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The population epidemiology of AKI is not well described. Here, we analyzed data from the Nationwide Inpatient Sample, a nationally representative dataset, to identify cases of dialysis-requiring AKI using validated International Classification of Diseases, Ninth Revision (ICD-9) codes. From 2000 to 2009, the incidence of dialysis-requiring AKI increased from 222 to 533 cases per million person-years, averaging a 10% increase per year (incidence rate ratio=1.10, 95% CI=1.10-1.11 per year). Older age, male sex, and black race associated with higher incidence of dialysis-requiring AKI. The rapid increase in incidence was evident in all age, sex, and race subgroups examined. Temporal changes in the population distribution of age, race, and sex as well as trends of sepsis, acute heart failure, and receipt of cardiac catheterization and mechanical ventilation accounted for about one third of the observed increase in dialysis-requiring AKI among hospitalized patients. The total number of deaths associated with dialysis-requiring AKI rose from 18,000 in 2000 to nearly 39,000 in 2009. In conclusion, the incidence of dialysis-requiring AKI increased rapidly in all patient subgroups in the past decade in the United States, and the number of deaths associated with dialysis-requiring AKI more than doubled.

Objectives: To evaluate ROP screening rates in a population-based cohort; and to identify characteristics of patients that were missed., Study Design: We used the California Perinatal Quality Care Collaborative data from 2005-2007 for a cross-sectional study. Using eligibility criteria, screening rates were calculated for each hospital. Multivariable regression was used to assess associations between patient clinical and sociodemographic factors and the odds of missing screening., Results: Overall rates of missed ROP screening decreased from 18.6% in 2005 to 12.8% in 2007. Higher gestational age (OR = 1.25 for increase of 1 week, 95% CI, 1.21-1.29), higher birth weight (OR = 1.13; 95% CI, 1.10-1.15), and singleton birth (OR = 1.2; 95% CI, 1.07-1.34) were associated with higher probability of missing screening. Level II neonatal intensive care units and neonatal intensive care units with lower volume were more likely to miss screenings., Conclusion: Although ROP screening rates improved over time, larger and older infants are at risk for not receiving screening. Furthermore, large variations in screening rates exist among hospitals in California. Identification of gaps in quality of care creates an opportunity to improve ROP screening rates and prevent impaired vision in this vulnerable population., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Medicare's new hospital pay-for-performance program for all acute care hospitals will begin in October 2012. It will be the largest Medicare quality improvement initiative for hospitals to date. Using 2009 data on hospital performance, we calculated hospital performance scores and projected payments under the new program for all eligible hospitals. Despite differences across hospitals in terms of performance, expected changes in payments were small, even for hospitals with the best and worst performance scores. Almost two-thirds of hospitals would experience changes of just a fraction of 1 percent. Although the program will in effect redistribute resources among hospitals, our data suggest that the redistribution is not likely to cause major problems because the amount being redistributed is also small. These results raise questions about whether the new pay-for-performance program will substantially alter the quality of hospital care, and they highlight the challenges of designing effective quality improvement incentives.

Objectives: To determine functional status and mortality rates after colon cancer surgery in older nursing home residents., Design: Retrospective cohort study., Setting: Nursing homes in the United States., Participants: Six thousand eight hundred twenty-two nursing home residents aged 65 and older who underwent surgery for colon cancer in the United States between 1999 and 2005., Measurements: Changes in functional status were assessed before and after surgery using the Minimum Data Set Activity of Daily Living (MDS-ADL) summary scale, a 28-point scale in which score increases as functional dependence increases. Regression techniques were used to identify patient characteristics associated with mortality and functional decline 1 year after surgery., Results: On average, residents who underwent colectomy had a 3.9-point worsening in MDS-ADL score at 1 year. One year after surgery, rates of mortality and sustained functional decline were 53% and 24%, respectively. In multivariate analysis, older age (≥ 80 vs 65-69, adjusted relative risk (ARR) = 1.53, 95% confidence interval (CI) = 1.15-2.04, P < .001), readmission after surgical hospitalization (ARR = 1.15, 95% CI = 1.03-1.29, P = .02), surgical complications (ARR = 1.11, 95% CI = 1.02-1.21, P = .01), and functional decline before surgery (ARR = 1.21, 95% CI = 1.11-1.32, P < .001) were associated with functional decline at 1 year., Conclusion: Mortality and sustained functional decline are common after colon cancer surgery in nursing home residents. Initiatives aimed at improving surgical outcomes are needed in this vulnerable population., (© 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.)

Objective: To determine surgical risk in nursing home residents undergoing major abdominal surgery., Background: Recent studies suggest that surgery can be performed safely in the very old. Surgical risk in nursing home residents is poorly understood., Methods: We used national Medicare claims and the nursing home Minimum Data Set (1999-2006) to identify nursing home residents undergoing surgery (surgery for bleeding duodenal ulcer, cholecystectomy, appendectomy, and colectomy, n = 70,719). We compared operative mortality and use of invasive interventions (mechanical ventilation, intravascular hemodynamic monitoring, feeding tube placement, tracheostomy, and vena cava filters) among nursing home residents to rates among noninstitutionalized Medicare enrollees age 65 and older undergoing the same procedures. (n = 1,060,389). We adjusted for patient characteristics using logistic regression., Results: Operative mortality among nursing home residents was substantially higher than among noninstitutionalized Medicare enrollees for all procedures (surgery for bleeding duodenal ulcer, 42% versus 26%, adjusted odds ratio (AOR) 1.79; colectomy, 32% versus 13%, AOR 2.06; appendectomy, 12% versus 2%, AOR 3.27; cholecystectomy, 11% versus 3%, AOR 2.65; P < 0.001 for all comparisons). Overall, invasive interventions were more common among nursing home residents than controls (ranging from 18% and 5%, respectively, for cholecystectomy to 55% and 43%, respectively, for surgery for bleeding duodenal ulcer, P < 0.0001 for all comparisons)., Conclusions: Nursing home residents experience substantially higher rates of mortality and invasive interventions after major surgery than other Medicare beneficiaries that are independent of age and measured comorbidities. Our data suggest that the risks of major surgery are substantially higher in nursing home residents and this information should inform decisions of physicians and patients and their families.

