Chronic Care Delivery
Call for Papers
Organizational Factors Associated with Successful Chronic
Care Delivery
Chair: Douglas Roblin, Ph.D.
Monday, June 7 • 8:30 a.m.-10:00 a.m.
• Measuring Gradations of Quality in Chronic Disease
Care
Stephen Davidson, Ph.D., Michael Shwartz, Ph.D., Randall
Stafford, M.D., Ph.D.
Presented by: Stephen Davidson, Ph.D., Professor, Policy and
Strategy, Boston University, School of Management, 595
Commonwealth Avenue, Room 625, Boston, MA 02215; Tel:
617.353.7422; Fax: 617.353.5244; E-mail: sdavidso@bu.edu
Research Objective: While it is widely accepted that quality of
care in the U. S. is a problem, few studies exam the extent to
which the care received by Americans achieves a desired
standard of high quality.
Study Design: Five levels of health care quality (neglected,
suboptimal, basic, better, best) were constructed via evidencebased standards from the medical literature for asthma,
diabetes, and heart failure. Included patients had an ICD-9
diagnosis noted on at least two claims in each year from 1994
through 1997. Patients were categorized into one of the five
quality categories each year based on medical and pharmacy
claims. Analyses were performed to determine: 1) the
distribution of quality levels for each condition, 2) the stability
of individuals’ quality level over time, and 3) quality differences
between patients with indemnity and managed care plans.
Population Studied: Patients with asthma (N=5,840),
diabetes (11,505), or heart failure (2,885) residing in a
northeastern metropolitan area who had health insurance
from 1994-1997. All major private and Medicare carriers were
included. Medicaid data was unavailable.
Principal Findings: Chronic care provided was infrequently
categorized as best or better care, regardless of condition. For
diabetes, the largest group in all 4 years was the suboptimal
category, ranging from 59% in 1994 to 50% in 1997. Between
21% and 24% were in the basic category and 15% in the
neglected category. The proportion in either better or best
categories grew from 4% in 1994 to 10% in 1997. Similarly,
only small proportions of asthma and heart failure patients
were in the highest quality categories. For asthma, 5% of
patients were in best care for 1994 and 13% in 1997. For heart
failure, 9% were in better/best care in 1994 and 16% in 1997.
Patients were remarkably stable in their quality level over time.
Half of those in the neglected and basic categories in 1994
remained in the same category in 1995. Of those in better or
best categories in 1994, 2/3 were in the same category in 1995.
Large proportions in each category in 1994 remained in the
same category through 1997.
Compared to patients with indemnity coverage, managed care
patients had higher levels of quality. Better/best care for
diabetes in 1997 was noted in 68% of managed care patients,
but only 11% of indemnity patients.
Conclusions: It is feasible to create useful quality categories
that array chronic disease patients from poor to high quality.
Our assessment suggests that poor quality care is common,
while the best care is infrequent. Patterns of care are
remarkably stable over time and patients covered by indemnity
plans are much less likely to have high quality of care.
Implications for Policy, Delivery or Practice: Insurers and
providers may readily adapt this method as a tool to assess
health care quality and to target improvement efforts. The
poorer quality in indemnity plans suggests the potential for
cost sharing to have negative effects on chronic disease care
quality. Rather than merely avoiding poor quality of care,
achieving high quality care must become a priority.
Primary Funding Source: CWF
• Chronic Care Model (CCM) Implementation Emphases
Marjorie Pearson, Ph.D., MSHS, Shinyi Wu, Ph.D., Stephen
Shortell, Ph.D., Jill Marsteller, Ph.D., Peter Mendel, Ph.D.,
Emmett Keeler, Ph.D.
Presented by: Marjorie Pearson, Ph.D., MSHS, Social
Scientist, Health, RAND Corporation, 1700 Main Street, Box
2138, Santa Monica, CA 90407; Tel: 310.828.0703 Ext. 7566;
Fax: 310.451.7025; E-mail: mpearson@rand.org
Research Objective: The Chronic Care Model (CCM), a
quality improvement (QI) framework, encourages
organizations to focus their change efforts on numerous
components of their care systems. This study’s objective is to
examine if the organizations that do the best in implementing
CCM overall are distinguished in the components they
emphasize.
Study Design: An observational study of implementation data
collected by the RAND/Berkeley Improving Chronic Illness
Care Evaluation of chronic care collaboratives. Interview and
progress report data on the changes undertaken by
participating organizations during the collaborative were
coded according to a hierarchical typology of CCM
intervention strategies. This typology included 23 strategies
grouped under the 6 major CCM components: delivery
system redesign, self-management support, decision support,
information support, community linkage, and health system
support. Paralleling the typology, 23 CCM emphasis variables
were created (defined as the percentage of the organization’s
change activities devoted to that particular change strategy).
Predefined rating criteria, grounded in CCM literature,
collaborative learning materials, and facilitator input, were
used to rate the likelihood of impact of the organizations’
change activities in each CCM strategy area. These ratings
were used to create implementation depth variables, which
were summed to provide an overall implementation depth
variable for each organization. Pearson correlation and OLS
regression analyses were used to examine the relationship
between the organizations’ emphases on change strategies
and their implementation performance as defined by the
overall implementation depth rating. Site variation in
emphases was evaluated by one-sample t-tests for each of the
23 emphasis variables.
Population Studied: 42 healthcare organizations that
participated in one of four QI collaboratives (two national and
two regional) to improve congestive heart failure, diabetes,
depression, or asthma care.
Principal Findings: The organizations significantly varied in
emphasis on each CCM strategy (p<0.01). Only 4 of the 23
CCM emphasis variables, however, were significantly
correlated with the overall implementation depth ratings. The
organizations with greater depth of implementation included
an emphasis on organizing and engaging a practice team
(Pearson correlation coefficient 0.46, p < 0.01), involving
patients in collaborative decision-making (0.37, p <0.05), or
encouraging provider participation in the QI efforts (0.31, p <
0.05). However, sites that emphasized traditional patient
education (as distinct from patient activation and selfmanagement support) showed poorer implementation
performance (-.41, p <0.01). Our parsimonious regression
equation model shows that three variables – practice team,
collaborative decision-making, and patient education (negative
effect) – explained 43% of variance in the depth rating (model
significant at p <0 .001 level).
