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International Benchmarking

International Benchmarking. Daniel Ray Director of Informatics University Hospitals Birmingham NHS Foundation Trust. Content. Who are we? - UHBFT Why do International Benchmarking? Evidence of International Benchmarking What is different in what we are doing? Barriers and challenges

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International Benchmarking

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  1. International Benchmarking Daniel Ray Director of Informatics University Hospitals Birmingham NHS Foundation Trust

  2. Content • Who are we? - UHBFT • Why do International Benchmarking? • Evidence of International Benchmarking • What is different in what we are doing? • Barriers and challenges • Comparability concerns: Coding definitions, staff and processes • Data analysis • Benchmarking tool • Conclusions

  3. UHB FT

  4. What we do • We treat 700,000 patients a year • Provide secondary care services for 450,000 • Regional, National and International services in cancer, burns, plastics, neurosciences, trauma, cardiac, liver and renal services (6m people) • c7,000 staff and annual budget of £620m / $1bn • Informatics for regulators and many NHS organisations

  5. What makes UHB different? • Host Royal Centre for Defence Medicine • National Research Centre for Surgical Reconstruction & Microbiology (trauma) • Largest organ transplant programme in Europe • Largest liver programme in world • Largest single critical care unit in Europe • Advanced clinical and patient support technologies • Leading edge Healthcare Informatics Capabilities • We Deliver!

  6. Why do International benchmarking? • GDP varies considerably on healthcare • Efficiency and clinical outcomes do not directly relate • Variation either due to cash input or process of care delivery • Healthcare Policy within countries will be the same which is the limiting factor when comparing one hospital to another within the same country.

  7. Why do International Benchmarking? • Understand Variation: • availability of resources • population demographics • policy • political and socio-economic climate • Information on Cost-Effectiveness is not available across countries. • International benchmarking enables lessons to be learned from best practice internationally. • The million dollar questions: Can we reduce healthcare costs by not compromising quality?

  8. Why now? • Economic climate and scarcity of resources. • International Data Maturity in developed countries • Healthcare costs have increased exponentially in the last decades and projections show a steep increase (pharmaceuticals, medical technology, population demographics). • Developed countries are facing new challenges in healthcare provision (older population, less resources). http://www.imf.org/external/np/seminars/eng/2011/paris/pdf/BClements.pdf

  9. Evidence of International Comparisons • An assessment study (Aisbett et al. 2004) concluded that for many countries (e.g. US, Australia, Sweden, England, Canada and Norway) it is possible to use standard hospital datasets to measure hospital performance. • Comparison of many different conditions • Looked at directly comparing disease groups to ensure they were comparable • Independent notes review in each country • Conclusion: it is possible to compare data between different countries. • However this was an isolated study not a robust routine flow of data.

  10. What is different in what we are doing? • Holistic patient level datasets • Analysis built up from patient level

  11. Summary of Data Analysis Approach • Stage 1: Accumulation of national / international data into one data warehouse. • Clinical data was shared between UHC, Roundtable and UHB. • The data is for X Hospitals in Australia, USA, New Zealand and England). • Stage 2: Ensuring the data from different health systems can be analysed in a comparable fashion. • UHB created a mapping algorithm that mapped England NHS data from ICD10 (International Classification of Diseases) and OPCS (Operating Procedure Classification System) across through to ICD9CM USA version. • For each disease group evaluated, the codes were verified by using coding guidelines standards. • Stage 3: Conduct preliminary analysis engaging relevant clinical and non-clinical professionals. • UHB carried out a descriptive analysis of the data with its clinicians and statisticians identifying the main differences in healthcare outcome for some of the main large disease groups including pneumonia, congestive heart failure, and acute myocardial infarction amongst others. • Stage 4: Identify true variation in outcome and remove the healthcare setting issues. • For example, considering mortality as an outcome of acute secondary care for comparison, if simply more patients are admitted to secondary care in one health system than another due to lower levels of community care availability then adjustment is required. • Stage 5: Identify causation in differences in outcome i.e. are different pathways types of diagnostics, treatments etc used in one health system compared to another? • Quantify these variations in proportions and activity and assess variation in outcome. Identify best practice and outcomes from both or multiple international health systems and classify these into higher cost interventions (procedure drug etc) and pathways of care. Take the best of both systems, implement and quantify differences in outcome of both quality and financial efficiency. • Stage 6: Write up case study identifying the process and benefits. This ultimately is the product.

