Research

The Center for Evaluating Health Reform leverages innovative team processes to produce grant proposals and research papers. We believe that generating these products can be done more efficiently and effectively through grant and paper sprints. Learn more about the sprint method here.

Grant Sprints

After a request for proposals (RFP) has been identified, the research team meets over two consecutive days for a focused development of the proposal narrative. The process begins by reviewing the RFP and critiquing the research project designed to address the questions in the RFP. In this way, limitations can be identified and rectified or addressed. The team then moves to drafting the proposal. Individuals are assigned a section of the narrative and all write simultaneously. The sections are then passed to other members of the team for review. In this way, each section of the narrative has been revised by at least two members of the research team. Because the various sections of the proposal are being written concurrently and the focused nature of meeting, at the end of the sprint, the research team has produced a near-final (if not final) version of the proposal with only minor tasks remaining. 

Download our Grant Sprint Manual here.

Paper Sprints

Paper sprints, like grant sprints, are focused meetings during which sections of a research paper are written concurrently by multiple members of a research team. In an initial planning sprint, the team will write the abstract, identify the analysis plan, identify the results we want to show and plan the next project steps. Then we spend one month performing the analysis according to the developed plans. Following analysis, the team meets to write the remaining portions of the paper in a 4-hour sprint.

Download our Paper Sprint Manual here

Association of Coded Severity with Readmission Reduction After the Hospital Readmissions Reduction Program

Andrew M. Ibrahim, Justin B. Dimick, Shashank S. Sinha, John M. Hollingsworth, Ushapoorna Nuliyalu, Andrew M. Ryan

Andrew Ibrahim Justin Dimick Shashank Sinha John Hollingsworth Andy Ryan

tipping scaleThe Hospital Readmission Reduction Program (HRRP), established in 2010, placed significant financial penalties on hospitals with rates of readmission that were higher than expected for 3 targeted medical conditions. Under the program, a hospital's readmission rate is adjusted based on patients' coded severity of illness. Although these adjustments reflect an effort from the Center for Medicare & Medicaid Services to avoid unfairly penalizing hospitals caring for patients with higher severity of illness, hospitals can improve their calculated rates of readmission by increasing their coded level of severity. It is unknown whether changes in coded severity of illness explain he previously described reductions in readmissions after implementation of the HRRP. 

The incremental effects of antihypertensive drugs: an instrumental variable analysis

Adam A. Markovitz, Jacob A. Mack, Brahmajee K. Nallamothu, John Z. Ayanian and Andrew M. Ryan

Adam Markovitz Brahmajee Nallamothu John Ayanian Andrew Ryan

person taking blood pressureThis work assesses the incremental effects of adding antihypertensive drugs to a patient's regimen while accounting for confounding by indication – when treatments appear less effective if used in sicker patients. The project uses randomized clinical trial data from 102 sites between 2010 and 2015 and instrumental variable analysis of Systolic Blood Pressure Intervention Trial (SPRINT) data, with random assignment to intensive versus standard treatment independently increasing the probability of a new drug class being added. In standard multivariable models not adjusted for confounding by indication, adding antihypertensive drugs was associated with modestly lower systolic blood pressure (SBP) (-1.3 mm Hg, 95% confidence interval [CI], -1.6 to -1.0) and no change in major cardiovascular events (absolute risk [AR] events per 1000 patient-years, 0.5, 95% CI, -1.5 to 2.3). In instrumental variable models, antihypertensive drugs were associated with clinically significant SBP reductions (-14.4 mm Hg, 95% CI, -15.6 to -13.3) and fewer major cardiovascular events (AR, -6.2, 95% CI, -10.9 to -1.3). SBP effects remained significant and similar in magnitude with each added drug and across all patient subgroups. Adding antihypertensive drugs was not associated with adverse events in either standard or instrumental variable models. After accounting for confounding by indication, adding antihypertensive drugs led to significant reductions in SBP and major cardiovascular events among patients at high risk for cardiovascular events but without diabetes. SBP effects persisted across all levels of baseline drug use and all patient subgroups.

