214 research outputs found
Trois essais sur l'impact des incitatifs financiers sur la productivité du système de la santé au Québec
Les incitatifs financiers dans le réseau de la santé sont reconnus avoir un effet sur le comportment des différents acteurs : médecins, patients, gestionnaires d’établissements. Ils peuvent prendre la forme de modèles de financement comme le financement à l’activité ou le financement selon la meilleure pratique ou bien des récompenses/pénalités financières offertes/appliquées selon le niveau des résultats atteints par rapport aux cibles fixées. Ces incitatifs financiers peuvent être liés directement au financement de l’établissement de santé ou à la rémunération médicale ou les deux simultanément. L’impact de ces leviers a été très peu testé dans le contexte québécois. L’objectif de cette thèse est de contribuer à la littérature d’évaluation de cet impact sur différents aspects de la productivité du système de santé au Québec. Ce dernier étant un système public caractérisé par une gouvernance coordonnée par le ministère de la santé et des services sociaux (MSSS). Les modèles de financement du réseau étant basé sur le modèle historique alors que la rémunération des professionnels de la santé étant majoritairement basée sur l’acte médical. Ces deux enveloppes budgétaires sont distinctes et le médecin prend le statut de travailleur autonome. Dans le premier chapitre, nous étudions l’effet causal d’un programme de financement à l’activité, le programme d’accès à la chirurgie, sur l’accès aux services et la qualité des soins. En utilisant des données administratives du Québec et un groupe de contrôle (données similaires de la Colombie britannique) et en se plaçant dans le cadre d’une approche de différence en différence, nous montrons que ce programme instauré depuis 2004 pour le secteur de la chirurgie et pour l’ensemble du réseau de la santé a permis de baisser les délais d’attente moyens aisni que les durées de séjour à l’hôpital, notamment pour les chirurgies de hanche et de genou, sans qu’il y ait détérioration dans certains indicateurs de la qualité des soins. En plus, l’effet de ce financement est non seulement positif mais aussi croît avec le niveau de financement. Dans le deuxième chapitre, mon analysons l’effet causal de l’introduction d’un programme de dépistage du cancer colorectal pour certains établissements pilotes. En utilisant les données des établissements non traités comme groupe de contrôle et à l’aide d’un modèle de transition multi-états, nous montrons l’effet positif de ce programme sur la qualité des soins ainsi que sur la santé de la population. Étant introduit au début en tant que stratégie clinique et combiné par la suite avec un financement récurrent selon la performance, ce programme a contribué à la baisse des durées de séjour pour un retour à domicile et à la diminution des coûts de traitement pour une chirurgie colorectale. Contrairement aux résultats du premier chapitre, cette analyse n’a pas permis de démontrer un effet positif du financement sur la baisse des durées de séjour. Ceci peut être dû à la courte durée de notre échantillon à partir de la date de l’annonce du financement additionnel pour les établissements pilotes. De l’autre côté, ce financement à la performance a contribué à une utilisation accrue d’une approche de traitement moins invasive. Dans le dernier chapitre, nous réalisons une analyse coût-efficience de ce programme de qualité afin de juger de la pertinence de poursuivre l’application de cette stratégie basée sur les protocoles cliniques ainsi que la pertinence de poursuivre le financement additionnel. Nous démontrons que le ratio bénéfice-coût de la stratégie clinique (tests de dépistage et protocole clinique) est non seulement supérieur à l’unité mais aussi supérieur à celui du programme incluant le financement additionnel. Ces résultats suggère une revue de la stratégie des incitatifs financiers en lien avec ce programme. Dans cette thèse, nous montrons comment les incitatifs financiers peuvent contribuer au changement du comportement et améliorer certains aspects de la productivité du système de la santé. Les leviers financiers ont été capables d’agir sur le comportement des médecins, dans la majorité des situations, malgré qu’ils ne sont pas directement liés à la rémunération médicale. Ceci témoigne d’une façon d’agir de la part des médecins qui n’est pas encore complètement documentée mais qui n’est certes pas détachée du contexte financier de l’établissement de santé. Cependant, ces leviers financiers doivent être utilisés dans le cadre général d’une stratégie clinique offrant un certain seuil minimal de conditions de réussite et d’atteinte des objectifs. Ils ne peuvent agir seuls dans le sens de l’objectif à atteindre mais certes en cohérence avec toute stratégie clinique basée sur un partenariat clinico-administratif.Financial incentives in health network system are supposed to have an effect on the behaviour of the different healthcare stakeholders : physicians, patients, facilities managers. They may be proposed as funding models such as activity based funding or best practice paiement or rewards / financial penalties offered / applied according to outcome indicators achieved and compared to targets. Financial incentives could be linked directly to the healthcare facility funding or to