Who is Assigned to Difficult Cases in the Hospital

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Who is Assigned to Difficult Cases in the Hospital

  1. 1. Romero N. SantiagoMentors: Guy David, Ph.D. and Mark Neuman, M.D.
  2. 2. Motivation  Elements that distort efficient matching of patients to physicians may impact patient wellbeing.  Perverse incentives to take or avoid difficult cases.  For the same condition, recommendations may vary by specialty (supplier induced demand). Inefficient matching is potentially costly to the healthcare system. Hospital reputation and malpractice pressure may not provide sufficient incentives to induce efficient matching.
  3. 3. Strategy Used to Study Task-Talent Matching  Review previous research discussing current framework of task-talent matching Read through the literature to find various incentives that could help explain cause of inefficient matching Analyze task-talent matching in a specific region and specialty to observe degree of matching problem
  4. 4. Project Overview  Are highly talented physicians performing the most difficult cases? Theoretical Framework Empirical Work Valuable insights about research experience
  5. 5. Garicano’s Pyramid Hierarchy is Not a Perfect Fit for Medicine  “Hierarchies and the Organization of Knowledge in Production” – Garicano  “Knowledge-based hierarchy” – production workers and specialized problem solvers (industrial sector).  Pyramidal structure with multiple levels, communication costs incurred with specialization  Knowledge of problem solvers incorporates knowledge of those asking them for advice on solving a particular problem  In medicine, no fine line between base level (production worker) and problem solver, levels overlap.
  6. 6. Specialization Creates Matching Issue Through Incentives Santos “Referrals” – Garicano and  Agent diagnosing opportunity/task incentivized to keep most valuable ones and refer least valuable  Top-down diagnosis generates no inefficiency, unlike bottom-up arrangements “Specialization and Matching” – Epstein and colleagues  Physicians in group partnerships specialize more than solo physicians, utilizing referral system  Matching of specialists to patient heightened under firm or group practice.
  7. 7. Macroscopic View of Florida’s Cardiac Surgeon Population  of Health website Utilized the Florida Department  Board-certified cardiac surgeons (162)  Graduation Year from Medical School  Residency and Fellowship Information Age of patient utilized as proxy for task difficulty Years of experience used as proxy for talent Data represents inpatient cases from 2005 to 2007  Mean age of patient = 66 years  Standard Deviation = 10.7 years  Mean Experience for Surgeon = 28.8 years  Standard Deviation = 7.9 years
  8. 8. Using Experience=15 as Cutoff Experience<15 Experience>=15Age<70 233 (60%)  24215 (57%)Age>=70 153 (40%) 18130 (43%) Experience<15 Experience>=15Age<80 343 (89%) 37359 (88%)Age>=80 43 (11%) 4986 (12%) Experience<15 Experience>=15Age<90 380 (98%) 41804 (99%)Age>=90 6 (2%) 541 (1%) Chi-squared values were 0.21, 0.70, and 0.63 respectively
  9. 9. Using Experience = 20 as CutoffAge<70 2815 (56%)  Experience<20 Experience>=20 21633 (57%)Age>=70 2174 (44%) 16109 (43%) Experience<20 Experience>=20Age<80 4393 (88%) 33309 (88%)Age>=80 596 (12%) 4433 (12%) Experience<20 Experience>=20Age<90 4923 (99%) 37261 (99%)Age>=90 66 (1%) 481 (1%) Chi-squared values were 0.23, 0.68, and 0.77 respectively
  10. 10. Using Experience=25 as cutoffAge<70 6962 (58%)  Experience<25 Experience>=25 17486 (57%)Age>=70 5044 (42%) 13239 (43%) Experience<25 Experience>=25Age<80 10635 (89%) 27067 (88%)Age>=80 1371 (11%) 3658 (12%) Experience<25 Experience>=25Age<90 11852 (99%) 30332 (99%)Age>=90 154 (1%) 393 (1%) Chi-squared values were 0.05, 0.16, and 0.98 respectively
  11. 11. Next Steps  Look for a more accurate way to define task and talent, as age and experience are very approximate proxies Analyzing various comorbidity indices to account for preexisting conditions among patients (task) Attempt to verify payment structure’s effect on task and talent matching in cardiac surgery Compare and contrast incentives and payment structures of various specialties
  12. 12. Interdisciplinary Mindset andCommunication are the Keys to Success   Thoroughly understanding the significance of assumptions is crucial.  Health services research requires an interdisciplinary approach and mindset.  Learning about prior research done in one’s topic is essential for future growth and advancement.  Communication and conversation is vital.  Combining Economics and Medicine
  13. 13. Special Recognition  Leonard Davis Institute of Health Economics Anesthesiology Department at Penn Medicine Mentors: Guy David, Ph.D. and Mark Neuman, M.D. LDI Staff  Joanne Levy,  Elisabeth Madden,  Hoag Levins,  Megan Pellegrino  Renee Zawacki
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