The California Competitive Model: How Has It Fared, And What's Next?

California became very successful in controlling rising health care costs by promoting price competition through market-based, managed care policies. However, recent data reveal that the state has not been able sustain its initial success in controlling growth in hospital prices. Two powerful trends emerged in California that eroded the conditions needed to sustain price competition. To ensure timely access to emergency hospital services, government regulators enacted regulations that had the unintended effect of giving hospitals tremendous leverage when contracting with health plans. Also, antitrust authorities allowed hospitals to consolidate into multihospital systems by adding members that were not direct competitors in local markets. The combined effect of these policies and consolidation trends was a substantial reduction in the competitiveness of provider markets in California, which reduced health plans' ability to leverage competitive provider markets and negotiate lower prices and other benefits for their members. Policy makers can and should act to restore competitive conditions.

Success of a Colorectal Surgical Site Infection Prevention Bundle in a Multihospital System.

Surgical site infections, readmissions, and extended hospital stays are risks for patients undergoing colon surgeries. These procedures are often urgent, and patients may have multiple comorbidities. Preoperative and postoperative steps to reduce the number of complications provide substantial benefits clinically, economically, and psychologically. We used a multidisciplinary, collaborative approach to identify best practices when developing and implementing a standardized approach to the management of patients undergoing elective colon surgery. Interventions included nutrition supplements and preoperative and postoperative protocols. Our management project showed a 74.6% reduction in readmissions, a 22.73% reduction in length of stay, an 85% reduction in colon surgical site infections measured by incidence (84.5% reduction) and standard infection ratio (54.55% reduction), and 95% compliance with the use of both order sets during an 18-month period. Applying standardized order sets for assessing and addressing patient comorbidities before colorectal surgery can result in a substantial and sustainable reduction in complications.

Control of Human Echinococcosis in Xinjiang, China, with 2,544 Surgeries in a Multihospital Network.

Human echinococcosis is a serious parasitic disease threatening public health worldwide especially in Xinjiang, China, an undeveloped farming and pastoral area. A multihospital surgical network was applied to improve human echinococcosis control. An innovative surgery network connected the 28 designated public hospitals, which distributed in a vast land of 1,600,000 m2. The surgery network integrated the efficient patient digital information sharing, treatment consulting, patient transfer, and financial support. The 6-year practical outcome of 2,544 surgeries in Xinjiang, China, was retrospectively analyzed. Electronic database and surgery network have been proven especially effective in undeveloped area with vast territory, sparse population, multiple languages, and poor traffic conditions. This network turned out effectively improved patient processing efficiency and decreased the medical cost.

PhotoExam: adoption of an iOS-based clinical image capture application at Mayo Clinic.

BACKGROUND: Mayo Clinic developed an internal iOS-based, point-of-care clinical image capture application for clinicians. We aimed to assess the adoption and utilization of the application at Mayo Clinic. METHODS: Metadata of 22,784 photos of 6417 patients taken by 606 users over 8040 clinical encounters between 3/1/2015 and 10/31/2015 were analyzed. A random sample of photos from 100 clinical encounters was assessed for quality using a five-item rubric. Use of traditional medical photography services before and after application launch were compared. RESULTS: The largest group of users was residents/fellows, accounting for 31% of users but only 18% of all photos. Attending physicians accounted for 29% of users and 30% of photos. Nurses accounted for 14% of users and 28% of photos. Surgical specialties had the most users (36% of users), followed by dermatology (14% of users); however, dermatology accounted for 54% of all photos, and surgery accounted for 26% of photos. Images received an average of 91% of possible points on the quality scoring rubric. Most frequent reasons for missing points were the location on the body not clearly being demonstrated (19% of encounters) and the perspective/scale not being clearly demonstrated (12% of encounters). There was no discernible pre-post effect of the application's launch on use of traditional medical photography services. CONCLUSIONS: Point-of-care clinical photography is a growing phenomenon with potential to become the new standard of care. Patient and provider attitudes and the impact on patient outcomes remain unclear.

