BACKGROUND: Although Sjögren's syndrome has been known to complicate with white matter lesions, encephalopathy, or stroke, reports of cerebral venous sinus thrombosis due to Sjögren's syndrome with atypical antibodies are rare.
CASE REPORT: A 50-year-old woman was admitted to our neurological ward with nausea and vomiting following acute onset of severe headache in the left occipital region. Brain computed tomography revealed no abnormalities. The patient was fully conscious, with normal cognitive functioning, but exhibited unsteady tandem gait. Both magnetic resonance venography and computed tomography venography suggested left transverse sinus blockage. Intravenous enoxaparin, followed by oral warfarin, was initiated as treatment for cerebral venous sinus thrombosis. After investigation, Sjögren's syndrome was diagnosed and lupus anticoagulant antibody test was positive. The patient was treated with hydroxychloroquine, and appeared fully recovered at the 6-month follow-up, with no clinical or radiological signs of relapse.
CONCLUSION: This case reports the relationship between cerebral venous sinus thrombosis and Sjögren's syndrome. It is necessary to screen autoimmune disorders in patients with cerebral venous sinus thrombosis that present with no common risk factors of venous thrombosis in order to prevent inappropriate management, and potentially adverse outcomes.
OBJECTIVE: To evaluate the effects of the Premier Inc. and Centers for Medicare and Medicaid Services Hospital Quality Incentive Demonstration (PHQID), a public quality reporting and pay-for-performance (P4P) program, on Medicare patient mortality, cost, and outlier classification.
DATA SOURCES: The 2000-2006 Medicare inpatient claims, Medicare denominator files, and Medicare Provider of Service files.
STUDY DESIGN: Panel data econometric methods are applied to a retrospective cohort of 11,232,452 admissions from 6,713,928 patients with principal diagnoses of acute myocardial infarction (AMI), heart failure, pneumonia, or a coronary-artery bypass grafting (CABG) procedure from 3,570 acute care hospitals between 2000 and 2006. Three estimators are used to evaluate the effects of the PHQID on risk-adjusted (RA) mortality, cost, and outlier classification in the presence of unobserved selection, resulting from the PHQID being voluntary: fixed effects (FE), FE estimated in the subset of hospitals eligible for the PHQID, and difference-in-difference-in-differences.
DATA EXTRACTION METHODS: Data were obtained from CMS. Principal Findings. This analysis found no evidence that the PHQID had a significant effect on RA 30-day mortality or RA 60-day cost for AMI, heart failure, pneumonia, or CABG and weak evidence that the PHQID increased RA outlier classification for heart failure and pneumonia.
CONCLUSIONS: By not reducing mortality or cost growth, this study suggests that the PHQID has made little impact on the value of inpatient care purchased by Medicare.
OBJECTIVE: To evaluate the impact of offering US$100 each to patients and their obstetricians or midwives for timely and comprehensive prenatal care on low birth weight, neonatal intensive care admissions, and total pediatric health care spending in the first year of life.
DATA SOURCES/STUDY SETTING: Claims and enrollment profiles of the predominantly low-income and Hispanic participants of a union-sponsored, health insurance plan from 1998 to 2001.
STUDY DESIGN: Panel data analysis of outcomes and spending for participants and nonparticipants using instrumental variables to account for selection bias. DATA COLLECTION/ABSTRACTION METHODS: Data provided were analyzed using t-tests and chi-squared tests to compare maternal characteristics and birth outcomes for incentive program participants and nonparticipants, with and without instrumental variables to address selection bias. Adjusted variables were analyzed using logistic regression models.
PRINCIPLE FINDINGS: Participation in the incentive program was significantly associated with lower odds of neonatal intensive care unit admission (0.45; 95 percent CI, 0.23-0.88) and spending in the first year of life (estimated elasticity of -0.07; 95 percent CI, -0.12 to -0.01), but not low birth weight (0.53; 95 percent CI, 0.23-1.18).
CONCLUSION: The use of patient and physician incentives may be an effective mechanism for improving use of recommended prenatal care and associated outcomes, particularly among low-income women.
