The evolution of financial incentives in the U.S. health care system

The U.S. health care system continues to evolve toward value-based payment, rewarding providers based upon outcomes per dollar spent. To date, payment innovation has largely targeted primary care, with little consideration for the role of surgical specialists. As such, there remains appropriate uncertainty surrounding the optimal role of the urologic oncologist in alternative payment models. This commentary summarizes the context of U.S. health care reform and offers insights into supply-side innovations including accountable care organizations and bundled payments. Additionally, and importantly, we discuss the implications of rising out-of-pocket health care expenditures giving rise to health care consumerism and the implications therein.     

Edgar J. Poth Memorial Lecture: Lessons learned inside the Beltway: one surgeon's encounters with health care policy

Our health care system continues to undergo transformation in a context of extreme financial pressures. New models of care delivery and financing challenge us to rethink our practices as individual surgeons and as system participants. Understanding the fiscal realities of health care and how we are perceived by health care policy makers can help us to be meaningful participants in channeling reform to create better delivery systems for our patients. This article presents some background information about health care in America with a focus on government programs, and shares insights from my health care policy colleagues.     

Racial Disparity in Delivering Definitive Therapy for Intermediate/High-risk Localized Prostate Cancer: The Impact of Facility Features and Socioeconomic Characteristics

Background

The gap in prostate cancer (PCa) survival between Blacks and Whites has widened over the past decade. Investigators hypothesize that this disparity may be partially attributable to differences in rates of definitive therapy between races.

The Portuguese Osteopathic Practitioners Estimates and RAtes (OPERA): A cross-sectional survey

ObjectivesOsteopathy is regulated as an independent healthcare profession in Portugal. The Osteopathic Practitioners Estimates and RAtes (OPERA) project was developed as a survey to profile the osteopathic profession. This study aimed to describe the characteristics of Portuguese osteopathic practitioners.MethodsA voluntary online-based survey was distributed across Portugal between February and June 2020. The survey, composed of 52 questions and seven sections, was formally translated from English to Portuguese and adapted from the original version. Two pilot tests evaluated cultural adaptation and reproducibility. Adult, self-defined osteopaths working in Portugal were eligible. Recruitment of participants was performed through social media and an e-based campaign.ResultsA total of 222 osteopaths participated in the study, 143 were male (64%), aging between 30 and 39 years (42%), mainly working in Lisbon (30%). Most respondents had preliminary healthcare training (68%), mainly as massage therapists. The majority of respondents were self-employed (83%), owner of a clinic (55%) and working alone (59%). The median number of consultations per week was 21–25 and respondents scheduled 46–60 min for each consultation. The majority of patients seek care for lumbar (52%), cervical (38%) and upper spine (38%) complaints. Although most respondents experience a strong osteopathic identity, they do not advertise themselves exclusively as osteopaths.ConclusionsThis study represents the first nationwide document to determine osteopaths' characteristics in Portugal. The study results provide a basis for future surveys that will include cohorts with higher levels of education, as well as findings from other European countries.     

Racial disparity in quality of care and overall survival among black vs. white patients with muscle-invasive bladder cancer treated with radical cystectomy: A national cancer database analysis

Objectives

To examine the impact of race on quality of care and overall survival (OS) among patients with muscle invasive bladder cancer (MIBC) treated with radical cystectomy (RC) in the U.S.

Are patients referred for NHS-funded dental implant treatment being selected in accordance with national guidelines and subsequently funded by their primary care trust?

INTRODUCTION

The Faculty of Dental Surgery, The Royal College of Surgeons of England (RCSE), published a national guideline document in 1997 detailing specific selection criteria for National Health Service (NHS) funded dental implant treatment. The aim of this audit was to assess whether patients selected for NHS-funded dental implants at Bristol Dental Hospital (BDH) met the RCSE national criteria for treatment and received funding from their primary care trust (PCT).

PATIENTS AND METHODS

A retrospective audit over a period of 2 years was undertaken using medical records and an existing Microsoft Excel database. All patients who had an application submitted to their local PCT for NHS-funded dental implants by BDH were included in this audit.