  12. Coding Definitions • Coding Standards • USA, England, New Zealand and Australia use versions of ICD for coding diagnosis. • Procedures are also coded using ICD codes (exc. England) • It is possible to map between ICD-9 and ICD-10 (inc.ref). • US and Australia use modifications of the Standard ICD codes. • UHB coding team has undertaken a mapping exercise to translate operation and diagnostic codes into ICD-9 format. • The translation has been supervised by a specialist coding trainer and has been validated empirically.

  13. Coding Training • England: • Clinical Coders receive frequent training courses organised by the Coding Academies (national organisations set up by the government). • Coders participate in continuing education events (on-site coder training sessions, workshops and external training). • Medical terminology, anatomy, and physiology classes are offered. • USA • Training is offered through the AHIMA approved coding programs, AHIMA's Coding Basics, and the Computer-Assisted Training System-CATS for advanced coders. • Continuing education audio seminars, textbooks, and other offerings are also available through AHIMA. • AHIMA's accredited colleges and universities offer local coding continuing education programs.   • Commercially, companies market Web-based training products and coding seminars. • Australia • Australian coders participate in continuing education events. • Update workshops offered by the National Centre for Classification in Health (NCCH) • NCCH offers print-based materials and other supportive resources • The Department of Health often organises coding meetings and training sessions.

  14. Clinical Coding: Qualifications • England • National Clinical Coding Qualification (NCCQ), a standard qualification that assesses coding skills and knowledge. • Has become mandatory for most coding positions • For novice coders, Clinical Coding Academies offer introduction courses to help the coders get the NCCQ. • USA • American Health Information Management Association (AHIMA) offers coding certificates for entry, intermediate and advanced level. • Eligibility to sit for the AHIMA Coding Certificates is based on demonstrated knowledge and experience. • AHIMA offers a model coding curriculum approval program for certificate programs. • Healthcare organizations in the US indicate that an AHIMA coding credential is either desirable or required, for employment. • Australia • University qualifications in Health Information Management or Health Information Management Association of Australia (AHIMAA) training. • New Zealand • Distance learning course for AHIMAA. http://library.ahima.org/xpedio/groups/public/documents/ahima/bok3_005534.hcsp?dDocName=bok3_005534

  15. Coding Process: Audit • England • National external audit conducted yearly by the Audit Commission, an independent watchdog. • Individual hospitals carry out regular internal audits on clinical coding and the quality of the data. • USA • Healthcare organizations conduct routine coding compliance audits (internally by supervisory coding staff). • Quarterly or bi-annual coding compliance audits conducted through external contracts with compliance audit firms, as a safety check against potential fraud and abuse charges. • Coding accuracy rates across all hospitals for inpatient, outpatient, and Emergency Department coding are considered appropriate when within the range of 95-100 percent accuracy on periodic sampling reviews.   • Australia • External audits by Clinical Information Audit Program • Annual Audits for teaching hospitals and biannual for regional and metropolitan hospitals. • Regular internal audits by individual hospitals.

  16. Clinical Coding: Other resources • Clinical Engagement • In Englandand Australia clinical coders engage on regular basis with clinical staff. • Each hospital organises ad-hoc meetings for specific questions as well as regular forums for coders to meet with clinical staff. • In US, AHIMA has established a more formal approach for clinical engagement . • In the US there are dedicated physician advisors that act as an intermediate between clinical staff and coders and a Clinical Documentation Improvement programme has been set up for addressing query types between coders and physicians. • In US, coders use forums such as Local/Regional Coding Roundtables and Community of Practice to network and discuss coding issues. http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_047343.hcsp?dDocName=bok1_047343

  17. History – Data Analysis: UHB-UHC collaboration • Data for English and US hospitals was exchanged between UHC and UHB. • The data was for the time period between April and October 2010. • UHC shared 1,086,633 inpatient encounters for this time period from US honour hospitals. • UHB conducted qualitative and quantitative analysis using the data between the two counties and the findings where shared with UHC Exec team. • For this piece of work, specific diagnostic groups were compared (i.e. Pneumonia, AMI, Lung Cancer). • UHB liaised with clinicians to identify these diagnostic groups for which outcomes and healthcare pathways vary between countries.

