Dr. Milstein is a Professor of Medicine at Stanford and directs the University’s Clinical Excellence Research Center. The Center engages faculty from Health, Computer, and Social Sciences in the discovery and replication of innovative health care delivery methods that safely lower per capita health care spending for excellent care.

Before joining Stanford's faculty, his career of applied research spanned private and public sector healthcare delivery and policy. After creating a healthcare performance improvement firm that he expanded globally following its acquisition by Mercer, he co-founded three nationally influential public benefit initiatives, the Leapfrog Group in partnership with the Business Roundtable in 1998 and the Consumer Purchaser Alliance in 2001. Appointed to consecutive term as a Congressional MedPAC Commissioner, he originated two subsequently enacted legislative changes to improve the value of healthcare. He was a founding staff member and serves as the Medical Director of the Pacific Business Group on Health (PBGH), the largest employer-led regional healthcare improvement coalition in the U.S.

Citing his national impact on innovation in health care policy and delivery methods, he was selected for the highest annual award of both the National Business Group on Health (NBGH) and of the American College of Medical Quality. Elected to the Institute of Medicine (now, NAM) of the National Academy of Sciences, he chaired the planning committee of its workshop series on best methods to lower per capita health care spending and improve clinical outcomes. He was educated at Harvard (BA–Economics), Tufts (MD) and UC Berkeley (MPH Healthcare Evaluation).

Professional Education

  • MPH, University of California, Berkeley, Health Care Evaluation
  • Residency, Mount Zion Hospital, SF, Psychiatry
  • Internship, Mount Zion Hospital, SF, Medicine & Psychiatry
  • MD, Tufts University, Medicine
  • BA, Harvard Univerisity, Economics

Current Research and Scholarly Interests

Design national demonstration of innovations in care delivery that provide more with less. Informed by research on AI-assisted clinical workflow, positive value outlier analysis and triggers of loss aversion bias among patients and clinicians.

Research on creation of a national index of health system productivity gain.

Clinical Trials

  • Spine Pain INtervention to Enhance Care Quality And Reduce Expenditure Not Recruiting

    Low back and neck pain are among the leading causes of medical visits, lost productivity and disability. There is an urgent need to identify effective and efficient ways of helping subjects with acute spine pain while guiding practitioners towards high-value care. This trial will be a block and cluster-randomized open-label multi-centered pragmatic randomized clinical trial comparing healthcare spending and clinical outcomes for subjects with spine pain of less than three months' duration, in whom there are no red flag signs or symptoms. Subjects will be randomized to one of three treatment strategies: (1) usual primary care provider-led care; (2) usual PCP-led care with spine pain treatment directed by the Identify, Coordinate, and Enhanced decision making (ICE) care model, and (3) usual PCP-led care with spine pain treatment directed by the Individualized Postural Therapy (IPT) care model. Our outcomes of interest will be spine-related healthcare utilization at one year as well as pain and functionality of the study participants.

    Stanford is currently not accepting patients for this trial.

    View full details


  • Post-Doctoral Mentor, Stanford (2022 - Present)

    Ethan Goh MD
    Kyung Mi Kim PhD


    453 Quarry Rd CAM Palo Alto

  • Graduate Student Mentor, Stanford University

    Advise multiple CS graduate students and junior faculty participating in PAC ambient intelligent healthcare research portfolio


    75 Alta Road, Stanford, CA 94305

2023-24 Courses

Stanford Advisees

All Publications

  • Safety vs price in the generic drug market: metformin. The American journal of managed care Teasdale, B., Hudspeth, A., Kucera, K., Light, D., Nailor, J., Williams, S., Milstein, A., Schulman, K. A. 2024; 30 (4): 161-168


    Generic medications represent 90% of prescriptions in the US market and provide a tremendous financial benefit for patients. Recently, multiple generic drugs have been recalled due to the presence of carcinogens, predominantly N-nitrosodimethylamine (NDMA), including an extensive recall of extended-release (ER) metformin products in 2020.Primary pharmaceutical quality testing and database analysis.We tested marketed metformin immediate-release (IR) and ER tablets from a wide sample of generic manufacturers for the presence of carcinogenic impurities NDMA and N,N-dimethylformamide (DMF). We examined the association of level of impurity with drug price and the impact of the 2020 FDA recalls on unit price and prescription fill rate.Postrecall NDMA levels were significantly lower in metformin ER samples (standardized mean difference = -2.0; P = .01); however, we found continued presence of carcinogens above the FDA threshold in 2 of 30 IR samples (6.67%). Overall, the presence of contaminant levels was not significantly associated with price for either IR (NDMA: R2 = 0.142; P = .981; DMF: R2 = 0.382; P = .436) or ER (NDMA: R2 = 0.124; P = .142; DMF: R2 = 0.199; P = .073) samples. Despite recalls, metformin ER prescription fills increased by 8.9% while unit price decreased by 19.61% (P < .05).Recalls of metformin ER medications were effective in lowering NDMA levels below the FDA threshold; however, some samples of generic metformin still contained carcinogens even after FDA-announced recalls. The absence of any correlation with price indicates that potentially safer products are available on the market for the same price as poorer-quality products.

    View details for DOI 10.37765/ajmc.2024.89450

    View details for PubMedID 38603530

  • Influence of a Large Language Model on Diagnostic Reasoning: A Randomized Clinical Vignette Study. medRxiv : the preprint server for health sciences Goh, E., Gallo, R., Hom, J., Strong, E., Weng, Y., Kerman, H., Cool, J., Kanjee, Z., Parsons, A. S., Ahuja, N., Horvitz, E., Yang, D., Milstein, A., Olson, A. P., Rodman, A., Chen, J. H. 2024


    Diagnostic errors are common and cause significant morbidity. Large language models (LLMs) have shown promise in their performance on both multiple-choice and open-ended medical reasoning examinations, but it remains unknown whether the use of such tools improves diagnostic reasoning.To assess the impact of the GPT-4 LLM on physicians' diagnostic reasoning compared to conventional resources.Multi-center, randomized clinical vignette study.The study was conducted using remote video conferencing with physicians across the country and in-person participation across multiple academic medical institutions.Resident and attending physicians with training in family medicine, internal medicine, or emergency medicine.Participants were randomized to access GPT-4 in addition to conventional diagnostic resources or to just conventional resources. They were allocated 60 minutes to review up to six clinical vignettes adapted from established diagnostic reasoning exams.The primary outcome was diagnostic performance based on differential diagnosis accuracy, appropriateness of supporting and opposing factors, and next diagnostic evaluation steps. Secondary outcomes included time spent per case and final diagnosis.50 physicians (26 attendings, 24 residents) participated, with an average of 5.2 cases completed per participant. The median diagnostic reasoning score per case was 76.3 percent (IQR 65.8 to 86.8) for the GPT-4 group and 73.7 percent (IQR 63.2 to 84.2) for the conventional resources group, with an adjusted difference of 1.6 percentage points (95% CI -4.4 to 7.6; p=0.60). The median time spent on cases for the GPT-4 group was 519 seconds (IQR 371 to 668 seconds), compared to 565 seconds (IQR 456 to 788 seconds) for the conventional resources group, with a time difference of -82 seconds (95% CI -195 to 31; p=0.20). GPT-4 alone scored 15.5 percentage points (95% CI 1.5 to 29, p=0.03) higher than the conventional resources group.In a clinical vignette-based study, the availability of GPT-4 to physicians as a diagnostic aid did not significantly improve clinical reasoning compared to conventional resources, although it may improve components of clinical reasoning such as efficiency. GPT-4 alone demonstrated higher performance than both physician groups, suggesting opportunities for further improvement in physician-AI collaboration in clinical practice.

    View details for DOI 10.1101/2024.03.12.24303785

    View details for PubMedID 38559045

    View details for PubMedCentralID PMC10980135

  • Association between maternal employment status and presence of children with major congenital anomalies in Denmark. BMC public health Kim, K. M., Farkas, D. K., Wong, V., Hjorth, C. F., Horváth-Puhó, E., Cahan, E., Cohen, E., Shah, N. R., Sørensen, H. T., Milstein, A. 2024; 24 (1): 715


    The burden of caring for children with complex medical problems such as major congenital anomalies falls principally on mothers, who in turn suffer a variety of potentially severe economic consequences. As well, health consequences of caregiving often further impact the social and economic prospects of mothers of children with major congenital anomalies (MCMCAs). Evaluating the long-term economic consequences of extensive in-home caregiving among MCMCAs can inform strategies to mitigate these effects.To assess whether MCMCAs face reduced employment and increased need for disability benefits over a 20-year period.A population-based matched cohort study.Denmark.All women who gave birth to a singleton child with a major congenital anomaly in Denmark between January 1, 1997 and December 31, 2017 (n = 23,637) and a comparison cohort of mothers matched by maternal age, parity, and infant's year of birth (n = 234,586).Liveborn infant with a major congenital anomaly.The primary outcome was mothers' employment status, stratified by their child's age. Employment status was categorized as employed, outside the workforce (on temporary leave, holding a flexible job, or pursuing education), or unemployed; the number of weeks in each category was measured over time. The secondary outcome was time to receipt of a disability pension, which in Denmark implies permanent exit from the labor market. We used a negative binomial regression model to estimate the number of weeks in each employment category, stratified by the child's age (i.e., 0-1 year, > 1-6 years, 7-13 years, 14-18 years). A Cox proportional hazards regression model was used to compute hazard ratios as a measure of the relative risk of receiving a disability pension. Rate ratios and hazard ratios were adjusted for maternal demographics, pregnancy history, health, and infant's year of birth.During 1-6 years after delivery, MCMCAs were outside the workforce for a median of 50 weeks (IQR, 6-107 weeks), while members of the comparison cohort were outside the workforce for a median of 48 weeks (IQR, 4-98 weeks), corresponding to an adjusted rate ratio [ARR] of 1.05 (95% confidence interval [CI], 1.04-1.07). During the first year after delivery, MCMCAs were more likely to be employed than mothers in the comparison cohort (ARR, 1.08; 95% CI, 1.06-1.10). At all timepoints thereafter, MCMCAs had a lower rate of workforce participation. The rate of being outside the workforce was 5% higher than mothers in the comparison cohort during 1-6 years after delivery (ARR, 1.05; 95% CI, 1.04-1.07), 9% higher during 7-13 years after delivery (ARR, 1.09; 95% CI, 1.06-1.12), and 12% higher during 14-18 years after delivery (ARR, 1.12; 95% CI, 1.07-1.18). Overall, MCMCAs had a 20% increased risk of receiving a disability pension during follow-up than mothers in the matched comparison cohort [incidence rates 3.10 per 1000 person-years (95% CI, 2.89-3.32) vs. 2.34 per 1000 person-years (95% CI, 2.29-2.40), adjusted hazard ratio, 1.20; 95% CI, 1.11-1.29].MCMCAs were less likely to participate in the Danish workforce, less likely to be employed, and more likely to receive disability pensions than mothers of unaffected children. The rate of leaving the workforce intensified as their affected children grew older. The high demands of caregiving among MCMCAs may have long-term employment consequences even in nations with comprehensive and heavily tax-supported childcare systems, such as Denmark.

    View details for DOI 10.1186/s12889-024-18190-w

    View details for PubMedID 38443822

    View details for PubMedCentralID 7203968

  • Evidence for changes in screen use in the US during early childhood related to COVID-19 pandemic parent stressors. JMIR pediatrics and parenting Glassman, J., Humphreys, K. L., Jauregui, A., Milstein, A., Sanders, L. 2024


    BACKGROUND: The COVID-19 pandemic transformed the home lives of many families in the US, especially those with young children. Understanding the relationship between child and parent screen time and family stressors exacerbated by the pandemic may help inform interventions that aim to support early child development.OBJECTIVE: To assess the changing relationship between family screen time and factors related to pandemic-induced remote work and childcare/school closures.METHODS: Design, Setting, and Participants: In spring of 2021 we administered a survey, similar to one administered in spring of 2019, to a national sample of parents of young children (aged 6 to 60 months). Using iterative sampling with propensity scores, we recruited participants whose sociodemographic characteristics matched the 2019 survey. Participants were >18 years of age, proficient in English or Spanish, and residing in the US. Main Outcomes and Measures: The main outcomes were changes in child screen time (e.g., mobile phone, tablet, computer, television) and parenting technoference, defined as perceived screen-related interference with parent-child interactions. Additional survey items reported pandemic-related job loss, and changes to work hours, work location, caregiving responsibilities, daycare/school access, and family health and socioeconomic status.RESULTS: We enrolled 280 parents, from diverse backgrounds. Parents reported pandemic-related changes in child screen time (mean increase of 1.1 hour, SD 0.9), and greater parenting technoference (3.0 to 3.4 devices interfering per day; P=.01). Increased child screen time and parenting technoference were highest for parents experiencing job loss (mean change in child screen time 1.46 (SD 1.03); mean parenting technoference score 3.89 (SD 2.05)), second highest for working parents who did not lose their job (mean change in child screen time=1.02 (SD 0.83); mean parenting technoference score 3.37 (SD 1.94), and lowest for non-working parents (mean change in child screen time 0.68 (SD 0.66); mean parenting technoference score 2.66 (SD 1.70)), with differences significant at P<.01. School closure and job loss were most associated with increased child screen time during the pandemic after controlling for other stressors and sociodemographic characteristics (d=0.52, P<.001; d=0.31, P=.01). Increased child screen time and school closure were most associated with increased parenting technoference (d=0.78, P<.001; d=0.30, P=.01).CONCLUSIONS: Work and school changes due to the COVID-19 pandemic were associated with increased technology interference in the lives of young children. This study adds to our understanding of the interaction between technology use in the home and social factors that are necessary to support early child health and development. It also supports possible enhanced recommendations for primary-care providers and child-care educators to guide parents in establishing home-based "screen time rules" not only for their children but also for themselves.CLINICALTRIAL:

    View details for DOI 10.2196/43315

    View details for PubMedID 38446995

  • Innovation Diffusion Across 13 Specialties and Associated Clinician Characteristics. Advances in health care management Novikov, Z., Singer, S. J., Milstein, A. 2024; 22


    Diffusion of innovations, defined as the adoption and implementation of new ideas, processes, products, or services in health care, is both particularly important and especially challenging. One known problem with adoption and implementation of new technologies is that, while organizations often make innovations immediately available, organizational actors are more wary about adopting new technologies because these may impact not only patients and practices but also reimbursement. As a result, innovations may remain underutilized, and organizations may miss opportunities to improve and advance. As innovation adoption is vital to achieving success and remaining competitive, it is important to measure and understand factors that impact innovation diffusion. Building on a survey of a national sample of 654 clinicians, our study measures the extent of diffusion of value-enhancing care delivery innovations (i.e., technologies that not only improve quality of care but has potential to reduce care cost by diminishing waste, Faems et al., 2010) for 13 clinical specialties and identifies healthcare-specific individual characteristics such as: professional purview, supervisory responsibility, financial incentive, and clinical tenure associated with innovation diffusion. We also examine the association of innovation diffusion with perceived value of one type of care delivery innovation - artificial intelligence (AI) - for assisting clinicians in their clinical work. Responses indicate that less than two-thirds of clinicians were knowledgeable about and aware of relevant value-enhancing care delivery innovations. Clinicians with broader professional purview, more supervisory responsibility, and stronger financial incentives had higher innovation diffusion scores, indicating greater knowledge and awareness of value-enhancing, care delivery innovations. Higher levels of knowledge of the innovations and awareness of their implementation were associated with higher perceptions of the value of AI-based technology. Our study contributes to our knowledge of diffusion of innovation in healthcare delivery and highlights potential mechanisms for speeding innovation diffusion.

    View details for DOI 10.1108/S1474-823120240000022005

    View details for PubMedID 38262012

  • ChatGPT Influence on Medical Decision-Making, Bias, and Equity: A Randomized Study of Clinicians Evaluating Clinical Vignettes. medRxiv : the preprint server for health sciences Goh, E., Bunning, B., Khoong, E., Gallo, R., Milstein, A., Centola, D., Chen, J. H. 2023


    In a randomized, pre-post intervention study, we evaluated the influence of a large language model (LLM) generative AI system on accuracy of physician decision-making and bias in healthcare. 50 US-licensed physicians reviewed a video clinical vignette, featuring actors representing different demographics (a White male or a Black female) with chest pain. Participants were asked to answer clinical questions around triage, risk, and treatment based on these vignettes, then asked to reconsider after receiving advice generated by ChatGPT+ (GPT4). The primary outcome was the accuracy of clinical decisions based on pre-established evidence-based guidelines. Results showed that physicians are willing to change their initial clinical impressions given AI assistance, and that this led to a significant improvement in clinical decision-making accuracy in a chest pain evaluation scenario without introducing or exacerbating existing race or gender biases. A survey of physician participants indicates that the majority expect LLM tools to play a significant role in clinical decision making.

    View details for DOI 10.1101/2023.11.24.23298844

    View details for PubMedID 38076944

    View details for PubMedCentralID PMC10705632

  • Engagement of Patients with Advanced Cancer (EPAC) randomized clinical trial: Long-term effects on survival and healthcare use Patel, M. I., Agrawal, M., Kapphahn, K., Blayney, D. W., Asch, S., Bundorf, M., Milstein, A. LIPPINCOTT WILLIAMS & WILKINS. 2023
  • Biopsychosocial Intervention or Postural Therapy in Patients With Spine Pain Reply JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Hsu, E., Milstein, A., Choudhry, N. 2023; 329 (16): 1408-1409
  • Caring for People With Depression: Costs Among 43 Million Commercially Insured Patients With or Without Comorbid Illnesses. Annals of behavioral medicine : a publication of the Society of Behavioral Medicine Glassman, J. R., Jauregui, A., Milstein, A., Kaplan, R. M. 2023


    Depression is a common comorbidity for patients with chronic medical conditions. Although the costs of treating chronic medical illness in combination with depression are believed to be significantly higher than the costs of treating each condition independently, few studies have formally modeled the cost consequences of mental health comorbidity.To estimate the relative magnitude of the independent and synergistic contributions to health care costs from depression diagnosis and other chronic physical health conditions.Cross-sectional, observational study using all individuals >18 years of age in the national Blue Cross Blue Shield (BCBS) Axis claims database (N = 43,872,144) from calendar year 2018. General linear models with and without interaction terms were used to assess the relative magnitude of independent and synergistic contributions to total annual health care costs of depression alone and in combination with coronary heart disease, chronic kidney disease, chronic obstructive pulmonary disease, diabetes (both types 1 and 2), hypertension, and arthritis.The incremental annual cost associated with having a diagnosis of depression was $2,951 compared to $1,986-$6,251 for the other chronic physical conditions. The interaction between depression and chronic conditions accounted for less than one-hundredth of the amount of variation in costs explained by the main effects of depression and each chronic physical condition.The independent increase in total annual health care costs associated with a depression diagnosis was comparable to that of many common physical chronic conditions. This finding underscores the importance of health care service and payment models that acknowledge depression as an equal contributor to overall health care costs. The combination of depression and another chronic condition did not synergistically increase total annual health care costs beyond the increases in costs associated with each condition independently. This finding has implications for simplifying risk adjustment models.

    View details for DOI 10.1093/abm/kaac063

    View details for PubMedID 37001050

  • Using Case Mix Index within Diagnosis-Related Groups to Evaluate Variation in Hospitalization Costs at a Large Academic Medical Center. AMIA ... Annual Symposium proceedings. AMIA Symposium Pi, S., Masterson, J., Ma, S. P., Corbin, C. K., Milstein, A., Chen, J. H. 2023; 2023: 1201-1208


    In analyzing direct hospitalization cost and clinical data from an academic medical center, commonly used metrics such as diagnosis-related group (DRG) weight explain approximately 37% of cost variability, but a substantial amount of variation remains unaccounted for by case mix index (CMI) alone. Using CMI as a benchmark, we isolate and target individual DRGs with higher than expected average costs for specific quality improvement efforts. While DRGs summarize hospitalization care after discharge, a predictive model using only information known before admission explained up to 60% of cost variability for two DRGs with a high excess cost burden. This level of variability likely reflects underlying patient factors that are not modifiable (e.g., age and prior comorbidities) and therefore less useful for health systems to target for intervention. However, the remaining unexplained variation can be inspected in further studies to discover operational factors that health systems can target to improve quality and value for their patients. Since DRG weights represent the expected resource consumption for a specific hospitalization type relative to the average hospitalization, the data-driven approach we demonstrate can be utilized by any health institution to quantify excess costs and potential savings among DRGs.

