A field guide to U.S. healthcare reform: The evolution to value-based healthcare.

OBJECTIVE: A consolidated state-of-the-art review of U.S. healthcare reform efforts that documents the evolution towards value-based healthcare (VBH) is lacking in peer-review literature. This field guide attempts to clarify working definitions and conceptual boundaries within the lexicon of U.S. healthcare reform efforts that predated and have common thematic perspectives within the evolving VBH reform paradigm. DATA SOURCES: Pubmed/MEDLINE/Google search. REVIEW METHODS: Pubmed/MEDLINE/Google search was performed during August 1, 2020-January14, 2021 for U.S. healthcare reform terms, legislative and government agency publications. Those citing relevant legislative, regulatory, philosophical and technological advancements integral to the development and function of VBH were catalogued according to the targeted stakeholders and evolving reform strategy or technology. CONCLUSIONS: Eight healthcare reform paradigms were identified as influential precursors to VBH: Patient-Centered Care Model, Patient-Centered Medical Home, Population Health, Personalized Medicine, P4 Medicine, Precision Medicine, Managed Care, and Accountable Care. Several of these models have similar nomenclature and, confusingly, many have multiple interpretations of the terms used to describe these models. However, consistent stakeholders identified within these paradigms are key to VBH; notably the patient, the physician and the payer (the "Big 3"). Demonstrable healthcare spending reductions have been best achieved when the Big 3 stakeholder interests are aligned within healthcare reform legislation. The definition of "Value" within each reform model was found to be based upon the perspective of the targeted stakeholder. Within VBH, the perspectives of the Big 3 stakeholders form a multidimensional meaning of "Value" that can be represented by the equation Value = Patient Experience Management 3 .

Contemporary analysis of otolaryngic allergy.

OBJECTIVES: Investigate the current trends in otolaryngic allergy (OA). STUDY DESIGN: Cross-sectional survey. METHODS: Survey of active AAOA membership. RESULTS: Response rate was 27.3%. Regional response distribution rates were proportional to the AAOA membership distribution within the United States (R2 = 0.95; P < 0.001), with no significant regional response bias demonstrated (P = 0.428). Self-reported duration to OA competency was 5.8 years. Physicians reporting OA competency were more likely to be board-certified (P < 0.001) and have AAOA fellowship status (P < 0.001). The AAOA was reported to be the most valuable educational resource toward achieving OA competency, with residency training being least valuable (P < 0.001). 91.5% of respondents' practices offered OA services. Subcutaneous injections predominated at twice the utilization of sublingual immunotherapy. Allergy immunotherapy tablets were rarely utilized. Home allergy shots were offered by 45.2% of respondents. In-office immunotherapy vial compounding was preferred (95.8%) to third-party vendors. 94% of AAOA respondents identified patient compliance to be an issue within OA. Non-inhalant allergy service integration included food allergy (63.5%), asthma (44.9%), allergic fungal sinusitis (43.8%), penicillin allergy (18%), stinging insect allergy (12.6%), and aspirin desensitization (3.9%). CONCLUSION: Reported duration to OA competency after residency was surprisingly long. Further investigation of current and future educational/clinical training is warranted given clinical integration reported for OA. Otolaryngology is in the unique position to develop a comprehensive sino-allergy evidence-based strategy integrating the extensive diagnostic and medical treatment arms alongside the surgical expertise of the specialty within a clinical sino-allergy home concept. LEVEL OF EVIDENCE: 5 Laryngoscope, 130:283-289, 2020.

Contemporary analysis of practicing otolaryngologists.

