Detecting bad actors in value-based payment models.

The U.S. federal government is spending billions of dollars to test a multitude of new approaches to pay for healthcare. Unintended consequences are a major consideration in the testing of these value-based payment (VBP) models. Since participation is generally voluntary, any unintended consequences may be magnified as VBP models move beyond the early testing phase. In this paper, we propose a straightforward unsupervised outlier detection approach based on ranked percentage changes to identify participants (e.g., healthcare providers) whose behavior may represent an unintended consequence of a VBP model. The only data requirements are repeated measurements of at least one relevant variable over time. The approach is generalizable to all types of VBP models and participants and can be used to address undesired behavior early in the model and ultimately help avoid undesired behavior in scaled-up programs. We describe our approach, demonstrate how it can be applied with hypothetical data, and simulate how efficiently it detects participants who are truly bad actors. In our hypothetical case study, the approach correctly identifies a bad actor in the first period in 86% of simulations and by the second period in 96% of simulations. The trade-off is that 9% of honest participants are mistakenly identified as bad actors by the second period. We suggest several ways for researchers to mitigate the rate or consequences of these false positives. Researchers and policymakers can customize and use our approach to appropriately guard VBP models against undesired behavior, even if only by one participant. Supplementary Information: The online version contains supplementary material available at 10.1007/s10742-021-00253-9.

The National Cancer Institute Community Cancer Centers Program (NCCCP): Sustaining Quality and Reducing Disparities in Guideline-Concordant Breast and Colon Cancer Care.

BACKGROUND: The National Cancer Institute Community Cancer Centers Program (NCCCP) pilot was designed to improve quality of cancer care and reduce disparities at community hospitals. The NCCCP's primary intervention was the implementation of the Commission on Cancer Rapid Quality Reporting System (RQRS). The RQRS is a hospital-based data collection and evaluation system allowing near real-time assessment of selected breast and colon cancer quality of care measures. Building on previous NCCCP analyses, this study examined whether improvements in quality cancer care within NCCCP hospitals early in the program were sustained and whether improvements were notable for minority or underserved populations. METHODS: We compared changes in concordance with three breast and two colon cancer quality measures approved by the National Quality Forum for patients diagnosed at NCCCP hospitals from 2006 to 2007 (pre-RQRS), 2008 to 2010 (early-RQRS), and 2011 to 2013 (later-RQRS). Data were obtained from NCCCP sites participating in the Commission on Cancer Rapid Quality Reporting System. Logistic regression analyses were performed to identify predictors of concordance with breast and colon cancer quality measures. RESULTS: The sample included 13,893 breast and 5,546 colon cancer patients. After RQRS initiation, all five quality measures improved significantly and improvements were sustained through 2013. Quality of care measures showed sustained improvements for both breast and colon cancer patients and for vulnerable patient subgroups including black, uninsured, and Medicaid-covered patients. CONCLUSIONS: Quality improvements in NCCCP hospitals were sustained throughout the duration of the program, both overall and among minority and underserved patients. Because many individuals receive cancer treatment at community hospitals, facilitating high-quality care in these environments must be a priority. IMPLICATIONS FOR PRACTICE: Quality improvement programs often improve practice, but the methods are not maintained over time. The implementation of a real-time quality reporting system and a network focused on improving quality of care sustained quality improvement at select community cancer centers. The NCCCP pilot increased numbers of patients receiving guideline-concordant care for breast and colon cancer in community settings, and initial improvements noted in earlier years of RQRS were sustained into later years, both overall and among minority and underserved patients. National initiatives that improve care for diverse patient groups are important for reducing and eliminating barriers to care.

Improving quality of cancer care at community hospitals: impact of the National Cancer Institute Community Cancer Centers Program pilot.