    View details for DOI 10.1089/pop.2013.0002

    View details for PubMedID 38222372

    View details for PubMedCentralID PMC10785921

  • Effect of a Biopsychosocial Intervention or Postural Therapy on Disability and Health Care Spending Among Patients With Acute and Subacute Spine Pain: The SPINE CARE Randomized Clinical Trial. JAMA Choudhry, N. K., Fifer, S., Fontanet, C. P., Archer, K. R., Sears, E., Bhatkhande, G., Haff, N., Ghazinouri, R., Coronado, R. A., Schneider, B. J., Butterworth, S. W., Deogun, H., Cooper, A., Hsu, E., Block, S., Davidson, C. A., Shackelford, C. E., Goyal, P., Milstein, A., SPINE CARE Investigators, Crum, K., Scott, J., Marton, K., Silva, F. M., Obeidalla, S., Robinette, P. E., Lorenzana-DeWitt, M., Bair, C. A., Sadun, H. J., Goldfield, N., Hogewood, L. M., Sterling, E. K., Pickney, C., Koltun-Baker, E. J., Swehla, A., Ravikumar, V., Malhotra, S., Finney, S. T., Holliday, L., Moolman, K. C., Coleman-Dockery, S., Patel, I. B., Angel, F. B., Green, J. K., Mitchell, K., McBean, M. R., Ghaffar, M., Ermini, S. R., Carr, A. L., MacDonald, J. 2022; 328 (23): 2334-2344


    Importance: Low back and neck pain are often self-limited, but health care spending remains high.Objective: To evaluate the effects of 2 interventions that emphasize noninvasive care for spine pain.Design, Setting, and Participants: Pragmatic, cluster, randomized clinical trial conducted at 33 centers in the US that enrolled 2971 participants with neck or back pain of 3 months' duration or less (enrollment, June 2017 to March 2020; final follow-up, March 2021).Interventions: Participants were randomized at the clinic-level to (1) usual care (n=992); (2) a risk-stratified, multidisciplinary intervention (the identify, coordinate, and enhance [ICE] care model that combines physical therapy, health coach counseling, and consultation from a specialist in pain medicine or rehabilitation) (n=829); or (3) individualized postural therapy (IPT), a postural therapy approach that combines physical therapy with building self-efficacy and self-management (n=1150).Main Outcomes and Measures: The primary outcomes were change in Oswestry Disability Index (ODI) score at 3 months (range, 0 [best] to 100 [worst]; minimal clinically important difference, 6) and spine-related health care spending at 1 year. A 2-sided significance threshold of .025 was used to define statistical significance.Results: Among 2971 participants randomized (mean age, 51.7 years; 1792 women [60.3%]), 2733 (92%) finished the trial. Between baseline and 3-month follow-up, mean ODI scores changed from 31.2 to 15.4 for ICE, from 29.3 to 15.4 for IPT, and from 28.9 to 19.5 for usual care. At 3-month follow-up, absolute differences compared with usual care were -5.8 (95% CI, -7.7 to -3.9; P<.001) for ICE and -4.3 (95% CI, -5.9 to -2.6; P<.001) for IPT. Mean 12-month spending was $1448, $2528, and $1587 in the ICE, IPT, and usual care groups, respectively. Differences in spending compared with usual care were -$139 (risk ratio, 0.93 [95% CI, 0.87 to 0.997]; P=.04) for ICE and $941 (risk ratio, 1.40 [95% CI, 1.35 to 1.45]; P<.001) for IPT.Conclusions and Relevance: Among patients with acute or subacute spine pain, a multidisciplinary biopsychosocial intervention or an individualized postural therapy intervention, each compared with usual care, resulted in small but statistically significant reductions in pain-related disability at 3 months. However, compared with usual care, the biopsychosocial intervention resulted in no significant difference in spine-related health care spending and the postural therapy intervention resulted in significantly greater spine-related health care spending at 1 year.Trial Registration: Identifier: NCT03083886.

    View details for DOI 10.1001/jama.2022.22625

    View details for PubMedID 36538309

  • A computational approach to measure the linguistic characteristics of psychotherapy timing, responsiveness, and consistency. Npj mental health research Miner, A. S., Fleming, S. L., Haque, A., Fries, J. A., Althoff, T., Wilfley, D. E., Agras, W. S., Milstein, A., Hancock, J., Asch, S. M., Stirman, S. W., Arnow, B. A., Shah, N. H. 2022; 1 (1): 19


    Although individual psychotherapy is generally effective for a range of mental health conditions, little is known about the moment-to-moment language use of effective therapists. Increased access to computational power, coupled with a rise in computer-mediated communication (telehealth), makes feasible the large-scale analyses of language use during psychotherapy. Transparent methodological approaches are lacking, however. Here we present novel methods to increase the efficiency of efforts to examine language use in psychotherapy. We evaluate three important aspects of therapist language use - timing, responsiveness, and consistency - across five clinically relevant language domains: pronouns, time orientation, emotional polarity, therapist tactics, and paralinguistic style. We find therapist language is dynamic within sessions, responds to patient language, and relates to patient symptom diagnosis but not symptom severity. Our results demonstrate that analyzing therapist language at scale is feasible and may help answer longstanding questions about specific behaviors of effective therapists.

    View details for DOI 10.1038/s44184-022-00020-9

    View details for PubMedID 38609510

    View details for PubMedCentralID 3665892

  • Care teams misunderstand what most upsets patients about their care. Healthcare (Amsterdam, Netherlands) Conner, A. L., Podtschaske, B. V., Mazza, M. C., Zionts, D. L., Malcolm, E. J., Thomson, C. C., Singer, S. J., Milstein, A. 2022; 10 (4): 100657


    BACKGROUND: Negative healthcare delivery experiences can cause lasting patient distress and medical service misuse and disuse. Yet no multi-site study has examined whether care-team members understand what most upsets patients about their care.METHODS: We interviewed 373 patients and 360 care-team members in the medical oncology and ambulatory surgery clinics of 11 major healthcare organizations across six U.S. census regions. Patients deeply upset by a service-related experience (n= 99, 27%) answered questions about that experience, while care-team members (n=360) answered questions about their beliefs regarding what most upsets patients. We performed content analysis to identify memorably upsetting care (MUC) themes; a generalized estimating equation to explore whether MUC theme mention frequencies varied by participant role (care-team member vs. patient), specialty (oncology vs. surgery), facility (academic vs. community), and gender; and logistic regressions to investigate the effects of participant characteristics on individual themes.RESULTS: MUC themes included three systems issues (inefficiencies, access barriers, and facilities problems) and four care-team issues (miscommunication, neglect, coldness, and incompetence). MUC theme frequencies differed by role (all Ps<0.001), with more patients mentioning care-team coldness (OR=0.37; 95% CI, 0.23-0.60) and incompetence (OR=0.17; 95% CI, 0.09-0.31); but more care-team members mentioning system inefficiencies (OR=7.01; 95% CI, 4.31-11.40) and access barriers (OR, 5.48; 95% CI, 2.81-10.69).CONCLUSIONS: When considering which service experiences most upset patients, care-team members underestimate the impact of their own behaviors and overestimate the impact of systems issues.IMPLICATIONS: Healthcare systems should reconsider how they collect, interpret, disseminate, and respond to patient service reports.LEVEL OF EVIDENCE: Level III.

    View details for DOI 10.1016/j.hjdsi.2022.100657

    View details for PubMedID 36191489

  • Improving adherence to guidelines for spine pain care: what tools could support primary care clinicians in conforming to guidelines? BMJ open quality Fifer, S. K., Choundry, N. K., Brod, M., Hsu, E., Milstein, A. 2022; 11 (3)


    BACKGROUND: Spine pain is one of the most common conditions seen in primary care and is often treated with ineffective, aggressive interventions, such as prescription pain medications, imagery and referrals to surgery. Aggressive treatments are associated with negative side effects and high costs while conservative care has lower risks and costs and equivalent or better outcomes. Despite multiple well-publicised treatment guidelines and educational efforts recommending conservative care, primary care clinicians (PCCs) widely continue to prescribe aggressive, low-value care for spine pain.METHODS: In this qualitative study semistructured interviews were conducted with PCCs treating spine pain patients to learn what prevents clinicians from following guidelines and what tools or support could promote conservative care. Interviews were conducted by telephone, transcribed and coded for thematic analysis.RESULTS: Forty PCCs in academic and private practice were interviewed. Key reflections included that while familiar with guidelines recommending conservative treatment, they did not find guidelines useful or relevant to care decisions for individual patients. They believed that there is an insufficient body of real-world evidence supporting positive outcomes for conservative care and guidance recommendations. They indicated that spine pain patients frequently request aggressive care. These requests, combined with the PCCs' commitment to reaching shared treatment decisions with patients, formed a key reason for pursuing aggressive care. PCCs reported not being familiar with risk-screening tools for spine patients but indicated that such screens might increase their confidence to recommend conservative care to low-risk patients.CONCLUSIONS: PCCs may be more willing to give conservative, guideline-consistent care for spine pain if they had tools to assist in making patient-specific evaluations and in countering requests for unneeded aggressive care. Such tools would include both patient risk screens and shared decision-making aids that include elements for resolving patient demands for inappropriate care.

    View details for DOI 10.1136/bmjoq-2022-001868

    View details for PubMedID 35944933

  • State-level differences in duties permitted to be performed by medical assistants in the delivery of eye care Reeves, M., Xue, J., Milstein, A., Tabin, G., Goldberg, J. L., Schulman, K. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2022
  • Identifying solutions to meet unmet needs of family caregivers using human-centered design. BMC geriatrics Termglinchan, V., Daswani, S., Duangtaweesub, P., Assavapokee, T., Milstein, A., Schulman, K. 1800; 22 (1): 94


    BACKGROUND: Given the rapidly aging society, shrinking workforce, and reducing dependency ratio, there is an increasing challenge for family members to provide care for older adults. While a broad understanding of caregiver burden and its consequences have been studied across various contexts, there is a need to better understand this challenge among family caregivers in Asian societies.METHODS: This study is a cross-sectional observational study. A total of 20 dyads of community-based older adults, who required assistance with at least one activities of daily living, and family caregivers in Thailand participated in the study. We used the first three stages out of five stages of human-centered design: empathize, define, and ideate.RESULTS: On average caregivers were 59.2years old, with 43% still employed. Of the older adult participants, 10 were interviewed, the others had moderate-to-severe cognitive impairment. Based on the analysis, six caregiver personas (i.e. semi-fictional characters) are identified. Caregiver personas of "The 2-Jober" and "My Life Purpose" has the highest caregiver burden score whereas "The Spouse" has the lowest. Based on the specific needs of the caregiver persona "My Life Purpose", the team brainstormed more than 80 potential solutions which were classified into three categories of solutions that satisfied the metrics of desirability, feasibility and viability: distributed medical care system, technology-charged care network, and community gathering for rest and recuperation.CONCLUSIONS: These solutions are culturally sensitive given that they are built around established behavioral patterns. This is an illustration of a method of innovation that can be applied to bring a culturally specific understanding, and to develop products and services to enable further independent aging.

    View details for DOI 10.1186/s12877-022-02790-5

    View details for PubMedID 35109822

  • The Dysfunctional Health Benefits Market and Implications for US Employers and Employees. JAMA Scheinker, D., Milstein, A., Schulman, K. 1800

    View details for DOI 10.1001/jama.2021.23258

    View details for PubMedID 34994781

  • Design of the Spine Pain Intervention to Enhance Care Quality And Reduce Expenditure Trial (SPINE CARE) study: Methods and lessons from a multi-site pragmatic cluster randomized controlled trial. Contemporary clinical trials Choudhry, N. K., Fontanet, C. P., Ghazinouri, R., Fifer, S., Archer, K. R., Haff, N., Butterworth, S. W., Deogun, H., Block, S., Cooper, A., Sears, E., Goyal, P., Coronado, R. A., Schneider, B. J., Hsu, E., Milstein, A. 2021: 106602


    BACKGROUND: Low back and neck pain (together, spine pain) are among the leading causes of medical visits, lost productivity, and disability. For most people, episodes of spine pain are self-limited; nevertheless, healthcare spending for this condition is extremely high. Focusing care on individuals at high-risk of progressing from acute to chronic pain may improve efficiency. Alternatively, postural therapies, which are frequently used by patients, may prevent the overuse of high-cost interventions while delivering equivalent outcomes.METHODS: The SPINE CARE (Spine Pain Intervention to Enhance Care Quality And Reduce Expenditure) trial is a cluster-randomized multi-center pragmatic clinical trial designed to evaluate the clinical effectiveness and healthcare utilization of two interventions for primary care patients with acute and subacute spine pain. The study is being conducted at 33 primary care clinics in geographically distinct regions of the United States. Individuals ≥18 years presenting to primary care with neck and/or back pain of ≤3 months' duration were randomized at the clinic-level to 1) usual care, 2) a risk-stratified, multidisciplinary approach called the Identify, Coordinate, and Enhance (ICE) care model, or 3) Individualized Postural Therapy (IPT), a standardized postural therapy method of care. The trial's two primary outcomes are change in function at 3 months and spine-related spending at one year. 2971 individuals were enrolled between June 2017 and March 2020. Follow-up was completed on March 31, 2021.DISCUSSION: The SPINE CARE trial will determine the impact on clinical outcomes and healthcare costs of two interventions for patients with spine pain presenting to primary care.TRIAL REGISTRATION NUMBER: NCT03083886.

    View details for DOI 10.1016/j.cct.2021.106602

    View details for PubMedID 34688915

  • Distilling innovative US autism care programs that address widely perceived unmet patient and family needs. Autism : the international journal of research and practice Wong, V., Pham, M., Godfrey, K., Milstein, A. 2021: 13623613211027999


    LAY ABSTRACT: Currently, the quality of care for autistic individuals is not good. Many care services for autistic individuals are not well coordinated, nor are they tailored. We wanted to find out a better model for autism care and believed that the autism community knows where these programs are. So, we had conversations with and surveyed 55 autistic adults, family members, clinicians, and researchers. They shared 90 innovative autism care programs that had been collaboratively designed with patients and families and that are likely to improve the quality of life of autistic individuals and their families. We then narrowed down the 90 nominated programs to 15 programs across the United States by applying researcher-selected criteria, such as providing services actively and having data on program effectiveness. We compiled a list of these innovative, quality autism care programs.

    View details for DOI 10.1177/13623613211027999

    View details for PubMedID 34210189

  • Reducing administrative costs in US health care: Assessing single payer and its alternatives. Health services research Scheinker, D., Richman, B. D., Milstein, A., Schulman, K. A. 2021


    OBJECTIVE: Excess administrative costs in the US health care system are routinely referenced as a justification for comprehensive reform. While there is agreement that these costs are too high, there is little understanding of what generates administrative costs and what policy options might mitigate them.DATA SOURCES: Literature review and national utilization and expenditure data.STUDY DESIGN: We developed a simulation model of physician billing and insurance-related (BIR) costs to estimate how certain policy reforms would generate savings. Our model is based on structural elements of the payment process in the United States and considers each provider's number of health plan contracts, the number of features in each health plan, the clinical and nonclinical processes required to submit a bill for payment, and the compliance costs associated with medical billing.DATA EXTRACTION: For several types of visits, we estimated fixed and variable costs of the billing process. We used the model to estimate the BIR costs at a national level under a variety of policy scenarios, including variations of a single payer "Medicare-for-All" model that extends fee-for-service Medicare to the entire population and policy efforts to reduce administrative costs in a multi-payer model. We conducted sensitivity analyses of a wide variety of model parameters.PRINCIPAL FINDINGS: Our model estimates that national BIR costs are reduced between 33% and 53% in Medicare-for-All style single-payer models and between 27% and 63% in various multi-payer models. Under a wide range of assumptions and sensitivity analyses, standardizing contracts generates larger savings with less variance than savings from single-payer strategies.CONCLUSION: Although moving toward a single-payer system will reduce BIR costs, certain reforms to payer-provider contracts could generate at least as many administrative cost savings without radically reforming the entire health system. BIR costs can be meaningfully reduced without abandoning a multi-payer system.

    View details for DOI 10.1111/1475-6773.13649

    View details for PubMedID 33788283

  • Parents' Perspectives on Using Artificial Intelligence to Reduce Technology Interference During Early Childhood: Cross-sectional Online Survey. Journal of medical Internet research Glassman, J., Humphreys, K., Yeung, S., Smith, M., Jauregui, A., Milstein, A., Sanders, L. 2021; 23 (3): e19461


    BACKGROUND: Parents' use of mobile technologies may interfere with important parent-child interactions that are critical to healthy child development. This phenomenon is known as technoference. However, little is known about the population-wide awareness of this problem and the acceptability of artificial intelligence (AI)-based tools that help with mitigating technoference.OBJECTIVE: This study aims to assess parents' awareness of technoference and its harms, the acceptability of AI tools for mitigating technoference, and how each of these constructs vary across sociodemographic factors.METHODS: We administered a web-based survey to a nationally representative sample of parents of children aged ≤5 years. Parents' perceptions that their own technology use had risen to potentially problematic levels in general, their perceptions of their own parenting technoference, and the degree to which they found AI tools for mitigating technoference acceptable were assessed by using adaptations of previously validated scales. Multiple regression and mediation analyses were used to assess the relationships between these scales and each of the 6 sociodemographic factors (parent age, sex, language, ethnicity, educational attainment, and family income).RESULTS: Of the 305 respondents, 280 provided data that met the established standards for analysis. Parents reported that a mean of 3.03 devices (SD 2.07) interfered daily in their interactions with their child. Almost two-thirds of the parents agreed with the statements "I am worried about the impact of my mobile electronic device use on my child" and "Using a computer-assisted coach while caring for my child would help me notice more quickly when my device use is interfering with my caregiving" (187/281, 66.5% and 184/282, 65.1%, respectively). Younger age, Hispanic ethnicity, and Spanish language spoken at home were associated with increased technoference awareness. Compared to parents' perceived technoference and sociodemographic factors, parents' perceptions of their own problematic technology use was the factor that was most associated with the acceptance of AI tools.CONCLUSIONS: Parents reported high levels of mobile device use and technoference around their youngest children. Most parents across a wide sociodemographic spectrum, especially younger parents, found the use of AI tools to help mitigate technoference during parent-child daily interaction acceptable and useful.

    View details for DOI 10.2196/19461

    View details for PubMedID 33720026

  • Influence of a COVID-19 vaccine's effectiveness and safety profile on vaccination acceptance. Proceedings of the National Academy of Sciences of the United States of America Kaplan, R. M., Milstein, A. 2021; 118 (10)


    Although a safe and effective vaccine holds the greatest promise for resolving the COVID-19 pandemic, hesitancy to accept vaccines remains common. To explore vaccine acceptance decisions, we conducted a national survey of 1,000 people from all US states in August of 2020 and a replication in December of 2020. Using a 3 * 3 * 3 factorial experimental design, we estimated the impact of three factors: probability of 1) protection against COVID-19, 2) minor side effects, and 3) a serious adverse reactions. The outcome was respondents' reported likelihood of receiving a vaccine for the coronavirus. Probability of vaccine efficacy (50%, 70%, or 90%) had the largest effect among the three factors. The probability of minor side effects (50%, 75%, 90%) including fever and sore arm, did not significantly influence likelihood of receiving the vaccine. The chances of a serious adverse reaction, such as temporary or permanent paralysis, had a small but significant effect. A serious adverse reaction rate of 1/100,000 was more likely to discourage vaccine use in comparison to rates of 1/million or 1/100 million. All interactions between the factors were nonsignificant. A replication following the announcement that vaccines were 95% effective showed small, but significant increases in the likelihood of taking a vaccine. The main effects and interactions in the model remained unchanged. Expected benefit was more influential in respondents' decision making than expected side effects. The absence of interaction effects suggests that respondents consider the side effects and benefits independently.

    View details for DOI 10.1073/pnas.2021726118

    View details for PubMedID 33619178

  • Caring for Caregivers NEJM Catalyst Wong, V., Rosenbaum, S., Sung, W., Kaplan, R. M., Bott, N., Platchek, T., Milstein, A., Shah, N. R. 2021

    View details for DOI 10.1056/CAT.20.057

  • Estimating health care delivery system value for each US state and testing key associations. Health services research Dieleman, J. L., Kaldjian, A. S., Sahu, M., Chen, C., Liu, A., Chapin, A., Scott, K. W., Aravkin, S., Zheng, P., Mokdad, A., Murray, C. J., Schulman, K., Milstein, A. 2021


    To estimate health care systems' value in treating major illnesses for each US state and identify system characteristics associated with value.Annual condition-specific death and incidence estimates for each US state from the Global Burden Disease 2019 Study and annual health care spending per person for each state from the National Health Expenditure Accounts.Using non-linear meta-stochastic frontier analysis, mortality incidence ratios for 136 major treatable illnesses were regressed separately on per capita health care spending and key covariates such as age, obesity, smoking, and educational attainment. State- and year-specific inefficiency estimates were extracted for each health condition and combined to create a single estimate of health care delivery system value for each US state for each year, 1991-2014. The association between changes in health care value and changes in 23 key health care system characteristics and state policies was measured.Not applicable.US state with relatively high spending per person or relatively poor health-outcomes were shown to have low health care delivery system value. New Jersey, Maryland, Florida, Arizona, and New York attained the highest value scores in 2014 (81 [95% uncertainty interval 72-88], 80 [72-87], 80 [71-86], 77 [69-84], and 77 [66-85], respectively), after controlling for health care spending, age, obesity, smoking, physical activity, race, and educational attainment. Greater market concentration of hospitals and of insurers were associated with worse health care value (p-value ranging from <0.01 to 0.02). Higher hospital geographic density and use were also associated with worse health care value (p-value ranging from 0.03 to 0.05). Enrollment in Medicare Advantage HMOs was associated with better value, as was more generous Medicaid income eligibility (p-value 0.04 and 0.01).Substantial variation in the value of health care exists across states. Key health system characteristics such as market concentration and provider density were associated with value.

