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Primary care is widely viewed as being in crisis despite its purported central role in addressing population issues related to healthcare cost, quality, access, and equity. Despite this pivotal role, the nature of the clinical practice today has largely emerged by default. We review the evolution of clinical practice in primary care from its genesis in small practices with paper charts and telephonic patient communication to managed care, pay-for-performance, and today’s era of the electronic medical record, value-based payment, and consumerism. We suggest a necessary “reset” of expectations that focuses on today’s practice structure and the historic face-to-face patient care expectations. Only by doing so can we successfully meet the demands of patients, society, and practicing internists.

To (1) compare the 2015 hospital grades reported on Medicare's Hospital Compare website for heart failure (HF) and acute myocardial infarction (AMI) readmissions with the HF- and AMI-specific scores for excess readmissions used to assess Medicare readmission penalties and (2) assess how often hospitals were penalized for excess readmissions in only 1 or 2 conditions, given that hospitals received a penalty impacting all Medicare payments based on an overall readmission score calculated from 5 conditions (HF, AMI, pneumonia, chronic obstructive pulmonary disease, and total hip/knee arthroplasty).Retrospective secondary data analysis.Descriptive analyses of hospital-specific, condition-specific grades and excess readmission scores and hospital-level penalties downloaded from Hospital Compare.Of the 2956 hospitals that had publicly reported HF grades on Hospital Compare, 91.9% (2717) were graded as "no different" than the national rate for HF readmissions, which included 48.6% that were scored as having excessive HF admissions, and 87% received an overall readmission penalty. Of 120 (4.1%) hospitals graded as "better" than the national rate for HF, none were scored as having excessive HF readmissions and 50% were penalized. AMI data yielded similar results. Among 2591 hospitals penalized for overall readmissions, 26.6% had only 1 condition with excess readmissions and 27.5% had 2 conditions.Many hospitals with an HF and AMI readmission grade of "no different" than the national rate on Hospital Compare received penalties for excessive readmissions under the Hospital Readmissions Reduction Program. The value signal to consumers and hospitals communicated by grades and penalties is therefore weakened because the methods applied to the same hospital data produce conflicting messages of "average grades" yet "bad enough for penalty."

Chart-based surveillance reviews indicate that the incidence of hospital-acquired pressure ulcers (HAPUs) declined 23 percent during 2010-14, equating to an estimated savings of $1 billion during that period. Yet it remains unclear whether the administrative data used to implement three Medicare value-based purchasing programs that target HAPUs indicate similar improvements, and how success varied by HAPU severity. These programs measure and penalize only for more severe ulcers (stage 3 or 4 or unstageable), which are much more costly than less severe cases (stage 1 or 2). We assessed HAPU incidence, severity, and trends using administrative data for 2009-14 from three states. The HAPU incidence we found was approximately one-twentieth of that found in chart-based surveillance review data. HAPU incidence in administrative data declined, but 96 percent of the change was due to a decline in the incidence of less severe HAPUs. Transitioning from administrative data to chart-based surveillance review to measure HAPUs (mirroring changes that have already been made in reporting hospital-acquired infections) and accounting for HAPU severity could improve the validity of HAPU measures for assessing the clinical and financial impact of value-based purchasing interventions.

In 2016, U.S. health care spending reached $3.3 trillion, a figure representing 17.9% of the nation's gross domestic product. Sadly, the skyrocketing cost of health care is not headline news. Rather, as aptly summarized by Warren Buffett, “The ballooning costs of health care act as a hungry tapeworm on the American economy” (1). Like a tapeworm, our health care cost problem degrades the overall vitality of our economy. Therefore, news that the CEOs of Amazon, Berkshire Hathaway, and JPMorgan Chase are coming together to combat health care cost has been met with anticipation and skepticism (1): anticipation—because these business giants may help solve what ails our health system—but also skepticism—because what do highly successful entrepreneurs, investment bankers, and money managers know about health care? Could blindness to the usual approaches to reducing health care cost be a strength?

To characterize patterns of emergency department (ED) utilization for ambulatory care-sensitive conditions (ACSCs) among patients with established care within a patient-centered medical home.Retrospective chart review using Michigan Medicine's (formerly University of Michigan Health System) electronic health record.Ten general medicine (GM) physicians reviewed 256 ambulatory care-sensitive ED encounters that occurred between January 1, 2014, and December 31, 2014, among patients of a GM medical home. Physician reviewers abstracted from the medical record the day and time of ED presentation and the source of ED referral (eg, patient self-referral vs physician referral). Physicians assessed the appropriateness of the care location (eg, ED vs primary care). Interrater reliability was assessed using the kappa statistic, and the χ2 test was used to assess differences in the appropriateness of the care location according to ED referral source.Compared with all other days of the week, the fewest number of ED visits occurred on weekend days, and nearly half of patients (48%) presented to the ED after daytime hours, which were defined as 8 am to 3:59 pm. The majority (n = 185; 72%) of patients were self-referred to the ED. The ED was considered the appropriate care location in more than half (53%) of the reviewed cases. Among the 119 cases considered appropriate for GM management, the majority (86%) were self-referred to the ED.Patients with ACSCs often presented to the ED without contacting their medical home. Frequently, the ED is the most appropriate location given symptoms at presentation.

Objectives To assess the financial effect of the 2008 Hospital-Acquired Conditions Initiative (HACI) pressure ulcer payment changes on Medicare, other payers, and hospitals. Design Retrospective before-and-after study of all-payer statewide administrative data for more than 2.4 million annual adult discharges in 2007 and 2009 using the Healthcare Cost and Utilization Project State Inpatient Datasets for California. How often and by how much the 2008 payment changes for pressure ulcers affected hospital payment was assessed. Setting Nonfederal acute care California hospitals (N = 311). Participants Adults discharged from acute-care hospitals. Measurements Pressure ulcer rates and hospital payment changes. Results Hospital-acquired pressure ulcer rates were low in 2007 (0.28%) and 2009 (0.27%); present-on-admission pressure ulcer rates increased from 2.3% in 2007 to 3.0% in 2009. According to clinical stage of pressure ulcer (available in 2009), hospital-acquired Stage III and IV ulcers occurred in 603 discharges (0.02%); 60,244 discharges (2.42%) contained other pressure ulcer diagnoses. Payment removal for Stage III and IV hospital-acquired ulcers reduced payment in 75 (0.003%) discharges, for a statewide payment decrease of $310,444 (0.001%) for all payers and $199,238 (0.001%) for Medicare. For all other pressure ulcers, the Hospital-Acquired Conditions Initiative reduced hospital payment in 20,246 (0.81%) cases (including 18,953 cases with present-on-admission ulcers), reducing statewide payment by $62,538,586 (0.21%) for all payers and $47,237,984 (0.32%) for Medicare. Conclusion The total financial effect of the 2008 payment changes for pressure ulcers was negligible. Most payment decreases occurred by removal of comorbidity payments for present-on-admission pressure ulcers other than Stages III and IV. The removal of payment for hospital-acquired Stage III and IV ulcers by implementation of the HACI policy was 1/200th that of the removal of payment for other types of pressure ulcers that occurred in implementation of the Hospital-Acquired Conditions Initiative.

