David C. Goodman

A systematic review of medical practice variation in OECD countries

BACKGROUNDnMajor variations in medical practice have been documented internationally. Variations raise questions about the quality, equity, and efficiency of resource allocation and use, and have important implications for health care and health policy.nnnOBJECTIVEnTo perform a systematic review of the peer-reviewed literature on medical practice variations in OECD countries.nnnMETHODSnWe searched MEDLINE to find publications on medical practice variations in OECD countries published between 2000 and 2011. We present an overview of the characteristics of published studies as well as the magnitude of variations for select high impact conditions.nnnRESULTSnA total of 836 studies were included. Consistent with the gray literature, there were large variations across regions, hospitals and physician practices for almost every condition and procedure studied. Many studies focused on high-impact conditions, but very few looked at the causes or outcomes of medical practice variations.nnnCONCLUSIONnWhile there were an overwhelming number of publications on medical practice variations the coverage was broad and not often based on a theoretical construct. Future studies should focus on conditions and procedures that are clinically important, policy relevant, resource intensive, and have high levels of public awareness. Further study of the causes and consequences of variations is important.

Epidemiologic Trends in Neonatal Intensive Care, 2007-2012

IMPORTANCEnNeonatal intensive care has been highly effective at improving newborn outcomes but is expensive and carries inherent risks. Existing studies of neonatal intensive care have focused on specific subsets of newborns and lack a population-based perspective.nnnOBJECTIVESnTo describe admission rates to neonatal intensive care units (NICUs) for US newborns across the entire continuum of birth weight and how these rates have changed across time, as well as describe the characteristics of infants admitted to NICUs.nnnDESIGN, SETTING, AND PARTICIPANTSnAn epidemiologic time-trend analysis was conducted on April 1, 2015, of live births (≥500 g) from January 1, 2007, to December 31, 2012, to residents of 38 US states and the District of Columbia, recorded using the 2003 revision of the US Standard Certificate of Live Birth (Nu2009=u200917,896,048).nnnEXPOSUREnBirth year.nnnMAIN OUTCOMES AND MEASURESnCrude, stratified (by birth weight), and adjusted admission rates. Trends in birth weight, gestational age, weight for gestational age, and use of assisted ventilation are presented to describe the cohort of admitted newborns.nnnRESULTSnIn 2012, there were 43.0 NICU admissions per 1000 normal-birth-weight infants (2500-3999 g), while the admission rate for very low-birth-weight infants (<1500 g) was 844.1 per 1000 live births. Overall, admission rates during the 6-year study period increased from 64.0 to 77.9 per 1000 live births (relative rate, 1.22; 95% CI, 1.21-1.22 [Pu2009<u2009.001]). Admission rates increased for all birth weight categories. Trends in relative rates adjusted for maternal and newborn characteristics showed a similar 23% increase (95% CI, 1.22-1.23 [Pu2009<u2009.001]). During the study period, newborns admitted to a NICU were larger and less premature, although no consistent trend was seen in weight for gestational age or the use of assisted ventilation.nnnCONCLUSIONS AND RELEVANCEnAfter adjustment for infant and maternal risk factors, US newborns at all birth weights are increasingly likely to be admitted to a NICU, which raises the possibility of overuse of neonatal intensive care in some newborns. Further study is needed into the causes of the increased use observed in our study as well as its implications for payers, policymakers, families, and newborns.