Background: Despite compelling evidence of the benefits of treatment and well-accepted guidelines for treatment, hypertension is controlled in less than one-half of United States citizens., Methods/design: This randomized controlled trial tests whether explicit financial incentives promote the translation of guideline-recommended care for hypertension into clinical practice and improve blood pressure (BP) control in the primary care setting. Using constrained randomization, we assigned 12 Veterans Affairs hospital outpatient clinics to four study arms: physician-level incentive; group-level incentive; combination of physician and group incentives; and no incentives (control). All participants at the hospital (cluster) were assigned to the same study arm. We enrolled 83 full-time primary care physicians and 42 non-physician personnel. The intervention consisted of an educational session about guideline-recommended care for hypertension, five audit and feedback reports, and five disbursements of incentive payments. Incentive payments rewarded participants for chart-documented use of guideline-recommended antihypertensive medications, BP control, and appropriate responses to uncontrolled BP during a prior four-month performance period over the 20-month intervention. To identify potential unintended consequences of the incentives, the study team interviewed study participants, as well as non-participant primary care personnel and leadership at study sites. Chart reviews included data collection on quality measures not related to hypertension. To evaluate the persistence of the effect of the incentives, the study design includes a washout period., Discussion: We briefly describe the rationale for the interventions being studied, as well as the major design choices. Rigorous research designs such as the one described here are necessary to determine whether performance-based payment arrangements such as financial incentives result in meaningful quality improvements., Trial Registration: http://www.clinicaltrials.govNCT00302718.

Objective: To examine the extent to which performance assessment methods affect the percentage of neonatal intensive care units (NICUs) and very low-birth-weight (VLBW) infants included in performance assessments, the distribution of NICU performance ratings, and the level of agreement in those ratings., Design: Cross-sectional study based on risk-adjusted nosocomial infection rates., Setting: NICUs belonging to the California Perinatal Quality Care Collaborative 2007-2008., Participants: One hundred twenty-six California NICUs and 10 487 VLBW infants., Main Exposures: Three performance assessment choices: (1) excluding "low-volume" NICUs (those caring for <30 VLBW infants per year) vs a criterion based on confidence intervals, (2) using Bayesian vs frequentist hierarchical models, and (3) pooling data across 1 vs 2 years., Main Outcome Measures: Proportion of NICUs and patients included in quality assessment, distribution of ratings for NICUs, and agreement between methods using the κ statistic., Results: Depending on the methods applied, 51% to 85% of NICUs and 72% to 96% of VLBW infants were included in performance assessments, 76% to 87% of NICUs were considered "average," and the level of agreement between NICU ratings ranged from 0.23 to 0.89., Conclusions: The percentage of NICUs included in performance assessments and their ratings can shift dramatically depending on performance measurement method. Physicians, payers, and policymakers should continue to closely examine which existing performance assessment methods are most appropriate for evaluating pediatric care quality.

Objectives: To estimate risk factors for premature neonates not receiving antenatal steroids in a population-based cohort and to determine whether the gains of a quality-improvement collaborative project on antenatal steroid administration were sustained long-term., Methods: Clinical data for premature neonates born in 2005–2007 were obtained from the California Perinatal Quality Care Collaborative, which collects data on more than 90% of neonatal admissions in California. Eligible neonates had a birth weight of less than 1,500 g or gestational age less than 34 weeks and were born at a Collaborative hospital. These data were linked to administrative data from California Vital Statistics. Sociodemographic and medical risk factors for not receiving antenatal steroids were determined. We also examined the effect of birth hospital participation in a previous quality-improvement collaborative project. A random effects logistic regression model was used to determine independent risk factors., Results: Of 15,343 eligible neonates, 23.1% did not receive antenatal steroids in 2005–2007. Hispanic mothers (25.6%), mothers younger than age 20 (27.6%), and those without prenatal care (52.2%) were less likely to receive antenatal steroids. Mothers giving birth vaginally (26.8%) and mothers with a diagnosis of fetal distress (26.5%) were also less likely to receive antenatal steroids. Rupture of membranes before delivery and multiple gestations were associated with higher likelihood of antenatal steroid administration. Hospitals that participated in a quality-improvement collaborative in 1999– 2000 had higher rates of antenatal steroid administration (85% compared with 69%, P<.001)., Conclusion: A number of eligible mothers do not receive antenatal steroids. Quality-improvement initiatives to improve antenatal steroid administration could target specific high-risk groups.

Objective: Accurate measurements of prevalence of "any" breastfeeding and "exclusive" breastfeeding help assess progress toward public health goals. We compared two commonly used data sources for measuring breastfeeding rates to assess agreement., Methods: The National Immunization Survey (NIS) is used by the Centers for Disease Control and Prevention to measure progress toward national breastfeeding goals and obtains breastfeeding outcomes retrospectively at 19-35 months. The California Newborn Screen (CNS) is a contemporaneous measure of breastfeeding during birth hospitalization and measures progress toward public health goals in California. We compared results for "any breastfeeding" and "exclusive breastfeeding" for California infants in the NIS to those in the CNS using descriptive statistics., Results: Our results show that the two methods produce similar results for "any" breastfeeding at <4 days: 82.7%, 95% confidence interval (79.6%, 85.8%) in the NIS and 86.1% (86.0%, 86.2%) in the CNS. However, the two methods produce very different results for "exclusive" breastfeeding at <4 days: 60.4% (56.6%, 64.1%) in the NIS and 41.6% (41.5%, 41.7%) in the CNS. Rates of "exclusive" breastfeeding varied more for some subgroups; for Hispanics, estimates were 61.1% (56.1%, 66.1%) in the NIS and 29.7% (29.5%, 29.9%) in the CNS., Conclusions: There is good agreement between two disparate methods for assessing "any" breastfeeding rates. However, our findings suggest that the NIS, the CNS, or both are flawed measures of "exclusive" breastfeeding. Validated methods for measuring "exclusive" breastfeeding would allow improved monitoring of breastfeeding prevalence.

Purpose: Existing intensive care unit (ICU) mortality measurement systems address in-hospital mortality only. However, early postdischarge mortality contributes significantly to overall 30-day mortality. Factors associated with early postdischarge mortality are unknown., Methods: We performed a retrospective study of 8484 ICU patients. Our primary outcome was early postdischarge mortality: death after hospital discharge and 30 days or less from ICU admission. Cox regression models assessed the association between patient, hospital, and utilization factors and the primary outcome., Results: In multivariate analyses, the hazard for early postdischarge mortality increased with rising severity of illness and decreased with full-code status (hazard ratio [HR], 0.33; 95% confidence interval [CI], 0.21-0.49). Compared with discharges home, early postdischarge mortality was highest for acute care transfers (HR, 3.18; 95% CI, 2.45-4.12). Finally, patients with very short ICU length of stay (<1 day) had greater early postdischarge mortality (HR, 1.86; 95% CI; 1.32-2.61) than those with longest stays (≥7 days)., Conclusions: Early postdischarge mortality is associated with patient preferences (full-code status) and decisions regarding timing and location of discharge. These findings have important implications for anyone attempting to measure or improve ICU performance and who rely on in-hospital mortality measures to do so., (Published by Elsevier Inc.)

