Physician payment methods: a focus on quality and cost control

With rising health care costs, governments must develop innovative methods to deliver efficient and equitable health care services. With physician remuneration being the third largest health care expense, the design of remuneration methods is a priority in health care policy. Otolaryngology-Head and Neck surgeons should have an understanding of the behavioural incentives associated with different physician payment methods. This article will outline the different physician payment methods with a focus on discussing the impact on quality of care and health care costs

Health utility reporting in Chronic Rhinosinusitis patients

Objectives: Direct comparison of different diseases allows clinicians and researchers to place the burden of symptoms and impact on quality of life of each condition in context. Generic health-related quality of life assessment tools allow such analysis, limited data is available for British patients with Chronic rhinosinusitis. Design: As part of a larger feasibility study, patients underwent baseline assessment using the SNOT-22, SF-12 and EQ-5D-5L tools. Data was analysed using Microsoft excel and algorithms available for the analysis of the later 2 tools. We plotted EQ-5D-5L VAS and utility scores and SF-12 MCS and PCS scores separately against SNOT-22 scores and quantified associations using bivariate ordinary least squares regression analysis. Setting: Patients were prospectively recruited from 6 UK outpatient clinics. Participants: Adult patients with chronic rhinosinusitis without nasal polyps (CRSsNPs). Main Outcome measures: Baseline SNOT-22, SF-12 and EQ-5D-5L scores. Results: Fifty-two adults were recruited with a mean age of 55 years, 51% were male. The mean SNOT-22 score was 43.82. Mental and physical component scores of the SF-12 were 46.53 and 46 respectively. Mean index score computed form the EQ-5D-5L was 0.75. Worse (higher) SNOT-22 scores were associated with lower EQ-5D-5L VAS and utility scores and SF-12 MCS and PCS scores. Conclusion: The EQ-5D-5L suggests that British CRSsNPs patients are negatively impacted with regards to quality of life. We found the SF-12 to be less sensitive and conclude that the EQ-5D-5L tool is a quick and accessible method for assessing QOL in order it can be compared with other disease states

Outcomes in endoscopic sinus surgery: olfaction, nose scale and quality of life in a prospective cohort study

OBJECTIVES: To determine the efficacy of endoscopic sinus surgery (ESS) on olfactory function in chronic rhinosinusitis patients with nasal polyps (CRSwNP) and without nasal polyps (CRSsNP) and to compare the nasal obstruction and symptom evaluation (NOSE) scale before and after surgery. DESIGN: A prospective cohort study. SETTING: Royal National Throat and Nose and Ear Hospital, London UK. PARTICIPANTS: One hundred and thirteen patients with CRS; 60 CRSwNP and 53 CRSsNP. OUTCOME ASSESSMENTS: Olfaction was measured using both the University of Pennsylvania Smell Investigation Test (UPSIT) and the ‘sense of smell’ visual analogue scale (VAS). The NOSE scale, the sinonasal outcome test (SNOT 22) and the Lund–Kennedy (LK) surgeon reported scores were also measured pre- and postoperatively at 6 months. RESULTS: The UPSIT psychophysical measurement significantly improved following ESS in the CRSwNP subgroup as did the patients perceived VAS sense of smell. However, in the CRSsNP subgroup, the improved VAS and UPSIT measurements were not significant. The NOSE, SNOT 22 and LK scores all improved significantly. The olfactory improvement as measured by the UPSIT correlated to the SNOT-22, but a correlation between the NOSE score and UPSIT was not found. CONCLUSIONS: Endoscopic sinus surgery significantly improved the patient's perceived and measured sense of smell in the CRSwNP subgroup which is the most surgically responsive CRS subgroup. Additionally, improved olfaction in the CRSwNP subgroup is most likely to improve the patient's quality of life. Endoscopic sinus surgery significantly improved the NOSE scale in both CRS subgroups at 6 months following surgery

CHronic Rhinosinusitis Outcome MEasures (CHROME), developing a core outcome set for trials of interventions in chronic rhinosinusitis

Statement of Problem: Evaluating the effectiveness of treatments in chronic rhinosinusitis (CRS) have been limited by both a paucity of high quality randomised trials, and the heterogeneity of outcomes in those that have been reported. Core outcome sets (COS) are an agreed, standardized set of outcomes that should be measured and reported by future trials as a minimum and will facilitate future meta-analysis of trial results in systematic reviews (SRs). We set out to develop a core outcome set for interventions for adults with CRS. Method(s) of study: A long-list of potential outcomes was identified by a steering group utilising a literature review, thematic analysis of a wide range of stakeholders’ views and systematic analysis of currently available Patient Reported Outcome Measures (PROMs). A subsequent e-Delphi process allowed 110 patients and healthcare practitioners to individually rate the outcomes in terms of importance, on a Likert scale. Main Results: After 2 rounds of the iterative Delphi process, the 54 initial outcomes were distilled down to a final core-outcome set of 15 items, over 4 domains. Principal Conclusions: The authors hope inclusion of these core outcomes in future trials will increase the value of research on interventions for CRS in adults. It was felt important to make recommendations regarding how these outcomes should be measured, although additional work is now required to further develop and revalidate existing outcome measures

