BACKGROUND: Comorbidity is increasingly important in the medical literature, with ever-increasing implications for diagnosis, treatment, prognosis, management and health care. The objective of this study is to measure casual versus causal comorbidity in primary care in three family practice populations.
METHODS: This is a longitudinal observational study using the Transition Project datasets. Transition Project family doctors in the Netherlands, Malta and Serbia recorded details of all patient contacts in an episode of care structure using electronic medical records and the International Classification of Primary Care, collecting data on all elements of the doctor-patient encounter, including diagnoses (1,178,178 in the Netherlands, 93,606 in Malta, 405,150 in Serbia), observing 158,370 patient years in the Netherlands, 43,577 in Malta, 72,673 in Serbia. Comorbidity was measured using the odds ratio of both conditions being incident or rest-prevalent in the same patient in one-year dataframes, as against not, corrected for the prior probability of such co-occurrence, between the 41 joint most prevalent (joint top 20) episode titles in the three populations. Specific associations were explored in different age groups to observe the changes in odds ratios with increasing age as a surrogate for a temporal or biological gradient.
RESULTS: The high frequency of observed comorbidity with low consistency in both clinically and statistically significant odds ratios across populations indicates more casual than causal associations. A causal relationship would be expected to be manifest more consistently across populations. Even in the minority of cases where odds ratios were consistent between countries and numerically larger, those associations were observed to weaken with increasing patient age.
CONCLUSIONS: After applying accepted criteria for testing the causality of associations, most observed primary care comorbidity is due to chance, likely as a result of increasing illness diversity.
BACKGROUND: This study was performed on electronic patient record datasets made publicly available by the University of Amsterdam Department of General Practice, and did not involve any patient intervention.

RN Braun observed that frequencies of health disorders in general practice are so consistent that he called his discovery \"Case Distribution Law\". Our study compares morbidity data from methodologically similar surveys in primary care practices over a period of fifty years. Frequency ranks were determined for each observation period and the first 150 ranks were compared with Spearman\'s correlation coefficients. All correlations were consistently positive. Frequency ranks were strikingly similar for surveys carried out at approximately the same time, especially when nomenclatural matching had been carried out before data collection. Ranks were also very similar where clear disease classifications were possible, but less so for non-specific symptoms.The consistency of the distribution of health disorders helps develop diagnostic strategies (diagnostic protocols) and appropriate labeling for non-specific, diagnostically open symptom classifications. According to Braun\'s considerations, the regularity of case distribution plays an important role in the professionalization of primary care.
UNASSIGNED: RN Braun beobachtete, dass Häufigkeiten von Gesundheitsstörungen in der Allgemeinmedizinpraxis so konsistent sind, dass er seine Entdeckung 1955 „Fälleverteilungsgesetz“ nannte. Unsere Studie vergleicht methodisch ähnliche Prävalenzerhebungen aus Hausarztpraxen innerhalb eines Zeitraums von fünfzig Jahren. Für jeden Beobachtungszeitraum wurden Häufigkeitsränge ermittelt und die jeweils ersten 150 Ränge mit den Korrelationskoeffizienten nach Spearman verglichen. Wir fanden insgesamt positive Korrelationen, die Häufigkeitsränge waren besonders ähnlich bei ungefähr zeitgleichen Erhebungen, und wenn vor der Datenerhebung eine nomenklatorische Abgleichung erfolgt war. Auch waren die Ränge sehr ähnlich, wo eindeutige Klassifizierungen möglich waren, hingegen weniger übereinstimmend bei unspezifischen Symptomen.Die Konsistenz der Verteilung der Gesundheitsstörungen ermöglicht es, für die unspezifischen, diagnostisch offenen Symptomklassifizierungen diagnostische Strategien (Programmierte Diagnostik) und adäquate Bezeichnungen zu erarbeiten. Gemäß Brauns Überlegungen spielt damit die Regelmäßigkeit der Fälleverteilung eine wichtige Rolle bei der Professionalisierung der Allgemeinmedizin.

BACKGROUND: The cost of medically attended RSV LRI (lower respiratory infection) is critical in determining the economic value of new RSV immunoprophylaxes. However, most studies have focused on intermittent RSV encounters, not the episode of care that captures the entirety of RSV illness.
METHODS: We created age- and condition-specific cohorts of children under 5 years of age using MarketScan® data (2015-2019). We contrasted aggregating healthcare costs over RSV-LRTI episodes to ascertaining costs based on RSV-specific encounters only. Economic burden was estimated by multiplying costs per encounter or per episode by their respective incidence rates.
RESULTS: Average cost was higher per episode than per encounter regardless of settings (inpatient: $28,586 vs. $18,056 and outpatient/ED: $2099 vs. $407 for infants). Across ages, the economic burden was highest for infants and RSV-LRTI requiring inpatient care, but the burden in outpatient/ED settings was disproportionately higher than costs due to higher incidence rates (for inpatient vs. outpatient episodes: $226,403 vs. $101,269; for inpatient vs. outpatient encounters: $151,878 vs. $38,819 per 1000 infant-years). For high-risk children, cost and burden were up to 3-10 times higher, respectively.
CONCLUSIONS: With a comprehensive stratification by settings and risk condition, the encounter- versus episode-based estimates provide a robust range for policymakers\' economic appraisal of new RSV immunoprophylaxes.