Conclusions: Of 23 change emphases, only 4 distinguished
the best CCM implementers (i.e., the organization whose
change activities were most likely to have impact, according to
CCM principles). These key emphases included organizing
and engaging practice teams, collaborative decision making
with patients, encouraging provider participation in QI efforts,
and de-emphasis on traditional patient education.
Implications for Policy, Delivery or Practice: To successfully
implement CCM, organizations should be encouraged to
emphasize practice teams, patient collaboration, and provider
participation in their QI strategies and to not over emphasize
traditional patient education. Collaborative facilitators and
organization leaders should consider if increased training and
resources are needed to support interventions in these areas.
Primary Funding Source: RWJF
• The Effect of Primary Health Care Orientation on Chronic
Illness Care Management
Julie Schmittdiel, M.A., Stephen Shortell, Ph.D., Thomas
Rundall, Ph.D.
Presented by: Julie Schmittdiel, M.A., Ph.D.
Candidate/Graduate Student Researcher, Health Services and
Policy Analysis, University of California, Berkeley, 1421 Tilia
Street, San Mateo, CA 94402; Tel: 650.572.9416; Fax:
650.572.2760; E-mail: jschmittdiel@yahoo.com
Research Objective: To determine whether there is a
relationship between greater levels of primary health care
orientation in physician organizations and organizations’
implementation of chronic illness care management.
Study Design: A cross-sectional telephone survey of 1,590
physician organizations throughout the U.S. conducted from
September 2000 to September 2001. The resulting response
rate was 70%.
Population Studied: 1,040 physician organizations with 20 or
more practicing physicians whose physicians treat at least one
of the following chronic illnesses: asthma, diabetes,
depression, or CHF.
Principal Findings: Of the eight measures of primary health
care orientation (severity of disease treated in primary care;
health promotion practice; health education practice; accepted
risk for hospitalization costs; required reporting to outside
organizations; rate of primary care practitioner turnover; use
of electronic medical record; use of electronic standardized
problem list), six are significantly related to physician
organization overall use of 11 measures of chronic care
management. This finding is valid after adjustment for
numerous control variables including age of organization, size
of organization, capital available, practice type, ownership, and
environment.
Conclusions: Organizations that emphasize the use of
primary health care, which emphasizes comprehensive health
services within primary care and a commitment to overall
patient health, appear to have greater use of chronic care
management practices.
Implications for Policy, Delivery or Practice: Policies that
help organizations to strengthen their commitment to primary
care may also help these organizations increase their use of
chronic care management. Recent research suggests that the
primary care setting is the ideal home for improved chronic
care delivery. This study gives empirical weight to this health
care approach, and gives policy makers and other stakeholders
a potential way to help close the “quality chasm” in chronic
illness care.
Primary Funding Source: RWJF
• A Meta-Analysis of Interventions to Improve Chronic
Illness Care
Alexander Tsai, M.A., Sally Morton, Ph.D., Emmett Keeler,
Ph.D.
Presented by: Alexander Tsai, M.A., Epidemiology and
Biostatistics, Case Western Reserve University, 2511 Overlook
Road, Suite 6, Cleveland Heights, OH 44106-2459; Tel:
216.321.5496; E-mail: act2@case.edu
Research Objective: The Chronic Care Model is a recently
developed framework aimed at improving chronic illness care.
While the Chronic Care Model in its entirety has not been
evaluated in controlled studies, there have been many trials of
interventions that have incorporated one or more elements.
We sought to use empirical data from the literature to address
two related research questions: 1) do interventions that
incorporate one or more elements of the Chronic Care Model
result in improved outcomes of interest for specific chronic
illnesses; and 2) are any elements essential or superfluous?
Study Design: To identify studies that incorporate one or
more elements of the Chronic Care Model, we reviewed
bibliographies of previously published systematic reviews and
meta-analyses relevant to this topic, searched the MEDLINE
database (1998-2003), and consulted with experts. Data were
extracted on study characteristics and intervention effects on
clinical outcomes, quality of life, and processes. Studies were
characterized by the elements of the chronic care model in
their intervention.
Population Studied: We identified randomized and nonrandomized controlled trials of interventions compared to a
control or usual care group for four conditions of interest:
asthma, congestive heart failure, depression, and diabetes.
Principal Findings: Of 1,345 abstracts screened, 112 studies
contributed data to the random-effects meta-analysis: 27
asthma studies, 21 congestive heart failure studies, 33
depression studies, and 31 diabetes studies. Interventions that
contained one or more elements of the chronic care model led
to a pooled effect size of –0.17 (95% CI, –0.24 to –0.11) on
clinical outcomes and 0.11 (95% CI, 0.02-0.21) on quality of
life, and a pooled relative risk of 1.19 (95% CI, 1.10-1.28) on key
processes. No single element was found to be essential or
superfluous for effectiveness. We detected evidence of
publication bias for studies of congestive heart failure (all
outcome measures) and asthma (clinical outcome measure).
Conclusions: Interventions that contain one or more
elements of the Chronic Care Model improve clinical
outcomes and processes -- and to a lesser extent, quality of life
-- for patients with chronic illnesses. The elements most
responsible for these benefits cannot be determined from
existing data.
Implications for Policy, Delivery or Practice: Interventions
that contain one or more elements of the Chronic Care Model
do improve outcomes and processes. An evaluation of three
Institute for Healthcare Improvement (IHI) Breakthrough
Series Collaboratives is currently underway to determine
whether or not the Chronic Care Model is an effective
intervention when implemented as a package.
Primary Funding Source: RWJF
• Sustainability and Spread of Chronic Illness Care
Improvement
Shin-Yi Wu, Ph.D., Marjorie Pearson, Ph.D., Emmett Keeler,
Ph.D., Stephen Shortell, Ph.D., Peter Mendel, Ph.D., Jill
Marsteller, Ph.D.
