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1.  Cost, Coverage, and Comparative Effectiveness Research: The Critical Issues for Oncology 
Journal of Clinical Oncology  2012;30(34):4275-4281.
A new national initiative in comparative effectiveness research (CER) is part of a broad and long-term evolution toward greater reliance on scientific evidence in clinical practice and medical policy. But CER has been controversial because of its high profile in the health care reform effort, its instantiation in a prominent new national research institute, and lingering concerns that the ultimate goal of CER is to empower the government and private insurers to reduce health care costs by restricting access to expensive new medical tests and treatments. This article presents an analysis of the policy development behind CER and focuses on its potential impact on insurance coverage and payment for oncology services. By itself, CER will not solve the tension that exists between the goal of innovative, personalized care and the eroding affordability of cancer treatment in the United States. But CER does offer an important opportunity for progress. Oncologists have taken important first steps in acknowledging their responsibility for addressing cost issues; as a professional society, they should now move forward to assume leadership in the effort to integrate clinical evidence with considerations of cost effectiveness to guide clinical practice and insurer policies.
PMCID: PMC3504329  PMID: 23071229
3.  The Diagnostic Performance of Multi-slice Coronary Computed Tomographic Angiography: a Systematic Review 
The use of coronary computed tomographic angiography (CCTA) for evaluation of patients with suspected coronary artery disease (CAD) is growing rapidly, yet questions remain regarding its diagnostic accuracy and its impact on clinical decision-making and patient outcomes.
A systematic literature review was conducted to identify studies examining (a) CCTA’s diagnostic accuracy; and (b) the impact of CCTA on clinical decision-making and/or patient outcomes. Diagnostic accuracy estimates were limited to patient-based analyses of occlusion; outcome studies were eligible for inclusion if they involved patients at low-to-intermediate risk of CAD. Pooled accuracy estimates were derived using bivariate random effects models; non-diagnostic CCTA results were conservatively assumed to be false positives.
A total of 42 diagnostic accuracy studies and 11 patient outcome studies were identified. The pooled mean sensitivity for CCTA in primary analyses was 98% (95% CI: 96%, 99%); specificity was 85% (81%, 89%). A small number of outcome studies set primarily in the emergency department found triage of low-risk patients using CCTA produced no serious adverse outcomes and was time-saving relative to standard triage care. Outcome studies in the outpatient setting were limited to four case series that did not directly compare patient care or outcomes with those of contemporaneous patients evaluated without CCTA.
CCTA appears to have high diagnostic accuracy in patients with suspected CAD, but its potential impact on clinical decision-making and patient outcomes is less well-understood, particularly in non-emergent settings.
PMCID: PMC3043190  PMID: 21063800
multislice CT; coronary artery disease; diagnostic value; systematic review
4.  Active Surveillance Compared With Initial Treatment for Men With Low-Risk Prostate Cancer 
In the United States, 192 000 men were diagnosed as having prostate cancer in 2009, the majority with low-risk, clinically localized disease. Treatment of these cancers is associated with substantial morbidity. Active surveillance is an alternative to initial treatment, but long-term outcomes and effect on quality of life have not been well characterized.
To examine the quality-of-life benefits and risks of active surveillance compared with initial treatment for men with low-risk, clinically localized prostate cancer.
Design and Setting
Decision analysis using a simulation model was performed: men were treated at diagnosis with brachytherapy, intensity-modulated radiation therapy (IMRT), or radical prostatectomy or followed up by active surveillance (a strategy of close monitoring of newly diagnosed patients with serial prostate-specific antigen measurements, digital rectal examinations, and biopsies, with treatment at disease progression or patient choice). Probabilities and utilities were derived from previous studies and literature review. In the base case, the relative risk of prostate cancer–specific death for initial treatment vs active surveillance was assumed to be 0.83. Men incurred short- and long-term adverse effects of treatment.
Hypothetical cohorts of 65-year-old men newly diagnosed as having clinically localized, low-risk prostate cancer (prostate-specific antigen level <10 ng/mL, stage ≤T2a disease, and Gleason score ≤6).
Main Outcome Measure
Quality-adjusted life expectancy (QALE).
Active surveillance was associated with the greatest QALE (11.07 quality-adjusted life-years [QALYs]), followed by brachytherapy (10.57 QALYs), IMRT (10.51 QALYs), and radical prostatectomy (10.23 QALYs). Active surveillance remained associated with the highest QALE even if the relative risk of prostate cancer–specific death for initial treatment vs active surveillance was as low as 0.6. However, the QALE gains and the optimal strategy were highly dependent on individual preferences for living under active surveillance and for having been treated.