Aim: The broad objective of this study was to examine multiple dimensions of depression in a large, diverse population of adults with diabetes. Specific aims were to measure the association of depression with: (1) patient characteristics; (2) outcomes; and (3) diabetes-related quality of care., Methods: Cross-sectional analyses were performed using survey and chart data from the Translating Research Into Action for Diabetes (TRIAD) study, including 8790 adults with diabetes, enrolled in 10 managed care health plans in 7 states. Depression was measured using the Patient Health Questionnaire (PHQ-8). Patient characteristics, outcomes and quality of care were measured using validated survey items and chart data., Results: Nearly 18% of patients had major depression, with prevalence 2-3 times higher among patients with low socioeconomic status. Pain and limited mobility were strongly associated with depression, controlling for other patient characteristics. Depression was associated with slightly worse glycemic control, but not other intermediate clinical outcomes. Depressed patients received slightly fewer recommended diabetes-related processes of care., Conclusions: In a large, diverse cohort of patients with diabetes, depression was most prevalent among patients with low socioeconomic status and those with pain, and was associated with slightly worse glycemic control and quality of care., (Copyright © 2010 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.)

Objective: The aim of this study was to determine the percentage of hospitals with adequate sample size to meaningfully compare performance by using the Agency for Healthcare Research and Quality (AHRQ) pediatric quality indicators (PDIs), which measure pediatric inpatient adverse events such as decubitus ulcer rate and infections due to medical care, have been nationally endorsed, and are currently publicly reported in at least 2 states., Methods: We performed a cross-sectional analysis of California hospital discharges from 2005-2007 for patients aged <18 years. For 9 hospital-level PDIs, after excluding discharges with PDIs indicated as present on admission, we determined for each PDI the volume of eligible pediatric patients for each measure at each hospital, the statewide mean rate, and the percentage of hospitals with adequate volume to identify an adverse event rate twice the statewide mean., Results: Unadjusted California-wide event rates for PDIs during the study period (N = 2 333 556 discharges) were 0.2 to 38 per 1000 discharges. Event rates for specific measures were, for example, 0.2 per 1000 (iatrogenic pneumothorax in non-neonates), 19 per 1000 (postoperative sepsis), and 38 per 1000 (pediatric heart surgery mortality), requiring patient volumes of 49 869, 419, and 201 to detect an event rate twice the statewide average; 0%, 6.6%, and 25%, respectively, of California hospitals had this pediatric volume., Conclusion: Using these AHRQ-developed, nationally endorsed measures of the quality of inpatient pediatric care, one would not be able to identify many hospitals with performance 2 times worse than the statewide average due to extremely low event rates and inadequate pediatric hospital volume., (2010 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: To examine whether physicians' use of information technology (IT) was associated with better knowledge of drug costs., Study Design/methods: A 2007 statewide survey of 247 primary care physicians in Hawaii regarding IT use and self-reported knowledge of formularies, copayments, and retail prices., Results: Approximately 8 in 10 physicians regularly used IT in clinical care: 60% Internet, 54% e-prescribing, 43% electronic health records (EHRs), and 37% personal digital assistants (PDAs). However, fewer than 1 in 5 often knew drug costs when prescribing, and more than 90% said lack of knowledge of formularies and copayments remained a barrier to considering drug costs for patients. In multivariate analyses adjusting for sex, practice size, years in practice, number of formularies, and use of clinical resources (eg, pharmacists), use of the Internet -- but not e-prescribing, EHRs, or PDAs -- was associated with physicians reporting slightly better knowledge of copayments (adjusted predicted percentage of 23% vs 11%; P = .04). No type of IT was associated with better knowledge of formularies or retail prices., Conclusions: Despite high rates of IT use, there was only a modest association between physicians' use of IT and better knowledge of drug costs. Future investments in health IT should consider how IT design can be improved to make it easier for physicians to access cost information at the point of care.

Background: Hospital leaders usually provide financial support to hospitalists groups, often with an expectation of improved performance on publicly reported quality metrics. Whether the presence of hospitalists is associated with differences in hospital-level performance is unknown., Objective: Assess the relationship between hospitalist prevalence and quality performance., Design: Cross-sectional study., Participants: A total of 208 California hospitals participating in a voluntary reporting initiative., Intervention: Survey of hospital personnel with knowledge of the utilization of hospitalists for patient care., Measurements: Sixteen publicly reported quality process measures across 3 medical conditions: acute myocardial infarction (AMI); congestive heart failure (CHF); and pneumonia. Using multivariable models, we assessed the relationship between the presence of hospitalists and the percentage of missed quality opportunities for each process measure., Results: Of 208 eligible hospitals, 170 (82%) had hospitalist services. After adjustment, hospitals with hospitalists had similar performance for cardiac and pneumonia measures assessed at admission and fewer missed processes for CHF measures assessed at discharge. Among sites with hospitalists, every 10% increase in the estimated percentage of patients admitted by hospitalists was associated with 0.5% fewer (P < 0.001) missed quality opportunities for AMI at admission, and 0.6% (P < 0.001), 0.5% (P = 0.004), and 1.5% (P = 0.006) fewer missed quality opportunities for AMI, CHF, and pneumonia assessed at discharge, respectively., Conclusions: The presence of hospitalists in California was associated with modest improvements in performance on publicly reported process measures. Whether hospitalists directly improve quality or simply reflect a hospital's level of investment in quality remains a subject for future study., ((c) 2010 Society of Hospital Medicine.)

Rationale: Pay-for-performance is a model for health care financing that seeks to link reimbursement to quality. The American Thoracic Society and its members have a significant stake in the development of pay-for-performance programs., Objectives: To develop an official ATS policy statement addressing the role of pay-for-performance in pulmonary, critical care and sleep medicine., Methods: The statement was developed by the ATS Health Policy Committee using an iterative consensus process including an expert workshop and review by ATS committees and assemblies., Measurements and Main Results: Pay-for-performance is increasingly utilized by health care purchasers including the United States government. Published studies generally show that programs result in small but measurable gains in quality, although the data are heterogeneous. Pay-for-performance may result in several negative consequences, including the potential to increase costs, worsen health outcomes, and widen health disparities, among others. Future research should be directed at developing reliable and valid performance measures, increasing the efficacy of pay-for-performance programs, minimizing negative unintended consequences, and examining issues of costs and cost-effectiveness. The ATS and its members can play a key role in the design and evaluation of these programs by advancing the science of performance measurement, regularly developing quality metrics alongside clinical practice guidelines, and working with payors to make performance improvement a routine part of clinical practice., Conclusions: Pay-for-performance programs will expand in the coming years. Pulmonary, critical care and sleep practitioners can use these programs as an opportunity to partner with purchasers to improve health care quality.

Although pay-for-performance (P4P) is being widely adopted, little is known about how different P4P strategies affect provider payment. These differences may be essential in motivating and maximizing quality improvement across all providers. We review hospitals' P4P strategies and describe differences in payments by size of reward; payment differences between high- and low-performing providers; ability to reward improvement in the absence of high performance; and the percentage of payments based on performance. Bonuses vary considerably by payment strategy, which suggests that the strategy selected should vary depending on program goals. These findings are relevant to P4P for any type of provider.

