Outpatient encounter data for risk adjustment: strategic issues for Medicare and Medicaid

Payers are increasingly using diagnostic data from outpatient encounter records to adjust the payment to health plans. Although much has been written about the ability of such data to predict health care costs, little has been written about the data itself--its quality and availability. Fee-for-service (FFS) data face several threats to their validity, including the possibility that they may seriously underreport diagnoses. Because the systems and incentives that yield FFS and managed care diagnosis data are quite different, they may not be comparable, depending on circumstances such as audit rules. The next generation of risk adjustment models should be designed around the capabilities and potentialities of plans' information systems.     

It's management not payment that we should focus on: comments on Welch

This comment discussed the ideas put forward by Peter Welch in his article on federal policy pertaining to managed care. Specifically, we assert that it is important to have as wide a data set as possible if one is to maximize the benefits of capitation. These benefits largely revolve around creating a tool that primarily represents a language that can facilitate communication between the financial and clinical sides of managed care.     

Turkey-baster babies: a view from Europe

Classification of artificial insemination as a medical procedure has largely endured because the practice met the perceived needs of clients, physicians, and society. For nearly two decades, however, the success of self-insemination has challenged both the necessity of involving physicians in the process and the traditional understanding of the procedure as therapy for infertile couples. Demedicalization of artificial insemination as a matter of policy would entail changes in law, custom, and attitudes. The advent of safe and effective self-insemination makes critical a public debate on the issues of reproductive freedom, the meaning of parenthood, and the interests of children.     

A view from Europe: stability, consistency or pragmatism

The last few years of this decade look like a period of reappraisal of radiation protection standards. The revised risk estimates from Japan will be available, and the United Nations Scientific Committee on the Effects of Atomic Radiation will be publishing new reports on biological topics. The International Commission on Radiological Protection (ICRP) has started a review of its basic recommendations, and the new specification for dose equivalent in radiation fields of the International Commission on Radiation Units and Measurements (ICRU) will be coming into use. All this is occurring at a time when some countries are still trying to catch up with committed dose equivalent and the recently recommended change in the value of the quality factor for neutrons. In Europe, the problems of adapting to new ICRP recommendations are considerable. The European Community, including 12 states and nine languages, takes ICRP recommendations as a basis and develops council directives that are binding on member states, which have then to arrange for their own regulatory changes. Any substantial adjustments could take 5 y or more to work through the system. Clearly, the regulatory preference is for stability. Equally clearly, trade unions and public interest groups favor a rapid response to scientific developments (provided that the change is downward). Organizations such as the ICRP have to balance their desire for internal consistency and intellectual purity against the practical problems of their clients in adjusting to change. This paper indicates some of the changes that might be necessary over the next few years and how, given a pragmatic approach, they might be accommodated in Europe without too much regulatory confusion.     

Nozzles of insecticide sprayers; comments from the point of view of malaria control

Certain performance characteristics of the insecticide-sprayer nozzle tip and its relationship to the pressure regulator are discussed.     

Statistical methods for estimating attributable risk from retrospective data

This paper extends Levin's measure of attributable risk¹ to adjust for confounding by aetiologic factors other than the exposure of interest. One can estimate this extended measure from case-control data provided either (i) from the control data one can estimate exposure prevalence within each stratum of the confounding factor; or (ii) one has additional information available concerning the confounder distribution and the stratum-specific disease rates. In both cases we give maximum likelihood estimates and their estimated asymptotic variances, and show them to be independent of the sampling design (matched vs. random). Computer simulations investigate the behaviour of these estimates and of three types of confidence intervals when sample size is small relative to the number of confounder strata. The simulations indicate that attributable risk estimates tend to be too low. The bias is not serious except when exposure prevalence is high among controls. In this case the estimates and their standard error estimates are also highly unstable. In general, the asymptotic standard error estimates performed quite well, even in small samples, and even when the true asymptotic standard error was too small. By contrast, the bootstrap estimate² tended to be too large. None of the three confidence intervals proved superior in accuracy to the other two. Thus there appears no advantage in using the log-based interval suggested by Walter^3′4 which is always longer than the simpler symmetric interval.     

Confidence intervals for relative risk estimates from affected-sib-pair data

Confidence intervals for relative risk parameters estimated using affected-sib-pair data are derived and evaluated for two markers showing previous evidence of linkage to bipolar illness. For D18S41 we found some evidence, and for D18S37 stronger evidence, of relative risks greater than 1, although in both cases the estimated confidence intervals for the parameters are wide. © 1997 Wiley-Liss, Inc.     