RESULTS

A total of 82 applications for dental implant funding were made by BDH and 100% met the RCSE criteria. Fifty-one patients (62.2%) in total had their application for funding approved. Thirty-one patients (37.8%) that met the RCSE guidelines for NHS-funded dental implant treatment had their applications refused. Twenty-five (49%) out of 51 cases in the partially dentate category and six (27.3%) cases in the edentulous group were unsuccessful in their application for NHS-funded dental implants. However, all applications for patients with acquired maxillofacial defects were successful.

CONCLUSIONS

Patient selection by the BDH for NHS-funded implants complied with the RCSE guidelines. However, there was significant variation in funding between PCTs for those patients who apparently fulfilled the RCSE guidelines. NHS resources are not being allocated equitably for dental implant ‘high-priority’ patients and it would appear that a so-called ‘postcode lottery’ exists between PCTs.     

Outcome measures in burn care. Is mortality dead?

Health care systems constantly struggle with ways to provide higher quality care in a cost-effective manner. Outcome measures serve to evaluate what works and what does not. Whether they are used for research or for the improvement of clinical practice, they are as such, efficiency markers and the first step in determining the consequences of health care. The accomplishments of the past decade have placed us in the midst of an exciting paradigm shift from what used to be primary concern (i.e. mortality), to areas that are more likely to enhance the quality of life of burn survivors. Optimal management of severely burned persons is enormously expensive, and even after survival is ensured, may require a protracted period of surgical, medical and psychological rehabilitative measures for many years. This article aims to review the outcome measures in the acute phase of burn management (mortality and morbidity from the post-burn hypermetabolic response). We further discuss long-term outcome measures (such as, quality of life measures, exercise tolerance and evaluation of return to pre-burn activities) that are now becoming of equal importance as the numbers of burn survivors increase.     

Insurance coverage mandates: Impact of physician utilization in moderating colorectal cancer screening rates

Precision public health requires research that supports innovative systems and health delivery approaches, programs, and policies that are part of this vision. This study estimated the effects of health insurance mandate (HiM) variations and the effects of physician utilization on moderating colorectal cancer (CRC) screening rates. A time-series analysis using a difference-in-difference-in-differences (DDD) approach was conducted on CRC screenings (1997–2014) using a multivariate logistic framework. Key variables of interest were HiM, CRC screening status, and physician utilization. The adjusted average marginal effects from the DDD model indicate that physician utilization increased the probability of being “up-to-date” vs. non-compliance by 9.9% points (p?=?0.007), suggesting that an estimated 8.85 million additional age-eligible persons would receive a CRC screening with HiM and routine physician visits. Routine physician visits and mandates that lower out-of-pocket expenses constitute an effective approach to increasing CRC screenings for persons ready to take advantage of such policies.     

Enhancing health care professionals’ and trainees’ knowledge of physical activity guidelines for adults with and without SCI

Background: Health care providers (HCPs) are preferred sources of physical activity (PA) information; however, minimal research has explored HCPs’ knowledge of spinal cord injury (SCI) PA guidelines, and no research has examined HCP trainees’ PA guideline knowledge.

Objective: The current study explored HCPs’ and trainees’ initial knowledge of PA guidelines for both adults with SCI and the general population, and the utility of an event-based intervention for improving this knowledge.

Methods: Participants (HCPs n?=?129; trainees n?=?573) reported guideline knowledge for both sets of guidelines (SCI and general population) immediately after, one-month, and six-months following the intervention. Frequencies determined guideline knowledge at each timepoint, while chi-squared tests examined differences in knowledge of both guidelines, as well as knowledge differences in the short- and long-term.

Results: Results demonstrated that HCPs and trainees lack knowledge of PA guidelines, particularly guidelines for adults with SCI. The results further suggest that a single event-based intervention is not effective for improving long-term guideline knowledge.

Conclusion: Suggestions are made for future research with the aim of improving interventions that target HCP and HCP trainees’ long-term guideline knowledge for adults with SCI and the general population.     