Objectives: Many elderly persons have drug benefits with coverage gaps, such as in Medicare Part D. Because beneficiaries who have such gaps must pay all drug costs, an accurate knowledge of gap thresholds and communication with providers about exceeding caps is important for elderly persons to manage out-of-pocket drug costs., Design: Cross-sectional survey., Setting: Health plan., Participants: One thousand three hundred eight health plan members aged 65 and older. The study was a 2002 cross-sectional survey of elderly persons with capped drug benefits in a managed care plan in one state. Participants were sampled so that half reached coverage caps and half did not., Methods: Participants reported cap levels, communication with providers about exceeding caps, and decreased medication use due to cost., Results: Of the 1,308 participants (65.4%response rate), 68.6%did not know their correct cap level. Rates were similar in those who exceeded caps (66.2%), reported difficulty paying for medications (63.9%), or decreased medication use (66%). For participants who exceeded caps, 59.1% did not know beforehand that they were close to exceeding caps and 50.2% did not tell providers afterward. In multivariate analyses accounting for demographics and health, the oldest participants (> or =85 vs 65-74) were at greater risk for not knowing cap levels (odds ratio (OR)=2.0, 95% confidence interval (CI)=1.2-3.4) and not telling providers about exceeding caps (OR=2.2, 95% CI=1.1-4.5)., Conclusions: Elderly patients often did not know correct cap levels and did not tell providers about exceeding caps. Providers, plans, and policymakers should actively assess and improve Medicare beneficiaries' knowledge of Part D coverage gaps.

Context: The Leapfrog Hospital Survey allows hospitals to self-report the steps they have taken toward implementing the Safe Practices for Better Healthcare endorsed by the National Quality Forum. The Leapfrog Group currently ranks hospital performance on the safe practices initiative by quartiles and presents this information to the public on its Web site. It is unknown how well a hospital's resulting Safe Practices Score (SPS) correlates with outcomes such as inpatient mortality., Objective: To determine the relationship between hospitals' SPSs and risk-adjusted inpatient mortality rates., Design, Setting, and Participants: Observational analysis of discharge data for all urban US hospitals completing the 2006 safe practices initiative and identifiable in the Nationwide Inpatient Sample. Leapfrog provided an SPS for each hospital as well as 3 alternative scores based on shorter versions of the original survey. Hierarchical logistic regression was used to determine the relationship between quartiles of SPS and risk-adjusted inpatient mortality, after adjusting for hospital discharge volume and teaching status. Subgroup analyses were performed using data from patients older than 65 years and patients with 5% or greater expected mortality risk., Main Outcome Measures: Inpatient risk-adjusted mortality by quartiles of survey score., Results: Of 1075 hospitals completing the 2006 Safe Practices Survey, 155 (14%) were identifiable in the National Inpatient Sample (1,772,064 discharges). Raw observed mortality in the primary sample was 2.09%. Fully adjusted mortality rates by quartile of SPS, from lowest to highest, were 1.97% (95% confidence interval [CI], 1.78%-2.18%), 2.04% (95% CI, 1.84%-2.25%), 1.96% (95% CI, 1.77%-2.16%), and 2.00% (95% CI, 1.80%-2.22%) (P = .99 for linear trend). Results were similar in the subgroup analyses. None of the 3 alternative survey scores was associated with risk-adjusted inpatient mortality, although P values for linear trends were lower (.80, .20, and .11)., Conclusion: In this sample of hospitals that completed the 2006 Safe Practices Survey, survey scores were not significantly associated with risk-adjusted inpatient mortality.

The use of incentives to improve quality of care is spreading rapidly across the health care system. Public reporting (PR) and pay-for-performance (PFP) are two examples of incentive-based programs. Although conclusive level I evidence for the positive impacts of these PR and PFP is limited, individual states and the federal government have begun to adopt and pilot these programs for a variety of specific clinical conditions. This article reviews the principles of health care quality performance measurement; current reporting and pay-for-performance programs; and the most recent literature documenting positive, negative and future impacts of these types of programs on urologic practice.

The veterans health care system administered by the U.S. Department of Veterans Affairs (VA) was established after World War I to provide health care for veterans who suffered from conditions related to their military service. It has grown to be the nation's largest integrated health care system. As the system grew, a number of factors contributed to its becoming increasingly dysfunctional. By the mid-1990s, VA health care was widely criticized for providing fragmented and disjointed care of unpredictable and irregular quality, which was expensive, difficult to access, and insensitive to individual needs. Between 1995 and 1999, the VA health care system was reengineered, focusing especially on management accountability, care coordination, quality improvement, resource allocation, and information management. Numerous systemic changes were implemented, producing dramatically improved quality, service, and operational efficiency. VA health care is now considered among the best in America, and the VA transformation is viewed as a model for health care reform.

Context: The Centers for Medicare and Medicaid Services will introduce the reporting of patient surveys in 2008. The Consumer Assessment of Health Care Providers and Systems (CAHPS) Hospital Survey contains 18 questions about hospital care. Internal consistency reliability of the discharge information scale is relatively low and some important domains of care are not represented., Objective: To determine whether adding questions increases the reliability and validity of the survey., Data Sources and Study Setting: Surveys of patients at 181 hospitals participating in the California Hospitals Assessment and Reporting Taskforce (CHART), an initiative for voluntary public reporting of hospital performance in California., Study Design: CHART added nine questions to the CAHPS Hospital Survey; two to improve reliability of the discharge information domain, five to create a coordination of care domain, and two relating to interpreter services., Data Collection: Surveys were sent to randomly selected patients from each CHART hospital., Principal Findings: A total of 40,172 surveys were included. Adding the new discharge information questions improved the internal consistency reliability from 0.45 to 0.72 and the hospital-level reliability from 0.75 to 0.81. New coordination of care composites had good internal consistency reliabilities ranging from 0.58 to 0.70 and hospital-level reliabilities ranging from 0.84 to 0.87. The new coordination of care composites were more closely correlated with overall hospital ratings and willingness to recommend than six of the seven original domains., Conclusions: The additional discharge information questions and the new coordination of care questions significantly improved the psychometric properties of the CAHPS Hospital Survey.