Presented by: Shin-Yi Wu, Ph.D., Associate Engineer, Health,
RAND Corporation, 1700 Main Street, Santa Monica, CA
90401; Tel: 310.3930411; Fax: 310.3934818; E-mail:
shinyi@rand.org
Research Objective: To assess the sustainability and spread
of Chronic Care Model (CCM) implementation efforts initiated
during quality improvement (QI) collaboratives and to
examine the relationships between CCM implementation
intensity and QI sustainability and spread.
Study Design: Observational study of data collected by the
RAND/Berkeley Improving Chronic Illness Care Evaluation
(ICICE). ICICE found that, during the collaboratives, the study
organizations implemented multiple change strategies
suggested by the CCM, a QI framework that encourages
change across six areas: delivery system redesign (DSR),
patient self-management support (SM), decision support
(DS), information support (IS), community linkages (CL), and
health system support (HSS). To examine if these change
activities were sustained and spread, we interviewed key
contact persons in each organization one year after the
collaborative and qualitatively coded the interview transcripts
to create variables for the post-collaborative status of their QI
activities (continued and expanded, maintained at
collaborative level only, or declined) and their reported
success at spread (any and type). We then used ordinal
regression models to examine whether successful QI
sustainability and spread were associated with the intensity
(quantity and depth) of the organizations’ CCM
implementation during the collaborative (overall and in
specific CCM areas), controlling for organization type (public
vs. nonpublic), disease focus, and the organization’s baseline
congruence with CCM (measured by Assessment of Chronic
Illness Care instrument).
Population Studied: 42 organizations participating in two
national and two regional collaboratives to improve care for
congestive heart failure, diabetes, depression, or asthma.
Principal Findings: The majority of the organizations (57%)
reported continuing and expanding their QI efforts after the
collaborative, while 25% maintained at their collaborative level
and 14% did not sustain their efforts. Seventy-nine percent
reported successfully spreading these changes: 42% within
their site, 30% to additional sites, and 27% to other chronic
conditions. The intensity of many of their change activities
during the collaborative was positively associated with both
sustainability and spread (p<.05). The best prediction models
for sustainability (judged by the highest Nagelkerke psudo Rsquare) were those that included the depth of CCM
implementation overall or the depth of changes to obtain HSS
(leadership support, provider participation, or coherent
system improvement), followed by depth in IS (patient registry
system, use of information for care management, or feedback
of performance data). The best prediction models for spread
included the quantity of changes to improve DS (guideline
institutionalization, provider education, or expert
consultation) or the quantity of changes overall.
Conclusions: One year later, large proportions of healthcare
organizations report sustaining and spreading the CCM
change efforts they initiated during a QI collaborative. The
intensity of the organization’s CCM implementation efforts
during the collaborative relates to successful sustainability and
spread. Efforts to acquire health system support and build
information support are particularly critical to sustaining QI
activities, while increased decision support capabilities can
facilitate successful spread.
Implications for Policy, Delivery or Practice: To maximize
continuation and spread of CCM changes, collaborative and
organizational leaders should encourage high intensity of
change efforts (in both quantity and depth) during the initial
collaborative period.
Primary Funding Source: RWJF
Call for Papers
Innovative Strategies to Integrate Patients into Chronic
Care Delivery
Chair: Michael Von Korff, Sc.D.
Monday, June 7 • 10:30 a.m.-12:00 p.m.
• Evidence-Based Checkup for Patient Education Web Sites
Suzanne Boren, M.H.A., E. Andrew Balas, M.D., Ph.D., Zaynab
Mustafa, B.A.
Presented by: Suzanne Boren, M.H.A., Associate Director,
Center for Health Care Quality, University of Missouri, 324
Clark Hall, Columbia, MO 65211; Tel: 573.882.1492; Fax:
573.884.0474; E-mail: BorenS@health.missouri.edu
Research Objective: To assist the development and selection
of better patient education web sites through identification of
essential issues to be covered by them based on the results of
pertinent randomized clinical trials.
Study Design: Checklist development: Systematic searches in
MEDLINE, HealthSTAR, and CINAHL were conducted for
patient education randomized controlled trials. Four eligibility
criteria were applied: (i) targeted clinical area, (ii) randomized
clinical trial, (iii) patient focused educational intervention
tested versus control, and (iv) measurement of the outcome
of care. Substantiated educational content items and achieved
improvements were abstracted into checklists. Web site
evaluation: Through extensive searches European and
American web sites were identified with the following eligibility
criteria: (i) academic health sciences center, (ii)
comprehensive patient information on the web, and (iii) focus
on a targeted clinical area. Provided web site information was
compared with the evidence-based checklists.
Population Studied: The targeted clinical areas of this study
included diabetes, asthma, and congestive heart failure.
Principal Findings: One hundred and seventy eligible patient
education trials were analyzed (11,760 patients in 88 diabetes
studies; 3,353 patients in 12 congestive heart failure studies;
10,857 patients in 70 asthma studies). Using the evidence
linking tested interventions to improved outcomes, there were
25 substantiated educational content items identified for
diabetes, 15 educational content items for congestive heart
failure, and 23 educational content items for asthma. The web
sites of 46 academic health science centers and referral sites
missed several essential content items. In diabetes, 59.7
percent of content items were missed; 44.8 percent of content
items were missed in congestive heart failure; and 65.5
percent of content items were missed in asthma.
Conclusions: With the rapidly accumulating results of clinical
trials, Internet-based patient education programs could be
redefined with evidence linking specific content items to better
outcomes. While many academic health centers offer valuable
information, there is a surprising lack of several critical items
in prestigious patient education web sites.
Implications for Policy, Delivery or Practice: Educating
patients and providers about good chronic care needs to be
based on scientifically sound evidence. Patient education
involves more than telling people what to do or giving them
instructional material to read. Packaging of educational
messages and alternative delivery techniques should be
analyzed in the future.
Primary Funding Source: , National Library of Medicine;
Information Society General Directorate of the European
Commission
• Evaluating Concordance to American Diabetes
Association Standards of Care for Type 2 Diabetes through
Group Visits in an Uninsured or Inadequately Insured
Patient Population
Dawn Clancy, M.D., Dennis Cope, M.D., Kathryn Marley
Magruder, Ph.D., Peng Huang, M.D., Tamara Wolfman, M.D.