OBJECTIVES/HYPOTHESIS: To investigate contemporary issues facing practicing otolaryngologists including workforce dynamics, ancillary service modeling, otolaryngic allergy integration, ambulatory surgery center utilization, and relevant certificate of need legislation. STUDY DESIGN: A cross-sectional survey analysis of academic and private practicing otolaryngologists in North and South Carolina in 2016. METHODS: A cross-sectional survey was e-mailed to 510 practicing otolaryngologists in North and South Carolina. RESULTS: A 21.3% survey response rate was achieved. Otolaryngology workforce was defined by horizontal aggregation of otolaryngologists into larger group models, with fewer solo practitioners being replaced by younger otolaryngologists or employing otolaryngology extenders. Excluding academic practice, few otolaryngologists have chosen direct hospital employment as a career option, although otolaryngologists with fewer years of practice are pursuing that option with greater frequency. Ancillary services showed audiology and hearing aid services being the most common, followed by otolaryngic allergy, point-of-service computed tomography, and ultrasound. Although otolaryngologists tend to avoid vertical integration, ambulatory surgery center (ASC) ownership trends favor a joint venture model with a hospital system partner. Most otolaryngologists favor changes to certificate of need legislation to improve patient access to these lower-cost facilities, regardless of whether they currently utilize or have access to an ASC. CONCLUSIONS: Otolaryngology is uniquely positioned to adapt and respond to current paradigm shifts within ambulatory medicine. Further analysis is needed to prepare current and future otolaryngologists for the demands and opportunities these challenges pose as patient-centered care models and consumer dynamics shape future patient expectations and utilization of healthcare. LEVEL OF EVIDENCE: 5. Laryngoscope, 2490-2499, 2018.

Early CT for suspected occult scaphoid fractures.

In this study, the use of computed tomography (CT) early in the management of suspected occult scaphoid fractures was evaluated. We retrospectively reviewed the notes and radiology of patients who had scaphoid CT scans over the preceding 3 years. Eighty-four patients that had CT scans within 14 days from injury were identified. Of the CT scans, 64% (n = 54) excluded a fracture and these patients were promptly mobilized. No patients returned with any complications from this management. Overall, 36% of CT scans were abnormal (n = 30), 7% revealed occult scaphoid fractures, 18% revealed occult carpal fractures of the triquetrum, capitate, and lunate, respectively, and 5% revealed distal radius fractures. All patients diagnosed with fractures were successfully managed with plaster immobilization and there was one case of complex regional pain syndrome. Early CT alters therapeutic decision making in suspected occult fractures preventing unnecessary immobilization in a working population without increase in cost.

The clinical scaphoid fracture: early computed tomography as a practical approach.

INTRODUCTION: Up to 40% of scaphoid fractures are missed at initial presentation as clinical examination and plain radiographs are poor at identifying scaphoid fractures immediately after the injury. Avoiding a delay in diagnosis is essential to prevent the risk of non-union and early wrist arthritis. We demonstrate the use of CT scanning for the early confirmation of a scaphoid fracture. PATIENTS AND METHODS: We conducted a retrospective, chronological review of patients who attended an upper limb fracture clinic from January 2001 to October 2003 in a small district general hospital. We performed a CT scan on all 'clinical scaphoid' patients who had negative plain X-ray films. RESULTS: Overall, 70% of patients had a CT scan within 1 week of injury and not from date of accident and emergency attendance; 83% of patients had a CT scan within 2 weeks of injury. Of 118 patients identified, 32% had positive findings and 22% of 'clinical scaphoid' patients had scaphoid fractures. The proportion of positive findings for an acute scaphoid fracture was 68%. Additional pathologies identified on CT were capitate, triquetral and radial fractures. CONCLUSIONS: Our audit shows that it is practical to perform CT on suspicious scaphoid fractures in a small district general hospital. We identified an extremely high false-negative rate for plain X-rays and demonstrate that the appropriate use of CT at initial fracture clinic attendance with 'clinical scaphoid' leads to an earlier diagnosis and reduces the need for prolonged immobilisation and repeated clinical review.

A study to explore the patient's experience of peritoneal surface malignancies: pseudomyxoma peritonei.

Pseudomyxoma peritonei (PMP) is a rare tumour originating from the appendix and producing extensive mucus accumulation within the abdomen and pelvis. Since UK government policy reinforces the importance of involving patients in the delivery of healthcare, it is essential to explore patients views so that service development can be fully responsive to the patients need. The primary objective of this study was to explore the impact of PMP on the lives of patients. The secondary objectives were to explore the sources of psychological support for patients, the symptoms experienced and their information concerns. In-depth interviews were conducted with a purposive sample of 13 patients. The interviews were tape recorded, with permission, transcribed in full and analysed for content and emerging themes. The emergent themes included significant uncertainty about the diagnosis and treatment of this rare condition. The difficulties associated with confirming an initial diagnosis and living with an uncertain prognosis were highlighted. Patients' choice and access to support by a specialist team were important themes. The data highlighted the particular needs of this under-researched patient group and provided evidence to further develop patient support, particularly using the Internet.