Context: Guidelines call for documenting ischemia in patients with stable coronary artery disease prior to elective percutaneous coronary intervention (PCI)., Objective: To determine the frequency and predictors of stress testing prior to elective PCI in a Medicare population., Design, Setting, and Patients: Retrospective, observational cohort study using claims data from a 20% random sample of 2004 Medicare fee-for-service beneficiaries aged 65 years or older who had an elective PCI (N = 23 887)., Main Outcome Measures: Percentage of patients who underwent stress testing within 90 days prior to elective PCI; variation in stress testing prior to PCI across 306 hospital referral regions; patient, physician, and hospital characteristics that predicted the appropriate use of stress testing prior to elective PCI., Results: In the United States, 44.5% (n = 10 629) of patients underwent stress testing within the 90 days prior to elective PCI. There was wide regional variation among the hospital referral regions with stress test rates ranging from 22.1% to 70.6% (national mean, 44.5%; interquartile range, 39.0%-50.9%). Female sex (adjusted odds ratio [AOR], 0.91; 95% confidence interval [CI], 0.86-0.97), age of 85 years or older (AOR, 0.83; 95% CI, 0.72-0.95), a history of congestive heart failure (AOR, 0.85; 95% CI, 0.79-0.92), and prior cardiac catheterization (AOR, 0.45; 95% CI, 0.38-0.54) were associated with a decreased likelihood of prior stress testing. A history of chest pain (AOR, 1.28; 95% CI, 1.09-1.54) and black race (AOR, 1.26; 95% CI, 1.09-1.46) increased the likelihood of stress testing prior to PCI. Patients treated by physicians performing 150 or more PCIs per year were less likely to have stress testing prior to PCI (AOR, 0.84; 95% CI, 0.77-0.93). No hospital characteristics were associated with receipt of stress testing., Conclusion: The majority of Medicare patients with stable coronary artery disease do not have documentation of ischemia by noninvasive testing prior to elective PCI.

Background: Percutaneous coronary intervention (PCI) is performed in many patients with stable coronary artery disease, despite evidence of little clinical benefit over optimal medical therapy., Objective: To examine physicians' beliefs, practices, and decision-making regarding elective PCI., Design: Six focus groups, three with primary care physicians and three with cardiologists. Participants discussed PCI using hypothetical case scenarios. Transcripts were analyzed using grounded theory, and commonly expressed themes regarding the decision-making pathway to PCI were identified., Participants: Twenty-eight primary care physicians and 20 interventional and non-interventional cardiologists in Butte County, Orange County, and San Francisco Bay Area, California, in 2006., Results: A number of factors led primary care physicians to evaluate non-symptomatic or minimally symptomatic patients for coronary artery disease and refer them to a cardiologist. The use of screening tests often led to additional testing and referral, as well as fear of missing a coronary stenosis, perceived patient expectations, and medicolegal concerns. The end result was a cascade such that any positive test would generally lead to the catheterization lab, where an "oculostenotic reflex" made PCI a virtual certainty., Conclusions: The widespread use of PCI in patients with stable coronary artery disease--despite evidence of little benefit in outcomes over medical therapy--may in part be due to psychological and emotional factors leading to a cascade effect wherein testing leads inevitably to PCI. Determining how to help physicians better incorporate evidence-based medicine into decision-making has important implications for patient outcomes and the optimal use of new technologies.

Background: There is evidence that patients with Medicaid insurance suffer worse outcomes from surgical conditions; but there is little research about whether this reflects clustering of such patients at hospitals with worse outcomes. We assess the outcomes of patients with colon and rectal cancers at hospitals with a high proportion of Medicaid patients., Study Design: California Cancer Registry patient-level records were linked to discharge abstracts from California's Office of Statewide Health Planning and Development. All operative California Cancer Registry patients from 1998 and 1999 were included. Hospitals with > 40% Medicaid patients were labeled high Medicaid hospitals (HMH). We analyzed the odds of mortality at 30 days, 1, and 5 years for colon cancer and rectal cancer separately. Multilevel logistic regression models were constructed, using MLwiN 2.0, to include patient and hospital-level characteristics., Results: Thirty-day mortality after colon operation was worse in HMH (1% versus 0.6%; p = 0.04); as was 1-year mortality (3.4% versus 2.4%; p = 0.001). There was no substantial difference in rates of 5-year mortality. Individuals who were insured by Medicaid had worse outcomes at 5 years. Adjustment for surgical volume eliminated the effect of HMH at 30 days (1% versus 0.7%; p = 0.45) but not at 1 year (3.4% versus 2.5%; p = 0.01). Adjustment for academic affiliation did not alter these results. There were an insufficient number of rectal cancer patients to detect any differences by hospital type., Conclusions: HMH have higher postoperative colon cancer mortality rates at 30 days and 1 year but not at 5 years. The early effect can be explained by surgical volume, but additional research is needed to determine which factors contribute to differences in intermediate outcomes after operations in HMH settings.

Background: Rural hospitals in the United States have demonstrated lower adherence to evidence based guidelines than their urban counterparts in national public reporting initiatives. We compared the quality of rural hospitals participating in a public reporting initiative to that of their urban counterparts using Hospital Compare, a new national database containing process measures., Methods: Cross-sectional analyses of hospitals participating in Hospital Compare in 2005, evaluating percent adherence to guidelines for 10 processes of care for acute myocardial infarction (AMI), heart failure (HF), and community-acquired pneumonia (CAP) using multivariable linear regression analyses., Results: Participating rural hospitals demonstrated lower adherence to evidence based guidelines in MI and HF quality measures (p<0.05) and higher adherence to prescribing antibiotics in a timely manner in CAP (p<0.05). Differences increased with bed size (F test for linear trend, p<0.05). After adjustment, the trends demonstrating lower adherence persisted in 6 AMI and HF measures and higher adherence in 1 CAP measure in spite of a disproportionate number of drop-outs among lower performing urban hospitals., Conclusions: Participating rural hospitals had lower performance than their urban counterparts. As the rural/urban quality gap varies by condition, bed size, and participation, we recommend comparing performance across a wide variety of condition-specific measures to enable targeted quality improvement.

Context: Safety-net hospitals (ie, those that predominantly treat poor and underserved patients) often have lower quality of care than non-safety-net hospitals. While public reporting and pay for performance have the potential to improve quality of care at poorly performing hospitals, safety-net hospitals may be unable to invest in quality improvement. As such, some have expressed concern that these incentives have the potential to worsen existing disparities among hospitals., Objective: To examine trends in disparities of quality of care between hospitals with high and low percentages of Medicaid patients., Design and Setting: Longitudinal study of the relationship between hospital performance and percentage Medicaid coverage from 2004 to 2006, using publicly available data on hospital performance. A simulation model was used to estimate payments at hospitals with high and low percentages of Medicaid patients., Main Outcome Measures: Changes in hospital performance between 2004 and 2006, estimating whether disparities in hospital quality between hospitals with high and low percentages of Medicaid patients have changed., Results: Of the 4464 participating hospitals, 3665 (82%) were included in the final analysis. Hospitals with high percentages of Medicaid patients had worse performance in 2004 and had significantly smaller improvement over time than those with low percentages of Medicaid patients. Hospitals with low percentages of Medicaid patients improved composite acute myocardial infarction performance by 3.8 percentage points vs 2.3 percentage points for those with high percentages, an absolute difference of 1.5 (P = .03). This resulted in a relative difference in performance gains of 39%. Larger performance gains at hospitals with low percentages of Medicaid patients were also seen for heart failure (difference of 1.4 percentage points, P = 0.04) and pneumonia (difference of 1.3 percentage points, P <.001). Over time, hospitals with high percentages of Medicaid patients had a lower probability of achieving high-performance status. In a simulation model, these hospitals were more likely to incur financial penalties due to low performance and were less likely to receive bonuses., Conclusions: Safety-net hospitals tended to have smaller gains in quality performance measures over 3 years and were less likely to be high-performing over time than non-safety-net hospitals. An incentive system based on these measures has the potential to increase disparities among hospitals.