Urine cytology of nonurothelial malignancies-a 10-year experience in a large multihospital healthcare system.

BACKGROUND: Urine cytology is the most frequently utilized test to detect urothelial cancer. Secondary bladder neoplasms need to be recognized as this impacts patient management. We report our experience on nonurothelial malignancies (NUM) detected in urine cytology over a 10-year period. METHODS: A 10-year retrospective search for patients with biopsy-proven NUM to the urothelial tract yielded 25 urine samples from 14 patients. Two cytopathologists blinded to the original cytology diagnosis reviewed the cytology and histology slides. The incidence, cytomorphologic features, diagnostic accuracy, factors influencing the diagnostic accuracy, and clinical impact of the cytology result were studied. RESULTS: The incidence of NUM was <1%. The male:female ratio was 1.3. An abnormality was detected in 60% of the cases; however, in only 4% of the cases, a primary site was identified accurately. Of the false negatives, 96% was deemed as sampling errors and 4% was interpretational. Patient management was not impacted in any of the false-negative cases due to concurrent or past tissue diagnosis. CONCLUSION: Colon cancer was the most frequent secondary tumor. Sampling error attributed to the false-negative results. Necrosis and dirty background was often associated with metastatic lesions from colon. Obtaining history of a primary tumor elsewhere was a key factor in diagnosis of a metastatic lesion. Hematopoietic malignancies remain to be a diagnostic challenge. Cytospin preparations were superior for evaluating nuclear detail and background material as opposed to monolayer (Thinprep) technology. Diagnostic accuracy was improved by obtaining immunohistochemistry. Diagn. Cytopathol. 2016. © 2016 Wiley Periodicals, Inc. Diagn. Cytopathol. 2017;45:22-28. © 2016 Wiley Periodicals, Inc.

Emergency physician focused cardiac ultrasound improves diagnosis of ascending aortic dissection.

STUDY OBJECTIVE: Ascending aortic dissection (AAD) is an uncommon, time-sensitive, and deadly diagnosis with a nonspecific presentation. Ascending aortic dissection is associated with aortic dilation, which can be determined by emergency physician focused cardiac ultrasound (EP FOCUS). We seek to determine if patients who receive EP FOCUS have reduced time to diagnosis for AAD. METHODS: We performed a retrospective review of patients treated at 1 of 3 affiliated emergency departments, March 1, 2013, to May 1, 2015, diagnosed as having AAD. All autopsies were reviewed for missed cases. Primary outcome measure was time to diagnosis. Secondary outcomes were time to disposition, misdiagnosis rate, and mortality. RESULTS: Of 386547 ED visits, targeted review of 123 medical records and 194 autopsy reports identified 32 patients for inclusion. Sixteen patients received EP FOCUS and 16 did not. Median time to diagnosis in the EP FOCUS group was 80 (interquartile range [IQR], 46-157) minutes vs 226 (IQR, 109-1449) minutes in the non-EP FOCUS group (P = .023). Misdiagnosis was 0% (0/16) in the EP FOCUS group vs 43.8% (7/16) in the non-EP FOCUS group (P = .028). Mortality, adjusted for do-not-resuscitate status, for EP FOCUS vs non-EP FOCUS was 15.4% vs 37.5% (P = .24). Median rooming time to disposition was 134 (IQR, 101-195) minutes for EP FOCUS vs 205 (IQR, 114-342) minutes for non-EP FOCUS (P = .27). CONCLUSIONS: Patients who receive EP FOCUS are diagnosed faster and misdiagnosed less compared with patients who do not receive EP FOCUS. We recommend assessment of the thoracic aorta be performed routinely during cardiac ultrasound in the emergency department.

Foreign-born care givers in Washington State nursing homes: characteristics, associations with quality of care, and views of administrators.