  18. And another thing….. • Hospital coverage (public or private) • This means that hospitals have to treat everyone. • In other countries, where the healthcare system is not free, there is a need to evaluate the impact of patient selection. • Possible solution: Risk adjustment

  19. Population and health statistics • Highest Life Expectancy (at birth) in Australia and lowest in US. • Median age, highest in England. Lowest in US an New Zealand. • Total expenditure on health, as a percentage of the GDP, is lowest in Australia and highest in US (more than double compared Australia). • Number of physicians per 1,000 population is higher in Australia (4.6) and lowest in US (2.4). • Number of Nursing personnel is highest in New Zealand (10.1 per 1,000 population and lowest in Australia (9.6) http://apps.who.int/gho/data/view.main.710 http://www.globalhealthfacts.org/data/topic/map.aspx?ind=79&by=Location

  20. Data Analysis: Overall summary • Data shared between UHC, UHB and The Health Roundtable; 4 Australian hospitals, 1 New Zealand hospital, 3 English Hospitals and US hospitals. • Approximately 1.3 million Inpatient Encounters. • Day surgery encounters only available for England and Australia. • Hospital population is oldest in England (median 57 yrs) and youngest in US (median 49 yrs). Australia and New Zealand somewhere in the middle. • England has highest Average Length of Stay and US has lowest. • % Emergency Encounters(*) is highest in Australia and lowest in England (*) Includes Urgent, Trauma and Emergency Encounters

  21. Data Analysis: Overall summary • Discharge patterns very between countries, 90% of English patients are discharged home whereas in Australia 81% of patients are discharged home. • In Australia, 16% of patients are discharged/transferred to a another hospital or nursing care: • Of which 7.6% are discharged to a another general hospital, 2.8% to an inpatient rehabilitation facility, 2.8% to a psychiatric hospital or unit of a hospital. • Mortality rate in England is more than double that of Australia and New Zealand. • Average coding depth varies between countries (New Zealand 4.6, England 7.2, USA 9.3 Australia 5.0). • Average number of interventions recorded is highest in Australia (3.6) and lowest in England 2.0 (New Zealand 3.2, US 3.0) Note: Findings refer to Inpatient Encounters

  22. Causes of admissions by countries • “Diseases of the circulatory system” and “Injury and poisoning” are the most common causes of admissions for each country. • Proportion of admissions for cancer are similar between US and England (8.4%) and 6.8% for Australia and New Zealand.

  23. Data Analysis: Congestive Heart Failure • Admissions with a diagnosis of Congestive Heart Failure are derived by using the methodology specified by AHRQ(1). For English data, the codes are validated by using NHS coding guidelines. • In-hospital mortality rate is highest in England (16.3%) and lowest in US (3.0%). • Average length of stay is also highest in England (11 days) and lowest in US and New Zealand (7 days). • 90-day non elective readmission rates are higher in New Zealand (25%) and lower in Australia (21 %). The rate in England is 22%. (Not possible US) • However, patients in England are on average 12-years older than patients in US. (*) Includes Urgent, Trauma and Emergency Encounters 1. Congestive Heart Failure (CHF) Admission Rate http://www.qualityindicators.ahrq.gov/Downloads/Modules/PQI/V41/TechSpecs/PQI%2008%20CHF%20Admission%20Rate.pdf

  24. Data Analysis: Congestive Heart Failure • Discharge patterns vary between countries. In Australia and US, 18% of patients are transferred/discharged to another facility (nursing, general hospital, rehabilitation centre). • To evaluate whether mortality rates are affected by discharge patterns we looked at average LoS by discharge method. • Fig. shows that for patients who died, the average LoS between US and England are similar. • The high average Length of Stay for patients being transferred in England is related to organisational structure of services

  25. Data Analysis: Congestive Heart Failure • Proportion of patients receiving Cardiac Resynchronisation Therapy (CRT-D or CRT-P) is also higher in England (9%) whereas in Australia and New Zealand it is 4%. Still working with clinicians to identify which ICD9CM procedure code is used to code CRT in the US, ? Day surgery which isnt in the UHC datset • CRT treatment is recommended to patients with more severe CHF. • Guidelines for CRT-D and CRT-P are similar between US(1) and Europe(2) and there is no evidence of differences in implantation rates(3) • To account for differences in patients severity of CHF disease, adjusted in-hospital mortality rates between the countries was compared. • In hospital mortality rates remained higher in England even after adjusting for patient case-mix (fig below). • Adjustment was achieved by using a logistic regression model and using age, co-morbidities (Charlson score), method of admission, gender, ethnicity, and a flag for CRT procedures(*). 1.American Heart Association (2009).Practice Guidelines for Diagnosis and Management of Heart Failure in Adults 2.European Heart Journal (2012). ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. 3.https://nicor4.nicor.org.uk/CRM/device.nsf/65153b7e3756850e80256aff003a2c78/$FILE/CRM%20National%20Clinical%20Audit%20Report%202010.pdf

