Payment for performance (P4P): any future in Italy?

<p>Abstract</p> <p>Background</p> <p>Pay for Performance (P4P) programs, based on provision of financial incentives for service quality, have been widely adopted to enhance quality of care and to promote a more efficient use of health care resources whilst improving patient outcomes. In Italy, as in other countries, the growing concern over the quality of health services provided and the scarcity of resources would make P4P programs a useful means of improving their performance. The aim of this paper is to evaluate whether it is possible to implement P4P programs in the Lombardy Region, in Italy, based on the existing data set.</p> <p>Methods</p> <p>Thirteen quality measures were identified regarding four clinical conditions (acute myocardial infarction (AMI), heart failure (HF), ischemic stroke and hip and knee replacement) on the basis of an international literature review. Data was collected using the database of three institutions, which included hospital discharge records (Scheda di Dimissione ospedaliera-SDO-) and letters of discharge. The study population was identified using both the Principal ICD-9-CM diagnosis codes and the discharge date. A Statistical Analysis System (SAS) program was used for the text analysis.</p> <p>Results</p> <p>It was possible to calculate almost all the parameters pertaining to the three hospitals as all the data required was available with the exception of inpatient mortality in two hospitals and smoking cessation advice/counseling in one hospital.</p> <p>Conclusions</p> <p>On the ground of this analysis, we believe that it is possible to implement a P4P program in the Lombardy Region. However, for this program to be initiated, all necessary data must be available in electronic format and uniformly collected. Moreover, several other factors must be assessed: which clinical conditions should be included, the threshold for each quality parameter, the amount of financial incentives offered and how they will be provided.</p

Medical and pharmacy students’ perspectives of remote synchronous interprofessional education sessions

Background Interprofessional education (IPE) at university level is an essential component of undergraduate healthcare curricula, as well as being a requirement of many associated regulatory bodies. In this study, the perception of pharmacy and medical students’ of remote IPE was evaluated. Methods A series of IPE sessions took place via Zoom and students’ feedback was collected after each session. Both qualitative and quantitative data were collected and analysed. Results 72% (23/32) of medical students strongly agreed that the sessions had helped to improve their appreciation of the role of pharmacists, whereas 37% (22/59) of pharmacy students strongly agreed, reporting a median response of ‘somewhat agreeing’, that their appreciation of the role of general practitioners had improved. This difference was found to be statistically significant (p = 0.0143). Amongst students who responded, 55% (53/97) identified remote teaching as their preferred mode of delivery for an IPE session. Conclusions The survey demonstrated that the students valued the development of their prescribing skills as well as the ancillary skills gained, such as communication and teamwork. Remote IPE can be a practical means of improving medical and pharmacy students’ understanding of each other’s professional roles, as well as improving the skills required for prescribing

