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Health plans develop predictive models to predict key clinical events (eg, admissions, readmissions, emergency department visits). The authors developed predictive models of admissions and readmissions for a quality improvement organization with many large government and private health plan clients. Its membership and authorization data were used to develop models predicting 2019 inpatient stays, and 2019 readmissions following 2019 admissions, based on patients' age and sex, diagnoses identified and procedures requested in 2018 authorizations, and 2018 admission authorizations. In addition to testing multivariate models, risk scores were calculated for admission and readmission for all patients in the model. The admissions model (C = 0.8491) is much more accurate than the readmissions model (C = 0.6237). Measures of risk score central tendency and skewness indicate that the vast majority of members had little risk of hospitalization in 2019; the mean (standard deviation) was 0.042 (0.074), and the median was 0.018. These risk scores can be used to identify members at risk of admission and to support proactive risk management (eg, design of health management programs). Different risk thresholds can be used to identify different subsets of members for follow-up, depending on overall strategy and available resources. This model development project was novel in employing authorization data rather than utilization data. Advantages of authorization data are their timeliness, and the fact that they are sometimes the only data available, but disadvantages of authorization data are that authorized services are not always actually performed, and diagnoses are often "rule out" rather than final diagnoses.

This article demonstrates effects on utilization of a clinical transformation: changing locus of care from a dedicated sickle cell day unit to an approach that “fast-tracks” patients through the emergency department (ED) into an observation unit with 24/7 access. Retrospective quantitative analyses of claims and Epic electronic medical record data for patients with sickle cell disease treated at Thomas Jefferson University (inpatient and ED) assessed effects of the clinical transformation. Additionally, case studies were conducted to confirm and deepen the quantitative analyses. This study was approved by the Thomas Jefferson University Institutional Review Board. The quantitative analyses show significant decreases in ED and inpatient utilization following the transformation. These effects likely were facilitated by increased observation stays. This study demonstrated the impact on utilization of transformation in care (from dedicated day unit to an approach that fast-tracks patients into an observation unit). Additional case studies support the quantitative findings.

The US health care system faces rising costs related to population aging, among other factors. One aspect of the high costs related to aging is Medicare outpatient therapy expenditures, which in 2010 totaled $5.642B for ∼4.7 million beneficiaries. Given the magnitude of these costs and the need to maximize value, this study developed and tested a predictive model of outpatient therapy costs. Retrospective analysis was performed on electronic medical record data from October 31, 2014-September 30, 2016 for 15,468 Medicare cases treated by physical therapists associated with a large, national rehabilitation provider. The analysis was a multiple linear regression of cost per case by 27 predictor variables: age group, sex, recent hospitalization, community vs. facility residence, the 10 states served, time from admission to initial evaluation, initial functional limitation reporting level, functional limitation reporting category, and 9 chronic conditions. The model was designed to be predictive and includes only variables available at the start of a case. The model was statistically significant (P .0001) but explained only 7.4% of the variance in cost. Of the predictor variables, 16 had statistically significant effects. Those most highly predictive included state in which service was provided (8 of the 16 effects), and 3 variables indicating physical functioning at initial evaluation (initial functional limitation category and level, and residence in community vs. facility). There is need for more research focusing on the effects of specific types of treatment, and also for a more proactive model for outpatient therapy reimbursement that emphasizes prevention as well as treatment.