多维视域下开放获取期刊撤稿原因分析——基于Retraction Watch Database数据

【目的】 透视和归纳开放获取(Open Access,OA)期刊的撤稿原因与趋势,为提高OA期刊的科研诚信管理质量和效果提供建议。【方法】 基于撤稿观察数据库(Retraction Watch Database),结合JCR中历年OA期刊名单,筛选2000年以来OA期刊撤稿记录,从整体趋势、原因共现、研究领域、所涉国别、发表期刊等视角对撤稿原因进行深入剖析。【结果】 当前OA期刊撤稿数量呈快速增长趋势;期刊和出版商关注的撤稿原因与科研机构存在差异,撤稿原因间共现情况各异;数据与结果相关问题是各领域OA期刊撤稿涉及的主要原因;同行评议问题在发展中国家较为突出,发达国家OA论文的数据和图像问题相对显著;较低影响因子期刊的撤稿原因比较高影响因子期刊更易于识别。【结论】 数据驱动的研究范式让管理实践应更重视数据和图像的准确性与可靠性,且应多元化监管主体、完善监管体系,优化期刊审稿流程与技术手段以更好地实现外部监管,同时辅以教育宣传以使科研诚信内化于行。     

Interval estimation of risk difference for data sampled from clusters

Risk difference (RD) is an important measure in epidemiological studies where the probability of developing a disease for individuals in an exposed group, for example, is compared with that in a control group. There are varying cluster sizes in each group and the binary responses within each cluster cannot be assumed independent. Under the cluster sampling scenario, Lui (Statistical Estimation of Epidemiological Risk. Wiley: CA, 2004; 7-27) discusses four methods for the construction of a confidence interval for the RD. In this paper we introduce two very simple methods. One method is based on an estimator of the variance of a ratio estimator (Sampling Techniques (3rd edn). Wiley: New York, 1977; 30-67) and the other method is based on a sandwich estimator of the variance of the regression estimator using the generalized estimating equations approach of Zeger and Liang (Biometrics 1986; 42:121-130). These two methods are then compared, by simulation, in terms of maintaining nominal coverage probability and average coverage length, with the four methods discussed by Lui (Statistical Estimation of Epidemiological Risk. Wiley: CA, 2004; 7-27). Simulations show at least as good properties of these two methods as those of the others. The method based on an estimate of the variance of a ratio estimator performs best overall. It involves a very simple variance expression and can be implemented with a very few computer codes. Therefore, it can be considered as an easily implementable alternative.     

The elephant in the room: a postphenomenological view on the electronic health record and its impact on the clinical encounter

Use of electronic health records (EHR) within clinical encounters is increasingly pervasive. The digital record allows for data storage and sharing to facilitate patient care, billing, research, patient communication and quality-of-care improvement—all at once. However, this multifunctionality is also one of the main reasons care providers struggle with the EHR. These problems have often been described but are rarely approached from a philosophical point of view. We argue that a postphenomenological case study of the EHR could lead to more in-depth insights. We will focus on two concepts—transparency and multistability—and translate them to the specific situation of the EHR. Transparency is closely related to an embodiment relation in which the user becomes less aware of the technology: it fades into the background, becoming a means of experience. A second key concept is that of multistability, referring to how a technology can serve multiple purposes or can have different meanings in different contexts. The EHR in this sense is multistable by design. Future EHR design could incorporate multistable information differently, allowing the provider to focus on patient care when interacting with the EHR. Moreover we argue that the use of the EHR in the daily workflow should become more transparent, while awareness of the computer in the specific context of the patient-provider relationship should increase.

     

A calibration hierarchy for risk models was defined: from utopia to empirical data

ObjectiveCalibrated risk models are vital for valid decision support. We define four levels of calibration and describe implications for model development and external validation of predictions.Study Design and SettingWe present results based on simulated data sets.ResultsA common definition of calibration is “having an event rate of R% among patients with a predicted risk of R%,” which we refer to as “moderate calibration.” Weaker forms of calibration only require the average predicted risk (mean calibration) or the average prediction effects (weak calibration) to be correct. “Strong calibration” requires that the event rate equals the predicted risk for every covariate pattern. This implies that the model is fully correct for the validation setting. We argue that this is unrealistic: the model type may be incorrect, the linear predictor is only asymptotically unbiased, and all nonlinear and interaction effects should be correctly modeled. In addition, we prove that moderate calibration guarantees nonharmful decision making. Finally, results indicate that a flexible assessment of calibration in small validation data sets is problematic.ConclusionStrong calibration is desirable for individualized decision support but unrealistic and counter productive by stimulating the development of overly complex models. Model development and external validation should focus on moderate calibration.     

Chromosomal aberrations and cancer risk: results of a cohort study from Central Europe

A high level of chromosomal aberrations in peripheral blood lymphocytes may be an early marker of cancer risk, but data on risk of specific cancers and types of chromosomal aberrations (chromosome type and chromatid type) are limited. A total of 6,430 healthy individuals from nine laboratories in Croatia, Hungary, Lithuania, Poland, and Slovakia, included in chromosomal aberration surveys performed during 1978-2002, were followed up for cancer incidence or mortality for an average of 8.5 years; 200 cancer cases were observed. Compared with that for the low-tertile level of chromosomal aberrations, the relative risks of cancer for the medium and high tertiles were 1.78 (95% confidence interval: 1.19, 2.67) and 1.81 (95% confidence interval: 1.20, 2.73), respectively. The relative risk for chromosome-type aberrations above versus below the median was 1.50 (95% confidence interval: 1.12, 2.01), while that for chromatid-type aberrations was 0.97 (95% confidence interval: 0.72, 1.31). The analyses of risk of specific cancers were limited by small numbers, but the association was stronger for stomach cancer. This study confirms the previously reported association between level of chromosomal aberrations and cancer risk and provides novel information on the type of aberrations more strongly predictive of cancer risk and on the types of cancer more strongly predicted by chromosomal aberrations.     

