The future of value-based emergency care: Development of an emergency medicine MIPS value pathway framework.

The Centers for Medicare & Medicaid Services (CMS) implemented the Merit-based Incentive Payment System (MIPS) to accelerate the transition of physician payment toward value-based care models and away from traditional fee-for-service payment programs. In recent years, CMS has sought to modify the program by developing a MIPS Value Pathway (MVP) framework intended to use existing and future physician quality and cost measures to reward value-based care delivery. This article describes the multi-step process of the MVP Task Force, convened by the American College of Emergency Physicians (ACEP) to develop an emergency medicine-specific MVP proposal informed by diverse stakeholder perceptions regarding: (1) which existing quality measures reflect high quality emergency care, and (2) the degree to which emergency clinicians can impact clinical outcomes and cost for the care domains captured by existing quality measures.

Research Priorities in Pelvic Venous Disorders in Women: Recommendations from a Multidisciplinary Research Consensus Panel.

Pelvic venous disorders (PeVDs) in women can present with chronic pelvic pain, lower-extremity and vulvar varicosities, lower-extremity swelling and pain, and left-flank pain and hematuria. Multiple evidence gaps exist related to PeVDs with the consequence that nonvascular specialists rarely consider the diagnosis. Recognizing this, the Society of Interventional Radiology Foundation funded a Research Consensus Panel to prioritize a research agenda to address these gaps.

Risk-adjusted outcomes of inpatient medicare medical admissions.

It is important that actual outcomes of care and not surrogate markers, such as process measures, be used to evaluate the quality of inpatient care. Because of the heterogenous composition of patients, risk-adjustment is essential for the objective evaluation of outcomes following inpatient care. Comparative evaluation of risk-adjusted outcomes can be used to identify suboptimal performance and can provide direction for care improvement initiatives.

Inpatient and Postdischarge Outcomes Following Elective Craniotomy for Mass Lesions.

Background: Interpretation of hospital quality requires objective evaluation of both inpatient and postdischarge adverse outcomes (AOs).

Objective: To develop risk-adjusted predictive models for inpatient and 90-d postdischarge AOs in elective craniotomy and apply those models to individual hospital performance to provide benchmarks to improve care.

Methods: The Medicare Limited Dataset (2012-2014) was used to define all elective craniotomy procedures for mass lesions in patients ≥65 yr.

Medicare risk-adjusted outcomes in elective major vascular surgery.

Background: Risk-adjusted outcomes of elective major vascular surgery that is inclusive of inpatient and 90-day post-discharge adverse outcomes together have not been well studied.

Methods: We studied 2012-2014 Medicare inpatients who received open aortic procedures, open peripheral vascular procedures, endovascular aortic procedures, and percutaneous angioplasty procedures of the lower extremity for risk-adjusted adverse outcomes of inpatient deaths, 3-sigma prolonged length-of-stay outliers, 90-day post-discharge deaths without readmission, and 90-day post-discharge associated readmissions after excluding unrelated events. Observed and predicted total adverse outcomes for hospitals meeting minimum risk-volume criteria were assessed and hospital-specific z-scores and risk-adjusted adverse outcomes were calculated to compare performance.

Comparison of Risk-Adjusted Outcomes in Medicare Open Laparoscopic Cholecystectomy.

More than 90 per cent of cholecystectomies are performed laparoscopically and this has resulted in concern that surgeons will not have sufficient experience to perform open procedures when clinical circumstances require it. We reviewed the open cholecystectomies (OCs) of Medicare patients from 2010 to 2012 in hospitals with 20 or more cases, created risk-adjusted models for adverse outcomes which were evaluated for 90-days after discharge, and compared the hospital-level outcomes with laparoscopic cholecystectomy performed in the same hospitals for the same period of time. Results demonstrated that inpatient deaths, inpatient prolonged length-of-stay outliers, 90-day postdischarge deaths without readmission, and 90-day readmissions were statistically the same with an overall adverse outcome rate of 21.

Risk-adjusted hospital outcomes in elective carotid artery surgery in patients with Medicare.

Background: The risk-adjusted outcomes by hospital of elective carotid endarterectomy that is inclusive of inpatient and 90-day postdischarge adverse outcomes have not been studied.

Methods: We studied Medicare inpatients to identify hospitals with 25 or more qualifying carotid endarterectomy cases between 2012-2014. Risk-adjusted prediction models were designed for adverse outcomes of inpatient deaths, 3-sigma prolonged duration-of-stay outliers, 90-day postdischarge deaths without readmission, and 90-day postdischarge associated readmissions.

Peri-operative emergency department utilization in inpatient and outpatient Medicare laparoscopic cholecystectomy.

Background: Preoperative emergency department (ED) visits may reflect the patient's biliary disease, or may signal unstable comorbid conditions that have relevance following inpatient laparoscopic cholecystectomy (ILC) and outpatient laparoscopic cholecystectomy (OLC) in Medicare patients.

Methods: We used the Medicare inpatient and outpatient Limited Datasets to identify elective laparoscopic cholecystectomy patients from 2011 to 2014. ED visits for 30-days before the surgical event were identified and correlated with the probability of patients returning to the ED in the 30-days following the procedure.

Risk-adjusted regional outcomes in elective medicare colorectal surgery.

Background: Regional differences in utilization of services in healthcare are commonly understood, but risk-adjusted evaluation of outcomes has not been done.

Methods: Risk-adjusted adverse outcomes (AOs) for elective Medicare colorectal resections were studied for 2012-2014. Risk-adjusted metrics were inpatient deaths, prolonged postoperative length-of-stay, 90-day post-discharge deaths, and 90-day relevant post-discharge readmissions.

