Currently Viewing:
The American Journal of Managed Care September 2016
Implications of Evolving Delivery System Reforms for Prostate Cancer Care
Brent K. Hollenbeck, MD, MS; Maggie J. Bierlein, MS; Samuel R. Kaufman, MS; Lindsey Herrel, MD; Ted A. Skolarus, MD, MPH; David C. Miller, MD, MPH; and Vahakn B. Shahinian, MD
New Strategies for Aligning Physicians With Health System Incentives
Amol S. Navathe, MD, PhD; Aditi P. Sen, MA; Meredith B. Rosenthal, PhD; Robert M. Pearl, MD; Peter A. Ubel, MD; Ezekiel J. Emanuel, MD, PhD; Kevin G. Volpp, MD, PhD
Cost-Benefit of Appointment-Based Medication Synchronization in Community Pharmacies
Julie A. Patterson, BS; David A. Holdford, PhD, MS, BSPharm; and Kunal Saxena, PhD, MS
Geographic Variation in Surgical Outcomes and Cost Between the United States and Japan
Michael P. Hurley, MD, MS; Lena Schoemaker, BA; John M. Morton, MD, MPH; Sherry M. Wren, MD; William B. Vogt, PhD; Sachiko Watanabe, RN, MHSA, MAE; Aki Yoshikawa, PhD; and Jay Bhattacharya, MD, PhD
The Opportunities and Challenges of the MSSP ACO Program: A Report From the Field
Farzad Mostashari, MD, ScM, and Travis Broome, MPH
Managing Inappropriate Requests of Laboratory Tests: From Detection to Monitoring
Maria Salinas, PhD; Maite López-Garrigós, PhD; Emilio Flores, PhD; Maria Leiva-Salinas, MD, PhD; Alberto Asencio, MD; Javier Lugo, MD; and Carlos Leiva-Salinas, MD, PhD
Measuring the Cost Implications of the Collaborative Accountable Care Initiative in Texas
Vivian Ho, PhD; Timothy K. Allen, PhD; Urie Kim, BBA; William P. Keenan, BA; Meei-Hsiang Ku-Goto, MA; and Mark Sanderson, PhD
Knowledge Gaps Inhibit Health IT Development for Coordinating Complex Patients' Care
Robert S. Rudin, PhD; Eric C. Schneider, MD, MSc; Zachary Predmore, BA; and Courtney A. Gidengil, MD, MPH
Mapping US Commercial Payers' Coverage Policies for Medical Interventions
James D. Chambers, PhD; Matthew D. Chenoweth, MPH; and Peter J. Neumann, ScD
Currently Reading
Opportunities to Improve the Value of Outpatient Surgical Care
Feryal Erhun, PhD; Elizabeth Malcolm, MD, MSHS; Maziyar Kalani, MD; Kimberly Brayton, MD, JD, MS; Christine Nguyen, MD, MS; Steven M. Asch, MD, MPH; Terry Platchek, MD; and Arnold Milstein, MD, MPH

Opportunities to Improve the Value of Outpatient Surgical Care

Feryal Erhun, PhD; Elizabeth Malcolm, MD, MSHS; Maziyar Kalani, MD; Kimberly Brayton, MD, JD, MS; Christine Nguyen, MD, MS; Steven M. Asch, MD, MPH; Terry Platchek, MD; and Arnold Milstein, MD, MPH
Outpatient surgeries in the United States account for roughly 7% of annual healthcare expenditures. To exploit substantial opportunities to improve the value of outpatient surgical care, the authors composed an evidence-based care delivery composite for national discussion and pilot testing.
Standard workflows and nonlabor inputs. Clinical algorithms yield to standardized workflows that, in turn, allow lower-cost clinical team members to perform work that is currently performed by more costly health professionals. Standard workflows extend outside the procedure to encompass tasks such as discharge planning58,59 and turnovers to reduce operating room down time.60 Standardizing nonlabor inputs, such as surgical supplies, based on comparative effectiveness and price, reduces the cost of surgery and allows for volume-based price discounts from suppliers. It also simplifies purchasing and reduces the time and effort needed to tailor supplies to surgical team preferences. Such standardization may lead to cost savings of roughly 20%61 and improve quality of care by reducing variation in equipment and supplies that support staff members must master, thus reducing errors attributed to unfamiliarity. 