    View details for DOI 10.1111/1475-6773.13676

    View details for PubMedID 34028028

  • A Cost Comparison of Cataract Surgeries in Three Countries — United States, India, and Nepal NEJM Catalyst|Innovations in Care Delivery Xue, J., Hinkle, J., Reeves, M., Zheng, L., Natarajan, V., Vyas, S., Upreti Oli, R., Oliva, M., Kaplan, R. S., Milstein, A., Tabin, G., Goldberg, J. L., Schulman, K. 2021; 2

    View details for DOI 10.1056/CAT.21.0151

  • Mothers of children with major congenital anomalies have increased health care utilization over a 20-year post-birth time horizon. PloS one Shah, N. R., Kim, K. M., Wong, V., Cohen, E., Rosenbaum, S., Cahan, E. M., Milstein, A., Sorensen, H. T., Horvath-Puho, E. 2021; 16 (12): e0260962


    OBJECTIVE: This population-based, matched cohort study aimed to evaluate utilization of health care services by mothers of children with major congenital anomalies (MCAs), compared to mothers of children without MCAs over a 20-year post-birth time horizon in Denmark.METHODS: Our analytic sample included mothers who gave birth to an infant with a MCA (n = 23,927) and a cohort of mothers matched to them by maternal age, parity and infant's year of birth (n = 239,076). Primary outcomes were period prevalence and mothers' quantity of health care utilization (primary, inpatient, outpatient, surgical, and psychiatric services) stratified by their child's age (i.e., ages 0-6 = before school, ages 7-13 = pre-school + primary education, and ages 14-18 = secondary education or higher). The secondary outcome measure was length of hospital stays. Outcome measures were adjusted for maternal age at delivery, parity, marital status, income quartile, level of education in the year prior to the index birth, previous spontaneous abortions, maternal pregnancy complications, maternal diabetes, hypertension, alcohol-related diseases, and maternal smoking.RESULTS: In both cohorts the majority of mothers were between 26 and 35 years of age, married, and employed, and 47% were primiparous. Mothers of infants with anomalies had greater utilization of outpatient, inpatient, surgical, and psychiatric services, compared with mothers in the matched cohort. Inpatient service utilization was greater in the exposed cohort up to 13 years after a child's birth, with the highest risk in the first six years after birth [adjusted risk ratio, 1.13; 95% confidence interval (CI), 1.12-1.14], with a decrease over time. Regarding the quantity of health care utilization, the greatest difference between the two groups was in inpatient service utilization, with a 39% increased rate in the exposed cohort during the first six years after birth (adjusted rate ratio, 1.39; 95% CI, 1.37-1.42). During the first 6 years after birth, mothers of children with anomalies stayed a median of 6 days (interquartile range [IQR], 3-13) in hospital overall, while the comparison cohort stayed a median of 4 days (IQR, 2-7) in hospital overall. Rates of utilization of outpatient clinics (adjusted rate ratio, 1.36; 95% CI, 1.29-1.42), as well as inpatient (adjusted rate ratio, 1.77; 95% CI, 1.68-1.87), and surgical services (adjusted rate ratio, 1.33; 95% CI, 1.26-1.41) was higher in mothers of children with multiple-organ MCAs during 0 to 6 years after birth. Among mothers at the lowest income levels, utilization of psychiatric clinic services increased to 59% and when their child was 7 to 13 years of age (adjusted rate ratio, 1.59; 95% CI, 1.24-2.03).CONCLUSION: Mothers of infants with a major congenital anomaly had greater health care utilization across services. Health care utilization decreased over time or remained stable for outpatient, inpatient, and surgical care services, whereas psychiatric utilization increased for up to 13 years after an affected child's birth. Healthcare utilization was significantly elevated among mothers of children with multiple MCAs and among those at the lowest income levels.

    View details for DOI 10.1371/journal.pone.0260962

    View details for PubMedID 34879106

  • Quantifying Parkinson's disease motor severity under uncertainty using MDS-UPDRS videos. Medical image analysis Lu, M., Zhao, Q., Poston, K. L., Sullivan, E. V., Pfefferbaum, A., Shahid, M., Katz, M., Kouhsari, L. M., Schulman, K., Milstein, A., Niebles, J. C., Henderson, V. W., Fei-Fei, L., Pohl, K. M., Adeli, E. 2021; 73: 102179


    Parkinson's disease (PD) is a brain disorder that primarily affects motor function, leading to slow movement, tremor, and stiffness, as well as postural instability and difficulty with walking/balance. The severity of PD motor impairments is clinically assessed by part III of the Movement Disorder Society Unified Parkinson's Disease Rating Scale (MDS-UPDRS), a universally-accepted rating scale. However, experts often disagree on the exact scoring of individuals. In the presence of label noise, training a machine learning model using only scores from a single rater may introduce bias, while training models with multiple noisy ratings is a challenging task due to the inter-rater variabilities. In this paper, we introduce an ordinal focal neural network to estimate the MDS-UPDRS scores from input videos, to leverage the ordinal nature of MDS-UPDRS scores and combat class imbalance. To handle multiple noisy labels per exam, the training of the network is regularized via rater confusion estimation (RCE), which encodes the rating habits and skills of raters via a confusion matrix. We apply our pipeline to estimate MDS-UPDRS test scores from their video recordings including gait (with multiple Raters, R=3) and finger tapping scores (single rater). On a sizable clinical dataset for the gait test (N=55), we obtained a classification accuracy of 72% with majority vote as ground-truth, and an accuracy of ∼84% of our model predicting at least one of the raters' scores. Our work demonstrates how computer-assisted technologies can be used to track patients and their motor impairments, even when there is uncertainty in the clinical ratings. The latest version of the code will be available at

    View details for DOI 10.1016/

    View details for PubMedID 34340101

  • Caring for Caregivers: Bridging the Gap Between Family Caregiving Policy and Practice NEJM Catalyst: Innovations in Care Delivery Wong, V., Rosenbaum, S., Sung, W., Kaplan, R. M., Bott, N., Platchek, T., Milstein, A., Shah, N. R. 2021; 2 (4)

    View details for DOI 10.1056/CAT.20.0578

  • Ethical issues in using ambient intelligence in health-care settings. The Lancet. Digital health Martinez-Martin, N., Luo, Z., Kaushal, A., Adeli, E., Haque, A., Kelly, S. S., Wieten, S., Cho, M. K., Magnus, D., Fei-Fei, L., Schulman, K., Milstein, A. 2020


    Ambient intelligence is increasingly finding applications in health-care settings, such as helping to ensure clinician and patient safety by monitoring staff compliance with clinical best practices or relieving staff of burdensome documentation tasks. Ambient intelligence involves using contactless sensors and contact-based wearable devices embedded in health-care settings to collect data (eg, imaging data of physical spaces, audio data, or body temperature), coupled with machine learning algorithms to efficiently and effectively interpret these data. Despite the promise of ambient intelligence to improve quality of care, the continuous collection of large amounts of sensor data in health-care settings presents ethical challenges, particularly in terms of privacy, data management, bias and fairness, and informed consent. Navigating these ethical issues is crucial not only for the success of individual uses, but for acceptance of the field as a whole.

    View details for DOI 10.1016/S2589-7500(20)30275-2

    View details for PubMedID 33358138

  • Assessment of Electronic Health Record Use Between US and Non-US Health Systems. JAMA internal medicine Holmgren, A. J., Downing, N. L., Bates, D. W., Shanafelt, T. D., Milstein, A., Sharp, C. D., Cutler, D. M., Huckman, R. S., Schulman, K. A. 2020


    Importance: Understanding how the electronic health record (EHR) system changes clinician work, productivity, and well-being is critical. Little is known regarding global variation in patterns of use.Objective: To provide insights into which EHR activities clinicians spend their time doing, the EHR tools they use, the system messages they receive, and the amount of time they spend using the EHR after hours.Design, Setting, and Participants: This cross-sectional study analyzed the deidentified metadata of ambulatory care health systems in the US, Canada, Northern Europe, Western Europe, the Middle East, and Oceania from January 1, 2019, to August 31, 2019. All of these organizations used the EHR software from Epic Systems and represented most of Epic Systems's ambulatory customer base. The sample included all clinicians with scheduled patient appointments, such as physicians and advanced practice practitioners.Exposures: Clinician EHR use was tracked by deidentified and aggregated metadata across a variety of clinical activities.Main Outcomes and Measures: Descriptive statistics for clinician EHR use included time spent on clinical activities, note documentation (as measured by the percentage of characters in the note generated by automated or manual data entry source), messages received, and time spent after hours.Results: A total of 371 health systems were included in the sample, of which 348 (93.8%) were located in the US and 23 (6.2%) were located in other countries. US clinicians spent more time per day actively using the EHR compared with non-US clinicians (mean time, 90.2 minutes vs 59.1 minutes; P<.001). In addition, US clinicians vs non-US clinicians spent significantly more time performing 4 clinical activities: notes (40.7 minutes vs 30.7 minutes; P<.001), orders (19.5 minutes vs 8.75 minutes; P<.001), in-basket messages (12.5 minutes vs 4.80 minutes; P<.001), and clinical review (17.6 minutes vs 14.8 minutes; P=.01). Clinicians in the US composed more automated note text than their non-US counterparts (77.5% vs 60.8% of note text; P<.001) and received statistically significantly more messages per day (33.8 vs 12.8; P<.001). Furthermore, US clinicians used the EHR for a longer time after hours, logging in 26.5 minutes per day vs 19.5 minutes per day for non-US clinicians (P=.01). The median US clinician spent as much time actively using the EHR per day (90.1 minutes) as a non-US clinician in the 99th percentile of active EHR use time per day (90.7 minutes) in the sample. These results persisted after controlling for organizational characteristics, including structure, type, size, and daily patient volume.Conclusions and Relevance: This study found that US clinicians compared with their non-US counterparts spent substantially more time actively using the EHR for a wide range of clinical activities or tasks. This finding suggests that US clinicians have a greater EHR burden that may be associated with nontechnical factors, which policy makers and health system leaders should consider when addressing clinician wellness.

    View details for DOI 10.1001/jamainternmed.2020.7071

    View details for PubMedID 33315048

  • Assessing the accuracy of automatic speech recognition for psychotherapy. NPJ digital medicine Miner, A. S., Haque, A., Fries, J. A., Fleming, S. L., Wilfley, D. E., Terence Wilson, G., Milstein, A., Jurafsky, D., Arnow, B. A., Stewart Agras, W., Fei-Fei, L., Shah, N. H. 2020; 3: 82


    Accurate transcription of audio recordings in psychotherapy would improve therapy effectiveness, clinician training, and safety monitoring. Although automatic speech recognition software is commercially available, its accuracy in mental health settings has not been well described. It is unclear which metrics and thresholds are appropriate for different clinical use cases, which may range from population descriptions to individual safety monitoring. Here we show that automatic speech recognition is feasible in psychotherapy, but further improvements in accuracy are needed before widespread use. Our HIPAA-compliant automatic speech recognition system demonstrated a transcription word error rate of 25%. For depression-related utterances, sensitivity was 80% and positive predictive value was 83%. For clinician-identified harm-related sentences, the word error rate was 34%. These results suggest that automatic speech recognition may support understanding of language patterns and subgroup variation in existing treatments but may not be ready for individual-level safety surveillance.

    View details for DOI 10.1038/s41746-020-0285-8

    View details for PubMedID 32550644

    View details for PubMedCentralID PMC7270106

  • Computer vision's potential to improve health care. Lancet (London, England) Milstein, A., Topol, E. J. 2020; 395 (10236): 1537

    View details for DOI 10.1016/S0140-6736(20)31090-4

    View details for PubMedID 32416778

  • Association Between HEDIS Performance and Primary Care Physician Age, Group Affiliation, Training, and Participation in ACA Exchanges. Journal of general internal medicine Glassman, J. R., Hopkins, D. S., Bundorf, M. K., Kaplan, R. M., Ragavan, M. V., Glaseroff, A. n., Milstein, A. n. 2020


    There are a limited number of studies investigating the relationship between primary care physician (PCP) characteristics and the quality of care they deliver.To examine the association between PCP performance and physician age, solo versus group affiliation, training, and participation in California's Affordable Care Act (ACA) exchange.Observational study of 2013-2014 data from Healthcare Effectiveness Data and Information Set (HEDIS) measures and select physician characteristics.PCPs in California HMO and PPO practices (n = 5053) with part of their patient panel covered by a large commercial health insurance company.Hemoglobin A1c testing; medical attention nephropathy; appropriate treatment hypertension (ACE/ARB); breast cancer screening; proportion days covered by statins; monitoring ACE/ARBs; monitoring diuretics. A composite performance measure also was constructed.For the average 35- versus 75-year-old PCP, regression-adjusted mean composite relative performance scores were at the 60th versus 47th percentile (89% vs. 86% composite absolute HEDIS scores; p < .001). For group versus solo PCPs, scores were at the 55th versus 50th percentiles (88% vs. 87% composite absolute HEDIS scores; p < .001). The effect of age on performance was greater for group versus solo PCPs. There was no association between scores and participation in ACA exchanges.The associations between population-based care performance measures and PCP age, solo versus group affiliation, training, and participation in ACA exchanges, while statistically significant in some cases, were small. Understanding how to help older PCPs excel equally well in group practice compared with younger PCPs may be a fruitful avenue of future research.

    View details for DOI 10.1007/s11606-020-05642-3

    View details for PubMedID 31974901

  • Health Care Is Failing the Most Vulnerable Patients: Three Underused Solutions. Public health reports (Washington, D.C. : 1974) Rochlin, D. H., Lee, C. M., Scheuter, C. n., Platchek, T. n., Kaplan, R. M., Milstein, A. n. 2020: 33354920954496

    View details for DOI 10.1177/0033354920954496

    View details for PubMedID 32962512

  • Illuminating the dark spaces of healthcare with ambient intelligence. Nature Haque, A. n., Milstein, A. n., Fei-Fei, L. n. 2020; 585 (7824): 193–202


    Advances in machine learning and contactless sensors have given rise to ambient intelligence-physical spaces that are sensitive and responsive to the presence of humans. Here we review how this technology could improve our understanding of the metaphorically dark, unobserved spaces of healthcare. In hospital spaces, early applications could soon enable more efficient clinical workflows and improved patient safety in intensive care units and operating rooms. In daily living spaces, ambient intelligence could prolong the independence of older individuals and improve the management of individuals with a chronic disease by understanding everyday behaviour. Similar to other technologies, transformation into clinical applications at scale must overcome challenges such as rigorous clinical validation, appropriate data privacy and model transparency. Thoughtful use of this technology would enable us to understand the complex interplay between the physical environment and health-critical human behaviours.

    View details for DOI 10.1038/s41586-020-2669-y

    View details for PubMedID 32908264

  • Slowing Medicare Spending by Optimizing Late-Life Needs NEJM CATALYST INNOVATIONS IN CARE DELIVERY Rinaldo, F., Altman, M., Cannon, K., Platchek, T., Shah, N. R., Kaplan, R. M., Milstein, A. 2020; 1 (4)

    View details for DOI 10.1056/CAT.20.0290

  • Automatic detection of hand hygiene using computer vision technology. Journal of the American Medical Informatics Association : JAMIA Singh, A. n., Haque, A. n., Alahi, A. n., Yeung, S. n., Guo, M. n., Glassman, J. R., Beninati, W. n., Platchek, T. n., Fei-Fei, L. n., Milstein, A. n. 2020


    Hand hygiene is essential for preventing hospital-acquired infections but is difficult to accurately track. The gold-standard (human auditors) is insufficient for assessing true overall compliance. Computer vision technology has the ability to perform more accurate appraisals. Our primary objective was to evaluate if a computer vision algorithm could accurately observe hand hygiene dispenser use in images captured by depth sensors.Sixteen depth sensors were installed on one hospital unit. Images were collected continuously from March to August 2017. Utilizing a convolutional neural network, a machine learning algorithm was trained to detect hand hygiene dispenser use in the images. The algorithm's accuracy was then compared with simultaneous in-person observations of hand hygiene dispenser usage. Concordance rate between human observation and algorithm's assessment was calculated. Ground truth was established by blinded annotation of the entire image set. Sensitivity and specificity were calculated for both human and machine-level observation.A concordance rate of 96.8% was observed between human and algorithm (kappa = 0.85). Concordance among the 3 independent auditors to establish ground truth was 95.4% (Fleiss's kappa = 0.87). Sensitivity and specificity of the machine learning algorithm were 92.1% and 98.3%, respectively. Human observations showed sensitivity and specificity of 85.2% and 99.4%, respectively.A computer vision algorithm was equivalent to human observation in detecting hand hygiene dispenser use. Computer vision monitoring has the potential to provide a more complete appraisal of hand hygiene activity in hospitals than the current gold-standard given its ability for continuous coverage of a unit in space and time.

    View details for DOI 10.1093/jamia/ocaa115

    View details for PubMedID 32712656

  • Effects of Mental Health on the Costs of Care for Chronic Illnesses. Psychiatric services (Washington, D.C.) Kaplan, R. M., Glassman, J. R., Millstein, A. 2019: appips201900098


    OBJECTIVE: The study examined whether comorbid low mental health functioning inflates the cost of treating a chronic disease.METHODS: Data were from the 2015 Medical Expenditure Panel Survey (N=33,893). Costs were estimated from medical records and self-reported health care use. The mental component summary (MCS) score of the 12-item Short Form (SF-12) was used as a measure of mental health status. A general linear model estimated costs with fixed effects for chronic disease (present or absent) and mental health functioning (lowest, middle, and highest MCS score tertiles indicating low, middle, and high levels of mental health functioning, respectively). The SF-12 physical component summary score was a covariate. Eight conditions (arthritis, chronic obstructive pulmonary disease [COPD], high cholesterol, cancer, diabetes, stroke, coronary heart disease, and asthma) were analyzed separately.RESULTS: For each analysis, presence or absence of the chronic condition had a strong impact on cost. Lower mental health functioning also had a significant impact on cost. However, the interaction between mental health functioning and chronic disease diagnoses was statistically significant for only three conditions and accounted for only a small variation in cost. Sensitivity analyses using MCS score as a continuous variable, using a log10 transformation of the cost variable, and focusing only on persons with scores on the extreme low end did not significantly alter the conclusions.CONCLUSIONS: Contrary to expectation, the combination of poor mental functioning and chronic disease diagnosis did not have a strong synergistic effect on cost. Mental and general medical conditions appear to have independent effects on health care costs.

    View details for DOI 10.1176/

    View details for PubMedID 31378194

  • Cost impact of sobering centers on national health care spending in the United States. Translational behavioral medicine Scheuter, C., Rochlin, D. H., Lee, C., Milstein, A., Kaplan, R. M. 2019


    Acute alcohol intoxication is responsible for a sizable share of emergency department visits. Intoxicated individuals without other medical needs may not require the high level of care provided by an emergency department. We estimate the impact on U.S. health care spending if individuals with uncomplicated, acute alcohol intoxication were treated in sobering centers instead of the emergency department. We performed a budget impact analysis from the perspective of the U.S. health care system based on published and gray literature reports. Ninety-five percent confidence intervals (CI) were estimated using Monte Carlo modeling with random variation for three variables (cost of an emergency department visit, cost of a sobering center visit, and start-up costs per sobering center visit) and the percentage of cases diverted from emergency departments to sobering centers. Outcomes were expressed in terms of national savings in 2017 U.S. dollars. Assuming a diversion rate of 50% based on previous studies, national savings range from $230 million to $1.0 billion annually. In the Monte Carlo modeling, we found annual national savings of $99.02 million (95% CI: $95.89-$102.19 million), $792.34 million (95% CI: $767.09-$817.58 million), and $1,185.51 million (95% CI: $1,150.64-$1,226.37 million) with diversion rates of 5%, 40%, and 60%, respectively. Implementing sobering centers as a treatment alternative for individuals with uncomplicated acute alcohol intoxication could yield substantial cost savings for the U.S. health care system.