medical payments or both. The impact of these levers has been little tested in the Quebec context. The objective of this thesis is to contribute to the literature of financial incentives impact assessment on various aspects of healthcare system productivity in Quebec. The latter being a public system characterized by a governance coordinated by the Ministry of Health and Social Services (MSSS). Network funding models being based on global budget while the healthcare professionnels paiement is mainly based on fees for services. Both budgets are distinct and the physician takes self-employed status. In the first chapter, we assess for the causal effect of the first Quebec activity based funding program, access to surgery program, on access to services and healthcare quality. Using Quebec administrative data, a control group ( similar data from British Columbia ) and a difference in difference approach, we show that this program, introduced in 2004 for the surgery sector in all facilities, reduced waiting times and hospital lengths of stay, especially for hip and knee replacements, without deterioration in some healthcare quality indicators. In addition, the effect of this funding is not only positive but also increases with funding level. In the second chapter, we estimate the causal effect of the introduction of a colorectal cancer screening program for some pilot facilities. Using data from untreated hospitals as control group and a multistate model, we show the positive impact of this program on the healthcare quality and population health. Introduced at the beginning as a clinical strategy and combined later with recurrent performance payments, the program has contributed to the decrease of hospital lengths of stay with home discharge and also lower treatment costs for colorectal surgeries. Contrary to the results of the first chapter, this analysis did not demonstrate a positive effect of financial incentives on lower lengths of stay. This may be due to the short duration of our sample since the date of additional funding announcement. On the other side, financial incentives contributed to increased use of a less invasive treatment approach. In the last chapter, we perform a cost-effectiveness analysis of this healthcare quality program to identify the relevance of continuing implementing the strategy based on clinical protocols and additional funding. We demonstrate that the benefit-cost ratio of clinical strategy ( screening tests and clinical protocol ) is not only greater than unity but also higher than the program including the additional funding ratio. These results suggest a review of the financial incentives strategy for this program. In this thesis , we show how financial incentives can help behaviour move and improve certain productivity aspects in the healthcare system. The financial levers have been able to influence the physicians behaviour, in most situations, although they are not directly related to their payments. This reflects a way of behaving for physicians that is not yet fully known but is certainly not disconnected from facilities financial context. Finally, these financial levers must be used in the general framework of a clinical strategy providing a minimum level of success conditions and achievement of objectives. They can not act alone in the direction of the goal but certainly they should be consistent with any clinical strategy especially when based on clinical-administrative partnership
Impacts of Black Box Warning, National Coverage Determination, and Risk Evaluation and Mitigation Strategies on the Inpatient On-Label and Off-label Use of Erythropoiesis-Stimulating Agents
Background: FDA black box warning, Risk Evaluation and Mitigation Strategies (REMS), and CMS national coverage determination (NCD) aim to reduce inappropriate use of erythropoiesis-stimulating agents (ESAs) that are widely used in anemic patients. Previous studies have not linked specific safety interventions to changes in ESA utilization patterns in the inpatient settings nor assessed such interventions on off-label use of the drugs. Ineffectiveness of the intervention and lag time between such interventions and the observed change in clinical practice could lead to serious clinical outcomes. In addition, such interventions may unintentionally reduce on-label and some off-label use of ESAs considered “appropriate” in patients who could otherwise benefit. Objectives: The primary aim of the study is to quantify the impacts of the (1) addition of black box warning, (2) implementation of NCD, and (3) institution of REMS on ESA on-label and off-label utilization patterns of adult inpatients. Demographic, clinical condition, physician, and hospital characteristics of ESAs users by their use category are also described in detail. Methods: Electronic health records in Cerner Database from January 1, 2005 to June 30, 2011 were used. The use of the two erythropoietic drugs: epoetin alfa and darbepoetin alfa were categorized into three groups using ICD-9-CM diagnoses and procedures codes and patients’ medication information. The three categories were (1) on-label use (approved by the FDA); (2) off-label use supported (use for the indications not approved by the FDA, but there is strong clinical evidence to support its use); and (3) off-label use unsupported (use for the indications not