Under a wide range of assumptions, for a 65-year-old man, active surveillance is a reasonable approach to low-risk prostate cancer based on QALE compared with initial treatment. However, individual preferences play a central role in the decision whether to treat or to pursue active surveillance.
PMCID: PMC3055173  PMID: 21119084
5.  Does Affiliation of Physician Groups with One Another Produce Higher Quality Primary Care? 
Journal of General Internal Medicine  2007;22(10):1385-1392.
Recent reports have emphasized the importance of delivery systems in improving health care quality. However, few prior studies have assessed differences in primary care quality between physician groups that differ in size and organizational configuration. We examined whether larger physician group size and affiliation with networks of multiple groups are associated with higher quality of care.
We conducted a cross-sectional observational analysis of 132 physician groups (including 4,358 physicians) who delivered primary care services in Massachusetts in 2002. We compared physician groups on performance scores for 12 Health Plan Employer Data and Information Set (HEDIS) measures reflecting processes of adult primary care.
Network-affiliated physician groups had higher performance scores than non-affiliated groups for 10 of the 12 HEDIS measures (p < 0.05). There was no consistent relationship between group size and performance scores. Multivariable models including group size, network affiliation, and health plan showed that network-affiliated groups had higher performance scores than non-affiliated groups on 8 of the 12 HEDIS measures (p < 0.05), and larger group size was not associated with higher performance scores. Adjusted differences in the performance scores of network-affiliated and non-affiliated groups ranged from 2% to 15%. For 4 HEDIS measures related to diabetes care, performance score differences between network-affiliated and non-affiliated groups were most apparent among the smallest groups.
Physician group affiliation with networks of multiple groups was associated with higher quality, and for measures of diabetes care the quality advantage of network-affiliation was most evident among smaller physician groups.
PMCID: PMC2305845  PMID: 17594130
quality of care; primary care; HEDIS measures; health care organization
6.  On Track: A Database For Evaluating the Outpatient Clinical Experience of Internal Medicine Residency Training 
Residents in internal medicine training programs spend an increasing amount of time in the outpatient setting, creating the potential for substantial variability in educational experiences among residents. We developed a data management system (On Track) that combines information on clinical experiences collected from an electronic medical record (EMR) and handheld personal data assistants (PDA). This information is translated into easily interpretable graphics and reports that provide insight into the overall residency curriculum as well as the experiences of individual residents.
PMCID: PMC1480328  PMID: 14728505
7.  Talking About Money 
Patients sometimes express concern about the influence of “perverse” financial incentives on their care. We recruited a convenience sample of 101 primary care physicians and obtained information on their compensation. Then we audiotaped them as they role-played a response to a videotaped mock patient who asked them how they were paid and how their method of compensation affected clinical decisions. Overall, 36% of the physicians did not give enough information in their role-play response to allow an independent determination of how they were paid. Adopting a broad spectrum of attitudes and approaches, nearly every physician avoided discussing the role of incentives and stressed instead that he or she could be trusted under any circumstance.
PMCID: PMC1494992  PMID: 11903778
financial incentives; doctor patient communication; trust
8.  Does Physician Education on Depression Management Improve Treatment in Primary Care? 
To assess the effect of physician training on management of depression.
Primary care physicians were randomly assigned to a depression management intervention that included an educational program. A before-and-after design evaluated physician practices for patients not enrolled in the intervention trial.
One hundred nine primary care physicians in 2 health maintenance organizations located in the Midwest and Northwest regions of the United States.
Computerized pharmacy and visit data from a group of 124,893 patients who received visits or prescriptions from intervention and usual care physicians.
Primary care physicians received education on diagnosis and optimal management of depression over a 3-month training period. Methods of education included small group interactive discussions, expert demonstrations, role-play, and academic detailing of pharmacotherapy, criteria for urgent psychiatric referrals, and case reviews with psychiatric consultants.
Pharmacy and visit data provided indicators of physician management of depression: rate of newly diagnosed depression, new prescription of antidepressant medication, and duration of pharmacotherapy. One year after the training period, intervention and usual care physicians did not differ significantly in the rate of new depression diagnosis (P = .95) or new prescription of antidepressant medicines (P = .10). Meanwhile, patients of intervention physicians did not differ from patients of usual care physicians in adequacy of pharmacotherapy (P = .53) as measured by 12 weeks of continuous antidepressant treatment.
