Common Health Problems | Conditions and treatments

A method for defining value in healthcare using cancer care as a model

EXECUTIVE SUMMARY

Value-based healthcare delivery is being discussed in a variety of healthcare forums. This concept is of great importance in the reform of the US healthcare delivery system. Defining and applying the principles of value-based competition in healthcare delivery models will permit future evaluation of various delivery applications. However, there are relatively few examples of how to apply these principles to an existing care delivery system. In this article, we describe an approach for assessing the value created when treating cancer patients in a multidisciplinary care setting within a comprehensive cancer center. We describe the analysis of a multidisciplinary care center that treats head and neck cancers, and we attempt to examine how this center integrates with Porter and Teisberg's (2006) concept of value-based competition based on the results analysis. Using the relationship between outcomes and costs as the definition of value, we developed a methodology to analyze proposed outcomes for a population of patients treated using a multidisciplinary approach, and we matched those outcomes to the costs of the care provided. We present this work as a model for defining value for a subset of patients undergoing active treatment. The method can be applied not only to head and neck treatments, but to other modalities as well. Public reporting of this type of data for a variety of conditions can lead to improved competition in the healthcare marketplace and, as a result, improve outcomes and decrease health expenditures.

INTRODUCTION

The healthcare delivery system in the United States has reached a critical turning point. Following decades of scientific and clinical innovations, we have developed a system that can provide some of the finest healthcare in the world, but a number of obvious deficiencies must be addressed. The costs of delivering care are too high and are rising at an unacceptable rate (Lee, Berenson, and Tooker 2010). Currently, US health expenditures represent approximately 17 percent of our gross national product (GNP), with projections reaching over 20 percent of GNP in the not-so-distant future. As a nation, we represent the world's highest per capita spending on healthcare, at $7,290 per person per year, exceeding the next-highest-spending country by over $1,000 per person per year (Levin-Scherz 2010). Despite this tremendous expenditure, we continually lag behind other developed nations in key health outcomes, such as life expectancy and infant mortality.

Variability in care delivery and payment systems is apparent at many levels. We have created a system in which the variability in access to care for broad segments of our population is unacceptable, due in large part to inequities in our payment system. The problems of the uninsured and underinsured populations further highlight the flaws in our fragmented system. Even for those with access and the ability to pay for care, unacceptable variability exists in the quality, safety, and effectiveness of care (Institute of Medicine 2000, 2001). At the core of the variability problem lies the current healthcare reimbursement system, which rewards providers for the volume and intensity of services provided rather than for quality, safety, effectiveness, or value.

Since the early 1990s, attempts have been made at the national level to reform the healthcare delivery and reimbursement systems, culminating with the passage of the recent healthcare reform bill in March 2010 (Patient Protection and Affordable Care Act 2010). This expansive bill attempts to address the problems of access, quality, and cost control through numerous measures. The most clearly defined measures will decrease but not eliminate the number of uninsured Americans over the next several years. Other aspects of the reform are designed to address quality of care and rising costs, but their capability to fix our system is uncertain.

Throughout the recent healthcare debate, statements were made about the need to improve the value of our healthcare system while improving the value of care for individual patients. The current bill uses the term "value" over 200 times yet never defines the term. In this analysis, we will examine the term value as it applies to healthcare. We use the field of cancer care to demonstrate how the concept can be used in reforms for the future. We specifically endeavored to develop a model that tests Porter and Teisberg's (2006) value proposition for healthcare that could be applied throughout our cancer center and that others might be able to use to examine value in various healthcare delivery systems.

College Women’s Perception and Knowledge of Human Papillomavirus (HPV) and Cervical Cancer. Study Limitations

The utility of the HBM as a full comprehensive model has never been examined with in the context of college-age men and HPV and cervical cancer. Previous studies have tested the HBM within the context of STIs to identify its predictive power of preventative sexual behavior in a college-age population (Petosa and Jackson, 1991; Zak-Place and Stern, 2004). Most recently Zak-Place and Stern (2004) did not find evidence to demonstrate the use of HBM in predicting college-age students’ sexual preventative behavior. The results of this study support the same conclusions in Zak-Place and Stern with the exception of two variables from the HBM; self-efficacy and perceived severity.
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The results of this study also show that while perceptions are important the most significant predictive factor in the HBM to intent to wear condoms with future sex partners is self-efficacy. The original intent of the HBM was to predict simple behavior and not lifestyle behaviors that require long-term changes (Glanz et al., 2002). Intent to wear condoms is a long-term behavior change and is something that sexually active college-age women must re-evaluate every time before a sexual encounter. Evidence shows that self-efficacy goes beyond predicting simple behavior and plays a central role in the prediction of initiation and maintenance of long-term healthy behavioral changes (Glanz et al., 2002). Health promotion campaigns designing interventions and/or curriculums on HPV preventative health behavior should create/enhance health educational experiences that augment college-age women’s efficacy to wear condoms.