African Americans with type 2 diabetes (T2D) have higher average A1c levels than White patients. However, few studies have examined racial disparities in diabetes management in primary care, particularly provider-level variability. Study goals were to analyze racial differences for patients with any/2 or more elevated A1cs, explore patterns of visits/providers seen in patients with ≥1 elevated A1c, and explore the contributions of provider variability in patient A1c. A retrospective secondary analysis of electronic medical record data from a large urban health system was conducted, involving adult African American or White patients (ages18-65 years) with ≥2 measured A1cs between January 1, 2017-February 1, 2018. Descriptive statistics were calculated for demographic variables; paired

Obesity is a potentially modifiable risk factor for many diseases, and a better understanding of its impact on health care utilization, costs, and medical outcomes is needed. The ability to accurately evaluate obesity outcomes depends on a correct identification of the population with obesity. The primary objective of this study was to determine the prevalence and accuracy of International Classification of Diseases, Ninth Revision (ICD-9) coding for overweight and obesity within a US primary care electronic health record (EHR) database compared against actual body mass index (BMI) values from recorded clinical patient data; characteristics of patients with obesity who did or did not receive ICD-9 codes for overweight/obesity also were evaluated. The study sample included 5,512,285 patients in the database with any BMI value recorded between January 1, 2014, and June 30, 2014. Based on BMI, 74.6% of patients were categorized as being overweight or obese, but only 15.1% of patients had relevant ICD-9 codes. ICD-9 coding prevalence increased with increasing BMI category. Among patients with obesity (BMI ≥30 kg/m2), those coded for obesity were younger, more often female, and had a greater comorbidity burden than those not coded; hypertension, dyslipidemia, type 2 diabetes mellitus, and gastroesophageal reflux disease were the most common comorbidities. Key findings: US outpatients with overweight or obesity are not being reliably coded, making ICD-9 codes undependable sources for determining obesity prevalence and outcomes. BMI data available within EHR databases offer a more accurate and objective means of classifying overweight/obese status.

As overdose rates continue to rise nationally, the development of interventions to address gaps inknowledge and a lack of consistency in clinical care is essential. Using a pre-post survey design, a cohort ofhealth professions students was asked to reflect on their levels of knowledge and awareness about opioidsbefore and after viewing the POPPED© curriculum. Analysis of group mean scores reflected an increasein knowledge about the opioid epidemic and initiatives associated with combating against it. These find-ings demonstrate the benefits of health education curricula in serving as instructional tools for populationsdirectly impacted by the opioid epidemic.

Erythropoiesis-stimulating agents (ESAs), found to be effective in reducing anemia in chemotherapy-treated cancer patients, also are associated with an increased risk of cardiovascular events, including stroke. In an attempt to mitigate the risk, the Food and Drug Administration implemented a Risk Evaluation Mitigation Strategy (REMS) in February 2010. The purpose of this study is to evaluate change over time in the incidence of stroke among these patients before and after implementation of REMS. A retrospective data analysis using the Medicare 5% Sample Dataset, 2008-2011, was performed. Patients had to be 65 years of age or older at the start of at least 1 year of continuous enrollment and to have lung and/or breast cancers along with chemotherapy-induced anemia (CIA) in both pre-REMS and post-REMS periods (1Q2008 through 4Q2009 and 1Q2010 through 4Q2011, respectively). Logistic regression was used to evaluate differences in proportions of patients who received ESAs and experienced a stroke pre and post REMS. The pre-REMS cohort included 1252 eligible patients prescribed ESAs; the post-REMS cohort included 949 patients. No statistically significant change in stroke incidence was observed post REMS among patients with CIA who received ESAs. There was a 29.5% decrease in ESA use in patients with lung cancer and a 27.8% decrease in patients with breast cancer. Both were statistically significant. Results adjusted for baseline characteristics and comorbid conditions were similar. There was a statistically significant decrease in ESA use in patients with breast and/or lung cancers post REMS; no statistically significant reduction in the incidence of stroke was observed regardless of cancer type.