Background: Medicare recently announced its intention to withhold additional payments for "serious preventable events.", The Intervention: Beginning in 2009, Medicare will withhold its usual additional payments associated with hospitalizations that included one of several potentially preventable adverse events, such as certain hospital-acquired infections, pressure ulcers, and retained surgical objects. Several more events are being considered for the future. A new coding category, "present on admission" (POA), has been added to identify patients whose adverse events occurred before the index hospitalization., Issues and Challenges: A "not paying for errors" policy seems reasonable if evidence demonstrates that most of the adverse events can be prevented by widespread adoption of achievable practices, the events can be measured accurately, the events resulted in clinically significant patient harm, and POA determination is feasible. Many of these criteria are met for the events in Medicare's starter set; but there are concerns about each event., Conclusions: Although the new Medicare policy will undoubtedly lead to instances of unfairness, gaming, and unforeseen consequences, it may be effective. This initial implementation should be considered a bold experiment, whose consequences are carefully monitored. Additional research will be needed to help identify preventable adverse events and evidence-based strategies to prevent them.

Purpose: In this retrospective cohort study we used data from the National Surgical Quality Improvement Program of the Veterans Health Administration to examine the effect of case volume and resident participation on radical retropubic prostatectomy outcomes., Materials and Methods: The study population included 5,736 patients who underwent radical retropubic prostatectomy in Veterans Administration hospitals between October 1, 2001 and September 30, 2004. Resource related outcomes included operative times and length of stay. Clinical outcomes included blood transfusion, complications, readmissions and reoperations. Hierarchical multivariate regression models were developed to predict outcomes. Risk adjustment was performed using patient chronic health factors and results of preoperative laboratory testing., Results: A total of 5,070 radical retropubic prostatectomy surgeries met inclusion criteria. After adjustment for case mix, academic training institutions had longer operative times (3.2 vs 2.4 hours, p <0.01) but shorter length of stay (3.4 vs 4.2 days, p <0.01). Surgery at academic institutions was not associated with greater risk of transfusion (p = 0.36), reoperation (p = 0.93), complications (p = 0.53) or readmissions (p = 0.97). However, among the academic institutions low vs high hospital radical retropubic prostatectomy volume was associated with longer length of stay (3.7 vs 3.1 days, p = 0.02) and higher transfusion rate (29.6% vs 18.2%, p = 0.02). Substantial clustering of outcomes at the hospital level was observed., Conclusions: Within the Veterans Administration system academic training institutions have longer operative times for radical retropubic prostatectomy, but shorter length of stay. Among the same institutions, high volume hospitals tend to have lower transfusion rates and shorter length of stay. Clustering of outcomes at the hospital level suggests that unmeasured institutional factors are key determinants of clinical and resource related outcomes.

Objectives: To determine whether elderly patients with high drug expenditures want and receive providers' help in managing drug costs., Design: Cross-sectional survey., Setting: A Medicare managed care plan (>400,000 members) in one state in 2002., Participants: One thousand one hundred six seniors (62% response rate) sampled so that half exceeded caps on their drug benefits the previous year, and all had total drug expenditures in the top quartile of members in their cap level., Measurements: Participants' preferences and experiences with providers discussing costs and participation in choosing medications., Results: Two-thirds reported difficulty paying for medications, and one-fourth decreased medication use because of cost. Most wanted providers to ask about medication affordability (81%), consider cost (86%), offer choices (70%), and to persuade them or decide for them which medication to use (88%), but few said providers asked about affordability (17%), usually or always discussed prices (19%), or offered choices (45%), although nearly all said providers chose their medications (93%). Sixty-two percent had asked providers for help with drug costs, although 34% who used less medication because of cost or had difficulty paying for medications had not asked for help., Conclusion: Providers should be aware that elderly patients want their help in managing drug costs but do not always receive it or ask for help when they need it. Providers could improve communication by initiating conversations about cost and by asking patients about preferences when prescribing.

Background: Percutaneous coronary intervention (PCI) is commonly performed in patients with stable coronary artery disease, despite current evidence suggesting that such patients derive minimal benefit from the procedure. We sought to determine the influences on cardiologists' decision to perform elective PCI in patients with stable coronary artery disease., Methods: We conducted a qualitative study using 3 focus groups of interventional and noninterventional cardiologists in California. Participants discussed issues surrounding the decision to perform PCI using hypothetical case scenarios. We analyzed the data according to the principles of grounded theory., Results: Despite acknowledging data showing that PCI offers no reduction in the risk of death or myocardial infarction in patients with stable coronary artery disease, cardiologists generally believed that PCI would benefit such patients. Reasons given for performing PCI included belief in the benefits of treating ischemia and the open artery hypothesis, especially with drug-eluting stents; potential regret for not intervening if a cardiac event could be averted; alleviation of patient anxiety; and medicolegal considerations. Participants believed that, in patients undergoing coronary angiography, an "oculostenotic reflex" prevailed and all significant amenable stenoses would receive intervention, even in asymptomatic patients., Conclusions: The widespread application of PCI in stable coronary artery disease for indications unsupported by evidence may reflect discordance between cardiologists' clinical knowledge and their beliefs about the benefits of PCI. Nonclinical factors appear to have substantial influence on physician decision making. Future studies should focus on the development of methods to help providers more fully incorporate clinical evidence into their medical decision making.

Objective: To demonstrate how failure to account for measurement error in an outcome (dependent) variable can lead to significant estimation errors and to illustrate ways to recognize and avoid these errors., Data Sources: Medical literature and simulation models., Study Design/data Collection: Systematic review of the published and unpublished epidemiological literature on the rate of preventable hospital deaths and statistical simulation of potential estimation errors based on data from these studies., Principal Findings: Most estimates of the rate of preventable deaths in U.S. hospitals rely upon classifying cases using one to three physician reviewers (implicit review). Because this method has low to moderate reliability, estimates based on statistical methods that do not account for error in the measurement of a "preventable death" can result in significant overestimation. For example, relying on a majority rule rating with three reviewers per case (reliability approximately 0.45 for the average of three reviewers) can result in a 50-100 percent overestimation compared with an estimate based upon a reliably measured outcome (e.g., by using 50 reviewers per case). However, there are statistical methods that account for measurement error that can produce much more accurate estimates of outcome rates without requiring a large number of measurements per case., Conclusion: The statistical principles discussed in this case study are critically important whenever one seeks to estimate the proportion of cases belonging to specific categories (such as estimating how many patients have inadequate blood pressure control or identifying high-cost or low-quality physicians). When the true outcome rate is low (<20 percent), using an outcome measure that has low-to-moderate reliability will generally result in substantially overestimating the proportion of the population having the outcome unless statistical methods that adjust for measurement error are used.

