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Deutsches Arzteblatt International Feb 2021
Topics: Humans; Risk Adjustment
PubMed: 33835009
DOI: 10.3238/arztebl.m2021.0056 -
International Journal of Environmental... May 2021Quality indicators (QIs) based on the Resident Assessment Instrument-Home Care (RAI-HC) offer the opportunity to assess home care quality and compare home care...
Quality indicators (QIs) based on the Resident Assessment Instrument-Home Care (RAI-HC) offer the opportunity to assess home care quality and compare home care organizations' (HCOs) performance. For fair comparisons, providers' QI rates must be risk-adjusted to control for different case-mix. The study's objectives were to develop a risk adjustment model for worsening or onset of urinary incontinence (UI), measured with the RAI-HC QI bladder incontinence, using the database HomeCareData and to assess the impact of risk adjustment on quality rankings of HCOs. Risk factors of UI were identified in the scientific literature, and multivariable logistic regression was used to develop the risk adjustment model. The observed and risk-adjusted QI rates were calculated on organization level, uncertainty addressed by nonparametric bootstrapping. The differences between observed and risk-adjusted QI rates were graphically assessed with a Bland-Altman plot and the impact of risk adjustment examined by HCOs tertile ranking changes. 12,652 clients from 76 Swiss HCOs aged 18 years and older receiving home care between 1 January 2017, and 31 December 2018, were included. Eight risk factors were significantly associated with worsening or onset of UI: older age, female sex, obesity, impairment in cognition, impairment in hygiene, impairment in bathing, unsteady gait, and hospitalization. The adjustment model showed fair discrimination power and had a considerable effect on tertile ranking: 14 (20%) of 70 HCOs shifted to another tertile after risk adjustment. The study showed the importance of risk adjustment for fair comparisons of the quality of UI care between HCOs in Switzerland.
Topics: Aged; Female; Home Care Services; Humans; Quality Indicators, Health Care; Quality of Health Care; Risk Adjustment; Switzerland
PubMed: 34063743
DOI: 10.3390/ijerph18115502 -
International Journal of Environmental... Oct 2013Interest has grown worldwide in risk adjustment and risk sharing due to their potential to contain costs, improve fairness, and reduce selection problems in health care...
Interest has grown worldwide in risk adjustment and risk sharing due to their potential to contain costs, improve fairness, and reduce selection problems in health care markets. Significant steps have been made in the empirical development of risk adjustment models, and in the theoretical foundations of risk adjustment and risk sharing. This literature has often modeled the effects of risk adjustment without highlighting the institutional setting, regulations, and diverse selection problems that risk adjustment is intended to fix. Perhaps because of this, the existing literature and their recommendations for optimal risk adjustment or optimal payment systems are sometimes confusing. In this paper, we present a unified way of thinking about the organizational structure of health care systems, which enables us to focus on two key dimensions of markets that have received less attention: what choices are available that may lead to selection problems, and what financial or regulatory tools other than risk adjustment are used to influence these choices. We specifically examine the health care systems, choices, and problems in four countries: the US, Canada, Chile, and Colombia, and examine the relationship between selection-related efficiency and fairness problems and the choices that are allowed in each country, and discuss recent regulatory reforms that affect choices and selection problems. In this sample, countries and insurance programs with more choices have more selection problems.
Topics: Canada; Chile; Choice Behavior; Colombia; Delivery of Health Care; Health Policy; Insurance, Health; Models, Theoretical; Risk Adjustment; United States
PubMed: 24284351
DOI: 10.3390/ijerph10115299 -
PloS One 2018We propose a nonparametric risk-adjusted cumulative sum chart to monitor surgical outcomes for patients with different risks of post-operative mortality due to risk...
We propose a nonparametric risk-adjusted cumulative sum chart to monitor surgical outcomes for patients with different risks of post-operative mortality due to risk factors that exist before the surgery. Using varying-coefficient logistic regression models, we accomplish the risk adjustment. Unknown coefficient functions are estimated by global polynomial spline approximation based on the maximum likelihood principle. We suggest a bisection minimization approach and a bootstrap method to determine the chart testing limit value. Compared with the previous (parametric) risk-adjusted cumulative sum chart, a major advantage of our method is that the morality rate can be modeled more flexibly by related covariates, which significantly enhances the monitoring efficiency. Simulations demonstrate nice performance of our proposed procedure. An application to a UK cardiac surgery dataset illustrates the use of our methodology.