Inpatient and 90-day post-discharge outcomes in elective Medicare spine fusion surgery.

Background Context: Elective spine surgery is a commonly performed operative procedure, that requires knowledge of risk-adjusted results to improve outcomes and reduce costs.

Purpose: To develop risk-adjusted models to predict the adverse outcomes (AOs) of care during the inpatient and 90-day post-discharge period for spine fusion surgery.

Study Design/setting: To identify the significant risk factors associated with AOs and to develop risk models that measure performance.

Defining Potentially Preventable Adverse Outcomes in Medicare Elective Lung Resections.

Objective: The aims of the study were to develop risk-adjusted models and apply them for comparisons of hospital performance to define potentially preventable adverse outcomes (OAs) in Medicare lung resection surgery.

Methods: The Medicare Limited Data Set for 2010-2012 was used to design predictive risk models for the four OAs of inpatient deaths, prolonged length-of-stay outliers, 90-day postdischarge deaths without hospital readmission, and 90-day readmissions after removal of unrelated readmission events. The probability of adverse events for each hospital was used to compute the hospital-specific standard deviation (SD) tailored to patient risk profiles.

Risk-Adjusted Hospital Outcomes in Medicare Total Joint Replacement Surgical Procedures.

Background: Comparative measurement of hospital outcomes can define opportunities for care improvement and will assume great importance as alternative payment models for inpatient total joint replacement surgical procedures are introduced. The purpose of this study was to develop risk-adjusted models for Medicare inpatient and post-discharge adverse outcomes in elective lower-extremity total joint replacement and to apply these models for hospital comparison.

Methods: Hospitals with ≥50 qualifying cases of elective total hip replacement and total knee replacement from the Medicare Limited Data Set database of 2010 to 2012 were studied.

Emergency Department Visits Following Joint Replacement Surgery in an Era of Mandatory Bundled Payments.

Objectives: The Center for Medicare & Medicaid Services (CMS) is actively testing bundled payments models. This study sought to identify relevant details for 90-day postdischarge emergency department (ED) visits of Medicare beneficiaries following total joint replacement (TJR) surgery meeting eligibility for a CMS bundled payment program.

Methods: The CMS research identifiable file for the State of Texas for 2011-2012 was used to identify patients who underwent TJR.

Risk-adjusted outcomes in Medicare inpatient nephrectomy patients.

Without risk-adjusted outcomes of surgical care across both the inpatient and postacute period of time, hospitals and surgeons cannot evaluate the effectiveness of current performance in nephrectomy and other operations, and will not have objective metrics to gauge improvements from care redesign efforts.We compared risk-adjusted hospital outcomes following elective total and partial nephrectomy to demonstrate differences that can be used to improve care. We used the Medicare Limited Dataset for 2010 to 2012 for total and partial nephrectomy for benign and malignant neoplasms to create prediction models for the adverse outcomes (AOs) of inpatient deaths, prolonged length-of-stay outliers, 90-day postdischarge deaths without readmission, and 90-day relevant readmissions.

Benchmarking hospital outcomes for improvement of care in Medicare elective colon surgery.

Background: Risk-adjusted outcomes are essential for hospitals to benchmark care improvement.

Methods: We used the Medicare Limited Data Set for 2010 to 2012 to create risk models in elective colon surgery for the adverse outcomes (AOs) of inpatient deaths, prolonged length-of-stay outliers, 90-day post-discharge deaths without readmission, and 90-day relevant readmissions. Risk models permitted the prediction of AOs for each hospital and the design of hospital-specific standard deviations (SDs) to define performance from observed values.

The appropriate measurement of postdischarge readmissions in Medicare colon surgery.

Background: Readmissions after inpatient care are being used as a metric for clinical outcomes for surgeons and hospitals, but without standardization of the appropriate postdischarge period.

Methods: Elective colon surgery (ECS) for Medicare patients was reviewed to define the frequency and causes of readmission at 30, 60, and 90 days after discharge. Elective, trauma, and cancer readmissions were excluded.

A Summary of the American Society of Echocardiography Foundation Value-Based Healthcare: Summit 2014: The Role of Cardiovascular Ultrasound in the New Paradigm.

Value-Based Healthcare: Summit 2014 clearly achieved the three goals set forth at the beginning of this document. First, the live event informed and educated attendees through a discussion of the evolving value-based healthcare environment, including a collaborative effort to define the important role of cardiovascular ultrasound in that environment. Second, publication of these Summit proceedings in the Journal of the American Society of Echocardiography will inform a wider audience of the important insights gathered.

Commentary: A call to leadership: the role of the academic medical center in driving sustainable health system improvement through performance measurement.

As the government attempts to address the high cost of health care in the United States, the issues being confronted include variations in the quality of care administered and the inconsistent application of scientifically proven treatments. To improve quality, methods of measurement and reporting with rewards or, eventually, penalties based on performance, must be developed. To date, well-intentioned national policy initiatives, such as value-based purchasing, have focused primarily on the measurement of discrete events and on attempts to construct incentives.

Quality in clinical practice.

This paper reports the proceedings of the discussion panel assigned to look at clinical aspects of quality in emergency medicine. One of the seven stated objectives of the Academic Emergency Medicine consensus conference on quality in emergency medicine was to educate emergency physicians regarding quality measures and quality improvement as essential aspects of the practice of emergency medicine. Another topic of interest was a discussion of the value of information technology in facilitating quality care in the clinical practice of emergency medicine.