Health Policy and Healthcare Services Research
Health policy and healthcare services research encompasses a wide range of topics, including the organization and financing of health care, health system change, access to care, and quality, outcomes, and appropriateness of care.
Kevin J. Bozic, M.D., M.B.A., William R. Murray Professor and Vice Chair, Department of Orthopaedic Surgery and Core Faculty of the Philip R. Lee the Institute for Health Policy Studies at the University of California, San Francisco (UCSF), has been spear-heading multiple investigations on the relationship between economics, health policy, and the practice of orthopaedic surgery. The results show there is much to be gained when orthopaedic surgeons bring their knowledge and clinical experience to bear on the policy-making process.
Lorrayne Ward, MBA, MPP, Project Manager – UCSF Medical Center Performance Excellence Department, manages the day-to-day implementation of the Bundled Payment initiative, including leading Lean improvement workshops for staff across a number of disciplines.
Vanessa Chan, MPH, Project Director of Health Policy Studies in the Department of Orthopaedic Surgery oversees all regulatory matters regarding health policy and healthcare services research in the Department of Orthopaedic Surgery.
Dr. Bozic’s primary research interests and focus are in the area of healthcare services and health policy. The primary goal of his research is to use methodologically sound, hypothesis driven research to influence United States health policy. An example of this is his sentinel work in measuring resource utilization in primary hip and knee replacement surgery, which was awarded the 2006 Orthopaedic Research & Education Foundation Clinical Research Award. More importantly, the results of this study were used by the Center for Medicare and Medicaid Services (CMS) to restructure hospital payment policy for the over 800,000 hip and knee replacement procedures that are performed in the United States, which has ultimately led to improved access and quality of care for hip and knee replacement patients.
Dr. Bozic’s current research focuses on three primary areas of health policy: (1) technology assessment, (2) surgical procedure and device registries, and (3) consumer incentives and shared decision making in health care. In the field of technology assessment, he is actively involved in evaluating the cost-effectiveness of surgical technologies. He has recently published a study on the cost-effectiveness of hip replacement implants, and the results of this study were adopted by the Center for Reviews and Dissemination in the United Kingdom.
He has also studied cost-effectiveness of hip resurfacing compared with hip replacement for patients with osteoarthritis of the hip. With respect to surgical procedure and device registries, He has assembled a multi-center team of clinicians and healthcare services researchers whose primary goal is to use administrative claims data to evaluate clinical outcomes associated with total hip and knee replacement procedures. This has proven to be a very productive collaboration, which has already produced 11 peer-reviewed publications and 4 national research awards (the James A. Rand Award, Lawrence D. Dorr Award, and the William Harris Award). As a result of his work with this group, he has been invited by leaders from the FDA, CMS, and AHRQ to participate in the development of a United States Total Joint Replacement Device Registry.
Finally, in the area of consumer incentives and shared decision making, he recently completed a three year study that was funded through a career development award from the Orthopaedic Research and Education Foundation to study shared decision making related to hip replacement procedures. The goal of this research was to improve the quality of information shared and the dialogue between surgeons and patients regarding the decision to undergo hip replacement surgery, and the choice of surgical technique and implant technology. As a result of this project, he has developed a valuable collaboration with Jeff Belkora, PhD, a member of the Core Faculty of the UCSF IHPS, and a world renowned expert in shared decision making in health care. Together they have developed a series of evaluations of individual-level strategies to approach patients, surgeons, and healthcare purchasers, about the benefits and costs associated with shared decision making.
Finally, he has an active research interest in evaluating consumer behavior and shared decision making in health care. His research group has published the only study on the impact of direct to consumer advertising related to orthopaedic technologies on physician and patient decision making. As a result of this study, he was recently invited to testify on Capital Hill to the Senate Committee on Aging in their hearing regarding the Risks and Benefits of Direct to Consumer Advertising of Restricted Medical Products.
Dr. Bozic received a 2011 Robert Wood Johnson Foundation (RWJF) Targeted Solicitation Award on Quality Improvement and Performance Measurement for his work entitled “Shared Decision Making in Patients with Osteoarthritis of the Hip and Knee.” Dr. Bozic and his multi-center, multi-stakeholder research group will assess the impact of decision support interventions on key patient, surgeon, and purchaser priorities, assess patient, surgeon, purchaser level of interest, willingness-to-pay, and facilitators to barriers to adoption on decision support interventions, and to develop and evaluate specific programs and financial incentives to address facilitators and barriers to adoption of SDM strategies.
Dr. Bozic received the 2006 OREF Clinical Research Award for his work entitled “Using Clinical and Economic Outcome Data to Influence Health Policy in the United States: The Case of Total Joint Replacement.” Dr. Bozic and his multi-center research group used patient–specific outcomes data from total joint replacement procedures to influence health policy. Additional diagnosis and procedure codes for joint replacement were developed based on Dr. Bozic′s research and by creating more detailed, accurate, and descriptive codes they were able to assist public health efforts, such as the American Joint Replacement Registry Project (AJRR), and pay–for–performance initiatives that are intended to improve the overall quality of care for joint replacement patients.
Variability in Costs Associated with Total Hip and Hip Knee Replacement Implants
Dr. Bozic and his collaborators at the Univeristy of California, Berkeley, Berkeley Center for Health Technology studies the patient, hospital, and market characteristic associated with variation in implant and total procedure costs for hip and knee arthroplasty. The results from their study found there are substantial variations in total hip replacement and total knee replacement implant costs within and across hospitals after controlling for patient diagnoses and comorbidities. This variation is responsible for the majority of variation in the overall cost of total hip and knee replacement surgery.