Continuous monitoring and adjustment of clinical algorithms and workflows. Additional reduction in variation can further boost the yield from algorithms and standard workflows by continuously analyzing deviations and making further refinements. As clinician confidence builds in algorithms, information technology tools, such as patient dashboards, automated check-in,62 and preadmission assessment,63 can ease care pathway implementation and improve the clinician and patient experience of care.

We estimate that net annual US savings associated with the REPLICATE element could approach $6.3 billion, or 3% of annual spending on outpatient surgeries after a 5-year implementation and refinement period.

DISCUSSION

Major opportunities remain to improve the value of US outpatient surgical care (Figure 2). To capitalize on these opportunities, we gathered evidence from diverse sources. The validity of our forecast for lowering the cost of better surgical care hinges on the quality and transferability of the evidence that we sourced. Pilot-testing of the Triple-R will reveal synergies and friction points among component parts.

Some elements of the composite, such as the expanded hours of operation, extend beyond directly relevant evidence and rely instead on successes in plausibly similar circumstances. When operationalizing such elements, it is important to consider context-dependent implementation hurdles; for example, expanding hours in the ASC context may present implementation challenges in incorporating provider and staff preferences for certain work hours. Furthermore, some of the reported efficiency in ASCs8,42,43 may be due to incentives to finish cases quickly because staffing is not performed in shifts. Thus, adding shifts may paradoxically lengthen case and turnaround times. Incentives, such as bonus payments for off-hour shifts may mitigate this issue. Expanded hours may also pose challenges to incorporating patient preferences. In previous studies of other procedures, patients have opted for inconvenient hours if the wait time for therapy was shorter.64 However, understanding patient preferences and trade-offs in elective surgery would be valuable; additionally, discounted pricing for unfavorable times may be considered.

We estimate that the potential for annual nationwide savings is roughly $40 billion net of implementation costs, or 19% of current annual spending on outpatient surgeries and more than 1% of total annual US healthcare spending. To achieve such savings, the Triple-R uses disruptive elements that would require structural and cultural shifts in the healthcare system. One such element is shifting procedures to ASCs despite current economic incentives to keep them in HOPDs. Our composite is designed with value-based payment, tiered networks, and reference pricing in mind, where such a tradeoff is indeed financially encouraged. However, even in other types of systems, market competition may ultimately work in favor of ASCs due to the low price, better convenience, and better quality. In addition, shifting higher turnover cases to ASCs will open up capacity at HOPDs, and allow them to streamline inputs and specialize their labor and care. Even with the shift, HOPDs will continue to produce a significant percentage of outpatient procedures (eg, complex procedures or procedures on medically complex patients).

The Triple-R focuses broadly on all outpatient procedures, but not all procedures will generate the same value. Future pilot studies will most likely focus on a smaller group of specialties. Although this choice will be site-dependent, there may be specialties and procedures that are likely to generate relatively more value from the application of our composite, due to, for example, a high volume of outpatient surgeries that can safely be moved to ASCs within the specialty. Our preliminary analysis suggests that certain procedures within the specialty areas of orthopedics, ophthalmology, plastic surgery, gastrointestinal, and gynecology may be good candidates for future pilot testing.

Results from pilot testing and scaling the proposed composite will hinge on each organization’s culture and management capabilities. Therefore, local operational and cultural factors must be a part of any implementation. The composite is designed to target levers with the highest opportunity to lower per capita healthcare spending safely. For example, even though there are opportunities to increase the value of care in HOPDs, ambulatory surgery represents a larger cost-reduction opportunity, and therefore has been chosen as the focus of the composite. Having said that, elements of REPLICATE can be used at HOPDs to increase efficiency and improve outcomes, while elements of REFINE apply to all outpatient procedures independent of surgical location.

CONCLUSIONS

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. We have begun partnerships with healthcare organizations to assess the impact of the REFINE-RESET-REPLICATE composite. As clinicians and their organizations face increasing use of value-based payment, tiered networks, and reference pricing,65 its successful implementation and refinement may help secure their financial viability.