PURPOSE: Patients with cancer treated at community hospitals may experience decreased quality of care compared with patients treated at higher-volume cancer hospitals. The National Cancer Institute Community Cancer Centers Program (NCCCP) pilot is designed to enhance research and improve cancer care at community hospitals. We assessed changes in quality of care among the 16 initial NCCCP sites versus 25 similar hospitals that did not participate in the NCCCP. METHODS: We compared changes in concordance with five National Quality Forum-approved quality of care measures (three for breast cancer, two for colon cancer) for patients diagnosed from 2006 to 2007 (pre-NCCCP initiation) versus 2008 to 2010 (post-NCCCP initiation) at NCCCP and comparison-group hospitals. Data were collected using the Commission on Cancer Rapid Quality Reporting System. Analyses were performed using multivariate logistic regression. RESULTS: Analyses included 18,608 patients with breast cancer and 7,031 patients with colon cancer. After NCCCP initiation, patient-level concordance rates for all five quality-of-care measures increased significantly among NCCCP and comparison-group hospitals. Increased quality of care among NCCCP sites was significantly greater than that among comparison-group hospitals for radiation therapy after breast-conserving surgery and hormonal therapy for women with hormone receptor-positive breast cancer. In multivariate regressions, increases in hormonal therapy among NCCCP-site patients were significantly greater than those among comparison-group hospitals. CONCLUSION: Both NCCCP and comparison-group hospitals showed improved quality of care; however, NCCCP sites had significantly greater improvements for a subset of measures. This greater increase may reflect the multidisciplinary focus of the NCCCP. Because many individuals receive cancer treatment at community hospitals, facilitating high-quality care in these environments must be a priority.

Race, healthcare access and physician trust among prostate cancer patients.

OBJECTIVE: To study the effect of healthcare access and other characteristics on physician trust among black and white prostate cancer patients. METHODS: A three-timepoint follow-up telephone survey after cancer diagnosis was conducted. This study analyzed data on 474 patients and their 1,320 interviews over three time periods. RESULTS: Among other subpopulations, black patients who delayed seeking care had physician trust levels that were far lower than that of both Caucasians as well as that of the black patients overall. Black patients had greater variability in their levels of physician trust compared to their white counterparts. CONCLUSIONS: Both race and access are important in explaining overall lower levels and greater variability in physician trust among black prostate cancer patients. Access barriers among black patients may spill over to the clinical encounter in the form of less physician trust, potentially contributing to racial disparities in treatment received and subsequent outcomes. Policy efforts to address the racial disparities in prostate cancer should prioritize improving healthcare access among minority groups.

Perceived family history risk and symptomatic diagnosis of prostate cancer: the North Carolina Prostate Cancer Outcomes study.

BACKGROUND: Prostate cancer (PrCA) is the most common cancer and the second leading cause of cancer death among US men. African American (AA) men remain at significantly greater risk of PrCA diagnosis and mortality than other men. Many factors contribute to the experienced disparities. METHODS: Guided by the Health Belief Model, the authors surveyed a population of AA and Caucasian men newly diagnosed with PrCA to describe racial differences in perceived risk of PrCA and to examine whether 1) perceived high risk predicts greater personal responsibility for prostate care; and 2) greater personal responsibility for prostate care predicts earlier, presymptomatic diagnosis. Multivariate general linear modeling was performed. RESULTS: The authors found that men with a PrCA family history appreciated their increased risk, but AA men with a family history were less likely to appreciate their increased risk. Nevertheless, neither reporting a PrCA family history nor perceived increased risk significantly predicted screening and preventive behaviors. Furthermore, higher physician trust predicted increased likelihood to have regular prostate exams and screening, indicating that the racial differences in seeking prostate care may be mediated through physician trust. Expressed personal responsibility for screening and more frequent preventive behaviors were associated with more frequent screening diagnoses, fewer symptomatic diagnoses, and less frequent advanced cancers. CONCLUSIONS: Together, these results indicate that appreciating greater risk for PrCA is not sufficient to ensure that men will intend, or be able, to act. Increased trust in physicians may be a useful, central marker that efforts to reduce disparities in access to medical care are succeeding.

Hidden barriers between knowledge and behavior: the North Carolina prostate cancer screening and treatment experience.

