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Health Services Research Aug 2018To propose nonparametric ensemble machine learning for mental health and substance use disorders (MHSUD) spending risk adjustment formulas, including considering...
OBJECTIVE
To propose nonparametric ensemble machine learning for mental health and substance use disorders (MHSUD) spending risk adjustment formulas, including considering Clinical Classification Software (CCS) categories as diagnostic covariates over the commonly used Hierarchical Condition Category (HCC) system.
DATA SOURCES
2012-2013 Truven MarketScan database.
STUDY DESIGN
We implement 21 algorithms to predict MHSUD spending, as well as a weighted combination of these algorithms called super learning. The algorithm collection included seven unique algorithms that were supplied with three differing sets of MHSUD-related predictors alongside demographic covariates: HCC, CCS, and HCC + CCS diagnostic variables. Performance was evaluated based on cross-validated R and predictive ratios.
PRINCIPAL FINDINGS
Results show that super learning had the best performance based on both metrics. The top single algorithm was random forests, which improved on ordinary least squares regression by 10 percent with respect to relative efficiency. CCS categories-based formulas were generally more predictive of MHSUD spending compared to HCC-based formulas.
CONCLUSIONS
Literature supports the potential benefit of implementing a separate MHSUD spending risk adjustment formula. Our results suggest there is an incentive to explore machine learning for MHSUD-specific risk adjustment, as well as considering CCS categories over HCCs.
Topics: Adult; Age Factors; Algorithms; Employment; Female; Humans; Insurance Claim Review; Machine Learning; Male; Mental Disorders; Mental Health Services; Middle Aged; Residence Characteristics; Risk Adjustment; Risk Factors; Sex Factors; Young Adult
PubMed: 29244202
DOI: 10.1111/1475-6773.12818 -
Annals of Surgery Nov 2017To longitudinally assess whether risk adjustment in Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) occurred over time and is...
OBJECTIVE
To longitudinally assess whether risk adjustment in Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) occurred over time and is associated with postoperative outcome.
BACKGROUND
ALPPS is a novel 2-stage hepatectomy enabling resection of extensive hepatic tumors. ALPPS has been criticized for its high mortality, which is reported beyond accepted standards in liver surgery. Therefore, adjustments in patient selection and technique have been performed but have not yet been studied over time in relation to outcome.
METHODS
ALPPS centers of the International ALPPS Registry having performed ≥10 cases over a period of ≥3 years were assessed for 90-day mortality and major interstage complications (≥3b) of the longitudinal study period from 2009 to 2015. The predicted prestage 1 and 2 mortality risks were calculated for each patient. In addition, questionnaires were sent to all centers exploring center-specific risk adjustment strategies.
RESULTS
Among 437 patients from 16 centers, a shift in indications toward colorectal liver metastases from 53% to 77% and a reverse trend in biliary tumors from 24% to 9% were observed. Over time, 90-day mortality decreased from initially 17% to 4% in 2015 (P = 0.002). Similarly, major interstage complications decreased from 10% to 3% (P = 0.011). The reduction of 90-day mortality was independently associated with a risk adjustment in patient selection (P < 0.001; OR: 1.62; 95% CI: 1.36-1.93) and using less invasive techniques in stage-1 surgery (P = 0.019; OR: 0.39; 95% CI: 0.18-0.86). A survey indicated risk adjustment of patient selection in all centers and ALPPS technique in the majority (80%) of centers.
CONCLUSIONS
Risk adjustment of patient selection and technique in ALPPS resulted in a continuous drop of early mortality and major postoperative morbidity, which has meanwhile reached standard outcome measures accepted for major liver surgery.
Topics: Aged; Colorectal Neoplasms; Female; Hepatectomy; Humans; Ligation; Liver Neoplasms; Logistic Models; Longitudinal Studies; Male; Middle Aged; Multivariate Analysis; Patient Selection; Portal Vein; Postoperative Complications; Registries; Risk Adjustment; Treatment Outcome
PubMed: 28806301
DOI: 10.1097/SLA.0000000000002446 -
Academic Pediatrics Apr 2022Outcome and utilization quality measures are adjusted for patient case-mix including demographic characteristics and comorbid conditions to allow for comparisons between...
BACKGROUND
Outcome and utilization quality measures are adjusted for patient case-mix including demographic characteristics and comorbid conditions to allow for comparisons between hospitals and health plans. However, controversy exists around whether and how to adjust for social risk factors.
OBJECTIVE
To assess an approach to incorporating social risk variables into a pediatric measure of utilization from the Pediatric Quality Measures Program (PQMP).