Study Limitations
Findings of this study may not be generalized to populations outside of this University due to the small sample size of the priority population. This study utilized a self-administered survey. Only behavioral intentions were measured and there was no verification to see if the behaviors occurred. Furthermore, participants may have omitted certain questions and those that completed the whole questionnaire could have succumbed to social desirability or acquiescence. Since the questionnaire was handed out in a public setting participants may have had trouble dealing with issues of confidentiality and limited the truthfulness of their responses.

Participant’s might have had previous knowledge of HPV and cervical cancer because of conversations with partner(s), spouse, or family member that has had these HPV infection (or the men have/had HPV infection). It is also possible they could have learned about HPV and its links to cervical cancer in another setting and/or through mass media sources. Furthermore, HIV health promotion overshadows education of other STIs such as HPV (Yacobi et al., 1999) thus participants’ may have performed well on the knowledge scale or shown intent to perform HPV preventative sexual behavior because of their background knowledge of HIV (in the questionnaire it was mentioned that HPV is a sexually transmitted infection). In addition, the subjects utilized in this study were university students, which generally tend to be more knowledgeable and informed than the overall population. Nonetheless, this study demonstrates that there is a need for greater HPV prevention education. College age women rate their understanding of HPV as poor and many are unaware that there is a vaccine available. Promoting self-efficacy is important as those participants with greater self-efficacy also demonstrated greater intent to have their partner use a condom.

College Women’s Perception and Knowledge of Human Papillomavirus (HPV) and Cervical Cancer. Part 8

In this study, self-efficacy was found to be a predictive factor of intent to wear condoms with their male partner(s) during their next sexual encounter at both the univariate and multivariate level. Thus if women felt confident in putting on a condom on their male partner(s) they are more likely to intent to make their partners wear a condom for the sake of preventing HPV infection during their next sexual encounter. The multivariate model incorporated key constructs of the HBM (perceived severity, susceptibility, benefits, obstacles and self-efficacy participant ethnicity) that were regressed with women’s intent to request that their male partner’s wear condoms. Overall, these results show that perceptions of disease may not be as important as having the confidence (self-efficacy) of wearing condoms during sexual encounters. Similar to Zak-Place and White (2004), self-efficacy was found to be a significant predictor of intent to use condoms at the multivariate level yet within the context of HPV health threats (50% of participants in this study were female). Winer et al. (2006) found that women are less likely to contract HPV infection if their male partners wear a condom. Wearing condoms is primarily a male oriented decision thus increasing the self efficacy of women to put condoms on their male partner(s) could increase a women’s role in that decision and help reduce the infection rate of HPV in that community.

Previous studies have examined the perceptions and knowledge of sexually experienced compared to sexually inexperienced female participants (Ramirez et al., 1997) and others have looked women from a large range of ages (Pitts and Clarke, 2002) but none has examined the presence of a relationship with a significant other as a predictor of HPV preventative sexual behavior specifically in college-age women. Participants in this study were more likely to intend to wear a condom and reduce their number of future male partners, in order to prevent HPV infection, if they were in a relationship with a significant other. In addition, women with high perceived severity to HPV infection were more likely to request that their male partner(s) wear a condom during their next sexual encounter. Ingledue et al. (2004) found no relationship between perceived severity in relation to condom use. Lastly, women from the white/non-Hispanic and Asian/Pacific-Islander community were more likely to intend to request their male partner(s) wear condoms during their next sexual encounter. As mentioned earlier very few studies have examined women’s perception, knowledge and intent to perform HPV preventative sexual behavior in college-age women.