BACKGROUND: Prostate cancer (PC) mortality is much greater for African American than for Caucasian men. To identify patient factors that might account for some of this disparity, men within 6 months of diagnosis were surveyed about health attitudes and behavior. METHODS: Using Rapid Identification in the North Carolina Cancer Registry, 207 African American and 348 Caucasian recently diagnosed PC patients were identified and surveyed. RESULTS: African American men were younger and less often currently married, and had lesser education, job status, and income than Caucasian men (all P < .001). African American men were at no greater distance to medical care, but had less access: poorer medical insurance coverage, more use of public clinics and emergency wards, less continuity with a primary physician, and more often omitted physician visits they felt they needed. They also expressed less trust in physicians. African American men acknowledged their greater risk of PC, accepted greater responsibility for their health, and reported more personal failures that delayed diagnosis. African American men more often requested the tests that diagnosed their cancers, which resulted more often from routinely ordered screening tests for Caucasian men. African American men expressed less interest in nontraditional treatments. CONCLUSIONS: Despite lesser education, African American men in North Carolina are aware of their increased risk of cancer, the importance of treatment, and their responsibility for their health. Obstacles to timely diagnosis and appropriate care, including greater physician distrust, appear more likely to arise from reduced access and continuity of medical care arising from their worse socioeconomic position.

Transplant tumor registry: donor related malignancies.

BACKGROUND: Transmission of donor malignancies has been intermittently reported since the early days of clinical transplantation. The incidence of United States donor related malignancies has not previously been documented. METHODS: All donor related malignancies reported to the Organ Procurement and Transplantation Network/United Network for Organ Sharing from 4/1/94-7/1/01 in a cohort of 34,933 cadaveric donors and 108,062 recipients were investigated by contacting the transplant centers to verify that the reported tumors were of donor origin. Time and mode of discovery, as well as graft and patient outcome, were determined. The status of other recipients from the donor was investigated. RESULTS: A total of 21 donor related malignancies from 14 cadaveric and 3 living donors were reported. Fifteen tumors were donor transmitted and 6 were donor derived. Transmitted tumors are malignancies that existed in the donor at the time of transplantation. Derived tumors are de novo tumors that develop in transplanted donor hematogenous or lymphoid cells after transplantation. The cadaveric donor related tumor rate is 0.04% (14 of 34,993). The donor related tumor rate among transplanted cadaveric organs is 0.017% (18 of 108,062). Among patients developing donor related malignancies, the overall mortality rate was 38%, with that of transmitted tumors being 46% and derived tumors being 33%. The cadaveric donor related tumor mortality rate is 0.007% (8 of 108,062). CONCLUSIONS: The United States incidence of donor related tumors is extremely small. The donor related tumor death rate is also extremely small, particularly when compared with waiting-list mortality.

Transplant tumor registry: donors with central nervous system tumors1.

BACKGROUND: Despite 13,000 central nervous system (CNS) tumor deaths per year in the United States, CNS tumor donors comprise only 1% of cadaveric donors recovered per year. Concern about tumor transmission may be a possible reason for this very small percentage. Both the size of the candidate waiting list and the number of deaths on the waiting list are progressively increasing because of the donor shortage. METHODS: During a 96-month period, the United Network for Organ Sharing recorded 42,340 cadaver donors of whom 397 had a past history of a CNS tumor or the cause of death listed as a CNS tumor. A total of 1,220 organs were transplanted from these 397 donors. All recipients who reported a posttransplant malignancy during a mean follow-up of 36 months were identified. RESULTS: There was no difference in patient survival of organs from CNS tumor donors when compared to donors with no CNS tumors. CNS tumor donors were not used more often for either urgent or older recipients. A total of 39 patients reported posttransplant malignancies but none of these tumors were donor-derived. There is a wide variation in the number of CNS tumor donors utilized by individual organ procurement organizations. CONCLUSIONS: The risk of tumor transmission from donors with CNS malignancies seems to be small. Certain tumors, such as glioblastoma multiforme and medulloblastoma, carry a high risk of transmission and should be avoided. The risk of tumor transmission should be weighed against the risk of the patient dying on the waiting list without a transplant.