Topics: Cardiac Surgical Procedures; General Surgery; Humans; Logistic Models; Models, Statistical; Models, Theoretical; Outcome Assessment, Health Care; Risk Adjustment; Risk Factors; Statistics, Nonparametric; Treatment Outcome
PubMed: 30089109
DOI: 10.1371/journal.pone.0200915 -
Academic Emergency Medicine : Official... Sep 2011The objectives were to conduct a comprehensive, systematic review of the literature for risk adjustment measures (RAMs) and outcome measures (OMs) for prehospital trauma... (Review)
Review
OBJECTIVES
The objectives were to conduct a comprehensive, systematic review of the literature for risk adjustment measures (RAMs) and outcome measures (OMs) for prehospital trauma research and to use a structured expert panel process to recommend measures for use in future emergency medical services (EMS) trauma outcomes research.
METHODS
A systematic literature search and review was performed identifying the published studies evaluating RAMs and OMs for prehospital injury research. An explicit structured review of all articles pertaining to each measure was conducted using the previously established methodology developed by the Canadian Physiotherapy Association ("Physical Rehabilitation Outcome Measures").
RESULTS
Among the 4,885 articles reviewed, 96 RAMs and/or OMs were identified from the existing literature (January 1958 to February 2010). Only one measure, the Glasgow Coma Scale (GCS), currently meets Level 1 quality of evidence status and a Category 1 (strong) recommendation for use in EMS trauma research. Twelve RAMs or OMs received Category 2 status (promising, but not sufficient current evidence to strongly recommend), including the motor component of GCS, simplified motor score (SMS), the simplified verbal score (SVS), the revised trauma score (RTS), the prehospital index (PHI), EMS provider judgment, the revised trauma index (RTI), the rapid acute physiology score (RAPS), the rapid emergency medicine score (REMS), the field trauma triage (FTT), the pediatric triage rule, and the out-of-hospital decision rule for pediatrics.
CONCLUSIONS
Using a previously published process, a structured literature review, and consensus expert panel opinion, only the GCS can currently be firmly recommended as a specific RAM or OM for prehospital trauma research (along with core measures that have already been established and published). This effort highlights the paucity of reliable, validated RAMs and OMs currently available for outcomes research in the prehospital setting and hopefully will encourage additional, methodologically sound evaluations of the promising, Category 2 RAMs and OMs, as well as the development of new measures.
Topics: Emergency Medical Services; Humans; Outcome Assessment, Health Care; Pilot Projects; Reproducibility of Results; Risk Adjustment; Trauma Severity Indices
PubMed: 21906205
DOI: 10.1111/j.1553-2712.2011.01148.x -
Health Services Research Oct 2016To compare risk scores computed by DxCG (Verisk) and Centers for Medicare and Medicaid Services (CMS) V21. (Comparative Study)
Comparative Study
OBJECTIVE
To compare risk scores computed by DxCG (Verisk) and Centers for Medicare and Medicaid Services (CMS) V21.
RESEARCH DESIGN
Analysis of administrative data from the Department of Veterans Affairs (VA) for fiscal years 2010 and 2011.
STUDY DESIGN
We regressed total annual VA costs on predicted risk scores. Model fit was judged by R-squared, root mean squared error, mean absolute error, and Hosmer-Lemeshow goodness-of-fit tests. Recalibrated models were tested using split samples with pharmacy data.
DATA COLLECTION
We created six analytical files: a random sample (n = 2 million), high cost users (n = 261,487), users over age 75 (n = 644,524), mental health and substance use users (n = 830,832), multimorbid users (n = 817,951), and low-risk users (n = 78,032).
PRINCIPAL FINDINGS
The DxCG Medicaid with pharmacy risk score yielded substantial gains in fit over the V21 model. Recalibrating the V21 model using VA pharmacy data-generated risk scores with similar fit statistics to the DxCG risk scores.
CONCLUSIONS
Although the CMS V21 and DxCG prospective risk scores were similar, the DxCG model with pharmacy data offered improved fit over V21. However, health care systems, such as the VA, can recalibrate the V21 model with additional variables to develop a tailored risk score that compares favorably to the DxCG models.
Topics: Administrative Claims, Healthcare; Centers for Medicare and Medicaid Services, U.S.; Clinical Pharmacy Information Systems; Health Care Costs; Humans; Models, Econometric; Prospective Studies; Risk Adjustment; United States; United States Department of Veterans Affairs
PubMed: 26839976
DOI: 10.1111/1475-6773.12454 -
BMC Geriatrics Dec 2017Medications are frequently reported as both predisposing factors and inducers of delirium. This review evaluated the available evidence and determined the magnitude of... (Review)
Review
BACKGROUND
Medications are frequently reported as both predisposing factors and inducers of delirium. This review evaluated the available evidence and determined the magnitude of risk of postoperative delirium associated with preoperative medication use.