Early Primary Care Provider Follow-up and Readmission After High-Risk Surgery

IMPORTANCEnFollow-up with a primary care provider (PCP) in addition to the surgical team is routinely recommended to patients discharged after major surgery despite no clear evidence that it improves outcomes.nnnOBJECTIVEnTo test whether PCP follow-up is associated with lower 30-day readmission rates after open thoracic aortic aneurysm (TAA) repair and ventral hernia repair (VHR), surgical procedures known to have a high and low risk of readmission, respectively.nnnDESIGN, SETTING, AND PARTICIPANTSnIn a cohort of Medicare beneficiaries discharged to home after open TAA repair (nu2009=u200912u2009679) and VHR (nu2009=u200952u2009807) between 2003 to 2010, we compared 30-day readmission rates between patients seen and not seen by a PCP within 30 days of discharge and across tertiles of regional primary care use. We stratified our analysis by the presence of complications during the surgical (index) admission.nnnMAIN OUTCOMES AND MEASURESnThirty-day readmission rate.nnnRESULTSnOverall, 2619 patients (20.6%) undergoing open TAA repair and 4927 patients (9.3%) undergoing VHR were readmitted within 30 days after surgery. Complications occurred in 4649 patients (36.6%) undergoing open TAA repair and 4528 patients (8.6%) undergoing VHR during their surgical admission. Early follow-up with a PCP significantly reduced the risk of readmission among open TAA patients who experienced perioperative complications, from 35.0% (without follow-up) to 20.4% (with follow-up) (Pu2009<u2009.001). However, PCP follow-up made no significant difference in patients whose hospital course was uncomplicated (19.4% with follow-up vs 21.9% without follow-up; Pu2009=u2009.31). In comparison, early follow-up with a PCP after VHR did not reduce the risk of readmission, regardless of complications. In adjusted regional analyses, undergoing open TAA repair in regions with high compared with low primary care use was associated with an 18% lower likelihood of 30-day readmission (odds ratio, 0.82; 95% CI, 0.71-0.96; P = .02), whereas no significant difference was found among patients after VHR.nnnCONCLUSIONS AND RELEVANCEnFollow-up with a PCP after high-risk surgery (eg, open TAA repair), especially among patients with complications, is associated with a lower risk of hospital readmission. Patients undergoing lower-risk surgery (eg, VHR) do not receive the same benefit from early PCP follow-up. Identifying high-risk surgical patients who will benefit from PCP integration during care transitions may offer a low-cost solution toward limiting readmissions.

Accountability for end-stage organ care: implications of geographic variation in access to kidney transplantation.

BACKGROUNDnThe provision of effective surgical care for end-stage renal disease (ESRD) requires efficient evaluation and transplantation. Prior assessments of transplant access have focused primarily on waitlisted patients rather than the overall populations served by accountable providers of transplant services.nnnMETHODSnNovel transplant referral regions (TRRs) were defined using United Network for Organ Sharing registry data for 301,092 kidney transplant listings to assign zip codes to accountable transplant programs. Subsequently, risk-adjusted observed to expected (O:E) rates of listing and transplant procedures were calculated for each TRR. Finally, the impact of variation in TRR listing and transplant rates on mortality was assessed for ESRD patients <60 years old diagnosed between 2000 and 2008.nnnRESULTSnIn total, 113 TRRs were defined, 51% of which included >1 transplant center. The likelihood of being evaluated and listed for transplant varied significantly between TRRs (risk-adjusted O:E, 0.58-1.95). Variation was greater for the overall transplant rate (0.62-2.19), living donor transplantation (0.36-3.08), and donation after cardiac death transplant (0-15.4) than for standard criteria donors (0.64-2.86). Mortality was decreased for ESRD patients living in TRRs in the highest tertile of listings (hazard ratio, 0.89; P < .0001) and transplantation (0.90; P < .0001).nnnCONCLUSIONnResidence in a TRR with care delivery systems that increase access to transplant services is associated with significant, risk-adjusted decreases in ESRD-related mortality. Transplant centers should continue to focus on improving access to care within the communities they serve.

Financial Incentives to Improve Quality Skating to the Puck or Avoiding the Penalty Box

Wayne Gretzky once explained how he became a hockey player of genius: “I skate to where the puck is going to be, not where it has been.” Since the Affordable Care Act (ACA) enacted the Hospital Readmissions Reduction Program, hospitals have been ever more focused on playing to the puck to avoid financial penalties for high rates of early readmission. This Viewpoint examines the Hospital Readmissions Reduction Program as an example of similar initiatives by the Centers for Medicare & Medicaid Services (CMS) and discusses the increasing use of financial penalties for changing the behavior of hospitals.