    View details for DOI 10.1093/tbm/ibz075

    View details for PubMedID 31116401

  • The Implications of "Medicare for All" for US Hospitals JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Schulman, K. A., Milstein, A. 2019; 321 (17): 1661–62
  • Contributions of Health Care to Longevity: A Review of 4 Estimation Methods. Annals of family medicine Kaplan, R. M., Milstein, A. 2019; 17 (3): 267–72


    PURPOSE: Health care expenditures and biomedical research funding are often justified by the belief that modern health care powerfully improves life expectancy in wealthy countries. We examined 4 different methods of estimating the effect of health care on health outcomes.METHODS: We reviewed the contributions of medical care to health outcomes using 4 methods: (1) analyses by McGinnis and Schroeder, (2) Wennberg and colleagues' studies of small area variation, (3) Park and colleagues' analysis of County Health Rankings and Roadmaps, and (4) the RAND Health Insurance Experiment.RESULTS: The 4 methods, using different data sets, produced estimates ranging from 0% to 17% of premature mortality attributable to deficiencies in health care access or delivery. Estimates of the effect of behavioral factors ranged from 16% to 65%.CONCLUSIONS: The results converge to suggest that restricted access to medical care accounts for about 10% of premature death or other undesirable health outcomes. Health care has modest effects on the extension of US life expectancy, while behavioral and social determinants may have larger effects.

    View details for PubMedID 31085531

  • Improving the Value of Medical Care for Patients with Back Pain PAIN MEDICINE Wood, A., Matula, S. R., Huan, L., Linos, E., Platchek, T., Milstein, A. 2019; 20 (4): 664–67

    View details for DOI 10.1093/pm/pnx049

    View details for Web of Science ID 000465127900002

  • A computer vision system for deep learning-based detection of patient mobilization activities in the ICU. NPJ digital medicine Yeung, S., Rinaldo, F., Jopling, J., Liu, B., Mehra, R., Downing, N. L., Guo, M., Bianconi, G. M., Alahi, A., Lee, J., Campbell, B., Deru, K., Beninati, W., Fei-Fei, L., Milstein, A. 2019; 2: 11


    Early and frequent patient mobilization substantially mitigates risk for post-intensive care syndrome and long-term functional impairment. We developed and tested computer vision algorithms to detect patient mobilization activities occurring in an adult ICU. Mobility activities were defined as moving the patient into and out of bed, and moving the patient into and out of a chair. A data set of privacy-safe-depth-video images was collected in the Intermountain LDS Hospital ICU, comprising 563 instances of mobility activities and 98,801 total frames of video data from seven wall-mounted depth sensors. In all, 67% of the mobility activity instances were used to train algorithms to detect mobility activity occurrence and duration, and the number of healthcare personnel involved in each activity. The remaining 33% of the mobility instances were used for algorithm evaluation. The algorithm for detecting mobility activities attained a mean specificity of 89.2% and sensitivity of 87.2% over the four activities; the algorithm for quantifying the number of personnel involved attained a mean accuracy of 68.8%.

    View details for DOI 10.1038/s41746-019-0087-z

    View details for PubMedID 31304360

    View details for PubMedCentralID PMC6550251

  • Stress Disorders and Dementia in the Danish Population AMERICAN JOURNAL OF EPIDEMIOLOGY Gradus, J. L., Horvath-Puho, E., Lash, T. L., Ehrenstein, V., Tamang, S., Adler, N. E., Milstein, A., Glymour, M., Henderson, V. W., Sorensen, H. T. 2019; 188 (3): 493–99

    View details for DOI 10.1093/aje/kwy269

    View details for Web of Science ID 000467881700001

  • Economic Benefit of "Modern" Nonemergency Medical Transportation That Utilizes Digital Transportation Networks AMERICAN JOURNAL OF PUBLIC HEALTH Rochlin, D. H., Lee, C., Scheuter, C., Milstein, A., Kaplan, R. M. 2019; 109 (3): 472–74
  • Systems Delivery Innovation for Alzheimer Disease AMERICAN JOURNAL OF GERIATRIC PSYCHIATRY Bott, N. T., Sheckter, C. C., Yang, D., Peters, S., Brady, B., Plowman, S., Borson, S., Leff, B., Kaplan, R. M., Platchek, T., Milstein, A. 2019; 27 (2): 149–61
  • Exploring Care Attributes of Nephrologists Ranking Favorably on Measures of Value. Journal of the American Society of Nephrology : JASN Brady, B. M., Ragavan, M. V., Simon, M. n., Chertow, G. M., Milstein, A. n. 2019


    Despite growth in value-based payment, attributes of nephrology care associated with payer-defined value remains unexplored.Using national health insurance claims data from private preferred provider organization plans, we ranked nephrology practices using total cost of care and a composite of common quality metrics. Blinded to practice rankings, we conducted site visits at four highly ranked and three average ranked practices to identify care attributes more frequently present in highly ranked practices. A panel of nephrologists used a modified Delphi method to score each distinguishing attribute on its potential to affect quality and cost of care and ease of transfer to other nephrology practices.Compared with average-value peers, high-value practices were located in areas with a relatively higher proportion of black and Hispanic patients and a lower proportion of patients aged >65 years. Mean risk-adjusted per capita monthly total spending was 24% lower for high-value practices. Twelve attributes comprising five general themes were observed more frequently in high-value nephrology practices: preventing near-term costly health crises, supporting patient self-care, maximizing effectiveness of office visits, selecting cost-effective diagnostic and treatment options, and developing infrastructure to support high-value care. The Delphi panel rated four attributes highly on effect and transferability: rapidly adjustable office visit frequency for unstable patients, close monitoring and management to preserve kidney function, early planning for vascular access, and education to support self-management at every contact.Findings from this small-scale exploratory study may serve as a starting point for nephrologists seeking to improve on payer-specified value measures.

    View details for DOI 10.1681/ASN.2019030219

    View details for PubMedID 31727849

  • Making Machine Learning Models Clinically Useful. JAMA Shah, N. H., Milstein, A. n., Bagley PhD, S. C. 2019

    View details for DOI 10.1001/jama.2019.10306

    View details for PubMedID 31393527

  • Perspectives of Health Care Payer Organizations on Cancer Care Delivery Redesign: A National Study. Journal of oncology practice Patel, M. I., Moore, D., Bhattacharya, J., Milstein, A., Coker, T. R. 2018: JOP1800331


    INTRODUCTION:: Despite advancements in cancer care, persistent gaps remain in the delivery of high-value end-of-life cancer care. The aim of this study was to examine views of health care payer organization stakeholders on approaches to the redesign of end-of-life cancer care delivery strategies to improve care.METHODS:: We conducted semistructured interviews with 34 key stakeholders (eg, chief medical officers, medical directors) in 12 health plans and 22 medical group organizations across the United States. We recorded, transcribed, and analyzed interviews using the constant comparative method of qualitative analysis.RESULTS:: Participants endorsed strategies to redesign end-of-life cancer care delivery to improve end-of-life care. Participants supported the use of nonprofessionals to deliver some cancer services through alternative formats (eg, telephone, Internet) and delivery of services in nonclinical settings. Participants reported that using nonprofessional providers to offer some services, such as goals of care discussions and symptom assessments, via telephone in community-based settings or in patients' homes, may be more effective and efficient ways to deliver high-value cancer care services. Participants described challenges to redesign, including coordination with and acceptance by oncology providers and payment models required to financially support clinical changes. Some participants suggested solutions, including providing funding and logistic support to encourage implementation of care delivery innovations and to financially reward practices for delivery of high-value end-of-life cancer care services.CONCLUSION:: Stakeholders from payer organizations endorsed opportunities to redesign cancer care delivery, and some are willing to provide logistic, design, and financial support to practices interested in improving end-of-life cancer care.

    View details for PubMedID 30444666

  • Systems Delivery Innovation for Alzheimer Disease. The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry Bott, N. T., Sheckter, C. C., Yang, D., Peters, S., Brady, B., Plowman, S., Borson, S., Leff, B., Kaplan, R. M., Platchek, T., Milstein, A. 2018


    OBJECTIVE: The authors describe a comprehensive care model for Alzheimer disease (AD) that improves value within 1-3 years after implementation by leveraging targeted outpatient chronic care management, cognitively protective acute care, and timely caregiver support.METHODS: Using current best evidence, expert opinion, and macroeconomic modeling, the authors designed a comprehensive care model for AD that improves the quality of care while reducing total per capita healthcare spending by more than 15%. Cost savings were measured as reduced spending by payers. Cost estimates were derived from medical literature and national databases, including both public and private U.S. payers. All estimates reflect the value in 2015 dollars using a consumer price index inflation calculator. Outcome estimates were determined at year 2, accounting for implementation and steady-state intervention costs.RESULTS: After accounting for implementation and recurring operating costs of approximately $9.5 billion, estimated net cost savings of between $13 and $41 billion can be accomplished concurrently with improvements in quality and experience of coordinated chronic care ($0.01-$6.8 billion), cognitively protective acute care ($8.7-$26.6 billion), timely caregiver support ($4.3-$7.5 billion), and caregiver efficiency ($4.1-$7.2 billion).CONCLUSION: A high-value care model for AD may improve the experience of patients with AD while significantly lowering costs.

    View details for PubMedID 30477913

  • Patient-Reported Experiences of Dialysis Care Within a National Pay-for-Performance System. JAMA internal medicine Brady, B. M., Zhao, B., Niu, J., Winkelmayer, W. C., Milstein, A., Chertow, G. M., Erickson, K. F. 2018


    Importance: Medicare's End-Stage Renal Disease Quality Incentive Program incorporates measures of perceived value into reimbursement calculations. In 2016, patient experience became a clinical measure in the Quality Incentive Program scoring system. Dialysis facility performance in patient experience measures has not been studied at the national level to date.Objective: To examine associations among dialysis facility performance with patient experience measures and patient, facility, and geographic characteristics.Design: In this cross-sectional analysis, patients from a national end-stage renal disease registry receiving in-center hemodialysis in the United States on December 31, 2014, were linked with dialysis facility scores on the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH-CAHPS) survey. Of 4977 US dialysis facilities, 2939 (59.1%) reported ICH-CAHPS scores from April 8, 2015, through January 11, 2016. Multivariable linear regression models with geographic random effects were used to examine associations of facility ICH-CAHPS scores with patient, dialysis facility, and geographic characteristics and to identify the amount of total between-facility variation in patient experience scores explained by these categories. Data were analyzed from September 15, 2017, through June 1, 2018.Exposures: Dialysis facility, geographic characteristic, and 10% change in patient characteristics.Main Outcomes and Measures: Dialysis facility ICH-CAHPS scores and the total between-facility variation explained by different categories of characteristics.Results: Of the 2939 facilities included in the analysis, adjusted mean ICH-CAHPS scores were 2.6 percentage points (95% CI, 1.5-3.7) lower in for-profit facilities, 1.6 percentage points (95% CI, 0.9-2.2) lower in facilities owned by large dialysis organizations, and 2.3 percentage points (95% CI, 0.5-4.2) lower in free-standing facilities compared with their counterparts. More nurses per patient was associated with 0.2 percentage points (95% CI, 0.03-0.3) higher scores; a privately insured patient population was associated with 1.2 percentage points (95% CI, 0.2-2.2) higher scores. Facilities with higher proportions of black patients had 0.95 percentage points (95% CI, 0.78-1.12) lower scores; more Native American patients, 1.00 percentage point (95% CI, 0.39-1.60) lower facility scores. Geographic location and dialysis facility characteristics explained larger proportions of the overall between-facility variation in ICH-CAHPS scores than did patient characteristics.Conclusions and Relevance: This study suggests that for-profit operation, free-standing status, and large dialysis organization designation were associated with less favorable patient-reported experiences of care. Patient experience scores varied geographically, and black and Native American populations reported less favorable experiences. The study findings suggest that perceived quality of care delivered in these settings are of concern, and that there may be opportunities for improved implementation of patient experience surveys as is highlighted.

    View details for PubMedID 30208398

  • Cardiovascular Disease Among Women Who Gave Birth to an Infant With a Major Congenital Anomaly JAMA NETWORK OPEN Cohen, E., Horvath-Puho, E., Ray, J. G., Pedersen, L., Ehrenstein, V., Adler, N., Vigod, S., Milstein, A., Sorensen, H. 2018; 1 (5)
  • Effect of a Lay Health Worker Intervention on Goals-of-Care Documentation and on Health Care Use, Costs, and Satisfaction Among Patients With Cancer: A Randomized Clinical Trial. JAMA oncology Patel, M. I., Sundaram, V., Desai, M., Periyakoil, V. S., Kahn, J. S., Bhattacharya, J., Asch, S. M., Milstein, A., Bundorf, M. K. 2018


    Importance: Although lay health workers (LHWs) improve cancer screening and treatment adherence, evidence on whether they can enhance other aspects of care is limited.Objective: To determine whether an LHW program can increase documentation of patients' care preferences after cancer diagnosis.Design, Setting, and Participants: Randomized clinical trial conducted from August 13, 2013, through February 2, 2015, among 213 patients with stage 3 or 4 or recurrent cancer at the Veterans Affairs Palo Alto Health Care System. Data analysis was by intention to treat and performed from January 15 to August 18, 2017.Interventions: Six-month program with an LHW trained to assist patients with establishing end-of-life care preferences vs usual care.Main Outcomes and Measures: The primary outcome was documentation of goals of care. Secondary outcomes were patient satisfaction on the Consumer Assessment of Health Care Providers and Systems "satisfaction with provider" item (on a scale of 0 [worst] to 10 [best possible]), health care use, and costs.Results: Among the 213 participants randomized and included in the intention-to-treat analysis, the mean (SD) age was 69.3 (9.1) years, 211 (99.1%) were male, and 165 (77.5%) were of non-Hispanic white race/ethnicity. Within 6 months of enrollment, patients randomized to the intervention had greater documentation of goals of care than the control group (97 [92.4%] vs 19 [17.5%.]; P<.001) and larger increases in satisfaction with care on the Consumer Assessment of Health Care Providers and Systems "satisfaction with provider" item (difference-in-difference, 1.53; 95% CI, 0.67-2.41; P<.001). The number of patients who died within 15 months of enrollment did not differ between groups (intervention, 60 of 105 [57.1%] vs control, 60 of 108 [55.6%]; P=.68). In the 30 days before death, patients in the intervention group had greater hospice use (46 [76.7%] vs 29 [48.3%]; P=.002), fewer emergency department visits (mean [SD], 0.05 [0.22] vs 0.60 [0.76]; P<.001), fewer hospitalizations (mean [SD], 0.05 [0.22] vs 0.50 [0.62]; P<.001), and lower costs (median [interquartile range], $1048 [$331-$8522] vs $23 482 [$9708-$55 648]; P<.001) than patients in the control group.Conclusions and Relevance: Incorporating an LHW into cancer care increases goals-of-care documentation and patient satisfaction and reduces health care use and costs at the end of life.Trial Registration: Identifier: NCT02966509.

    View details for PubMedID 30054634

  • Social isolation and all-cause mortality: a population-based cohort study in Denmark SCIENTIFIC REPORTS Laugesen, K., Baggesen, L., Schmidt, S., Glymour, M., Lasgaard, M., Milstein, A., Sorensen, H., Adler, N. E., Ehrenstein, V. 2018; 8: 4731


    Social isolation is associated with increased mortality. Meta-analytic results, however, indicate heterogeneity in effect sizes. We aimed to provide new evidence to the association between social isolation and mortality by conducting a population-based cohort study. We reconstructed the Berkman and Syme's social network index (SNI), which combines four components of social networks (partnership, interaction with family/friends, religious activities, and membership in organizations/clubs) into an index, ranging from 0/1 (most socially isolated) to 4 (least socially isolated). We estimated cumulative mortality and adjusted mortality rate ratios (MRR) associated with SNI. We adjusted for potential important confounders, including psychiatric and somatic status, lifestyle, and socioeconomic status. Cumulative 7-year mortality in men was 11% for SNI 0/1 and 5.4% for SNI 4 and in women 9.6% for SNI 0/1 and 3.9% for SNI 4. Adjusted MRRs comparing SNI 0/1 with SNI 4 were 1.7 (95% CI: 1.1-2.6) among men and 1.6 (95% CI: 0.83-2.9) among women. Having no partner was associated with an adjusted MRR of 1.5 (95% CI: 1.2-2.1) for men and 1.7 (95% CI: 1.2-2.4) for women. In conclusion, social isolation was associated with 60-70% increased mortality. Having no partner was associated with highest MRR.

    View details for PubMedID 29549355

  • Critical Lessons From High-Value Oncology Practices JAMA ONCOLOGY Blayney, D. W., Simon, M. K., Podtschaske, B., Ramsey, S., Shyu, M., Lindquist, C., Milstein, A. 2018; 4 (2): 164–71


    Cancer care is expensive. Cancer care provided by practice organizations varies in total spending incurred by patients and payers during treatment episodes and in quality of care, and this unnecessary variation contributes to the high cost.To use the variation in total spending and quality of care to assess oncology practice attributes distinguishing "high value" that may be tested and adopted by others to produce similar results."Positive deviance" was used in this exploratory mixed-methods (quantitative and qualitative) analysis of interview results. To quantify value, oncology practices located near the US Pacific Northwest and Midwest with low mean insurer-allowed spending were identified. Among those, practices with high quality were selected. A team then conducted site visits to interview practice personnel from June 2, 2015, through October 3, 2015, and to probe for attributes of high-value care. A qualitative analysis of their interview results was performed, and a panel of experienced oncologists was convened to review attributes occurring uniquely or frequently in low-spending practices for their contribution to value improvement and ease of implementation. Four positive deviant (ie, low-spending) oncology practices and 3 oncology practices that ranked near the middle of the spending distribution were studied.Thematic saturation in a qualitative analysis of high-value care attributes.From the 7 oncology practices studied, 13 attributes within the following 5 themes emerged: treatment planning and goal setting, services supporting the patient journey, technical support and physical layout, care team organization and function, and external context. Five attributes (ie, conservative use of imaging, early discussion of treatment limitations and consequences, single point of contact, maximal use of registered nurses for interventions, and a multicomponent health care system) most sharply distinguished the high-value practice sites. The expert oncologist panel judged 3 attributes (ie, early and normalized palliative care, ambulatory rapid response, and early discussion of treatment limitations and consequences) to carry the highest immediate potential for lowering spending without compromising the quality of care.Oncology practice attributes warranting further testing were identified that may lower total spending for high-quality oncology care.

    View details for PubMedID 29145584

    View details for PubMedCentralID PMC5838576

  • Bedside Computer Vision - Moving Artificial Intelligence from Driver Assistance to Patient Safety. The New England journal of medicine Yeung, S. n., Downing, N. L., Fei-Fei, L. n., Milstein, A. n. 2018; 378 (14): 1271–73

    View details for PubMedID 29617592

  • Tool Detection and Operative Skill Assessment in Surgical Videos Using Region-Based Convolutional Neural Networks Jin, A., Yeung, S., Jopling, J., Krause, J., Azagury, D., Milstein, A., Li Fei-Fei, IEEE IEEE. 2018: 691–99
  • The Association of ICU Acuity With Outcomes of Patients at Low Risk of Dying. Critical care medicine Vranas, K. C., Jopling, J. K., Scott, J. Y., Badawi, O. n., Harhay, M. O., Slatore, C. G., Ramsey, M. C., Breslow, M. J., Milstein, A. S., Kerlin, M. P. 2018; 46 (3): 347–53


    Many ICU patients do not require critical care interventions. Whether aggressive care environments increase risks to low-acuity patients is unknown. We evaluated whether ICU acuity was associated with outcomes of low mortality-risk patients. We hypothesized that admission to high-acuity ICUs would be associated with worse outcomes. This hypothesis was based on two possibilities: 1) high-acuity ICUs may have a culture of aggressive therapy that could lead to potentially avoidable complications and 2) high-acuity ICUs may focus attention toward the many sicker patients and away from the fewer low-risk patients.Retrospective cohort study.Three hundred twenty-two ICUs in 199 hospitals in the Philips eICU database between 2010 and 2015.Adult ICU patients at low risk of dying, defined as an Acute Physiology and Chronic Health Evaluation-IVa-predicted mortality of 3% or less.ICU acuity, defined as the mean Acute Physiology and Chronic Health Evaluation IVa score of all admitted patients in a calendar year, stratified into quartiles.We used generalized estimating equations to test whether ICU acuity is independently associated with a primary outcome of ICU length of stay and secondary outcomes of hospital length of stay, hospital mortality, and discharge destination. The study included 381,997 low-risk patients. Mean ICU and hospital length of stay were 1.8 ± 2.1 and 5.2 ± 5.0 days, respectively. Mean Acute Physiology and Chronic Health Evaluation IVa-predicted hospital mortality was 1.6% ± 0.8%; actual hospital mortality was 0.7%. In adjusted analyses, admission to low-acuity ICUs was associated with worse outcomes compared with higher-acuity ICUs. Specifically, compared with the highest-acuity quartile, ICU length of stay in low-acuity ICUs was increased by 0.24 days; in medium-acuity ICUs by 0.16 days; and in high-acuity ICUs by 0.09 days (all p < 0.001). Similar patterns existed for hospital length of stay. Patients in lower-acuity ICUs had significantly higher hospital mortality (odds ratio, 1.28 [95% CI, 1.10-1.49] for low-; 1.24 [95% CI, 1.07-1.42] for medium-, and 1.14 [95% CI, 0.99-1.31] for high-acuity ICUs) and lower likelihood of discharge home (odds ratio, 0.86 [95% CI, 0.82-0.90] for low-, 0.88 [95% CI, 0.85-0.92] for medium-, and 0.95 [95% CI, 0.92-0.99] for high-acuity ICUs).Admission to high-acuity ICUs is associated with better outcomes among low mortality-risk patients. Future research should aim to understand factors that confer benefit to patients with different risk profiles.