After education on optimal management of depression, intervention physicians did not differ from their usual care colleagues in depression diagnosis or pharmacotherapy.
PMCID: PMC1495259  PMID: 11556942
physician education; primary care; depression
9.  Patients' Trust in Physicians: Many Theories, Few Measures, and Little Data 
Trust is one of the central features of patient-physician relationships. Rapid changes in the health care system are feared by many to be threatening patients' trust in their physicians. Yet, despite its acknowledged importance and potential fragility, rigorous efforts to conceptualize and measure patient trust have been relatively few. This article presents a synopsis of theories about patient trust and the evolution of methods to measure it. Clinicians, educators, and researchers interested in this area may find this information useful in practice and teaching. The gaps identified in our knowledge about trust can help target new efforts to strengthen the methodological basis of work to understand this vital element of medical relationships.
PMCID: PMC1495476  PMID: 10940139
10.  Depression Among High Utilizers of Medical Care 
To determine the prevalence of unrecognized or unsuccessfully treated depression among high utilizers of medical care, and to describe the relation between depression, medical comorbidities, and resource utilization.
Three HMOs located in different geographic regions of the United States.
A total of 12,773 HMO members were identified as high utilizers. Eligibility criteria for depression screening were met by 10,461 patients.
Depression status was assessed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Depression screening was completed in 7,203 patients who were high utilizers of medical care, of whom 1,465 (20.3%) screened positive for current major depression or major depression in partial remission. Among depressed patients, 621 (42.4%) had had a visit with a mental health specialist or a diagnosis of depression or both within the previous 2 years. The prevalence of well-defined medical conditions was the same in patients with and patients without evidence of depression (41.5% vs 41.5%, p = .87). However, high-utilizing patients who had not made a visit for a nonspecific complaint during the previous 2 years were at significantly lower risk of depression (13.1% vs 22.4%, p < .001). Patients with current depression or depression in partial remission had significantly higher numbers of annual office visits and hospital days per 1,000 than patients without depression.
Although there was evidence that mental health problems had previously been recognized in many of the patients, a large percentage of high utilizers still suffered from active depression that either went unrecognized or was not being treated successfully. Patients who had not made visits for nonspecific complaints were at significantly lower risk of depression. Depression among high utilizers was associated with higher resource utilization.
PMCID: PMC1496724  PMID: 10491229
depression; health screening; primary care; health care utilization
11.  Communication Problems for Patients Hospitalized with Chest Pain 
In many settings, primary care physicians have begun to delegate inpatient care to hospitalists, but the impact of this change on patients' hospital experience is unknown. To determine the effect on physician-patient communication of having the regular outpatient physician (continuity physician) continue involvement in hospital care, we surveyed 1,059 consecutive patients hospitalized with chest pain. Patients whose continuity physicians remained involved in their hospital care were less likely to report communication problems regarding tests (20% vs 31%, p = .03), activity after discharge (42% vs 51%, p = .02), and health habits (31% vs 38%, p = .07). In a setting without a designated hospitalist system, communication problems were less frequent among patients whose continuity physicians were involved in their hospital care. New models of inpatient care delivery can maintain patient satisfaction but to do so must focus attention on improving physician-patient communication.
PMCID: PMC1497043  PMID: 9844081
patient-provider communication; quality of care; hospitalists; primary care
12.  Informal Consultations Provided to General Internists by the Gastroenterology Department of an HMO 
To study the process, outcomes, and time spent on informal consultations provided by gastroenterologists to the primary care general internists of an HMO.
Observational study.
A large, urban staff-model HMO.
Seven gastroenterologists constituting the total workforce of the gastroenterology department of the HMO.
Data on 91 informal consultations were obtained, of which 55 (60%) involved the acute management of a patient with new symptoms or test results, and 36 (40%) were for questions related to nonacute diagnostic test selection or medical therapy. Questions regarding patients previously unknown to the gastroenterology department accounted for 74 (81%) of the consultations. Formal referral was recommended in only 16 (22%) of these cases. As judged by the time data gathered on the 91 consultations, the gastroenterologists spent approximately 7.2 hours per week to provide informal consultation for the entire HMO.
Gastroenterologists spend a significant amount of time providing informal consultation to their general internist colleagues in this HMO. The role informal consultation plays in the workload of physicians and in the clinical care of populations is an important question for health care system design, policy, and research.
PMCID: PMC1496993  PMID: 9686708
informal consultation; gastroenterologists; health maintenance organization (HMO); physician workload

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