Achieving higher-value obstetrical care.

Obstetrical care in the United States is unnecessarily costly. Birth is 1 of the most common reasons for healthcare use in the United States and 1 of the top expenditures for payers every year. However, compared with other Organization for Economic Cooperation and Development countries, the United States spends substantially more money per birth without better outcomes. Our team at the Clinical Excellence Research Center, a center that is focused on improving value in healthcare, spent a year studying ways in which obstetrical care in the United States can deliver better outcomes at a lower cost. After a thoughtful discovery process, we identified ways that obstetrical care could be delivered with higher value. In this article, we recommend 3 redesign steps that foster the delivery of higher-value maternity care: (1) to provide long-acting reversible contraception immediately after birth, (2) to tailor prenatal care according to women's unique medical and psychosocial needs by offering more efficient models such as fewer in-person visits or group care, and (3) to create hospital-affiliated integrated outpatient birth centers as the planned place of birth for low-risk women. For each step, we discuss the redesign concept, current barriers and implementation solutions, and our estimation of potential cost-savings to the United States at scale. We estimate that, if this model were adopted nationally, annual US healthcare spending on obstetrical care would decline by as much as 28%.

Systematic review: comparison of the quality of medical care in Veterans Affairs and non-Veterans Affairs settings.

BACKGROUND: The Veterans Health Administration, the nation's largest integrated delivery system, launched an organizational transformation in the mid 1990 s to improve the quality of its care. PURPOSE: To synthesize the evidence comparing the quality of medical and other nonsurgical care in Veterans Affairs (VA) and non-VA settings. DATA SOURCES: MEDLINE database and bibliographies of retrieved studies. STUDY SELECTION: Studies comparing the technical quality of nonsurgical care in VA and US non-VA settings published between 1990 and August 2009. DATA EXTRACTION: Two physicians independently reviewed 175 unique studies identified using the search strategy and abstracted data related to 6 domains of study quality. DATA SYNTHESIS: Thirty-six studies met the inclusion criteria. All 9 general comparative studies showed greater adherence to accepted processes of care or better health outcomes in the VA compared with care delivered outside the VA. Five studies of mortality following an acute coronary event found no clear survival differences between VA and non-VA settings. Three studies of care processes after an acute myocardial infarction found greater rates of evidence-based drug therapy in VA, and 1 found lower use of clinically-appropriate angiography in the VA. Three studies of diabetes care processes demonstrated a performance advantage for the VA. Studies of hospital mortality found similar risk-adjusted mortality rates in VA and non-VA hospitals. LIMITATIONS: Most studies used decade-old data, assessed self-reported service use, or included only a few VA or non-VA sites. CONCLUSIONS: Studies that assessed recommended processes of care almost always demonstrated that the VA performed better than non-VA comparison groups. Studies that assessed risk-adjusted mortality generally found similar rates for patients in VA and non-VA settings.

Operation Access: a proven model for providing volunteer surgical services to the uninsured in the United States.

BACKGROUND: Numerous studies have shown that patients without insurance lack coordinated health care and access to surgical procedures. Operation Access (OA) has coordinated uncompensated, low-risk outpatient surgical and specialty services to the uninsured in a volunteer setting for 15 years. Our objective was to evaluate the quality of outpatient surgical care provided by OA volunteers. STUDY DESIGN: Retrospective cohort study using data from OA's secure database to evaluate the quality of care provided to all patients eligible for OA services from 1994 through 2008. Primary outcomes included quality of care as measured by the Institute of Medicine's six quality aims, ie, safety, efficiency, effectiveness, timeliness, patient-centered care, and equity. RESULTS: Six-thousand five-hundred and forty-two patients were referred to OA during the past 15 years; 83.4% met eligibility criteria. Of these, 3,518 unduplicated patients received 3,098 surgical, endoscopic, and minor procedures. Only 12 of 1,880 surgical patients experienced a complication requiring hospitalization. Patient care was efficient, with a 95.3% overall compliance rate; approximately $7.56 of services were provided for every dollar of philanthropic support. OA's strong emphasis on case management, focus on continuity of care, and patient-selection criteria contributed to the organization's provision of safe, efficient, effective, timely, and patient-centered care. A higher percentage of Latinos and a lower percentage of African Americans relative to the geographic demographics received OA services. CONCLUSIONS: A volunteer program providing low-risk outpatient operations using the OA model delivers safe, efficient, effective, timely, and patient-centered care.

Quality of care in surgical oncology.