OBJECTIVE: Following national trends, Washington State relies heavily on foreign-born workers to provide long-term care. Our study assesses state nursing facility characteristics, quality ratings, and the views of facility administrators about the implications of an increasing number of foreign-born employees. METHODS: We used independently available data to supplement a survey of nursing home administrators. RESULTS: Nearly half of the administrators reported difficulty hiring U.S.-born job applicants. Three in four administrators reported problems related to language differences, and just more than a third reported challenges related to cultural and/or religious differences. Nonetheless, the proportion of foreign-born employees was positively associated with independent facility quality ratings. Almost half of the administrators reported discrimination by patients/clients toward their foreign-born workers. Quality ratings were negatively associated with for-profit, chain, or multi-ownership status. DISCUSSION: The proportion of foreign-born employees in nursing facilities may be associated with improved performance.

Operating characteristics of residential care communities, by community bed size: United States, 2012.

In 2012, the majority of residential care communities had 4­25 beds, yet 71% of residents lived in communities with more than 50 beds. A lower percentage of communities with 4­25 beds were chain-affiliated, nonprofit, and in operation 10 years or more, compared with communities with 26­50 and more than 50 beds. Dementia-exclusive care or dementia care units were more common as community size increased. A higher percentage of communities with more than 50 beds screened for cognitive impairment and offered dementia-specific programming compared with communities with 4­25 and 26­50 beds. A higher percentage of communities with more than 50 beds screened for depression compared with communities with 4­25 beds. Compared with communities with 4­25 beds, a higher percentage of communities with 26­50 beds and more than 50 beds provided therapeutic, hospice, mental health, and dental services; but a lower percentage of communities with more than 50 beds provided skilled nursing services than did smaller communities. This report presents national estimates of residential care communities, using data from the first wave of NSLTCP. This brief profile of residential care communities provides useful information to policymakers, providers, researchers, and consumer advocates as they plan to meet the needs of an aging population. The findings also highlight the diversity of residential care communities across different sizes. Corresponding state estimates and their standard errors for the national figures in this data brief can be found on the NSLTCP website at http://www.cdc.gov/nchs/nsltcp/ nsltcp_products.htm. These national and state estimates establish a baseline for monitoring trends among residents living in residential care.

Service duplication within urban hospital clusters.

BACKGROUND: Approximately 80% of multihospital system member hospitals in U.S. urban areas are clustered with other same-system member hospitals located in the same market area. A key argument for clustering is the potential for reducing service duplication across cluster members. PURPOSE: The aim of this study is to examine the effects of characteristics of hospital clusters on service duplication within 339 hospital clusters in U.S. metropolitan statistical areas and adjacent counties in 2002. METHODOLOGY/APPROACH: Ordinary least squares regression is used to estimate the relationship between cluster characteristics in 1998 and duplicated services per cluster member in 2002. FINDINGS: Duplication is higher in hospitals clusters with higher case mix index and higher bed size range. Duplication is lower in hospital clusters with more members, for-profit ownership, and more geographic dispersion. PRACTICE IMPLICATIONS: Increases in the size of hospital clusters allow more opportunities for service rationalization. For-profit clusters may be innovators in rationalization activity, and they should be studied in this regard. Clusters with a higher case mix, lower geographic dispersion, and hub-and-spoke design (with high bed-size range) may find service reallocation less feasible.

Shared care obesity management in 3-10 year old children: 12 month outcomes of HopSCOTCH randomised trial.

