4

Outcomes Research

Mark S. Litwin; Jonathan Bergman

Questions

1.Barriers to health care access may include which of the following?

a.Lack of health insurance.

b.Lack of transportation.

c.Beliefs about the health care system.

d.Culture.

e.All of the above.

2.Costs of hospital care are best approximated by measuring:

a.charges.

b.collections.

c.resources used.

d.severity of illness.

e.all of the above.

3.A true assessment of health care costs must include the amount of money spent on:

a.facilities.

b.disposable supplies.

c.personnel.

d.equipment.

e.all of the above.

4.The introduction of diagnosis-related groups (DRGs) in the 1980s led to:

a.longer hospital stays for most patients.

b.shorter hospital stays for most patients.

c.higher reimbursements for hospitals.

d.higher reimbursements for physicians.

e.increased costs.

5.Quality-adjusted life years (QALYs) are a metric used in:

a.basic quality-of-life analysis in individual patients.

b.cost-effectiveness analysis for populations of patients.

c.patient satisfaction analysis for individual patients.

d.cost-benefit analysis for individual patients.

e.determining the number of years an individual is free of the condition.

6.Case mix is a metric that may be used in the study of medical outcomes to adjust for:

a.comorbidity of a population cared for by a given provider.

b.severity of illness in a population cared for by a given provider.

c.both.

d.neither.

7.In the Donabedian model of quality of care, measures of structure include:

a.interpersonal skill with which a physician interacts with patients.

b.perioperative mortality rates.

c.patient satisfaction.

d.board certification of physicians in a provider group.

e.complication rates.

8.In the Donabedian model of quality of care, measures of outcome include:

a.patient satisfaction.

b.health-related quality of life.

c.survival.

d.all of the above.

9.Health-related quality of life is best assessed by:

a.patients themselves.

b.spouses or immediate family members of patients.

c.primary care physicians caring for patients.

d.specialists caring for patients.

e.specially trained examiners.

.Dysfunction and its related distress (also called "bother") are generally:

a.perfectly correlated.

b.completely independent.

c.related but imperfectly correlated.

d.measures of the same phenomenon.

e.meaningful when the correlation coefficient is 0.1.

.Disease-specific health-related quality of life domains in patients with urologic cancer include:

a.physical function.

b.emotional well-being.

c.social function.

d.sexual dysfunction.

e.cardiac function.

.In psychometric terms, reliability refers to how free an instrument is of:

a.missing data.

b.measurement error.

c.grammatical or typographic errors.

d.invalid data.

e.selection bias.

.When a scale has a coefficient alpha of 0.90, the scale has a high degree of:

a.alternate form reliability.

b.test-retest reliability.

c.internal consistency reliability.

d.concurrent validity.

e.construct validity.

Answers

1.e. All of the above. Barriers to access may be financial or nonfinancial and include any factor that decreases the likelihood that an individual in need will receive medical services.

2.c. Resources used. Charges are notoriously poor proxies for actual medical costs because of the way in which hospital budgets are calculated; actual collections do not account for deductibles, copayments, and opportunity costs.

3.d. All of the above. Each of the factors mentioned contributes to the total cost of health care.

4.b. Shorter hospital stays for most patients. DRGs allow for the calculation of prospective payments to hospitals and thus have led to shorter lengths of stay; they have also led to decreased reimbursements to hospitals.

5.b. Cost-effectiveness analysis for populations of patients. QALYs are used in population analysis and not for individual patients.

6.c. Both. Measuring case mix allows for outcomes to be controlled for both the underlying medical diseases and the severity of the disease of interest among groups of patients under the care of a provider.

7.d. Board certification of physicians in a provider group. Structural attributes of health care include clinician characteristics such as board certification, but not measures of process such as interpersonal style or outcome measures such as mortality and patient satisfaction.

8.d. All of the above. Each of these factors may be considered a valid measure of medical outcomes.

9.a. Patients themselves. It is axiomatic that health-related quality-of-life outcomes must be reported by patients themselves, as they perceive them.

.c. Related but imperfectly correlated. In the various domains of diseasespecific health-related quality of life, function and bother are loosely

associated with each other but measure discrete phenomena.

.d. Sexual dysfunction. Disease-specific, health-related, quality-of-life instruments focus on domains that are directly relevant to the specific disease or treatment.

.b. Measurement error. Reliability refers to what proportion of a test score is true and what proportion is due to chance variation (or measurement error).

.c. Internal consistency reliability. The Cronbach coefficient alpha is a wellestablished measure of internal consistency reliability.

Chapter review

1.Costs—what the provider spends to supply the service.

2.Charges—what the provider bills for the service, not necessarily what the provider collects for the service.

3.Resource utilization takes into account the duration, frequency, and intensity of the service.

4.Length of stay may be used to quantify resource utilization.

5.Cost-effectiveness is calculated by developing a probability model of possible medical outcomes for different interventions. The different interventions may then be compared taking into account costs.

6.Life years—the number of years lived for a population, not an individual patient.

7.Quality-adjusted life years—adjustment of the life years to account for the impact of various treatments on the health status of an individual.

8.Cost-benefit analysis takes into account not only cost but other factors that may not have a monetary value such as extra years of life.

9.Case mix refers to the severity of illness and the degree of comorbidity in

a group of patients.

10.The most financially burdensome urologic conditions include stones, urinary tract infections, incontinence, and benign prostatic hyperplasia.

11.Proxy measures may be used to measure outcomes when actual measurement of the outcome is impossible or impractical; they are surrogate end points thought to be predictive of the actual true outcome.

12.Reliability refers to what proportion of a test score is true and what proportion is due to chance variation (or measurement error).

PART II

Basics of Urologic Surgery