Showing papers by "Jane Hall published in 2016"

Advance care planning in patients with incurable cancer: study protocol for a randomised controlled trial

Abstract: Introduction There is limited evidence documenting the effectiveness of Advance Care Planning (ACP) in cancer care. The present randomised trial is designed to evaluate whether the administration of formal ACP improves compliance with patients9 end-of-life (EOL) wishes and patient and family satisfaction with care. Methods and analysis A randomised control trial in eight oncology centres across New South Wales and Victoria, Australia, is designed to assess the efficacy of a formal ACP intervention for patients with cancer. Patients with incurable cancer and an expected survival of 3–12 months, plus a nominated family member or friend will be randomised to receive either standard care or standard care plus a formal ACP intervention. The project sample size is 210 patient–family/friend dyads. The primary outcome measure is family/friend-reported: (1) discussion with the patient about their EOL wishes and (2) perception that the patient9s EOL wishes were met. Secondary outcome measures include: documentation of and compliance with patient preferences for medical intervention at the EOL; the family/friend9s perception of the quality of the patient9s EOL care; the impact of death on surviving family; patient–family and patient–healthcare provider communication about EOL care; patient and family/friend satisfaction with care; quality of life of patient and family/friend subsequent to trial entry, the patient9s strength of preferences for quality of life and length of life; the costs of care subsequent to trial entry and place of death. Ethics and dissemination Ethical approval was received from the Sydney Local Health District (RPA Zone) Human Research Ethical Committee, Australia (Protocol number X13-0064). Study results will be submitted for publication in peer-reviewed journals and presented at national and international conferences. Trial registration number Pre-results; ACTRN12613001288718.

Associations Between End-of-Life Cancer Care Patterns and Medicare Expenditures.

Abstract: Background The purpose of this study was to examine the extent to which patterns of intensive end-of-life care explain geographic variation in end-of-life care expenditures among cancer decedents. Methods Using the SEER-Medicare database, we identified 90,465 decedents who were diagnosed with cancer in 2004-2011. Measures of intensive end-of-life care included chemotherapy received within 14 days of death; more than 1 emergency department visit, more than 1 hospitalization, or 1 or more intensive care unit (ICU) admissions within 30 days of death; in-hospital death; and hospice enrollment less than 3 days before death. Using hierarchical generalized linear models, we estimated risk-adjusted expenditures in the last month of life for each hospital referral region and identified key contributors to variation in expenditures. Results The mean expenditure per cancer decedent in the last month of life was $10,800, ranging from $8,300 to $15,400 in the lowest and highest expenditure quintile areas, respectively. There was considerable variation in the percentage of decedents receiving intensive end-of-life care intervention, with 41.7% of decedents receiving intensive care in the lowest quintile of expenditures versus 57.9% in the highest quintile. Regional patterns of late chemotherapy or late hospice use explained only approximately 1% of the expenditure difference between the highest and lowest quintile areas. In contrast, the proportion of decedents who had ICU admissions within 30 days of death was a major driver of variation, explaining 37.6% of the expenditure difference. Conclusions Promoting appropriate end-of-life care has the potential to reduce geographic variation in end-of-life care expenditures.

Use of Point-of-Care Ultrasound in the Emergency Department: Insights From the 2012 Medicare National Payment Data Set.

Abstract: Objectives Point-of-care ultrasound is a valuable tool with potential to expedite diagnoses and improve patient outcomes in the emergency department. However, little is known about national patterns of adoption. This study examined nationwide point-of-care ultrasound reimbursement among emergency medicine (EM) practitioners and examined regional and practitioner level variations. Methods Data from the 2012 Center for Medicare and Medicaid Services Fee-for-Service Provider Utilization and Payment Data include all practitioners who received more than 10 Medicare Part B fee-for-service reimbursements for any Healthcare Common Procedure Coding System code in 2012. Odds ratios (ORs) and descriptive statistics were calculated to assess relationships between ultrasound reimbursement and practice location, nearby presence of an EM residency, and time elapsed since practitioner graduation. Results Of 52,928 unique EM practitioners, 391 (0.7%) received limited ultrasound reimbursements for a total of 16,389 scans in 2012. Urban counties had an OR of 5.4 (95% confidence interval, 3.8–7.8) for receiving point-of-care ultrasound reimbursements compared to rural counties. Counties with an EM residency had an OR of 84.7 (95% confidence interval, 42.6–178.8) for reimbursement compared to counties without. The OR for receiving reimbursement was independent of medical school graduation year (P = .83); however, recent graduates performed more scans (P = .02). Conclusions A small minority of EM practitioners received reimbursements for point-of-care ultrasound from Medicare beneficiaries. These practitioners were more likely to reside in urban and academic settings. Future efforts should assess the degree to which our findings reflect either low point-of-care ultrasound use or low rates of billing for ultrasound examinations that are performed.

