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Health Affairs (Project Hope) Jan 2023The objective of risk adjustment is not to predict spending accurately but to support the social goals of a payment system, which include equity. Setting...
The objective of risk adjustment is not to predict spending accurately but to support the social goals of a payment system, which include equity. Setting population-based payments at accurate predictions risks entrenching spending levels that are insufficient to mitigate the impact of social determinants on health care use and effectiveness. Instead, to advance equity, payments must be set above current levels of spending for historically disadvantaged groups. In analyses intended to guide such reallocations, we found that current risk adjustment for the community-dwelling Medicare population overpredicts annual spending for Black and Hispanic beneficiaries by $376-$1,264. The risk-adjusted spending for these populations is lower than spending for White beneficiaries despite the former populations' worse risk-adjusted health and functional status. Thus, continued movement from fee-for-service to population-based payment models that omit race and ethnicity from risk adjustment (as current models do) should result in sizable resource reallocations and incentives that support efforts to address racial and ethnic disparities in care. We found smaller overpredictions for less-educated beneficiaries and communities with higher proportions of residents who are Black, Hispanic, or less educated, suggesting that additional payment adjustments that depart from predictive accuracy are needed to support health equity. These findings also suggest that adding social risk factors as predictors to spending models used for risk adjustment may be counterproductive or accomplish little.
Topics: United States; Humans; Health Equity; Risk Adjustment; Medicare; Fee-for-Service Plans; Ethnicity
PubMed: 36623215
DOI: 10.1377/hlthaff.2022.00916 -
Advances in Chronic Kidney Disease Nov 2020Nephrologists are routinely involved in the care of pregnant women with glomerulonephritis. Prepregnancy counseling is vital to inform women of the potential risks of... (Review)
Review
Nephrologists are routinely involved in the care of pregnant women with glomerulonephritis. Prepregnancy counseling is vital to inform women of the potential risks of pregnancy and to reduce those risks by optimizing clinical status and medications. In general, for all glomerulonephritides, the best pregnancy outcomes are achieved when the disease is in remission and the woman has preserved renal function with no proteinuria or hypertension. Each glomerulonephritis has specific considerations, for example in lupus nephritis, mycophenolate is teratogenic and must be stopped at least 6 weeks before conception, hydroxychloroquine is recommended for all pregnant women, and flares are frequently encountered and must be treated appropriately. De novo glomerulonephritis should be considered when significant proteinuria is found early in pregnancy or an acute kidney injury with active urine is encountered. Biopsy can be safely undertaken in the first trimester. Treatment is often with corticosteroids, azathioprine, and/or tacrolimus. Rituximab is increasingly used for severe disease. Women with glomerulonephritis should ideally be managed in a joint renal-obstetric clinic. This review details the approach to the care of women with glomerulonephritis from prepregnancy counseling, through antenatal care and delivery, to the postpartum period. Special attention is given to medications and treatment of glomerulonephritis in pregnancy.
Topics: Female; Glomerulonephritis; Humans; Kidney Glomerulus; Patient Care; Pregnancy; Pregnancy Complications; Pregnancy, High-Risk; Risk Adjustment
PubMed: 33328063
DOI: 10.1053/j.ackd.2020.08.001 -
Advances in Chronic Kidney Disease Nov 2020Women with chronic kidney disease (CKD) are at high risk for adverse outcomes in pregnancy. In the United States, pregnancy rates in women with risk factors for CKD such... (Review)
Review
Women with chronic kidney disease (CKD) are at high risk for adverse outcomes in pregnancy. In the United States, pregnancy rates in women with risk factors for CKD such as obesity and advanced maternal age are increasing; thus, more pregnancies are likely to be affected by CKD. Strategies that involve coordinated multidisciplinary care to optimize preconception health, perform meticulous antenatal monitoring, and provide continued care in the postpartum "fourth trimester" appear to be most beneficial for both the mother and baby. Discussions surrounding preconception risk stratification should be individualized based on CKD stage/serum creatinine level, degree of hypertension and proteinuria, and comorbid conditions. Preparation for pregnancy should include optimization of comorbidities and medication adjustments to those compatible with pregnancy. Unless contraindicated, all women with CKD should be prescribed low-dose aspirin in pregnancy to reduce risk of preeclampsia. After delivery, women with CKD may benefit from an early postpartum visit (within 7-10 days) for blood pressure check and may require serial monitoring of serum creatinine and proteinuria as appropriate. Breastfeeding is safe and can be recommended for most women with CKD. A contraceptive plan that includes patients' preferences, feasibility, medical eligibility, duration, and effectiveness of the contraceptive method should be implemented.