METHODS
We used data from California Medicaid claims (2015-16) and Massachusetts All Payer Claims Database (2014-2015) to calculate health plan performance using measure specifications from the Pediatric Asthma Emergency Department Use measure. Health plan performance categories were assessed using mixed effect negative binomial models with and without adjustment for social risk factors, with both models adjusting for age, gender and chronic condition category. Mixed effects linear models were then used to compare patient social risk for health plans that changed performance categories to patient social risk for health plans that did not.
RESULTS
Of 133 health plans, serving 404,649 pediatric patients with asthma, 7% to 13% changed performance categories after social risk adjustment. Health plans that moved to higher performance categories cared for lower socioeconomic status (SES) patients whereas those that moved to lower performance categories cared for higher SES patients.
CONCLUSIONS
Adjustment for social risk factors changed performance rankings on the PQMP Pediatric Asthma Emergency Department Use measure for a substantial number of health plans. Some health plans caring for higher risk patients performed more poorly when social risk factors were not included in risk adjustment models. In light of this, social risk factors are incorporated into the National Quality Forum-endorsed measure; whether to incorporate social risk factors into pediatric quality measures will differ depending on the use case.
Topics: Asthma; Child; Hospitals; Humans; Medicaid; Risk Adjustment; Risk Factors; United States
PubMed: 35339237
DOI: 10.1016/j.acap.2021.09.023 -
Medicine Sep 2018It is important that actual outcomes of care and not surrogate markers, such as process measures, be used to evaluate the quality of inpatient care. Because of the... (Observational Study)
Observational Study
It is important that actual outcomes of care and not surrogate markers, such as process measures, be used to evaluate the quality of inpatient care. Because of the heterogenous composition of patients, risk-adjustment is essential for the objective evaluation of outcomes following inpatient care. Comparative evaluation of risk-adjusted outcomes can be used to identify suboptimal performance and can provide direction for care improvement initiatives.We studied the risk-adjusted outcomes of 6 medical conditions during the inpatient and 90-day post-discharge period to identify the opportunities for care improvement. The Medicare Limited Dataset for 2012 to 2014 was used to identify acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), pneumonia (PNEU), cerebrovascular accidents (CVA), and gastrointestinal hemorrhage (GIH). Stepwise logistic predictive models were developed for the adverse outcomes (AOs) of inpatient deaths, 3-sigma prolonged length-of-stay outliers, 90-day post-discharge deaths, and 90-day readmissions after unrelated events were excluded. Observed and predicted AOs were determined for each hospital with ≥75 cases for each of the 6 medical conditions. Z-scores and risk-adjusted AO rates for each hospital permitted comparative analysis of outcomes after adjusting for covariance among the medical conditions.There were a total of 1,811,749 patients from 973 acute care hospitals with the 6 medical conditions. A total of 41% of all patients had ≥1 AO events. One or more readmissions were identified in 29.8% of patients. A total of 64 hospitals (6.4%) were 2 standard deviations better than the mean for risk-adjusted outcomes, and 72 (7.4%) were 2 standard deviations poorer. The best performing decile of hospitals had mean AO rates of 35.1% (odds ratio = 0.766; 95% confidence interval (CI) CI: 0.762-0.771) and the poorest performing decile a mean AO rate of 48.5% (odds ratio = 1.357; 95% CI: 1.346-1.369). Volume of qualifying cases ranged from 670 to 9314; no association was identified for increased volume of patients (P < .40).Risk-adjusted AO rates demonstrated nearly a 14% opportunity for care improvement between top and suboptimal performing hospitals. Hospitals must be able to benchmark objective measurement of outcomes to inform quality initiatives.
Topics: Aged; Benchmarking; Hospital Mortality; Hospitalization; Humans; Inpatients; Length of Stay; Medicare; Outcome Assessment, Health Care; Patient Readmission; Quality Indicators, Health Care; Quality of Health Care; Risk Adjustment; United States
PubMed: 30212962
DOI: 10.1097/MD.0000000000012269 -
Heart (British Cardiac Society) Feb 2019While fixed-dose combinations (FDC) can improve adherence, they may add complexity to the prescribing/dispensing process, potentially increasing risk of medication... (Observational Study)
Observational Study
OBJECTIVE
While fixed-dose combinations (FDC) can improve adherence, they may add complexity to the prescribing/dispensing process, potentially increasing risk of medication errors. This study aimed to determine if prescriptions for antihypertensive FDCs increase the risk of therapeutic duplication and drug-drug interactions (DDI).
