Improving quality of breast cancer surgery through development of a national breast cancer surgical outcomes (BRCASO) research database

<p>Abstract</p> <p>Background</p> <p>Common measures of surgical quality are 30-day morbidity and mortality, which poorly describe breast cancer surgical quality with extremely low morbidity and mortality rates. Several national quality programs have collected additional surgical quality measures; however, program participation is voluntary and results may not be generalizable to all surgeons. We developed the Breast Cancer Surgical Outcomes (BRCASO) database to capture meaningful breast cancer surgical quality measures among a non-voluntary sample, and study variation in these measures across providers, facilities, and health plans. This paper describes our study protocol, data collection methods, and summarizes the strengths and limitations of these data.</p> <p>Methods</p> <p>We included 4524 women ≥18 years diagnosed with breast cancer between 2003-2008. All women with initial breast cancer surgery performed by a surgeon employed at the University of Vermont or three Cancer Research Network (CRN) health plans were eligible for inclusion. From the CRN institutions, we collected electronic administrative data including tumor registry information, Current Procedure Terminology codes for breast cancer surgeries, surgeons, surgical facilities, and patient demographics. We supplemented electronic data with medical record abstraction to collect additional pathology and surgery detail. All data were manually abstracted at the University of Vermont.</p> <p>Results</p> <p>The CRN institutions pre-filled 30% (22 out of 72) of elements using electronic data. The remaining elements, including detailed pathology margin status and breast and lymph node surgeries, required chart abstraction. The mean age was 61 years (range 20-98 years); 70% of women were diagnosed with invasive ductal carcinoma, 20% with ductal carcinoma in situ, and 10% with invasive lobular carcinoma.</p> <p>Conclusions</p> <p>The BRCASO database is one of the largest, multi-site research resources of meaningful breast cancer surgical quality data in the United States. Assembling data from electronic administrative databases and manual chart review balanced efficiency with high-quality, unbiased data collection. Using the BRCASO database, we will evaluate surgical quality measures including mastectomy rates, positive margin rates, and partial mastectomy re-excision rates among a diverse, non-voluntary population of patients, providers, and facilities.</p

The Impact of a Group Health Cooperative HPV Vaccination Promotion Program on Initiation of the HPV Vaccine

Thesis (Master's)--University of Washington, 2016-06Purpose: The purpose of this study is to examine the impact of a Group Health Cooperative outreach and reminder program on initiation of the HPV vaccine among 10-12 year olds receiving care at seven Group Health clinics in Western Washington. Study Design: The outreach and reminder initiative was a randomized control trial. Eligible children were randomized to receive an outreach letter and reminder calls about the HPV vaccine (intervention) or usual care (control). Randomization was at the child-level and stratified by clinic and gender, but outreach and reminder efforts were addressed and targeted to parents. Methods: This study conducted a preliminary analysis of the impact of the outreach and reminder program on initiation of the HPV vaccine for the overall study population and stratified by age. Chi-square tests were used to assess associations between group assignment (intervention or control) and receipt of HPV dose 1. Kaplan-Meier survival curves with log-rank tests were used to compare HPV vaccine initiation over time between the intervention and control groups. Results: A total of 1,805 children were included in the study; 1,354 were randomized to the intervention and 451 to control. Our analysis included 1,770 children after excluding 35 children who disenrolled after randomization, but before the intervention began. Overall, the intervention was not significantly associated with initiation of the HPV vaccine; 398 (30.1%) intervention children received HPV dose 1 compared to 121 (27.1%) control children (Chi-square test, p=0.23). There was also no association between the intervention and initiation of the HPV vaccine when the children were stratified by age (Chi-square test, 10 yrs, p=0.78; 11 yrs, p=0.31; 12 yrs, p=0.38). The Kaplan-Meier analyses showed that the difference in the vaccine initiation rates between the groups was not significant, overall (Log-rank test, p=0.08), nor when the children were stratified by age (Log-rank test, 10 yrs, p=0.71; 11 yrs, p=0.10; 12 yrs, p=0.31). Yet, a secondary analysis looking at vaccine initiation from the start of the reminder calls to the end of the analysis period showed a 6.2% difference in vaccine initiation rates between the intervention and control groups for 11 year olds (Chi-square test, p=0.07, Log-rank test, p=0.06). Conclusions: Group Health’s outreach and reminder program was not significantly associated with an increase in initiation of the HPV vaccine. However, while not significant, our data suggests that reminder calls may increase the initiation of the HPV vaccine among 11 year old children eligible for the vaccine in an insured population