approved by the FDA and lacking clinical evidence). The immediate and trend impacts of the interventions on the proportion of ESAs prescribed for each usage category between 2005 and 2011 were assessed using an interrupted time series technique. The likelihood of receiving ESAs among patients with on-label, off-label supported, off-label unsupported indications was assessed using a generalized estimating equation approach with binary logistic regression technique, clustering for hospitals and controlling for potential confounders such as patient characteristics, patient clinical conditions, physician specialty, and hospital characteristics. Results: During the study period, there were 111,363 encounters of ESA use. These encounters represented 86,763 patients admitted to Cerner health system between January 1, 2005 and June 30, 2011. Of these patients, 66,121 were prescribed epoetin alfa only (76.2%); 20,088 darbepoetin alfa only (23.2%); and 554 were prescribed both epoetin alfa and darbepoetin alfa (0.6%). Forty-nine percent of the patients used ESAs for the on-label indications, 8.6% for off-label supported indications, and 42.7% for the off-label unsupported indications. The main uses of ESAs in our sample were for CKD (ONS, 41.1%) and chronic anemia (OFU, 31.8%). From 2005 to 2010, the proportion of visits with ESA ONS and OFS use decreased 53.2% and 81.9%, while ESA OFU increased 112.6%. Results from binary logistic regression using GEE model showed overall decreasing trends in ESA use for the on-label and off-label supported indications, but not off-label unsupported indications. REMS had no impact on the odds of receiving ESAs among patients with on-label and off-label conditions. Black box warning reduced the odds of being prescribed with epoetin alfa in patients with off-label unsupported conditions by 40%. It was also associated with 4% and 15% per month reduction in the odds of using darbepoetin alfa in patients with off-label supported and unsupported conditions. Lastly, there was a significant decline in all categories of ESA use the month after Medicare national coverage determination was implemented. The impact of NCD ranged from a 20% reduction in the odds of off-label supported use to a 37% reduction in on-label use. Age, gender, race, source of payment, admission type, clinical complexity, discharge disposition, and hospital size were significant associated with ESA use on-label and off-label. Conclusion: This study was the first to determine the impact of safety interventions on ESA on-label and off-label utilization patterns in the inpatient settings using the Cerner database. We demonstrated lag between the interventions and observed change in clinical practice, and the relative impacts of three types of safety interventions on on-label and off-label ESA use in the hospital settings. The indirect impact of the reimbursement change was the potential unintended consequence of reducing the likelihood of receiving ESAs for a patient with indicated conditions who could have otherwise benefited from the drugs
Recommended from our members
Empirical Modeling and Applications in Financial Economics and Healthcare Management
With increased availability of data in various fields, researchers often need to combine efficient empirical methods with innovative analytical modeling techniques to make data-driven decisions and gain managerial insights from the large-scale raw data. In light of this, my thesis combines empirical methods and analytical modeling to study several data-related problems in the fields of financial economics and healthcare management. The first two parts of the thesis focus on two topics in financial economics: the role of dynamic information in asset pricing and the link between index-based investment and intraday stock dynamics. The last two parts of the thesis study the ICU admission decisions and cardiac surgery scheduling using data from different hospital units.
The first part of the thesis focuses on the role of information in financial market. As a fundamental topic in asset pricing, information is known to play an important role in determining asset prices and market volatility. In most of the existing literature, the information environment, i.e., the amount of knowable information, is assumed to be fixed and independent of investor's choice. However, in a dynamic market, the level of available information can vary substantially due to changes in technology and regulations. On the other hand, rational news producers may respond to investors' demand for information. Such effects are commonly seen in the reality, but are less studied in the literature. To bridge this gap, we develop a model of investor information choices and asset prices where the availability of information about fundamentals is time-varying. A competitive research sector produces more information when more investors are willing to pay for that research. This feedback, from investor willingness to pay for information to more information production, generates two regimes in equilibrium, one having high prices and low volatility, the other the opposite. Information dynamics move the market between regimes, creating large price drops even with no change in fundamentals. In our calibration, the model suggests an important role for information dynamics in financial crises.