Stereotactic radiosurgery (SRS) has emerged as an important modality for the treatment of intracranial metastases. There are currently few established guidelines delineating indications for SRS use and fewer still regarding plan evaluation in the treatment of multiple brain metastases. An 18 question electronic survey was distributed to radiation oncologists at National Cancer Institute (NCI) designated cancer centers in the USA (60). Centers without radiation oncologists were excluded. Physicians who indicated that they do not prescribe SRS were excluded from the remaining survey questions. Sign test and Chi-square test were used to determine if responses differed significantly from random distribution. One hundred sixteen of the 697 radiation oncologists surveyed completed the questionnaire, representing 51 institutions. Sixty-two percent reported treating patients with brain metastases using SRS. Radiation oncologists prescribing SRS most commonly treat CNS (66.2%) and lung (49.3%) malignancies. SRS was used more frequently for 10 brain metastases (82.5%; p

Summary What is known and objective The Food and Drug Administration (FDA) instituted a risk evaluation mitigation strategy (REMS) for erythropoiesis-stimulating agent (ESA) use in patients with cancer in February 2010. Implementation of REMS was considered likely to reduce ESA use and increase red blood cell transfusions. We aimed to quantify ESA and transfusion use pre- and post-REMS. Methods A retrospective data analysis was conducted using the Medicare 5% Sample Database from 2008 through 2011. Patients were 66 years of age or older and had lung and/or breast cancers along with chemotherapy-induced anaemia. Patients initiated chemotherapy in pre-REMS and post-REMS periods (1Q2008 through 4Q2009 and 1Q2010 through 4Q2011, respectively). Logistic regression was used to evaluate differences in proportions of patients receiving ESAs and transfusions pre-REMS and post-REMS. Results and discussion The pre-REMS group included 1526 patients and the post-REMS group included 1689 patients. ESA use in patients with lung cancer decreased 30·2% from pre- to post-REMS and 33·1% in patients with breast cancer. Both decreases were statistically significant. Transfusion rates increased 22·1% from the pre-REMS period to the pre-REMS period in patients with breast cancer (P

DESCRIPTION OF THE PROBLEM The ACR accreditation process is a voluntary review that allows for an impartial peer evaluation of radiation oncology departments. Accreditation is a mechanism for departments to demonstrate to patients, providers, and payers adherence to recognized standards of care and quality performance. Among the goals of the process listed by the ACR are recognizing quality radiation oncology practices, as well as recommending potential practice improvements based on nationally recognized standards. As part of the accreditation process, an onsite survey of departmental facilities, staff, and procedures is carried out by board-certified radiation oncologists and medical physicists. During the onsite survey, the external reviewers interview key personnel, assess documentation of departmental policies and procedures, audit the department’s existing quality assurance and improvement program, and review patient records to assess adherence to nationally recognized clinical standards. Although quality of care is a challenging metric to assess in radiation oncology, accreditation programs focus on components of a department’s structure, process, and outcomes. Most quantifiable outcomes fall into the structure and process categories of quality assessment. Our department sought to quantify the quality improvement

Despite an estimated 2 million osteoporosis (OP)-related fractures annually, quality of care for post-fracture OP management remains low. This study aimed to identify patient and provider characteristics associated with achieving or not achieving optimal post-fracture OP management, as defined by the current HEDIS quality measure. The study included women 67 to 85 years of age, with ≥1 fracture, and continuous enrollment in a Humana insurance plan. The study identified a higher percentage of black women in the not achieved group (6.2% vs 5.4%; P < .0001) and Hispanic women in the achieved group (3.0% vs 1.3%; P < .0001). The not achieved group largely included patients residing in the South and urban and suburban areas. The majority of providers were primary care or OP-related specialty, and 66% did not achieve the 4-star OP rating. The study findings can guide development of predictive models to identify at-risk women to improve post-fracture OP management.

Sickle cell disease (SCD), an inherited red blood cell disorder, is characterized by anemia, end-organ damage, unpredictable episodes of pain, and early mortality. Emergency department (ED) visits and hospitalizations are frequent, leading to increased burden on patients and increased health care costs. This study assessed the effects of a multidisciplinary care team intervention on acute care utilization among adults with SCD. The multidisciplinary care team intervention included monthly team meetings and development of individualized care plans. Individualized care plans included targeted pain management plans for management of uncomplicated pain crisis. Following implementation of the multidisciplinary care team intervention, a significant decrease in ED utilization was identified among those individuals with a history of high ED utilization. Findings highlight the potential strength of multidisciplinary interventions and suggest that targeting interventions toward high-utilizing subpopulations may offer the greatest impact.