To understand hospitals\' approaches to spending reduction in commercial episode-based payment programs and inform incentive design.
Qualitative arm of an explanatory sequential mixed-methods study involving semistructured interviews with hospital leaders participating in a statewide quality improvement collaborative with novel episode-based incentive payments introduced by the state\'s largest commercial payer.
We recruited 21 leaders from 8 purposively selected, diverse hospitals with both high and low performance. Video teleconference-based interviews followed a standardized protocol and addressed 4 domains: choice of clinical condition for evaluation, strategies for episode spending reduction, best practices for success in earning incentives, and barriers to achievement. Rapid qualitative analysis with purposeful data reduction was employed to generate a matrix of key themes within the study domains.
Strategies were similar between high- and low-performing hospitals. When selecting conditions, some hospitals focused on areas of underperformance, aiming for improvement opportunities, whereas others chose conditions already achieving highest efficiency. Many tried to synergize with other ongoing improvement initiatives and clinical areas with established leaders and champions. Key strategies included data-driven improvement, care standardization, and protocol dissemination. Best practices for success included readmission prevention and postacute care spending containment.
The findings highlighted hospitals\' most common strategies and approaches, providing several insights into optimal design of commercial episode-based incentives: They must be lucrative enough to earn attention or consistent with larger federal programs; hospitals need opportunities to succeed through both improved performance and sustained excellence; and programs may incur malalignment between hospitals and credentialed physicians.

OBJECTIVE: As value-based care grows in popularity across the United States, more payers have turned toward bundled payment models for surgical procedures. Though episode costs in spine are highly variable, physical therapy (PT) has been identified as a driver of 90-day cost. The goal of this study is to assess the impact of postoperative PT on patient-reported outcomes and cost after lumbar fusion surgery using bundled insurance data.
METHODS: Bundled payment information of lumbar fusion episodes-of-care (EOC) from 2019 to 2021 was reviewed at a single, urban, tertiary care center. EOC comprised a 210-day period surrounding the date of the procedure, beginning 30 days preoperatively and ending 180 days postoperatively. Patients were grouped into physical therapy (PT) and no physical therapy (no PT) groups based on the presence of PT claims.
RESULTS: Bivariate analysis of surgical outcomes revealed similar overall complication rates (P = 0.413), 30-day readmissions (P = 0.366), and 90-day readmissions (P = 0.774). Patients who did not participate in postoperative PT had significantly better preoperative physical component score (PCS) (P = 0.003), 6-month postoperative PCS (P = 0.001), and 6-month ΔPCS (P = 0.026) compared with patients who participated in postoperative PT. At 1-year follow-up, patients who did not participate in PT had less leg pain (P = 0.041) than those who did participate in PT.
CONCLUSIONS: Our study finds that PT after lumbar fusion is not associated with significant improvement in Oswestry Disability Index, PCS, mental component score, or visual analog scale pain scores. Additionally, the number of PT sessions a patient attends has no correlation with improvement in these outcomes.

BACKGROUND: Payment structured around Episodes of Care is a method for incentivizing decreased care utilization after major procedures. We examined Major Bowel Episodes of Care (MB-EoC)-the focus among general surgery procedures-within a large health system to determine the contribution of emergency bowel surgery to higher costs of care.
METHODS: Adult MB-EoC cases from July 2018 to June 2021 were reviewed for 90-d costs, examining patient age, insurance, diagnosis, cost of care, and contributors to cost. For patients aged ≥45 y who had nonelective care for colon cancer, incidence of prior screening colonoscopy was examined.
RESULTS: We identified 1292 colectomy cases. Mean age was 65 y. Of these patients, 90% had Medicare/commercial insurance. Colon cancer comprised 41% of primary diagnoses. Twenty-eight percent of cases were nonelective, more likely to have Medicaid/underinsured (21% versus 7%, P < 0.001), and had higher utilization of postdischarge cost-drivers. Ninety-day EoC per case cost was 66% higher for emergent versus elective cases. Of eligible emergency cancer cases, 43% (40/93) had undergone prior colonoscopy within 10 y. For patients with colon cancer, 90-d EoC per case was 39% higher for emergent versus elective cases.
CONCLUSIONS: Emergency MB-EoC cases disproportionally contribute to higher 90-d care utilization and costs. Efforts to increase screening colonoscopy in appropriate populations may have a substantial impact on MB-EoC costs.