In this issue of JGIM, Miller and colleagues draw attention to important trends in the evolution of academic general internal medicine.1 By examining the membership of the Society of General Internal Medicine (SGIM), they provide a snapshot not only of the Society, but also the trajectory of academic internal medicine. While one can belabor methodological concerns such as response rate and generalizability of the results, the overarching portrait of academic general medicine rings true: a growing proportion of SGIM members identify as hospitalists. Compared to non-hospitalists, Miller et al. found that hospitalists were younger, more junior in academic rank, and more often engaged in medical education roles. Additional noteworthy differences included the fact that hospitalists reported greater interest in developing clinical skills and less interest in advocacy than their non-hospitalist peers, and (somewhat surprisingly) they were more focused on research. Finally, hospitalist respondents were less likely to identify SGIM as their “professional home.”

Over the last three decades, numerous health care process measures and surrogate health outcome measures have exploded onto the scene, often driven by payers wanting to show commitment to “value.” With increasing popularity of pay-for-performance and other value-based incentive programs aimed at maximizing quality while minimizing costs, primary care practices are confronted with an ever-increasing sea of quality metrics that they are urged to satisfy. In our health system at the University of Michigan, Blue Cross Blue Shield—a payer that spends one in five medical claim dollars on value-based payment arrangements—incentivizes at least 200 different quality metrics (Abelson 2014). Primary care physicians (PCPs) constantly chase this dizzying array of metrics, recognizing that such measures frequently fail to help them care for their sickest, most vulnerable patients. When seeing a homeless patient with uncontrolled diabetes and food insecurity, for example, recording their smoking history seems less pressing. Time spent at a practice on such “quality metrics” diverts from addressing the highest priority areas for the patient—areas that often do not have a quality checkbox from a payer. PCPs face this tension daily in balancing “checkbox” care that supposedly achieves high “quality” with the actual clinical value they strive to provide vulnerable patients. Aligning health care payments with quality measurement has long been promoted as a vehicle for achieving higher quality of care (2001), but which existing metrics, if any, truly measure quality? For example, does the mere documentation of smoking status equate to quality? What if the patient does not want to follow the advice of the physician? Is the physician providing bad quality care? Should the physician be paid less? If the goal is ultimately to improve health, quality must be measured as meaningful health improvement, recognizing the role patients play in the interaction, and incentivized accordingly. Measuring and reporting quality has been a challenge as quality scores were first publicly reported for surgeons performing coronary artery bypass grafting (CABG) in New York. Despite widespread enthusiasm for this type of quality measurement and reporting, there is concern that such programs may actually penalize physicians caring for medically and psychosocially complex patients (Hofer et al. 1999). In the case of CABG ratings, physicians may have been incentivized to “dump” their sicker patients (Werner and Asch 2005). Similarly, PCPs may be willing to fire patients who do not comply with their medical recommendations (Farber et al. 2008). This dumping behavior is actually encouraged by incentive programs that promote compliance with simple quality metrics but fail to account for the complex interventions necessary for care of high-risk patients. The unintended consequence may be decreased access to care, lower quality of care—or both—for many vulnerable patients with multiple chronic conditions or difficult socioeconomic circumstances (McMahon, Hofer, and Hayward 2007). Thus, the challenge health services researchers face today is determining how best to use performance measures to incentivize health care quality for those who need it most. In this issue of Health Services Research, Jason Wang and colleagues offer a notable case study of three overlapping incentive programs promoting quality improvement in a network of small primary care practices in New York City. They examine the impact of meaningful use, patient-centered medical home (PCMH) and pay-for-performance incentives on seven quality metrics comprising both process and outcome measures related to smoking, obesity, blood pressure, blood sugar, and vascular disease management. Practices participating in all three programs demonstrated improvement in the study's chosen quality metrics during the follow-up period between 2009 and 2012, with PCMH practices achieving improvement on the greatest number of measures. However, each program chose different quality measures to incentivize, leading to potential complexity and confusion during implementation in individual practices. While there was observed improvement in some clinically relevant metrics such as delivery of smoking cessation interventions, other “quality improvements” were largely driven by process measures that do not directly impact patient outcomes, such as the simple documentation of smoking status and body mass index. Focusing on identifying which incentive programs most effectively drive improvements in quality metrics overlooks a more fundamental issue—how do we meaningfully measure quality in primary care? Health services researchers have measured quality at various levels, but commonly in ways that are not clinically relevant. First, we have recorded whether a health care process is done or not done—these checklist-like process measures are not nuanced, but are relatively easy to measure and improve (often by increasing documentation alone). Second, we have evaluated health outcome measures. Given the long follow-up required to obtain meaningful outcomes such as disability and mortality, we have more often assessed surrogate measures of health, such as hemoglobin A1C for diabetes control. These intermediate outcomes often employ arbitrary cut-offs and rarely take into account which patients would benefit most from chronic disease management such as blood sugar lowering in diabetes (Kerr et al. 2003). For example, a diabetic patient with a high baseline hemoglobin A1C (severe disease) may benefit more from aggressive blood sugar lowering, even if he or she never meets an arbitrary cut-off of a hemoglobin A1C less than 7–8 (recommended diabetic control) (Vijan, Hofer, and Hayward 1997). Setting an arbitrary goal blood glucose target for the whole population may disincentivize primary care providers from caring for high-risk patients who would benefit most from disease management. Even what we once thought were the best measures to incentivize—for example, low density lipoprotein—often turn out to be the wrong target and have to be revisited (Hayward et al. 2010; Smith and Grundy 2014). Thus, it is unclear whether either process or outcome measures target the right goal (Kerr et al. 2001). To improve population health, we need more clinically nuanced measurements of quality that weight the value of high-priority care more and low-priority care less (McMahon and Heisler 2008). It is time to abandon the one-size-fits-all approach that we know does not work. Instead we need to advance quality improvement metrics to the next level by using population-based modeling to incentivize approaches aimed at achieving the greatest health improvements in primary care practices, as determined by patients and their primary care providers. We could utilize the vast amount of “big data” available in health systems to decide which patients to target and how to optimally improve health outcomes in a given population. This would entail use of multivariable risk assessment and stratification to identify high-risk subgroups of patients that are most likely to benefit from certain interventions (McMahon et al. 2005). Practices could tailor quality improvement programs to their local population and incentivize what is most valuable to improving their patients' health. Few populations could benefit more from such health improvement than low-income individuals with Medicaid or medically complex patients. Many Medicaid managed care plans have actually employed such modeling to target high-risk patients for care management programs (2008). Other plans and health systems may similarly use the wealth of data available to them to create tailored programs for their high-risk patients. As Wang et al. mention in their article, recording of risk factors is a “critical first step in prevention of adverse outcomes.” However, this one step is not sufficient to improve quality in primary care. With advances in predictive modeling and increasing availability of electronic health information, we can do much more to meaningfully improve care delivery. We need to take the next step of population-based risk stratification and tailored interventions that provide true clinical value to vulnerable patients who need care most. It is time to stop incentivizing checkbox medicine and to start incentivizing health.