Validation of human immunodeficiency virus diagnosis codes among women enrollees of a U.S. health plan

Abstract Background Efficiently identifying patients with human immunodeficiency virus (HIV) using administrative health care data (e.g., claims) can facilitate research on their quality of care and health outcomes. No prior study has validated the use of only ICD-10-CM HIV diagnosis codes to identify patients with HIV. Methods We validated HIV diagnosis codes among women enrolled in a large U.S. integrated health care system during 2010–2020. We examined HIV diagnosis code-based algorithms that varied by type, frequency, and timing of the codes in patients’ claims data. We calculated the positive predictive values (PPVs) and 95% confidence intervals (CIs) of the algorithms using a medical record-confirmed diagnosis of HIV as the gold standard. Results A total of 272 women with ≥ 1 HIV diagnosis code in the administrative claims data were identified and medical records were reviewed for all 272 women. The PPV of an algorithm classifying women as having HIV as of the first HIV diagnosis code during the observation period was 80.5% (95% CI: 75.4–84.8%), and it was 93.9% (95% CI: 90.0-96.3%) as of the second. Little additional increase in PPV was observed when a third code was required. The PPV of an algorithm based on ICD-10-CM-era codes was similar to one based on ICD-9-CM-era codes. Conclusion If the accuracy measure of greatest interest is PPV, our findings suggest that use of ≥ 2 HIV diagnosis codes to identify patients with HIV may perform well. However, health care coding practices may vary across settings, which may impact generalizability of our results

Reductions in Medical Resource Use Among Primary Care Physicians Following the Adoption of Personalized, Transparent Reporting

Background/Aims: With Group Health’s commitment to Affordable Excellence, Group Health has implemented multifaceted interventions since 2011 around helping clinicians become aware of their health services use relative to their colleagues, with the goal of increasing quality and reducing waste. This quality improvement initiative aims to measure changes in physician medical resource use and identify physician practice characteristics associated with decreasing use of low-value services. Methods: We calculated physician ordering rates for specialty referrals, prescriptions, high-end imaging, and lab tests for 197 practicing primary care physicians with panels greater than 500 in 2012 and 2013. Our primary outcomes were the differences between 2013 and 2012 ordering rates per 1,000 patients adjusted for age, sex and clinical complexity. Multiple regression models were used to examine associations between outcomes and physician years in practice and FTE-adjusted panel size. Models also were adjusted for gender and ethnicity. Results: In 2012, mean (with standard deviation) primary care physician ordering rates for referrals, prescriptions, imaging and labs were 336.1 (142.7), 7,838.2 (1,601.3), 19.8 (10.6) and 1,805.7 (647.5), respectively. Between 2013 and 2012, ordering decreased across all services; mean change in referrals, prescriptions, imaging and labs was -89.6 (125.7), -1,255.5 (1,509.5), -5.3 (8.9) and -435.9 (562.1), respectively. For referral, imaging and lab test orders, reduction was greatest in physicians newer to practice. Also for lab test orders, physicians with smaller panels had greater reductions. We did not observe any significant practice characteristics associated with change in prescriptions. Discussion: Group Health physicians with fewer years practicing and smaller panel sizes were associated with larger decreases in resource use from 2013 to 2012. The larger decrease in resource use in newer physicians may be associated with a learning curve early in practice and may represent an important time for early feedback and intervention. Since the multifaceted intervention also may have influenced physician resource use, more understanding of what accounts for reductions in resource use is useful for future development of interventions