  26. Data Analysis: COPD • Admissions with a diagnosis of COPD are derived by using the methodology specified by AHRQ(1). For English data, the codes are validated by using NHS coding guidelines. • In-hospital mortality rate is highest in England (5.1%) and lowest in US (1.2%). • Average length of stay is also highest in England and Australia (8 days) and lowest in US (5 days). • Patients in England are on average 7-years older that patients in US, New Zealand and Australia. • Discharge patterns vary between countries; of the patients discharged alive only 5% of New Zealand patients are discharged home, 6% England, 14% in Australia and 15% in US. http://www.qualityindicators.ahrq.gov/Downloads/Modules/PQI/V41/TechSpecs/PQI%2005%20Chronic%20Obstructive%20Pulmonary%20Disease%20(COPD)%20Admission%20Rate.pdf

  27. Data Analysis: COPD • 90-day non elective readmission rates are higher in New Zealand (34%) and lower in Australia 27%. The rate in England is 30%. • After adjusting for patients case-mix (age, gender, co-morbidities, admission method and ethnicity), observed mortality remained highest in England. • The proportion of interventions also varies between countries. In New Zealand and US, the proportion of patients undergoing lobectomy or pneumonectomy is 7% and 5% respectively. The proportion of this procedures for England and Australia is less than 1%.

  28. Data Analysis: Pneumonia • Admissions with a diagnosis of Pneumonia are derived by using ICD-9-CM codes 480-486. For English data, the codes are validated by using NHS coding guidelines. • In-hospital mortality rate is highest in England (21.5%) and lowest in US (3.2%). • Average length of stay is also highest in England (11 days) and lowest in New Zealand (5 days). • Patients in England are on average 16-years older than patients in US. • Discharge patterns vary between countries; of the patients discharged alive, the percentage of patients discharged home is 82% in Australia, 88% in England 93% in New Zealand, 79% in US.

  29. Data Analysis: Pneumonia • 90-day non elective readmission rates are higher in New Zealand (16%) and lower in Australia 13%. The rate in England is 15%. • After adjusting for patients case-mix (age, gender, co-morbidities, admission method and ethnicity), observed mortality remained highest in England.

  30. Fracture of Neck of Femur (FNOF) • To identify admissions for FNOF, AHRQ guidelines were used(1). • The average age for these patients is higher in New Zealand and lower in US (difference of 9 years). • Average length of stay and mortality rates are higher in England. • Proportion of emergency admissions is lower in Australia (related to differences in definition). • Different discharge patterns between the countries proportion of patients discharged home (out of patients discharged alive) is 82% in Australia, 32% in England, 75% in New Zealand and 77% in US. 1.http://www.qualityindicators.ahrq.gov/Downloads/Modules/IQI/V41/TechSpecs/IQI%2019%20Hip%20Fracture%20Mortality.pdf

  31. Fracture of Neck of Femur (FNOF) • Non Elective Readmission rates are higher in England (10.1%) and lower in Australia (7.4%). • There is a difference in the type of interventions that patients admitted with FNOF receive in each country • In England, 43% of patients undergo hip arthroplasty procedures, 29% in Australia, 36%in New Zealand and 31% in US. • More patients receive fixations and reduction (open and closed) procedures in US (67%) and New Zealand (68%). In England and Australia the percentages are 40 and 57% respectively. • Even after adjusting for patient case-mix mortality rate for FNOF is higher in England compared to the other countries. • Adjustment was achieved by using a logistic regression model and using age, co-morbidities (Charlson score), method of admission, gender, and ethnicity. • After adjustments the standardised mortality rate in England is approximately twice that of other countries.