Acknowledgments

The authors wish to thank Dani Zionts, MSPH, for reviewing the article, and Rajbinder Mann for administrative support. They also thank Craig Albanese, MD, MBA; Jeffrey Belkora, PhD; John Chardos, MD; Alana Conner, PhD; David Hopkins, PhD; Mohit Kaushal, MD; Dhruv Kazi, MD; William Kennedy, MD; Thomas Krummel, MD; Richard Levy, PhD; Harold Luft, PhD; Richard Popp, MD; Stanley Rosenschein, PhD; Kristan Staudenmayer, MD; Ming Tai-Seale, PhD, MPH; Samuel Wald, MD, MBA; Thomas Weiser, MD; Paul Wise, MD, MPH; and Donna Zulman, MD, for their guidance. 

Author Affiliations: Clinical Excellence Research Center (KB, FE, MK, AM, EM, CN, TP) and Division of General Medical Disciplines (SMA, FE, AM, EM, CN), Stanford University, Stanford, CA; Department of Neurosurgery, Stanford University Medical Center (MK), Stanford, CA; Department of Pediatrics, Lucile Packard Children’s Hospital (TP), Stanford, CA.

Source of Funding: The study was supported by the Sue and Dick Levy Fund, an advised fund of the Silicon Valley Community Foundation.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.  

Authorship Information: Concept and design (SMA, KB, FE, MK, AM, CN, TP); acquisition of data (KB, FE, MK, AM, CN, TP); analysis and interpretation of data (SMA, KB, FE, MK, EM, AM, CN, TP); drafting of the manuscript (SMA, KB, FE, MK, AM, EM); critical revision of the manuscript for important intellectual content (SMA, KB, FE, AM, EM, TP); statistical analysis (CN); provision of patients or study materials (MK); obtaining funding (AM); administrative, technical, or logistic support (FE, EM, TP); and supervision (SMA, MK, AM, EM, TP).

Address Correspondence to: Feryal Erhun, PhD, Judge Business School, University of Cambridge, Trumpington S, Cambridge CB2 1AG, UK. E-mail: f.erhun@jbs.cam.ac.uk.
REFERENCES

1. Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States, 2006. Natl Health Stat Report. 2009;Jan 28(11):1-25.

2. Manchikanti L, Parr AT, Singh V, Fellows B. Ambulatory surgery centers and interventional techniques: a look at long-term survival. Pain Physician. 2011;14(2):E177-E215.

3. CMS. National health expenditures 2013 highlights.  Hearthland Institute website. https://www. https://www.heartland. org/_template-assets/documents/publications/national_health_expenditures_highlights.pdf. Accessed December 5, 2014.


4. 2013 health care cost and utilization report. Health Care Cost Institute website. http://www.healthcostinsti- tute.org/files/2013%20HCCUR%2012-17-14.pdf. Published October 2014. Accessed December 5, 2014.


5. Farrell D, Jensen E, Kocher B, et al. Accounting for the cost of US health care: a new look at why Americans spend more. McKinsey Global Institute website. Published December  2008. Accessed December 5, 2014.

6. Manohar A, Cheung K, Wu CL, Stierer TS. Burden incurred by patients and their caregivers after outpatient surgery: a prospective observational study. Clin Orthop Relat Res. 2013;472(5):1416-1426. doi: 10.1007/ s11999-013-3270-6.


7. Fox JP, Vashi AA, Ross JS, Gross CP. Hospital-based, acute care after ambulatory surgery center discharge. Surgery. 2014;155(5):743-753. doi: 10.1016/j.surg.2013.12.008.


8. Munnich EL, Parente ST. Procedures take less time at ambulatory surgery centers, keeping costs down and ability to meet demand up. Health Aff (Millwood). 2014;33(5):764-769. doi: 10.1377/hlthaff.2013.1281.


9. Platchek T, Rebitzer R, Zulman D, Milstein A. Better health, less spending: Stanford’s Clinical Excellence Research Center. Heal Manag Policy Innov. 2014;2(1):10-17.

