Using Information on Clinical Conditions to Predict High-Cost Patients

Objective. To compare the ability of different models to predict prospectively whether someone will incur high medical expenditures. Data Source. Using nationally representative data from the Medical Expenditure Panel Survey (MEPS), prediction models were developed using cohorts initiated in 1996–1999 (N=52,918), and validated using cohorts initiated in 2000–2003 (N=61,155). Study Design. We estimated logistic regression models to predict being in the upper expenditure decile in Year 2 of a cohort, based on data from Year 1. We compared a summary risk score based on diagnostic cost group (DCG) prospective risk scores to a count of chronic conditions and indicators for 10 specific high‐prevalence chronic conditions. We examined whether self‐rated health and functional limitations enhanced prediction, controlling for clinical conditions. Models were evaluated using the Bayesian information criterion and the c‐statistic. Principal Findings. Medical condition information substantially improved prediction of high expenditures beyond gender and age, with the DCG risk score providing the greatest improvement in prediction. The count of chronic conditions, self‐reported health status, and functional limitations were significantly associated with future high expenditures, controlling for DCG score. A model including these variables had good discrimination (c=0.836). Conclusions. The number of chronic conditions merits consideration in future efforts to develop expenditure prediction models. While significant, self‐rated health and indicators of functioning improved prediction only slightly.     

Assessing Patient Activation among High-Need,High-Cost Patients in Urban Safety Net Care Settings

We sought to examine the literature using the Patient Activation Measure (PAM) or the Patient Enablement Instrument (PEI) with high-need, high-cost (HNHC) patients receiving care in urban safety net settings. Urban safety net care management programs serve low-income, racially/ethnically diverse patients living with multiple chronic conditions. Although many care management programs track patient progress with the PAM or the PEI, it is not clear whether the PAM or the PEI is an effective and appropriate tool for HNHC patients receiving care in urban safety net settings in the United States. We searched PubMed, EMBASE, Web of Science, and PsycINFO for articles published between 2004 and 2015 that used the PAM and between 1998 and 2015 that used the PEI. The search was limited to English-language articles conducted in the United States and published in peer-reviewed journals. To assess the utility of the PAM and the PEI in urban safety net care settings, we defined a HNHC patient sample as racially/ethnically diverse, low socioeconomic status (SES), and multimorbid. One hundred fourteen articles used the PAM. All articles using the PEI were conducted outside the U.S. and therefore were excluded. Nine PAM studies (8%) included participants similar to those receiving care in urban safety net settings, three of which were longitudinal. Two of the three longitudinal studies reported positive changes following interventions. Our results indicate that research on patient activation is not commonly conducted on racially and ethnically diverse, low SES, and multimorbid patients; therefore, there are few opportunities to assess the appropriateness of the PAM in such populations. Investigators expressed concerns with the potential unreliability and inappropriate nature of the PAM on multimorbid, older, and low-literacy patients. Thus, the PAM may not be able to accurately assess patient progress among HNHC patients receiving care in urban safety net settings. Assessing progress in the urban safety net care setting requires measures that account for the social and structural challenges and competing demands of HNHC patients.     

The ACO paradox impacting physicians

Accountable care organizations (ACOs) would hold care providers jointly accountable for the quality and costs of care, allow consumers the freedom to choose their providers, and involve physicians and consumers in their shared decision-making. Even though the ACO model proposes physician empowerment, it also poses significant financial and change-management challenges for physicians. Furthermore, the "patient-centered" ACOs that have been established to safeguard consumer sovereignty pose the risks of concentrating healthcare markets further and exacerbating the existing disparities in healthcare. We conducted a survey study to understand physicians' perspectives of ACOs by seeking their first-hand feedback. The survey results suggest that there are significant communication gaps between physicians and healthcare administrators; and efficient communication can help improve physician-administrator alignment and help them identify opportunities that would be critical to the success of ACOs.     

The forgotten players in ACO development: nursing homes

Given the history and dynamics of the Patient Protection and Affordable Care Act, nursing homes have been left out of the business of Accountable Care Organization (ACO) development and implementation over the last year. Only now are ACOs, hospitals, and physicians realizing that an effective ACO needs long-term care and rehabilitation as a key component to maximize shared savings in the ACO environment. This article discusses the history of ACO development, examines why nursing homes may have been left out, and explains why nursing homes are critical participants in ACO effectiveness. The article also discusses how nursing homes will need to position their businesses for ACO participation.     