Patient-related Risk Factors for Periprosthetic Joint Infection and Postoperative Mortality Following Total Hip Arthroplasty in Medicare Patients
Dr. Bozic and the Multi Total Joint Arthroplasty Health Services Research Group studied the specific patient comorbidities associated with an increased risk of periprosthetic joint infection and of ninety-day postoperative mortality in U.S. Medicare patients undergoing total hip arthroplasty. Comorbid conditions associated with an increased risk of periprothetic joint infection in Medicare patients who under total hip arthroplasty included were rheumatologic disease, obesity, coagulopathy, and preoperative anemia. Comorbid conditions associated with an increase adjusted risk of ninety-day postoperative mortality were congestive heart failure, metastatic cancer, pyschoses, renal disease, dementia, hemiplegia or paraplegia, cerebrovascular disease, and chronic pulmonary disease. This information is important when counseling elderly patients regarding the risks of periprosthetic joint infection and mortality following total hip arthroplasty, as well as for risk adjustment of publicly reported total hip arthroplasty outcomes.
The Impact of Direct-to-Consumer Advertising in Orthopaedics
Dr. Bozic and his colleagues received the 2007 ABJS Marshall Urist Award for their work entitled “The Impact of Direct-to-consumer advertising in Orthopaedic.” This study evaluated the influence of direct-to-consumer advertising on surgeon and patient opinions and behavior in orthopaedics by surveying orthopaedic surgeons who perform hip and knee arthroplasties and patients who were scheduled to have hip or knee arthroplasty. Based on his research findings, Dr. Bozic was invited to testify on behalf of the American Academy of Orthopaedic Surgeons (AAOS) and the American Association of Hip and Surgeons (AAHKS) at a Senate Special Committee on Aging hearing on medical device direct-to-consumer advertising to express concern over the direct-to-consumer advertising (DTCA) of restricted medical products. Also on behalf of AAOS and AAHKS, Dr. Bozic offered specific recommendations to the Committee as it examines the consequences of the DTCA of medical devices.
The Role for Aspirin in Venous Thromboembolism Prophylaxis After Total Knee Replacement
Dr. Bozic, Dr. Vail and colleagues received the 2007 James. Rand Award for their study entitled “Is There a Role for Aspirin in Venous Thromboembolism Prophylaxis After Total Knee Replacement?” Dr. Bozic and colleagues compared the risk of venous thromboembolism (VTE), bleeding, surgical site infection, and mortality in patients receiving aspirin or guideline approved VTE prophylactic therapies (warfarin, low-molecular weight, heparins, synthetic pentasaccharides) in total knee arthroplasty (TKA). The results suggest that aspirin, when used in conjunction with other clinical care protocols, may be effective against VTEP for certain TKA patients. The findings from this study have been used by policy makers when developing clinical practice guidelines for TKA patients.
Epidemiology of Total Joint Replacement Using Administrative Data
The American Association of Hip and Knee Surgeons honored Dr. Bozic with the 2008 Lawrence D. Dorr Award on his study “The Epidemiology of Revision Total Hip Arthroplasty in the United States,” which evaluated the mechanisms of failure and the types of revision total hip arthroplasty procedures performed in the United States with use of newly implemented ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) diagnosis and procedure codes specifically to revision total hip arthroplasty in a large, nationally representative population. Dr. Bozic and his colleagues have done extensive research over the past 3 years using these new administrative codes to evaluate causes of failure in both hip and knee replacement patients. This type of information is proving increasing valuable in directing research objectives, implant design, and clinical decision making.
The Impact of Volume and Adherence to Evidence Based Practice Guidelines on Quality and Cost in Orthopaedic Surgery
The Orthopaedic Research Society (ORS) honored Dr. Bozic with the 2010 William Harris Award for his work entitled “The Influence of Procedure Volumes and Adherence to Evidence-Based Processes of Care on Quality and Efficiency in Total Joint Arthroplasty.” This study evaluated the independent contributions of surgeon procedure volume, hospital procedure volume, and standardization of care on short-term post-operative outcomes and resource utilization in lower extremity total joint arthroplasty. The findings from this study indicated that hospitals and surgeons who adhere to standardized processes of care have improved total joint arthroplasty patient outcomes, independent of hospital and surgeon procedure volume.
In 2012, UCSF was selected as a pilot site for the Center for Medicare and Medicaid Innovation’s Bundled Payment for Care Improvement Initiative. Under this program, UCSF will be one of the few Academic Medical Centers in the United States to receive a bundled payment from Medicare covering the entire acute inpatient episode of care for total joint arthroplasty patients. This new payment methodology drives higher quality and a greater focus on value by incentivizing greater care coordination amongst various providers and making the hospital and providers financially accountable for patient outcomes, such as readmissions related to the surgery.
At UCSF, the effort has been jointly led by Dr. Bozic and Dr. Mervyn Maze, the chair of the Department of Anesthesia and Peri-Operative Care. A multidisciplinary team spanning clinical and administrative functions has been assembled to design the appropriate implementation infrastructure for Bundled Payment. A core part of this initiative has been the reliance on Lean continuous improvement methodology to map and redesign the care episode with the goal of developing an integrated care pathway to deliver reliable, high-quality and high-value care for every patient. In parallel, UCSF is trialing a time-driven activity-based costing approach to understand health care delivery costs at a granular level in order to identify cost savings opportunities.
Selected Current Projects:
- Shared Decision Making in Total Joint Replacement
- Episode of Care “Bundled” Payments
- Patient Activation and Functional Recovery in Patients Undergoing Primary TJA
- The Impact of Surgeon on Smoking Cessation Prior to Elective Hip or Knee Replacement
- Efficacy of Home Physical Therapy after TKA