10. Bradley EH, Curry LA, Ramanadhan S, Rowe L, Nembhard IM, Krumholz HM. Research in action: using positive deviance to improve quality of health care. Implement Sci. 2009;4(1):25. doi: 10.1186/1748-5908-4-25.


11. Chan PS, Patel MR, Klein LW, et al. Appropriateness of percutaneous coronary intervention. JAMA. 2011;306(1):53-61. doi: 10.1001/jama.2011.916.


12. Epstein NE, Hood DC. “Unnecessary” spinal surgery: a prospective 1-year study of one surgeon’s experience. Surg Neurol Int. 2011;2:83. doi: 10.4103/2152-7806.82249.


13. Arterburn D, Wellman R, Westbrook E, et al. Introducing decision aids at group health was linked to sharply lower hip and knee surgery rates and costs. Health Aff (Millwood). 2012;31(9):2094-2104. doi:10.1377/hlthaff.2011.0686.

14. Al-Khatib SM, Hellkamp A, Curtis J, et al. Non-evidence-based ICD implantations in the United States. JAMA. 2011;305(1):43-49. doi:10.1001/jama.2010.1915.

15. Schroeck FR, Hollingsworth JM, Kaufman SR, Hollenbeck BK, Wei JT. Population based trends in the surgical treatment of benign prostatic hyperplasia. J Urol. 2012;188(5):1837-1841. doi:10.1016/j.juro.2012.07.049.

16. Leape LL. Unnecessary surgery. Annu Rev Public Health. 1992;13:363-383.

17. Hollingsworth JM, Ye Z, Strope SA, Krein SL, Hollenbeck AT, Hollenbeck BK. Physician-ownership of ambulatory surgery centers linked to higher volume of surgeries. Health Aff (Millwood). 2010;29(4):683-689.  doi: 10.1377/hlthaff.2008.0567.


18. Hollenbeck BK, Dunn RL, Suskind AM, Zhang Y, Hollingsworth JM, Birkmeyer JD. Ambulatory surgery centers and outpatient procedure use among Medicare beneficiaries. Med Care. 2014;52(10):926-931.  doi: 10.1097/MLR.0000000000000213.


19. Froehlich F, Pache I, Burnand B, et al. Performance of panel-based criteria to evaluate the appropriateness of colonoscopy: a prospective study. Gastrointest Endosc. 1998;48(2):128-136.

20. Hannan EL, Samadashvili Z, Cozzens K, et al. Appropriateness of diagnostic catheterization for suspected coronary artery disease in New York State. Circ Cardiovasc Interv. 2014;7(1):19-27.  doi: 10.1161/ CIRCINTERVENTIONS.113.000741.


21. Delaune J, Everett W. Waste and inefficiency in the U.S. health care system—clinical care: a compre- hensive analysis in support of system-wide improvements. New England Healthcare Institute website. http:// www.nehi.net/writable/publication_files/file/waste_clinical_care_report_final.pdf. Published February 2008. Accessed December 10, 2014.

 
22. Fowler FJ, Levin CA, Sepucha KR. Informing and involving patients to improve the quality of medical decisions. Health Aff (Millwood). 2011;30(4):699-706. doi: 10.1377/hlthaff.2011.0003.


23. Friedberg MW, Chen PG, Van Busum KR, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. RAND Corporation website. http://www. rand.org/pubs/research_reports/RR439.html. Published 2013. Accessed January 21, 2015.


24. Shared decision making between patients and providers has promise, but obstacles remain. RAND Corporation website. http://www.rand.org/health/feature/shared_decision_making.html. Accessed December 5, 2014.

25. Rothberg MB, Pekow PS, Lahti M, Brody O, Skiest DJ, Lindenauer PK. Antibiotic therapy and treatment failure in patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease. JAMA. 2010;303(20):2035-2042.  doi: 10.1001/jama.2010.672.

26. Stacey D, Bennett CL, Barry MJ, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2011;Oct 5(10):CD001431. doi: 10.1002/14651858.CD001431.pub3.


27. Friedberg MW, Van Busum K, Wexler R, Bowen M, Schneider EC. A demonstration of shared decision making in primary care highlights barriers to adoption and potential remedies. Health Aff (Millwood). 2013;32(2):268-275. doi: 10.1002/14651858.CD001431.pub3.


