JAMA Internal Medicine: Health Care Reform Topic Collection

Availability of Consumer Prices From US Hospitals for a Common Surgical Procedure Availability of Consumer Prices From US Hospitals

Rosenthal JA, Lu X, Cram P. — Mon, 25 Mar 2013 00:00:00 GMT

Importance

Many proposals for health care reform incentivize patients to play a more active role in selecting health care providers on the basis of quality and price. While data on quality are increasingly available, availability of pricing data is uncertain.

Objective

To examine whether we could obtain pricing data for a common elective surgical procedure, total hip arthroplasty (THA).

Design

We randomly selected 2 hospitals from each state (plus Washington, DC) that perform THA, as well as the 20 top-ranked orthopedic hospitals according to US News and World Report rankings. We contacted each hospital by telephone between May 2011 and July 2012. Using a standardized script, we requested from each hospital the lowest complete “bundled price” (hospital plus physician fees) for an elective THA that was required by one of the author's 62-year-old grandmother. In our scenario, the grandmother did not have insurance but had the means to pay out of pocket. We explained that we were seeking the lowest complete price for the procedure. When we encountered hospitals that could provide the hospital fee only, we contacted a random hospital affiliated orthopedic surgery practice to obtain the physician fee. Each hospital was contacted up to 5 times in efforts to obtain pricing information.

Setting/Participants

All top-ranked and a sample of non–top-ranked US hospitals performing THA.

Main Outcome Measures

Percentage of hospitals able to provide a complete price estimate for THA (physician and hospital fee) for top-ranked and non–top-ranked hospitals and range of prices quoted by each group.

Results

Nine top-ranked hospitals (45%) and 10 non–top-ranked hospitals (10%) were able to provide a complete bundled price (P < .001). We were able to obtain a complete price estimate from an additional 3 top-ranked hospitals (15%) and 54 non–top-ranked hospitals (53%) (P = .002) by contacting the hospital and physician separately. The range of complete prices was wide for both top-ranked ($12 500-$105 000) and non–top-ranked hospitals ($11 100-$125 798).

Conclusions and Relevance

We found it difficult to obtain price information for THA and observed wide variation in the prices that were quoted. Many health care providers cannot provide reasonable price estimates. Patients seeking elective THA may find considerable price savings through comparison shopping.

Types and Origins of Diagnostic Errors in Primary Care Settings Diagnostic Errors in Primary Care

Singh H, Giardina T, Meyer AD, et al. — Mon, 25 Mar 2013 00:00:00 GMT

Importance

Diagnostic errors are an understudied aspect of ambulatory patient safety.

Objectives

To determine the types of diseases missed and the diagnostic processes involved in cases of confirmed diagnostic errors in primary care settings and to determine whether record reviews could shed light on potential contributory factors to inform future interventions.

Design

We reviewed medical records of diagnostic errors detected at 2 sites through electronic health record–based triggers. Triggers were based on patterns of patients' unexpected return visits after an initial primary care index visit.

Setting

A large urban Veterans Affairs facility and a large integrated private health care system.

Participants

Our study focused on 190 unique instances of diagnostic errors detected in primary care visits between October 1, 2006, and September 30, 2007.

Main Outcome Measures

Through medical record reviews, we collected data on presenting symptoms at the index visit, types of diagnoses missed, process breakdowns, potential contributory factors, and potential for harm from errors.

Results

In 190 cases, a total of 68 unique diagnoses were missed. Most missed diagnoses were common conditions in primary care, with pneumonia (6.7%), decompensated congestive heart failure (5.7%), acute renal failure (5.3%), cancer (primary) (5.3%), and urinary tract infection or pyelonephritis (4.8%) being most common. Process breakdowns most frequently involved the patient-practitioner clinical encounter (78.9%) but were also related to referrals (19.5%), patient-related factors (16.3%), follow-up and tracking of diagnostic information (14.7%), and performance and interpretation of diagnostic tests (13.7%). A total of 43.7% of cases involved more than one of these processes. Patient-practitioner encounter breakdowns were primarily related to problems with history-taking (56.3%), examination (47.4%), and/or ordering diagnostic tests for further workup (57.4%). Most errors were associated with potential for moderate to severe harm.

Conclusions and Relevance

Diagnostic errors identified in our study involved a large variety of common diseases and had significant potential for harm. Most errors were related to process breakdowns in the patient-practitioner clinical encounter. Preventive interventions should target common contributory factors across diagnoses, especially those that involve data gathering and synthesis in the patient-practitioner encounter.

Ask-Advise-Connect A New Approach to Smoking Treatment Delivery in Health Care Settings Ask-Advise-Connect Approach to Smoking Treatment

Vidrine J, Shete S, Cao Y, et al. — Mon, 25 Mar 2013 00:00:00 GMT

Importance

Several national health care–based smoking cessation initiatives have been recommended to facilitate the delivery of evidence-based treatments, such as quitline (telephone-based tobacco cessation services) assistance. The most notable examples are the 5 As (Ask, Advise, Assess, Assist, Arrange) and Ask. Advise. Refer. (AAR) programs. Unfortunately, rates of primary care referrals to quitlines are low, and most referred smokers fail to call for assistance.

Objective

To evaluate a new approach—Ask-Advise-Connect (AAC)—designed to address barriers to linking smokers with treatment.

Design

A pair-matched, 2-treatment-arm, group-randomized design in 10 family practice clinics in a single metropolitan area. Five clinics were randomized to the AAC (intervention) and 5 to the AAR (control) conditions. In both conditions, clinic staff were trained to assess and record the smoking status of all patients at all visits in the electronic health record, and smokers were given brief advice to quit. In the AAC clinics, the names and telephone numbers of smokers who agreed to be connected were sent electronically to the quitline daily, and patients were called proactively by the quitline within 48 hours. In the AAR clinics, smokers were offered a quitline referral card and encouraged to call on their own. All data were collected from February 8 through December 27, 2011.

Setting

Ten clinics in Houston, Texas.

Participants

Smoking status assessments were completed for 42 277 patients; 2052 unique smokers were identified at AAC clinics, and 1611 smokers were identified at AAR clinics.

Interventions

Linking smokers with quitline-delivered treatment.

Main Outcome Measure

Impact was based on the RE-AIM (Reach, Efficacy, Adoption, Implementation, and Maintenance) conceptual framework and defined as the proportion of all identified smokers who enrolled in treatment.

Results

In the AAC clinics, 7.8% of all identified smokers enrolled in treatment vs 0.6% in the AAR clinics (t₄ = 9.19 [P < .001]; odds ratio, 11.60 [95% CI, 5.53-24.32]), a 13-fold increase in the proportion of smokers enrolling in treatment.

Conclusions and Relevance

The system changes implemented in the AAC approach could be adopted broadly by other health care systems and have tremendous potential to reduce tobacco-related morbidity and mortality.