OBJECTIVE: To determine whether general practice surveillance for childhood obesity, followed by obesity management across primary and tertiary care settings using a shared care model, improves body mass index and related outcomes in obese children aged 3-10 years. DESIGN: Randomised controlled trial. SETTING: 22 family practices (35 participating general practitioners) and a tertiary weight management service (three paediatricians, two dietitians) in Melbourne, Australia. PARTICIPANTS: Children aged 3-10 years with body mass index above the 95th centile recruited through their general practice between July 2009 and April 2010. INTERVENTION: Children were randomly allocated to one tertiary appointment followed by up to 11 general practice consultations over one year, supported by shared care, web based software (intervention) or "usual care" (control). Researchers collecting outcome measurements, but not participants, were blinded to group assignment. MAIN OUTCOME MEASURES: Children's body mass index z score (primary outcome), body fat percentage, waist circumference, physical activity, quality of diet, health related quality of life, self esteem, and body dissatisfaction and parents' body mass index (all 15 months post-enrolment). RESULTS: 118 (60 intervention, 56 control) children were recruited and 107 (91%) were retained and analysed (56 intervention, 51 control). All retained intervention children attended the tertiary appointment and their general practitioner for at least one (mean 3.5 (SD 2.5, range 1-11)) weight management consultation. At outcome, children in the two trial arms had similar body mass index (adjusted mean difference -0.1 (95% confidence interval -0.7 to 0.5; P=0.7)) and body mass index z score (-0.05 (-0.14 to 0.03); P=0.2). Similarly, no evidence was found of benefit or harm on any secondary outcome. Outcomes varied widely in the combined cohort (mean change in body mass index z score -0.20 (SD 0.25, range -0.97-0.47); 26% of children resolved from obese to overweight and 2% to normal weight. CONCLUSIONS: Although feasible, not harmful, and highly rated by both families and general practitioners, the shared care model of primary and tertiary care management did not lead to better body mass index or other outcomes for the intervention group compared with the control group. Improvements in body mass index in both groups highlight the value of untreated controls when determining efficacy. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12608000055303.

Unexplained extreme hyperbilirubinemia among neonates in a multihospital healthcare system.

We report a series of neonates who developed a total serum bilirubin (TSB) >20mg/dL during a recent ten-year period in a multihospital healthcare system. The incidence of a TSB >20mg/dL fell after instituting a pre-hospital discharge bilirubin screening program in 2003/2004 (91.3 cases/10,000 births before vs. 72.4/10,000 after), but the incidence has subsequently remained unchanged. No specific cause for the hyperbilirubinemia was identified in 66% of (n=32) cases with a TSB >30 mg/dL or in 76% of (n=112) cases with a TSB 25.0-29.9 mg/dL. We hypothesized that hemolysis was a common contributing mechanism, but our review of hospital records indicated that in most instances these infants were not evaluated sufficiently to test this hypothesis. Records review showed maternal and neonatal blood types and direct antiglobulin testing were performed in >95% cases, but rarely were other tests for hemolysis obtained. In the ten-year period reviewed there were zero instances where erythrocyte morphology from a blood film examination or Heinz body evaluation by a pediatric hematologist or pathologist were performed. In 3% of cases pyruvate kinase was tested, 3% were evaluated by hemoglobin electrophoresis, 3% had a haptoglobin measurement, and 16% were tested for G6PD deficiency. Thus, determining the cause for hyperbilirubinemia in neonates remains a problem at Intermountain Healthcare and, we submit, elsewhere. As a result, the majority of infants with a TSB >25mg/dL have no specific causation identified. We speculate that most of these cases involve hemolysis and that the etiology could be identified if searched for more systematically. With this in mind, we propose a "consistent approach" to evaluating the cause(s) of hyperbilirubinemia among neonates with a TSB >25mg/dL.

Prevalence of error-prone abbreviations used in medication prescribing for hospitalised patients: multi-hospital evaluation.

The use of error-prone abbreviations in prescribing is a potential cause of misinterpretation that may lead to medication error. This study determined frequency and type of error-prone abbreviations in inpatient medication prescribing across three Australian hospitals. Three hundred and sixty-nine (76.9%) patients had one or more error-prone abbreviations used in prescribing, with 8.4% of orders containing at least one error-prone abbreviation and 29.6% of these considered to be high risk for causing significant harm.

Fulminant necrotizing enterocolitis in a multihospital healthcare system.

