Global Advances in Value-Based Payment and Their Implications for Global Health Management Education, Development, and Practice.

Global advances in health policy reform, health system improvement and health management education and practice need to be closely aligned to successfully change national health policies and improve the performance of health care delivery organizations. This paper describes the globally acknowledged need for incentive-based organizational performance and relevant implications for health care management education (HCME) and practice. It also outlines the major rationale underlying Value-Based Payment (VBP) or Pay for Performance (P4P) health policy initiatives and their basic elements. Clearly, the major global health policy shift that is underway will likely ultimately have major impacts on the strategic and operational management and performance of health care delivery organizations. Thus, practical specific suggestions are made regarding changes that need to be introduced and strengthened in contemporary health care management education and development programs to help organizational managers in the future.

Is There a Relationship Between Value-Based Purchasing and Hospital Profitability? An Exploratory Study of Missouri Hospitals.

Recent US legislation is attempting to transition inpatient Medicare payments to a value-based purchasing (VBP) program. The VBP program is a pay-for-performance (P4P) system that incentivizes hospitals to improve patient satisfaction, health outcomes, and adherence to clinical protocols while simultaneously holding down costs. Our study evaluates (1) the impact of financial performance on the VBP adjustments and (2) whether there is a correlation between the VBP adjustment and the financial performance of Missouri hospitals that opted into the program. While upward and downward adjustments to the inpatient base rate may be related to hospital financial performance, prior financial performance may also be related to the adjustments. Financial health may allow facilities to invest and position the hospital for favorable future P4P adjustments. The results of our analysis indicate the VBP adjustment to the inpatient base rate is very small (±0.18%), clustered around zero, and is not correlated with financial performance. We also find that financial performance and improvement in the years prior to the adjustment are not related to the VBP adjustment or its respective components. This suggests that CMS is avoiding penalizing less profitable facilities, but the adjustment is also so small and tightly clustered around zero that it is failing to provide an adequate incentive to hospitals. The costs of improving patient satisfaction, clinical process adherence, health care outcomes, and efficiency above that of peers coupled with the growing number of metrics being used to calculate the VBP adjustments call into question the financial incentives of the hospital VBP program.

Development of a patient safety culture measurement tool for ambulatory health care settings: analysis of content validity.

The development of patient safety culture in health care organizations is a necessary precursor to patient safety improvement. However, existing tools to measure patient safety culture are intended for implementation in hospitals. A new, abbreviated patient safety culture survey was developed for use in ambulatory health care settings. This survey was tested for content validity utilizing a panel of six experts. It had a clarity interrater agreement (IR) of 0.75, a clarity content validity index (CVI) of 0.95, a representativeness IR of 0.75 and a representativeness CVI of 0.95. The content validity analysis served as a useful tool for assessing the relevance and comprehensiveness of this survey of patient safety culture in ambulatory care organizations.

Physician adoption of hyperbaric oxygen therapy in the treatment of chronic wounds.

Hyperbaric oxygen therapy, a treatment alternative for chronic wounds, has been used for several decades yet little is known about factors that influence physicians to incorporate this therapy into practice. To assess wound care physician knowledge of, attitudes toward, and adoption of hyperbaric oxygen therapy and to identify factors associated with physician adoption of this therapy, a 23-item questionnaire, based on Rogers' diffusion of innovation model, was developed by the authors and distributed to 653 American Academy of Wound Management Board-certified physicians. Of the 246 (43%) physicians in the study population who responded to the study survey, 167 (68%) reported they had used or referred patients for hyperbaric oxygen therapy during the past 12 months. More than half of the respondents reported a relatively high level of familiarity with and a positive attitude toward the effects of hyperbaric oxygen therapy on wound healing. Physician adoption of hyperbaric oxygen therapy was significantly associated with a community of >100,000 residents (adjusted odds ratio = 2.29, 95% confidence interval = 1.05 to 5.04); patient request for hyperbaric oxygen therapy (adjusted odds ratio = 5.38, 95% confidence interval = 2.50 to 11.56); positive attitude toward (adjusted odds ratio = 3.38, 95% confidence interval = 1.49 to 7.66) and high level of familiarity with hyperbaric oxygen therapy (adjusted odds ratio = 5.33, 95% confidence interval = 1.72 to 6.49); and practice location in either Florida or Texas (adjusted odds ratio = 3.44, 95% confidence interval = 1.24 to 9.54). Although the majority of the respondents reported adoption of hyperbaric oxygen therapy, most adopters are concentrated only in a few geographic areas. Despite the limitations of this study, especially the potential effects of sampling and response bias, the results help explain factors that have facilitated and hindered the adoption of this technology into practice.

Major issues in quality assessment and improvement of clinical hyperbaric services: an international perspective.