BACKGROUND: Tobacco quitlines offer clinicians a means to connect their patients with evidence-based treatments. Innovative methods are needed to increase clinician referral. METHODS: This is a clinic randomized trial that compared usual care (n = 25 clinics) vs a pay-for-performance program (intervention) offering $5000 for 50 quitline referrals (n = 24 clinics). Pay-for-performance clinics also received monthly updates on their referral numbers. Patients were eligible for referral if they visited a participating clinic, were 18 years or older, currently smoked cigarettes, and intended to quit within the next 30 days. The primary outcome was the clinic's rate of quitline referral (ie, number of referrals vs number of smokers seen in clinic). RESULTS: Pay-for-performance clinics referred 11.4% of smokers (95% confidence interval [CI], 8.0%-14.9%; total referrals, 1483) compared with 4.2% (95% CI, 1.5%-6.9%; total referrals, 441) for usual care clinics (P = .001). Rates of referral were similar in intervention vs usual care clinics (n = 9) with a history of being very engaged with quality improvement activities (14.1% vs 15.1%, respectively; P = .85). Rates were substantially higher in intervention vs usual care clinics with a history of being engaged (n = 22 clinics; 10.1% vs 3.0%; P = .001) or less engaged (n = 18 clinics; 10.1% vs 1.1%; P = .02) with quality improvement. The rate of patient contact after referral was 60.2% (95% CI, 49.7%-70.7%). Among those contacted, 49.4% (95% CI, 42.8%-55.9%) enrolled, representing 27.0% (95% CI, 21.3%-32.8%) of all referrals. The marginal cost per additional quitline enrollee was $300. CONCLUSION: A pay-for-performance program increases referral to tobacco quitline services, particularly among clinics with a history of less engagement in quality improvement activities.
PURPOSE: To determine whether a specific pay-for-performance program design will result in a decrease in global health care expenditures attributable to implementation of that program.
METHODS: A retrospective analysis was performed of costs referable to the health plan during a baseline year in comparison to the year following the program implementation. All claims paid during the year prior to program implementation (Baseline) were compared with all costs during the first year of program deployment (Intervention). The primary outcome measure was global health plan expenditure. Secondary outcomes measures included global health plan expenditures adjusted for catastrophic cases and changes in costs by provider type attributable to the program implementation.
RESULTS: Global expenditures, for Implementation relative to Baseline years, decreased to $2,049,780 from $2,316,929 (11.5%). When adjustment was made for catastrophic cases, costs decreased to $1,645,568 from $1,811,840 (9.2%). This cost reduction was achieved despite approximately a 10% increase in provider pricing per unit of service.
CONCLUSIONS: In this pilot, implementing the program was an effective way to reduce the total health care costs in the first year of implementation. This supports the concept and documents for the first time in a commercial population that an appropriately designed pay-for-performance system can reduce total health care costs by reduction in units of service. This reduction in units of service will more than offset a substantive increase in physician payment per unit of service. Pay-for-performance measures will impact the practice of ophthalmology as government, payers, employers, and consumers focus on value and on demonstrable, auditable outcomes of the care process.
With purchasers' increasing frustration with healthcare costs, more innovative approaches to performance-based reimbursement are in demand. Establishing pay-for-performance programs has become a popular strategy for reorienting payments from rewarding volume to rewarding adherence to performance measures. However, while performance on quality measures has improved, no reports exist about the return on investment (ROI) of pay-for-performance programs. This article compares the overall costs of implementing and maintaining a pay-for-performance program with the resulting cost trend savings for diabetes care for a health maintenance organization's (HMO's) population. The program was a five-year partnership (2000-2004) between a health plan and an independent practice association (IPA) for the HMO product. It reported performance scores on quality, patient satisfaction, and practitioner efficiency at the individual physician level. Physician performance reporting began in 1999, and payment for that performance began in 2002. The cost of the program was 1,150,000 dollars yearly. Savings for diabetes alone in 2003, the first post-intervention year, were 1,894,471dollars. Second-year (2004) savings against the two-year rolling trend were 2,923,761 dollars. For 2003, the resulting ROI was 1.6:1, and for 2004, it was 2.5:1. To our knowledge, this article is the first report of a positive ROI for an HMO-based pay-for-performance program, and it begins to answer the question of whether the investment in such programs is worth the effort.
