The growing awareness of the wide variation in health care prices, increased availability of price data, and increased patient cost sharing are expected to drive patients to shop for lower-cost medical services. We conducted a nationally representative survey of 2,996 nonelderly US adults who had received medical care in the previous twelve months to assess how frequently patients are price shopping for care and the barriers they face in doing so. Only 13 percent of respondents who had some out-of-pocket spending in their last health care encounter had sought information about their expected spending before receiving care, and just 3 percent had compared costs across providers before receiving care. The low rates of price shopping do not appear to be driven by opposition to the idea: The majority of respondents believed that price shopping for care is important and did not believe that higher-cost providers were of higher quality. Common barriers to shopping included difficulty obtaining price information and a desire not to disrupt existing provider relationships.

A key challenge in widespread application of NLP is adapting existing systems to new clinical settings.

Background Colonoscopy is the predominant method for colorectal cancer screening in the US. Prior studies have documented variation across physicians in colonoscopy quality as measured by the adenoma detection rate (ADR). ADR is the primary quality measure of colonoscopy exams and an indicator of the likelihood of subsequent patient colorectal cancer. There is interest in mechanisms to improve ADR. In Central Illinois, a local employer and a quality improvement organization partnered to publically report physician colonoscopy quality. Objective To assess whether this initiative was associated with an improvement in ADR. Design This study compares ADR before and after public reporting at a private practice endoscopy center of 11 gastroenterologists in Peoria, Illinois who participated in the initiative. To generate ADR, colonoscopy and pathology reports from exams performed over four years at the endoscopy center were analyzed using previously validated natural language processing software. Setting Central Illinois Endoscopy Center Results The ADR for colonoscopy in the pre-public reporting era was 25.1%, and after public reporting was 36.4% (increase of 11.3%, p<0.001). Detection of advanced adenomas increased from 10.0% to 12.7% (p<0.001). Each physician’s ADR increased (range of 4.3% to 17.4%). Similar increases in ADR were observed when the analysis was restricted to screening colonoscopy. Limitation There was no concurrent control group to assess whether the increased ADR was due to a secular trend. Conclusion A public reporting initiative on colonoscopy quality was associated with a relative forty-five percent increase in ADR and a 25% increase in advanced adenoma detection. Public reporting may be a means to improve colonoscopy quality.

Background The adenoma detection rate (ADR) is a validated and widely used measure of colonoscopy quality. There is uncertainty in the published literature on which colonoscopy examinations should be excluded when measuring a physician’s ADR. Objective To examine the impact of varying the colonoscopy exclusion criteria on physician ADR. Design We applied different exclusion criteria used in 30 prior studies to a dataset of endoscopy and pathology reports. Under each exclusion criterion, we calculated physician ADR. Setting A private practice colonoscopy center affiliated with the University of Illinois College of Medicine. Patients Data on 20,040 colonoscopy examinations and associated pathology notes performed by 11 gastroenterologists from July 2009 to May 2013. Main Outcome Measurements ADR across all colonoscopy exainations, each physician’s ADR, and ADR ranking. Results There were 28 different exclusion criteria used when measuring ADR. Each study used a different combination of these exclusion criteria. The fraction of all colonoscopy examinations in the dataset excluded under these combinations of exclusion criteria ranged from 0 to 93.1%. The mean ADR across all colonoscopy examination was 35.9%. The change in mean ADR after applying the 28 exclusion criteria ranged from −4.6 to +3.1 percentage points. However, the exclusion criteria impacted each physician’s ADR relatively equally, and therefore physicians’ rankings via ADR were stable. Limitations ADR assessment was limited to a single private endoscopy center. Conclusions There is wide variation in the exclusion criteria used when measuring ADR. Although these exclusion criteria can impact overall ADR, the relative rankings of physicians by ADR were stable. A consensus definition on which exclusion criteria are applied when measuring ADR is needed.

Under health care reform, a series of new financing and delivery models are being piloted to integrate health and long-term care services for older adults. To date, these programs have not encompassed residential care facilities, with most programs focusing on long-term care recipients in the community or the nursing home. Our analyses indicate that individuals living in residential care facilities have similarly high rates of chronic illness and Medicare utilization when compared with similar populations in the community and nursing home. These results suggest the residential care facility population could benefit greatly from models that coordinate health and long-term care. However, few providers have invested in integrated delivery models. Several challenges exist toward greater integration including the private payment of residential care facility services and the fact that residential care facilities do not share in any Medicare savings due to improved coordination of care.