Supply sensitive services in Swiss ambulatory care: An analysis of basic health insurance records for 2003-2007

BackgroundSwiss ambulatory care is characterized by independent, and primarily practice-based, physicians, receiving fee for service reimbursement. This study analyses supply sensitive services using ambulatory care claims data from mandatory health insurance. A first research question was aimed at the hypothesis that physicians with large patient lists decrease their intensity of services and bill less per patient to health insurance, and vice versa: physicians with smaller patient lists compensate for the lack of patients with additional visits and services. A second research question relates to the fact that several cantons are allowing physicians to directly dispense drugs to patients (self-dispensation) whereas other cantons restrict such direct sales to emergencies only. This second question was based on the assumption that patterns of rescheduling patients for consultations may differ across channels of dispensing prescription drugs and therefore the hypothesis of different consultation costs in this context was investigated.MethodsComplete claims data paid for by mandatory health insurance of all Swiss physicians in own practices were analyzed for the years 2003-2007. Medical specialties were pooled into six main provider types in ambulatory care: primary care, pediatrics, gynecology & obstetrics, psychiatrists, invasive and non-invasive specialists. For each provider type, regression models at the physician level were used to analyze the relationship between the number of patients treated and the total sum of treatment cost reimbursed by mandatory health insurance.ResultsThe results show non-proportional relationships between patient numbers and total sum of treatment cost for all provider types involved implying that treatment costs per patient increase with higher practice size. The related additional costs to the health system are substantial. Regions with self-dispensation had lowest treatment cost for primary care, gynecology, pediatrics and for psychiatrists whereas prescription only areas had lowest cost for specialists with non-invasive and invasive activities.ConclusionsThe results indicate that payment methods for services and for prescription drugs are associated with variations in treatment cost that are unlikely warranted by different medical needs of patients alone. Promoting physician accountability of care by linking reimbursements to quality, not quantity, of services are important policy measures to be considered for health care in Switzerland.

Health System Characteristics and Rates of Readmission After Acute Myocardial Infarction in the United States

Background Interventions to reduce early readmissions have focused on patient characteristics and the importance of early follow‐up; however, less is known about the characteristics of health systems, including quality, capacity, and intensity, and their influence on readmission rates in the United States. Therefore, we examined the association of hospital patterns of medical care with rates of 30‐day readmission. Methods and Results Medicare beneficiaries hospitalized for an AMI (n=188 611) between 2008 and 2009 in 1088 hospitals in the United States were included in our cohort. We tested the association between hospital patterns of medical care quality (discharge planning care quality), capacity (hospital size measured as the number of beds, hospital‐level Medicare all medical admission rates, supply of primary care physicians and cardiologists), and intensity (measures of care during the last 6 months of life) on CMS risk‐adjusted rates of 30‐day readmission using Poisson multilevel mixed‐effects models adjusting for patient‐ and hospital‐level covariates. There were 38 350 readmissions at 30‐days (20.3%) AMI discharges. Controlling for patient characteristics, measures of hospital care associated with higher rates of readmission included higher hospital‐level rates for all medical admissions, per capita primary care physicians and cardiologists, and last 6 months of life care intensity measures including increased number of hospital days, number of ICU days, number of physician visits, and 10 or more different physicians seen during the last 6 months of life. Better discharge quality and larger hospitals were associated with lower rates of readmission. Conclusions In addition to quality of care, high 30‐day readmission rates are associated with hospital‐level measures of capacity and intensity. Efforts to reduce readmission rates may need to address these broader patterns of medical care.