Context: Clinicians can find it difficult to know which drugs are covered for their Medicare patients because formularies vary widely among Medicare Part D plans and many states have 50 or more such plans., Objective: To determine whether Part D formularies in California (the state with the most Medicare beneficiaries) and Hawaii have at least 1 drug within each of 8 treatment classes for hypertension, hyperlipidemia, and depression that can be identified for clinicians as "widely covered" by the vast majority of Part D plans., Design and Setting: Use of the medicare.gov Web site (March 1-April 15, 2006) to examine 72 California and 43 Hawaii Part D formularies' coverage of 8 treatment classes (angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, beta-blockers, calcium channel blockers, loop diuretics, selective serotonin reuptake inhibitors, statins, and thiazide diuretics), with evaluation of how often drugs were widely covered (defined as inclusion in >or=90% of formularies at co-payments of

Safety-net hospitals (SNHs) may gain little financial benefit from the rapidly spreading adoption of public reporting and pay-for-performance, but may feel compelled to participate (and bear the costs of data collection) to meet public expectations of transparency and accountability. To better understand the concerns that SNH administrators have regarding public reporting and pay-for-performance, we interviewed 37 executives at randomly selected California SNHs. The main concerns noted by SNH executives were that human and financial resource constraints made it difficult for SNHs to accurately measure their performance. Additionally, some executives felt that market-driven public reporting and pay-for-performance may focus on clinical areas and incentive structures that may not be high-priority clinical areas for SNHs. Executives at SNHs suggested several policy responses to these concerns-such as offering training programs for SNH data collectors-that could be relatively inexpensive and might improve the cost-benefit ratio of public reporting and pay-for-performance programs.

The use of pay for performance (P4P) and public reporting of performance (PR) in health care is increasing rapidly worldwide. The rationale for P4P and PR comes from experience in other industries and from theories about incentive use from psychology, economics, and organizational behavior. This paper reviews the major themes from this prior research and considers how they might be applied to health care. The resulting conceptual model addresses the dual nature (combining direct financial and reputational incentives) of the initiatives many policymakers are pursuing. It also includes explicit recognition of the key contextual factors (at the levels of the markets and the provider organization) and provider and patient characteristics that can enhance or mitigate response to incentives. Evaluation of the existing literature (through June 2005) about incentive use in health care in light of the conceptual model highlights important weaknesses in the way that trials have been reported to date and suggests future research topics.

Background: Although disease management programs are widely implemented, little is known about their effectiveness., Objective: To determine whether disease management by physician groups is associated with diabetes care processes, control of intermediate outcomes, or the amount of medication used when intermediate outcomes are above target levels., Design: Cross-sectional study., Setting: Patients were randomly sampled from 63 physician groups nested in 7 health plans sponsored by Translating Research into Action for Diabetes (87%) and from 4 health plans with individual physician contracts (13%)., Patients: 8661 adults with diabetes who completed a survey (2000-2001) and had medical record data., Measurements: Physician group and health plan directors described their organizations' use of physician reminders, performance feedback, and structured care management on a survey; their responses were used to determine measures of intensity of disease management. The current study measured 8 processes of care, including most recent hemoglobin A1c level, systolic blood pressure, serum low-density lipoprotein cholesterol level, and several measures of medication use., Results: Increased use of any of 3 disease management strategies was significantly associated with higher adjusted rates of retinal screening, nephropathy screening, foot examinations, and measurement of hemoglobin A1c levels. Serum lipid level testing and influenza vaccine administration were associated with greater use of structured care management and performance feedback. Greater use of performance feedback correlated with an increased rate of foot examinations (difference, 5 percentage points [95% CI, 1 to 8 percentage points]), and greater use of physician reminders was associated with an increased rate of nephropathy screening (difference, 15 percentage points [CI, 6 to 23 percentage points]). No strategies were associated with intermediate outcome levels or level of medication management., Limitations: Physician groups were not randomly sampled from population-based listings, and disease management strategies were not randomly allocated across groups., Conclusions: Disease management strategies were associated with better processes of diabetes care but not with improved intermediate outcomes or level of medication management. A greater focus on direct measurement, feedback, and reporting of intermediate outcome levels or of level of medication management may enhance the effectiveness of these programs.

Public reporting of provider performance is becoming increasingly commonplace. In this chapter, we first review studies of prior public reports (or report cards) that show real but small impact on provider attempts to improve quality, on consumers' impressions of providers, and even on consumer selection of providers. Among other factors, two potential explanations for the low level of impact are that, in most early reports, the large majority of providers have been labeled "average" and consumers may have had difficulty understanding the statistical assessments. In response, some current report card producers are using or considering a variety of methods to increase the number of distinctions among providers and the ease of comprehension of the labels used. Therefore, we also consider the advantages and disadvantages of several novel approaches to analyzing and reporting provider performance.

Concerns among patients and physicians that health plans would deny coverage for medically necessary services has brought about legislation mandating independent medical review (IMR) of denied services. Among 1,400 cases submitted in California, the most common areas for dispute were cancer care, endocrine/metabolic care (especially for obesity), orthopedic care, and neurological disorders. Surgery and pharmacy services constituted 52 percent of cases. In 58 percent of cases, IMR upheld the health plan's decision, while in 33 percent of cases the health plan's decision was overturned, which suggests that external IMR provides additional patient protection in California's health care system.

Various approaches have been proposed to adjust for differences in enrollee risk in health plans. Because risk-selection strategies may have different effects on enrollment, we simulated three types of selection--dumping, skimming, and stinting. Concurrent diagnosis-based risk adjustment, and a hybrid using concurrent adjustment for about 8% of the cases and prospective adjustment for the rest, perform markedly better than prospective or demographic adjustments, both in terms of R2 and the extent to which plans experience unwarranted gains or losses. The simulation approach offers a valuable tool for analysts in assessing various risk-adjustment strategies under different selection situations.

Background: The impact of the surgeon and surgical center characteristics on choice of autogenous arteriovenous (AV) fistula versus artificial AV graft as permanent vascular access for hemodialysis has not been studied., Methods: We used national data from the Department of Veterans Affairs Veterans Health Administration to measure the association of surgeon and surgical center characteristics with choice of initial permanent vascular access among patients undergoing their first vascular access placement procedure between October 1, 2000 and September 30, 2001 (fiscal year 2001). Data were analyzed using a hierarchical logistic regression model clustered for surgical center and surgeon., Results: The study population included 1114 patients, 74 Veterans Administration Medical Centers, and 182 surgeons. Seventy-two percent of patients received an AV fistula as their initial form of permanent vascular access. After adjusting for differences in patient, center, and surgeon characteristics, odds of AV fistula placement at high volume centers (>30 procedures per year) were more than three times greater than at low volume centers [odds ratio (OR) 3.26, 95% confidence interval (95% CI) 1.37 to 7.75, P = 0.008]. In addition, a strong clustering effect was present at the level of the surgeon (OR 1.55, 95% CI 1.19 to 2.03, P = 0.001) but not at the level of the surgical center, indicating an association with surgeon practice pattern., Conclusion: Barriers to AV fistula placement can exist at the levels of the surgeon and surgical center, respectively. Future strategies to improve AV fistula placement rates should target surgeons and surgical centers in addition to patients, nephrologists, and primary care providers.