Background Retrospective medical record review is used to categorize urinary tract infections (UTIs) as symptomatic, catheter-associated, and/or healthcare-associated to generate National Healthcare Safety Network (NHSN) surveillance and claims data. We assessed how often patients with UTI diagnoses in claims data had a catheter in place, had documented symptoms, or met the NHSN criteria for catheter-associated UTI (CAUTI). Methods Two physicians retrospectively reviewed medical records for 294 randomly selected patients hospitalized with UTI as a secondary diagnosis, discharged between October 2008 and September 2009 from the University of Michigan. We applied a modification of recent NHSN criteria to estimate how often UTIs in claims data may be an NHSN CAUTI. Results The 294 patients included 193 women (66%). The mean patient age was 63 years, and the median length of hospital stay was 7.5 days. Catheter use was noted for 216 of 294 postadmission records (74%), including 126 (43%) with a Foley catheter. NHSN symptoms were noted in 113 records (38%); 62 (21%) had symptoms other than fever. Of 136 hospitalizations meeting urine culture criteria, 17 (5.8%) met the criteria for a potential NHSN CAUTI. Conclusions Retrospective medical record review to identify symptoms and catheter use is complicated and resource-intensive. Requiring standard documentation of symptoms and catheter status when ordering urine cultures could simplify and improve CAUTI surveillance and its fidelity as a hospital quality indicator.

Sodium-glucose cotransporter-2 (SGLT-2) inhibitors are a new class of diabetes medications with significant cardiovascular benefit. There is uncertainty regarding the appropriate prescribing service. This survey assessed the practice patterns of cardiologists, endocrinologists and primary care

Objective Abdominal obesity has been associated with erosive oesophagitis (EO) and Barrett9s oesophagus (BO). As gluteofemoral obesity protects against diabetes mellitus and cardiovascular disease, we hypothesised that gluteofemoral obesity would be inversely associated with EO and BO. Design We conducted a cross-sectional study on 822 male colorectal cancer screenees who were recruited to also undergo upper endoscopy. An additional 80 patients with BO clinically detected by upper endoscopy referred for clinical indications were recruited shortly after their diagnoses of BO. Logistic regression was used to estimate the effects of abdominal obesity (waist circumference), gluteofemoral obesity (hip circumference) and waist-to-hip ratio (WHR) on EO and BO (vs neither condition). Results There were 225 cases of either BO or EO and 675 controls. After adjustment for potential confounders, a positive association was observed between waist circumference and BO and/or EO, which became stronger with further adjustment for hip circumference. In contrast, hip circumference was inversely associated with BO and/or EO. Compared with the lowest quartile of WHR, the adjusted ORs were 1.32 (95% CI 0.747 to 2.33) for the 2nd quartile, 1.54 (95% CI 0.898 to 2.63) for the 3rd quartile, and 2.68 (95% CI 1.57 to 4.55) for the highest quartile. Similar results were obtained for BO and EO treated as separate outcomes. Conclusions In a population of older, mostly overweight men, the distribution of obesity is associated with the presence of EO and BO. Abdominal obesity appears to increase the risk of these outcomes, whereas gluteofemoral obesity may be protective.

Risk factors for Barrett's esophagus include gastroesophageal reflux disease (GERD) symptoms, age, abdominal obesity, and tobacco use. We aimed to develop a tool using these factors to predict the presence of Barrett's esophagus.Male colorectal cancer (CRC) screenees were recruited to undergo upper endoscopy, identifying newly diagnosed cases of Barrett's esophagus. Logistic regression models predicting Barrett's esophagus using GERD symptoms alone and together with abdominal obesity, tobacco use, and age were compared.Barrett's esophagus was found in 70 (8.5%) of 822 CRC screenees. Mutually adjusting for other covariates, Barrett's esophagus was associated with weekly GERD (odds ratio (OR)=2.33, 95% confidence interval (CI)=1.34, 4.05), age (OR per 10 years=1.53, 95% CI=1.05, 2.25), waist-to-hip ratio (OR per 0.10=1.44, 95% CI=0.898, 2.32) and pack-years of cigarette use (OR per 10 pack-years=1.09, 95% CI=1.04, 1.14). A model including those four factors had a greater area under the receiver operating characteristics curve than did a model based on GERD frequency and duration alone (0.72 vs. 0.61, P0.001), and it had a net reclassification improvement index of 19-25%.The prevalence of Barrett's esophagus was substantial in our population of older overweight men. A model based on GERD, age, abdominal obesity, and cigarette use more accurately classified the presence of Barrett's esophagus than did a model based on GERD alone. Following validation of the tool in another population, its use in clinical practice might improve the efficiency of screening for Barrett's esophagus.

Readmission rates after pneumonia, heart failure, and acute myocardial infarction hospitalizations are risk-adjusted for age, gender, and medical comorbidities and used to penalize hospitals. To assess the impact of disability and social determinants of health on condition-specific readmissions beyond current risk adjustment. Retrospective cohort study of Medicare patients using 1) linked Health and Retirement Study-Medicare claims data (HRS-CMS) and 2) Healthcare Cost and Utilization Project State Inpatient Databases (Florida, Washington) linked with ZIP Code-level measures from the Census American Community Survey (ACS-HCUP). Multilevel logistic regression models assessed the impact of disability and selected social determinants of health on readmission beyond current risk adjustment. Outcomes measured were readmissions ≤30 days after hospitalizations for pneumonia, heart failure, or acute myocardial infarction. HRS-CMS models included disability measures (activities of daily living [ADL] limitations, cognitive impairment, nursing home residence, home healthcare use) and social determinants of health (spouse, children, wealth, Medicaid, race). ACS-HCUP model measures were ZIP Code-percentage of residents ≥65 years of age with ADL difficulty, spouse, income, Medicaid, and patient-level and hospital-level race. For pneumonia, ≥3 ADL difficulties (OR 1.61, CI 1.079–2.391) and prior home healthcare needs (OR 1.68, CI 1.204–2.355) increased readmission in HRS-CMS models (N = 1631); ADL difficulties (OR 1.20, CI 1.063–1.352) and ‘other’ race (OR 1.14, CI 1.001–1.301) increased readmission in ACS-HCUP models (N = 27,297). For heart failure, children (OR 0.66, CI 0.437–0.984) and wealth (OR 0.53, CI 0.349–0.787) lowered readmission in HRS-CMS models (N = 2068), while black (OR 1.17, CI 1.056–1.292) and ‘other’ race (OR 1.14, CI 1.036-1.260) increased readmission in ACS-HCUP models (N = 37,612). For acute myocardial infarction, nursing home status (OR 4.04, CI 1.212–13.440) increased readmission in HRS-CMS models (N = 833); ‘other’ patient-level race (OR 1.18, CI 1.012–1.385) and hospital-level race (OR 1.06, CI 1.001–1.125) increased readmission in ACS-HCUP models (N = 17,496). Disability and social determinants of health influence readmission risk when added to the current Medicare risk adjustment models, but the effect varies by condition.