Towards a novel biologically-inspired cloud elasticity framework

With the widespread use of the Internet, the popularity of web applications has significantly increased. Such applications are subject to unpredictable workload conditions that vary from time to time. For example, an e-commerce website may face higher workloads than normal during festivals or promotional schemes. Such applications are critical and performance related issues, or service disruption can result in financial losses. Cloud computing with its attractive feature of dynamic resource provisioning (elasticity) is a perfect match to host such applications. The rapid growth in the usage of cloud computing model, as well as the rise in complexity of the web applications poses new challenges regarding the effective monitoring and management of the underlying cloud computational resources. This thesis investigates the state-of-the-art elastic methods including the models and techniques for the dynamic management and provisioning of cloud resources from a service provider perspective. An elastic controller is responsible to determine the optimal number of cloud resources, required at a particular time to achieve the desired performance demands. Researchers and practitioners have proposed many elastic controllers using versatile techniques ranging from simple if-then-else based rules to sophisticated optimisation, control theory and machine learning based methods. However, despite an extensive range of existing elasticity research, the aim of implementing an efficient scaling technique that satisfies the actual demands is still a challenge to achieve. There exist many issues that have not received much attention from a holistic point of view. Some of these issues include: 1) the lack of adaptability and static scaling behaviour whilst considering completely fixed approaches; 2) the burden of additional computational overhead, the inability to cope with the sudden changes in the workload behaviour and the preference of adaptability over reliability at runtime whilst considering the fully dynamic approaches; and 3) the lack of considering uncertainty aspects while designing auto-scaling solutions. This thesis seeks solutions to address these issues altogether using an integrated approach. Moreover, this thesis aims at the provision of qualitative elasticity rules. This thesis proposes a novel biologically-inspired switched feedback control methodology to address the horizontal elasticity problem. The switched methodology utilises multiple controllers simultaneously, whereas the selection of a suitable controller is realised using an intelligent switching mechanism. Each controller itself depicts a different elasticity policy that can be designed using the principles of fixed gain feedback controller approach. The switching mechanism is implemented using a fuzzy system that determines a suitable controller/- policy at runtime based on the current behaviour of the system. Furthermore, to improve the possibility of bumpless transitions and to avoid the oscillatory behaviour, which is a problem commonly associated with switching based control methodologies, this thesis proposes an alternative soft switching approach. This soft switching approach incorporates a biologically-inspired Basal Ganglia based computational model of action selection. In addition, this thesis formulates the problem of designing the membership functions of the switching mechanism as a multi-objective optimisation problem. The key purpose behind this formulation is to obtain the near optimal (or to fine tune) parameter settings for the membership functions of the fuzzy control system in the absence of domain experts’ knowledge. This problem is addressed by using two different techniques including the commonly used Genetic Algorithm and an alternative less known economic approach called the Taguchi method. Lastly, we identify seven different kinds of real workload patterns, each of which reflects a different set of applications. Six real and one synthetic HTTP traces, one for each pattern, are further identified and utilised to evaluate the performance of the proposed methods against the state-of-the-art approaches

The Effect of Performance-Based Financial Incentives on Improving Patient Care Experiences: A Statewide Evaluation

Patient experience measures are central to many pay-for-performance (P4P) programs nationally, but the effect of performance-based financial incentives on improving patient care experiences has not been assessed. The study uses Clinician &amp; Group CAHPS data from commercially insured adult patients (n = 124,021) who had visits with 1,444 primary care physicians from 25 California medical groups between 2003 and 2006. Medical directors were interviewed to assess the magnitude and nature of financial incentives directed at individual physicians and the patient experience improvement activities adopted by groups. Multilevel regression models were used to assess the relationship between performance change on patient care experience measures and medical group characteristics, financial incentives, and performance improvement activities. Over the course of the study period, physicians improved performance on the physician-patient communication (0.62 point annual increase, p &lt; 0.001), care coordination (0.48 point annual increase, p &lt; 0.001), and office staff interaction (0.22 point annual increase, p = 0.02) measures. Physicians with lower baseline performance on patient experience measures experienced larger improvements (p &lt; 0.001). Greater emphasis on clinical quality and patient experience criteria in individual physician incentive formulas was associated with larger improvements on the care coordination (p &lt; 0.01) and office staff interaction (p &lt; 0.01) measures. By contrast, greater emphasis on productivity and efficiency criteria was associated with declines in performance on the physician communication (p &lt; 0.01) and office staff interaction (p &lt; 0.001) composites. In the context of statewide measurement, reporting, and performance-based financial incentives, patient care experiences significantly improved. In order to promote patient-centered care in pay for performance and public reporting programs, the mechanisms by which program features influence performance improvement should be clarified

Difference in symptom severity between early and late grass pollen season in patients with seasonal allergic rhinitis