Topics: Female; Humans; Pregnancy; Pregnancy Complications; Pregnancy Outcome; Pregnancy, High-Risk; Renal Insufficiency, Chronic; Risk Adjustment
PubMed: 33328062
DOI: 10.1053/j.ackd.2020.04.003 -
European Journal of Cardio-thoracic... Dec 2021
Topics: Adult; Cardiac Surgical Procedures; Heart Defects, Congenital; Humans; Risk Adjustment
PubMed: 34448825
DOI: 10.1093/ejcts/ezab266 -
Cardiology Clinics Feb 2021Cardiovascular disease and cardiovascular disease-related disorders remain among the most common causes of maternal morbidity and mortality in the United States. Due to... (Review)
Review
Cardiovascular disease and cardiovascular disease-related disorders remain among the most common causes of maternal morbidity and mortality in the United States. Due to increased rates of obesity, delayed childbearing, and improvements in medical technology, greater numbers of women are entering pregnancy with preexisting medical comorbidities. Use of cardiovascular medications in pregnancy continues to increase, and medical management of cardiovascular conditions in pregnancy will become increasingly common. Obstetricians and cardiologists must familiarize themselves with the pharmacokinetics of the most commonly used cardiovascular medications in pregnancy and how these medications respond to the physiologic changes related to pregnancy, embryogenesis, and lactation.
Topics: Cardiovascular Agents; Cardiovascular Diseases; Female; Heart Disease Risk Factors; Humans; Pregnancy; Pregnancy Complications, Cardiovascular; Risk Adjustment
PubMed: 33222813
DOI: 10.1016/j.ccl.2020.09.011 -
Journal of the American Geriatrics... Feb 2020
Topics: Geriatricians; Geriatrics; Humans; Medicare; Quality Indicators, Health Care; Risk Adjustment; United States
PubMed: 31880311
DOI: 10.1111/jgs.16295 -
Chest Jul 2016Patients who are critically ill and hospitalized often require invasive procedures as a part of their medical care. Each procedure carries a unique set of risks and... (Review)
Review
Patients who are critically ill and hospitalized often require invasive procedures as a part of their medical care. Each procedure carries a unique set of risks and associated complications, but common to all of them is the risk of hemorrhage. Central venous catheterization, arterial catheterization, paracentesis, thoracentesis, tube thoracostomy, and lumbar puncture constitute a majority of the procedures performed in patients who are hospitalized. In this article, the authors will discuss the risk factors for bleeding complications from each of these procedures and methods to minimize risk. Physicians often correct coagulopathy prior to procedures to decrease bleeding risk, but there is minimal evidence to support this practice.
Topics: Critical Illness; Diagnostic Techniques and Procedures; Hemorrhage; Humans; Risk Adjustment; Risk Factors
PubMed: 26836937
DOI: 10.1016/j.chest.2016.01.023 -
Thoracic Surgery Clinics Aug 2017Achieving high-quality care for all patients undergoing esophageal cancer requires identifying and modifying risk factors associated with poor outcomes. These factors... (Review)
Review
Achieving high-quality care for all patients undergoing esophageal cancer requires identifying and modifying risk factors associated with poor outcomes. These factors occur at different time points from the preoperative to the postoperative periods. A straightforward model for predicting outcomes has proved difficult to identify. This article reviews the current studies addressing risk adjustment and performance measurement for esophageal cancer resection.
Topics: Anesthesia Recovery Period; Esophageal Neoplasms; Humans; Outcome Assessment, Health Care; Postoperative Complications; Prognosis; Risk Adjustment; Thoracic Surgical Procedures
PubMed: 28647068
DOI: 10.1016/j.thorsurg.2017.03.002 -
Clinical Obstetrics and Gynecology Jun 2020Congenital malformations occur in about 3% of all live births and are a leading cause of perinatal morbidity and mortality. An evolving understanding of the developing... (Review)
Review
Congenital malformations occur in about 3% of all live births and are a leading cause of perinatal morbidity and mortality. An evolving understanding of the developing human fetus, advances in imaging, availability of cutting-edge instrumentation, and enhanced understanding of fetal pathophysiology, have allowed for prenatal surgical interventions to improve fetal diseases and neonatal outcomes. Fetal surgical therapy is no longer restricted to life-threatening prenatal diagnoses and can be categorized into either open surgical techniques or minimally invasive endoscopic/ultrasound-guided techniques. Patient selection requires a thorough multidisciplinary evaluation and shared decision-making process.
Topics: Congenital Abnormalities; Female; Fetal Diseases; Fetus; Humans; Patient Selection; Pregnancy; Prenatal Care; Prenatal Diagnosis; Risk Adjustment; Surgical Procedures, Operative
PubMed: 32265364
DOI: 10.1097/GRF.0000000000000534 -
Zeitschrift Fur Geburtshilfe Und... Dec 2017
Topics: Birthing Centers; Delivery, Obstetric; Female; Germany; Home Childbirth; Humans; Infant, Newborn; Midwifery; Patient Satisfaction; Pregnancy; Risk Adjustment
PubMed: 29237223
DOI: 10.1055/s-0043-121367