28. Patient decision aids: alphabetical list of decision aids by health topic. The Ottawa Hospital Research Institute website. http://decisionaid.ohri.ca/AZlist.html. Accessed January 30, 2015.


29. McGinn TG, McCullagh L, Kannry J, et al. Efficacy of an evidence-based clinical decision support in primary care practices: a randomized clinical trial. JAMA Intern Med. 2013;173(17):1584-1591. doi: 10.1377/hlthaff.2012.1084.

30. McLeod W, Eidus R, Stewart EE. Clinical decision support: using technology to identify patients’ unmet needs. Fam Pract Manag. 2012;19(2):22-28.

31. About. Choosing Wisely website. http://www.choosingwisely.org/about-us/. Accessed April 8, 2015.


32. Begley S. Medicare pays billions of dollars for wasteful procedures–study. Reuters website. http://www.reuters.com/article/2014/05/12/us-usa-healthcare-medicare-idUSBREA4B0SX20140512. Published 2014. Accessed April 8, 2015.

33. Strauss CE, Porten BR, Chavez IJ, et al. Real-time decision support to guide percutaneous coronary intervention bleeding avoidance strategies effectively changes practice patterns. Circ Cardiovasc Qual Outcomes. 2014;7(6):960-967. doi: 10.1161/CIRCOUTCOMES.114.001275.


34. Appropriate use criteria. American Academy of Orthopaedic Surgeons website. http://www.aaos.org/ auc/?ssopc=1. Published 2015. Accessed April 8, 2015.


35. James BC. Implementing practice guidelines through clinical quality improvement. Front Health Serv Manage. 1993;10(1):3-37, 54-56.

36. UC awards four grants to expand health care innovations. University of California website. http://health. universityofcalifornia.edu/2014/03/10/uc-awards-four-grants-to-expand-health-care-innovations/. Published 2014. Accessed April 8, 2015.


37. Rosenthal L. Electronic specialist consultations reduce unnecessary referrals and wait times for specialty appointments for uninsured and underinsured patients. Agency for Healthcare Research and Quality website. https://innovations.ahrq.gov/profiles/electronic-specialist-consultations-reduce-unnecessary-referrals-and- wait-times-specialty#contactInnovator. Updated August 13, 2014. Accessed April 8, 2015.

38. Sheridan R, Ammann HK. Mission possible: implementing eConsult in the Los Angeles County healthcare system. Blue Shield of California Foundation website. http://www.blueshieldcafoundation.org/sites/default/ files/publications/downloadable/Mission%20Possible%20-%20Implementing%20eConsult%20-%20Sept%20 2013.pdf. Published September 2013. Accessed August 2016.

39. McAdams M, Cannavo L, Orlander JD. A medical specialty e-Consult program in a VA health care system. Fed Pract. 2014;31(5):26-31.

40. ASC to HOPD conversion: costly consequences. Washington Ambulatory Surgery Center Association website. http://www.wasca.net/wp-content/uploads/2007/03/ASC-to-HOPD-Conversion-Costly-Consequences. pdf. Accessed January 10, 2015.

41. Jackson IJB, McWhinnie D, Skues M. BADS Directory of Procedures. London, UK: British Association of Day Surgery; 2013.


42. Carey K. Price increases were much lower in ambulatory surgery centers than hospital outpatient departments in 2007-12. Health Aff (Millwood). 2015;34(10):1738-1744. doi: 10.1377/hlthaff.2015.0252.

43. Trentman T, Mueller J, Gray R, Pockaj B, Simula D. Outpatient surgery performed in an ambulatory surgery center versus a hospital: comparison of perioperative time intervals. Am J Surg. 2010;200(1):64-67. doi: 10.1016/j.amjsurg.2009.06.029.


44. Khanna T, Rangan K V., Manocaran M. Narayana Hrudayalaya Heart Hospital: cardiac care for the poor (A). Harvard Bus Case 9-505-078. 2011.

45. Sosa JA, Bowman HM, Tielsch JM, Powe NR, Gordon TA, Udelsman R. The importance of surgeon experience for clinical and economic outcomes from thyroidectomy. Ann Surg. 1998;228(3):320-330.