The classic risk factors for coronary heart disease: Experience in Europe

This article is based on the follow-up of 9,182 men from 13 cohorts of five European countries (Finland, Greece, Italy, Holland, and Yugoslavia). Its purpose is to explore the associations of known risk factors for coronary heart disease (CHD). A significant positive association was found between age and 10-year mortality from CHD (10-MCHD), between systolic blood pressure (SBP) and 10-MCHD (steeper for the Finns than for men from Mediterranean countries), and between serum cholesterol and 10-MCHD (more pronounced in northern than southern European men). Age-standardized 10-MCHD was found to increase with degree of smoking; the regression slope of this correlation was steeper for men from northern than from southern Europe. Although death from all causes tended to be inversely related to relative body weight, no consistent evidence of a relation between relative body weight or body fatness and CHD was found. Incidence rate of CHD was not consistently related to physical activity characteristics of the groups. Resting pulse rate was an important risk factor for all causes of death in 10 years, but of less consequence for MCHD. Regression slopes were steeper for northern than for southern Europeans. Vital capacity was a significant risk factor for MCHD for Italian but not for Finnish, Greek, or Serbian men. The 10-year adjusted MCHD was correlated with total fat in the diet; the correlation with saturated fatty acids was much more significant.     

Convergence and divergence of life expectancy in Europe: a centennial view

It has been noted that national life expectancies have diverged in Europe in recent decades, but it is unknown how these recent trends compare to longer term developments. Data on life expectancy, cause-specific mortality and determinants of mortality were extracted from harmonized international data-bases. Variation was quantified with the inter-quartile range, and the contribution of changing economic conditions was analyzed by comparing observed life expectancy variations with those expected on the basis of changes in levels of national income and/or changes in the relation between national income and life expectancy. During the first decades of the 20^th century, variation in life expectancy in Europe increased to reach peak values around 1920, then decreased to reach its lowest values in 1960 (among men) and 1970 (among women), and finally increased strongly again. The first widening was due to less rapid decline in mortality in Southern and Central and Eastern Europe, particularly from infectious diseases, and coincided with an increasing strength of the national income—life expectancy relation. The second widening was due to stagnating or increasing mortality in Central and Eastern Europe, particularly from cardiovascular diseases, and coincided with a very strong rise of between-country differences in national income. Despite some similarities, differences between both episodes of widening differences in life expectancy cast doubt on the idea that the current episode of widening represents a simple delay of epidemiological transitions. Instead, it is an alarming phenomenon that should be a main focus of European policy making.     

Evaluating Medicaid HMOs when encounter data are missing: case of developmentally delayed children

In evaluating Medicaid Health Maintenance Organizations (HMOs), crucial information regarding severity of illness of patients is often missing – in part because encounter data are not available. If we assume that patients are either in the HMO or in fee-for-service (FFS) plans (i.e., no in or out migration); then severity of HMO patients can be deduced from encounters of FFS patients. We applied this approach to effectiveness of HMO services for developmentally delayed children. Data supported the assumption of a closed system. Data also showed that over 12 months, severity of FFS patients declined. Therefore, we inferred that the HMO was attracting sicker patients. The HMO was paid less than FFS plan, despite the fact that it attracted sicker patients.     

Strategies for dismissing dietary risks: insights from user-generated comments online

Communication around chronic dietary risks has proved challenging as dietary health risks are ostensibly met with attenuated perceptions of their likelihood and consequences. In this article, we examine the strategies that an online public use to negotiate risk messages from expert stakeholders that may be incongruent with their own position on a risk. Progressing from conceptualisations of amplification as laid out in the social amplification of risk framework, we are particularly interested in understanding whether and how amplifications of risk may be attributed towards other stakeholders. The article presents an analysis of comments posted on a website oriented to a British audience. These comments were left by members of the public in reply to two online media articles published in 2012 reporting on an epidemiological study carried out in the United States on the risks of red meat consumption. We found that the comments generally expressed resistance to the risk message, embodied in two main strategies. The first strategy was to discount the message itself by deploying rules of thumb that undermined the applicability of the general risk message to the particularities of the individual. The second strategy was to undermine the risks by casting doubt on the credibility of the message source. Together, these strategies allowed the commenters to argue that the risks and the process of communicating them resulted in an exaggerated picture. These findings highlight that by attributing amplification to others, further polarisation of risk views between stakeholders may occur. Thinking about amplification as an attribution provides a distinct and significant conceptual contribution to the study of incongruent risk responses.