Geographic variation in the cost of ambulatory care in Switzerland

Objectives Swiss health care is relatively costly. In order better to understand the drivers of spending, this study analyses geographic variation in per capita consultation costs for ambulatory care. Methods Small area and longitudinal analysis of costs of ambulatory services covered by compulsory health insurance, 2003-07. Results The results show considerable geographic variation in per capita consultation costs, with higher costs in urban compared to rural areas. Areas with higher availability of care had higher costs, and residents of urban and high income areas used more specialist care and generated higher costs than residents of rural areas. Conclusions There are persistent regional differences in the per capita cost of ambulatory care that are not explained by demographic factors, access to care, or needs. It is likely that higher access to care leads to greater inappropriate use, particularly of specialists. Implementing gatekeeping systems and financial incentives that encourage better coordination of primary care may slow growth in costs and improve care.

Hospital Variation in Health Care Utilization by Children With Medical Complexity

BACKGROUND: Although children with medical complexity have high health care needs, little is known about the variation in care provided between centers. This information may be particularly useful in identifying opportunities to improve quality and reduce costs. METHODS: We conducted a retrospective population-based observational cohort study using all payer claims databases for children aged 30 days to <18 years residing in Maine, New Hampshire, and Vermont from 2007 to 2010. We identified hospital-affiliated cohorts (n = 6) of patients (n = 8216) with medical complexity by using diagnostic codes from both inpatient and outpatient claims. Children were assigned to the hospital where they received the most inpatient days, or their outpatient visits if no hospitalization occurred. Outcomes of interest included patient encounters, medical imaging, and diagnostic testing. Adjusted relative rates were calculated with overdispersed Poisson regression models. RESULTS: Adjusting for patient characteristics, the number of inpatient (relative rate 0.84 vs 2.28) and intensive care days (relative rate 0.45 vs 1.28) varied by more than twofold, whereas office (relative rate 0.77 vs 1.12) and emergency department visits (relative rate 0.71 vs 1.37) varied to a lesser extent. There was also marked variation in the use of imaging, and other diagnostic tests, with particularly high variation in electrocardiography (relative rate 0.35 vs 2.81) and head MRI (relative rate 0.72 vs 2.12). CONCLUSIONS: Depending on where they receive care, children with medical complexity experience widely different patterns of utilization. These findings indicate the need for identifying best practices for this growing patient population.

Thoracic endovascular aneurysm repair, race, and volume in thoracic aneurysm repair

BACKGROUNDnVolume-based disparities in surgical care are often associated with poorer results in African American patients. We examined the effect of treatment patterns and outcomes, by race, for isolated thoracic aortic aneurysm (TAA).nnnMETHODSnUsing Medicare claims (1999-2007), we studied all patients undergoing repair of TAAs, via open surgery or thoracic endovascular aneurysm repair (TEVAR). We studied 30-day mortality and complications by race, procedure type, and hospital volume.nnnRESULTSnWe studied 12,573 patients who underwent open TAA repair (4% of whom were black) and 2732 patients who underwent TEVAR (8% of whom were black). In open repair, black patients had higher 30-day mortality than white patients (18% vs 10%; P<.001), while mortality rates were similar with TEVAR (8% black vs 9% white; P=.56). For open repair, black patients were more likely to undergo surgery at low-volume hospitals, where overall operative mortality was highest (14% at very low-volume hospitals, 7% at very high-volume hospitals; P<.001). However, for TEVAR, black patients were not more likely to undergo repair at low-volume hospitals, and mortality differences were not evident across volume strata (9% at very low-volume hospitals, 7% at very high-volume hospitals; P=.328). Multivariable analyses adjusting for age, sex, race, comorbidity, and volume confirmed that increased perioperative mortality was associated with black race for open surgery (OR, 2.0, 95% CI, 1.5-2.5; P<.001) but not TEVAR (OR, 0.9, 95% CI, 0.6-1.5; P=.721).nnnCONCLUSIONSnWhile racial disparities in surgical care have a significant effect on mortality with open thoracoabdominal aortic aneurysm repair, black patients undergoing TEVAR obtain similar outcomes as white patients. New technology can limit the effect of racial disparities in surgical care.