Drivers of Variability in 90-day Cost for Primary Single-level Microdiscectomy.

BACKGROUND: The healthcare reimbursement models are rapidly transitioning to pay-per-performance episode of care payment models. These models, if designed well, must account for the variability in the cost of index surgeries during the global period. OBJECTIVE: To analyze the variability in 90-d cost and determine the drivers of the variability in total 90-d cost associated with single-level microdiscectomy. METHODS: A total of 203 patients undergoing primary microdiscectomy for degenerative lumbar conditions were included in the study. The total 90-d cost was derived as the sum of cost of surgery, cost associated with postdischarge utilization. A multivariable linear regression model for total 90-d cost was built. RESULTS: The mean total cost within 90-d after single-level primary microdiscectomy was $7962 ± $2092. In a multivariable linear regression model, obesity, history of myocardial infarction, factors that lengthen the time of surgery and hospital stay, complications and readmission within 90-d, postdischarge healthcare utilization including emergency room visits, time to opioid independence, number of days on nonopioid pain medications, diagnostic imaging, and the number of days in outpatient and inpatient rehabilitation contribute to the total 90-d cost. The model performance as measured by R2 is 0.76. CONCLUSION: Utilizing prospectively collected data, we highlight major drivers of variation in cost following a single-level primary microdiscectomy. Our model explains about three-quarters of the variation in cost. The risk-adjusted cost estimates powered by models such as the one presented here can be used to formulate a sustainable total 90-d episode of care bundle payment.

Reducing Inappropriate Testing for the Evaluation of Diarrhea Among Hospitalized Patients.

BACKGROUND: Diarrhea is one of the most common illnesses in the United States. Evaluation frequently does not follow established guidelines. The objective of this study was to evaluate the effectiveness of a computerized physician order entry-based test guidance algorithm with regard to the clinical, financial, and operational impacts. METHODS: Our population was patients with diarrheal illness at a tertiary academic medical center. The intervention was a computerized physician order entry-based test guidance algorithm that restricted the use of stool cultures and ova and parasites testing of diarrhea in the adult inpatient location vs nonintervention sites, which were the emergency department, pediatric inpatient and adult and pediatric outpatient locations. We measured stool culture, ova and parasites, and Clostridium difficile testing rates from July 1, 2012 to January 31, 2016. Additionally, we calculated advisor usage, consults generated, accuracy of information, and cost savings. RESULTS: There was a significant decrease in stool culture and ova and parasites testing rates at the adult inpatient (P = .001 for both), pediatric (P < .001 for both), and adult emergency department (P < .001; P = .009) locations. The decrease at the intervention site was immediate, whereas the other locations showed a delayed but sustained decrease that suggests a collateral impact. A significant increase in the rate of stool culture and ova and parasites testing was observed in the outpatient setting (P = .02 and P = .001). We estimate that $21,931 was saved annually. CONCLUSIONS: A point-of-order test restriction algorithm for hospitalized adults with diarrhea reduced stool testing. Similar programs should be considered at other institutions and for the evaluation of other conditions.

Evidence for an elders' advantage in the naive product usability judgments of older and younger adults.

OBJECTIVE: To determine whose naive judgments of consumer product usability are more accurate--those of younger or older adults. Accuracy is here defined as judgments compatible with results from performance-based usability tests. BACKGROUND: Older adults may be better able to predict usability problems than younger adults, making them particularly good participants in studies contributing to the user-centered design of products. This advantage, if present, may stem from older adults' motivation for more usable products or from their experience adapting their own environments to meet their changing physical, cognitive, and sensory needs. METHOD: Sixty older participants (ages 65-75 years) and 60 younger ones (ages 18-22 years) evaluated illustrations of consumer products on specific criteria (e.g., readability, learnability, or error rates). They either rated a single design for each product or ranked six alternative designs. They also explained their choices, indicated which features were most critical for usability, and selected usability-enhancing modifications. RESULTS: Although there was no reliable age difference in the amount of usability information provided in the open-ended explanations, older adults were more accurate at ranking alternative designs, selecting the most usability-critical features, and selecting usability-enhancing modifications (all ps < .05). CONCLUSION: The usability judgments of older adults are more accurate than those of younger adults when these judgments are solicited in a fixed-alternative, but not open-ended, format. APPLICATION: Because older adults are more discerning about potential product usability problems, they may be particularly valuable as research participants in early-stage design research (prior to the availability of working prototypes).