Many people belong to loyalty programs for coffee shops, hotel chains, or airlines. Despite a highly consumer-oriented approach in some health systems, similar types of loyalty programs have not been developed. Why this disconnect for customer loyalty between health care and other industries?

Objective.To evaluate whether hospital-acquired catheter-associated urinary tract infections (CA-UTIs) are accurately documented in discharge records with the use of International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes so that nonpayment is triggered, as mandated by the Centers for Medicare and Medicaid Services (CMS) Hospital-Acquired Conditions Initiative.Methods.We conducted a retrospective medical record review of 80 randomly selected adult discharges from May 2006 through September 2007 from the University of Michigan Health System (UMHS) with secondary-diagnosis urinary tract infections (UTIs). One physician-abstractor reviewed each record to categorize UTIs as catheter associated and/or hospital acquired; these results (considered “gold standard”) were compared with diagnosis codes assigned by hospital coders. Annual use of the catheter association code (996.64) by UMHS coders was compared with state and US rates by using Healthcare Cost and Utilization Project data.Results.Patient mean age was 58 years; 56 (70%) were women; median length of hospital stay was 6 days; 50 patients (62%) used urinary catheters during hospitalization. Hospital coders had listed 20 secondary-diagnosis UTIs (25%) as hospital acquired, whereas physician-abstractors indicated that 37 (46%) were hospital acquired. Hospital coders had identified no CA-UTIs (code 996.64 was never used), whereas physician-abstractors identified 36 CA-UTIs (45%; 28 hospital acquired and 8 present on admission). Catheter use often was evident only from nursing notes, which, unlike physician notes, cannot be used by coders to assign discharge codes. State and US annual rates of 996.64 coding (~1% of secondary-diagnosis UTIs) were similar to those at UMHS.Conclusions.Hospital coders rarely use the catheter association code needed to identify CA-UTI among secondary-diagnosis UTIs. Coders often listed a UTI as present on admission, although the medical record indicated that it was hospital acquired. Because coding of hospital-acquired CA-UTI seems to be fraught with error, nonpayment according to CMS policy may not reliably occur.

The efficacy of screening and surveillance EGD for esophageal adenocarcinoma (EAC) is controversial.To examine the effect of an EGD before the diagnosis of EAC on survival after the diagnosis of cancer among patients with gastroesophageal reflux (GER).A retrospective, controlled cohort study.The national administrative databases of the Veterans Affairs were accessed, and patients diagnosed with EAC, from 1995 through 2003, who had a prior diagnosis consistent with GER were identified. Electronic medical records were then abstracted. Cases were subjects who had an EGD performed between 1 and 5 years before the diagnosis of EAC; controls were those subjects without a prior EGD.A total of 155 subjects with EAC and GER were identified. Cases with a history of an EGD at least 1 year before a diagnosis of EAC (n = 25) were diagnosed at earlier stages than those without a prior EGD (P = .02) but did not experience a significant improvement in survival (adjusted hazard ratio 0.93 [95% CI, 0.58-1.50]). Cases who had been enrolled in surveillance programs that adhered to published guidelines trended toward improved survival, but long-term survival reverted toward the rate found without any surveillance.A prior EGD was associated with an improved stage at the diagnosis of EAC but did not alter long-term survival. In the absence of prospective, randomized, controlled trials, the benefit of screening and surveillance to decrease mortality from EAC cannot be confirmed.

BACKGROUND Gastroesophageal reflux disease (GERD) and obesity are associated with esophageal AND AIMS: adenocarcinoma (EAC). We hypothesized that the obesity‐EAC relation is mediated by factors secreted from adipocytes. Adiponectin is a peptide secreted by adipocytes, and its plasma levels are inversely associated with obesity. We aimed to estimate the effect of circulating adiponectin on the risk of Barrett’s esophagus (BE), an accepted precursor of EAC, controlling for GERD symptoms and other potential confounders. METHODS: We conducted a case‐control study in cases of BE compared with controls without BE; most controls had GERD. Odds ratios (OR), corresponding to associations with BE, were estimated from conditional and unconditional logistic regression analyses of 50 matched pairs. RESULTS: BE was inversely associated with plasma adiponectin level (OR for each 10-µg/mL decrement 4.7, 95% confidence interval [CI] 1.4‐15.0) and positively associated with GERD duration ≥10 yr, male gender, tobacco smoking, body mass index (BMI), waist circumference, and waist-to-hip ratio. Further adjustment for GERD duration, tobacco use, and BMI increased the adiponectin‐BE association (OR 6.4, 95% CI 1.1‐37.0), but the estimated OR was reduced when adjusting for measures of abdominal obesity (e.g., OR 2.5, 95% CI 0.49‐13.00) and further adjusting for gender (OR 1.8, 95% CI 0.66‐4.70). CONCLUSIONS: Despite methodologic limitations, including the small sample size, our findings suggest that adiponectin may be involved in the etiology of BE. Rather than simply a mechanical effect of obesity promoting GERD, the effects of abdominal obesity on the risk of BE might be mediated by adiponectin and other circulating factors. (Am J Gastroenterol 2008;103:1358‐1364)

OBJECTIVES: To assess use of urinary collection devices (external, intermittent, and indwelling catheters; pads or briefs) and examine predictors of indwelling catheters in skilled nursing facilities (SNFs). DESIGN: Retrospective cohort study. SETTING: SNFs in California, Florida, Michigan, New York, and Texas. PARTICIPANTS: All patients admitted to SNFs in 2003 who remained there for 1 year (N 557,302). MEASUREMENTS: Characteristics of patients who used different collection strategies (indwelling, intermittent, and external catheterization; pads or briefs) and predictors of indwelling urinary catheterization from the Nursing Home Minimum Data Set using multinomial logistic regression. RESULTS: The prevalence of indwelling catheterization was 12.6% at admission and 4.5%at the annual assessment (Po.001). Intermittent and external catheterization were infrequently used (o1% at admission and annual assessment). Paraplegia, quadriplegia, multiple sclerosis, and comatose state were strongly associated with indwelling catheterization. Male residents were more likely to use an indwelling catheter at every assessment, as were obese patients; individuals with diabetes mellitus, renal failure, skin conditions, deep vein thrombosis, aphasia, or end-stage disease; and those who were taking more medications. CONCLUSION: Coinciding with federal regulations, urinary catheterization was lower than has been reported previously and declined over time. Further reduction should be targeted atthe evaluation ofskin problems, appropriateness of multiple medications, and alternative measures in patients with diabetes mellitus, obesity, deep vein thrombosis, and communication problems. J Am Geriatr Soc 56:854– 861, 2008.