College Women’s Perception and Knowledge of Human Papillomavirus (HPV) and Cervical Cancer. Part 7

College-age women in this study did have high knowledge of important concepts of HPV infection and cervical cancer. Women scored over 80% on questions that had to do with transmission, infection and links to cervical cancer (items #3, #11, #12, and #13 on the knowledge scale). However, college-age women need more information regarding the symptoms and behavior of HPV infection since more than 43% thought that HPV causes herpes and 22% thought that genital warts are caused by the herpes virus. Also, it is imperative to teach women about the efficacy and availability of diagnostics tests to detect HPV infection since 38% believed that a negative test for HPV means that they do not have HPV.

The majority of participants (83.1%) perceived HPV infection to be severe. In Yacobi et al. (1999) and Ingledue et al. (2004) participants felt low perceived susceptibility to HPV infection. Similarly, in this study only 15.6% of the participants felt susceptible to HPV infection. However, a large majority of participants did not perceive obstacles and had high perceived benefits in reducing their number of sex partners for the sake of preventing HPV. Appropriate on campus health education efforts should create or modify interventions to place emphasis on effective ways to reduce the number of future sexual partners. Research shows that sex abstinence education is not effective in reducing the likelihood of a college students having sex so health educators will have to come up with other innovative ways to promote the reduction of sex partners. Only 20% of the participants felt self-efficacious to put a condom on their male partner(s). Despite of the existence of female condoms, male condoms are the standard use of protection among sexually active couples thus it is advantageous that women also know how to put on a condom on their male partners to help prevent HPV infection.

Condoms are a primary method of preventing STIs in sexually active individuals yet less than half of all college students report using condoms consistently (Zak-Place and Stern, 2004). Consistent with these results 49.5% did not use a condom and 50.5% did request the use of a condom form their male partners. Of 106 participants that answered the questions about condom wearing behavior 47.2% tend not to use condom and 52.8% tend to use a condom during their sexual encounters. Previous condom wearing behavior of women is indicative of their intent to wear condoms the next time they have sex; 41.2% intent to wear condoms the next time they have sex. Condom wearing behavior is important since only 57% of women intent to reduce their number of future sex partners to prevent HPV infection. More sexual encounters increase the likelihood of infection especially if the majority women do not intent to request their male partners to wear condoms to protect themselves. Thus, it is important for health promotion campaigns to be able to predict college age women’s intent to reduce future sex partners and their self-efficacy to put on a condom on their male partner(s) during the next sexual encounter in order to prevent HPV infection.

College Women’s Perception and Knowledge of Human Papillomavirus (HPV) and Cervical Cancer. Part 6

Each construct of the HBM was independently regressed with each of the two outcome variables of the study. Participants with greater self-efficacy were more likely to request that their partners wear condoms [OR=14.59, CI (5.44-39.14)] during their next sexual encounter to prevent HPV infection. Participants that were in relationships at the time of the study were more likely to intend to request that their partners wear condoms [OR=3.36, CI (1.16-9.70)] and reduce their number of sexual partners to prevent HPV infection [OR=.23, CI (.07-.68)]. Ethnicity and student living situation was not a predictor of HPV preventative sexual behavior. With all constructs of the HBM and ethnicity equal, participant’s self-efficacy to request proper condom use and perceived severity to HPV infection were protective factors in those that intend to wear condoms to prevent HPV infection (Table 4). In addition, being of Asian/Pacific Islander and White/Non-Hispanic decent were also seen as protective factors in those that intended to wear condoms to prevent HPV infection.
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Discussion
Most studies that have analyzed college-age women’s perceptions, attitudes and knowledge of HPV have been done with primarily White/non-Hispanic participants (Burk et al., 1996, Phillips et al., 2003; Ramirez et al., 1997; Yacobi et al., 1999). This study was representative of a multi-ethnic population typical of the ethnic representation at this University.

