Accuracy of medical billing data against the electronic health record in the measurement of colorectal cancer screening rates.

ObjectiveMedical billing data are an attractive source of secondary analysis because of their ease of use and potential to answer population-health questions with statistical power. Although these datasets have known susceptibilities to biases, the degree to which they can distort the assessment of quality measures such as colorectal cancer screening rates are not widely appreciated, nor are their causes and possible solutions.MethodsUsing a billing code database derived from our institution's electronic health records, we estimated the colorectal cancer screening rate of average-risk patients aged 50-74 years seen in primary care or gastroenterology clinic in 2016-2017. 200 records (150 unscreened, 50 screened) were sampled to quantify the accuracy against manual review.ResultsOut of 4611 patients, an analysis of billing data suggested a 61% screening rate, an estimate that matches the estimate by the Centers for Disease Control. Manual review revealed a positive predictive value of 96% (86%-100%), negative predictive value of 21% (15%-29%) and a corrected screening rate of 85% (81%-90%). Most false negatives occurred due to examinations performed outside the scope of the database-both within and outside of our institution-but 21% of false negatives fell within the database's scope. False positives occurred due to incomplete examinations and inadequate bowel preparation. Reasons for screening failure include ordered but incomplete examinations (48%), lack of or incorrect documentation by primary care (29%) including incorrect screening intervals (13%) and patients declining screening (13%).ConclusionsBilling databases are prone to substantial bias that may go undetected even in the presence of confirmatory external estimates. Caution is recommended when performing population-level inference from these data. We propose several solutions to improve the use of these data for the assessment of healthcare quality

Completion of Preventive Health Care Actions by Older Women with HIV/AIDS

The widespread use of highly active antiretroviral therapy (HAART) has resulted in longer lifespans for HIV seropositive women in the United States, during which preventive health care is recommended. Failing to complete recommended cancer screening tests can result in cancer being diagnosed at a later stage with a poorer prognosis. The purpose of the study, based on the ecosocial theory, was to describe the sociodemographic and clinical variables of HIV seropositive women who failed to complete recommended screening tests for breast, cervical, and colorectal cancers, and determine if the presence of hypertension, obesity, diabetes, depression, or tobacco use impacted the completion of these screening tests. The electronic medical records of 142 HIV seropositive women were reviewed. Univariate analysis, bivariate analysis, and logistic regression were conducted to create a model associated with the completion of preventive health care screening tests. For breast cancer, cervical cancer, and colorectal cancer, 69%, 71.8%, and 69.7% failed to complete screening, respectively. Number of years living with HIV infection and HIV stage were associated with breast cancer screening; distance between residence and health care facility, and HIV stage were associated with cervical cancer screening; and age and marital status were associated with colorectal cancer screening. Addressing issues related to the completion of cancer screening tests over the lifespans of HIV seropositive women can result in positive social change by preventing disease and disability, which can negatively impact these women, their families, and their communities

Modeling Second Order Impacts of Healthcare Innovation

Any single health service organization today is likely engaged in dozens of concurrent, often times unrelated change initiatives. Each of these change initiatives is likely supported by evidence that demonstrates the innovation’s intended, first order impact. However, very little attention has been paid to the unintended, second order impacts of innovation. In this dissertation we introduce a model to provide a framework for inquiring about this very type of non-immediate impact. Next, using three innovations currently being implemented in the healthcare industry—training primary care residents to perform in-office colonoscopies, Studer Group’s ‘Evidence Based Leadership,’ and implementation of electronic health records in a hospital-integrated pediatric network—we model the innovations’ second order impacts within the context of our second order impact conceptual model. Cost effectiveness analysis, multiple analysis of variance (MANOVA), and two-level fixed effects modeling are used to across the three interventions. Results from the primary care residency intervention support further investment in colorectal cancer screening training for primary care residents. Results from the Studer Group’s ‘Evidence Based Leadership’ intervention demonstrate mixed results across change interventions and across categories of tenure, suggesting receptivity towards change and organization tenure is highly dependent upon the nuances of a specific change intervention. Finally, results from the implementation of the electronic health record demonstrate improved charge capture. We conclude that this further probing of popular innovations in the industry is warranted for multiple reasons. For one, it is entirely possible that social scientists and economists are prematurely ‘moving on’ to other innovations as soon they have published results from an initial round of inquiry. However, as we will demonstrate in our model, it is conceivable that after the “lights have dimmed” on an innovation’s initial glow, the artifacts of the innovation could very well continue to disrupt structures and processes long after its implementation. If these latent disruptions adversely affect the organization, one could argue that any initial positive impacts were likely overstated. Conversely, if these latent disruptions go on to produce additional benefit to the organization one could argue that any initial positive results were actually understated