Radiofrequency turbinate reduction: a NOSE evaluation.

BACKGROUND: The symptoms and treatments for nasal obstruction are numerous and common. Yet, a consensus on a surgical approach or, even more importantly, how to define the success of any approach is lacking in the literature. A disease-specific outcomes instrument recently developed by the American Academy of Otolaryngology, known as the Nasal Obstruction Symptom Evaluation (NOSE) scale, has allowed for a validated, uniform method to compare different treatments for nasal obstruction. METHODS: Using the NOSE scale, we prospectively compared the use of bilateral radiofrequency inferior turbinate reduction (BRITR) only with that of BRITR with septoplasty in the treatment of nasal obstruction caused by the combination of septal deviation and turbinate hypertrophy. NOSE scores were obtained pretreatment and at 3 month and 6 month follow-up. RESULTS: Our data demonstrated significant improvement from baseline after 6 months for the NOSE scores in both the BRITR (P < .001) and BRITR/septoplasty groups (P = .023). No statistical difference was noted in the amount of postoperative improvement between the two treatment groups (P = .304). Both groups did demonstrate a large, clinically important effect using a distribution-based assessment of clinical change. Despite equal clinically effective results, estimated costs for each treatment option differed significantly, with the office-based BRITR only group providing significant cost savings compared with the hospital-based BRITR/septoplasty group. CONCLUSIONS: This study suggests that BRITR should be considered as an initial treatment option for nasal obstruction rather than a septoplasty with turbinate reduction in patients with the clinical findings of both a septal deviation and turbinate hypertrophy after failure of medical therapy.

Welfare effects of reduced milk production associated with Johne's disease on Johne's-positive versus Johne's-negative dairy operations.

An examination of the economic impacts of reduced milk production associated with Johne's disease on Johne's-positive and Johne's-negative dairy operations indicated that, if Johne's disease had not existed in US dairy cows in 1996, then the economic surplus of Johne's-negative operations would have been $600 million+/-$530 million lower, while the economic surplus of Johne's-positive operations would have been higher by $28 million+/-$79 million, which was not significantly different from zero. The data available for projecting changes in surplus were not sufficiently precise to allow an exact statement on whether Johne's-positive operations would have been better or worse off economically, in terms of the value received for producing more milk if they had not been affected by Johne's disease. The changes in producer surplus, based upon eliminating specific epidemiological risk factors for Johne's disease, were disaggregated between Johne's-positive dairy operations exposed to the risk factor and all other US dairy operations. Eliminating the risk factor of having any cows not born on the operation would have had a significant positive effect on the economic surplus of Johne's-positive operations that had any cows not born on the operation.

Economic impacts of reduced milk production associated with papillomatous digital dermatitis in dairy cows in the USA.

The goal of this study was to measure the economic impacts of reduced milk production associated with papillomatous digital dermatitis (PDD) in dairy cows in the USA, and of specific risk factors for PDD, in 1996. The method applied was an economic-welfare analysis of producer and consumer surplus, with the GUM Workbench used to analyse uncertainties in the measurements. Reduced milk production associated with PDD was found to reduce consumer surplus by Dollars 750 million +/- Dollars 580 million, and to increase the economic surplus of producers by Dollars 560 million +/- Dollars 470 million, with a net economic loss of Dollars 190 million +/- Dollars 130 million. An examination of the economic effects of specific epidemiologic risk factors for PDD showed that having dairy cows that were not born on the operation had important economic consequences associated with the disease, as did the type of land to which dairy cows had access during the winter months and the type of flooring on which cows walked. Washing hoof-trimming equipment between cows was an important biosecurity measure that was associated with reduced PDD. The epidemiologic model used also implicated hoof trimmers who trimmed cattle hooves on other operations as having an important economic impact associated with this disease, although this finding may have been erroneous.