<p>Abstract</p> <p>Background</p> <p>For the development of forecasts for seasonal allergic rhinitis symptoms, it is essential to understand the relationship between grass pollen concentrations and the symptoms of grass pollen allergic patients.</p> <p>Objective</p> <p>The aim of this study was to delineate this relationship between seasonal allergic rhinitis symptoms and grass pollen concentrations in the Netherlands.</p> <p>Methods</p> <p>Grass pollen allergic patients (n = 80 [2007] - 84 [2008]) were enrolled into the study. They were asked to enter their seasonal allergic rhinitis symptoms (runny nose, sneezing, blocked nose, post nasal drip, and eye symptoms) daily on a scale from 0 to 3 to the study centre either by short message service (SMS) or by internet from May-July 2007 and April-July 2008. Daily pollen counts were used to define the early and the late grass pollen season as the period 'before and during' respectively 'after' the first grass pollen peak (more than 150 pollen/m³).</p> <p>Results</p> <p>At similar grass pollen concentrations, the daily mean of the individual maximum symptom scores reported in the early season were higher as compared to that reported in the late season [differences of -0.41 (2007) and -0.30 (2008)]. This difference could not be explained by medication use by the patients nor by co-sensitization to birch.</p> <p>Conclusions</p> <p>We conclude that seasonal allergic rhinitis symptoms at similar grass pollen concentrations are more severe in the early flowering season as compared to those in the late flowering season. This finding is not only relevant for development of forecasts for seasonal allergic rhinitis symptoms but also for understanding symptom development and planning and analysis of clinical studies.</p

Key issues in the design of pay for performance programs

Pay for performance (P4P) is increasingly being used to stimulate healthcare providers to improve their performance. However, evidence on P4P effectiveness remains inconclusive. Flaws in program design may have contributed to this limited success. Based on a synthesis of relevant theoretical and empirical literature, this paper discusses key issues in P4P-program design. The analysis reveals that designing a fair and effective program is a complex undertaking. The following tentative conclusions are made: (1) performance is ideally defined broadly, provided that the set of measures remains comprehensible, (2) concerns that P4P encourages "selection" and "teaching to the test" should not be dismissed, (3) sophisticated risk adjustment is important, especially in outcome and resource use measures, (4) involving providers in program design is vital, (5) on balance, group incentives are preferred over individual incentives, (6) whether to use rewards or penalties is context-dependent, (7) payouts should be frequent and low-powered, (8) absolute targets are generally preferred over relative targets, (9) multiple targets are preferred over single targets, and (10) P4P should be a permanent component of provider compensation and is ideally "decoupled" form base payments. However, the design of P4P programs should be tailored to the specific setting of implementation, and empirical research is needed to confirm the conclusions

Performance measurement for co-occurring mental health and substance use disorders

<p>Abstract</p> <p>Background</p> <p>Co-occurring mental health and substance use disorders (COD) are the norm rather than the exception. It is therefore critical that performance measures are developed to assess the quality of care for individuals with COD irrespective of whether they seek care in mental health systems or substance abuse systems or both.</p> <p>Methods</p> <p>We convened an expert panel and asked them to rate a series of structure, process, and outcomes measures for COD using a structured evaluation tool with domains for importance, usefulness, validity, and practicality.</p> <p>Results</p> <p>We chose twelve measures that demonstrated promise for future pilot testing and refinement. The criteria that we applied to select these measures included: balance across structure, process, and outcome measures, quantitative ratings from the panelists, narrative comments from the panelists, and evidence the measure had been tested in a similar form elsewhere.</p> <p>Conclusion</p> <p>To be successful performance measures need to be developed in such a way that they align with needs of administrators and providers. Policymakers need to work with all stakeholders to establish a concrete agenda for developing, piloting and implementing performance measures that include COD. Future research could begin to consider strategies that increase our ability to use administrative coding in mental health and substance use disorder systems to efficiently capture quality relevant clinical data.</p

ISO spectroscopy of gas and dust: from molecular clouds to protoplanetary disks

Observations of interstellar gas-phase and solid-state species in the 2.4-200 micron range obtained with the spectrometers on board the Infrared Space Observatory are reviewed. Lines and bands due to ices, polycyclic aromatic hydrocarbons, silicates and gas-phase atoms and molecules (in particular H2, CO, H2O, OH and CO2) are summarized and their diagnostic capabilities illustrated. The results are discussed in the context of the physical and chemical evolution of star-forming regions, including photon-dominated regions, shocks, protostellar envelopes and disks around young stars.Comment: 56 pages, 17 figures. To appear in Ann. Rev. Astron. Astrophys. 2004. Higher resolution version posted at http://www.strw.leidenuniv.nl/~ewine/araa04.pd