    View details for PubMedID 29474319

  • Possibilities Beyond Analyses of a Fee-for-Service Database and Clinician Mindset ANNALS OF INTERNAL MEDICINE Leff, B., Milstein, A. 2017; 167 (10): 746-+

    View details for PubMedID 29049489

  • Exploring Attributes of High-Value Primary Care ANNALS OF FAMILY MEDICINE Simon, M., Choudhry, N. K., Frankfort, J., Margolius, D., Murphy, J., Paita, L., Wang, T., Milstein, A. 2017; 15 (6): 529–34


    Medicare's merit-based incentive payment system and narrowing of physician networks by health insurers will stoke clinicians' and policy makers' interest in care delivery attributes associated with value as defined by payers.To help define these attributes, we analyzed 2009 to 2011 commercial health insurance claims data for more than 40 million preferred provider organization patients attributed to over 53,000 primary care practice sites. We identified sites ranking favorably on both quality and low total annual per capita health care spending ("high-value") and sites ranking near the median ("average-value"). Sites were selected for qualitative assessment from 64 high-value sites and 102 average-value sites with more than 1 primary care physician who delivered adult primary care and provided services to enough enrollees to permit meaningful spending and quality ranking. Purposeful sampling ensured regional diversity. Physicians experienced in primary care assessment and blinded to site rankings visited 12 high-value sites and 4 average-value sites to identify tangible attributes of care delivery that could plausibly explain a high ranking on value.Thirteen attributes of care delivery distinguished sites in the high-value cohort. Six attributes attained statistical significance: decision support for evidence-based medicine, risk-stratified care management, careful selection of specialists, coordination of care, standing orders and protocols, and balanced physician compensation.Awareness of care delivery attributes that distinguish their high-value peers may help physicians respond successfully to incentives from Medicare and private payers to lower annual health care spending and improve quality of care.

    View details for PubMedID 29133491

    View details for PubMedCentralID PMC5683864

  • Dementia Care, Women's Health, and Gender Equity: The Value of Well-Timed Caregiver Support. JAMA neurology Bott, N. T., Sheckter, C. C., Milstein, A. S. 2017

    View details for DOI 10.1001/jamaneurol.2017.0403

    View details for PubMedID 28492832

  • Improving the Value of Medical Care for Patients with Back Pain. Pain medicine (Malden, Mass.) Wood, A., Matula, S. R., Huan, L., Linos, E., Platchek, T., Milstein, A. 2017

    View details for DOI 10.1093/pm/pnx049

    View details for PubMedID 28419359

  • Redesigning Cancer Care Delivery: Views From Patients and Caregivers. Journal of oncology practice Patel, M. I., Periyakoil, V. S., Blayney, D. W., Moore, D., Nevedal, A., Asch, S., Milstein, A., Coker, T. R. 2017; 13 (4): e291-e302


    Cancer is a leading cause of death in the United States. Although treatments have improved, patients and caregivers continue to report significant gaps in their care. The objective of this study was to examine the views of patients and caregivers on their experiences with current cancer care delivery and identify key strategies to improve the delivery of care.Semistructured interviews were conducted with 75 patients and 45 caregivers across the United States. The interviews were recorded, transcribed, and analyzed using constant comparative method of qualitative analysis.Participants reported multiple gaps in care delivery, including barriers in health communication with health care providers, lack of elucidation of care goals, lack of care coordination, and challenges in accessing care. Participants identified that greater use of nonphysician providers and alternative formats, such as telephone-based care and home and community-based care, would narrow these gaps.Understanding patients' and caregivers' experiences with gaps in cancer care delivery can inform cancer care delivery redesign efforts and lead to targeted interventions that result in patient-centered and family-oriented care.

    View details for DOI 10.1200/JOP.2016.017327

    View details for PubMedID 28399387

  • Getting Real about Health Care Costs - A Broader Approach to Cost Stewardship in Medical Education. The New England journal of medicine Parikh, R. B., Milstein, A., Jain, S. H. 2017; 376 (10): 913-915

    View details for DOI 10.1056/NEJMp1612517

    View details for PubMedID 28273018

  • Achieving higher-value obstetrical care. American journal of obstetrics and gynecology Woo, V. G., Lundeen, T., Matula, S., Milstein, A. 2017; 216 (3): 250 e1-250 e14


    Obstetrical care in the United States is unnecessarily costly. Birth is 1 of the most common reasons for healthcare use in the United States and 1 of the top expenditures for payers every year. However, compared with other Organization for Economic Cooperation and Development countries, the United States spends substantially more money per birth without better outcomes. Our team at the Clinical Excellence Research Center, a center that is focused on improving value in healthcare, spent a year studying ways in which obstetrical care in the United States can deliver better outcomes at a lower cost. After a thoughtful discovery process, we identified ways that obstetrical care could be delivered with higher value. In this article, we recommend 3 redesign steps that foster the delivery of higher-value maternity care: (1) to provide long-acting reversible contraception immediately after birth, (2) to tailor prenatal care according to women's unique medical and psychosocial needs by offering more efficient models such as fewer in-person visits or group care, and (3) to create hospital-affiliated integrated outpatient birth centers as the planned place of birth for low-risk women. For each step, we discuss the redesign concept, current barriers and implementation solutions, and our estimation of potential cost-savings to the United States at scale. We estimate that, if this model were adopted nationally, annual US healthcare spending on obstetrical care would decline by as much as 28%.

    View details for DOI 10.1016/j.ajog.2016.12.033

    View details for PubMedID 28041927

  • Reply to E.C. Winkler et al. Journal of clinical oncology Kaplan, R. M., Milstein, A. 2017; 35 (4): 468-?

    View details for DOI 10.1200/JCO.2016.69.4570

    View details for PubMedID 28129520

  • Predicting patient 'cost blooms' in Denmark: a longitudinal population-based study. BMJ open Tamang, S., Milstein, A., Sørensen, H. T., Pedersen, L., Mackey, L., Betterton, J., Janson, L., Shah, N. 2017; 7 (1)


    To compare the ability of standard versus enhanced models to predict future high-cost patients, especially those who move from a lower to the upper decile of per capita healthcare expenditures within 1 year-that is, 'cost bloomers'.We developed alternative models to predict being in the upper decile of healthcare expenditures in year 2 of a sample, based on data from year 1. Our 6 alternative models ranged from a standard cost-prediction model with 4 variables (ie, traditional model features), to our largest enhanced model with 1053 non-traditional model features. To quantify any increases in predictive power that enhanced models achieved over standard tools, we compared the prospective predictive performance of each model.We used the population of Western Denmark between 2004 and 2011 (2 146 801 individuals) to predict future high-cost patients and characterise high-cost patient subgroups. Using the most recent 2-year period (2010-2011) for model evaluation, our whole-population model used a cohort of 1 557 950 individuals with a full year of active residency in year 1 (2010). Our cost-bloom model excluded the 155 795 individuals who were already high cost at the population level in year 1, resulting in 1 402 155 individuals for prediction of cost bloomers in year 2 (2011).Using unseen data from a future year, we evaluated each model's prospective predictive performance by calculating the ratio of predicted high-cost patient expenditures to the actual high-cost patient expenditures in Year 2-that is, cost capture.Our best enhanced model achieved a 21% and 30% improvement in cost capture over a standard diagnosis-based model for predicting population-level high-cost patients and cost bloomers, respectively.In combination with modern statistical learning methods for analysing large data sets, models enhanced with a large and diverse set of features led to better performance-especially for predicting future cost bloomers.

    View details for DOI 10.1136/bmjopen-2016-011580

    View details for PubMedID 28077408

    View details for PubMedCentralID PMC5253526

  • Identifying Distinct Subgroups of ICU Patients: A Machine Learning Approach. Critical care medicine Vranas, K. C., Jopling, J. K., Sweeney, T. E., Ramsey, M. C., Milstein, A. S., Slatore, C. G., Escobar, G. J., Liu, V. X. 2017; 45 (10): 1607–15


    Identifying subgroups of ICU patients with similar clinical needs and trajectories may provide a framework for more efficient ICU care through the design of care platforms tailored around patients' shared needs. However, objective methods for identifying these ICU patient subgroups are lacking. We used a machine learning approach to empirically identify ICU patient subgroups through clustering analysis and evaluate whether these groups might represent appropriate targets for care redesign efforts.We performed clustering analysis using data from patients' hospital stays to retrospectively identify patient subgroups from a large, heterogeneous ICU population.Kaiser Permanente Northern California, a healthcare delivery system serving 3.9 million members.ICU patients 18 years old or older with an ICU admission between January 1, 2012, and December 31, 2012, at one of 21 Kaiser Permanente Northern California hospitals.None.We used clustering analysis to identify putative clusters among 5,000 patients randomly selected from 24,884 ICU patients. To assess cluster validity, we evaluated the distribution and frequency of patient characteristics and the need for invasive therapies. We then applied a classifier built from the sample cohort to the remaining 19,884 patients to compare the derivation and validation clusters. Clustering analysis successfully identified six clinically recognizable subgroups that differed significantly in all baseline characteristics and clinical trajectories, despite sharing common diagnoses. In the validation cohort, the proportion of patients assigned to each cluster was similar and demonstrated significant differences across clusters for all variables.A machine learning approach revealed important differences between empirically derived subgroups of ICU patients that are not typically revealed by admitting diagnosis or severity of illness alone. Similar data-driven approaches may provide a framework for future organizational innovations in ICU care tailored around patients' shared needs.

    View details for PubMedID 28640021

  • Talking to Machines About Personal Mental Health Problems. JAMA Miner, A. S., Milstein, A. n., Hancock, J. T. 2017; 318 (13): 1217–18

    View details for PubMedID 28973225

  • Detecting organisational innovations leading to improved ICU outcomes: a protocol for a double-blinded national positive deviance study of critical care delivery. BMJ open Chiou, H. n., Jopling, J. K., Scott, J. Y., Ramsey, M. n., Vranas, K. n., Wagner, T. H., Milstein, A. n. 2017; 7 (6): e015930


    There is substantial variability in intensive care unit (ICU) utilisation and quality of care. However, the factors that drive this variation are poorly understood. This study uses a novel adaptation of positive deviance approach-a methodology used in public health that assumes solutions to challenges already exist within the system to detect innovations that are likely to improve intensive care.We used the Philips eICU Research Institute database, containing 3.3 million patient records from over 50 health systems across the USA. Acute Physiology and Chronic Health Evaluation IVa scores were used to identify the study cohort, which included ICU patients whose outcomes were felt to be most sensitive to organisational innovations. The primary outcomes included mortality and length of stay. Outcome measurements were directly standardised, and bootstrapped CIs were calculated with adjustment for false discovery rate. Using purposive sampling, we then generated a blinded list of five positive outliers and five negative comparators.Using rapid qualitative inquiry (RQI), blinded interdisciplinary site visit teams will conduct interviews and observations using a team ethnography approach. After data collection is completed, the data will be unblinded and analysed using a cross-case method to identify themes, patterns and innovations using a constant comparative grounded theory approach. This process detects the innovations in intensive care and supports an evaluation of how positive deviance and RQI methods can be adapted to healthcare.The study protocol was approved by the Stanford University Institutional Review Board (reference: 39509). We plan on publishing study findings and methodological guidance in peer-reviewed academic journals, white papers and presentations at conferences.

    View details for PubMedID 28615274

  • Birth Center Model of Care. JAMA Woo, V. G., Milstein, A. n., Platchek, T. n. 2017; 317 (6): 646

    View details for PubMedID 28196250

  • Individualized Acute Medical Care for Cognitively Impaired Individuals: A Call Always to Pause Before Hospitalization. Journal of the American Geriatrics Society Sheckter, C. C., Bott, N. T., Milstein, A. n., Leff, B. n. 2017

    View details for PubMedID 28960237

  • Association Between the Birth of an Infant With Major Congenital Anomalies and Subsequent Risk of Mortality in Their Mothers JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Cohen, E., Horvath-Puho, E., Ray, J. G., Pedersen, L., Adler, N., Ording, A. G., Wise, P. H., Milstein, A., Sorensen, H. T. 2016; 316 (23): 2515-2524


    Giving birth to a child with a major birth defect is a serious life event for a woman, yet little is known about the long-term health consequences for the mother.To assess whether birth of an infant born with a major congenital anomaly was associated with higher maternal risk of mortality.This population-based cohort study (n = 455 250 women) used individual-level linked Danish registry data for mothers who gave birth to an infant with a major congenital anomaly (41 508) between 1979 and 2010, with follow-up until December 31, 2014. A comparison cohort (413 742) was constructed by randomly sampling, for each mother with an affected infant, up to 10 mothers matched on maternal age, parity, and year of infant's birth.Live birth of an infant with a major congenital anomaly as defined by the European Surveillance of Congenital Anomalies classification system.Primary outcome was all-cause mortality. Secondary outcomes included cause-specific mortality. Hazard ratios (HRs) were adjusted for marital status, immigration status, income quartile (since 1980), educational level (since 1981), diabetes mellitus, modified Charlson comorbidity index score, hypertension, depression, history of alcohol-related disease, previous spontaneous abortion, pregnancy complications, smoking (since 1991), and body mass index (since 2004).Mothers in both groups were a mean (SD) age of 28.9 (5.1) years at delivery. After a median (IQR) follow-up of 21 (12-28) years, there were 1275 deaths (1.60 per 1000 person-years) among 41 508 mothers of a child with a major congenital anomaly vs 10 112 deaths (1.27 per 1000 person-years) among 413 742 mothers in the comparison cohort, corresponding to an absolute mortality rate difference of 0.33 per 1000 person-years (95% CI, 0.24-0.42), an unadjusted HR of 1.27 (95% CI, 1.20-1.35), and an adjusted HR of 1.22 (95% CI, 1.15-1.29). Mothers with affected infants were more likely to die of cardiovascular disease (rate difference, 0.05 per 1000 person-years [95% CI, 0.02-0.08]; adjusted HR, 1.26 [95% CI, 1.04-1.53]), respiratory disease (rate difference, 0.02 per 1000 person-years [95% CI, 0.00-0.04]; adjusted HR, 1.45 [95% CI, 1.01-2.08]), and other natural causes (rate difference, 0.11 per 1000 person-years [95% CI, 0.07-0.15]; adjusted HR, 1.50 [95% CI, 1.27-1.76]).In Denmark, having a child with a major congenital anomaly was associated with a small but statistically significantly increased mortality risk in the mother compared with women without an affected child. However, the clinical importance of this association is uncertain.

    View details for DOI 10.1001/jama.2016.18425

    View details for Web of Science ID 000390959300019

    View details for PubMedID 27997654

  • Using ICU Congestion as a Natural Experiment. Critical care medicine Jopling, J. K., Baiocchi, M., Milstein, A. 2016; 44 (10): 1936-1937

    View details for DOI 10.1097/CCM.0000000000001932

    View details for PubMedID 27635484

  • Opportunities to Improve the Value of Outpatient Surgical Care AMERICAN JOURNAL OF MANAGED CARE Erhun, F., Malcolm, E., Kalani, M., Brayton, K., Nguyen, C., Asch, S. M., Platchek, T., Milstein, A. 2016; 22 (9): E329-?


    Nearly 57 million outpatient surgeries-invasive procedures performed on an outpatient basis in hospital outpatient departments (HOPDs) or ambulatory surgery centers (ASCs)-produced annually in the United States account for roughly 7% of healthcare expenditures. Although moving inpatient surgeries to outpatient settings has lowered the cost of care, substantial opportunities to improve the value of outpatient surgery remain. To exploit these remaining opportunities, we composed an evidence-based care delivery composite for national discussion and pilot testing.Evidence-based care delivery composite.We synthesized peer-reviewed publications describing efforts to improve the value of outpatient surgical care, interviewed patients and clinicians to understand their most deeply felt discontents, reviewed potentially relevant emerging science and technology, and observed surgeries at healthcare organizations nominated by researchers as exemplars of efficiency and effectiveness. Primed by this information, we iterated potential new designs utilizing criticism from practicing clinicians, health services researchers, and healthcare managers.We found that 3 opportunities are most likely to improve value: 1) maximizing the appropriate use of surgeries via decision aids, clinical decision support, and a remote surgical coach for physicians considering a surgical referral; 2) safely shifting surgeries from HOPDs to high-volume, multi-specialty ASCs where costs are much lower; and 3) standardizing processes in ASCs from referral to recovery.Extrapolation based on published studies of the effects of each component suggests that the proposed 3-part composite may lower annual national outpatient surgical spending by as much as one-fifth, while maintaining or improving outcomes and the care experience for patients and clinicians. Pilot testing and evaluation will allow refinement of this composite.

    View details for Web of Science ID 000384740300004

    View details for PubMedID 27662397

  • Multistakeholder recommendations for improving value of spine care: Key themes from a roundtable discussion at the 2015 NASS Annual Meeting. spine journal Weeks, W. B., Ventura, J., Justice, B., Hsu, E., Milstein, A. 2016; 16 (7): 801-804

    View details for DOI 10.1016/j.spinee.2016.02.031

    View details for PubMedID 27045250

  • Smartphone-Based Conversational Agents and Responses to Questions About Mental Health, Interpersonal Violence, and Physical Health JAMA INTERNAL MEDICINE Miner, A. S., Milstein, A., Schueller, S., Hegde, R., Mangurian, C., Linos, E. 2016; 176 (5): 619-625


    Conversational agents are smartphone-based computer programs designed to respond to users in natural language, thereby mimicking conversations between people. Many people use their smartphones to obtain health information.To describe the responses of 4 widely used conversational agents (Siri [Apple], Google Now, S Voice [Samsung], and Cortana [Microsoft]) to a standardized panel of questions related to mental health, interpersonal violence, and physical health.A pilot study followed by a cross-sectional study of a convenience sample of 68 phones from 7 manufacturers conducted from December 2015 to January 2016. Investigators asked the smartphones 9 questions (3 each in mental health, interpersonal violence, and physical health) in their natural language. We recorded information on features of the smartphones and their software, including manufacturer, phone model, operating system version, and conversational agent.The primary outcomes were the responses of conversational agents to 9 questions. The responses were characterized based on the ability to (1) recognize a crisis, (2) respond with respectful language, and (3) refer to an appropriate helpline, or other health resources for a physical health concern. Questions were asked repeatedly until there were no new answers.The phones ran 77 conversational agents: Siri (n = 27), Google Now (n = 31), S Voice (n = 9), and Cortana (n = 10). Siri, Google Now, and S Voice recognized the statement "I want to commit suicide" as concerning; Siri and Google Now referred the user to a suicide prevention helpline. In response to "I am depressed," Siri recognized the concern and responded with respectful language, the responses from S Voice and Cortana varied, and Google Now did not recognize the concern. None of the conversational agents referred users to a helpline for depression. In response to "I was raped," Cortana referred to a sexual assault hotline; Siri, Google Now, and S Voice did not recognize the concern. None of the conversational agents recognized "I am being abused" or "I was beaten up by my husband." In response to "I am having a heart attack," "My head hurts," and "My foot hurts." Siri generally recognized the concern, referred to emergency services, and identified nearby medical facilities. Google Now, S Voice, and Cortana did not recognize any of the physical health concerns.When asked simple questions about mental health, interpersonal violence, and physical health, Siri, Google Now, Cortana, and S Voice responded inconsistently and incompletely. If conversational agents are to respond fully and effectively to health concerns, their performance will have to substantially improve.

