Rethinking Informed Consent: The Case for Shared Medical Decision-Making, by Jaime Staples King and Benjamin Moulton (American Journal of Law & Medicine)
Extending The P4P Agenda, Part 1: How Medicare Can Improve Patient Decision Making And Reduce Unnecessary Care, by John E. Wennberg, Annette M. O’Connor, E. Dale Collins and James N. Weinstein (Health Affairs)
The decision to undergo many discretionary medical treatments should be based on informed patient choice. Shared decision making is an effective strategy for achieving this goal. The Centers for Medicare and Medicaid Services (CMS) should extend its pay-for-performance (P4P) agenda to assure that all Americans have access to a certified shared decision-making process. This paper outlines a strategy to achieve informed patient choice as the standard of practice for preference-sensitive care.
Extending The P4P Agenda, Part 2: HowMedicare Can Reduce Waste And Improve The Care Of The Chronically Ill By targeting Americans with chronic illnesses, Medicare can begin to solidify a strategy of rewarding providers for truly improving care, by John E. Wennberg, Elliott S. Fisher, Jonathan S. Skinner, and Kristen K. BronnerIglehart (Health Affairs)
The care of Americans with severe chronic illnesses is disorganized, unnecessarily costly, and undisciplined by sound clinical science. The federal government should invest in a crash program to improve the scientific basis of managing chronic illness, and the Centers for Medicare and Medicaid Services (CMS) should extend its pay-for-performance (P4P) agenda to ensure that within ten years all Americans with severe chronic illnesses have access to accountable health care organizations providing evidence-based prospective care. This paper recommends a strategy for achieving this goal.
The Care of Patients with Severe Chronic Illness: An Online Report on the Medicare Program by the Dartmouth Atlas Program. Dartmouth Atlas of Health Care 2006, by The Center for the Evaluative Clinical Sciences Dartmouth Medical School
Impacts of Rising Health Care Costs on Families with Employment-Based Private Insurance: A National Analysis with State Fixed Effects, by Hao Yuand Andrew W. Dick (Health Services Research)
Background. Given the rapid growth of health care costs, some experts were concerned with erosion of employment-based private insurance (EBPI). This empirical analysis aims to quantify the concern.
Methods. Using the National Health Account, we generated a cost index to represent state-level annual cost growth. We merged it with the 1996–2003 Medical Expenditure Panel Survey. The unit of analysis is the family. We conducted both bivariate and multivariate logistic analyses.
Results. The bivariate analysis found a significant inverse association between the cost index and the proportion of families receiving an offer of EBPI. The multivariate analysis showed that the cost index was significantly negatively associated with the likelihood of receiving an EBPI offer for the entire sample and for families in the first, second, and third quartiles of income distribution.
The cost index was also significantly negatively associated with the proportion of families with EBPI for the entire year for each family member (EBPI-EYEM). The multivariate analysis confirmed significance of the relationship for the entire sample, and for families in the second and third quartiles of income distribution.
Among the families with EBPI-EYEM, there was a positive relationship between the cost index and this group’s likelihood of having out-of-pocket expenditures exceeding 10 percent of family income. The multivariate analysis confirmed significance of the relationship for the entire group and for families in the second and third quartiles of income distribution.
Conclusions. Rising health costs reduce EBPI availability and enrollment, and the financial protection provided by it, especially for middle-class families.
The Long-Term Effect of Premier Pay for Performance on Patient Outcomes, by Ashish K. Jha, Karen E. Joynt, E. John Orav and Arnold M. Epstein (The New England Journal of Medicine)
Background. Pay for performance has become a central strategy in the drive to improve health care. We assessed the long-term effect of the Medicare Premier Hospital Quality Incentive Demonstration (HQID) on patient outcomes.
Methods. We used Medicare data to compare outcomes between the 252 hospitals participating in the Premier HQID and 3363 control hospitals participating in public reporting alone. We examined 30-day mortality among more than 6 million patients who had acute myocardial infarction, congestive heart failure, or pneumonia or who underwent coronary-artery bypass grafting (CABG) between 2003 and 2009.