METHODS
This retrospective observational study used administrative pharmacy claims data from the Irish Primary Care Reimbursement Service. Prescriptions dispensed to adults in 2015 were included if they contained an antihypertensive FDC, or the same drugs prescribed separately. The outcomes were therapeutic duplication and potentially serious DDI involving FDC drugs. Relative risk (RR) of these outcomes, adjusted for prescription and patient factors, was determined using generalised linear models with Poisson distributions and propensity score matching.
RESULTS
This study included 307 833 FDC prescriptions (67.0%) and 151 632 separate component prescriptions. Half of patients prescribed FDCs were female with a mean age of 67.1 (SD 12.5) years and, compared with separate component prescriptions, FDCs were less often coprescribed with other cardiovascular medications. Therapeutic duplication occurred in 0.8% of prescriptions, most often involving calcium channel blockers, and 10.6% contained a DDI (most often amlodipine and simvastatin). The RR of therapeutic duplication on FDC prescriptions compared with separate component prescriptions was 1.46 (95% CI 1.17 to 1.83) and the adjusted RR was 2.06 (95% CI 1.64 to 2.60). For DDIs, there was no significant difference between FDC and separate component prescriptions after confounder adjustment.
CONCLUSIONS
This study found FDCs were associated with increased risk of duplication. When considering prescribing FDCs, this safety consideration should be weighed against potential benefits.
Topics: Aged; Antihypertensive Agents; Blood Pressure; Comorbidity; Drug Combinations; Drug Interactions; Drug Synergism; Female; Humans; Hypertension; Insurance Claim Review; Ireland; Male; Medication Adherence; Medication Errors; Middle Aged; Retrospective Studies; Risk Adjustment; Risk Assessment; Risk Factors
PubMed: 30072364
DOI: 10.1136/heartjnl-2018-313492 -
BMC Geriatrics Oct 2017Thiazides are commonly prescribed to older people for the management of hypertension. The objective of this study was to identify the evidence on the risks and benefits... (Review)
Review
BACKGROUND
Thiazides are commonly prescribed to older people for the management of hypertension. The objective of this study was to identify the evidence on the risks and benefits of their use among adults aged ≥65 years and to develop recommendations to reduce potentially inappropriate use.
METHODS
Systematic review (SR) of the literature covering six databases. We applied a staged search approach, where each search was undertaken only if the previous one did not yield high quality results. Searches 1 and 2 identified relevant SRs and meta-analyses published up to December 2015 from all databases. Search 3 identified additional individual interventional studies (IS) and observational studies (OS) not identified by the preceding searches. We included all studies evaluating the effect of thiazides on patient-relevant outcomes in the management of hypertension with a sufficient number of participants aged ≥65 years or a subgroup analysis based on age. Two independent reviewers extracted data and carried out quality appraisal. Recommendations were developed using the GRADE methodology.
RESULTS
Searches 1 to 3 were performed. We included 34 articles reporting on 12 IS and 4 OS. Mean ages ranged from 59 to 83.8 years. Four studies had performed a subgroup analysis by age. Information on comorbidity, polypharmacy and frailty of the participants was scarce or not available. The IS compared thiazides to placebo or other antihypertensive drugs and evaluated cardiovascular endpoints or all-cause-mortality as primary outcomes. The OS investigated the association between thiazide use and the risk of gout, fractures and adverse effects. Our results suggest that thiazides are efficacious in preventing cardiovascular events for this population group. Low-dose regimens of thiazides may be safer than high-dose (low quality of evidence), and a history of gout may increase the risk of adverse events (low quality of evidence). Three recommendations were developed.
CONCLUSIONS
The use of low dose treatment with thiazides for the management of hypertension in adults aged 65 and older seems justified, unless a history of gout is present. The quality of the evidence is low and studies rarely describe characteristics of the participants such as polypharmacy and frailty. Further good quality studies are needed.
Topics: Aged; Antihypertensive Agents; Humans; Hypertension; Inappropriate Prescribing; Risk Adjustment; Thiazides; Treatment Outcome
PubMed: 29047359
DOI: 10.1186/s12877-017-0576-3 -
Journal of the American College of... Apr 2021The prevalence of cardiovascular disease (CVD) in pregnancy, both diagnosed and previously unknown, is rising, and CVD is a leading cause of maternal morbidity and... (Review)
Review
The prevalence of cardiovascular disease (CVD) in pregnancy, both diagnosed and previously unknown, is rising, and CVD is a leading cause of maternal morbidity and mortality. Historically, women of child-bearing potential have been underrepresented in research, leading to lasting knowledge gaps in the cardiovascular care of pregnant and lactating women. Despite these limitations, clinicians should be familiar with the safety of frequently used diagnostic and therapeutic interventions to adequately care for this at-risk population. This review, the fourth of a 5-part series, provides evidence-based recommendations regarding the use of common cardiovascular diagnostic tests and medications in pregnant and lactating women.