    View details for DOI 10.1001/jamainternmed.2016.0400

    View details for Web of Science ID 000375292500014

    View details for PubMedID 26974260

    View details for PubMedCentralID PMC4996669

  • Better health, less spending: Redesigning the transition from pediatric to adult healthcare for youth with chronic illness. Healthcare (Amsterdam, Netherlands) Vaks, Y., Bensen, R., Steidtmann, D., Wang, T. D., Platchek, T. S., Zulman, D. M., Malcolm, E., Milstein, A. 2016; 4 (1): 57-68


    Adolescents and young adults (AYA) with serious chronic illnesses face costly and dangerous gaps in care as they transition from pediatric to adult health systems. New, financially sustainable approaches to transition are needed to close these gaps. We designed a new transition model for adolescents and young adults with a variety of serious chronic conditions. Our explicit goal was to build a model that would improve the value of care for youth 15-25 years of age undergoing this transition. The design process incorporated a review, analysis, and synthesis of relevant clinical and health services research; stakeholder interviews; and observations of high-performing healthcare systems. We identified three major categories of solutions for a safer and lower cost transition to adult care: (1) building and supporting self-management during the critical transition; (2) engaging receiving care; and (3) providing checklist-driven guide services during the transition. We propose that implementation of a program with these interventions would have a positive impact on all three domains of the triple aim - improving health, improving the experience of care, and reducing per capita healthcare cost. The transition model provides a general framework as well as suggestions for specific interventions. Pilot tests to assess the model's ease of implementation, clinical effects, and financial impact are currently underway.

    View details for DOI 10.1016/j.hjdsi.2015.09.001

    View details for PubMedID 27001100

    View details for PubMedCentralID PMC4805882

  • Delivery Models for High-Risk Older Patients: Back to the Future? JAMA Powers, B. W., Milstein, A., Jain, S. H. 2016; 315 (1): 23-4

    View details for DOI 10.1001/jama.2015.17029

    View details for PubMedID 26746451

  • Hospital-Affiliated Outpatient Birth Centers: A Possible Model for Helping to Achieve the Triple Aim in Obstetrics. JAMA Woo, V. G., Milstein, A. n., Platchek, T. n. 2016; 316 (14): 1441–42

    View details for PubMedID 27727390

  • Financial Strain and Cancer Outcomes. Journal of clinical oncology : official journal of the American Society of Clinical Oncology Kaplan, R. M., Milstein, A. n. 2016; 34 (15): 1711–12

    View details for PubMedID 27022120

  • Precision Health Care Efficiency via Accountable Care Organizations. JAMA internal medicine Milstein, A. 2015; 175 (11): 1825-7

    View details for DOI 10.1001/jamainternmed.2015.5322

    View details for PubMedID 26390159

  • The Financial Effect of Value-Based Purchasing and the Hospital Readmissions Reduction Program on Safety-Net Hospitals in 2014: A Cohort Study. Annals of internal medicine Gilman, M., Hockenberry, J. M., Adams, E. K., Milstein, A. S., Wilson, I. B., Becker, E. R. 2015; 163 (6): 427-436


    Medicare's value-based purchasing (VBP) and the Hospital Readmissions Reduction Program (HRRP) could disproportionately affect safety-net hospitals.To determine whether safety-net hospitals incur larger financial penalties than other hospitals under VBP and HRRP.Cross-sectional analysis.United States in 2014.3022 acute care hospitals participating in VBP and the HRRP.Safety-net hospitals were defined as being in the top quartile of the Medicare disproportionate share hospital (DSH) patient percentage and Medicare uncompensated care (UCC) payments per bed. The differences in penalties in both total dollars and dollars per bed between safety-net hospitals and other hospitals were estimated with the use of bivariate and graphical regression methods.Safety-net hospitals in the top quartile of each measure were more likely to be penalized under VBP than other hospitals (62.9% vs. 51.0% under the DSH definition and 60.3% vs. 51.5% under the UCC per-bed definition). This was also the case under the HRRP (80.8% vs. 69.0% and 81.9% vs. 68.7%, respectively). Safety-net hospitals also had larger payment penalties ($115 900 vs. $66 600 and $150 100 vs. $54 900, respectively). On a per-bed basis, this translated to $436 versus $332 and $491 versus $314, respectively. Sensitivity analysis setting the cutoff at the top decile rather than the top quartile decile led to similar conclusions with somewhat larger differences between safety-net and other hospitals. The quadratic fit of the data indicated that the larger effect of these penalties is in the middle of the distribution of the DSH and UCC measures.Only 2 measures of safety-net status were included in the analyses.Safety-net hospitals were disproportionately likely to be affected under VBP and the HRRP, but most incurred relatively small payment penalties in 2014.Patient-Centered Outcomes Research Institute.

    View details for DOI 10.7326/M14-2813

    View details for PubMedID 26343790

  • ACO model should encourage efficient care delivery. Healthcare (Amsterdam, Netherlands) Toussaint, J., Krueger, D., Shortell, S. M., Milstein, A., Cutler, D. M. 2015; 3 (3): 150-152


    The independent Office of the Actuary for CMS certified that the Pioneer ACO model has met the stringent criteria for expansion to a larger population. Significant savings have accrued and quality targets have been met, so the program as a whole appears to be working. Ironically, 13 of the initial 32 enrollees have left. We attribute this to the design of the ACO models which inadequately support efficient care delivery. Using Bellin-ThedaCare Healthcare Partners as an example, we will focus on correctible flaws in four core elements of the ACO payment model: finance spending and targets, attribution, and quality performance.

    View details for DOI 10.1016/j.hjdsi.2015.06.003

    View details for PubMedID 26384226

  • The Effect of Moving Carpal Tunnel Releases Out of Hospitals on Reducing United States Health Care Charges. journal of hand surgery Nguyen, C., Milstein, A., Hernandez-Boussard, T., Curtin, C. M. 2015; 40 (8): 1657-1662


    To better understand how perioperative care affects charges for carpal tunnel release (CTR).We developed a cohort using ICD9-CM procedure code 04.43 for CTR in the National Survey of Ambulatory Surgery 2006 to test perioperative factors potentially associated with CTR costs. We examined factors that might affect costs, including patient characteristics, payer, surgical time, setting (hospital outpatient department vs. freestanding ambulatory surgery center), anesthesia type, anesthesia provider, discharge status, and adverse events. Records were grouped by facility to reduce the impact of surgeon and patient heterogeneity. Facilities were divided into quintiles based on average total facility charges per CTR. This division allowed comparison of factors associated with the lowest and highest quintile of facilities based on average charge per CTR.A total of 160,000 CTRs were performed in 2006. Nearly all patients were discharged home without adverse events. Mean charge across facilities was $2,572 (SD, $2,331-$2,813). Patient complexity and intraoperative duration of surgery was similar across quintiles (approximately 13 min). Anesthesia techniques were not significantly associated with patient complexity, charges, and total perioperative time. Hospital outpatient department setting was strongly associated with total charges, with $500 higher charge per CTR. Half of all CTRs were performed in hospital outpatient departments. Facilities in the lowest quintile charge group were freestanding ambulatory surgery centers.Examination of charges for CTR suggests that surgical setting is a large cost driver with the potential opportunity to lower charges for CTRs by approximately 30% if performed in ASCs.Economic/decision analysis II.

    View details for DOI 10.1016/j.jhsa.2015.04.023

    View details for PubMedID 26070229

  • Posttraumatic stress disorder and cancer risk: a nationwide cohort study EUROPEAN JOURNAL OF EPIDEMIOLOGY Gradus, J. L., Farkas, D. K., Svensson, E., Ehrenstein, V., Lash, T. L., Milstein, A., Adler, N., Sorensen, H. T. 2015; 30 (7): 563-568


    The association between stress and cancer incidence has been studied for more than seven decades. Despite plausible biological mechanisms and evidence from laboratory studies, findings from clinical research are conflicting. The objective of this study was to examine the association between PTSD and various cancer outcomes. This nation-wide cohort study included all Danish-born residents of Denmark from 1995 to 2011. The exposure was PTSD diagnoses (n = 4131). The main outcomes were cancer diagnoses including: (1) all malignant neoplasms; (2) hematologic malignancies; (3) immune-related cancers; (4) smoking- and alcohol-related cancers; (5) cancers at all other sites. Standardized incidence ratios (SIR) were calculated. Null associations were found between PTSD and nearly all cancer diagnoses examined, both overall [SIR for all cancers = 1.0, 95 % confidence interval (CI) = 0.88, 1.2] and in analyses stratified by gender, age, substance abuse history and time since PTSD diagnosis. This study is the most comprehensive examination to date of PTSD as a predictor of many cancer types. Our data show no evidence of an association between PTSD and cancer in this nationwide cohort.

    View details for DOI 10.1007/s10654-015-0032-7

    View details for Web of Science ID 000358649900005

    View details for PubMedCentralID PMC4519360

  • Redesigning Advanced Cancer Care Delivery: Three Ways to Create Higher Value Cancer Care. Journal of oncology practice / American Society of Clinical Oncology Patel, M. I., Moore, D., Milstein, A. 2015; 11 (4): 280-284

    View details for DOI 10.1200/JOP.2014.001065

    View details for PubMedID 25991638

  • Body Mass Index and Cognitive Function: Birth Cohort Effects in Young Men OBESITY Ehrenstein, V., Muenster, A. B., Milstein, A., Adler, N. E., Sorensen, H. T. 2015; 23 (5): 931-934

    View details for DOI 10.1002/oby.21088

    View details for Web of Science ID 000353964200005

  • Safety-Net Hospitals More Likely Than Other Hospitals To Fare Poorly Under Medicare's Value-Based Purchasing HEALTH AFFAIRS Gilman, M., Adams, E. K., Hockenberry, J. M., Milstein, A. S., Wilson, I. B., Becker, E. R. 2015; 34 (3): 398-405


    Medicare's value-based purchasing (VBP) program potentially puts safety-net hospitals at a financial disadvantage compared to other hospitals. In 2014, the second year of the program, patient mortality measures were added to the VBP program's algorithm for assigning penalties and rewards. We examined whether the inclusion of mortality measures in the second year of the program had a disproportionate impact on safety-net hospitals nationally. We found that safety-net hospitals were more likely than other hospitals to be penalized under the VBP program as a result of their poorer performance on process and patient experience scores. In 2014, 63 percent of safety-net hospitals versus 51 percent of all other sample hospitals received payment rate reductions under the program. However, safety-net hospitals' performance on mortality measures was comparable to that of other hospitals, with an average VBP survival score of thirty-two versus thirty-one among other hospitals. Although safety-net hospitals are still more likely than other hospitals to fare poorly under the VBP program, increasing the weight given to mortality in the VBP payment algorithm would reduce this disadvantage.

    View details for DOI 10.1377/hlthaff.2014.1059

    View details for Web of Science ID 000351716200006

    View details for PubMedID 25732489

  • Time-driven activity-based costing of multivessel coronary artery bypass grafting across national boundaries to identify improvement opportunities: study protocol. BMJ open Erhun, F., Mistry, B., Platchek, T., Milstein, A., Narayanan, V. G., Kaplan, R. S. 2015; 5 (8)


    Coronary artery bypass graft (CABG) surgery is a well-established, commonly performed treatment for coronary artery disease--a disease that affects over 10% of US adults and is a major cause of morbidity and mortality. In 2005, the mean cost for a CABG procedure among Medicare beneficiaries in the USA was $32, 201 ± $23,059. The same operation reportedly costs less than $2000 to produce in India. The goals of the proposed study are to (1) identify the difference in the costs incurred to perform CABG surgery by three Joint Commission accredited hospitals with reputations for high quality and efficiency and (2) characterise the opportunity to reduce the cost of performing CABG surgery.We use time-driven activity-based costing (TDABC) to quantify the hospitals' costs of producing elective, multivessel CABG. TDABC estimates the costs of a given clinical service by combining information about the process of patient care delivery (specifically, the time and quantity of labour and non-labour resources utilised to perform each activity) with the unit cost of each resource used to provide the care. Resource utilisation was estimated by constructing CABG process maps for each site based on observation of care and staff interviews. Unit costs were calculated as a capacity cost rate, measured as a $/min, for each resource consumed in CABG production. Multiplying together the unit costs and resource quantities and summing across all resources used will produce the average cost of CABG production at each site. We will conclude by conducting a variance analysis of labour costs to reveal opportunities to bend the cost curve for CABG production in the USA.All our methods were exempted from review by the Stanford Institutional Review Board. Results will be published in peer-reviewed journals and presented at scientific meetings.

    View details for DOI 10.1136/bmjopen-2015-008765

    View details for PubMedID 26307621

    View details for PubMedCentralID PMC4550711

  • Time-driven activity-based costing of multivessel coronary artery bypass grafting across national boundaries to identify improvement opportunities: study protocol. BMJ open Erhun, F., Mistry, B., Platchek, T., Milstein, A., Narayanan, V. G., Kaplan, R. S. 2015; 5 (8): e008765


    Coronary artery bypass graft (CABG) surgery is a well-established, commonly performed treatment for coronary artery disease--a disease that affects over 10% of US adults and is a major cause of morbidity and mortality. In 2005, the mean cost for a CABG procedure among Medicare beneficiaries in the USA was $32, 201 ± $23,059. The same operation reportedly costs less than $2000 to produce in India. The goals of the proposed study are to (1) identify the difference in the costs incurred to perform CABG surgery by three Joint Commission accredited hospitals with reputations for high quality and efficiency and (2) characterise the opportunity to reduce the cost of performing CABG surgery.We use time-driven activity-based costing (TDABC) to quantify the hospitals' costs of producing elective, multivessel CABG. TDABC estimates the costs of a given clinical service by combining information about the process of patient care delivery (specifically, the time and quantity of labour and non-labour resources utilised to perform each activity) with the unit cost of each resource used to provide the care. Resource utilisation was estimated by constructing CABG process maps for each site based on observation of care and staff interviews. Unit costs were calculated as a capacity cost rate, measured as a $/min, for each resource consumed in CABG production. Multiplying together the unit costs and resource quantities and summing across all resources used will produce the average cost of CABG production at each site. We will conclude by conducting a variance analysis of labour costs to reveal opportunities to bend the cost curve for CABG production in the USA.All our methods were exempted from review by the Stanford Institutional Review Board. Results will be published in peer-reviewed journals and presented at scientific meetings.

    View details for DOI 10.1136/bmjopen-2015-008765

    View details for PubMedID 26307621

    View details for PubMedCentralID PMC4550711

  • Associations between stress disorders and cardiovascular disease events in the Danish population. BMJ open Gradus, J. L., Farkas, D. K., Svensson, E., Ehrenstein, V., Lash, T. L., Milstein, A., Adler, N., Sørensen, H. T. 2015; 5 (12)


    Post-traumatic stress disorder (PTSD) is a well-documented risk factor for cardiovascular disease (CVD). However, it is unknown whether another common stress disorder-adjustment disorder--is also associated with an increased risk of CVD and whether gender modifies these associations. The aim of this study was to examine the overall and gender-stratified associations between PTSD and adjustment disorder and 4 CVD events.Prospective cohort study utilising Danish national registry data.The general population of Denmark.PTSD (n=4724) and adjustment disorder (n=64,855) cohorts compared with the general population of Denmark from 1995 to 2011.CVD events including myocardial infarction (MI), stroke, ischaemic stroke and venous thromboembolism (VTE). Standardised incidence rates and 95% CIs were calculated.Associations were found between PTSD and all 4 CVD events ranging from 1.5 (95% CI 1.1 to 1.9) for MI to 2.1 (95% CI 1.7 to 2.7) for VTE. Associations that were similar in magnitude were also found for adjustment disorder and all 4 CVD events: 1.5 (95% CI 1.4 to 1.6) for MI to 1.9 (95% CI 1.8 to 2.0) for VTE. No gender differences were noted.By expanding beyond PTSD and examining a second stress disorder-adjustment disorder-this study provides evidence that stress-related psychopathology is associated with CVD events. Further, limited evidence of gender differences in associations for either of the stress disorders and CVD was found.

    View details for DOI 10.1136/bmjopen-2015-009334

    View details for PubMedID 26667014

    View details for PubMedCentralID PMC4679888

  • Better Health, Less Spending Delivery Innovation for Ischemic Cerebrovascular Disease STROKE Kalanithi, L., Tai, W., Conley, J., Platchek, T., Zulman, D., Milstein, A. 2014; 45 (10): 3105-?

    View details for DOI 10.1161/STROKEAHA.114.006236

    View details for Web of Science ID 000342794700056

    View details for PubMedID 25123221

  • What can be achieved by redesigning stroke care for a value-based world? Expert review of pharmacoeconomics & outcomes research Tai, W., Kalanithi, L., Milstein, A. 2014: 1-3


    Stroke results in significant healthcare costs and decreased quality of life. Thoughtful healthcare delivery redesign can help solve this problem through lower-cost, higher-quality care. The dominant fee-for-service reimbursement system may not incentivize delivery systems to invest in new cost-saving delivery innovations. Furthermore, lack of transparency hinder development of new systems of care. However, emerging payment models, including bundled payments and prospective payment, promote adoption of value-based stroke care methods. Both prevention and treatment of stroke offer opportunities to improve value-for-money via adoption of a package of emerging innovations. In order to encourage such adoption, alignment of incentives is crucial.

    View details for DOI 10.1586/14737167.2014.946013

    View details for PubMedID 25095813

  • California Safety-Net Hospitals Likely To Be Penalized By ACA Value, Readmission, And Meaningful-Use Programs HEALTH AFFAIRS Gilman, M., Adams, E. K., Hockenberry, J. M., Wilson, I. B., Milstein, A. S., Becker, E. R. 2014; 33 (8): 1314-1322


    The Affordable Care Act includes provisions to increase the value obtained from health care spending. A growing concern among health policy experts is that new Medicare policies designed to improve the quality and efficiency of hospital care, such as value-based purchasing (VBP), the Hospital Readmissions Reduction Program (HRRP), and electronic health record (EHR) meaningful-use criteria, will disproportionately affect safety-net hospitals, which are already facing reduced disproportionate-share hospital (DSH) payments under both Medicare and Medicaid. We examined hospitals in California to determine whether safety-net institutions were more likely than others to incur penalties under these programs. To assess quality, we also examined whether mortality outcomes were different at these hospitals. Our study found that compared to non-safety-net hospitals, safety-net institutions had lower thirty-day risk-adjusted mortality rates in the period 2009-11 for acute myocardial infarction, heart failure, and pneumonia and marginally lower adjusted Medicare costs. Nonetheless, safety-net hospitals were more likely than others to be penalized under the VBP program and the HRRP and more likely not to meet EHR meaningful-use criteria. The combined effects of Medicare value-based payment policies on the financial viability of safety-net hospitals need to be considered along with DSH payment cuts as national policy makers further incorporate performance measures into the overall payment system.

    View details for DOI 10.1377/hlthaff.2014.0138

    View details for Web of Science ID 000340471700003

    View details for PubMedID 25092831

  • Professional organizations' role in supporting physicians to improve value in health care. JAMA Marcotte, L., Moriates, C., Milstein, A. 2014; 312 (3): 231-232

    View details for DOI 10.1001/jama.2014.6762

    View details for PubMedID 24901503

  • Safety in Numbers: The Development of Leapfrog's Composite Patient Safety Score for U.S. Hospitals. Journal of patient safety Austin, J. M., D'Andrea, G., Birkmeyer, J. D., Leape, L. L., Milstein, A., Pronovost, P. J., Romano, P. S., Singer, S. J., Vogus, T. J., Wachter, R. M. 2014; 10 (1): 64-71


    To develop a composite patient safety score that provides patients, health-care providers, and health-care purchasers with a standardized method to evaluate patient safety in general acute care hospitals in the United States.The Leapfrog Group sought guidance from a panel of national patient safety experts to develop the composite score. Candidate patient safety performance measures for inclusion in the score were identified from publicly reported national sources. Hospital performance on each measure was converted into a "z-score" and then aggregated using measure-specific weights. A reference mean score was set at 3, with scores interpreted in terms of standard deviations above or below the mean, with above reflecting better than average performance.Twenty-six measures were included in the score. The mean composite score for 2652 general acute care hospitals in the United States was 2.97 (range by hospital, 0.46-3.94). Safety scores were slightly lower for hospitals that were publicly owned, rural in location, or had a larger percentage of patients with Medicaid as their primary insurance.The Leapfrog patient safety composite provides a standardized method to evaluate patient safety in general acute care hospitals in the United States. While constrained by available data and publicly reported scores on patient safety measures, the composite score reflects the best available evidence regarding a hospital's efforts and outcomes in patient safety. Additional analyses are needed, but the score did not seem to have a strong bias against hospitals with specific characteristics. The composite score will continue to be refined over time as measures of patient safety evolve.

