compared changes over time in urinary incontinence, falls, and mental and physical health between clinics providing augmented PROMs (N = 202 patients) and control clinics (N = 102 patients). Both the control and treatment groups exhibited improvements, but there was no significant difference in outcomes over time. These results suggest that measuring and printing out PROMs for primary care physicians will not result in better patient outcomes without physician clinical engagement.

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Association of Receiving Multiple, Concurrent Fracture-Associated Drugs With Hip Fracture Risk

JAMA Network

Rebecca T. Emeny, PhD, MPH; Chiang-Hua Chang, PhD; Jonathan Skinner, PhD; A. James O’Malley, PhD; Jeremy Smith, MPH; Gouri Chakraborti, MA;Clifford J. Rosen, MD; Nancy E. Morden, MD, MPH

Choosing between competing treatment options is difficult for patients and clinicians when results from randomized and observational studies are discordant. Observational real-world studies yield more generalizable evidence for decision making than randomized clinical trials, but unmeasured confounding, especially in time-to-event analyses, can limit validity.

Health Care Employment Growth and the Future of US Cost Containment

JAMA
Jonathan Skinner, PhD; Amitabh Chandra, PhD

In 2013, the growth rate in US health care spending of 3.6% was the lowest in 50 years. Health policy experts and the media viewed the “unprecedented” decline as demonstrating that growth in health care costs had finally slowed.1 However, one number that was not consistent with this popular narrative was employment growth in the health care sector. In 2013, health care jobs continued to increase by 1.4%, slightly below the annual average of 1.9% during the prior 5 years.

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Association Between Medicare Expenditure Growth and Mortality Rates in Patients With Acute Myocardial Infarction A Comparison From 1999 Through 2014

JAMA
Donald S. Likosky, Jessica Van Parys, Weiping Zhou, William B. Borden, Milton C.Weinstein, Jonathan S. Skinner

Many studies have considered the association between Medicare spending and health outcomes at a point in time; few have considered the association between the long-term growth in spending and outcomes.

De-adoption and exnovation in the use of carotid revascularization: retrospective cohort study

British Medical Journal
Kimon Bekelis, Jonathan Skinner, Daniel Gottlieb, Philip Goodney

Objective: To determine physician characteristics associated with exnovation (scaling back on use) and de-adoption (abandoning use) of carotid revascularization.

Conclusion: Surgeons with more experience and the lowest share in carotid revascularization practice reduced their use of the procedure the most. These practice factors should be considered in quality improvement efforts when the evidence base evolves away from a specific treatment.

Structuring and Visualizing Healthcare Claims Data Using Systems Architecture Methodology

International Journal of Biological, Biomolecular, Agricultural, Food and Biotechnological Engineering
Khayal IS, Zhou W, Skinner JS

Healthcare delivery systems around the world are in crisis. The need to improve health outcomes while decreasing healthcare costs have led to an imminent call to action to transform the healthcare delivery system. While Bioinformatics and Biomedical Engineering have primarily focused on biological level data and biomedical technology, there is clear evidence of the importance of the delivery of care on patient outcomes. Classic singular decomposition approaches from reductionist science are not capable of explaining complex systems. Approaches and methods from systems science and systems engineering are utilized to structure healthcare delivery system data. Specifically, systems architecture is used to develop a multi-scale and multi-dimensional characterization of the healthcare delivery system, defined here as the Healthcare Delivery System Knowledge Base. This paper is the first to contribute a new method of structuring and visualizing a multi-dimensional and multi-scale healthcare delivery system using systems architecture in order to better understand healthcare delivery.

Prospective Identification of Patients at Risk for Unwarranted Variation in Treatment

Journal Palliat Med
Kelley AS, Bollens-Lund E, Covinsky KE, Skinner JS, Morrison RS

Understanding factors associated with treatment intensity may help ensure higher value healthcare. We identified people with incident serious illness (a serious medical condition, for example, metastatic cancer or functional impairment); calculated subjects' one-year mortality risk; and then followed them for one year. We examined relationships between individual and regional characteristics and total Medicare costs, and then stratified analyses by one-year mortality risk: low, moderate, and high.

Among seriously ill older adults, indicators of poor health are associated with higher costs. Yet, among those with poorest prognoses, nonmedical characteristics-race and regional practice patterns-have greater influence on treatment. This suggests there may be novel opportunities to improve care quality and value by assuring patient-centered, goal-directed care.

End-Of-Life Medical Spending In Last Twelve Months Of Life Is Lower Than Previously Reported

Health Affairs
French EB, McCauley J, Aragon M, Bakx P, Chalkley M, Chen SH, Christensen BJ, Chuang H, Côté-Sergent A, De Nardi M, Fan E, Échevin D, Geoffard PY, Gastaldi-Ménager C, Gørtz M, Ibuka Y, Jones JB, Kallestrup-Lamb M, Karlsson M,Klein TJ, de Lagasnerie G, Michaud PC, O’Donnell O, Rice N, Skinner JS, van Doorslaer E, Ziebarth NR, Kelly E.