Welfare effects of the use of recombinant bovine somatotropin in the USA.

The welfare effects of increased milk production associated with the use of recombinant bovine somatotropin (rBST) on dairy operations in the USA were examined for 1996. Results that derived from three different estimates of the milk-production response to rBST were evaluated and compared. One estimate, derived from a survey of dairy producers in Connecticut, led to economic-impact estimates that were not statistically significant. A second, derived from a national survey that concentrated on the health and management of dairy cattle, led to estimates that were unbelievably high. A third, derived from a national survey that concentrated on the economics of dairy producers, provided the most reasonable estimates of economic impacts. Results of economic analysis, using the latter results, indicated that if rBST had not caused milk production to increase, then the market price of milk would have been 2.2 +/- 1.5 cents/kg higher, and the total value of the milk produced would have risen from Dollars 23.0 +/- 0.6 billion to Dollars 24.1 +/- 1.0 billion. A welfare analysis demonstrated that the increased milk production (and the reduced market price) associated with the use of rBST in the USA caused the economic surplus of consumers to rise by Dollars 1.5 +/- 1.0 billion, while the economic surplus of dairy producers fell by Dollars 1.1 +/- Dollars 0.8 billion. Increased milk production associated with rBST yielded a total gain to the US economy of Dollars 440 +/- 280 million. An analysis of annual percent changes in the number of dairy cows per operation, milk production per cow, total milk production, total number of dairy cows, and total number of dairy operations in the USA suggested that the dairy industry's long-term economic growth path was stable from 1989-2001 inclusive, and did not receive a shock resulting from the introduction of rBST.

Economic impacts of reduced milk production associated with epidemiological risk factors for Johne's disease on dairy operations in the USA.

An examination of the economic effects of epidemiologic risk factors for Johne's disease identified regional and herd size differences as having the greatest impact. Having dairy cows that were not born on the operation was the most important factor over which individual producers had the most immediate control. Economic consequences associated with using multiple-cow-maternity housing and multiple-preweaned-calf housing were not statistically significant. Economic welfare analysis was applied, and the GUM Workbench was used to analyse uncertainties in the estimates of the economic impacts.

Economic impact of reduced milk production associated with Johne's disease on dairy operations in the USA.

Accurately assessing the economic impacts of diseases and other factors that affect milk production requires that the demand for milk be taken into account. Because demand for milk in the USA is relatively inelastic (i.e., consumers generally purchase a somewhat fixed amount over a given time frame, regardless of fluctuations in price), consumers tend to reap much of the benefit of enhanced production. An examination of the economic impacts of Johne's disease indicated that reduced milk production, associated with the determination of dairy operations as Johne's-positive, reduced consumer surplus by 770 million dollars+/- 690 million dollars, and resulted in a total loss of 200 million dollars+/- 160 million dollars to the US economy in 1996. Most of the economic surplus lost by consumers was transferred to producers, whose economic surplus increased by 570 million dollars+/- 550 million dollars as a result of the reduced milk production associated with Johne's disease. Uncertainty analysis showed that the estimated reduction in milk production on Johne's-positive dairy operations accounted for most of the uncertainty in the economic-impact estimates. If Johne's disease had not been present on US dairy operations, then an additional 580 million+/-460 million kg of milk would have been produced, but the price would have fallen by 1.1+/-1.0 cents/kg, and the total value of the milk would have decreased by 580 million dollars+/- 560 million dollars.

Economic impacts of the mortality rate for suckling pigs in the United States.