One increasingly popular mechanism for stimulating quality improvements is pay-for-performance, or incentive, programs. This article examines the cost-effectiveness of a hospital incentive system for heart-related care, using a principal-agent model, where the insurer is the principal and hospitals are the agents. Four-year incentive system costsfor the payer were dollar 22,059,383, composed primarily of payments to the participating hospitals, with approximately 5 percent in administrative costs. Effectiveness is measured in stages, beginning with improvements in the processes of heart care. Care process improvements are converted into quality-adjusted life years (QALYs) gained, with reference to literatures on clinical effectiveness and survival. An estimated 24,418 patients received improved care, resulting in a range of QALYs from 733 to 1,701, depending on assumptions about clinical effectiveness. Cost per QALY was found to be between dollar 12,967 and dollar 30,081, a level well under consensus measures of the value of a QALY.
OBJECTIVE: To investigate the effect of performance-based financial incentives on the influenza immunization rate in primary care physicians' offices. DESIGN: Randomized controlled trial during the 1991 influenza immunization season. SETTING: Rochester, New York, and surrounding Monroe County during the Medicare Influenza Vaccine Demonstration Project. PARTICIPANTS: A total of 54 solo or group practices that had participated in the 1990 Medicare Demonstration Project. INTERVENTIONS: All physicians in participating practices agreed to enumerate their ambulatory patients aged 65 or older who had been seen during the 1990 or 1991 calendar years, and to track the immunization rate on a weekly basis using a specially designed poster from September 1991 to January 1, 1992. Additionally, physicians agreed to be randomized, by practice group, to the control group or to the incentive group, which could receive an additional $.80 per shot or $1.60 per shot if an immunization rate of 70% or 85%, respectively, was attained. MEASUREMENTS: The main outcome measures are the 1991 immunization rate and the improvement in immunization rate from the 1990 to 1991 influenza seasons for each group practice. RESULTS: For practices in the incentive group, the mean immunization rate was 68.6% (SD 16.6%) compared with 62.7% (SD 18.0%) in the control group practices (P = .22). The median practice-specific improvement in immunization rate was +10.3% in the incentive group compared with +3.5% in the control group (P = .03). CONCLUSIONS: Despite high background immunization rates, this modest financial incentive was responsible for approximately 7% increase in immunization rate among the ambulatory elderly.
A social experiment was conducted in San Diego to test the effectiveness of monetary incentives in improving the health of nursing home residents and lowering Medicaid expenditures. Use of a Markov model to represent the resulting health changes of nursing home residents shows that the monetary incentives had beneficial effects on both the quality and the cost of nursing home care. Moreover, the nursing homes admitted more people with severe disabilities, and the average length of their stays was shortened. If implemented, this kind of incentive program would save Medicaid substantial amounts of money, but not through lowering nursing home payments. Instead, the more efficient use of nursing homes would transfer more people out of hospitals and thereby save unnecessary hospital reimbursement.
Although Sjögren's syndrome has been known to complicate with white matter lesions, encephalopathy, or stroke, reports of cerebral venous sinus thrombosis due to Sjögren's syndrome with atypical antibodies are rare.
CASE REPORT:
A 50-year-old woman was admitted to our neurological ward with nausea and vomiting following acute onset of severe headache in the left occipital region. Brain computed tomography revealed no abnormalities. The patient was fully conscious, with normal cognitive functioning, but exhibited unsteady tandem gait. Both magnetic resonance venography and computed tomography venography suggested left transverse sinus blockage. Intravenous enoxaparin, followed by oral warfarin, was initiated as treatment for cerebral venous sinus thrombosis. After investigation, Sjögren's syndrome was diagnosed and lupus anticoagulant antibody test was positive. The patient was treated with hydroxychloroquine, and appeared fully recovered at the 6-month follow-up, with no clinical or radiological signs of relapse.
CONCLUSION:
This case reports the relationship between cerebral venous sinus thrombosis and Sjögren's syndrome. It is necessary to screen autoimmune disorders in patients with cerebral venous sinus thrombosis that present with no common risk factors of venous thrombosis in order to prevent inappropriate management, and potentially adverse outcomes.
