Impact of Financial Incentives and Guideline Discussions on Decreasing Albumin Use in Critical Care Public

Abstract

Increasing concern for health care quality and rapidly growing costs has revived debates on the effectiveness of financial incentives for promoting higher value care. However, few financial incentive studies have looked at its effect on reducing overused, controversial, and expensive treatments such as albumin, for which literature generally finds no survival advantages over cheaper alternatives. Using observational data on patients treated in eight intensive care units (ICU) at two Georgia hospitals, this study examines the impact of a financial incentive program and guideline discussions on decreasing albumin use. Over 10 months, providers in eight ICUs in these two hospitals participated in a multi-faceted financial incentive program to decrease albumin use. Simultaneously, five of the eight ICUs directly participated on an Albumin Utilization Taskforce Committee to discuss system-wide guidelines. One year of baseline data was also observed. To identify independent effects for the financial incentives and guideline discussions, we employed a quasi-experimental, pre-post intervention design with non- equivalent comparison groups. Two-part regression models adjusting for health status and other covariates provided estimates of independent effects. Overall, the eight ICUs saw a significant, unadjusted 23.1% decrease in mean albumin orders per admission during the intervention year (p<0.001). Financial incentives were significantly associated with 0.38 fewer orders of albumin at a mean of 1.37 orders per encounter (p<0.001). Guideline discussions tended to decrease orders by 0.26 orders at the mean, but this overall estimate was not statistically significant (p=0.059). Independent effects for both interventions on volume of albumin orders were relatively larger in magnitude and statistical significance compared to effects on probability of any albumin use. Decreases among ICUs with high baseline albumin use constituted the majority of albumin decrease observed across all ICUs. Changes in albumin use were achieved without a significant change in mortality rates. These study findings contribute to the broader discussion on the role of financial incentive programs and organizational interventions in medical care and on their potential implications for costs related to albumin use.

Table of Contents

INTRODUCTION .............................................................................................................. 1

LITERATURE REVIEW ................................................................................................... 3

Background on Human Albumin................................................................................................. 3

Clinical Effectiveness of Albumin .............................................................................................. 3

Cost Implications......................................................................................................................... 5

Promoting Clinical Practice Change............................................................................................ 6

Pay-for-Performance ............................................................................................................... 7

Institutional Guidelines and Albumin Use .............................................................................. 8

OBJECTIVES & RESEARCH QUESTION .................................................................... 10

METHODOLOGY ........................................................................................................... 11

Data Source................................................................................................................................ 11

Theoretical Framework.............................................................................................................. 12

Study Design.............................................................................................................................. 17 Variables.................................................................................................................................... 18

Dependent Variable............................................................................................................... 18

Independent Variables........................................................................................................... 18

Statistical Methods - Main Analysis ......................................................................................... 19

Additional Analysis ................................................................................................................... 21

Sensitivity Analysis............................................................................................................... 21

Subgroup Analysis ................................................................................................................ 21

Mortality Analysis................................................................................................................. 22

RESULTS ......................................................................................................................... 23

Descriptive Statistics ................................................................................................................. 23

Financial Incentive & Guideline Discussion Effects................................................................. 24

Unadjusted Analysis.............................................................................................................. 24

Adjusted Analysis ................................................................................................................. 26

Sensitivity Analysis............................................................................................................... 30

Subgroup Analysis of High and Low Albumin Users .......................................................... 31

Additional Outcomes................................................................................................................. 33

DISCUSSION ................................................................................................................... 34

Summary of Findings ................................................................................................................ 34

Impact on Provider Decision-Making ....................................................................................... 35

Clinical & Policy Implications .................................................................................................. 38

Study Limitations ...................................................................................................................... 39

Internal Validity .................................................................................................................... 39

External Validity ................................................................................................................... 41

Future Directions ....................................................................................................................... 42

CONCLUSION................................................................................................................. 43

REFERENCES ................................................................................................................. 45 APPENDIX....................................................................................................................... 51

About this Master's Thesis

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School	Rollins School of Public Health
Department	Health Policy and Management
Degree	MSPH
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health Health Sciences, Health Care Management
Mot-clé	fluid therapy critical care clinical decision making consensus guidelines health care costs albumin financial incentives intensive care unit medical economics
Committee Chair / Thesis Advisor	Hockenberry, Jason Michael, Emory University
Committee Members	Gaydos, Laurie, Emory University Howard, David H, Emory University Murphy, David J, Emory University
Partnering Agencies	Emory University schools, faculty or affiliated programs Hospital or other health care provider

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