Doctor of Philosophy

dissertationFamily history has been called the "cornerstone of individualized disease prevention" but it is underutilized in clinical practice. In order to use it more effectively, its role in assessing risk for disease needs to be better quantified and understood. Family history has been identified as an important risk factor for colorectal cancer (CRC) and risk prediction in CRC is potentially worthwhile because of the possibility of preventing the disease through application of individualized screening programs tailored to risk. The overall project objective was to explore how family history can be better utilized to predict who will develop CRC. First, we used the Utah Population Database (UPDB) to define familial risk for CRC in more detail than has previously been reported. Second, we explored whether individuals at increased familial risk for CRC or at increased risk based on other risk factors such as a personal history of CRC or adenomatous polyps, are more compliant with screening and surveillance recommendations using colonoscopy than those who are at normal risk. Third, we measured how well family history can predict who will develop CRC over a period of 20 years, using family history by itself as a risk factor, and also in combination with the risk factor, age. We found that increased numbers of affected first-degree relatives influence risk much more than affected relatives from the second or third degrees. However, when combined with a positive firstdegree family history, a positive second- and third-degree family history can significantly increase risk. Next, we found that colonoscopy rates were higher in those with risk factors, according to risk-specific guidelines, but improvements in compliance are still warranted. Lastly, it was determined that family history by itself is not a strong predictor of exactly who will acquire colorectal cancer within 20 years. However, stratification of risk using absolute risk probabilities may be more helpful in focusing screening on individuals who are more likely to develop the disease. Future work includes using these findings as a basis for a cost/benefit analysis to determine optimal screening recommendations and building tools to better capture and utilize family history data in an electronic health record system

Primary Care Based Population Health in a Community Health System: Evaluation of Strategies, Lessons Learned and Key Results

Theory: As value-based programs continue to proliferate, healthcare delivery providers must adapt accordingly to meet these new demands. This study examines the strategies, lessons learned, and key results of the Greater Baltimore Health Alliance (GBHA), a patient-centered medical home (PCMH) community healthcare provider, in the population health context. Methods: This study follows the work-place challenge format and as such includes an organizational assessment, plan for new service, program evaluation, economic evaluation, and discussion of implications. The organizational assessment leverages survey tools to study GBHA staff and leaders using the Baldrige Excellence Framework. The plan for new services outlines a plan and early results for integrated behavioral health in the PCMH setting. The program evaluation includes a run chart analysis, bivariate analysis, and logistic regression analysis to study colorectal cancer screening compliance rates at GBHA. The economic evaluation methods include a cost consequence analysis and return on investment analysis for GBHA. The implications section leverages a literature review and general discussion. Results: The organizational assessment of GBHA revealed strengths in leadership, strategy, workforce and operations. The organizational assessment also indicated that GBHA has opportunity for improvement in the areas of customers, measurement, analysis and knowledge management, and results. The plan for new service revealed a nearly completed implementation of integrated behavioral health and early results indicate further opportunity for outcome measure refinement, workflow standardization, policy and procedure development, and the establishment of goal thresholds. The program evaluation indicated special cause variation in the run chart as well as increased odds of screening for patients seen in practices with greater length of time recognized as a PCMH. The economic evaluation indicated significant investment in GBHA, largely positive quality outcomes, and progressively increasing return on investment each fiscal year. The discussion of implications underlined the importance of GBHA to stay abreast of federal regulations, which may dictate strategy changes. Conclusions: GBHA has been largely successful in meeting the evolving demands of the population health landscape. GBHA’s location in Maryland provides additional financial incentive to make investment in PCMH strategies more feasible. Additional study is necessary as the behavioral health integration implementation continues

An Investigation of the Diagnostic Potential of Autofluorescence Lifetime Spectroscopy and Imaging for Label-Free Contrast of Disease

The work presented in this thesis aimed to study the application of fluorescence lifetime spectroscopy (FLS) and fluorescence lifetime imaging microscopy (FLIM) to investigate their potential for diagnostic contrast of diseased tissue with a particular emphasis on autofluorescence (AF) measurements of gastrointestinal (GI) disease. Initially, an ex vivo study utilising confocal FLIM was undertaken with 420 nm excitation to characterise the fluorescence lifetime (FL) images obtained from 71 GI samples from 35 patients. A significant decrease in FL was observed between normal colon and polyps (p = 0.024), and normal colon and inflammatory bowel disease (IBD) (p = 0.015). Confocal FLIM was also performed on 23 bladder samples. A longer, although not significant, FL for cancer was observed, in paired specimens (n = 5) instilled with a photosensitizer. The first in vivo study was a clinical investigation of skin cancer using a fibre-optic FL spectrofluorometer and involved the interrogation of 27 lesions from 25 patients. A significant decrease in the FL of basal cell carcinomas compared to healthy tissue was observed (p = 0.002) with 445 nm excitation. A novel clinically viable FLS fibre-optic probe was then applied ex vivo to measure 60 samples collected from 23 patients. In a paired analysis of neoplastic polyps and normal colon obtained from the same region of the colon in the same patient (n = 12), a significant decrease in FL was observed (p = 0.021) with 435 nm excitation. In contrast, with 375 nm excitation, the mean FL of IBD specimens (n = 4) was found to be longer than that of normal tissue, although not statistically significant. Finally, the FLS system was applied in vivo in 17 patients, with initial data indicating that 435 nm excitation results in AF lifetimes that are broadly consistent with ex vivo studies, although no diagnostically significant differences were observed in the signals obtained in vivo.Open Acces

Quality of Health Care for Medicare Beneficiaries: A Chartbook

Provides the results of a review of recently published studies and reports about the quality of health care for elderly Medicare beneficiaries. Includes examples of deficiencies and disparities in care, and some promising quality improvement initiatives

Advancing Physician Performance Measurement: Using Administrative Data to Assess Physician Quality and Efficiency

Summarizes national initiatives to advance the practice of standardized measurement and outlines goals for developing a method for tracking efficiency and quality that will reward physicians and enable patients to make informed healthcare choices