Costs of children with medical complexity in Australian public hospitals

Abstract: Aim To describe the hospital costs, hospital types and differences across states and territories for children with medical complexity cared for in Australian public hospitals. Methods Retrospective national administrative database study of 212 Australian public hospitals from six states (excluding Queensland) and two territories that submitted cost data to the National Hospital Costing Data Collection for 2010-2011. Participants included all hospitalised patients with comparisons between adults and children (17 years of age and younger), and adults with chronic diseases and children with medical complexity. Total hospital costs were the main outcome measure. Results The National Hospital Costing Data Collection contained data from 212 public hospitals; total admissions (adults and children) were 3 519 140 at a total hospital cost of $16 187 400 000. Children accounted for 350 499 (9.9%) of the admissions at a total hospital cost of $1 931 585 123 (11.9%). Of all children, those with medical complexity accounted for 48 758 (13.9%), and their total hospital costs were $620 948 769 (32.1%). Six children's hospitals had 145 213 (41%) of the total children admissions at a total hospital cost of $936 041 843 (48%). Across the states and territories, the number of childhood admissions ranged from 9164 to 146 618 with 4.7-14.8% for children with medical complexity. Total hospital costs ranged from $44 to $592 million with 15.4-39.4% for children with medical complexity. Conclusions The national burden of hospitalised children is substantial. Children with medical complexity only account for a small percentage of hospitalisations but almost one third of total hospital costs for children, with children's hospitals bearing the major costs.

Ageing, entitlement and funding health care

Abstract: Universal access to health-care services funded under Medicare is one of the universal benefit programs targeted for scrutiny as government moves to end, or at least reduce, the age of entitlement. Successive Intergenerational Reports have demonstrated the extent to which health-care expenditure is predicted to grow more rapidly than Commonwealth government spending on aged care and pensions (Commonwealth of Australia 2010; 2015). While the latter is clearly related to population ageing, the former has also been attributed to the same demographic change (for example, Dutton 2014a, 2014b). The predicted growth in health-care expenditure has been characterised as inevitable and as threatening the viability of the health system as it is currently unless some significant changes are made (Ley 2015; Knott 2015). Thus the rhetoric posits causative links from ageing of the population to poorer population health to health-spending blowout to justification for major changes to current health-care financing.

Paying hospitals for quality: can we buy better care?

Abstract: Economic theory predicts that changing financial rewards will change behaviour. This is valid in terms of service use; higher costs reduce health care use. It should follow that paying more for quality should improve quality; however, the research evidence thus far is equivocal, particularly in terms of better health outcomes. One reason is that "financial incentives" encompass a range of payment types and sizes of reward. The design of financial incentives should take into account the desired change and the context of existing payment structures, as well as other strategies for improving quality; further, financial incentives should be fair in rewarding effort. Financial incentives may have unintended consequences, including rewarding hospitals for selecting patients with lower risks, diverting attention from the overall patient population to specific conditions, gaming, and "crowding out" or displacing intrinsic motivation. Managers and clinicians can only respond to financial incentives if they have the data, tools and skills to effect changes. Australia should not adopt widespread use of financial incentives for improving quality in health care without careful consideration of their design and context, the potential for unintended effects (particularly beyond their immediate targets), and evaluation of outcomes. The relative cost-effectiveness of financial incentives compared with, or in concert with, other strategies should also be considered.

Maynard the globe trotter

Abstract: Alan is a frequent guest speaker in different parts of the world. However his hosts, be they policy makers, clinicians or health service managers, are seldom soothed by congratulations on their latest reform attempts or offered the latest panacea from the National Health Service in England. Rather, they are challenged to specify their objectives and to support their strategies with data and evidence. Alan was always particularly annoyed at reorganisation that passed as reform – successive “re-disorganisation” as he termed it – which consumed scarce resources in terms of funds and labour.