OBJECTIVE: A subset of necrotizing enterocolitis (NEC) cases is fulminant, characterized by rapid progression to death with massive bowel necrosis found at laparotomy or autopsy. We sought to identify and report all such cases in a multihospital healthcare system during the past 9 years and to characterize this entity using case-control methodologies. STUDY DESIGN: This was a multicentered, cross-sectional, historic cohort study conducted using Intermountain Healthcare hospital patient data. All neonates who died of NEC within 48 h of onset, during 2001 to 2009, were compared with two matched control groups: (1) demographically matched controls who developed non-fulminant NEC, (2) demographically matched controls that did not develop NEC. RESULT: During this period, 2 71 327 live births occurred in the Intermountain Healthcare hospitals. Of these, 318 had a diagnosis of NEC (Bell stage ≥II). Also during this period, 205 other neonates were transferred into an Intermountain hospital for treatment of NEC. Of these 523 NEC cases, 35 (6.7%) had a fulminant course. Compared with the non-fulminant cases, the fulminant group were born at lower weight (1088±545 vs 1652±817 g, P=0.000) and earlier gestational age (27.5±3.3 vs 31.1±4.4 weeks, P=0.000), and were more likely to have: (1) radiographic evidence of portal venous air (P=0.000), (2) hematocrit <22% (P=0.000), (3) increase in feeding volume >20 ml/kg/day (P=0.003), (4) immature to total (I/T) neutrophil ratio >0.5 (P=0.005), (5) blood lymphocyte count <4000/µl (P=0.018), (6) an increase in concentration of human milk fortifier within 48 h before developing NEC (P=0.020). CONCLUSION: Portal venous air, anemia, rapid feeding escalation, a high I/T neutrophil ratio, a low lymphocyte count and recent increases in fortifier may all be associated with fulminant NEC.

Quality assurance analysis of a large multicenter practice: does increased complexity of intensity-modulated radiotherapy lead to increased error frequency?

PURPOSE: Error reduction is an important concern in clinical medicine. Intensity-modulated radiotherapy (IMRT) is an important advancement in radiation oncology that increases the complexity of treatment, potentially increasing the error risk. We studied the frequency and severity of errors in a large multicenter practice to ascertain the impact of quality improvement interventions over time, IMRT, and type of practice. METHODS AND MATERIALS: We analyzed prospective data from three academic and 16 community practice sites with 24,775 courses of radiotherapy (9,210 IMRT courses and 15,565 non-IMRT) between January 2006 and December 2009. All IMRT treatment was performed using one centralized dose planning center for all sites. RESULTS: We prospectively identified various errors or potential errors in 0.14 % vs. 0.40 % of the IMRT vs. non-IMRT courses (13/9,210 vs. 62/15,565, p = 0.0004) and excluding potential errors: 0.03 % for IMRT vs. 0.21% for non-IMRT. We developed the Clinical Radiotherapy Error Severity Scale (CRESS) to classify error severity from 1 to 10, with 1 to 3 for potential or completely correctable errors, 4 to 5 for dose variations <5%, and 6 to 10 for dose variations >5%. Multivariate analyses of CRESS values, severity >4, and any error (including potential) correlated significantly reduced errors with IMRT (p = 0.0001-0.0024) but found no significant difference between the academic and community practice sites and no change in error frequency over time despite implementation of 39 system-wide policy changes by the centralized quality improvement committee. CONCLUSIONS: Despite the increase in complexity with IMRT compared with conventional radiotherapy, it can be delivered with reduced error frequency.

Urban hospital 'clusters' do shift high-risk procedures to key facilities, but more could be done.

Since the 1990s, rapid consolidation in the hospital sector has resulted in the vast majority of hospitals joining systems that already had a considerable presence within their markets. We refer to these important local and regional systems as "clusters." To determine whether hospital clusters have taken measurable steps aimed at improving the quality of care-specifically, by concentrating low-volume, high-complexity services within selected "lead" facilities-this study examined within-cluster concentrations of high-risk cases for seven surgical procedures. We found that lead hospitals on average performed fairly high percentages of the procedures per cluster, ranging from 59 percent for esophagectomy to 87 percent for aortic valve replacement. The numbers indicate that hospitals might need to work with rival facilities outside their cluster to concentrate cases for the lowest-volume procedures, such as esophagectomies, whereas coordination among cluster members might be sufficient for higher-volume procedures. The results imply that policy makers should focus on clusters' potential for restructuring care and further coordinating services across hospitals in local areas.