BACKGROUND Mammography screening rates are below national recommendations for older women. Understanding the relation between the characteristics of primary care physicians (PCPs) and mammography rates for older women can help to target screening improvement efforts. METHODS Subjects were 2527 PCPs practicing in Michigan between 1997 and 1998. A cross-sectional design used Medicare data to identify women age 68 years or older in 1998 whom PCPs treated in 1997–1998 and to determine whether these women had a mammogram between 1996 and1998. Eligible women were Medicare beneficiaries age 65 years or older by 1996, residing in Michigan from 1996 to 1998, without specified comorbidities likely to affect decisions regarding mammography. Correlations and multiple regressions examined the relation between this score and characteristics of both PCPs and their practice populations of older women. RESULTS Mammography rates across physicians' practices ranged from 3–100% (mean = 59%, standard deviation = 17%). Five predictors accounted for 55% of the variance in mammography rates across practices. Higher mammography rates were found to be independently related to physicians who have: a lower mean age for female Medicare patients, a higher mean number of physicians billing for patients' care, a lower mean number of inpatient admissions, obstetrics/gynecology practices, and a higher mean education level in patient's zip code (beta weights ≥ 0.25, P < 0.0001). CONCLUSIONS PCPs vary substantially with regard to mammography rates for older women. Mammography rates vary more with the population of patients in physicians' practices than with commonly measured personal characteristics of physicians. Mammography rates should be adjusted for patient population to target individual PCPs with low mammography rates for interventions. Cancer 2003. © 2003 American Cancer Society.

Hospitals are commonly compared with each other within diagnosis-related group (DRG) categories. Administrators infer that hospitals with a higher cost per case within a DRG are less efficient than hospitals with a lower cost per case after case mix and severity adjustment. The authors assess whether hospitals that carry a heavy load of high-cost DRGs potentially distribute the added expenses of treating these patients onto their lower cost DRGs using data gathered from the 47 hospitals in the University Hospital Consortium database between January 1994 and December 1995. The results indicate that given standard hospital allocation practices, some of the costs associated with high-cost patients were likely shifted downward, thereby inflating the cost per case for less expensive patients. As researchers adopt more benchmarking methodologies, it is important to recognize that standard accounting practices in which cost shifting from one class of patient to another may impair the ability to understand the actual cost structure for classes of patients.

Current efforts to slow health care spending center on changing the way physicians are paid. As payers move away from fee-for-service, physician organizations are increasingly taking on contracts with population spending budgets.1 This transition revamps their business model. Revenue centers can become cost centers. Loss leaders can become opportunities for savings. With a budget in hand at the beginning of a year, physician organizations must now decide how to pay their constituent providers in a way that maximizes the value of care they deliver. This is a difficult task amidst organizational hierarchies that reflect the fee-for-service paradigm. Across the country, many physician organizations are bracing for battles between departments and divisions for shares of a constrained budget. Paying the old way based on relative value units (RVUs) is not ideal, as volume can drive down potential savings under the budget. Paying for quality is difficult, as quality metrics outside of primary care remain underdeveloped. Splitting the global budget into mini-budgets is plausible, but determining the amount and growth rate for one practice or specialty relative to another is challenging. Innovations in physician payment are needed, yet frameworks for how to innovate are lacking. We discuss a simple framework for thinking about innovations in physician payment.

Purpose: To determine whether differences in the conduct of individual practices of attending vascular surgeons account for variations in resource use at a university hospital. Methods: The practice patterns of six attending vascular surgeons at the University of Michigan Hospital were assessed for patient length of stay (LOS), ancillary service use, and the number of nursing hours required. Included in the study were 1930 hospitalized patients who had one of the 10 most frequently encountered diagnostic related groups (DRGs). Statistical analyses of variables that were thought likely to affect resource use included multiple regression models. Results: Patient age, sex, insurance, source of admission (direct admission or transfer admission), surgeon, and DRG category together accounted for 22% of LOS variation, 27.7% of variation in ancillary service use, and 29.4% of variation in nursing hours. In no model did the individual surgeon's practice significantly effect the LOS, ancillary use, or nursing hours. Patients transferred from other hospitals had increased resource use in all models. The DRG category alone explained 20.9% of the variance in LOS, 25.2% of the variation in ancillary service use, and 21.2% of the variance in nursing hours. Conclusion: Differences in the conduct of individual vascular surgeons' practices accounted for less than 1% variation in hospital resource use. The most important influences on resource use were the DRG category and the source of patient admission. Modification of the frequency and manner of accepting transfer patients to vascular surgery services of a university hospital may have a major impact on hospital resource use. (J Vasc Surg 1997 26:193-8.)

Value-based purchasing programs use administrative data to compare hospitals by rates of hospital-acquired pressure ulcers (HAPUs) for public reporting and financial penalties. However, validation of these data is lacking.To assess the validity of the administrative data used to generate HAPU rates by comparing the rates generated from these data with those generated from surveillance data.Retrospective analysis of 2 million all-payer administrative records from 448 California hospitals and quarterly hospitalwide surveillance data from 213 hospitals from the Collaborative Alliance for Nursing Outcomes (as publicly reported on the CalHospitalCompare Web site).196 acute care hospitals with at least 6 months of available administrative and surveillance data.Nonobstetric adults discharged in 2009.Hospital-specific HAPU rates were computed as the percentage of discharged adults (from administrative data) or examined adults (from surveillance data) with at least 1 stage II or greater HAPU (HAPU2+). Categorization of hospital performance based on administrative data was compared with the grade assigned when surveillance data were used.When administrative data were used, the mean hospital-specific HAPU2+ rate was 0.15% (95% CI, 0.13% to 0.17%); when surveillance data were used, the rate was 2.0% (CI, 1.8% to 2.2%). Among the 49 hospitals with HAPU2+ rates in the highest (worst) quartile from administrative data, use of the surveillance data set resulted in performance grades of "superior" for 3 of these hospitals, "above average" for 14, "average" for 15, and "below average" for 17.Data are from 1 state and 1 year.Hospital performance scores generated from HAPU2+ rates varied considerably according to whether administrative or surveillance data were used, suggesting that administrative data may not be appropriate for comparing hospitals.Agency for Healthcare Research and Quality.

