William J. Riley

Cost implications of implementation of pathogen-inactivated platelets

Pathogen inactivation (PI) is a new approach to blood safety that may introduce additional costs. This study identifies costs that could be eliminated, thereby mitigating the financial impact.

Tax Levy Financing for Local Public Health Fiscal Allocation, Effort, and Capacity

BACKGROUNDnLocal health departments (LHDs) rely on a wide variety of funding sources, and the level of financing is associated with both LHD performance in essential public health services and population health outcomes. Although it has been shown that funding sources vary across LHDs, there is no evidence regarding the relationship between fiscal allocation (local tax levy); fiscal effort (tax capacity); and fiscal capacity (community wealth).nnnPURPOSEnThe purpose of this study is to analyze local tax levy support for LHD funding. Three research questions are addressed: (1) What are tax levy trends in LHD fiscal allocation? (2) What is the role of tax levy in overall LHD financing? and (3) How do local community fiscal capacity and fiscal effort relate to LHD tax levy fiscal allocation?nnnMETHODSnThis study focuses on 74 LHDs eligible for local tax levy funding in Minnesota. Funding and expenditure data for 5 years (2006 to 2010) were compiled from four governmental databases, including the Minnesota Department of Health, the State Auditor, the State Demographer, and the Metropolitan Council. Trends in various funding sources and expenditures are described for the time frame of interest. Data were analyzed in 2012.nnnRESULTSnDuring the 2006-2010 time period, total average LHD per capita expenditures increased 13%, from

Integrated Approach to Reduce Perinatal Adverse Events: Standardized Processes, Interdisciplinary Teamwork Training, and Performance Feedback

50.98 to

Decreasing Malpractice Claims by Reducing Preventable Perinatal Harm.

57.63. Although the overall tax levy increase in Minnesota was 25%, the local tax levy for public health increased 5.6% during the same period. There is a direct relationship between fiscal effort and LHD expenditures.nnnCONCLUSIONSnLocal funding reflects LHD community priorities and the relative importance in comparison to funding other local programs with tax dollars. In Minnesota, local tax levy support for local public health services is not keeping pace with local tax support for other local government services. These results raise important questions about the relationship between tax levy resource effort, resource allocation, and fiscal capacity as they relate to public health spending in local communities.

Local Fiscal Allocation for Public Health Departments

OBJECTIVEnTo improve safety practices and reduce adverse events in perinatal units of acute care hospitals.nnnDATA SOURCESnPrimary data collected from perinatal units of 14 hospitals participating in the intervention between 2008 and 2012. Baseline secondary data collected from the same hospitals between 2006 and 2007.nnnSTUDY DESIGNnA prospective study involving 342,754 deliveries was conducted using a quality improvement collaborative that supported three primary interventions. Primary measures include adoption of three standardized care processes and four measures of outcomes.nnnDATA COLLECTION METHODSnChartxa0audits were conducted to measure the implementation of standardized care processes. Outcome measures were collected and validated by the National Perinatal Information Center.nnnPRINCIPAL FINDINGSnThe hospital perinatal units increased use of all three care processes, raising consolidated overall use from 38 to 81 percent between 2008 and 2012. The harms measured by the Adverse Outcome Index decreased 14 percent, and a run chart analysis revealed two special causes associated with the interventions.nnnCONCLUSIONSnThis study demonstrates the ability of hospital perinatal staff to implement efforts to reduce perinatal harm using a quality improvement collaborative. Findings help inform the relationship between the use of standardized care processes, teamwork training, and improved perinatal outcomes, and suggest that a multiplicity of integrated strategies, rather than a single intervention, may be essential to achieve high reliability.

Texas Medicaid Payment Reform: Fewer Early Elective Deliveries And Increased Gestational Age And Birthweight

OBJECTIVEnTo evaluate the association of improved patient safety practices with medical malpractice claims and costs in the perinatal units of acute care hospitals.nnnDATA SOURCESnMalpractice and harm data from participating hospitals; litigation records and medical malpractice claims data from American Excess Insurance Exchange, RRG, whose data are managed by Premier Insurance Management Services, Inc. (owned by Premier Inc., a health care improvement company).nnnSTUDY DESIGNnA quasi-experimental prospective design to compare baseline and postintervention data. Statistical significance tests for differences were performed using chi-square, Wilcoxon signed-rank test, and t-test.nnnDATA COLLECTIONnClaims data were collected and evaluated by experienced senior claims managers through on-site claim audits to evaluate claim frequency, severity, and financial information. Data were provided to the analyzing institution through confidentiality contracts.nnnPRINCIPAL FINDINGSnThere is a significant reduction in the number of perinatal malpractice claims paid, losses paid, and indemnity payments (43.9 percent, 77.6 percent, and 84.6 percent, respectively) following interventions to improve perinatal patient safety and reduce perinatal harm. This compares with no significant reductions in the nonperinatal claims in the same hospitals during the same time period.nnnCONCLUSIONSnThe number of perinatal malpractice claims and dollar amount of claims payments decreased significantly in the participating hospitals, while there was no significant decrease in nonperinatal malpractice claims activity in the same hospitals.