Results. At baseline, the composite 30-day mortality was similar for Premier and non-Premier hospitals (12.33% and 12.40%, respectively; difference, −0.07 percentage points; 95% confidence interval [CI], −0.40 to 0.26). The rates of decline in mortality per quarter at the two types of hospitals were also similar (0.04% and 0.04%, respectively; difference, −0.01 percentage points; 95% CI, −0.02 to 0.01), and mortality remained similar after 6 years under the pay-for-performance system (11.82% for Premier hospitals and 11.74% for non-Premier hospitals; difference, 0.08 percentage points; 95% CI, −0.30 to 0.46). We found that the effects of pay for performance on mortality did not differ significantly among conditions for which outcomes were explicitly linked to incentives (acute myocardial infarction and CABG) and among conditions not linked to incentives (congestive heart failure and pneumonia) (P=0.36 for interaction). Among hospitals that were poor performers at baseline, mortality was similar in the two groups of hospitals at the start of the study (15.12% and 14.73%; difference, 0.39 percentage points; 95% CI, −0.36 to 1.15), with similar rates of improvement per quarter (0.10% and 0.07%; difference, −0.03 percentage points; 95% CI, −0.08 to 0.02) and similar mortality rates at the end of the study (13.37% and 13.21%; difference, 0.15 percentage points; 95% CI, −0.70 to 1.01).
Conclusions. We found no evidence that the largest hospital-based pay-for-performance program led to a decrease in 30-day mortality. Expectations of improved outcomes for programs modeled after Premier HQID should therefore remain modest.
Comparative Effectiveness of Revascularization Strategies, by William S. Weintraub, Maria V. Grau-Sepulveda, Jocelyn M. Weiss, Sean M. O’Brien, Eric D. Peterson, Paul Kolm, Zugui Zhang, Lloyd W. Klein, Richard E. Shaw, Charles McKay, Laura L. Ritzenthaler, A., Jeffrey J. Popma, John C. Messenger, David M. Shahian, Frederick L. Grover, John E. Mayer, Cynthia M. Shewan, Kirk N. Garratt, Issam D. Moussa, George D. Dangas and Fred H. Edwards (The New England Journal of Medicine)
Background. Questions persist concerning the comparative effectiveness of percutaneous coronary intervention (PCI) and coronary-artery bypass grafting (CABG). The American College of Cardiology Foundation (ACCF) and the Society of Thoracic Surgeons (STS) collaborated to compare the rates of long-term survival after PCI and CABG.
Methods. We linked the ACCF National Cardiovascular Data Registry and the STS Adult Cardiac Surgery Database to claims data from the Centers for Medicare and Medicaid Services for the years 2004 through 2008. Outcomes were compared with the use of propensity scores and inverse-probability-weighting adjustment to reduce treatment-selection bias.
Results. Among patients 65 years of age or older who had two-vessel or three-vessel coronary artery disease without acute myocardial infarction, 86,244 underwent CABG and 103,549 underwent PCI. The median follow-up period was 2.67 years. At 1 year, there was no significant difference in adjusted mortality between the groups (6.24% in the CABG group as compared with 6.55% in the PCI group; risk ratio, 0.95; 95% confidence interval [CI], 0.90 to 1.00). At 4 years, there was lower mortality with CABG than with PCI (16.4% vs. 20.8%; risk ratio, 0.79; 95% CI, 0.76 to 0.82). Similar results were noted in multiple subgroups and with the use of several different analytic methods. Residual confounding was assessed by means of a sensitivity analysis.
Conclusions. In this observational study, we found that, among older patients with multivessel coronary disease that did not require emergency treatment, there was a long-term survival advantage among patients who underwent CABG as compared with patients who underwent PCI.
Medicare’s Readmissions-Reduction Program — A Positive Alternative, by Robert A. Berenson, Ronald A. Paulus and Noah S. Kalman (The New England Journal of Medicine)
Thirty-Day Readmissions — Truth and Consequences, by Karen E. Joynt and Ashish K. Jha (The New England Journal of Medicine)