OBJECTIVE: To evaluate inter-hospital variation in 90-day total episode spending for sepsis, estimate the relative contributions of each component of spending, and identify drivers of spending across the distribution of episode spending on sepsis care.
METHODS: Medicare fee-for-service claims for beneficiaries (n=324,694) discharged from acute care hospitals for sepsis, defined by MS-DRG, between October 2014 and September 2018.
METHODS: Multiple linear regression with hospital-level fixed effects was used to identify average hospital differences in 90-day episode spending. Separate multiple linear regression and quantile regression models were used to evaluate drivers of spending across the episode spending distribution.
RESULTS: The mean total episode spending among hospitals in the most expensive quartile was $30,500 compared with $23,150 for the least expensive hospitals ( P <0.001). Postacute care spending among the most expensive hospitals was almost double that of least expensive hospitals ($7,045 vs. $3,742), accounting for 51% of the total difference in episode spending between the most expensive and least expensive hospitals. Female patients, patients with more comorbidities, urban hospitals, and BPCI-A-participating hospitals were associated with significantly increased episode spending, with the effect increasing at the right tail of the spending distribution.
CONCLUSIONS: Inter-hospital variation in 90-day episode spending on sepsis care is driven primarily by differences in post-acute care spending.

Ankle fractures are one of the most resource-consuming traumatic orthopedic injuries. Few studies have successfully evaluated the episode-of-care costs (EOCC) of common traumatic orthopedic injuries. The objective of this study was to determine the EOCC associated with the surgical management of ankle fractures. A retrospective cohort study of 105 consecutive patients who underwent open reduction internal fixation of an isolated ankle fracture at a Canadian Level-1 trauma center was conducted. Episode-of-care costs were generated using an activity-based costing framework. The median global episode-of-care cost for ankle fracture surgeries performed at the studied institution was $3,487 CAD [IQR 880] ($2,685 USD [IQR 616]). Patients aged 60 to 90 years had a significantly higher median EOCC than younger patients (p = .01). Supination-adduction injuries had a significantly higher median EOCC than other injury patterns (p = .01). The median EOCC for patients who underwent surgery within 10 days of their injury ($3,347 CAD [582], $2,577 USD [448]) was significantly lower than the cost for patients who had their surgery delayed 10 days or more after the injury ($3,634 CAD [776], $2,798 USD [598]) (p = .03). Patient sex, anesthesia type, ASA score and surgeon\'s fellowship training did not affect the EOCC. This study provides valuable data on predictors of EOCC in the surgical management of ankle fractures. Delaying simple ankle fracture cases due to operating time constraints can increase the total cost and burden of these fractures on the healthcare system. In addition, this study provides a framework for future episode-of-care cost analysis studies in orthopedic surgery.

UNASSIGNED: The International Classification of Primary Care (ICPC) has represented the international standard reduction for measuring the content of primary care for over 30 years. In the process of its third revision, its authors, the Wonca International Classification Committee (WICC), delegated a major part of the technical work to a purposely formed Consortium. However, in the process of such revision, standard classification principles and rules have been inconsistently applied with the result that ICPC-3 has been published with major errors and an inconsistent structure.
UNASSIGNED: To formally describe and critically appraise the revision process of ICPC-3.
UNASSIGNED: The formal review of ICPC-3 performed by an expert group within WICC and commissioned by the Executive Council of Wonca Europe is presented in abridged form.
UNASSIGNED: ICPC-3 as currently presented introduces major departures from formal classification principles and rules, besides other major errors and inconsistencies, all of which are listed and described.
UNASSIGNED: Major changes in ICPC-3 defy categorisation and conceptualisation standards. ICPC-3 now represents an untested departure from international standard presentations, without a formal academic base. The direct inclusion of measures of functioning in a classification of reasons for encounter and health problems fails to address the dichotomy of these domains, the boundaries of and relationships between which are not satisfactorily resolved by the system. Analysis of ICPC-3 data will require the development and implementation of alternative, as yet undefined, models of the relationships between disease and health. By including different domains without resolving ambiguity, and by splitting function from other body systems, ICPC-3 becomes an internally fractured instrument.

The Electronic Health Record system BUPdata served Norwegian Child and Adolescent Mental Health Services (CAMHS) for over 35 years and is still an important source of information for understanding clinical practice. Secondary usage of clinical data enables learning and service quality improvement. We present some insights from explorative data analysis for interpreting the records of patients referred for hyperkinetic disorders. The major challenges were data preparation, pre-analysis, imputation, and validation. We summarize the main characteristics, spot anomalies, and detect errors. The results include observations about the patient referral diversity based on 12 different variables. We modeled the activities in an individual episode of care, described our clinical observations among data, and discussed the challenges of data analysis.