Chronic rhinosinusitis: Patient experiences of primary and secondary care - a qualitative study

Objectives: To explore the experience of CRS and its management from the perspective of patients with CRS. To our knowledge this is the first qualitative study exploring sinus disease. Design: Semi-structured qualitative interviews. Setting: ENT outpatient clinic. Participants: 21 adult patients with CRS: 11 male, 10 female. Patients suffered from a range of types of CRS (including polyps and fungal disease) and differing durations of symptoms (1.5- 47 years). Participants were purposively selected. Thematic analysis was used. Outcome measures: Patient experience of CRS and its management. Results: Patients had concerns regarding management of their symptoms by both healthcare professionals and themselves, including delays to referral and repeated medications. They reported reduced quality of life and high financial and psychosocial costs associated with living with CRS. Conclusions: Despite guidelines for CRS treatment, outcomes remain variable leading to dissatisfaction with treatment. Adherence to existing guidelines may result in fewer repeated consultations in primary care and earlier referrals to secondary care

HTA Implementation Roadmap in Central and Eastern European Countries.

The opportunity cost of inappropriate health policy decisions is greater in Central and Eastern European (CEE) compared with Western European (WE) countries because of poorer population health and more limited healthcare resources. Application of health technology assessment (HTA) prior to healthcare financing decisions can improve the allocative efficiency of scarce resources. However, few CEE countries have a clear roadmap for HTA implementation. Examples from high-income countries may not be directly relevant, as CEE countries cannot allocate so much financial and human resources for substantiating policy decisions with evidence. Our objective was to describe the main HTA implementation scenarios in CEE countries and summarize the most important questions related to capacity building, financing HTA research, process and organizational structure for HTA, standardization of HTA methodology, use of local data, scope of mandatory HTA, decision criteria, and international collaboration in HTA. Although HTA implementation strategies from the region can be relevant examples for other CEE countries with similar cultural environment and economic status, HTA roadmaps are not still fully transferable without taking into account country-specific aspects, such as country size, gross domestic product per capita, major social values, public health priorities, and fragmentation of healthcare financing

Eight-point compass rose underlay technique in 72 consecutive elderly patients with large incisional hernia

Background: Repair of incisional hernia (IH) in the elderly is a challenge for the surgeon. Primary closure is preferable but is not always possible because of high recurrence rates of IH repaired without a prosthesis and/or possible respiratory and cardiovascular complications due to extreme tension of the margins. We report our experience with underlay mesh placement in elderly patients with large IH. Methods: A total of 72 patients from January 2003 to December 2009 underwent IH repair involving placement of an intraperitoneal Gore® DualMesh® prosthesis. The prosthesis was first anchored at eight points in a compass rose pattern using a Gore® suture passer and then firmly secured to the abdominal wall with a 360° internal crown running suture. Results: Two intraoperative intestinal tears occurred during debridement and were immediately sutured. Postoperative complications included seven seromas, four hematomas, and two infections, one of which was resolved with conservative treatment while one required prosthesis removal. Conclusion: This surgical procedure, like laparoscopic treatment, allows the surgeon to avoid dissection of the abdominal layer and improves prosthesis adhesion with reinforcement of the incisional area near the abdominal defect. The reduction in operation time is remarkable. Despite good results in terms of safety and minimal recurrence for laparoscopy in the management of IH, the use of minimally invasive techniques for large incisional wall defects, especially in elderly patients, is still controversial and practiced by few surgeons. This open technique avoids cardiopulmonary complications arising from pneumoperitoneum in the elderly

Increasing the use of second-line therapy is a cost-effective approach to prevent the spread of drug-resistant HIV: a mathematical modelling study

METHODS: We develop a deterministic mathematical model representing Kampala, Uganda, to predict the prevalence of TDR over a 10-year period. We then compare the impact on TDR and cost-effectiveness of: (1) introduction of pre-therapy genotyping; (2) doubling use of second-line treatment to 80% (50-90%) of patients with confirmed virological failure on first-line ART; and (3) increasing viral load monitoring from yearly to twice yearly. An intervention can be considered cost-effective if it costs less than three times the gross domestic product per capita per quality adjusted life year (QALY) gained, or less than $3420 in Uganda.RESULTS: The prevalence of TDR is predicted to rise from 6.7$1612 to $2234 (IQR$450-dominated) per QALY gained.CONCLUSIONS: While earlier treatment initiation will result in a predicted increase in the proportion of patients infected with drug-resistant HIV, the absolute numbers of patients infected with drug-resistant HIV is predicted to decrease. Increasing use of second-line treatment to all patients with confirmed failure on first-line therapy is a cost-effective approach to reduce TDR. Improving access to second-line ART is therefore a major priority.INTRODUCTION: Earlier antiretroviral therapy (ART) initiation reduces HIV-1 incidence. This benefit may be offset by increased transmitted drug resistance (TDR), which could limit future HIV treatment options. We analyze the epidemiological impact and cost-effectiveness of strategies to reduce TDR