Hospitals may not support programs that improve the quality of care delivered to heart failure patients because these programs lower readmission rates and empty beds, and therefore further diminish already-declining revenues. A conflict between the highest quality of care and financial solvency does not serve the interests of patients, physicians, hospitals, or payers. In principle, resolution of this conflict is simple: reimbursement systems should reward higher quality care. In practice, resolving the conflict is not simple. A recent roundtable discussion sponsored by the Heart Failure Society of America identified 4 major challenges to the design and implementation of reimbursement schemes that promote higher quality care for heart failure: defining quality, accounting for differences in disease severity, crafting novel payment mechanisms, and overcoming professional parochialism. This article describes each of these challenges in turn.

We examined eleven communities in which an employer coalition created a report card to compare the performance of the community's hospitals. After interviewing employer coalition and hospital representatives from each community, we found great variability in report cards' capacity to prompt quality improvement. Although some were successful, others had less impact because of conflicts between employer coalitions and hospitals. Areas of disagreement included selection of appropriate goals, methodology of quality measurement, whether report cards should be publicly released, and the use of economic incentives to improve quality. We describe these conflicts and offer recommendations for future hospital report cards.

Background: There remains considerable uncertainty about whether prospective or concurrent risk adjustment (RA) is preferable. Although concurrent models have better predictive power than prospective models, the large payments associated with concurrent RA create incentives for fraudulent coding. A hybrid strategy--in which prospective payments were used for patients with low expected costs and concurrent payments were available upon the diagnosis of a small number of common, expensive conditions--might improve predictive performance while requiring less auditing than fully concurrent RA. In addition, within-condition RA (using clinical data) for the selected conditions could further improve predictive power., Objectives: To assess how such a hybrid strategy might perform, focusing on a small number of chronic, expensive conditions that are verifiable (hence auditable)., Subjects and Measures: All patients from seven health plans who had two complete years of utilization data were considered. RA models were estimated among patients younger than 65 (n = 319,209) using the Hierarchical Coexisting Conditions (HCC) model with and without stratification of the sample based on the presence of one or more of 100 verifiable, expensive, predictive conditions (VEP100). R2 and predictive ratios were calculated for each model studied., Results: Patients with a VEP100 condition (9.3% of the population) accounted for 84.3% of the variation in cost. R2 was 0.08 using a prospective HCC model on the entire population, but increased to 0.26 for a hybrid using prospective HCCs on the 90.7% of the sample without a VEP100 condition and a simple concurrent model consisting of dummy variables for each of the VEP100 conditions., Conclusion: Combined with targeted auditing, a hybrid approach to RA could improve our ability to match payments to costs. However, because this would require additional, costly data collection, more research is needed to determine whether this benefit justifies the data collection and auditing burden.

Background: Patients on dialysis therapy are inactive, are at high risk for conditions that can be prevented or ameliorated by exercise, and often receive most of their care from their nephrologist. Exercise counseling by physicians can increase patients' levels of physical activity. The aim of the study is to determine the frequency of exercise assessment and counseling among practicing nephrologists, characteristics of nephrologists who provide exercise counseling to their dialysis patients, and barriers to exercise counseling perceived by nephrologists., Methods: A 25-item survey regarding exercise counseling was administered to nephrologists attending the World Congress of Nephrology meeting in 2001., Results: Five hundred five nephrologists completed the survey. Overall, 38% reported "almost always" or "often" assessing patient level of physical activity and counseling inactive patients to increase activity. Older (P < 0.0001), more active (P = 0.033), and women (P = 0.018) nephrologists, as well as those who provided primary care to more of their patients (P = 0.007), were more likely to provide exercise counseling. Nephrologists who do not provide routine counseling were more likely to endorse lack of time (P < 0.0001), lack of confidence in their ability to counsel patients (P < 0.0001), and lack of conviction that patients will respond as barriers to counseling (P = 0.01). In addition, noncounseling nephrologists were more likely to believe that other medical issues were more important than exercise (P = 0.01)., Conclusion: Rates of exercise counseling among nephrologists are low, although dialysis patients are a high-risk group unlikely to receive advice about exercise from other health care providers. The low rates of counseling, particularly among younger nephrologists, could be addressed by including information about counseling in fellowship training and/or practice guidelines for the care of patients on dialysis therapy., (Copyright 2003 by the National Kidney Foundation, Inc.)

In this paper, we review the literature on a number of the potential explanations for the rise in health care expenditures in the United States: the aging population, the costs of dying, technology, physician incomes, administrative costs, prescription drugs, managed care, and the underfunding of public health. Our goal is not to pass definitive judgment on the force(s) driving health care costs, but rather to make the reader a more educated consumer of these widely cited data. We place special emphasis on how health expenditures are measured and the inherent weaknesses in the methodology. We find that frequently it is difficult to accurately estimate how individual forces influence total health care expenditures. Moreover, we conclude that interpreting the causes of the rise in expenditures goes beyond simple observations of trends and depends on how we value various segments and aspects of health and health care.

Background: Referral to specialized physicians or institutions often is deemed necessary in clinical medicine, but no method exists to assess the clinical benefit of such referrals., Objectives: To describe a method, which is shared patient analysis, to measure the expected improvement in clinical management associated with referrals and to apply that method in the field of abdominal and pelvic oncological radiology., Subjects: All patients referred, during a 4-year period, to surgical oncologists at four academic centers (the referral providers, or RPs) with radiographs performed before referral at a community site (the initial providers, or IPs). Patients (n = 396) for whom both the IP interpretation and a final diagnosis was available were eligible. All IP and RP readings were placed in random order and presented to surgical oncologists, who then recommended a treatment course., Measurements: Diagnostic accuracy of the IP and RP readings and the proportion of patients who were assigned to an appropriate treatment by the oncologist were determined., Results: When the indication for imaging was primary diagnosis or staging, the kappa for presence of cancer was 0.70. When the indication was cancer follow-up, the kappa for presence of recurrent/progressing cancer was 0.66. There were disagreements between the IP and RP radiologists over the interpretation of 162 films, with the RP radiologists being correct in 153 (94%). Had the patients been treated using IP readings, there would have been 19 more inappropriate surgeries and 19 more admissions (both P <0.05) than if the oncologists had based their recommendations on RP readings., Conclusions: The technique of shared patient analysis permits assessment of the clinical benefits associated with referrals.