Presented by: Dawn Clancy, M.D., Assistant Professor of
Medicine, Medical University of South Carolina, 1614
Regimental Lane, Johns Island, SC 29455; Tel: 843.953.8986;
Fax: 843.953.8980; E-mail: clancyd@musc.edu
Research Objective: To evaluate the effectiveness of a
managed care approach to health care delivery, group visits, in
the management of uninsured or inadequately insured
patients with type 2 diabetes.
Study Design: One hundred twenty patients with
uncontrolled type 2 diabetes were randomly assigned to
receive their care in group visits or usual care for 6 months.
After 6 months, concordance with 10 process-of-care
indicators recommended by the American Diabetes
Association (ADA) standards of care1 was evaluated through
chart abstraction. The 10 items evaluated were: up-to-date
HbA1c levels and lipid profiles, urine for microalbumin,
appropriate use of angiotensin converting enzyme inhibitor or
angiotensin receptor blockers, use of lipid lowering agents
where indicated, daily aspirin use, annual foot examinations,
annual referrals for retinal examinations, and immunizations
against streptococcal pneumoniae and influenza.
Population Studied: Uninsured and underinsured patients
with type 2 diabetes in an outpatient general medicine clinic
that serves predominantly disadvantaged African Americans.
Principal Findings: Patients who received care in group visits
showed statistically significant improvement in concordance
with these 10 process-of-care indicators (p<0.001). 76% of
the patients who received care in group visits had at least 9 of
these 10 items up to date as compared to 23% of control
patients; 86% of patients in group visits had at least 8 of the
10 indicators as compared to 47% of control patients.
Conclusions: Group visits proved more effective in promoting
concordance with ADA standards of care than usual care in
the treatment of uninsured or inadequately insured patients
with type 2 diabetes.
Implications for Policy, Delivery or Practice: Primary care
providers caring for patinets with type 2 diabetes may want to
consider using groups to provide education and care for
people with type 2 diabetes because it may be both more costefficient and effective than individual consultations.
Primary Funding Source: RWJF, Agency for Healthcare
Quality and Research
• Managing Old-Age Diabetes: The Effect of Health Club
Enrollment and Use on Medical Costs and Outcomes
among Older Adults
Kun (Sue) Gao, Ph.D. student, M.A., MAJ Marsha Patrick,
Ph.D., M.H.A., Matthew Maciejewski, Ph.D., James LoGerfo,
M.D., M.P.H.
Presented by: Kun (Sue) Gao, Ph.D. student, M.A., Research
Assistant, Department of Health Services, University of
Washington, 1959 N.E. Pacific Street, Seattle, WA 98195; Tel:
206.484.2620; E-mail: suekgao@u.washington.edu
Research Objective: The purpose of this study was to
examine the effect of health club enrollment and use on the
healthcare costs and outcomes in an older population with
diabetes.
Study Design: This nested retrospective cohort study used
healthcare utilization and cost data with a sample size of
3,183. Annualized total cost, inpatient cost, primary care cost
and prescription drug cost were compared using health club
enrollment status and actual health club weekly visits. The
generalized linear model with the gamma distribution and log
link was used for all cost analyses. Ordinary least-squares
regression was used to examine the effect of health club
enrollment and use on disease outcome as measured by the
HbA1c level. Age, sex, co-morbidity, duration of participation,
baseline costs and baseline physical measures were included
in all models to control for possible selection bias, and data
were weighted according to the length of enrollment.
Population Studied: From a larger cohort of all 6,583
Medicare+Choice enrollees at Group Health Cooperative of
Puget Sound who chose a free health club benefit (HCB) and
19,749 age and sex matched controls, we selected all 758
diabetics from the HCB group and the 2,425 diabetics from
the control group. HCB is a health club benefit that is used by
several major managed Medicare programs in the U.S.
Principal Findings: HCB enrollees and controls had
comparable chronic disease score (CDS) and baseline Hba1c
level. HCB enrollees scored higher in almost all baseline
medical costs. In the follow-up period HCB enrollees had
significantly higher primary care costs (ratio=1.17, p< .001) but
lower adjusted HbA1c levels than controls (7.42% vs. 7.57%,
p< .001). In terms of actual health club use, the low users who
averaged less than one visit per week showed the same
pattern as the total HCB enrollees, while the high users
averaging one or more weekly visits had significantly lower
adjusted total cost compared to both controls (ratio= 0.97, p<
.05) and the low users (ratio= 0.80, p< .01). The high users
and low users did not differ much in terms of HbA1c levels
(7.31% vs. 7.44% respectively), yet both were significantly
lower than controls (7.57%).
Conclusions: Enrollment in HCB alone did not result in
significant cost-savings, however, enrollees did perform better
in terms of disease outcomes. Moreover, enrollees who
averaged one or more health club visits per week had
significantly lower annual total healthcare costs.
Implications for Policy, Delivery or Practice: Cost saving
and better management of diabetes could be potentially
achieved by promoting more actual health club use on top of
the membership benefit. More behavioral experimental
studies are also needed to identify motivational factors that
would encourage diabetic older adults to engage in higher
levels of exercise.
Primary Funding Source: CDC
• Collaborative Care Needs and Preferences of Primary
Care Patients with Multimorbidity
Polly Noel, Ph.D., Michael Parchman, M.D., M.P.H., John
Williams, Jr., M.D., M.H.Sc., John Cornell, Ph.D., B. Chris
Frueh, Ph.D., Anne Larme, Ph.D., Lewis Kazis, Sc.D., Austin
Lee, Ph.D., Jacqueline Pugh, M.D.
Presented by: Polly Noel, Ph.D., Associate Director/Assistant
Professor, Medicine, VERDICT Center of Excellence/STVHCS
& UTHSCSA, 7400 Merton Minter Boulevard, San Antonio, TX
78229; Tel: 210.617.5110; Fax: 210.567.4423; E-mail:
pollyh@verdict.uthscsa.edu
Research Objective: To describe the health care experiences
of patients with multimorbidity and their collaborative care
needs and preferences.
