John Fontanesi

How Effectively Can Health Care Settings Beyond the Traditional Medical Home Provide Vaccines to Adolescents

OBJECTIVES. Our goal was to evaluate the capacity of various health care settings to supplement the activities of the traditional medical home by delivering vaccines to adolescents. METHODS. A group of experts in the fields of adolescent-immunization delivery and the provision of preventive care in various health care settings summarized the available literature, considered setting-specific factors, and assessed the ability of various health care settings beyond the traditional medical home to conform to the immunization quality standards set by the National Vaccine Advisory Committee, report vaccination information for the quantitative assessment of vaccine-coverage rates, be likely to offer vaccines to adolescents, and be viewed by adolescents as acceptable sites for receiving vaccinations. RESULTS. Seven candidate settings were evaluated: pharmacies, obstetrics-gynecology practices, sexually transmitted disease clinics, hospital emergency departments, family planning clinics, teen clinics, and local public health department immunization clinics. The panel concluded that all could safely provide vaccinations to adolescents but that vaccination efforts at some of the settings could potentially have a markedly greater impact on overall adolescent-immunization rates than could those at other settings. In addition, for adolescent-vaccination services to be practical, candidate settings need to have a clear interest in providing them. Conditional on that, several issues need to be addressed: (1) funding; (2) orienting facilities to provide preventive care services; (3) enhancing access to immunization registries; and (4) clarifying issues related to immunization consent. CONCLUSIONS. With supporting health policy, health education, and communication, health care settings beyond the traditional medical home have the potential to effectively augment the vaccination efforts of more traditional settings to deliver vaccines to adolescents. These health care settings may be particularly well suited to reach adolescents who lack access to traditional sources of preventive medical care or receive fragmented medical care.

Magnetic resonance imaging and liver histology as biomarkers of hepatic steatosis in children with nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in children. In order to advance the field of NAFLD, noninvasive imaging methods for measuring liver fat are needed. Advanced magnetic resonance imaging (MRI) has shown great promise for the quantitative assessment of hepatic steatosis but has not been validated in children. Therefore, this study was designed to evaluate the correlation and diagnostic accuracy of MRI‐estimated liver proton density fat fraction (PDFF), a biomarker for hepatic steatosis, compared to histologic steatosis grade in children. The study included 174 children with a mean age of 14.0 years. Liver PDFF estimated by MRI was significantly (P < 0.01) correlated (0.725) with steatosis grade. The correlation of MRI‐estimated liver PDFF and steatosis grade was influenced by both sex and fibrosis stage. The correlation was significantly (P < 0.01) stronger in girls (0.86) than in boys (0.70). The correlation was significantly (P < 0.01) weaker in children with stage 2‐4 fibrosis (0.61) than children with no fibrosis (0.76) or stage 1 fibrosis (0.78). The diagnostic accuracy of commonly used threshold values to distinguish between no steatosis and mild steatosis ranged from 0.69 to 0.82. The overall accuracy of predicting the histologic steatosis grade from MRI‐estimated liver PDFF was 56%. No single threshold had sufficient sensitivity and specificity to be considered diagnostic for an individual child. Conclusions: Advanced magnitude‐based MRI can be used to estimate liver PDFF in children, and those PDFF values correlate well with steatosis grade by liver histology. Thus, magnitude‐based MRI has the potential for clinical utility in the evaluation of NAFLD, but at this time no single threshold value has sufficient accuracy to be considered diagnostic for an individual child. (Hepatology 2015;61:1887–1895)

Life expectancy and health expenditure evolution in Eastern Europe—DiD and DEA analysis

ABSTRACT Background: Exploration of long-term health expenditure and longevity trends across three major sub-regions of Eastern Europe since 1989. Methods: 24 countries were classified as EU 2004, CIS, or SEE. European Health for All Database (HFA-DB) 1989–2012 data were processed using difference-in-difference (DiD) and data envelopment analysis (DEA). Results: The strongest expenditure growth was recorded in EU 2004 followed by SEE and the CIS. A surprisingly similar longevity increase was present in SEE and EU 2004. In 1989, countries that joined EU in 2004 were relatively inefficient in the number of life-years gained yet had a lower life expectancy than the SEE region and was only slightly higher than the CIS region (DEA). By 2012 the revenue spent was roughly linear to additional life-year expectancies. Conclusion: EU 2004 members were the best performers in terms of balanced longevity increase followed by health expenditure growth. The SEE economies’ longevity gains were lagging slightly behind at a far lower cost. An extrapolated CIS expenditure to longevity increase ratio has the fastest-growing long-term promise.