Financial fraud and abuse are rampant within our healthcare system. Recent estimates suggest that $68 to $234 billion is lost to fraud annually. Despite numerous efforts, current strategies have met with limited success in preventing and remediating this practice. Why have we not been better able to tackle this problem? Current strategies aimed at preventing healthcare fraud and abuse fail to appreciate the spectrum that lies between clinically appropriate care and fraudulent practice. This oversight is critical, as what may be fitting treatment in one setting may just as easily be fraudulent in another. Therefore, in order to untangle the web of fraud and abuse, novel techniques and engagement of physicians who best understand these nuances are necessary. In this commentary, we introduce "forensic health services research," an extension of this scientific discipline that can best identify wasteful and fraudulent expenditure. The use of health services research in this fashion is not only synergistic with ongoing efforts, but greatly enhances current approaches. Despite the promise of this endeavor, important policy changes are needed to nurture this novel niche. We review these challenges and outline a path to move forward using this platform.

Although Americans pay much more for a day in the hospital than Canadians, we know little about whether inpatient physician practice patterns might explain some of this difference. The authors compared the utilization of all diagnostic imaging (plain radiographs, computed tomography (CT) and magnetic resonance imaging (MRI) scanning, ultrasound, nuclear medicine and vascular studies) and selected laboratory tests (hematology, basic biochemistry, and advanced biochemistry) for all patients discharged with selected medical and surgical diagnoses in 1990 and 1991 from four university hospitals and four community hospitals in Canada (n = 6,491) and the United States (n = 7,980). Overall, US medical patients received 22% more diagnostic tests than their Canadian counterparts (544.2 relative value units [RVUs] vs. 446.5 RVUs in Canada, P < 0.001), which was mainly the result of higher radiology use. Although mean radiology use was 40% higher in the United States (370.0 vs. 264.5 RVUs in Canada, P < 0.05), there was little difference in the use of laboratory tests between countries (174.2 vs. 182.4 RVUs in Canada, P = 0.3). Within radiology, only CT and MRI use differed significantly between countries (US patients received 119% more tests than Canadians). These findings were consistent after adjustments for age, gender, diagnosis-related group, and university status. Differences in test use between countries were mainly the result of more testing among the US elderly than counterparts in Canada. Among surgical patients, there was little difference between countries for radiology (76.3 vs. 67.3 RVUs in Canada, P < 0.05) and laboratory (83.6 vs. 91.4 RVUs in Canada, P < 0.05). Comparable inpatients admitted to US hospitals received more diagnostic tests than their Canadian counterparts even in hospitals with similar availability of technology. Differences between countries were larger for high-cost tests than for lower-cost tests. Much of the difference in test use is explained by more intensive use for the elderly in the United States.

Prospective payment has created incentives for hospitals to identify physicians who are responsible for high or excessive rates of resource use. However, at teaching hospitals it is unclear whether individual attending or resident physicians account for a substantial portion of the observed variations in hospital resource use. To explore this issue, case-mix adjusted hospital length of stay and ancillary resource use at a university teaching hospital for 7,667 consecutive discharges on general medicine wards and 7,566 discharges on medical subspecialty wards were evaluated. After controlling for case mix and patient characteristics (patients' age, sex, marital status, insurance status, and ward service), only 2% of the length of stay variance (log transformed) was attributable to the attending physician on general medicine wards (P = 0.06) and 1% on subspecialty medicine wards (P < 0.01). For total ancillary resource use, about 2% of the variance was attributable to general medicine and subspecialty ward attendings. Similar associations were found for resident physicians, although the overlap of attending and resident physicians' month-long rotations prevented critical appraisal of their independent contributions to resource use. Furthermore, labeling attending physicians as high or low hospital resource utilizers based on data from one month of attending duty (mean admissions = 33 +/- 7) would be scarcely better than randomly classifying them (kappas ranged from -0.05 for length of stay on subspecialty services to 0.18 for pharmacy use on general medicine services). In conclusion, in this university teaching hospital, attendings and residents account or a small, although statistically significant, amount of the variation in hospital resource use. It would be impractical for the hospital to reliably profile the resource use intensity of individual physicians.

Over the past 10 years there have been dramatic changes in health care financing in the United States, such as Medicare's Prospective Payment System for hospitalized Medicare beneficiaries, and in health services delivery, such as the growth in health maintenance organizations and other forms of managed care. These changes have occurred largely in response to payors' concerns about the rising cost of health care. A study of such changes in financing and delivery, and how specific groups of patients are affected is necessary so that the effects of these changes on patients' health can be determined. We examined the hospitalization rates for patients with musculoskeletal diseases in Michigan from 1980 through 1987. During this period, the overall ageadjusted hospitalization rates decreased 7.0% per year (p = 0.001). The decrease occurred less for surgical discharges (6.0% per year) than for medical discharges (8.6% per year) (p < 0.001). While these overall trends are of interest, they obscure disease-specific trends that vary significantly from both the overall, and the medical and surgical trends. For example, while surgical discharges, in general declined, procedures related to major joint and limb reattachment (DRG # 209) increased at a rate of 6.3% per year. And while medical discharges in general decreased over this period, discharges for osteomyelitis increased 5.4% per year. The patterns of diseasespecific trends offers insight into the possible causes for these changes. Finally, it is important to understand the epidemiology of hospital use to evaluate the effects of new medical care delivery and payment systems on the care of subsets of patients.

The purpose of this study was to analyze changes in rates of unscheduled readmissions and changes in technical efficiency following the introduction of the Medicare Prospective Payment System (PPS). We developed the RiskAdjusted Readmissions Index (RARI), which allowed us to make comparisons in rates of unanticipated readmissions across hospitals and over time. Data envelopment analysis (DEA), a linear programming technique, was used to measure changes in technical efficiency by comparing the inputs used and the outputs produced across a cohort of hospitals, while adjusting for changes over time in case mix and case complexity. Rates of unscheduled readmissions and efficiency scores were computed for a sample of 245 hospitals for each year. Although both readmission rates and efficiency scores increased for most hospitals, there was no evidence that those hospitals that experienced the greatest increases in efficiency had the largest increases in their rates of unscheduled readmissions.

To assess use of urinary collection devices (external, intermittent, and indwelling catheters; pads or briefs) and examine predictors of indwelling catheters in skilled nursing facilities (SNFs).Retrospective cohort study.SNFs in California, Florida, Michigan, New York, and Texas.All patients admitted to SNFs in 2003 who remained there for 1 year (N=57,302).Characteristics of patients who used different collection strategies (indwelling, intermittent, and external catheterization; pads or briefs) and predictors of indwelling urinary catheterization from the Nursing Home Minimum Data Set using multinomial logistic regression.The prevalence of indwelling catheterization was 12.6% at admission and 4.5% at the annual assessment (P.001). Intermittent and external catheterization were infrequently used (1% at admission and annual assessment). Paraplegia, quadriplegia, multiple sclerosis, and comatose state were strongly associated with indwelling catheterization. Male residents were more likely to use an indwelling catheter at every assessment, as were obese patients; individuals with diabetes mellitus, renal failure, skin conditions, deep vein thrombosis, aphasia, or end-stage disease; and those who were taking more medications.Coinciding with federal regulations, urinary catheterization was lower than has been reported previously and declined over time. Further reduction should be targeted at the evaluation of skin problems, appropriateness of multiple medications, and alternative measures in patients with diabetes mellitus, obesity, deep vein thrombosis, and communication problems.