  32. Data Analysis: AMI Medical • Medical AMI admissions are derived as the number of admissions with a primary diagnose of AMI (admitting diagnose) for which patients did not undergo a CABG or PCI procedure. • Percentage of patients discharged home Australia 82%, England 81%, New Zealand 80% USA 85%. • In-hospital mortality rate is highest in England (11%) and lowest in Australia (6%). • Average length of stay in England is almost double that of other countries (9 days). • Average age in England is also higher than other countries. • Percentage of patients discharged home in Australia is 75%, England 81%, New Zealand 82% and US 73%.

  33. Data Analysis: AMI Medical • Non Elective Readmission rate in New Zealand is the highest (20%), 14% England and in 15% Australia. • After case-mix adjustments, mortality rates from England and New Zealand are higher than expected. Mortality rate for Australia is lower than expected.

  34. Prostate cancer:Treatments and Evidence of Effectiveness • Prostate cancer is the second most frequently diagnosed cancer and the sixth leading cause of cancer death among men worldwide1. • However, patients with clinically localized prostate cancer have a favourable long-term overall and cancer-specific rate of survival regardless of treatment choice (Prostatectomy or Radiotherapy). • Population based survival show that there are huge variation in survival rates between countries. Highest survival rates are reported in US and lowest in England and Australia. • However, higher survival rates in US are attributed to screening programmes and early detection (lead time bias?). • In England, national screening programmes for prostate cancer have not been adopted due to the lack of evidence of the cost effectiveness. Clinical trials have failed to show a benefit of screening programmes. • Prostate cancer can be treated surgically (prostatectomy) or radiotherapy. • Clinical trials have shown that there are also no long term differences in functional outcomes between the two types of intervention. • However there are differences in costs. The cost of prostatectomy (more than US$30 000) in US has been estimated to be significantly higher than radiotherapy (roughly US$17 000)3. • http://cebp.aacrjournals.org/content/19/8/1893.full.pdf+html • New England Journal (Jan 2013). Long-Term Functional Outcomes after Treatment for Localized Prostate Cancer • http://www.europeanurology.com/article/S0302-2838(11)00864-5/fulltext • http://jco.ascopubs.org/content/20/12/2869.full.pdf

  35. Data Analysis: Open Prostatectomy • To identify open prostatectomy procedures ICD-9-CM codes 603-605 and 6061, 6062, 6069 were used. • Clinicians suggested that TURP procedures should be excluded from the analysis due to the variation in guidelines for these procedures. • Also, open prostatectomy are more complex procedures and are mainly done for treatment of prostate cancer, making the comparisons between countries more alike. • Proportion on patients admitted with prostate cancer and undergoing an open prostatectomy in Australia is 42%, England 47%, New Zealand 56%, and USA 92%. • The high rate of surgical treatment for prostate cancer has been widely reviewed in the literature.(1) • The procedure remains quite popular in US, even though clinical trials have not shown long term benefits.(2) • Overall mortality rates for Prostate Cancer are lower in US but this has been attributed as a result of screening initiatives.(3) • Proportions discharged home is 100%, except New Zealand (99%). • http://jnci.oxfordjournals.org/content/99/13/1052.full • http://www.nejm.org/doi/full/10.1056/NEJMoa1209978 • http://cebp.aacrjournals.org/content/19/8/1893.full

  36. Data Analysis: CABG • To identify open CABG procedures ICD-9-CM codes 3610-3619 were used. • Mortality rate and average length of stay are higher in England. • Average age of patients is similar between the countries. • In England, less procedures are done in emergency settings, whereas in US, 1 in 2 procedures is recorded as emergency. • Proportion of patients discharged home is highest in England (94%) and lowest in US (77%). In Australia 86% and in New Zealand 90%/ • After adjusting for patients case-mix mortality rate in England was the highest. • 90-day non elective readmission rates are lowest in England (2%) and between 3-4% for Australia and New Zealand.

  37. Example International Comparison Outputs England NHS – USA health • Refer to paper.

  38. However some interventions compared between the two health systems have the opposite outcomes:

  39. Hip and Knee Replacement • No procedures of hip replacement available for New Zealand and Australia. • Proportion of patients undergoing hip replacement discharged home is 98% in England and 64% in US. • Proportion of patients undergoing knee replacement discharged home is 60% in Australia, 98% in England, 91% in New Zealand and 58% in US.