Topics: Cardiovascular Agents; Cardiovascular Diseases; Diagnostic Techniques, Cardiovascular; Female; Humans; Lactation; Pregnancy; Pregnancy Complications, Cardiovascular; Pregnancy, High-Risk; Risk Adjustment
PubMed: 33832607
DOI: 10.1016/j.jacc.2021.01.056 -
Health Policy (Amsterdam, Netherlands) Aug 2019Risk-adjustment in resource allocation is commonly used for regional redistribution or for eliminating risk selection motives of multiple statutory health insurers. In...
BACKGROUND
Risk-adjustment in resource allocation is commonly used for regional redistribution or for eliminating risk selection motives of multiple statutory health insurers. In the Czech Republic, revenue redistribution between health insurers takes place since the 1990's. Since 2018, the risk-adjustment mechanism includes an adjustment for insured with chronic diseases using Pharmacy-based Cost Group (PCG) classification. In addition, retrospective compensation for very high cost patients has been strengthened.
AIM
To provide an internationally relevant overview of the Czech risk-adjustment system. To assess the implication of the 2018 reform for health insurers and for the development of chronic care.
METHOD
The framework of the Health Reform Monitor is used to analyse the policy process. Data from Czech health insurers and Czech Ministry of Health are used to assess likely impact of the reform.
RESULTS
The reform increases coverage of predictable individual health risks and combines prospective risk-rating with strengthened retrospective risk-sharing among insurers. The reform results in moderate changes in risk-adjusted allocations of individual insurers.
CONCLUSION
The Czech experience with risk-adjustment reforms is relevant for countries with multiple health insurers as well as for countries with risk-adjusted regional redistribution mechanisms. Combining prospective risk factors of age, sex, and PCGs with retrospective compensation of expensive cases limits potential losses to a manageable level, also for small risk-pools. It reduces incentives for cream skimming based on health status, enables higher use of risk-sharing contracts, and incentivizes the development of disease management programs in the Czech Republic.
Topics: Chronic Disease; Czech Republic; Drug Utilization; Health Care Reform; Humans; Insurance Carriers; Insurance, Health; Risk Adjustment; Risk Sharing, Financial
PubMed: 31196570
DOI: 10.1016/j.healthpol.2019.05.017 -
The American Journal of Managed Care Feb 2020The authors disagree with previous research concluding that the Home Health Care Consumer Assessment of Healthcare Providers and Services (CAHPS) publicly reported data...
The authors disagree with previous research concluding that the Home Health Care Consumer Assessment of Healthcare Providers and Services (CAHPS) publicly reported data are insufficiently adjusted for patient comorbidities.
Topics: Carcinoma, Hepatocellular; Centers for Medicare and Medicaid Services, U.S.; Health Care Surveys; Humans; Liver Neoplasms; Risk Adjustment; United States
PubMed: 32059090
DOI: 10.37765/ajmc.2020.42391 -
Frontiers in Immunology 2018"Epitope matching" became a trending topic in organ transplantation. In fact, discussions on clinical implementation and utilization of this approach in organ allocation... (Review)
Review
"Epitope matching" became a trending topic in organ transplantation. In fact, discussions on clinical implementation and utilization of this approach in organ allocation algorithms are currently on-going. More recently, the term "eplet mismatch load" was introduced in publications. While the terms are often used synonymously, they are NOT equivalent. This short overview is meant to emphasize the differences between the terms epitope matching and eplet mismatching (or mismatch load) as well as to provide perspective on different approaches for interpretation of immune compatibility between the donor of an organ transplant and the recipient. It highlights some of the less explored qualities of HLA-epitopes, and stresses the need to understand the differences between donor and recipient in terms of immunogenicity and ability to initiate an immune response. While the field of "epitope matching" shows enormous promise, it is still in its infancy. What is sorely missing is understanding of EPITOPE COMPATIBILITY rather than matching. Further work is required before new approaches can be introduced into routine clinical practice and organ allocation schemes.
Topics: Algorithms; Epitopes; Graft Rejection; Graft Survival; HLA Antigens; Histocompatibility; Histocompatibility Testing; Humans; Organ Transplantation; Resource Allocation; Risk; Risk Adjustment
PubMed: 30233594
DOI: 10.3389/fimmu.2018.02010