Study Design: Combined qualitative/quantitative methods.
First, we conducted focus groups at 8 primary care clinics in 4
states. A general interview guide included open-ended
questions derived from the 4 collaborative care elements
proposed by Von Korff and colleagues to enhance the
management of chronic illness (identification of patientcentered problems, targeting & goal-setting, self-management
needs, and active sustained follow-up). Identified themes
were used to finalize a mailed survey to examine the difference
in collaborative care needs and preferences among 360
primary care patients with multimorbidity and 360 patients
with only 1 chronic illness.
Population Studied: Primary care patients with multiple
chronic illnesses served by the Veterans Health
Administration.
Principal Findings: Focus Group: Sixty patients with two or
more chronic illnesses participated. Patient-identified
problems included negative effects on physical and emotional
functioning, work/leisure, and relationships. Polypharmacy
was a major concern and affected patients’ lives in a number
of areas. Problematic interactions with providers and the
health care system were also mentioned, often in relation to
specialty care. These health care system “hassles” included
long waits for referrals, difficulty accessing nonscheduled
urgent care, poor continuity of care between primary and
subspecialty clinics, and juggling multiple appointments.
Patients were more likely to blame the system, as opposed to
individual providers, for these problems, but several patients
related incidents in which providers had overlooked or ignored
their concerns or provided conflicting advice. Most
participants, however, expressed overall satisfaction with their
care and their primary care providers. Many said they lacked
knowledge or skills needed to manage their chronic illnesses.
Patients were willing to use technology for monitoring or
educational purposes as long as it did not preclude human
contact. Patients were also very receptive to receiving care or
monitoring from nonphysician providers as long as they were
used to augment, not eliminate, a physician’s care. Survey:
422 surveys were returned. Patients with multimorbidity
reported significantly more health care hassles and problems
with polypharmacy, but greater satisfaction with their primary
care providers. Patients with multimorbidity were more likely
than patients with only a single chronic illness to have been
monitored between appointments, participated in health
education, or been seen by a nonphysician provider in the
prior 6 months, but the overwhelming majority did not receive
these services. Patients with multimorbidity were also more
likely to express a desire to learn a variety of self-care skills,
including strategies to manage their medications, improve
their ability to communicate with their providers, lose weight,
manage their pain, and improve their sexual relationships.
Conclusions: The needs and preferences of patients with
multimorbidity are consistent with the basic tenets of patientcentered, collaborative care. In spite of their general
satisfaction, patients with multimorbidity are more likely to
report health care system “hassles.” Educational support and
monitoring for these patients appears suboptimal.
Implications for Policy, Delivery or Practice: Multimorbidity
creates an enormous burden for these patients. Clinics that
organize and deliver services in accordance with a
collaborative care approach may best meet the needs of these
complex patients.
Primary Funding Source: VA
• Motivational Interviewing to Support Antiretroviral
Treatment Adherence
Angela Thrasher, M.P.H., Carol Golin, M.D., Jo Anne Earp,
Sc.D.
Presented by: Angela Thrasher, M.P.H., Doctoral Student,
Cecil G. Sheps Center for Health Services Research, University
of North Carolina at Chapel Hill, 725 Airport Road, CB# 7590,
Chapel Hill, NC 27599-7590; Tel: 919.824.4794; E-mail:
angela_thrasher@unc.edu
Research Objective: Although research explicitly linking
motivational interviewing (MI) -- a client-centered counseling
style shown to effectively improve the health behavior of
individuals -- to behavior change exists, few studies report on
MI’s quality or examine how quality influences effectiveness.
We studied the relationship between MI quality and adherence
to antiretroviral therapy (ART) in the context of the PACT
study, a randomized, controlled trial of an MI-based
intervention with 158 HIV-infected patients failing their current
regimen to an educational control.
Study Design: Among the first 48 people randomized to
receive the MI-based intervention, we evaluated the quality of
professionally-transcribed audiotaped MI sessions. The
Motivational Interviewing Skill Code (MISC), a standardized
MI coding scheme, globally assesses patient-counselor
interactions and counts specific recommended
communication behaviors of therapist and client. We used the
MISC to measure the proportion of interactions that achieved
a standardized quality level for 22 specific, counseling
behaviors and 6 global measures. We assessed ART
adherence using electronic bottle cap monitor and pill count
data at 4, 8, and 12 weeks follow-up. We then correlated ART
adherence and specific MI counseling behaviors.
Population Studied: HIV-positive patients who have failed
antiretroviral therapy and are attending a university-based
infectious-disease clinic.
Principal Findings: The sample (n=48) was predominantly
male (70%) and minority (90%), with an average age of 40
years and an average adherence level at exit of 85% (range: 5100%). On 4 of 5 behavioral indicators, the majority of MI
sessions achieved the targeted quality level: 67% achieved it
for global therapist rating; 88% for reflections to questions
ratio; 33% percent for using open-ended questions; 96%
percent for complex reflections; 100% for MI-consistent
statements. On a 7-point scale, interviewers were rated
highest on “genuineness” (5.3) and “warmth” (5.3), lowest on
“egalitarianism” (4.0). Interviewer behaviors significantly
associated with or trending towards an association with ART
adherence were: total number of facilitative comments (r=.42,
p=.026), total number of paraphrases (r=.35, p=.069), number
of open-ended questions asked (r=.34, p=.077), and ratio of
reflections given to questions asked (r=.32, p=.097).
Conclusions: High quality MI can be conducted within the
structure of a randomized, controlled trial. Moreover, MI
quality affect effectiveness. Further studies should concentrate
on teasing out the specific counseling behaviors most closely
associated with behavioral change.
Implications for Policy, Delivery or Practice: Program
fidelity is a key aspect of intervention success. Using the MISC
along with regular feedback to the interviewers is an effective
way of assessing and increasing MI program fidelity.
Primary Funding Source: Society for General Internal
Medicine
Call for Papers
Issues in Chronic Care Delivery & Quality
Chair: Sherrie Kaplan, Ph.D., M.P.H.