The Effects of Risk-Adjustment on Episode Payments in Medicare's Cardiac Bundled Care Program

Adam A. Markovitz, Andrew M. Ryan, Chad Ellimoottil, Sam Mullangi, Devraj Sukul, Brahmajee Nallamothu and Lena Chen

Adam Markovitz Andrew Ryan Chad Ellimoottil Brahmajee Nallamothu Lena Chen

stethoscopeThe Acute Myocardial Infarction (AMI) and Coronary Artery Bypass Graft (CABG) Episode Payment Models (EPMs) are 90-day episode-based bundled payment initiatives of the Centers for Medicare & Medicaid Services (CMS) set to start in October 2017. By way of "reconciliation payments", CMS will financially penalize or reward hospitals for episode spending above or below a predetermined benchmark, respectively. This paper examines whether patients' medical complexity and/or social risk is associated with estimated hospital performance in cardiac EPMs. We first examined the relationship of hospitals' estimated reconciliation payments and the characteristics of Medicare fee-for-service beneficiaries who were hospitalized between January 1, 2011 and December 31, 2013 for Medicare-Severity Diagnosis Related Groups (MS-DRGs) relevant to the cardiac EPMs. We then estimated the financial impact of not accounting for medical complexity and/or social risk (i.e., risk-adjustment) in the calculation of reconciliation payments at both the hospital and state level. From 100% Medicare claims, we identified 331,592 episodes of fee-for-service beneficiaries 65 years or older hospitalized at 2,424 hospitals for AMI with medical management, AMI treated with percutaneous coronary intervention, or CABG. For each one-point increase in medical complexity, there was a $1,655 decrease in reconciliation payment per episode (95% confidence interval [CI], -$2139, -$1170; P<0.001). For each percentage-point increase in share of dual-eligible patients, there was a $34 decrease in reconciliation payment per episode (95% CI, -$42, -$25, P<0.001). Reconciliation payment per episode was not associated with hospitals' share of black patients, disability, or average neighborhood poverty. Accounting medical complexity in the calculation of reconciliation payments substantially reduced the financial burden imposed on: high medical-severity hospitals, reducing penalties from -$1,218 to -$512 per episode (net +$706, 95% CI, $503, $909; P<0.001); safety-net hospitals (net +$136, 95% CI, $104, $168; P<0.001); and minority-serving hospitals (net +$120, 95% CI, $100, $140; P<0.001). Accounting for social risk factors also increased payments to these hospitals, but resulted in minimal change after incorporating medical complexity. At the state-level, risk-adjustment increased payments throughout New England and the Mid-Atlantic and decreased payments in the Great Plains and Mountain West. Without accounting for these factors, we estimated that high-severity, safety-net, and minority-serving hospitals collectively stand to lose an additional $9.4M, $1.6M and $2.6M annually. Hospitals and states that serve medically complex or socially at-risk populations had lower reconciliation payments compared to other hospitals. By performing risk-adjustment in the calculation of reconciliation payments, CMS may mitigate this unintended consequence.

Modeling the Cost-Effectiveness of Pay-for-Performance in Primary Care for the UK

Ankur Pandya, Tim Dorna, Jinyi Zhu, Simon Walker, Emily Arntson and Andrew M. Ryan

englandIntroduced in 2004, the United Kingdom's Quality and Outcomes Framework (QOF) is the world's largest primary care pay-for-performance programme. We assessed the cost-effectiveness of continuing versus stopping the QOF. We developed a lifetime simulation model to estimate quality-adjusted life years (QALYs) and costs for a UK population cohort aged 40-74 years (n=27,070,862) exposed to the QOF and for a counterfactual scenario without exposure. Based on a previous retrospective cross-country analysis using data from 1994-2010, we assumed the benefits of the QOF to be a change in age-adjusted mortality of -3∙68 per 100,000 population (95% CI: -8∙16 to 0∙80). In our base-case analysis, we assumed that QOF-related mortality benefits were attributable to reductions in cardiovascular disease mortality. We estimated non-fatal health effects and increased healthcare utilization stemming from QOF incentives based on published sources and tested these assumptions in sensitivity analyses. We used cost-effectiveness thresholds of £30,000/QALY, £20,000/QALY, and £13,000/QALY to determine the optimal strategy in base-case and sensitivity analyses. In our base-case analysis, continuing the QOF increased population-level QALYs and healthcare costs yielding an incremental cost-effectiveness ratio (ICER) of £56,739/QALY. The ICER remained >£30,000/QALY in scenarios with and without including non-fatal outcomes or increased drug costs, and under differing assumptions about the duration of QOF benefit following its hypothetical discontinuation. The ICER for continuing the programme fell below £30,000/QALY when QOF incentive payments were 50% lower, and in scenarios where the QOF resulted in substantial reductions in healthcare spending or non-fatal cardiovascular disease events. Continuing the QOF was cost-effective in 6%, 0%, and 0% of probabilistic sensitivity analysis iterations using thresholds of £30,000/QALY, £20,000/QALY and £13,000/QALY, respectively. Estimated population opportunity cost of continuing the QOF was 312,246-1,178,695 QALYs lost. The UK should re-design the QOF or pursue alternative interventions to efficiently improve population health.

Surveys

heart handsHospital Administrator Perceptions on Value-Based Purchasing (HAPVBP) is a national survey of hospital administrators. This survey will inform policy decisions by shedding light on how administrators think about and navigate health reform.