The Cost of Doing Business: Cost Structure of Electronic Immunization Registries

OBJECTIVE To predict the true cost of developing and maintaining an electronic immunization registry, and to set the framework for developing future cost-effective and cost-benefit analysis. DATA SOURCES/STUDY SETTING Primary data collected at three immunization registries located in California, accounting for 90 percent of all immunization records in registries in the state during the study period. STUDY DESIGN A parametric cost analysis compared registry development and maintenance expenditures to registry performance requirements. DATA COLLECTION/EXTRACTION METHODS Data were collected at each registry through interviews, reviews of expenditure records, technical accomplishments development schedules, and immunization coverage rates. PRINCIPAL FINDINGS The cost of building immunization registries is predictable and independent of the hardware/software combination employed. The effort requires four man-years of technical effort or approximately

Decoding laboratory test names: a major challenge to appropriate patient care.

250,000 in 1998 dollars. Costs for maintaining a registry were approximately

The Cost to Immunize During Well-Child Visits

5,100 per end user per three-year period. CONCLUSIONS There is a predictable cost structure for both developing and maintaining immunization registries. The cost structure can be used as a framework for examining the cost-effectiveness and cost-benefits of registries. The greatest factor effecting improvement in coverage rates was ongoing, user-based administrative investment.

A multisite study of performance drivers among institutional review boards

Clinical laboratory tests have no value if clinicians cannot quickly order and obtain the results they need. We found that efforts to obtain even the most commonly ordered tests are often derailed by excessively complex nomenclature. Ordering the right laboratory tests is critical to diagnosis and treatment, but existing mechanisms for entering lab orders actively interfere with physicians’ efforts to provide good clinical care. Rather than simplifying lab orders, the advent of computerized physician order entry (CPOE) systems—generally programmed by non-clinicians—has introduced new and vexing practical problems. Medical laboratories have filled their test menus, whether paper or electronic, with bewildering nomenclature and abbreviations, and have failed to appreciate the dangers of assigning perilously similar names to different tests. The efficient and efficacious patient care demanded by the quality care initiative requires progress beyond traditional solutions, such as convening naming conventions, to the development of innovative software with intelligent, real-time, clinically driven search functions that will allow these programs to help rather than hinder physicians.

Markov modeling in hepatitis B screening and linkage to care

The objective of this study was to determine the incremental labor costs or opportunity costs associated with the provision of immunizations in ambulatory care settings. A time and motion analysis of primary care health visits by pediatric patients was performed in 10 community clinics and 5 private primary care practices. These clinics and practices were located in areas designated as Health Professional Shortage Areas, with traditionally low immunization coverage rates and other unmet primary care needs. The outcome measure for this study was the comparative duration of the visit, contrasting well-child visits during which immunization was given with well-child visits during which no immunization was given. The results suggested that immunizations present an opportunity cost during well-child visits. The average time of patient-provider contact found in this study supports other findings showing that this time is now significantly longer than that reported in the past. In order for providers to comply with increased recommendations and requirements for preventive health care services, the allotted visit time, capitation rates, and overall clinic system effectiveness need to be reexamined.

Improving prompt effectiveness in diabetes care: an intervention study.

Introduction The time required to obtain Institutional Review Board (IRB) approval is a frequent subject of efforts to reduce unnecessary delays in initiating clinical trials. This study was conducted by and for IRB directors to better understand factors affecting approval times as a first step in developing a quality improvement framework. Methods 807 IRB-approved clinical trials from 5 University of California campuses were analyzed to identify operational and clinical trial characteristics influencing IRB approval times. Results High workloads, low staff ratios, limited training, and the number and types of ancillary reviews resulted in longer approval times. Biosafety reviews and the need for billing coverage analysis were ancillary reviews that contributed to the longest delays. Federally funded and multisite clinical trials had shorter approval times. Variability in between individual committees at each institution reviewing phase 3 multisite clinical trials also contributed to delays for some protocols. Accreditation was not associated with shorter approval times. Conclusions Reducing unnecessary delays in obtaining IRB approval will require a quality improvement framework that considers operational and study characteristics as well as the larger institutional regulatory environment.

Multi-class appointments in individualized healthcare: Analysis for scheduling rules

BackgroundWith up to 240 million people chronically infected with hepatitis B worldwide, including an estimated 2 million in the United States, widespread screening is needed to link the infected to care and decrease the possible consequences of untreated infection, including liver cancer, cirrhosis and death. Screening is currently fraught with challenges in both the developed and developing world. New point-of-care tests may have advantages over standard-of-care tests in terms of cost-effectiveness and linkage to care. Stochastic modeling is applied here for relative utility assessment of point-of-care tests and standard-of-care tests for screening.MethodsWe analyzed effects of point-of-care versus standard-of-care testing using Markov models for disease progression in individual patients. Simulations of large cohorts with distinctly quantified models permitted the assessment of particular screening schemes. The validity of the trends observed is supported by sensitivity analyses for the simulation parameters.ResultsIncreased utilization of point-of-care screening was shown to decrease hepatitis B-related mortalities and increase life expectancy at low projected expense.ConclusionsThe results suggest that standard-of-care screening should be substituted by point-of-care tests resulting in improved linkage to care and decrease in long-term complications.