About 21.5% of the participants in this study had never heard of HPV prior to this study. Philips et al. (2003) and Yacobi et al. (1999) reported that 69.4% and 63% of their participants had never heard of HPV, respectively. Approximately 68.2% (n=148) of the participants scored above the 50th percentile and 31.8% scored below the 50th percentile. However, the mean knowledge score was 63.69% which suggests similar knowledge deficits reported among college-age women (Ramirez et al., 1997; Vail-Smith and White, 1992; Yacobi et al., 1999). Pitts and Clarke (2002) reported an overall low awareness of risk factors for cervical cancer, amongst those knowledgeable of HPV infection. These results suggest that despite the advent of vaccines to prevent HPV and the impact of cervical cancer deaths there has not been major advances in HPV awareness and education in women at the college level. This may be because HIV health education overshadows other STI education efforts including that of HPV (Yacobi et al., 1999). Comparatively, a larger percentage of women in this study have heard of HPV. Women reported hearing of HPV through a myriad of sources but overwhelmingly through TV and radio, newspapers, magazines and the internet. This is likely due to the strong media campaigns strongly advocating for the widespread availability of the newly developed drug named Gardasil (vaccine that prevents most types of HPV infection in women). Only 20.9% had heard about it through a health care provider and 5 participants (2.9%) had heard about HPV from a significant other/male partner. Outreaching to medical doctors should be a top priority and more emphasis should be place on training them to be key roles players in the informed decisions making process of college-women and preventative behaviors that decrease the likelihood of HPV infection. Having heard of HPV, however, also does not translate into higher perceived knowledge of HPV. In fact, 79.5% of women in this study rated their subjective knowledge of HPV as poor, and only 58% knew that a vaccine now exists to prevent HPV infection. HPV health promotion campaigns should do more to incorporate HPV vaccine education in STD and HPV educational interventions.

College Women’s Perception and Knowledge of Human Papillomavirus (HPV) and Cervical Cancer. Part 5

Of the 172 women, 61.6% stated that they were in a relationship with a significant other and 38.4% stated they were not. In the 105 participants that responded, 96.2% considered themselves to be in monogamous relationships. Over 60% (n=105) of the participants were sexually active at the time the questionnaire was administered. A total of 106 women stated that they were sexually active with men only. The rest either answered no or chose the option marked “not sexually active.” Thirty-three percent (33.1%) of the participants have not had a sexual encounter in the last 12 months, 49.4% had one sexual partner, 14.5% had two to three partners, 2.3% had 4-5 partners and .6% (1 participant) had more than 5 sexual partners. One-hundred eleven participants responded to the question that asked whether or not they asked they partner to wear a condom during their last sexual encounter (the rest marked that they were not sexually active): 49.5% did not use a condom and 50.5% did request the use of a condom. One hundred six participants answered the questions that asked about their condom wearing behavior and 47.2% tended not to use a condom and 52.8% used a condom during their sexual encounters.

Of the 172 participants, 21.5% had never heard of HPV. Seventy-eight percent (78.5%) had heard about HPV through various sources (each category is non-inclusive): 55.8% had heard about it through television/radio, 37.2% had heard about it through classes at the University, 29.1% percent had heard about through a family member, 20.9% had heard about it through a health care provider, 17.4% had heard about through newspapers/magazines, and 16.3% heard about it through the internet. Only five participants (2.9%) had heard about HPV from a significant other/male partner.

Of the 172 female participants, 79.5% felt that they had poor subjective knowledge of HPV and 20.5% rated their subjective knowledge as “good.” Most notably, 55% (n=160) knew that HPV causes genital warts, 91.4% (n=162) knew that HPV can cause cervical cancer, 58% (n=157) knew that there now exists a vaccine to prevent certain types of HPV infection, and 92.4% (n=158) knew that that they could still transmit HPV to their partners even if they do not have any symptoms. Approximately 68.2% (n=148) of the participants scored above the 50th percentile and 31.8% scored below the 50th percentile and overall participants had a mean score of 63.69%.

A majority of participants (83.1%) perceived that contracting HPV infection would be severe. Of the167 participants that answered the question about perceived susceptibility to HPV infection, 84.4% did not feel susceptible to HPV infection. In addition, 41.2% intended to use condoms the next time they have sex and 57% intend to reduce their number of sex partners to decrease their probability of contracting HPV infection.

College Women’s Perception and Knowledge of Human Papillomavirus (HPV) and Cervical Cancer. Part 5

Outcome and predictor variables were also examined via a 4 point Likert-type scale and dichotomized as in McPartland et al. (2005) for the purpose of data analysis. Unadjusted logistic regression analysis was performed to assess the relationship between all the variables aforementioned. Predictor variables with a p-value less than 0.20 were then included in an adjusted multivariate logistic regression model. This was performed to calculate the odds ratio (OR) with constructs significant at the univariate level, with all other variables equal. Furthermore, in a separate analysis the Health Belief Model and ethnicity were also examined via an adjusted logistic regression model in order to test the predictability of HBM as a model (not a combination of constructs).