This study investigates the organizational culture and associated characteristics of the newly established primary care units (PCUs)-collaborative teams of general practitioners (GPs) who provide patients with integrated health care services-in the Emilia-Romagna Region (RER), Italy. A survey instrument covering 6 cultural dimensions was administered to all 301 GPs in 21 PCUs in the Local Health Authority (LHA) of Parma, RER; the response rate was 79.1%. Management style, organizational trust, and collegiality proved to be more important aspects of PCU organizational culture than information sharing, quality, and cohesiveness. Cultural dimension scores were positively associated with certain characteristics of the PCUs including larger PCU size and greater proportion of older GPs. The presence of female GPs in the PCUs had a negative impact on collegiality, organizational trust, and quality. Feedback collected through this assessment will be useful to the RER and LHAs for evaluating and guiding improvements in the PCUs.

Board certified radiation oncologists and medical physicists are required to earn self-assessment module (SAM) continuing medical education (CME) credit, which may require travel costs or usage fees. Data indicate that faculty participation in resident teaching activities is beneficial to resident education. Our hypothesis was that providing the opportunity to earn SAM credit in resident didactics would increase faculty participation in and improve resident education.SAM applications, comprising CME certified category 1 resident didactic lectures and faculty-generated questions with respective answers, rationales, and references, were submitted to the American Board of Radiology for formal review. Surveys were distributed to assess main academic campus physician, affiliate campus physician, physicist, and radiation oncology resident impressions regarding the quality of the lectures. Survey responses were designed in Likert-scale format. Sign-test was performed with P.05 considered statistically different from neutral.First submission SAM approval was obtained for 9 of 9 lectures to date. A total of 52 SAM credits have been awarded to 4 physicists and 7 attending physicians. Main academic campus physician and affiliate campus physician attendance increased from 20% and 0%, respectively, over the 12 months preceding CME/SAM lectures, to 55.6% and 20%, respectively. Survey results indicated that the change to SAM lectures increased the quality of resident lectures (P = .001), attending physician participation in resident education (P.0001), physicist involvement in medical resident education (P = .0006), and faculty motivation to attend resident didactics (P = .004). Residents reported an increased amount of time required to prepare lectures (P = .008).We are the first department, to our knowledge, to offer SAM credit to clinical faculty for participation in resident-generated didactics. Offering SAM credit at resident lectures is a cost-effective alternative to purchasing SAM resources, increases faculty attendance, and may improve the quality of radiation oncology resident education.

Purpose The Next Accreditation System (NAS) requires radiation oncology residents to do a formal quality improvement project during their residency. The American Board of Radiology (ABR) Maintenance of Certification (MOC) program requires certified physicians to complete a Practice Quality Improvement (PQI) project approximately every 3 years. The purpose of our project was to develop a clinical transition of care policy via a process that resulted in quality improvement project credit for residents and PQI credit for participating faculty. Methods and materials Approval for project implementation was obtained from the ABR MOC committee. The PQI project consisted of an initial survey to assess resident perception on resident transition of care in our department, formal sign-out training, and 2 postintervention surveys after 1 and 11 months. The primary endpoint was the percentage of questions with ≤1 unfavorable responses. Sign-test was used to determine response difference from neutral. Results One hundred percent of surveyed residents completed the preintervention (n = 6), postintervention 1 (n = 7), and postintervention 2 (n = 8) surveys. In the preintervention, postintervention 1, and postintervention 2 surveys, 71.4%, 57.1%, and 57.1% of questions were answered with ≤1 unfavorable response, respectively. The number of questions with ≥75% favorable response was 7 (50%), 7 (50%), and 11 (78.5%) in the preintervention, postintervention 1, and postintervention 2 surveys, respectively ( P = .13). A written sign-out template and monthly protected sign-out meetings were instituted. One resident and 3 attending physicians received credit for Accreditation Council of Graduate Medical Education NAS quality improvement and ABR MOC PQI projects, respectively. Conclusions This project shows the feasibility of a combined attending and resident physician effort to improve patient care and fulfill his or her respective ABR MOC PQI and Accreditation Council of Graduate Medical Education NAS requirements. Attending and resident physicians can tailor collaborative projects to fulfill MOC and NAS requirements unique to their subspecialty. Written sign-out templates and protected sign-out time may improve transition of care.