The continued rapid worldwide diffusion of clinical hyperbaric facilities has substantially increased interest in clinical quality assessment and service improvement. This paper examines major issues, perspectives, and methods integral to the measurement and improvement of the quality of care provided to hyperbaric patients and their relevance and applicability across different societies. Special focus is directed toward the importance of quality assessment and improvement of clinical hyperbaric care, multiple stakeholder perspectives on improved clinical quality, measurement of clinical outcomes of hyperbaric care, importance of facility accreditation, process improvement methods, and the future importance of quality management in clinical hyperbaric facilities.

Measuring a hospital's ability to improve.

The aim of this study was to test whether a recently developed measure of Continuous Quality Improvement (CQI) implementation can provide health care researchers and administrators with a tool to assist in understanding and with developing an appropriate structure for improvement efforts in hospitals. Two hundred respondents from 40 Missouri hospitals completed a 28-item survey addressing 8 domains of CQI. Overall, hospital scores showed low implementation of a structure that supports improvement efforts. All survey domains showed acceptable psychometric results. Leadership proved to be the most important domain of CQI because it differentiated well between all levels of the scale. Because of its ease of administration and analysis, and its reliability, validity, and level differentiation results, the researchers recommend the widespread use of this tool to understand and develop a hospital's organizational structure to support improvement activities.

Hyperbaric oxygen technology: an overview of its applications, efficacy, and cost-effectiveness.

OBJECTIVES: To examine the growing evidence and the consensus in the medical community concerning the efficacy and cost-effectiveness of hyperbaric oxygen therapy (HBO2T) and to suggest future research areas to ensure the appropriate use of this technology. METHODS: A literature search of articles published between 1985 and 2000 was conducted using PubMed to describe the growth of HBO2T-related articles published over the past fifteen years. In addition, articles involving the qualitative synthesis of the efficacy and cost-effectiveness of HBO2T in thirteen major application areas were identified and compared with the changing view of the medical community toward the evidence of HBO2T. RESULTS: The total number of HBO2T-related articles published annually has steadily increased over the past fifteen years. This increase has gradually contributed to a consensus in the medical community concerning the evidence of efficacy in its major application areas. However, information regarding the cost-effectiveness of HBO2T is still extremely limited. CONCLUSIONS: Although evidence concerning the efficacy of HBO2T has been growing in the past, more evidence is still needed for some of its major application areas. Moreover, there is an urgent need to shift part of the research focus on HBO2T to its cost-effectiveness to provide decision makers with relevant information to evaluate this technology objectively.

Cost-effectiveness of adjunctive hyperbaric oxygen in the treatment of diabetic ulcers.

OBJECTIVES: This study estimates the cost-effectiveness (CE) of the adjunctive use of hyperbaric oxygen (HBO2) therapy in the treatment of diabetic ulcers based on the payer's and societal perspectives. METHODS: The study population was a hypothetical cohort of 1,000 patients sixty years of age with severe diabetic foot ulcers. A decision tree model was constructed to estimate the CE of HBO2 therapy in the treatment of diabetic ulcers at years 1, 5, and 12. Scenario and one-way sensitivity analyses were also undertaken to identify parameters that may significantly influence the estimates. RESULTS: The CE model estimated that the incremental cost per additional quality-adjusted life year (QALY) gained at years 1, 5, and 12, was dollar 27,310, dollar 5,166, and dollar 2,255, respectively. CONCLUSIONS: The study results indicate that HBO2 therapy in the treatment of diabetic ulcers is cost-effective, particularly based on a long-term perspective. However, the results are limited by the clinical studies that provide the basis of the CE estimation.

Development of a healthcare quality improvement measurement tool: results of a content validity study.

Current methods of measuring continuous quality improvement (CQI) implementation are too long and not comprehensive. A new survey for CQI implementation was developed and tested for content validity using a panel of 8 experts--7 from the United States and 1 from England. The survey was reduced from 70 items to 22. The resultant survey had a clarity interrater agreement (IR) of .91, a representativeness IR of .93, a clarity content validity index (CVI) of .73, and a representativeness CVI of .91. Content validity served as an excellent data reduction method in building a valid, concise, and comprehensive measure of CQI implementation.

Competency-based health services management education: contemporary issues and emerging challenges.

Health service executives increasingly recognize managerial competencies as an important element of contemporary health services management education and practice. This paper addresses reasons for the growing interestin the topic, provides a brief review of selected literature, and presents findings from two Delphi studies of the identification and use of competencies in health services management. The two studies reveal that there is a high level of agreement among academicians and practitioners concerning which domains of competencies are effectively addressed in health management education, but many still have concerns regarding how the competencies should be applied. The paper concludes with unresolved issues and their implications for future research.