In the second part of this thesis, we investigate how the growth of index-based investing impacts the intraday stock dynamics using a large high-frequency dataset, which consists of 1-second level trade data for all S&P 500 constituents from 2004 to 2018 (500GB). We estimate intraday trading volume, volatility, correlation, and beta using estimators that are statistically efficient under market microstructure noise and observation asynchronicity. We find the intraday patterns indeed change substantially over time. For example, in the recent decade, the trading volume and correlation significantly increase at the end of trading session; the betas of different stocks start dispersed in the morning, but generally move towards one during the day. Besides, the daily dispersion in trading volume is high at the market open and low near the market close. These intraday patterns demonstrate the implication of the growth of index-based strategies and the active-open, passive-close intraday trading profile. We theoretically support our interpretation via a market impact model with time-varying liquidity provision from both single-stock and index-fund investors.
In the third part of the thesis, we study the intensive care units (ICUs) admission decisions in a large hospital system. In the case of ICUs, which provide the highest level of care for the most severe patients, it is known that admission rates of some patients decrease as occupancy increases. It is also known that, for at least some conditions, ICU admission is not just a function of patients’ illness, and that a significant proportion of the variation in ICU admission rates is due to hospital, not patient, factors. To understand such variation, we employ two years of data from patients admitted to 21 Kaiser Permanente Northern California ICUs from the ED. We quantify the variation in ICU admission from the ED under varying degrees of ICU and ED occupancy. We find that substantial heterogeneity in admission rates is present, and that it cannot be explained either by patient factors or occupancy levels alone. We use a structural model to understand the extent that intertemporal externalities could account for some of this variation. Using counterfactual simulations, we find that, if hospitals had more information regarding their behaviors, and if it were possible to alter hospital admission processes to incorporate such information, hospitals could reduce their ICU congestion in a safe way.
The last part of the thesis focuses on the impact of system workload on service time and quality in the context of cardiac surgeries. Using a detailed data set of more than 5,600 cardiac surgeries in a large hospital, we quantify how surgeon's daily workload level (e.g., number of surgeries) affects surgery duration and patient outcomes. To handle the endogeneity of surgeon's daily workload, we construct instrument variables using hospital operational factors, including the block schedule of surgeons. We find high daily workload of surgeons is associated with longer incision times and worse patient outcomes. Specifically, increased daily workload of surgeons leads to longer post-surgery length-of-stay in ICU and hospital, as well as higher likelihoods of reoperation and readmission for their patients. These results highlight the potential negative impact of surgeon's fatigue under long working hours. We then develop a surgery scheduling model that incorporates the effects of surgeon's daily workload levels
Graduate course catalog (Florida International University). [2021-2022]
This catalog contains a description of the various policies, graduate programs, degree requirements, and course offerings at Florida International University during the 2021-2022 academic year.https://digitalcommons.fiu.edu/catalogs/1082/thumbnail.jp
Graduate course catalog (Florida International University). [2023-2024]
This catalog contains a description of the various policies, graduate programs, degree requirements, and course offerings at Florida International University during the 2023-2024 academic year.https://digitalcommons.fiu.edu/catalogs/1086/thumbnail.jp
Graduate course catalog (Florida International University). [2022-2023]
This catalog contains a description of the various policies, graduate programs, degree requirements, and course offerings at Florida International University during the 2022-2023 academic year.https://digitalcommons.fiu.edu/catalogs/1084/thumbnail.jp
Graduate course catalog (Florida International University). [2016-2017]
This catalog contains a description of the various policies, graduate programs, degree requirements, and course offerings at Florida International University during the 2016-2017 academic year.https://digitalcommons.fiu.edu/catalogs/1072/thumbnail.jp
Graduate Catalog, 2017-2018
Marshall University Graduate Course Catalog for the 2017-2018 academic year.https://mds.marshall.edu/catalog_2010-2019/1012/thumbnail.jp
Graduate course catalog (Florida International University). [2020-2021]
This catalog contains a description of the various policies, graduate programs, degree requirements, and course offerings at Florida International University during the 2020-2021 academic year.https://digitalcommons.fiu.edu/catalogs/1080/thumbnail.jp
- …