Enrolling Pregnant Women: Issues in Clinical Research

BackgroundDespite the fact that many pregnant women are affected by a range of serious health conditions and take medications for these conditions, there is widespread reticence to include them in clinical intervention research. Hence, their clinical care is typically not informed by evidence derived from pregnant populations.MethodIn October 2010, the National Institutes of Health Office of Research on Women's Health convened a workshop to address ethical, regulatory, and scientific issues raised by the enrollment of pregnant women in clinical research. This report summarizes three areas that emerged from that meeting as important next steps to be taken to promote ethically responsible and scientifically sound research during pregnancy.FindingsThe three areas are: 1) Reclassify pregnant women from their current status in regulations as a “vulnerable” population to a scientifically “complex” population and change the presumption of exclusion to one of inclusion; 2) examine the institutional review boards' (IRB) gatekeeper role in interpreting regulations governing pregnancy research and identify steps to facilitate IRB approval of ethically informed pregnancy research; and 3) develop a pregnancy-focused research agenda that addresses pressing clinical needs, identifies opportunities to gather information from existing resources and studies, and encourages important new research areas.ConclusionResearch is needed to address the therapeutic needs of pregnant women and to study pregnancy as it may shed light on a pregnant woman's later health and the health of her child.     

Preliminary Report of a Palliative Care and Case Management Project in an Emergency Department for Chronically Ill Elderly Patients

The Palliative Care Service at Montefiore Medical Center (MMC) established a pilot project in the emergency department (ED) to identify chronically ill older adults in need of palliative care, homecare, and hospice services and to link such patients with these services. Two advance practice nurses conducted consultations on elderly patients who were found to have one or more “palliative care triggers” on initial screening. A standardized medical record abstraction form was developed. Service utilization and survival were evaluated using the Clinical Information Systems of MMC. Activity of daily living items were developed from the Outcome and Assessment Information Set and the Palliative Care Performance Scale (PPS). Risk factors for hospitalization and use of the ED were taken from the SIGNET model risk screening tool. Physical and emotional symptoms were evaluated using the 28-item Memorial Symptom Assessment Scale short form. Preliminary outcomes and characteristics are presented for 291 patients who completed the intake needs assessment questionnaire. Almost one third (30.9%) of the study cohort died during the project period. Most of the deaths occurred beyond the medical center (7.7% died in the medical center and 23.3% outside the medical center). Thirty percent of patients who died were enrolled on a hospice. Survival time was predicted by the presence of dyspnea, clinician prediction of death on the current hospitalization, psychosocial distress, and PPS scores. Chronically ill patients visiting an urban community ED had complex medical and psychosocial problems with limited support systems and homecare services. Significant proportions of such patients can be expected to have limited likelihood of survival. The presence of palliative homecare and hospice outreach services in the ED in urban community hospitals may provide an effective strategy for linkage of elderly patients at the end of life with otherwise underutilized services. O’ Mahony, Simpson, Huvane, McHugh, Hutcheson, Karakas, and Higgins are with the Palliative Care Service, Department of Family and Social Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA; Blank and Selwyn are with the Department of Family and Social Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA; Persaud is with the Memorial Sloan Kettering Cancer Center, New York, NY, USA; McAllen and Davitt are with the Emergency Department, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA.     

血透患者体液平衡状态测试仪器的研制

为了实时地正确评价血液透析患者的体液平衡状态,作者设计并研制了生物电阻抗法为基础的体液状态测试仪。介绍了仪器的硬件和软件设计。该仪器使用安全并具有良好的稳定性和重复性。初步的临床测试结果表明其可灵敏地反映透析前后的体液状态变化。     

Getting up to speed. Execs detail IT needs, investments required to support an ACO

The push for accountable care organizations means a push for more information technology that allows the sharing of data. So hospitals and other providers that are forming ACOs are feeling new urgency to ramp up their IT improvements. At Banner Health it means figuring out how to deal with independent physicians' "mishmash" of systems. "There has been an acceleration of interest," says Dr. John Hensing, left, Banner's chief medical officer.     

Enrolling uninsured children in SCHIP. Lessons learned from community health centers

In 1997 Congress established the State Child Health Insurance Program (SCHIP) to address the problem of the nation's low-income uninsured children. To help children become eligible for SCHIP and to tap into the potential revenue stream for previously uninsured children, community health centers have taken differing approaches. This study examines the lessons learned from enrolling children at 14 health centers in six states. The lessons can be valuable for primary care centers and other safety-net providers.     

The Role of Patients in Designing Health Information Systems: The Case of Applying Simulation Techniques to Design an Electronic Patient Record (EPR) Interface

One overall objective of Electronic Patient Records (EPRs) is to improve patient education and to enhance the patient experience through the use of information technology (IT) so as to facilitate the sharing of information between providers and their patients. The research project reported on herein took place at University Health Network (UHN) in Toronto (Canada), which is a large academic health science center with multiple hospital sites in the city. As a first step in this process, we examined the literature to investigate the human factors issues related to healthcare as well as other settings. Subsequently, we interviewed a number of interested stakeholders from two groups: the physicians (both family and attending) and the patients themselves. Finally, using a simulation environment, we explored the content that UHN lung-transplant patients would be interested in having within their own EPRs. In this paper, we report on the research, the methodology and the findings pertaining to the both the content and the design of an electronic patient record.