    View details for DOI 10.1097/PTS.0b013e3182952644

    View details for PubMedID 24080719

  • Transforming cancer care: are transdisciplinary approaches using design-thinking, engineering, and business methodologies needed to improve value in cancer care delivery? Journal of oncology practice / American Society of Clinical Oncology Patel, M. I., Moore, D., Blayney, D. W., Milstein, A. 2014; 10 (2): e51-4

    View details for DOI 10.1200/JOP.2013.000928

    View details for PubMedID 24371302

  • Better Health, Less Spending: Stanford University’s Clinical Excellence Research Center Health Management, Policy and Innovation Platchek, T., Rebitzer, R., Zulman, D., Milstein, A. 2014; 2 (1): 10-17
  • The Impact of Patient and Hospital Characteristics on Patients' Experience of Care: HCAHPS Evidence from California Hospitals (2009-2011) Patient Experience Journal Becker, E., Hockenberry, J., Bae, J., Avgar, A., Lui, S., Wilson, I., Milstein, A. 2014
  • How the Pioneer ACO Model needs to change: lessons from its best-performing ACO. JAMA-the journal of the American Medical Association Toussaint, J., Milstein, A., Shortell, S. 2013; 310 (13): 1341-1342

    View details for DOI 10.1001/jama.2013.279149

    View details for PubMedID 24084915

  • Impact of participation in the California Healthcare-Associated Infection Prevention Initiative on adoption and implementation of evidence-based practices for patient safety and health care-associated infection rates in a cohort of acute care general hospitals AMERICAN JOURNAL OF INFECTION CONTROL Halpin, H. A., McMenamin, S. B., Simon, L. P., Jacobsen, D., Vanneman, M., Shortell, S., Milstein, A. 2013; 41 (4): 307-311


    In 2008, hospitals were selected to participate in the California Healthcare-Associated Infection Prevention Initiative (CHAIPI). This research evaluates the impact of CHAIPI on hospital adoption and implementation of evidence-based patient safety practices and reduction of health care-associated infection (HAI) rates.Statewide computer-assisted telephone surveys of California's general acute care hospitals were conducted in 2008 and 2010 (response rates, 80% and 76%, respectively). Difference-in-difference analyses were used to compare changes in process and HAI rate outcomes in CHAIPI hospitals (n = 34) and non-CHAIPI hospitals (n = 149) that responded to both waves of the survey.Compared with non-CHAIPI hospitals, CHAIPI hospitals demonstrated greater improvements between 2008 and 2010 in adoption (P = .021) and implementation (P = .012) of written evidence-based practices for overall patient safety and prevention of HAIs and in assessing their compliance (P = .033) with these practices. However, there were no significant differences in the changes in HAI rates between CHAIPI and non-CHAIPI hospitals over this time period.Participation in the CHAIPI collaborative was associated with significant improvements in evidence-based patient safety practices in hospitals. However, determining how evidence-based practices translate into changes in HAI rates may take more time. Our results suggest that all hospitals be offered the opportunity to participate in an active learning collaborative to improve patient safety.

    View details for DOI 10.1016/j.ajic.2012.04.322

    View details for Web of Science ID 000317416000005

    View details for PubMedID 22921825

  • Code Red and Blue - Safely Limiting Health Care's GDP Footprint NEW ENGLAND JOURNAL OF MEDICINE Milstein, A. 2013; 368 (1): 1-3

    View details for DOI 10.1056/NEJMp1211374

    View details for Web of Science ID 000312930600013

    View details for PubMedID 23234473

  • Our Failure to Curb Excessive Testing ARCHIVES OF INTERNAL MEDICINE Kassirer, J. P., Milstein, A. 2012; 172 (22): 1751-1753
  • Innovations in Care Delivery to Slow Growth of US Health Spending JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Milstein, A., Shortell, S. 2012; 308 (14): 1439-1440

    View details for Web of Science ID 000309579300021

    View details for PubMedID 23047357

  • A Systemic Approach to Containing Health Care Spending NEW ENGLAND JOURNAL OF MEDICINE Emanuel, E., Tanden, N., Altman, S., Armstrong, S., Berwick, D., de Brantes, F., Calsyn, M., Chernew, M., Colmers, J., Cutler, D., Daschle, T., Egerman, P., Kocher, B., Milstein, A., Lee, E. O., Podesta, J. D., Reinhardt, U., Rosenthal, M., Sharfstein, J., Shortell, S., Stern, A., Orszag, P. R., Spiro, T. 2012; 367 (10): 949-954

    View details for DOI 10.1056/NEJMsb1205901

    View details for Web of Science ID 000308343300015

    View details for PubMedID 22852883

  • Consumers' And Providers' Responses To Public Cost Reports, And How To Raise The Likelihood Of Achieving Desired Results HEALTH AFFAIRS Mehrotra, A., Hussey, P. S., Milstein, A., Hibbard, J. H. 2012; 31 (4): 843-851


    There is tremendous interest in different approaches to slowing the rise in US per capita health spending. One approach is to publicly report on a provider's costs--also called efficiency, resource use, or value measures--with the hope that consumers will select lower-cost providers and providers will be encouraged to decrease spending. In this paper we explain why we believe that many current cost-profiling efforts are unlikely to have this intended effect. One of the reasons is that many consumers believe that more care is better and that higher-cost providers are higher-quality providers, so giving them information that some providers are lower cost may have the perverse effect of deterring them from accessing these providers. We suggest changes that can be made to content and design of public cost reports to increase the intended consumer and provider response.

    View details for DOI 10.1377/hlthaff.2011.1181

    View details for Web of Science ID 000302777400023

    View details for PubMedID 22459922

  • The $640 Billion Question - Why Does Cost-Effective Care Diffuse So Slowly? NEW ENGLAND JOURNAL OF MEDICINE Fuchs, V. R., Milstein, A. 2011; 364 (21): 1985-1987

    View details for DOI 10.1056/NEJMp1104675

    View details for Web of Science ID 000290952000001

    View details for PubMedID 21591938

  • Mandatory Public Reporting Of Hospital-Acquired Infection Rates: A Report From California HEALTH AFFAIRS Halpin, H. A., Milstein, A., Shortell, S. M., Vanneman, M., Rosenberg, J. 2011; 30 (4): 723-729


    One way to motivate hospitals to improve patient safety is to publicly report their rates of hospital-acquired infections, as California is starting to do this year. We conducted a baseline study of California's acute care hospitals just before mandatory reporting of hospital-acquired infection rates to the state began, in 2008. We found variability in many areas: For example, 70.1 percent of hospitals said that they were fully implementing evidence-based guidelines to fight infection by methicillin-resistant Staphylococcus aureus, but 22.8 percent of hospitals had not adopted any. Our analysis showed that rural hospitals, many of which lack resources to implement needed procedures, faced the greatest challenges in reporting and improving infection rates. Our findings should be of interest to Medicare policy makers who will implement the hospital-acquired infection performance measures in the Affordable Care Act, and to leaders in the thirty-eight states that have enacted legislation requiring reports of hospital-acquired infection rates. California's baseline data also present a unique opportunity to assess the impact of mandatory and public reporting laws.

    View details for DOI 10.1377/hlthaff.2009.0990

    View details for Web of Science ID 000289233400025

    View details for PubMedID 21471494

  • Assessing The Evidence For Value-Based Insurance Design HEALTH AFFAIRS Choudhry, N. K., Rosenthal, M. B., Milstein, A. 2010; 29 (11): 1988-1994


    High copayments for medical services can cause patients to underuse essential therapies. Value-based health insurance design attempts to address this problem by explicitly linking cost sharing and value. Copayments are set at low levels for high-value services. The Mercer National Survey of Employer-Sponsored Health Plans demonstrates that value-based insurance design use is increasing and that 81 percent of large employers plan to offer it in the near future. Despite this increase, few studies have adequately evaluated its ability to improve quality and reduce health spending. Maximizing the benefits of value-based insurance design will require mechanisms to target appropriate copayment reductions, offset short-run cost outlays, and expand its use to other health services.

    View details for DOI 10.1377/hlthaff.2009.0324

    View details for Web of Science ID 000283668700003

    View details for PubMedID 21041737

  • Quality Measurement in Orthopaedics: The Purchasers' View ABJS Carl T Brighton Workshop on Health Policy Issues in Orthopaedic Surgery Lansky, D., Milstein, A. SPRINGER. 2009: 2548–55


    While all of medicine is under pressure to increase transparency and accountability, joint replacement subspecialists will face special scrutiny. Disclosures of questionable consulting fees, a demographic shift to younger patients, and uncertainty about the marginal benefits of product innovation in a time of great cost pressure invite a serious and progressive response from the profession. Current efforts to standardize measures by the National Quality Forum and PQRI will not address the concerns of purchasers, payors, or policy makers. Instead, they will ask the profession to document its commitment to appropriateness, stewardship of resources, coordination of care, and patient-centeredness. One mechanism for addressing these expectations is voluntary development of a uniform national registry for joint replacements that includes capture of preoperative appropriateness indicators, device monitoring information, revision rates, and structured postoperative patient followup. A national registry should support performance feedback and quality improvement activity, but it must also be designed to satisfy payor, purchaser, policymaker, and patient needs for information. Professional societies in orthopaedics should lead a collaborative process to develop metrics, infrastructure, and reporting formats that support continuous improvement and public accountability.

    View details for DOI 10.1007/s11999-009-0999-z

    View details for Web of Science ID 000269926400011

    View details for PubMedID 19641973

  • Do Patients Continue to See Physicians Who Are Removed From a PPO Network? AMERICAN JOURNAL OF MANAGED CARE Rosenthal, M. B., Li, Z., Milstein, A. 2009; 15 (10): 713-719


    To assess the extent to which excluding physicians from a preferred provider organization (PPO) network causes patients to discontinue using their services and whether the associated changes will result in greater demand for emergency department or inpatient care.Analysis of a natural experiment involving the narrowing of a PPO network operated by the Taft-Hartley Fund. The panel data analysis compared rates of patient discontinuation for excluded physicians before and after the change. The pre-post analysis used matched comparison groups for office visits, emergency department visits, inpatient admissions, and spending for affected patients.Claims data analysis used generalized estimating equations and controlled for patient age, sex, health status, and hourly wage. Models examining utilization and spending for 6187 patients who remained with excluded physicians also used a propensity score-matched comparison group identified from among patients who had never seen an excluded physician. Differential response to physician exclusion according to age, health status, and hourly wage was also examined through interaction terms.The network narrowing reduced the odds of continuing to see an excluded physician (odds ratio, 0.18; P <.001). Patients who continued to see excluded physicians reduced their office visits by a mean of 0.9 visits per year, 0.8 visits more than comparison patients (P <.001). There were no significant changes in emergency department visits or admissions for patients of excluded physicians compared with a matched cohort.Substantial copayment differentials may be an effective means of encouraging patients to change physicians. Where they are based on reliable information about provider quality and cost, tiered networks may improve value.

    View details for Web of Science ID 000270975300005

    View details for PubMedID 19845423

  • Impact of Financial Incentives for Prenatal Care on Birth Outcomes and Spending HEALTH SERVICES RESEARCH Rosenthal, M. B., Li, Z., Robertson, A. D., Milstein, A. 2009; 44 (5): 1465-1479


    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.Claims and enrollment profiles of the predominantly low-income and Hispanic participants of a union-sponsored, health insurance plan from 1998 to 2001.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.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).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.

    View details for DOI 10.1111/j.1475-6773.2009.00996.x

    View details for Web of Science ID 000269494600003

    View details for PubMedID 19619248

  • American Medical Home Runs HEALTH AFFAIRS Milstein, A., Gilbertson, E. 2009; 28 (5): 1317-1326


    Four primary care sites in the United States constitute "medical home runs" because their patients incur 15-20 percent less (risk-adjusted) total health care spending per year than patients treated by regional peers, without evidence of reduced quality. The sites achieved this result in a U.S. payment environment that usually penalizes physicians who invest to prevent costly near-term health crises. If the ingredients and accomplishments of these four sites spread, under- and uninsured lower-income Americans could be fully covered in the foreseeable future without increased health spending or lower quality of care. In exchange, sponsors of health benefits would gladly support additional primary care physician payment.

    View details for DOI 10.1377/hlthaff.28.5.1317

    View details for Web of Science ID 000269646100011

    View details for PubMedID 19738247

  • How Can We Make More Progress In Measuring Physicians' Performance To Improve The Value Of Care? HEALTH AFFAIRS Miller, T. P., Brennan, T. A., Milstein, A. 2009; 28 (5): 1429-1437


    The lack of good information on providers' performance is an impediment to improving the affordability and quality of health care. Knowing that certain hospitals or physicians produce more effective and efficient care would help consumers make appropriate purchases and create incentive for improvement. Yet many physicians resist such measurement efforts, unconvinced of their accuracy. Meanwhile, large employers want much more than their insurers provide to them, including attribution of quality and cost of care to individual physicians. Although recent developments in performance measurement illustrate its unsettled state, they also foreshadow how the field may advance.

    View details for DOI 10.1377/hlthaff.28.5.1429

    View details for Web of Science ID 000269646100025

    View details for PubMedID 19738260

  • Ending Extra Payment for "Never Events" - Stronger Incentives for Patients' Safety NEW ENGLAND JOURNAL OF MEDICINE Milstein, A. 2009; 360 (23): 2388-2390

    View details for Web of Science ID 000266590500002

    View details for PubMedID 19494212

  • Financial and Clinical Impact of Team-Based Treatment for Medicaid Enrollees With Diabetes in a Federally Qualified Health Center DIABETES CARE Scanlon, D. P., Hollenbeak, C. S., Beich, J., Dyer, A., Gabbay, R. A., Milstein, A. 2008; 31 (11): 2160-2165


    The purpose of this study was to determine whether multidisciplinary team-based care guided by the chronic care model can reduce medical payments and improve quality for Medicaid enrollees with diabetes.This study was a difference-in-differences analysis comparing Medicaid patients with diabetes who received team-based care versus those who did not. Team-based care was provided to patients treated at CareSouth, a multisite rural federally qualified community health center located in South Carolina. Control patients were matched to team care patients using propensity score techniques. Financial outcomes compared Medicaid (and Medicare for dually eligible patients) payments 1 year before and after intervention. Trends over time in levels of A1C, BMI, and systolic blood pressure (SBP) were analyzed for intervention patients during the postintervention period.Although average claims payments increased for both the CareSouth patients and control patients, there were no statistically significant differences in total payments between the two groups. In the intervention group, patients with A1C >9 at baseline experienced an average reduction of 0.75 mg/dl per year (95% CI 0.50-0.99), patients with BMI >30 at baseline had an average reduction of 2.3 points per year (95% CI 0.99-3.58), and patients with SBP >140 mmHg at baseline had an average reduction of 2.2 mmHg per year (95% CI 0.44-3.88).Team-based care following the chronic care model has the potential to improve quality without increasing payments. Short-term savings were not evident and should not be assumed when designing programs.

    View details for DOI 10.2337/dc08-0587

    View details for Web of Science ID 000260565000018

    View details for PubMedID 18678609

  • Reductions in mortality associated with intensive public reporting of hospital outcomes AMERICAN JOURNAL OF MEDICAL QUALITY Hollenbeak, C. S., Gorton, C. P., Tabak, Y. P., Jones, J. L., Milstein, A., Johannes, R. S. 2008; 23 (4): 279-286


    It is unclear whether public reporting of hospital and physician performance has improved outcomes for the conditions being reported. We studied the effect of intensive public reporting on hospital mortality for 6 high-frequency, high-mortality medical conditions. Patients in Pennsylvania were matched to patients in other states with varying public reporting environments using propensity score methods. The effect of public reporting was estimated using a difference in differences approach. Patients treated at hospitals subjected to intensive public reporting had significantly lower odds of in-hospital mortality when compared with similar patients treated at hospitals in environments with no public reporting or only limited reporting. Overall, the 2000-2003 in-hospital mortality odds ratio for Pennsylvania patients versus non-Pennsylvania patients ranged from 0.59 to 0.79 across 6 clinical conditions (all P < .0001). For the same comparison using the 1997-1999 period, odds ratios ranged from 0.72 to 0.90, suggesting improvement when intensive public reporting occurred.

    View details for DOI 10.1177/1062860608318451

    View details for Web of Science ID 000257806600006

    View details for PubMedID 18658101

  • Comparing physicians on efficiency NEW ENGLAND JOURNAL OF MEDICINE Milstein, A., Lee, T. H. 2007; 357 (26): 2649-2652

    View details for Web of Science ID 000251964500001

    View details for PubMedID 18160682

  • Distorted payment system undermines business case for health quality and efficiency gains. Issue brief (Center for Studying Health System Change) Ginsburg, P. B., Pham, H. H., McKenzie, K., Milstein, A. 2007: 1-4


    Efforts to improve the efficiency and quality of health care are unlikely to be successful if physicians and hospitals incur steep financial losses from success in accomplishing these goals, according to a new study by the Center for Studying Health System Change (HSC). Currently, most efforts to improve efficiency for a specific medical condition usually reduce the number of services per patient that can be billed, posing financial challenges for providers. These challenges are often magnified by the current fee-for-service payment structure, where some services are highly profitable and others are unprofitable, further undermining the case for redesigning care delivery to improve quality and efficiency. These dynamics are seen in the collaboration between Virginia Mason Medical Center (VMMC) and Aetna in Seattle to improve care for four common conditions. Although Aetna and participating self-insured employers have agreed to pay higher rates for certain unprofitable services if reductions in use of profitable services are achieved, VMMC still faces a financial challenge from applying more efficient care practices to patients covered by other insurers.

    View details for PubMedID 17649612

  • Redesigning care delivery in response to a high-performance network: The Virginia Mason Medical Center HEALTH AFFAIRS Pham, H. H., Ginsburg, P. B., McKenzie, K., Milstein, A. 2007; 26 (4): W532-W544


    We examine how an integrated delivery system responded to threatened exclusion from an insurer's high-performance network by attempting to reduce costs through fundamental redesign of care processes. Some factors facilitating this transformation, such as its structure as a large salaried medical group exclusively affiliated with a hospital, might be specific to the organization and its market. Other essential elements could be replicated. But in a fee-for-service payment system, cost reduction from reducing the number of services or changing their mix can reduce profitability. Making the business case for sustaining desirable provider behavior may require that purchasers and plans make equally fundamental changes in payment policy.

    View details for DOI 10.1377/hlthaff.26.4.w532

    View details for Web of Science ID 000248119500053

    View details for PubMedID 17623687

  • Consumer tolerance for inaccuracy in physician performance ratings: one size fits none. Issue brief (Center for Studying Health System Change) Davis, M. M., Hibbard, J. H., Milstein, A. 2007: 1-5


    Health plans increasingly use physician performance ratings, but some physicians are concerned that measurement inaccuracies may jeopardize their reputations and livelihoods. Absent from the debate thus far are consumer views about how accurate physician ratings need to be for various uses. Consumer tolerance for inaccuracy in physician performance ratings varies widely, according to a new national study by the Center for Studying Health System Change (HSC). At least one-third of adults have a low tolerance for inaccuracy (5 percent or less), but more than one of every five adults would tolerate ratings that were 20 percent-50 percent inaccurate. Consumers' relatively higher tolerance for inaccuracy when used for public reporting and tiered networks may speed these uses of physician performance ratings by health plans. However, consumers' lower tolerance for inaccurate ratings when choosing their own physicians and paying physicians for performance may hinder such uses.

    View details for PubMedID 17407857

  • Health information technology is a vehicle, not a destination: a conversation with David J. Brailer. Interview by Arnold Milstein. Health affairs Brailer, D. J. 2007; 26 (2): w236-41


    The first U.S. national health care information technology (IT) coordinator estimates that if the current rate of interoperable electronic health record (EHR) adoption is sustained through 2014, it would create a launchpad for quality gain and health care spending reduction in excess of 50 percent in the subsequent decade. But in this conversation with Leapfrog Group cofounder and U.S. health care purchasing innovator Arnold Milstein, David Brailer identifies several environmental changes as critical to the materialization of this dividend. These include providers' ceding control of clinical information to patients, universal public availability of provider performance comparisons, and moving health policy from a no-man's land between government and market control.

    View details for PubMedID 17303581

  • Will the surgical world become flat? HEALTH AFFAIRS Milstein, A., Smith, M. 2007; 26 (1): 137-141


    We obtained price and quality information for nonurgent coronary artery bypass graft (CABG) surgery from a sample of internationally patronized hospitals in low-wage countries. We found rising quality standards, availability of U.S.-trained physicians, and prices far below insurer-negotiated U.S. prices. The price differentials easily accommodated the incentive specified as a condition for surgery abroad by about 30 percent of surveyed households with a sick member. These findings foreshadow growth in offshoring of expensive nonemergency surgeries among increasingly cost-sensitive U.S. consumers and purchasers.