It was anticipated that participants will have low levels of all predictor variables. The HBM was not expected to be a good predictor of the participant’s intent to change future sexual behavior. Participants with lower scores on independent variables were predicted to have lower intention to reduce number of sexual partners. Also, participants with lower scores on independent variables were predicted to have lower intention to use condoms the next time they have sex. Participants that were in a monogamous relationship were not expected to be more likely to intend to wear condoms the next time they have sex and to reduce their number of sexual partners in the future to prevent HPV infection. Ethnicity and living independently were expected to be confounding variables. Furthermore, those that have never heard of HPV before and those that have low subjective knowledge of HPV were not expected to intend to change their future sexual behavior. All appropriate statistical analyses were conducted with the Statistical Package for the Social Science (SPSS) software, version 14.0 (SPSS Inc., Chicago, IL).

Results
Of the 190 females in the HESC101 classes, a total of 186 questionnaires were collected. Four students were under the age of 18. Of the 186 collected, 172 were included in data analysis (participation rate 93%). Fourteen surveys were excluded because the survey was less than 50% complete. Of the 172 participants 50.6% were freshmen, 35.5% were sophomores, 9.9% were juniors, and 4.1 were seniors. Ninety-seven percent (97%) were full time and 2.9% were part time students. The ethnic distribution of the participants included 4.1 % Black/African Americans, 13.4% Asian/Pacific Islander, 42.4% Latino/Hispanics 30.2% White and 7.6% other. This was similar to the ethnic distribution of the University. Seventy-six percent of the participants live independently without the presence of parent/guardians.

College Women’s Perception and Knowledge of Human Papillomavirus (HPV) and Cervical Cancer. Part 4

Procedures
There were a total of 10 personal health classes (with seven different instructors) offered during the Spring Semester 2007. Ten sections of the personal health course were given “live” at the campus and two were offered as “on-line” web based courses. A letter and e-mail were sent to personal health instructors requesting class time to distribute the questionnaires during the last ten minutes of a pre-determined class lecture. No outreach was given to internet based classes because the collection of completed questionnaires from such participants would have compromised the anonymity of potential participants.

Permission was granted from the six of the seven professors to pass out the questionnaires in their classes. Questionnaires were collected from a total of nine personal health classes (one professor taught three classes, another one taught two classes). The questionnaires were passed out before the topic of sexually transmitted infections was presented in each class. All students in attendance were given the self-administered questionnaire to create an atmosphere of inclusion. This study does not include questionnaires filled out by male participants.

In each class the investigator first verbally notified the student of their rights as participants as stated by IRB protocol. The study investigator then described the necessary steps required to filling out the questionnaire without giving too much information regarding specifics of the study. After completing the survey, students were asked to place all completed, partially completed and incomplete questionnaires in a box located in the front of the room. This enabled the opportunity to ascertain the number of non-respondents. The study investigator left the room while the participants filled out their questionnaires. The box and the absence of the study investigator were actions that intended to increase the anonymity and comfortability of potential participants. All personal health professors were offered an HPV guest lecture in appreciation for allocating class time to aid this study. General knowledge HPV pamphlets (published by the Centers for Disease Control) were placed next to the questionnaire box for students to take at will.

Design and Analysis
The operationalization of the HBM was expected to provide a more holistic look at cognitive measures that affect women’s behavior in regards to HPV and cervical cancer. However, the HBM was not operationalized as one unit since research suggests that it is not effective at measuring perceptions and behavioral intent when tested as a collection of equally weighted variables operating simultaneously (Glanz et al., 2002). Each variable is independent of each other and some have been shown to be more predictive of behavior than others depending on the priority population and the behavioral intent being measured. Each HBM variable was operationalized (via a 4-point Likert scale) and assessed as predictor variables (Table 2). Two variables, intent to reduce number of sexual partners and intent of using a condom the next time were utilized as dependent (outcome) variables. This study measured intent to carry out two different HPV preventative sexual behaviors. Demographic variables were also analyzed for possible confounding affects including: participant’s ethnic background, number of sexual partners in the last 12 months, whether the participants were in a relationship and if they lived independently or dependent on a parent/guardian.