Tuesday, June 8 • 9:15 a.m.-10:45 a.m.
• Persistent High Out-of-Pocket Costs among Medicare
Beneficiaries
Wenke Hwang, Ph.D, Jennifer Wolff, Ph.D, Gerard Anderson,
Ph.D
Presented by: Wenke Hwang, Ph.D, Assistant Research
Scientist, Department of Health Policy and Management,
Johns Hopkins University, 624 North Broadway, Room 307,
Baltimore, MD 21205; Tel: 410.614.3199; Fax: 410.955.2301; Email: whwang@jhsph.edu
Research Objective: Medicare’s cost-sharing requirements
and benefit limits leave some beneficiaries with high out-ofpocket (OOP) costs in any given year. We explore the extent
to which high OOP costs tend to persist over time among
Medicare beneficiaries, and what types of health services are
primarily responsible for persistent high OOP costs.
Study Design: The Medicare Current Beneficiary Survey was
used to examine OOP costs for beneficiaries who were
continuously surveyed from 1997 through 1999. Out-ofpocket spending reflects cost-sharing for Medicare covered
services and direct medical spending for Medicare noncovered services. High out-of-pocket expense was defined as
the highest decile (top 10%) of out-of-pocket spending in any
given year. Beneficiaries were assigned to three categories: (1)
those with consistent high out-of-pocket expenditures over all
three years (“always high”), (2) those with one or two years of
high out-of-pocket expenditures (“intermittent high”), and (3)
those without high out-of-pocket expenditures in any year
(“never high”) OOP costs. Logistic regression was used to
examine baseline characteristics associated with being
categorized in the “always high” OOP group. Characteristics
that were considered include age, gender, race, supplemental
health insurance, place of residence (community versus
institution), and numbers of self-reported chronic conditions.
Population Studied: Institutional and community-dwelling
Medicare beneficiaries age 65 and older (N=3,052).
Principal Findings: Beneficiaries with “always high” OOP
costs were on average 91 years of age, predominantly female
(79%), white (95%), and incurred an average of $16,067
annually in direct medical spending, and another $1,292 in
health insurance premiums. Total personal health care costs
for individuals with “always high” OOP costs were four times
higher than beneficiaries with “intermittent high” OOP costs
($3,860), and more than 20 times higher than beneficiaries
with “never high” OOP experience ($735). For beneficiaries
with “always high” OOP costs, more than 85% of personal
spending was for institutional care compared to 33% for
beneficiaries with “intermittent high” OOP costs, and 3% for
the “never high” OOP group. Overall, Medicare contributed
51% of total health care costs for its beneficiaries, but its
contribution was less than 25% of total health care costs for
those with “always high” OOP costs.
After adjusting for age, gender, race, and insurance status,
beneficiaries residing in an institution were 20 times (OR =
23.33, 95% CI, 11.9 – 43.24) more likely to have “always high”
OOP costs than beneficiaries living in communities; and
beneficiaries with multiple chronic conditions were 2.7 times
(OR = 2.69, 95% CI 1.5-4.4) more likely to have “always high”
OOP costs compared to beneficiaries with no or only one
chronic condition.
Conclusions: Medicare beneficiaries who have multiple
chronic conditions or incur institutional long-term care were
much more likely to have persistent high OOP costs.
Implications for Policy, Delivery or Practice: These data
suggest that Medicare is unable to fulfill its intended role of
spreading risk to buffer individuals from financially
devastating consequences related to health care need. As
increasing number of beneficiaries grow older, Medicare
needs a substantial reform in its benefit design in the areas of
chronic and long-term care.
Primary Funding Source: RWJF
• Measuring Quality of Care in People with Arthritis
Sarah Sampsel, M.P.H., Catherine MacLean, M.D., Ph.D.,
Philip Renner, M.B.A., Russell Mardon, Ph.D.
Presented by: Sarah Sampsel, M.P.H., Senior Health Care
Analyst, Quality Measurement, National Committee for
Quality Assurance, 2000 L Street, NW, Suite 500,
Washington, DC 20036; Tel: 202.955.1716; Fax: 202.955.3599;
E-mail: sampsel@ncqa.org
Research Objective: Arthritis is one of the leading causes of
disability in the United States, yet no standard set of measures
currently exists to measure the quality of arthritis care and
bring effective care processes to the attention of health care
providers, hospitals and health plans. To develop new clinical
performance measures to assess care of patients with
arthritis.
Study Design: Observational study conducted in five health
plans. A clinical expert panel was convened to develop
measure specifications based on guidelines and evidence
supporting critical aspects of arthritis care. Four aspects of
care were assessed during the summer of 2004: DMARD
utilization for patients with rheumatoid arthritis; appropriate
gastrointestinal prophylaxis for patients utilizing NSAIDS;
comprehensive osteoarthritis care; and comprehensive
symptom assessment.
Population Studied: Five health plans participated in the
study by providing patient-level administrative and medical
record data. The enrollments of these plans ranged from
nearly 1 million to approximately 150,000. The plans included
network and staff models, and were located in several
geographic regions of the country. Plan products included
commercial, Medicare and Medicaid.
Principal Findings: We found that the implementation of
performance measures for key aspects of arthritis care is
challenged by the availability of administrative data. However,
we identified the potential for improvement in each of the four
areas studied. For the Initiation of DMARD Therapy for
Patients with Rheumatoid Arthritis, two of three health plans
showed performance higher than 51%; the range was 31 – 76
%, with a mean rate of 66.7%. Performance on the
prophylaxis against gastrointestinal bleeding among high-risk
patients treated with nonsteroidal anti-inflammatory drugs
measure ranged from 22.6% to 40.8% with a mean
performance rate of 35.9%. For the arthritis symptom
assessment measure, performance ranged from
approximately 50 - 90 % for the pain assessment (mean rate
of 79.6%) and 50 - 60% (mean rate of 62.0%) for functional
assessment. Finally, the comprehensive osteoarthritis
treatment measure which required reporting of three
components, had the following mean rates by component:
recommendation for weight loss – 48.4%, recommendation
for physical activity/therapeutic exercise – 42.5%, and first line
acetaminophen use – 15.1%.