Choosing Wisely: Using the EHR to Identify Variability in Provider Ordering Behavior for High-End Imaging of the Head

Background/Aims: Over the last three years, a team of Group Health researchers and clinical leaders has worked collaboratively on projects to reduce low-value care. The team investigates, tests and implements metrics and interventions to improve care and reduce costs. The team’s work is informed by the national Choosing Wisely campaign, which works with specialty medical societies to generate lists of low-value clinical activities. Group Health participates in the Washington State Choosing Wisely Task Force, which has identified and defined 10 high-priority recommendations on topics such as imaging, screening and antibiotic use. Methods: Our team is developing methods to assess variability in clinician ordering behavior with regard to the Task Force recommendation to avoid high-end imaging for uncomplicated headache. Claims data, as in the Group Health virtual data warehouse (VDW), generally do not identify the ordering provider for radiology procedures, which typically have different ordering and performing providers. To understand ordering patterns, we are instead using clinical data to identify ordering provider, and to detect both completed and cancelled orders. We examine all electronic health record (EHR) orders with a CPT code denoting head computed tomography or magnetic resonance imaging, and identify orders with an ICD code signifying uncomplicated headache. All orders, whether completed or not, should be accompanied by a justifying diagnosis, although the specifics of radiology ordering add significant challenges to identifying these diagnoses. For completed orders, we gather additional diagnosis information from EHR billing data, which (unlike claims data) still identifies the ordering provider. Results: We will compare the sensitivity of EHR ordering data, EHR billing data, and claims-based VDW data in identifying ordering of high-end imaging for headache. Achieving high specificity may not be feasible for this measure, given the resources required for chart review and programming exclusionary criteria. However, since our main goal at this point is to document variability between providers, high specificity for any individual provider is less critical. Discussion: Once we validate measures for headache imaging, we will distribute data to clinics and providers for review and discussion, and develop measures for other imaging-related Task Force recommendations. We also will investigate the feasibility of adding ordering provider to Group Health VDW data for services provided in Group Health clinics

Primary Care Provider Perspectives on Reducing Low-Value Care

Background/Aims: Constraining costs and enhancing value in health care delivery is a national priority. Understanding the clinician perspective is particularly important because health care professionals play key roles in choosing what health care services are used. This study explores clinicians’ perceived use of and professional responsibility for reducing low-value care, barriers to decreasing its use, and knowledge and perceived legitimacy of the Choosing Wisely campaign. Methods: We conducted an online survey of 304 primary care clinicians at Group Health in Fall 2013. The overall response rate was 62% (n=189). Results: Nearly all (93%) responded that the cost of care they personally deliver is important to different stakeholders and believe it is fair to ask providers to be cost-conscious. Over half (62%) said patients request unnecessary tests or procedures at least several times per week. The majority indicated they were somewhat or completely comfortable discussing low-value care with colleagues (70%) and patients (88%); conversations with patients were reported much more frequently than with providers (10% and 56% five or more discussions in the past 30 days, respectively). Providers indicated patients follow their advice the majority of the time about unnecessary tests or procedures when conversations happen. Notable perceived barriers to decreasing low-value care included: time (45%), community standards (43%), challenges overcoming patient preferences and values (43%), fear of patients’ dissatisfaction (40%), patients’ knowledge about harms of having low-value care (37%), availability of tools to support relevant shared decision-making (36%) and fear of litigation (31%). Almost two-thirds of providers were aware of the national Choosing Wisely campaign, nearly all of which considered it a legitimate source of information on unnecessary tests and procedures. Discussion: There were few differences in national physician surveys and our survey of integrated delivery system clinicians — patients listen to their providers and the majority of providers report talking with patients about reasons to avoid unnecessary tests. Awareness and perceived legitimacy of the Choosing Wisely campaign suggests the campaign and others like it may be used to activate providers to be conscientious stewards of limited health care resources. Additional focus on training providers to have discussions with colleagues about low-value care could be beneficial