Health services research in surgery—definitions,approaches and methods

Background and aims  Health services research (HSR) investigates the translation of clinical studies into the practice of health care in relation to quality and efficiency from the individual and socioeconomic perspective. Given the fact that HSR has become increasingly popular during the last decade, this article aims at providing an overview of the significance and benefit of HSR in general and especially in the field of surgery. Results  The first part of the overview provides various definitions that apply to the field, gives a brief historical overview of the development in Germany in contrast to the USA and Great Britain, and describes relevant theoretical frameworks and methods. In the second part it deals with gaps in patient care, patient-related outcomes, registry research, the integration of clinical and ambulatory surgery, and research on implementation of guidelines into practice. Conclusions  This overview shows that HSR is by now regarded as an essential field, at least in developed countries, and that we are just at the beginning to understand why demonstrated effective strategies in the clinical context do not or rarely translate into routine patient’s care.     

Burn care costing: the Welsh experience

It has been accepted for many years that the cost of care for the burn-injured patient is high. There is, however, little published data to show how "expensive" it is. At the Welsh Centre for burns we have undertaken a costing exercise in an attempt to define the true cost to the treatment of burns. Using our current cost base and activity, we established a cost per health related group (HRG) for burns and also prospectively calculated costs for three inpatients to determine whether HRG-based burn tariffs accurately represent these costs. The NHS is under increasing pressure to provide evidence to support budgetary requirements; we feel this paper offers a framework for burn care costing upon which calculations could be based.     

Body Contouring with Solid Silicone Implants

Background  Body-contouring implants are becoming increasingly popular and more accepted and requested for aesthetic purposes. These implants must be placed in a safe and reproducible plane of anatomic dissection for a successful long-term outcome. Poor implant placement techniques result in greater complications such as asymmetry, implant migration, capsular contracture, and infection. This article discusses (1) the history and the evolution of body-contouring implants, (2) the different techniques and dissection planes in which to put the implants in the calf, gluteal, pectoral, and triceps/biceps areas, and (3) the complications associated with the different implantation techniques. Methods  The different anatomical areas that have been treated with solid silicone implants are the gluteus, pectoral, calf, deltoids, biceps, triceps, and trapezium. Results  Determining the ideal plane for implant placement is the most important surgical goal for satisfactory aesthetic results. Conclusion  Aesthetic contouring of the chest, back, arms, buttocks, and calf can be done safely with solid silicone implants. Proper pocket dissection and location are paramount to successful implant placement and decreased complications.     

Physiologically focused triage criteria improve utilization of pediatric surgeon-directed trauma teams and reduce costs

Introduction

Pediatric surgeon-directed trauma teams (STTs) provide lifesaving treatment but at a high cost. We used physiologically based criteria to improve STT utilization.

Methods

We reviewed 152 consecutive STT activations at one center, comparing standard and physiologically focused criteria and 24-hour hospital costs/charges for overtriaged patients vs level 2 (emergency department managed) blunt trauma patients matched for age, Injury Severity Score (ISS), and necessity for operation.

Results

Our cohort (73.0% male; 86.8% blunt; median age, 8.0 [interquartile range, 4.0-14.0] years) had 10 deaths (6.6%) and 18 (11.8%) emergent operations. Twenty-nine patients met neither standard nor physiologic criteria (group 1), 25 met standard but not physiologic criteria (overtriaged, group 2), and 98 met physiologic criteria (group 3). Group 3 had higher median ISS (19.0 [10.0-33.0] vs 10.0 [4.0-17.0] and 5.5 [5.0-16.75] for groups 1 and 2, P = .001), more intensive care unit admissions (67.2% vs 31.0% and 52.0%, P = .001), longer hospitalization (5.0 [3.0-9.25] days vs 3.0 [1.0-5.0] and 4.0 [2.0-5.0] days, P = .002), and all patients who died or required emergent operation (P < .001). Physiologic criteria maintained 100% sensitivity but improved specificity (49.2% vs 23.0%). Overtriaged patients (n = 18) had 78.2% higher charges ($4700; 95% confidence interval, 13.3%-180.1%; P = .013) and 53.4% higher costs ($800; 95% confidence interval, 1.8%-131.2%; P = .041) than level 2 patients (n = 259) after adjusting for age, ISS, and need for operation, largely because of computed tomography and emergency department charges (66% of overtriaged charges).

Conclusions

Physiologic STT activation criteria would have saved 25 activations, $20,000 in costs, and $120,000 in charges annually without compromising patient safety.