BACKGROUND: High-quality health care is safe, effective, efficient, timely, patient-centered, and equitable. A current focus on quality assessment and improvement in oncology care, specifically in surgical oncology, is aimed toward providing optimal health services that consistently fulfill these elements for cancer patients. METHODS: In surgical oncology, outcomes have historically focused on perioperative morbidity and mortality. To assess care metrics in the United States, we review structural and process measures of quality care in surgical oncology. RESULTS: Most quality metrics in surgical oncology pertain to structural measures of care such as accreditation, procedure volumes, provider specialization, and multidisciplinary teams. Process measures, such as surgical technique, are also important but are not easily quantified. CONCLUSIONS: Policy implications of quality metrics in surgical oncology include formal regionalization of care, changes in payment structures, and public reporting. More comprehensive assessments of outcomes are gaining traction in the field of surgical oncology; this shift in focus to the patient's perspective will enhance the quality of care delivered by surgical oncologists.

Histologic inflammation is a risk factor for progression to colorectal neoplasia in ulcerative colitis: a cohort study.

BACKGROUND & AIMS: Although inflammation is presumed to contribute to colonic neoplasia in ulcerative colitis (UC), few studies have directly examined this relationship. Our aim was to determine whether severity of microscopic inflammation over time is an independent risk factor for neoplastic progression in UC. METHODS: A cohort of patients with UC undergoing regular endoscopic surveillance for dysplasia was studied. Degree of inflammation at each biopsy site had been graded as part of routine clinical care using a highly reproducible histologic activity index. Progression to neoplasia was analyzed in proportional hazards models with inflammation summarized in 3 different ways and each included as a time-changing covariate: (1) mean inflammatory score (IS-mean), (2) binary inflammatory score (IS-bin), and (3) maximum inflammatory score (IS-max). Potential confounders were analyzed in univariate testing and, when significant, in a multivariable model. RESULTS: Of 418 patients who met inclusion criteria, 15 progressed to advanced neoplasia (high-grade dysplasia or colorectal cancer), and 65 progressed to any neoplasia (low-grade dysplasia, high-grade dysplasia, or colorectal cancer). Univariate analysis demonstrated significant relationships between histologic inflammation over time and progression to advanced neoplasia (hazard ration (HR), 3.0; 95% CI: 1.4-6.3 for IS-mean; HR, 3.4; 95% CI: 1.1-10.4 for IS-bin; and HR, 2.2; 95% CI: 1.2-4.2 for IS-max). This association was maintained in multivariable proportional hazards analysis. CONCLUSIONS: The severity of microscopic inflammation over time is an independent risk factor for developing advanced colorectal neoplasia among patients with long-standing UC.

Chemoprevention of colorectal neoplasia in ulcerative colitis: the effect of 6-mercaptopurine.

BACKGROUND & AIMS: Evidence suggests that mesalamine-based anti-inflammatory medicines may prevent colorectal cancer (CRC) in ulcerative colitis (UC). If mesalamine exerts its chemopreventive effect by its anti-inflammatory activity, then other medications that reduce colitis activity also should possess chemopreventive properties. Our aim was to determine the effect of the immunomodulators 6-mercaptopurine (6MP) and azathioprine (AZA) in preventing the development of dysplasia or CRC in UC. METHODS: Patients with UC who underwent a surveillance colonoscopy in 1996-1997 were identified from a gastrointestinal pathology database. A proportional hazards analysis assessing 6MP/AZA use as a time-changing covariate was performed to evaluate the effect of 6MP/AZA on: (1) progression to any neoplasia (low-grade dysplasia, high-grade dysplasia, or CRC), and (2) progression to advanced neoplasia (high-grade dysplasia or CRC). RESULTS: A total of 315 subjects met inclusion criteria and were followed for an average of 8 years from their first surveillance examination. There were no significant differences in rates of progression to advanced neoplasia or to any neoplasia between 6MP/AZA users and never-users by log-rank testing. The proportional hazards analysis resulted in hazard ratios of 1.06 (95% confidence interval, .59-1.93) and 1.30 (95% confidence interval, .45-3.75) when considering the effect of exposure to 6MP/AZA on progression to any or to advanced neoplasia, respectively. The results were unaffected by known potential confounders. CONCLUSIONS: In UC patients with no initial history of dysplasia, 6MP/AZA use appears to have little or no effect on the rate of neoplastic transformation in the colon. Importantly, the use of 6MP/AZA did not increase malignant transformation in UC.