Conclusions: The key challenge to the feasibility of arthritis
performance measures is the lack of administrative data to
identify the eligible population. Administrative data capture
suffers as a result of under-coding and under-recognition of
arthritis. Developing measures that can be specified at the
provider or provider group level can facilitate quality
improvement in patient care, however, it is not known if such
efforts would also improve the appropriate diagnosis and
coding to improve data capture. This project has provided
meaningful and useful information to NCQA to pursue the
development of provider level measurement and promote use
in pay for performance modules.
Implications for Policy, Delivery or Practice: Consensus
around a single set of measures creates a powerful tool for
focusing on key components of arthritis care as a basis for
quality improvement and allows for a valid comparison of care
within and across health care settings. However, in the
absence of reliable and available administrative data, quality
improvement and performance measurement activities might
best be focused at the provider or provider group level.
Primary Funding Source: Corporate Grant - Pharmaceutical
Sponsor
• Adverse Maternal Outcomes among Asthmatic Women
Nancy MacMullen, Ph.D., APN/CCNS, Jay Shen, Ph.D., Jay
Shen, Ph.D., Catherine Tymkow, ND, APN, CWHNP
Presented by: Jay Shen, Ph.D., University Professor, Health
Administration, Governors State University, One University
Parkway, University Park, IL 60466; Tel: 708.534.3144; Fax:
708.534.8041; E-mail: j-shen@govst.edu
Research Objective: Limited research has been done on
adverse maternal outcomes of asthmatic women who are
more susceptible to poorer outcomes. This study examines
differences in adverse maternal outcomes between women
with asthma and women without asthma.
Study Design: Twelve adverse maternal outcome measures
examined were pre-term labor, hypertensive disorders of
pregnancy (3 measures), gestational diabetes, antepartum
hemorrhage (2 measures), membrane disorders (2
measures), cesarean section, postpartum hemorrhage and
pregnancy longer than 42 weeks. Maternal age, ethnicity,
health insurance status, the income level and comorbidities
were adjusted.
Population Studied: A total of 7,777 asthmatic patients
identified from 563,621 women aged from 13 to 55 who had a
delivery in 2001, abstracted from the National Inpatient
Sample. Of the women who delivered, 1.4 percent had
asthma. 31,108 (four times of 7,777) patients were randomly
selected from 541,719 non-asthmatic women as the
comparison group of the asthmatic patients.
Principal Findings: Compared to non-asthmatic women,
women with asthma had a higher risk of having preterm labor
(Odds Ratio (OR) [95% Confidence Interval, CI] 1.22 [1.06,
1.41]), pre-eclampsia (OR [CI], 1.50 [1.25, 1.81]), transient
hypertension of pregnancy (OR [CI], 1.34 [1.10, 1.63]),
pregnancy-induced hypertension (OR [CI], 1.45 [1.27, 1.66]),
gestational diabetes (OR [CI], 1.68 [1.47, 1.92]), placenta previa
(OR [CI], 1.52 [1.05, 2.21]), infection of the amniotic cavity (OR
[CI], 1.53 [1.27, 1.84]), cesarean section (OR [CI], 1.34 [1.26,
1.43]) and pregnancy term longer than 42 weeks (OR [CI], 1.15
[1.02. 1.30]). Women with asthma had a lower risk of having
abruption placenta (OR [CI], 0.07 [0.01, 0.66]), and had
comparable risk of having premature rupture of membrane
(OR [CI], 0.20 [0.03, 1.38] and postpartum hemorrhage ((OR
[CI], 0.19 [0.02, 1.83].
Conclusions: In comparing adverse maternal outcomes of
non-asthmatic women, asthmatic women had poorer
outcomes in nine of the 12 measures, better outcome in one
measure, and comparable outcomes in two measures.
Asthmatic women were clinically much more vulnerable to
having adverse maternal outcomes, especially pre-eclampsia,
pregnancy-induced hypertension, gestational diabetes,
placenta previa and infection of the amniotic cavity.
Implications for Policy, Delivery or Practice: Health care
providers should be aware of adverse pregnancy outcomes
resulting from etiological factors related to asthma.
Preventive interventions such as educational programs,
symptom and medication management, and avoidance of
environmental and stress related triggers will assist women to
co-manage their asthma during pregnancy.
Primary Funding Source: AHRQ
• Does Literacy Impact the Effectiveness of a Disease
Management Program in Congestive Heart Failure?
Brad Smith, Ph.D, Autumn Dawn Galbreath, M.D., Robert
Ellis, M.D., Emma Forkner, R.N., Richard Krasuski, M.D.,
Gregory Freeman, M.D.
Presented by: Brad Smith, Ph.D, Statistician, UTHSCSA
Disease Management Center/Altarum Institute, 4243 Piedras
Drive E., Suite 240, San Antonio, TX 78228; Tel: 210.567.9708;
Fax: 210.567.9712; E-mail: smithp5@uthscsa.edu
Research Objective: To investigate whether the effectiveness
of disease management in congestive heart failure (CHF)
patients is influenced by a patient’s literacy level, as measured
by educational attainment.
Existing studies of the efficacy of disease management (DM)
programs have largely been conducted on group-insured
populations that tend to be employed and have above average
levels of education. Consequently, we have little idea whether
such programs will be effective as they expand to more
diverse, and possibly less-well-educated, patient populations.
Study Design: For this study, primary outcomes included
mortality, time to first emergency department visit and New
York Heart Association (NYHA) functional class. Secondary
outcomes included daily sodium intake (in milligrams) and
patient confidence in self-management of symptoms (scale: 0100). The key independent variable examined was literacy for
which educational attainment (measured ordinally) served as
a proxy. Contingency tables and Mantel- Haenszel chi-squared
test statistics assessed whether the rate of improvement
across outcome variables differed across educational strata.
To determine whether the size of improvement varied by
educational attainment, one-way ANOVA was employed.
Logistic regression analysis assessed whether education had
effects on outcomes net of gender, age and type of heart
failure.