In this study we used information from discharge abstracts to develop three different risk-adjusted measures of hospital performance: a Risk-Adjusted Mortality Index, a Risk-Adjusted Readmissions Index, and a Risk-Adjusted Complications Index. The adjustments have face validity, and appear to account for much of the variation across hospitals in the rates of these adverse events. The indexes are stable over time, and are not biased with respect to hospital size, ownership, or teaching status. All three indexes appear to have construct validity when tested against the changes in hospital care that occurred when PPS was introduced.

Capitation plans may place their enrollees at risk of rationed services if they do not adjust for underlying patient characteristics that dictate differing levels of care. To assess the degree to which population-based socioeconomic characteristics are associated with hospital use, this study explored small-area variation in hospital discharges for gastrointestinal and liver (GI) Diagnosis Related Groups (DRGs). Utilizing a 1980 Michigan database of 1.5 million discharges, we constructed age-adjusted, population-based discharge rates for the GI DRGs. We then evaluated the effect of poverty, defined by the percent of households in a hospital market community below the poverty line. Using regression techniques, we found that poverty explained 27.5% of the variation in GI hospital discharges, with the poor admitted more often (p less than 0.0001). Using cost weighted discharge rates as the dependent variable, we found that poverty explained 20.3% (p = 0.0003) of the variation in cost weighted discharges. These results suggest that poverty explains a significant amount of variation in hospital discharges and has a significant effect on associated small-area hospitalization costs in GI diseases. Practicing gastroenterologists and surgeons need to be aware of factors that influence patients utilizing their services in order to retain their role as patient advocates as changes in payment systems are suggested.

The rapid emergence of hospitalist care in the United States has been extraordinary, with more than 20,000 hospitalists practicing today.1 Several factors underlie this growth, including the increased demands placed on primary care physicians that make caring for both inpatients and outpatients difficult, restrictions on the work hours of residents, and the belief that “practice makes perfect.”1,2 Although hospitalists may improve outcomes and enhance clinical efficiency, there has been concern that fragmenting the continuity of care could lead to more medical errors and dissatisfied patients.3 Early research focusing on cost and clinical outcomes sought to inform the debate about . . .

Gastroenterologists' approach to surveillance for Barrett's esophagus is variable. We hypothesized that financial incentives and concerns over malpractice litigation influence gastroenterologists' usual practices regarding screening and surveillance.We surveyed gastroenterologists (N = 224) regarding their usual practice of screening or surveillance for Barrett's esophagus, belief in the efficacy of screening, knowledge of published guidelines, demographic factors, compensation structure, volume of endoscopies, and malpractice history. Practices were characterized as aggressive or conservative in the utilization of services compared with a published guideline.Twenty-one percent of attending gastroenterologists reported being identified as a defendant in at least one malpractice suit. Prior malpractice defendants had practiced gastroenterology longer and performed a higher volume of endoscopies, but had similar knowledge regarding published screening guidelines to those who had not been defendants. They were more likely to be aggressive rather than conservative in screening and surveillance for Barrett's esophagus (odds ratio [OR] 3.6, 95% confidence interval [CI] 1.1-12), and remained so after controlling for other factors. In particular, they were more likely to recommend screening for populations with a lower risk of development of cancer, and to perform more frequent surveillance for low-grade dysplasia. Other factors were not associated with aggressive practice, including compensation structure.History of at least one prior malpractice suit appears to be associated with the more aggressive use of endoscopic screening and surveillance for Barrett's esophagus, irrespective of physician belief regarding the efficacy of that strategy in reducing mortality. Hypervigilance and fear of future malpractice suits may drive this increased use.

Unlike many areas of the economy where value is relatively easy to measure and reward, healthcare is "messy." Patients bring both clinical heterogeneity and illness-severity complexities to the interchange with their physician. The measurable outcomes or process measures are as likely to be due to patient characteristics as they are to be due to the actions (or inactions) of the patient's provider. Moreover, data suggest that the simplest fix for providers with bad metrics is to "dump" their sickest patients. Perhaps the most pernicious consequence of physician-level pay-for-performance (P4P) systems is how these systems can affect the neediest patients and their providers. As patient characteristics (eg, illness severity, preferences, resources) are more likely to be an issue in our poorer and minority communities, these patients' physicians will be at a financial disadvantage in a P4P system. It is likely that the widespread adoption of P4P systems will further limit these necessary resources.

General Internal Medicine (GIM) faces a burgeoning crisis in the United States, while patients with chronic illness confront a disintegrating health care system. Reimbursement that rewards using procedures and devices rather than thoughtful examination and management, plus onerous administrative burdens, are prompting physicians to pursue specialties other than GIM. This monograph promotes 9 principles supporting the concept of Coordinated Care--a strategy to sustain quality and enhance the attractiveness and viability of care delivered by highly trained General Internists who specialize in the longitudinal care of adult patients with acute and chronic illness. This approach supplements and extends the concept of the Advanced Medical Home set forth by the American College of Physicians. Specific components of Coordinated Care include clinical support, information management, and access and scheduling. Success of the model will require changes in the payment system that fairly reimburse physicians who provide leadership to teams that deliver high quality, coordinated care.

One of the touchstones of academic General Internal Medicine, whether practiced in an ambulatory care setting or at the patient’s bedside, is its focus on enhancing and teaching patient-centered care. In an era of increasing cost consciousness, patient centeredness requires thoughtful, ongoing discussions about the risks and benefits of a myriad of medical tests and procedures. Against this backdrop, the Society of General Internal Medicine (SGIM) chose to participate in the American Board of Internal Medicine Foundation’s Choosing Wisely initiative. The Choosing Wisely initiative aims to promote conversations between patients and their physicians around tests and procedures whose necessity should be questioned and whose potential harms and benefits clarified within the context of each patient’s care plan. To date, 54 medical societies and 17 consumer groups have identified 280 potentially unnecessary medical tests and treatments that are commonly performed in the United States. 1 To further assist patients in engaging with their physicians in discussions about these tests and procedures, Consumer Reports is partnering in this process to develop and disseminate materials for patients through large, publically oriented consumer groups. This alliance of science, advocacy and policy is ultimately designed to improve patient care and clinical outcomes, and reduce wasteful and unnecessary healthcare expenditures. In discussing health care costs and the Choosing Wisely approach, Castle and Guest from the American Board of Internal Medicine (ABIM) Foundation note, “The initial focus should be on overuse of medical resources, which not only is a leading factor in the high level of spending on healthcare but also places patients at risk of harm.” 2 Some estimates suggest that as much as 30 % of all healthcare spending is wasteful. 3 Volpp and colleagues also identify the promise of the Choosing Wisely initiative when they note, “The Choosing Wisely initiative represents an important first step toward the identification of low-value services, more meaningful because it is a step taken jointly by consumer groups and professional societies.” 4 They go on to note, “Given fiscal realities, reducing low-value services is what will allow continued support for the coverage of high-value services.” 4 The ad hoc SGIM Choosing Wisely Committee was selected from the existing SGIM Clinical Practice Committee, and the Evidence-based Medicine Task Force, as well as selected society members. The goal of the ad hoc committee was to identify important topics for academic general internal medicine faculty across the spectrum of clinical practice. The committee operated under a few notable constraints. First, there had to beexistingevidence onthe selected topic, as there was no opportunity to construct new systematic reviews or evidence syntheses as part of the process. Second, the Choosing Wisely initiative was limited to five topics or