46. Bell CM, Redelmeier DA. Enhanced weekend service: an affordable means to increased hospital procedure volume. CMAJ. 2005;172(4):503-504.

47. Rogers AE. The effects of fatigue and sleepiness on nurse performance and patient safety. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality (US); 2008.

48. Birkmeyer JD, Siewers AE, Finlayson EVA, et al. Hospital volume and surgical mortality in the United States. N Engl J Med. 2002;346(15):1128-1137. doi: 10.1056/NEJMsa012337.

49. Hannan EL, Radzyner M, Rubin D, Dougherty J, Brennan MF. The influence of hospital and surgeon volume on in-hospital mortality for colectomy, gastrectomy, and lung lobectomy in patients with cancer. Surgery. 2002;131(1):6-15.

50. Elhauge E, ed. The Fragmentation of U.S. Health Care: Causes and Solutions. New York, NY: Oxford University Press; 2010.

51. Leung GM. Hospitals must become “focused factories”. BMJ. 2000;320(7239):942-943.

52. Vanhaecht K, Panella M, van Zelm R, Sermeus W. An overview on the history and concept of care pathways as complex interventions. Int J Care Pathways. 2010;14(3):117-123. doi: 10.1258/jicp.2010.010019.

53. James BC, Savitz LA. How Intermountain trimmed health care costs through robust quality improvement efforts. Health Aff (Millwood). 2011;30(6):1185-1191. doi: 10.1377/hlthaff.2011.0358.


54. Rotter T, Kinsman L, James E, et al. Clinical pathways: Effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database Syst Rev. 2010;(3):CD006632. doi: 10.1002/14651858. CD006632.pub2.

55. Strong for Surgery. CERTAIN website. http://www.becertain.org/strong_for_surgery. Accessed January 10, 2015.


56. Hulzebos EHJ, Helders PJM, Favié NJ, De Bie RA, Brutel de la Riviere A, Van Meeteren NLU. Preoperative intensive inspiratory muscle training to prevent postoperative pulmonary complications in high-risk patients undergoing CABG surgery: a randomized clinical trial. JAMA. 2006;296(15):1851-1857. doi: 10.1001/jama.296.15.1851

57. Møller AM, Villebro N, Pedersen T, Tønnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet. 2002;359(9301):114-117.

58. Proactive discharge planning keeps LOS low. Hospital Case Management. 2009; 17(12):185.

59. Quality and Service Improvement Tools: Discharge Planning. The NHS Institute for Innovation and Improvement website. http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_im- provement_tools/discharge_planning.html. Accessed April 10, 2015.

60. Cendán JC, Good M. Interdisciplinary work flow assessment and redesign decreases operating room turnover time and allows for additional caseload. Arch Surg. 2006;141(1):65-69; discussion 70.

61. Avansino JR, Goldin AB, Risley R, Waldhausen JHT, Sawin RS. Standardization of operative equipment reduces cost. J Pediatr Surg. 2013;48(9):1843-1849. doi: 10.1016/j.jpedsurg.2012.11.045.

62. NCR. Case study: Vanguard Urologic Institute reduces patient wait times via self-service. Health IT Outcomes website. http://www.healthitoutcomes.com/doc/reduces-patient-wait-times-via-self-service-0001. Published January 18, 2011. Accessed August 2016.


63. Dublin Surgery Center. OneMedical Passport website. http://onemedicalpassportcompany.com/wp-content/uploads/2013/08/Dublin_Surgery_case_study.pdf. Accessed August 2016.


64. Brown A, Atyeo J, Field N, Cox J, Bull C, Gebski V. Evaluation of patient preferences towards treatment during extended hours for patients receiving radiation therapy for the treatment of cancer: a time trade-off study. Radiother Oncol. 2009;90(2):247-252. doi: 10.1016/j.radonc.2008.11.019.


65. Burwell SM. Setting value-based payment goals—HHS efforts to improve U.S. health care. N Engl J Med. 2015;372(10):897-899. doi: 10.1056/NEJMp1500445.

PDF
 
Copyright AJMC 2006-2020 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
x
Welcome the the new and improved AJMC.com, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up