  40. HEDBenchmarking tool

  41. Why did we develop HED? • Good quality internal data • Poor quality, narrowly focused comparative data • Data integration • Superior Outputs • Continual Development • Alerting • Speed – Internet Accessed

  42. National / International Data Databases Local Data ONS Death Certificate International Data England (IP,OP,AE) National Returns Unified & relational system warehouse Tariff & Spend National Audits Cancer Registry Incidents Complaints Patient Experience E-Prescribing and PAS Workforce Theatres Labs Risk Assessment

  43. HED Overview • Nationally bench-marked indicators for all hospitals • Clinical Quality • Financial Opportunity • Operational Efficiency • Patient safety • High-level comparative reporting against peers • Consists of Business Intelligence Modules • Drill throughs • Maps

  44. How HED can be used (Inter-Hospital, Regional, National and International) • Use made by Hospitals • Internal quality and efficiency monitoring • Comparison to neighbouring or peer trusts • Market share evaluation • Use made by MoH/Regulators • Identify potentially failing organisations for attention • Understand relative efficiency • Use made by other organisations (eg Consultancy) • Viability assessments

  45. Quality framework Quantitative Qualitative Board level balanced scorecard Example metrics dummy data Example Quality dashboard Your strategic goals Speciality metrics Clinical and non clinical Sub-Speciality metrics/ CCG/ HRG Patient level information

  46. UCLHFT Walsall 3 Year Survival by Trust best and worst Oesophageal Cancerstandardised

  47. 3 Year Survival by Trust allOesophageal Cancerstandardised

  48. Live Demo But first…..

  49. Links and references Healthcare costs and projections in US and Europe, International Monetary Fund: http://www.imf.org/external/np/seminars/eng/2011/paris/pdf/BClements.pdf Clinical Coding Workforce Internationally: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok3_005534.hcsp?dDocName=bok3_005534 Clinical Improvement Programs in US: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_047343.hcsp?dDocName=bok1_047343 Life Expectancy, WHO: http://apps.who.int/gho/data/view.main.710 Population Statistics by Country: http://www.globalhealthfacts.org/data/topic/map.aspx?ind=79&by=Location OECD Health Care Quality Indicator (HCQI): Health Working Papers No. 22 http://www.oecd-ilibrary.org/social-issues-migration-health/health-care-quality-indicators-project_481685177056 Description of Alternative Approaches to Measure and Place a Value on Hospital Products in Seven OECD Countries: http://www.oecd-ilibrary.org/social-issues-migration-health/description-of-alternative-approaches-to-measure-and-place-a-value-on-hospital-products-in-seven-oecd-countries_5kgdt91bpq24-en Congestive Heart Failure (CHF) Admission Rate: http://www.qualityindicators.ahrq.gov/Downloads/Modules/PQI/V41/TechSpecs/PQI%2008%20CHF%20Admission%20Rate.pdf

  50. Links and references American Heart Association (2009). Practice Guidelines for Diagnosis and Management of Heart Failure in Adults. European Heart Journal (2012). ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. Cardiac Device Implantation in England: https://nicor4.nicor.org.uk/CRM/device.nsf/65153b7e3756850e80256aff003a2c78/$FILE/CRM%20National%20Clinical%20Audit%20Report%202010.pdf Chronic Obstructive Pulmonary Disease (COPD) Admission Rate http://www.qualityindicators.ahrq.gov/Downloads/Modules/PQI/V41/TechSpecs/PQI%2005%20Chronic%20Obstructive%20Pulmonary%20Disease%20(COPD)%20Admission%20Rate.pdf Hip Fracture Mortality Rate http://www.qualityindicators.ahrq.gov/Downloads/Modules/IQI/V41/TechSpecs/IQI%2019%20Hip%20Fracture%20Mortality.pdf Cancer Epidemiology, Global patterns: http://cebp.aacrjournals.org/content/19/8/1893.full.pdf+html Long-Term Functional Outcomes after Treatment for Localized Prostate Cancer New England Journal (Jan 2013). Low-dose-rate Brachytherapy, Radical Prostatectomy, or External-beam Radiation Therapy for Localised Prostate Carcinoma: The Growing Dilemma:http://www.europeanurology.com/article/S0302-2838(11)00864-5/fulltext Comparing the Costs of Radiation Therapy and Radical Prostatectomy for the Initial Treatment of Early-Stage Prostate Cancer http://jco.ascopubs.org/content/20/12/2869.full.pdf

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