Critical pathways are healthcare management plans that specify patient goals and the sequence and timing of actions necessary to achieve these goals with optimal efficiency. More than 80% of hospitals in the United States use critical pathways for at least some of their patients. Unfortunately, critical pathway effectiveness in improving clinical efficiency is unclear.To assess whether critical pathways have been successful in reducing patient length of stay (LOS) and resource utilization in our tertiary-care academic medical center.A before-and-after observational study using multivariate linear regression analyses.We identified all critical pathways initiated in our medical center between 1993 and 1996 in which at least 50 adult patients would be evaluated in the year preceding and succeeding pathway implementation; 13 pathways satisfied these inclusion criteria. Using a before-and-after design, multivariate linear regression was used to evaluate each pathway's effect on average monthly LOS and resource utilization after adjusting for case mix and secular trends.Three of the 13 pathways were associated with a statistically significant immediate decrease in inpatient LOS: acute myocardial infarction (20.7% decrease; P = .001), cesarean section (14.6% decrease; P = .03), and kidney transplantation (24.5% decrease; P = .003). Only 1 pathway, percutaneous transluminal coronary angioplasty (PTCA), produced a statistically significant decrease in LOS slope (a decrease of 5.2% per month; P = .001). Two pathways were accompanied by a statistically significant immediate reduction in ancillary resource utilization: kidney transplantation (26.4% decrease; P = .001) and community-acquired pneumonia (21.8% decrease; P = .002). Only the PTCA pathway produced a statistically significant decrease in resource utilization slope during the 12-month follow-up period (a decrease of 8.4% per month; P.001).Although some pathways did reduce LOS or resource utilization or both, most pathways reduced neither. Because substantial resources must be expended on pathway development, implementation, and maintenance, future efforts should be placed on further evaluating the effectiveness of critical pathways and understanding the reasons behind their success or failure before additional resources are consumed for this management strategy.

Article-at-a-Glance Background This study compared the number of care-related injuries reported to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) with the number reported to 15 mandatory-reporting states. Methods The primary outcome measure was the number of patient injuries reported to each in 1999. Results In all categories examined, the number of reports submitted by accredited hospitals to states equaled or exceeded the number reported to JCAHO. Discussion State-reporting systems identified a greater number of care-related injuries than did the JCAHO system. Although JCAHO received fewer reports from accredited hospitals, its process requires an analysis of the event and a prevention plan, and it disseminates the lessons learned from reported events. For adverse event reporting to improve patient safety, there must be assurances that lessons are learned from these events, preventive measures are taken, and information is shared so others may benefit without having to experience the same adverse event. Conclusion This study represents an early attempt to understand the system characteristics that influence hospital reporting of care-related patient injuries. As reporting systems become more prevalent and standardized, the influence of factors such as legal protections, confidentiality, and technology on reporting should be better understood.

The study purpose was to increase mammography screening among older women by identifying female Medicare beneficiaries without a recent mammogram and assesses the cost-effectiveness of a personalized targeted mailing encouraging them to have a mammogram.A randomized paired controlled trial included 1229 pairs of women matched on zip code, race, and urban or rural county. Postintervention mammography claims were measured from November 1997 through December 1998. The subjects were female Medicare beneficiaries ageor = 70, living in Michigan foror = 5 years, having no significant comorbidity likely to affect screening, and no mammogram foror = 5 years. Intervention subjects received a personally addressed letter from the Medical Director of Michigan Medicare with materials emphasizing the individual's lack of use of the Medicare mammography screening benefit, reasons for screening, and how to be screened.Women who received the mailing were 60% more likely to have a subsequent mammogram (OR 1.6, P0.005), with diagnostic mammograms increasing more than screening mammograms (2.8% vs. 0.8%). The absolute increase was greatest for women age 70 to 79, 10.6% in the intervention group versus 6.5% for controls, odds ratio 1.7 (P0.02). A statewide Medicare intervention in Michigan would cost of 108,000 US dollars to 238,000 US dollars, producing 3500 to 4300 additional mammograms at 31 US dollars to 55 US dollars per additional mammogram.The intervention increased mammography among long-term noncompliant older women, particularly increasing diagnostic mammograms. This approach can be directly implemented in other states and nationally. It may also be useful for other preventive services.

BACKGROUND Major national interventions occurred in the early and mid-1990s to increase mammography screening rates among older women. The current study examined mammography utilization by older women during this period. Relation between mammography utilization and demographic measures and health care-related factors also were examined. METHODS A cross-sectional design examined variations in mammography during the 5 years between 1993 to 1997 in a representative sample of 10,000 female Medicare beneficiaries in Michigan age ≥ 65 years in 1993. Medicare and census data were used. Separate analyses were performed for having undergone any mammogram and, for the 5680 women who had undergone a mammogram, the number of mammograms. Relations were examined between mammography utilization and 15 demographic variables (e.g., age and African-American race) and health care-related variables (e.g., inpatient admissions and number of physicians involved in care). RESULTS In the 5 years 43% of older women had no evidence of having undergone a mammogram. Those with any mammogram averaged 2.8 mammograms. Meaningful independent predictors of both having undergone a mammogram and having more than one mammogram were more physicians involved in care, fewer inpatient admissions, and younger age. Having undergone a mammogram also was found to be associated with seeing an obstetrician/gynecologist. CONCLUSIONS Even with screening mammography as a covered benefit and after several national informational campaigns, the current study found that in 5 years, 60% of older women either had not undergone a mammogram or had undergone only 1. Intervention efforts should emphasize screening based on functional status, not age. This message should be targeted to physicians as well as to older women without claims for recent mammograms and who are likely to be in good health. Cancer 2003;97:1147–55. © 2003 American Cancer Society. DOI 10.1002/cncr.11172