METHODS
A systematic search in Medline and EMBASE was conducted using MeSH terms and keywords for postoperative delirium and medication. Studies which included patients 18 years and older who underwent major surgery were included. The methodological quality of included studies was assessed independently by two authors using the Newcastle-Ottawa quality assessment scale for cohort studies.
RESULTS
Twenty-nine studies; 25 prospective cohort, three retrospective cohort and one post hoc analysis of RCT data were included. Only four specifically aimed to assess medicines as an independent predictor of delirium, all other studies included medicines among a number of potential predictors of delirium. Of the studies specifically testing the association with a medication class, preoperative use of beta-blockers (OR = 2.06[1.18-3.60]) in vascular surgery and benzodiazepines RR 2.10 (1.23-3.59) prior to orthopedic surgery were significant. However, evidence is from single studies only. Where medicines were included as one possible factor among many, hypnotics had a similar risk estimate to the benzodiazepine study, with one significant and one non-significant result. Nifedipine use prior to cardiac surgery was found to be significantly associated with delirium. The non-specific grouping of psychoactive medication use preoperatively was generally higher with an associated two-to-seven-fold higher risk of postoperative delirium, while only two studies included narcotics without other agents, with one significant and one non-significant result.
CONCLUSIONS
There was a limited number of high quality studies in the literature quantifying the direct association between preoperative medication use and postsurgical delirium. More studies are required to evaluate the association of specific preoperative medications on the risk of postoperative delirium so that comprehensive guidelines for medicine use prior to surgery can be developed to aid delirium prevention.
TRIAL REGISTRATION
This systematic review has been registered on PROSPERO International prospective register of systematic reviews (Registration number: CRD42016051245 ).
Topics: Aged; Benzodiazepines; Delirium; Humans; Postoperative Complications; Premedication; Preoperative Care; Risk Adjustment; Surgical Procedures, Operative
PubMed: 29284416
DOI: 10.1186/s12877-017-0695-x -
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 -
American Family Physician Aug 2018Surgical outcomes are significantly influenced by patients' overall health, function, and life expectancy. A comprehensive geriatric preoperative assessment of older... (Review)
Review
Surgical outcomes are significantly influenced by patients' overall health, function, and life expectancy. A comprehensive geriatric preoperative assessment of older adults requires expanding beyond an organ-based or disease-based assessment. At a preoperative visit, it is important to establish the patient's goals and preferences, and to determine whether the risks and benefits of surgery match these goals and preferences. These discussions should cover the possibility of resuscitation and ventilator support, prolonged rehabilitation, and loss of independence. The assessment should include evaluation of medical comorbidities, cognitive function, decision-making capacity, functional status, fall risk, frailty, nutritional status, and potentially inappropriate medication use. Problems identified in any of these key areas are associated with an increased risk of postoperative complications, institutionalization, functional decline, and, in some cases, mortality. If a patient elects to proceed with surgery, the risks should be communicated to surgical teams to allow for inpatient interventions that lower the risk of postoperative complications and functional decline, such as early mobilization and limiting medications that can cause delirium. Alcohol abuse and smoking are associated with increased rates of postoperative complications, and physicians should discuss cessation with patients before surgery. Physicians should also assess patients' social support systems because they are a critical component of discharge planning in this population and have been shown to predict 30-day postoperative morbidity.
Topics: Aged; Clinical Decision-Making; Geriatric Assessment; Humans; Postoperative Complications; Preoperative Care; Risk Adjustment; Risk Factors
PubMed: 30215973
DOI: No ID Found -
Journal of Health Economics Dec 2017Much of the risk adjustment literature has focused on how persons should be classified and given weights. It has given less attention to the amount of funds in the risk...
Much of the risk adjustment literature has focused on how persons should be classified and given weights. It has given less attention to the amount of funds in the risk adjustment pool. If, however, there is an outside option, as there is in the principal American risk adjustment systems, there can be favorable or adverse selection in the risk pool. To address any such selection requires that the risk adjustment system not be zero sum; the main American risk adjustment systems differ in this respect.
Topics: Algorithms; Humans; Insurance Coverage; Insurance Selection Bias; Medicare Part C; Risk Adjustment; United States
PubMed: 29248055
DOI: 10.1016/j.jhealeco.2017.01.001