The yearly radiation oncology in-training examination (ITE) by the American College of Radiology is a widely used, norm-referenced educational assessment, with high test reliability and psychometric performance. We distributed a national survey to evaluate the academic radiation oncology community's perception of the ITE.In June 2014, a 7-question online survey was distributed via e-mail to current radiation oncology residents, program directors, and attending physicians who had completed residency in the past 5 years or junior attendings. Survey questions were designed on a 5-point Likert scale. Sign test was performed with P ≤ .05 considered statistically different from neutral.Thirty-one program directors (33.3%), 114 junior attendings (35.4%), and 225 residents (41.2%) responded. Junior attendings and program directors reported that the ITE directly contributed to their preparation for the American Board of Radiology written certification (P = .050 and .004, respectively). Residents did not perceive the examination as an accurate assessment of relevant clinical and scientific knowledge (P.0001) and feel the quality assurance is insufficient in its current form (P.0001). Residents and junior attendings agree that there are factual errors, and unclear questions/answers (P.0001 and .04, respectively). Free response suggestions included: less questions on rare disease sites (16.4%), more relevance to clinical practice (15.4%), avoiding questions that discriminate between a few percentage points (11.8%), and designing the test similar to the written certification examination (9.2%).Despite high examination reliability and psychometric performance, resident and attending physicians report a need for improved quality assurance and clinical relevance in the ITE. Although the current examination allows limited feedback, establishing a venue for individualized feedback may allow continual and timely improvement of the ITE. Adopting a criterion-referenced examination may further increase resident investment in and utilization of this valuable learning tool.

Objectives Develop predictive models using an administrative healthcare database that provide information for Patient-Centred Medical Homes to proactively identify patients at risk of hospitalisation for conditions that may be impacted through improved patient care. Design Retrospective healthcare utilisation analysis with multivariate logistic regression models. Data A population-based longitudinal database of residents served by the Emilia-Romagna, Italy, health service in the years 2004–2012 including demographic information and utilisation of health services by 3 726 380 people aged ≥18 years. Outcome measures Models designed to predict risk of hospitalisation or death in 2012 for problems that are potentially avoidable were developed and evaluated using the area under the receiver operating curve C-statistic, in terms of their sensitivity, specificity and positive predictive value, and for calibration to assess performance across levels of predicted risk. Results Among the 3 726 380 adult residents of Emilia-Romagna at the end of 2011, 449 163 (12.1%) were hospitalised in 2012; 4.2% were hospitalised for the selected conditions or died in 2012 (3.6% hospitalised, 1.3% died). The C-statistic for predicting 2012 outcomes was 0.856. The model was well calibrated across categories of predicted risk. For those patients in the highest predicted risk decile group, the average predicted risk was 23.9% and the actual prevalence of hospitalisation or death was 24.2%. Conclusions We have developed a population-based model using a longitudinal administrative database that identifies the risk of hospitalisation for residents of the Emilia-Romagna region with a level of performance as high as, or higher than, similar models. The results of this model, along with profiles of patients identified as high risk are being provided to the physicians and other healthcare professionals associated with the Patient Centred Medical Homes to aid in planning for care management and interventions that may reduce their patients’ likelihood of a preventable, high-cost hospitalisation.