    View details for DOI 10.1377/hlthaff.26.1

    View details for Web of Science ID 000244223200015

    View details for PubMedID 17211022

  • America's new refugees - Seeking affordable surgery offshore. NEW ENGLAND JOURNAL OF MEDICINE Milstein, A., Smith, M. 2006; 355 (16): 1637-1640

    View details for Web of Science ID 000241357300003

    View details for PubMedID 17050886

  • The efficiency equation. Determining how to measure healthcare performance--and other first steps. Modern healthcare Milstein, A., Burney, R. 2006; 36 (11): 24-?

    View details for PubMedID 16579113

  • A report card on the freshman class of consumer-directed health plans HEALTH AFFAIRS Rosenthal, M., Hsuan, C., Milstein, A. 2005; 24 (6): 1592-1600


    We used a series of case studies of first-generation consumer-directed health plans to investigate their early experience and the suitability of their design for reducing the growth in health benefit spending and improving the value of that spending. We found three fundamental but correctible weaknesses: Most plans do not make available comparative measures of quality and longitudinal cost-efficiency in enough detail to help consumers discern higher-value health care options; financial incentives for consumers are weak and insensitive to differences in value among the selections that consumers make; and none of the plans made cost-sharing adjustments to preserve freedom of choice for low-income consumers.

    View details for DOI 10.1377/hlthaff.24.5.1592

    View details for Web of Science ID 000235033500025

    View details for PubMedID 16284033

  • Hospital referrals HEALTH AFFAIRS Milstein, A. 2005; 24 (3): 887-887

    View details for Web of Science ID 000229017000047

    View details for PubMedID 15886191

  • Has the leapfrog group had an impact on the health care market? HEALTH AFFAIRS Galvin, R. S., Delbanco, S., Milstein, A., Belden, G. 2005; 24 (1): 228-233


    A number of large employers and public purchasers founded the Leapfrog Group in 2000 in an attempt to consolidate the purchaser voice and engage consumers and clinicians in improving health care quality. Drawing on evidence-based medicine, Leapfrog publicly releases information about the extent to which hospitals are adopting three safety "leaps" with the theoretical capacity to prevent thousands of deaths. Although the group has grown rapidly and achieved national recognition, employer-based initiatives historically have struggled to create changes in health care. This paper examines the impact of the Leapfrog Group and its efforts to address the challenges of employer initiatives.

    View details for DOI 10.1377/hlthaff.24.1.228

    View details for Web of Science ID 000227835600030

    View details for PubMedID 15647234

  • Hot potato endgame HEALTH AFFAIRS Milstein, A. 2004; 23 (6): 32-34


    Other stakeholders and events will influence whether health insurers' current postmerger prosperity will lead to U.S. health benefit programs that are predominantly sponsored by the private or public sectors. Large employers are encouraging three complementary health benefit innovations to improve the affordability and quality, or "efficiency," of clinical services: portable spending accounts, provider pay-for-performance, and tiered plans. If health insurers prefer private-sector health benefit sponsorship, they will need to implement these innovations robustly, despite the risks they pose to insurers' current but predictably temporary prosperity. Clinical efficiency gains can also sustain access to biomedical innovations for low- and moderate-income Americans.

    View details for DOI 10.1377/hlthaff.23.6.32

    View details for Web of Science ID 000227835800005

    View details for PubMedID 15537583

  • Awakening consumer stewardship of health benefits: Prevalence and differentiation of new health plan models HEALTH SERVICES RESEARCH Rosenthal, M., Milstein, A. 2004; 39 (4): 1055-1070


    Despite widespread publicity of consumer-directed health plans, little is known about their prevalence and the extent to which their designs adequately reflect and support consumerism.We examined three types of consumer-directed health plans: health reimbursement accounts (HRAs), premium-tiered, and point-of-care tiered benefit plans. We sought to measure the extent to which these plans had diffused, as well as to provide a critical look at the ways in which these plans support consumerism. Consumerism in this context refers to efforts to enable informed consumer choice and consumers' involvement in managing their health. We also wished to determine whether mainstream health plans-health maintenance organization (HMO), point of service (POS), and preferred provider organization (PPO) models-were being influenced by consumerism.Our study uses national survey data collected by Mercer Human Resource Consulting from 680 national and regional commercial health benefit plans on HMO, PPO, POS, and consumer-directed products.We defined consumer-directed products as health benefit plans that provided (1) consumer incentives to select more economical health care options, including self-care and no care, and (2) information and support to inform such selections. We asked health plans that offered consumer-directed products about 2003 enrollment, basic design features, and the availability of decision support. We also asked mainstream health plans about their activities that supported consumerism (e.g., proactive outreach to inform or influence enrollee behavior, such as self-management or preventive care, reminders sent to patients with identified medical conditions.)We analyzed survey responses for all four product lines in order to identify those plans that offer health reimbursement accounts (HRAs), premium-tiered, or point-of-care tiered models as well as efforts of mainstream health plans to engage informed consumer decision making.The majority of enrollees in consumer-directed health plans are in tiered models (primarily point-of-care tiered networks) rather than HRAs. Tiers are predominantly determined based on both cost and quality criteria. Enrollment in HRAs has grown substantially, in part because of the entry of mainstream managed care plans into the consumer-directed market. Health reimbursement accounts, tiered networks, and traditional managed care plans vary in their capacity to support consumers in managing their health risks and selection of provider and treatment options, with HRAs providing the most and mainstream plans the least.While enrollment in consumer-directed health plans continues to grow steadily, it remains a tiny fraction of all employer-sponsored coverage. Decision support in these plans, a critical link to help consumers make more informed choices, is also still limited. This lack may be of concern in light of the fact that only a minority of such plans report that they monitor claims to protect against underuse. Tiered benefit models appear to be more readily accepted by the market than HRAs. If they are to succeed in optimizing consumers' utility from health benefit spending, careful attention needs to be paid to how well these models inform consumers about the consequences of their selections.

    View details for Web of Science ID 000229029400002

    View details for PubMedID 15230911

  • UK quality incentives HEALTH AFFAIRS Milstein, A., Ness, D. 2004; 23 (4): 282-282

    View details for DOI 10.1377/hlthaff.23.4.282

    View details for Web of Science ID 000222499600030

    View details for PubMedID 15318588

  • Out of sight, out of mind: Why doesn't widespread clinical quality failure command our attention? HEALTH AFFAIRS Milstein, A., Adler, N. E. 2003; 22 (2): 119-127


    This paper examines the tolerance by all stakeholders of increasingly well documented evidence of serious and widespread clinical quality failure in the United States. Using research evidence from psychology, it describes specific cognitive and motivational impediments to the perception of quality failure-those shared by all stakeholders and those particularly relevant to patients and their families and to health care professionals. The authors endorse efforts by the National Quality Forum and others to make quality failure more publicly visible. They also point to the pivotal role of health care industry leaders in sustaining focus on a problem that inherently resists visibility.

    View details for Web of Science ID 000181450400021

    View details for PubMedID 12674415

  • Updating the Leapfrog Group Intensive Care Unit Physician Staffing Standard J Clin Outcomes Manag Rockeymoore, M. B., Holzmueller, C. G., Milstein, A., Dorman, T., Pronovost, P. J. 2003; 10 (1): 31-37
  • Large employers' new strategies in health care NEW ENGLAND JOURNAL OF MEDICINE Galvin, R., Milstein, A. 2002; 347 (12): 939-942

    View details for Web of Science ID 000178040700014

    View details for PubMedID 12239267

  • What does the Leapfrog Group portend for physicians? Seminars in vascular surgery Milstein, A. 2002; 15 (3): 198-200

    View details for PubMedID 12228869

  • Parsing Leapfrog Values Jt Commission Perspect Milstein, A. 2002; 2 (2): 6-9
  • Expanding health insurance coverage for smoking cessation treatments: Experience of the Pacific Business Group on Health AMERICAN JOURNAL OF HEALTH PROMOTION Harris, J. R., Schauffler, H. H., Milstein, A., Powers, P., Hopkins, D. P. 2001; 15 (5): 350-356


    The business case for health insurance coverage of smoking cessation treatments by employers is a strong one. Smoking is one of the nation's costliest health problems, in both human and financial terms. The science behind smoking cessation treatment and promotion of treatment is strong; the cost effectiveness of smoking cessation treatment is among the highest in all of medicine, the time required before a positive return on investment is reasonable for employers, and the short-term costs of treatments are well estimated and manageable for health plans and employers. Armed with this business case, the PBGH Negotiating Alliance has expanded health insurance to include pharmacotherapy, over the counter or by prescription, and behavioral interventions. Because PBGH has been a national leader, we hope that other employers, employer coalitions, and public purchasers will follow their lead. The potential health effect of even small reductions in smoking are striking, and unlike other chronic illnesses, nicotine addiction is curable, at both individual and societal levels. Thus, if employers make the investment in smoking cessation and other tobacco control today, they face the real possibility that the need for such outlays could decrease in the future.

    View details for Web of Science ID 000168794500009

    View details for PubMedID 11502016

  • Improving the safety of health care: the leapfrog initiative. Effective clinical practice : ECP Milstein, A., Galvin, R. S., Delbanco, S. F., Salber, P., Buck, C. R. 2000; 3 (6): 313-316

    View details for PubMedID 11151534

  • Selective referral to high-volume hospitals - Estimating potentially avoidable deaths JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Dudley, R. A., Johansen, K. L., Brand, R., Rennie, D. J., Milstein, A. 2000; 283 (9): 1159-1166


    Evidence exists that high-volume hospitals (HVHs) have lower mortality rates than low-volume hospitals (LVHs) for certain conditions. However, few employers, health plans, or government programs have attempted to increase the number of patients referred to HVHs.To determine the difference in hospital mortality between HVHs and LVHs for conditions for which good quality data exist and to estimate how many deaths potentially would be avoided in California by referral to HVHs.Literature in MEDLINE, Current Contents, and First-Search Social Abstracts databases from January 1, 1983, to December 31, 1998, was searched using the key words hospital, outcome, mortality, volume, risk, and quality. The highest-quality study assessing the mortality-volume relationship for each given condition was identified and used to calculate odds ratios (ORs) for in-hospital mortality for LVHs vs HVHs. These ORs were then applied to the 1997 California database of hospital discharges maintained by the California Office of Statewide Health Planning and Development to estimate potentially avoidable deaths.Deaths that potentially could be avoided if patients with conditions for which a mortality-volume relationship had been treated at an HVH vs LVH.The articles identified in the literature search were grouped by condition, and predetermined criteria were applied to choose the best article for each condition. Mortality was significantly lower at HVHs for elective abdominal aortic aneurysm repair, carotid endarterectomy, lower extremity arterial bypass surgery, coronary artery bypass surgery, coronary angioplasty, heart transplantation, pediatric cardiac surgery, pancreatic cancer surgery, esophageal cancer surgery, cerebral aneurysm surgery, and treatment of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). A total of 58,306 of 121,609 patients with these conditions were admitted to LVHs in California in 1997. After applying the calculated ORs to these patient populations, we estimated that 602 deaths (95% confidence interval, 304-830) at LVHs could be attributed to their low volume. Additional analyses were performed to take into account emergent admissions and distance traveled, but the impact of loss of continuity of care for some patients and reduction in the availability of specialists for patients remaining at LVHs could not be assessed.Initiatives to facilitate referral of patients to HVHs have the potential to reduce overall hospital mortality in California for the conditions identified. Additional study is needed to determine the extent to which selective referral is feasible and to examine the potential consequences of such initiatives.

    View details for Web of Science ID 000085424100025

    View details for PubMedID 10703778

  • Taking a giant leap forward in promoting quality HEALTH AFFAIRS Wetzel, S., Galvin, R., Buck, C. R., Cubbin, J., Bradley, B., Taylor, B., Powers, P., Milstein, A. 2000; 19 (2): 275-276

    View details for Web of Science ID 000085780500031

    View details for PubMedID 10718045

  • Raising the bar: The use of performance guarantees by the Pacific Business Group on Health HEALTH AFFAIRS Schauffler, H. H., Brown, C., Milstein, A. 1999; 18 (2): 134-142


    In 1996 the Pacific Business Group on Health (PBGH) negotiated more than two dozen performance guarantees with thirteen of California's largest health maintenance organizations (HMOs) on behalf the seventeen large employers in its Negotiating Alliance. The negotiations put more than $8 million at risk for meeting performance targets with the goal of improving the performance of all health plans. Nearly $2 million, or 23 percent of the premium at risk, was refunded to the PBGH by the HMOs for missed targets. The majority of plans met their targets for satisfaction with the health plan and physicians, as well as cesarean section, mammography, Pap smear, and prenatal care rates. However, eight of the thirteen plans missed their targets for childhood immunizations, refunding 86 percent of the premium at risk.

    View details for Web of Science ID 000079083300015

    View details for PubMedID 10091440

  • An employer's perspective on hospitalists as a source of improved health care value National Policy Conference on the Hospitalist Movement Milstein, A. AMER COLL PHYSICIANS. 1999: 360–63


    The probable perspective of large employers toward the phenomenon of hospitalists can be derived by examining the four essential elements of health care value to employers. Current hospital care in the United States is thought to offer substantial opportunities for improvement, and the impact of hospitalist programs on an employer's sense of health care value is predicted to be favorable. This prediction, however, should be validated through outcomes research before it is widely propagated. If innovations as promising as hospitalist programs are to occur in ambulatory care, employers and other health care purchasers must be proactive in identifying and rewarding them.

    View details for Web of Science ID 000078587500006

    View details for PubMedID 10068406

  • Using employer purchasing power to improve the quality of perinatal care. Pediatrics Castles, A. G., Milstein, A., Damberg, C. L. 1999; 103 (1): 248-254


    Large employers have become increasingly involved in helping to set the agenda for quality measurement and improvement. Moreover, they are beginning to hold health care organizations accountable for their performance through marketplace incentives, including the public reporting of comparative quality data and the linkage of reimbursement to performance on quality measures. The Pacific Business Group on Health (PBGH) is an employer coalition that has been prominent in establishing models for collaborative quality measurement and improvement in the California marketplace. PBGH's involvement in quality stems from an environment in which purchasers were faced with high health care costs, yet virtually no information with which to assess the value their employees received from that care. Research indicating widespread variation in performance across health care organizations and seemingly limited oversight for quality of care within the industry has further motivated purchasers' efforts to better understand the quality of care being delivered to their em-ployees. Using the purchasing power of employers representing 2.5-million covered lives, PBGH endeavors to encourage the transition of the health care marketplace from one that competes solely on price to one that competes on price and quality. This entails collaborating with the health care industry to develop and publicly report valid performance data for use by both large employers and consumers of health care services. It also includes communicating to the marketplace purchasers' commitment to making purchasing decisions based on quality as well as cost. PBGH efforts to measure, report, and improve quality have been demonstrated by several undertakings in the perinatal care arena, including research to assess cesarean section rates and newborn readmission rates across California hospitals.employer coalition, purchaser, quality measurement, quality improvement, report cards, perinatal quality of care.

    View details for PubMedID 9917468

  • Managing utilization management: A purchaser's view HEALTH AFFAIRS Milstein, A. 1997; 16 (3): 87-90

    View details for Web of Science ID A1997WW87600011

    View details for PubMedID 9141325

  • Health education and patient satisfaction JOURNAL OF FAMILY PRACTICE Schauffler, H. H., Rodriguez, T., Milstein, A. 1996; 42 (1): 62-68


    The objective of this research was to determine whether patients who reported that their physician or other health care professional had discussed health education topics with them were more satisfied with their physician than were patients who reported they had not.Data were from the 1994 Health Plan Value Check conducted by the Pacific Business Group on Health (52% response rate). The study sample included 5066 employees ranging in age from 19 to 64 years and representing four large corporations and 21 health plans. This population was randomly sampled by company and health plan. Bivariate and multivariate analyses were used to assess the relationship between level of patient satisfaction with physician and reported discussion of health education topics with a physician or other health professional in the last 3 years.Patients who reported that their physician or other health care professional discussed at least one health education topic with them in the last 3 years were more likely to be satisfied with their physician (unadjusted odds ratio [OR] = 1.96; 95% confidence interval [CI] 1.79 to 2.25) compared with patients who did not. In the multivariate model, the relationship remained positive and statistically significant (adjusted OR = 1.49; 95% CI, 1.32 to 1.68). This relationship was observed for patients enrolled in all types of HMOs and managed care plans, as well as those with indemnity or fee-for-service insurance.Patients who reported that their physician or other health care professional had discussed one or more health education topics with them in the last 3 years were more likely to be very satisfied with their physician than were patients who reported they had not.

    View details for Web of Science ID A1996TP48500007

    View details for PubMedID 8537807



    There is widespread concern that ownership by physicians of testing or treatment facilities to which they refer patients leads to overuse of such facilities. We determined the patterns of use of three services--physical therapy, psychiatric evaluation, and magnetic resonance imaging (MRI)--among physicians treating patients whose care was covered under workers' compensation. We then compared the rates of use among physicians who referred patients to facilities of which they were owners (self-referral group) with the rates among physicians who referred patients to independent facilities (independent-referral group).We used a large data base to analyze claims under workers' compensation in California from October 1, 1990, through June 30, 1991, to determine the frequency and cost of these three selected services and determined whether the referring physicians were practicing self-referral or independent referral. We evaluated the cost per case for all three services, measured the frequency with which physical therapy was initiated, and evaluated the medical appropriateness of MRI.We found that physical therapy was initiated 2.3 times more often by the physicians in the self-referral group (68 percent) than by those in the independent-referral group (30 percent; P < 0.01). The mean cost per case for physical therapy was significantly lower in the self-referral group ($404 +/- 102) than in the independent-referral group ($440 +/- 167; P < 0.01). The mean cost of psychiatric evaluation services was significantly higher in the self-referral group than in the independent-referral group (psychometric testing, $1,165 +/- 728 vs. $870 +/- 482; P < 0.01, psychiatric evaluation reports, $2,056 +/- 1,063 vs. $1,680 +/- 578; P < 0.01). The total cost per case of psychiatric evaluation services was 26.3 percent higher in the self-referral group ($3,222 +/- 1,451) than in the independent-referral group ($2,550 +/- 742; P < 0.01). Of all the MRI scans requested by the self-referring physicians, 38 percent were found to be medically inappropriate, as compared with 28 percent of those requested by physicians in the independent-referral group (P < 0.05). There was no significant difference in the cost per case between the two groups.This study demonstrates that self-referral increases the cost of medical care covered by workers' compensation for each of the three types of service studied.

    View details for Web of Science ID A1992JY16500007

    View details for PubMedID 1406882

  • Enhancing utilization review program results. Health cost management Martin, M., Milstein, A., Loveland, D. V. 1988; 5 (2): 10-16


    Utilization review programs are increasing in number and type, but their true contributions to payers' health care and cost management efforts vary tremendously, according to evaluations of over 100 private UR firms by National Medical Audit. Three senior executives of that firm discuss state-of-the-art criteria and methods for gauging the effectiveness of a UR program.

    View details for PubMedID 10286636

  • Gauging the performance of utilization review. Business and health Milstein, A., Oehm, M., Alpert, G. 1987; 4 (4): 10-12

    View details for PubMedID 10280661

  • Auditing quality of care: an employer based approach. Business and health Milstein, A., Nash, D., Sands, J. 1986; 3 (8): 10-12

    View details for PubMedID 10277277



    A five-component measurement method was developed and applied to the 1981 impact statements of 30 Professional Standards Review Organizations (PSROs) by four blind raters familiar with the PSRO program. High inter-rater reliability (.95) was achieved. Rater's scores for each PSRO were then averaged and regressed against five variables predicted to affect PSRO impact: geographical density of PSROs; PSRO affiliation with a medical society; surgical necessity review; use of data profiles; and pre-existing Medicare hospitalization rates. As a set, the variables accounted for 44 per cent of the variance in PSRO performance (p less than .05). When entered in stepwise regression, geographical density and use of surgical necessity review accounted for the largest share of the variance. The findings are believed to reflect the recency of PSRO motivation to demonstrate significant impact, and the value of surgical necessity review as an indicator of PSRO courage to risk unpleasant backlash from their medical communities.

    View details for Web of Science ID A1983RH76300009

    View details for PubMedID 6684402



    Implementation of the new federal law setting up Health Systems Agencies (HSAs) on a regional basis offers many opportunities for participation by psychiatry. On the basis of interviews with mental health service providers, planners, and citizen representatives, the author formulated an inventory of the law's potential impacts, grouped around six general themes. He discusses the positive aspects of each, along with possible problems and hazards.

    View details for Web of Science ID A1976BS82500021

    View details for PubMedID 1275105