Medical care research and review : MCRR
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There is growing interest in shared decision making (SDM) in the United States and globally, at both the clinical and policy levels. SDM is typically employed during "preference-sensitive" decisions, where there is equipoise between treatment options with equal or similar outcomes from a medical standpoint. ⋯ In situations of low evidence, where evidence is conflicting, unavailable or not applicable to an individual patient, supporting SDM can present unique challenges, above and beyond the challenges faced during more standard preference-sensitive decisions. This article discusses challenges in supporting shared decisions when clinical evidence is low, describes strategies that can facilitate SDM despite low evidence, and suggests avenues for future research to explore further these proposed strategies.
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Risk adjustment of managed care organization (MCO) payments is essential to avoid creating financial incentives for MCOs adopting enrollee selection strategies. However, all risk-adjustment methods have an inherent structural flaw that rewards preventable deterioration in enrollee health status and improved coding of disease burden. We propose a payment adjustment to offset this flaw. ⋯ The payment impact caused by the change in enrollee health status across MCOs ranged from +3.67% to -7.27% for enrollees with diabetes and from +5.25% to -7.69% for enrollees with hypertension. The MCO payment impact for diabetes and hypertension ranged from +0.19% to -0.31%. This difference can be used as the basis for creating payment incentives for MCOs to reduce the long-term costs of chronically ill enrollees.
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Concern exists regarding care patients receive while boarding (staying in the emergency department [ED] after a decision to admit has been made). This exploratory study compares care for such ED patients under "Inpatient Responsibility" (IPR) and "ED Responsibility" (EDR) models using mixed methods. The authors abstracted quantitative data from 1,431 patient charts for ED patients admitted to two academic hospitals in 2004-2005 and interviewed 10 providers for qualitative data. ⋯ EDR patients had more delays to receiving home medications over the first 26 hours of admission but fewer while boarding; EDR patients had fewer delayed cardiac enzymes checks. Interviews revealed that culture, resource prioritization, and systems issues made care for boarded patients challenging. A theoretically better responsibility model may not deliver better care to boarded patients because of cultural, resource prioritization, and systems issues.
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Increased emergency department (ED) overcrowding has renewed interest in identifying remedies for unnecessary ED utilization. One potential remedy receiving more attention is patient-centered care. Relatively little is known, however, about how patient-centered care might decrease ED utilization. ⋯ Cross-sectional path analysis of 8,140 chronically ill patients found that patients reporting higher levels of patient-centered care were less likely to have experienced problems of care coordination, and in turn were associated with decreased likelihood of having delayed care and fewer ED visits. These findings suggest that understanding how care is delivered, and not simply whether it is available or provided, is an important consideration in understanding ED utilization. Our findings suggest that fostering more fair and respectful relationships between patients and providers may be a particularly important way of reducing ED utilization.
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Recent changes in diabetes treatment guidelines and the introduction of new, more expensive pharmaceuticals appear to increase the financial challenges for nonelderly adults with diabetes. The authors used Medical Expenditure Panel Survey data to examine changes in the prevalence of diabetes and comorbidities, diabetes treatment, financial burdens, and the relationship between high financial burdens and patient characteristics. ⋯ About a fifth of diabetes patients spent 10% or more of their family income on health care, and about one in nine spent 20% or more of their family income on health care. In 2006-2007, diabetes patients who were older, female, in poor health, or lacked insurance were more likely than others to have high burdens.