Evaluating the impact a proposed family planning model would have on maternal and infant mortality in Afghanistan

INTRODUCTIONnWe examined the percentage of local government taxes (fiscal allocation) dedicated to local health departments on a national level, as well as correlates of local investment in public health.nnnMETHODSnUsing the most recent data available--the 2008 National Association of City and County Health Officials Profile survey and the 2007 U.S. Census Bureau Census of Local Governments-generalized linear regression models examined associations between fiscal allocation and local health department setting, governance, finance, and service provision. Models were stratified by the extent of long-term debt for the jurisdiction. Analyses were performed in 2014.nnnRESULTSnAverage fiscal allocation for public health was 3.31% of total local taxes. In multivariate regressions, per capita expenditures, having a local board of health and public health service provision were associated with higher fiscal allocation. Stratified models showed that local board of health and local health department taxing authority were associated with fiscal allocation in low and high long-term debt areas, respectively.nnnCONCLUSIONSnThe proportion of all local taxes allocated to local public health is related to local health department expenditures, service provision, and governance. These relationships depend upon the extent of long-term debt in the jurisdiction.

Evolution of the nation's blood supply system

Infants born at full term have better health outcomes. However, one in ten babies in the United States are born via a medically unnecessary early elective delivery: induction of labor, a cesarean section, or both before thirty-nine weeks gestation. In 2011 the Texas Medicaid program sought to reduce the rate of early elective deliveries by denying payment to providers for the procedure. We examined the impact of this policy on clinical care practice and perinatal outcomes by comparing the changes in Texas relative to comparison states. We found that early elective delivery rates fell by as much as 14xa0percent in Texas after this payment policy change, which led to gains of almost five days in gestational age and six ounces in birthweight among births affected by the policy. The impact on early elective delivery was larger in magnitude for minority patients. Other states may look to this Medicaid payment reform as a model for reducing early elective deliveries and disparities in infant health.

Blood product recalls in the United States

OBJECTIVEnThis study aimed to assess the potential impact a proposed family planning model would have on reducing maternal and infant mortality in Afghanistan.nnnBACKGROUNDnAfghanistan has a high total fertility rate, high infant mortality rate, and high maternal mortality rate. Afghanistan also has tremendous socio-cultural barriers to and misconceptions about family planning services.nnnMETHODSnWe applied predictive statistical models to a proposed family planning model for Afghanistan to better understand the impact increased family planning can have on Afghanistans maternal mortality rate and infant mortality rate. We further developed a sensitivity analysis that illustrates the number of maternal and infant deaths that can be averted over 5u2009years according to different increases in contraceptive prevalence rates.nnnRESULTSnIncrementally increasing contraceptive prevalence rates in Afghanistan from 10% to 60% over the course of 5u2009years could prevent 11,653 maternal deaths and 317,084 infant deaths, a total of 328,737 maternal and infant deaths averted.nnnCONCLUSIONnAchieving goals in reducing maternal and infant mortality rates in Afghanistan requires a culturally relevant approach to family planning that will be supported by the population. The family planning model for Afghanistan presents such a solution and holds the potential to prevent hundreds of thousands of deaths.

Exploratory analysis of high CT scan utilization in claims data

A fter the human immunodeficiency virus epidemic, changes began in the US blood supply system. Quality and regulatory activities became more stringent, blood supply organizations became more business-like, and operations and finances became more tightly managed. Longstanding unspoken understandings regarding donor groups and hospital service areas were no longer recognized and competition for hospital blood contracts and for donor groups emerged. At the same time, efforts to contain health care costs caused hospitals to press for lower costs for their blood supply. Recently new medical data regarding indications for transfusion, the management of anemic or bleeding patients, and the complications of transfusion have appeared. It is clear that patients can be maintained at lower hemoglobin levels than have been the longstanding custom. Robotic, minimally invasive, and other surgical techniques have led to decreases in surgically related blood transfusion. Pharmacologic agents such as erythropoietin or tranexamic acid have eliminated transfusion in some situations. Implementing these practice changes using blood management programs is a positive for patients, but has resulted in declining blood use, which has led to decreasing revenue for blood supply organizations. These organizations are now experiencing major financial pressure in attempts to reset production capacity while implementing technology, regulatory, and quality developments. While revenues decline, there have been increased costs. Screening tests such as West Nile virus and Trypanosoma cruzi and bacterial culture of platelets (PLTs) have been added. Some test methods involve DNA amplification and thus must be done in complex laboratories. These factors and changes have transformed the organizations that provide the nation’s blood supply into barebones operations, with little product development and tense competition for hospital contracts and blood donors. There has been wonderful innovation in transfusion medicine supported by blood centers, federal funding, industry, and universities. Federal funding continues at a substantially reduced level, but there is almost no support for innovation from the other three sources. Industry is no longer willing to develop new products as there is little likelihood that the innovations will be implemented. There has even been a call for federal mandate as a way to introduce innovation. As a result, blood supply organizations are exploring new organizational structures and strategic alliances including: 1) affiliations, 2) purchasing groups, 3) partnerships, and 4) networks. However, these strategies do not constitute sufficient integration and alignment to respond effectively to the turbulent market conditions. With a few exceptions, true integration is not yet occurring and the benefits of consolidation will not be achieved. For example, there is continuation of multiple Food and Drug Administration (FDA) licenses, overlapping sets of standard operating procedures, inconsistent policies regarding donor selection and deferral, quality systems, conflicting approaches to regulatory affairs, and multiple accounting and software systems are coexisting. Providing blood and blood products is costly. Some activities can be carried out more efficiently by larger organizations through economy of scale. However, while the United States has seen consolidation across many of its health care sectors, that impact on quality (i.e., patient outcomes) is less clear. “The harsh reality is that it is difficult to find well-documented examples of health care mergers that have generated measurably better outcomes or lower overall costs.” As hospitals, health insurers, and physician groups have experienced, cost pressures usually lead to a smaller number of larger organizations thus altering the current structure; yet the same tools, tests, and workflow are still likely to be in place. There is very little evidence that mergers improve quality and costs will not necessarily decrease. Thus, policy makers should anticipate that a new blood supply system will develop.