Getting What You Pay For: The Economics of Quality Care for Sexually Transmitted Infections.

BACKGROUND: Understanding the relationship between charges, reimbursement, and quality for sexually transmitted infection (STI) care is necessary to evaluate consequences of shifting patients from STI specialty to nonspecialty settings and to inform quality improvement efforts in this area. METHODS: Chart reviews were used to evaluate quality of documented STI care among 450 patients across 5 different clinical settings within a large safety net hospital in Massachusetts for patients presenting with penile discharge/dysuria or vaginal discharge. Charges billed and recouped by the hospital for each visit were extracted from billing records. Univariate methods examined unadjusted differences between quality and other patient and practice characteristics, and charges billed and recouped, whereas a multivariable model predicted the effect of quality on charges and reimbursements after adjusting for potential confounders. RESULTS: Higher documented quality of care was associated with higher charges, with each additional quality point predicting a 9% increase in visit charges. However, these charges were not recouped by the institution, as quality was not associated with higher levels of hospital reimbursement. Among sites of care, the STI clinic had the highest average quality score, as well as the lowest average amount billed and recouped. CONCLUSIONS: The relationship we find between documented quality and charges billed may reflect resource use for patient visits. The hospital, however, did not recoup any more on average from higher-quality visits, thus posing an incentive problem for the institution. Our findings suggest that loss of government funds for STI clinics may not be replaced by hospital billing and may lead to lower quality of care.

Evaluating Quality of Care for Sexually Transmitted Infections in Different Clinical Settings.

BACKGROUND: We examined quality of care across different clinical settings within a large safety-net hospital in Massachusetts for patients presenting with penile discharge/dysuria or vaginal discharge. METHODS: Using a modified Delphi approach, a list of sex-specific sexually transmitted infection (STI) quality measures, covering 7 domains of clinical care (history, examination, laboratory testing, assessment, treatment, additional screening, counseling), was selected as standard of care by a panel of 5 STI experts representing emergency department (ED), obstetrics/gynecology (Ob/Gyn), family medicine (FM), primary care (PC), and infectious disease. Final measures were piloted with 50 charts per sex from the STI Clinic and age, sex, and visit date-matched charts from PC, FM, ED, and Ob/Gyn. Performance was scored as compliance among individual measures within 7 domains, standardized to add up to one to adjust for variable number of measures per domain, with an overall score of 7 indicating complete adherence to standards. RESULTS: Expert review process took 2 weeks and resulted in 24 and 34 final measures for male and female patients, respectively. Performance on 7 clinical domains ranged from 3.16 to 4.36 for male patients and 3.17 to 4.33 for female patients. Sexually transmitted infection clinic seemed to score higher on laboratory testing, additional screening, and counseling, but lower on examination and assessment, and ED seemed to score higher on examination and treatment, PC and FM on laboratory testing for male patients and on examination and treatment for female patients, and Ob/Gyn on treatment. CONCLUSIONS: An instrument to discern standard of care and identify strengths and weaknesses in specific domains of clinical documentation for patients presenting with STI complaints can be developed and implemented for quality evaluation across care settings. Further research is needed on whether these findings can be integrated into site-specific quality improvement processes and linked to cost analyses.

Health reform and shifts in funding for sexually transmitted infection services.

BACKGROUND: In the Affordable Care Act era, no-cost-to-patient publicly funded sexually transmitted infection (STI) clinics have been challenged as the standard STI care delivery model. This study examined the impact of removing public funding and instituting a flat fee within an STI clinic under state-mandated insurance coverage. METHODS: Cross-sectional database analysis examined changes in visit volumes, demographics, and payer mix for 4 locations in Massachusetts' largest safety net hospital (STI clinic, primary care [PC], emergency department [ED], obstetrics/gynecology [OB/GYN] for 3 periods: early health reform implementation, reform fully implemented but public STI clinic funding retained, termination of public funding and institution of a US$75 fee in STI clinic for those not using insurance). RESULTS: Sexually transmitted infection visits decreased 20% in STI clinic (P < 0.001), increased 107% in PC (P < 0.001), slightly decreased in ED, and did not change in OB/GYN. The only large demographic shift observed was in the sex of PC patients--women comprised 51% of PC patients seen for STI care in the first time period, but rose sharply to 70% in the third time period (P < 0.0001). After termination of public funding, 50% of STI clinic patients paid flat fee, 35% used public insurance, and 15% used private insurance. CONCLUSIONS: Mandatory insurance, public funding loss, and institution of a flat STI clinic fee were associated with overall decreases in STI visit volume, with significant STI clinic visit decreases and PC STI visit increases. This may indicate partial shifting of STI services into PC. Half of STI clinic patients chose to pay the flat fee even after reform was fully implemented.

Limited health literacy and decline in executive function in older adults.

Limited health literacy is associated with worse executive function, but the association between limited health literacy and decline in executive function has not been established because of a lack of longitudinal studies. The authors aimed to examine this association by studying a prospective cohort in the setting of a randomized controlled trial to promote walking in older adults. Participants were community-dwelling older adults (65 years of age or older) who scored 2 or more on the Mini-Cog, without depression (score of less than 15 on the 9-item Patient Health Questionnaire), and who completed baseline and 12-month evaluations (n = 226). Health literacy was measured using the Short Test of Functional Health Literacy in Adults. Executive function measured at baseline and 12 months using the Trail Making Test (TMT), Controlled Oral Word Association Test, and Category Fluency. The associations between health literacy and 12-month decline in each test of executive function were modeled using multivariate linear regression. Health literacy was found to be limited in 37% of participants. Limited health literacy was associated with reduced performance on all 3 executive function tests. In fully adjusted models, limited health literacy was associated with greater 12-month decline in performance on the TMT than higher health literacy (p = .01). In conclusion, older adults with limited health literacy are at risk for more rapid decline in scores on the TMT, a measure of executive function.

Unique distribution by the peroneal nerves: a case report.

PURPOSE: Among the branches of common peroneal nerve, the superficial peroneal provides cutaneous innervation to major part of the dorsum of the foot and deep peroneal nerve supplies the skin over the first interdigital cleft region. METHODS: The present rare case was observed during routine dissection of leg for undergraduate students, in a 52-year-old male, formalin fixed cadaver. RESULTS: The superficial peroneal nerve provided solely motor branches to peroneus longus and brevis, whereas cutaneous branches were provided by deep peroneal nerve. In the lower one-third of the leg deep peroneal nerve divided into medial and lateral branches. The medial branch supplied tibialis anterior and the lateral branch supplied skin of medial three and half toes. Moreover, the sural nerve supplied the skin of lateral one and a half toes. CONCLUSION: Awareness of this type of variations in the course of nerves helps to alert the surgeons when there are complaints of atypical or unique pain in that particular region.