OBJECTIVE: To measure economic impacts attributable to the mortality rate for suckling pigs in the United States. DESIGN: Economic analysis that incorporated data from various sources. SAMPLE POPULATION: Suckling pigs on U.S. swine farms. PROCEDURE: Economic impacts associated with the mortality rate for suckling pigs during 1995 were estimated from supply-and-demand curves for pork and from an estimate of the elasticity of production for pigs entering the grower-finisher phase of production. RESULTS: A decrease in the mortality rate for suckling pigs would have caused an increase in pork production and a decrease in price and total value of production. Assuming no suckling pigs had died during 1995, consumer surplus would have increased by (mean +/- SE) 430 +/- 160 million dollars, whereas producer surplus would have decreased by 180 +/- 140 million dollars. The total gain to the US economy would have been 250 +/- 30 million dollars. CONCLUSIONS AND CLINICAL RELEVANCE: Researchers who attempt to estimate the economic impact of mortality and morbidity rates of livestock should not ignore the influence of demand and the possibility of price adjustments. Consumers would stand to benefit from an increase in pork production associated with a reduction in the mortality rate for suckling pigs, whereas the swine industry would experience an economic loss. Individual producers need to compare the costs of measures intended to reduce the mortality rate for suckling pigs with the anticipated benefits.

Supportive care in the cancer setting: rhetoric or reality?

BACKGROUND: Since 1995, UK cancer policy has been directed at organizational changes to secure improvements in treatment outcomes and quality of supportive care for cancer patients. The substantial increase in hospital-based specialist cancer nurses (SCNs) during this time suggests they have a major role to play in the delivery of supportive care. AIM: To explore how SCNs implemented their role in the context of organizational change and newly-formed multidisciplinary teams. METHODS: Twenty-nine SCNs participated in observation and/or interviews, resulting in 135 hours of observation and in-depth semi-structured interviews with 17 SCNs. Data were collected and analysed using a grounded theory approach. RESULTS: The prominence of the treatment agenda--the process of investigating, diagnosing and treating cancer--presented the biggest challenge to the delivery of supportive care. The treatment agenda influenced how support was offered, determined professional boundaries and relegated support to a subordinate position in patient care. CONCLUSIONS: Access to supportive care is a central tenet of current cancer policy and crucial to the philosophy of patient-centred care. While SCNs are essential to the delivery of supportive care, this study highlights the challenges they encounter in organizations which prioritise treatment and improvements to treatment outcomes.

Economic impacts of reduced milk production associated with an increase in bulk-tank somatic cell count on US dairies.

OBJECTIVE: To measure the economic impacts attributable to an increase in bulk-tank somatic cell count (BTSCC) on US dairies. DESIGN: Meta-analysis of data from various sources. PROCEDURE: Economic impacts attributable to reduced milk production associated with an increase in BTSCC (> or = 200,000 cells/mL) in dairy cows during 1996 were estimated from supply-and-demand curves for milk and from an estimate of the effect of increased BTSCC on milk production. RESULTS: Reduced milk production associated with an increase in BTSCC in dairy cows during 1996 caused an economic loss (mean +/- 2SE) of 3.1 +/- 2.1 billion dollars to consumers, an economic gain of 2.2 +/- 1.7 billion dollars to dairy producers, and a total loss of 810 +/- 480 million dollars to the US economy as a whole. CONCLUSIONS AND CLINICAL RELEVANCE: Consumers would stand to benefit from increased milk production associated with reducing the BTSCC to < 200,000 cells/mL on all dairy operations, whereas the US dairy industry would experience an economic loss. Individual dairy producers need to compare the costs of measures intended to reduce BTSCC with the anticipated benefits from a decrease in BTSCC.

Economic impacts of reduced pork production associated with the diagnosis of Actinobacillus pleuropneumoniae on grower/finisher swine operations in the United States.

An examination of the economic impacts of the diagnosis of Actinobacillus pleuropneumoniae on grower/finisher swine operations indicated that reduced pork production, associated with the diagnosis of A. pleuropneumoniae on the operation, diminished consumer surplus by $53+/-52 million, and resulted in a total loss of $32+/-30 million to the US economy in 1995. Most of the economic surplus lost by consumers was transferred to producers, whose economic surplus increased by $21+/-25 million (which was not significantly different from zero). Uncertainty analysis showed that an estimate of the decline in production associated with the diagnosis of A. pleuropneumoniae accounted for most of the uncertainty of the change in consumer surplus and of the total loss to the economy. The estimate of the price elasticity of demand for pork also contributed towards a lot of the uncertainty in the estimated change in producer surplus.