Design and Use of Performance Measures to Decrease Low-Value Services and Achieve Cost-Conscious Care.
ABSTRACT Improving quality of care while decreasing the cost of health care is a national priority. The American College of Physicians recently launched its High-Value Care Initiative to help physicians and patients understand the benefits, harms, and costs of interventions and determine whether services provide good value. Public and private payers continue to measure underuse of high-value services (for example, preventive services, medications for chronic disease), but they are now widely using performance measures to assess use of low-value interventions (such as imaging for patients with uncomplicated low back pain) and using the results for public reporting and pay-for-performance. This paper gives an overview of performance measures that target low-value services in order to help physicians understand the strengths and limitations of these measures, provides specific examples of measures that assess use of low-value services, and discusses how these measures can be used in clinical practice and policy.
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ABSTRACT: Background The need to better understand processes of removing, reducing, or replacing healthcare services that are no longer deemed essential or effective is common across publicly funded healthcare systems. This paper explores expert international opinion regarding, first, the factors and processes that shape the successful implementation of decommissioning decisions and, second, consensus as to current best practice.MethodsA three round Delphi study of 30 international experts was undertaken. In round one, participants identified factors that shape the outcome of decommissioning processes; responses were analysed using conventional content analysis. In round two, responses to 88 Likert scale statements derived from round one were analysed using measures of the degree of consensus. In round three the statements that achieved low consensus were then repeated but presented alongside the overall results from round two. The responses were re-analysed to observe whether the degree of consensus had changed. Any open comments provided during the Delphi study were analysed thematically.ResultsParticipants strongly agreed that three considerations should ideally inform decommissioning decisions: quality and patient safety, clinical effectiveness and cost-effectiveness. Although there was less consensus as to which considerations informed such decisions in practice, those that drew the most agreement were: cost/budgetary pressures, government intervention and capital costs/condition. Important factors in shaping decommissioning were: strength of executive leadership, strength of clinical leadership, quality of communications, demonstrable benefits and clarity of rationale/case for change. Amongst the 19 best practice recommendations high consensus was achieved for: establishing a strong leadership team, engaging clinical leaders from an early stage, and establishing a clear rationale for change.Conclusions There was a stark contrast between what experts thought should determine decommissioning decisions and what does so in practice; a contrast mirrored in the distinction the participants drew between the technical and political aspects of decommissioning processes. The best practice recommendations which we grouped into three categories¿change management and implementation; evidence and information; and relationships and political dimensions¿can be seen as contemporary responses or strategies to manage the tensions that emerged between the rhetoric and reality of implementing decommissioning decisions.Implementation Science 09/2014; 9(1):123. DOI:10.1186/s13012-014-0123-y · 3.47 Impact Factor
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ABSTRACT: Background: Colorectal cancer (CRC) screening is effective but underutilized. Although physician recommendation is an important predictor of screening, considerable variation in CRC screening completion remains. Purpose: To characterize the influence of patient trust in care providers on CRC screening behavior. Methods: Data were collected as part of a cluster-randomized CRC screening intervention trial performed in the San Francisco Community Health Network from March 2007 to January 2012 (analysis, Spring 2012). All study participants received a recommendation to complete CRC screening from their primary care provider (PCP). Included participants were aged 50-79 years, not current with screening, and completed the Wake Forest Trust Scale (WFTS) measuring trust in PCPs and doctors in general. Primary outcome was CRC screening completion (colonoscopy or fecal occult blood testing) within 12 months following enrollment. Multivariable association adjusted for race/ethnicity, language, and other sociodemographics was estimated using generalized estimating equations with logit link and binomial distribution. Results: WFTS response was 70.3% (701). Most participants (83%) were Latino, Asian, or black. Most had income <$30,000 (96%) and public health insurance (86%). Higher trust in PCP was associated with screening completion (OR=1.11, 95% CI=1.03, 1.17), but trust in doctors was not (OR=1.02, 95% CI=0.82, 1.28). Race, language, and other sociodemographic factors were not significant in multivariable analysis. Conclusions: After controlling for traditional factors, trust in PCP remained the only significant driver of CRC screening completion in low-income patients. Interventions to promote CRC screening may be improved by including efforts to enhance patient trust in PCP. (C) 2014 American Journal of Preventive MedicineAmerican Journal of Preventive Medicine 07/2014; 47(4). DOI:10.1016/j.amepre.2014.04.020 · 4.28 Impact Factor
Journal of General Internal Medicine 05/2014; 29(9). DOI:10.1007/s11606-014-2887-9 · 3.42 Impact Factor