Although end-of-life medical spending is often viewed as a major component of aggregate medical expenditure, accurate measures of this type of medical spending are scarce. We used detailed health care data for the period 2009–11 from Denmark, England, France, Germany, Japan, the Netherlands, Taiwan, the United States, and the Canadian province of Quebec to measure the composition and magnitude of medical spending in the three years before death. In all nine countries, medical spending at the end of life was high relative to spending at other ages. Spending during the last twelve months of life made up a modest share of aggregate spending, ranging from 8.5 percent in the United States to 11.2 percent in Taiwan, but spending in the last three calendar years of life reached 24.5 percent in Taiwan. This suggests that high aggregate medical spending is due not to last-ditch efforts to save lives but to spending on people with chronic conditions, which are associated with shorter life expectancies.

Managing New Health Technologies

OCED Observer
Jonathan S. Skinner and Amitabh Chandra

Countries around the world are struggling with rising healthcare bills. Every introduction of pricey new biologics, surgical procedures, and exotic “precision” treatments causes ever- increasing fiscal stress, leading to deficit spending, cutbacks in other government services, and insurance costs shouldered by firms and employees alike. Yet, freezing budgetary allocations is clearly not an option, as citizens in our ageing societies are likely to demand more and better access to new health innovations, and essential healthcare services. What can be done?

Costs and Consequences of Early Hospital Discharge After Major Inpatient Surgery in Older Adults

JAMA Surgery
Regenbogen SE, Cain-Nielsen AH, Norton EC, Chen LM, Birkmeyer JD, Skinner JS

As prospective payment transitions to bundled reimbursement, many US hospitals are implementing protocols to shorten hospitalization after major surgery. These efforts could have unintended consequences and increase overall surgical episode spending if they induce more frequent postdischarge care use or readmissions.

Hemoglobin A1c Testing and Amputation Rates in Black, Hispanic, and White Medicare Patients

Annals of Vascular Surgery
Suckow BD, Newhall KA, Bekelis K, Faerber AE, Gottlieb DJ, Skinner JS

Major (above-knee or below-knee) amputation is a complication of diabetes and is seen more common among black and Hispanic patients. While amputation rates have declined for patients with diabetes in the last decade, it remains unknown if these improvements have equitably extended across racial groups and if measures of diabetic care, such as hemoglobin A1c testing, are associated with these improvements. We set out to characterize secular changes in amputation rates among black, Hispanic, and white patients, and to determine associations between hemoglobin A1c testing and amputation risk.

Physician Practice Style Variation—Implications for Policy

JAMA Internal Medicine
Van Parys J and Skinner J

Practice style variation at the regional level has been well documented at different geographic levels, but there is much less research focusing on the role of individual physician variability in practice. Two studies have shown considerable variation in the practice styles of cardiologists who treat patients with acute myocardial infarction and obstetricians who perform cesarean-sections, but less is known about how the use of non-recommended or “low-value” care varies across physicians.

Long-Term Revisional or Contralateral Treatments After Carotid Revascularization in the Vascular Quality Initiative

Journal of Vascular Surgery
Svoboda RM, Newhall K, Sedrakyan A, Skinner J, Stone DH, Goodney PP

Significant work has detailed the risk of long-term stroke, myocardial infarction, and death in patients undergoing carotid endarterectomy (CEA) and carotid artery stenting (CAS). However, little is known about the relative rates of subsequent intervention following these procedures. We aimed to compare the rates of subsequent carotid artery intervention—either ipsilateral or contralateral—for patients undergoing CEA and CAS.

Primary Stroke Center Hospitalization for Elderly Patients With Stroke Implications for Case Fatality and Travel Times

JAMA Internal Medicine
Kimon Bekelis, MD; Nancy J. Marth, MS, MSN; Kendrew Wong, BS; Weiping Zhou, MS; John D. Birkmeyer, MD; Jonathan Skinner, PhD

Physicians often must decide whether to treat patients with acute stroke locally or refer them to a more distant Primary Stroke Center (PSC). There is little evidence on how much the increased risk of prolonged travel time offsets benefits of a specialized PSC care.

An analysis of patient-sharing physician networks and implantable cardioverter defibrillator therapy

Health Services and Outcomes Research Methodology
Moen EL, Austin AM, Bynum JP, Skinner JS, O’Malley AJ

The application of social network analysis to the organization of healthcare delivery is a relatively new area of research that may not be familiar to health services statisticians and other methodologists. We present a methodological introduction to social network analysis with a case study of physicians’ adherence to clinical guidelines regarding use of implantable cardioverter defibrillators (ICDs) for the prevention of sudden cardiac death. We focus on two hospital referral regions in Indiana, Gary and South Bend, characterized by different rates of evidence-based ICD use (86 and 66 %, respectively). Using Medicare Part B claims, we construct a network of physicians who care for cardiovascular disease patients based on patient-sharing relationships. Approaches for weighting physician dyads and aggregating physician dyads by hospital are discussed. Then, we obtain a set of weighted network statistics for the positions of hospitals in their referral region, global statistics for the physician network within each hospital, and of the network positions of individual physicians within hospitals, providing the mathematical specification and sociological intuition underlying each measure. We find that adjusting for network measures can reduce the observed differences between referral regions for evidence-based ICD therapy. This study supports previous reports on how variation in physician network structure relates to utilization of care, and motivates future work using physician network measures to examine variation in evidence-based medicine.