Population Studied: Data were collected through telephone
interviews, periodic clinic visits and a chart review conducted
among a sample of 646 patients enrolled in the DM arm of a
community-based study of CHF patients.
Principal Findings: Education strongly influences
improvement in sodium intake: 80% of patients who had
completed some college coursework or better showed a
decrease in daily sodium intake while only 69% of patients
with a high school degree or less reduced dietary sodium
intake (p=.003). Differences in the magnitude of improvement
in dietary habits were also apparent. The least-well-educated
patients reduced their sodium intake by 505 milligrams daily
while the patients with at least some college education
reduced their intake by 734 milligrams daily (p=.001). For
confidence in self-management of symptoms, approximately
52% of patients with at least a college degree reported feeling
more confident about managing their disease while 43% of
patients with a high school degree or less felt more confident
(p=.008). The difference in the magnitude of improvement
was modest: the less-well-educated group added 2.2 points on
the confidence scale compared to the 2.6 points added by the
better educated (p=ns). In multivariate analyses, education
was a statistically significant predictor of both decreased
sodium intake as well as improved self-confidence, net of
controls. No statistically significant relationships were
observed between education and primary study outcomes
including mortality, time to first emergency department visit,
rates of health care utilization and improvement in NYHA
functional class.
Conclusions: These results suggest that literacy, as measured
by educational attainment, has an important impact on the
secondary, but not primary, goals of a disease management
program for CHF patients.
Implications for Policy, Delivery or Practice: Those who
provide disease management services to the chronically ill
may be able to further improve important clinical and patient
satisfaction outcomes by paying special attention to literacy
levels, and education more generally.
Primary Funding Source: Direct federal appropriation
• Is Managed Care Superior to Traditional Fee-For-Service
among HIV-Infected Beneficiaries of Medi-Cal?
David Zingmond, M.D., Ph.D., Susan Ettner, Ph.D., William
Cunningham, M.D., M.P.H.
Presented by: David Zingmond, M.D., Ph.D., Visiting
Assistant Professor of Medicine, Division of General Internal
Medicine and Health Services Research, UCLA School of
Medicine, 911 Broxton Plaza, Los Angeles, CA 90095-1736; Tel:
310.794.0786; Fax: 310.794.0732; E-mail:
dzingmond@mednet.ucla.edu
Research Objective: Medicaid is the single largest payer for
healthcare services for HIV-infected Americans. Since the
1997 Balanced Budget Amendment, Medicaid has encouraged
the adoption of managed care approaches to control costs.
The adoption of managed care for HIV-infected Medicaid
enrollees has been controversial with primary concerns for
maintaining access to HIV specialists and initiation of
effective HIV treatments. Little is known regarding the relative
success or failure of such programs. California’s Medicaid
program (Medi-Cal) has instituted mandatory and optional
managed care enrollment on a county-by-county basis. The
goal of this study was to examine whether HMO enrollment
impacted use of antiretroviral therapy, hospitalizations, and
mortality among Medi-Cal beneficiaries.
Study Design: Retrospective longitudinal study of Medi-Cal
beneficiaries with HIV/AIDS. We used linked Medi-Cal
enrollment files, Medi-Cal claims, hospital discharge abstracts
from the Office of Statewide Health Planning and
Development, death records, and California AIDS Registry
records to perform patient level analysis of mortality, disease
progression (AIDS or death), hospitalization, and use of highly
active antiretroviral therapy (HAART) among HIV-infected
Medi-Cal enrollees. Multivariate probit analyses predicting the
impact of HMO-enrollment on outcome controlled for patient
demographics and disease characteristics. In order to
account for unmeasured severity, sensitivity analyses using a
treatment selection model (e.g. bivariate probit) based upon
county Medi-Cal enrollment policy were performed. Relative
risks were based upon model predictions with confidence
intervals estimated by bootstrap.
Population Studied: Medi-Cal beneficiaries with HIV/AIDS
enrolled in Medi-Cal as of January 1999 and with continuous
enrollment til January 2002 or death.
Principal Findings: A total of 22,761 HIV-infected patients
were enrolled continuously from January 1, 1999 til death or
the end of the observation period. Of these, 3,183 (14%) were
enrolled at study entry in a Medi-Cal HMO, and the remainder
in traditional FFS Medi-Cal. By county, 6.9% of enrollees
resided in counties with primarily mandatory HMO
enrollment, 85.3% were in counties with optional HMO
enrollment, and the remainder lived in rural counties without
HMOs. Enrolled patients were heterogeneous by gender
(70% male), race (43% white, 28% black, 19% Latino, 3%
Asian, and 8% other/unknown), age (8% < 30 years, 68%
between 30 and 49, and 24% 50 and older), and disease stage
(51% with confirmed AIDS). Among AIDS patients at
baseline, 54% were receiving HAART and 86% were receiving
some kind of antiretroviral therapy (19% and 44% respectively
for non-AIDS patients). By the end of 2001, 18% of AIDS
patients and 9% of non-AIDS patients had died. For both
groups of patients, HAART use at baseline was less likely for
HMO-enrolled patients (AIDS patients: relative risk (RR) 0.85,
95% confidence interval (CI) 0.79 to 0.92 and non-AIDS
patients: RR 0.77, 95% CI 0.67 to 0.91). HMO-enrollment did
not predict differences in three-year mortality or
hospitalization. Using treatment selection models, HMOenrollment was not associated with any differences in
medication use or outcomes for AIDS or non-AIDS patients.
Inclusion of patients with non-continuous enrollment does
not impact these results.
Conclusions: Managed care models for the care of Medicaid
enrollees infected with HIV have similar outcomes as
traditional Medicaid Fee-For-Service models in California
when a separate HIV drug benefit is provided. Other aspects
of care, including overall cost, patient satisfaction, and access
to outpatient specialty care should also be considered as
factors in deciding whether managed care models should be
adopted for the care of HIV-infected enrollees in Medicaid.
Implications for Policy, Delivery or Practice: The adoption
of managed care approaches for chronically ill Medicaid
populations can be as clinically effective as those in traditional
FFS Medicaid. Wholesale adoption of a managed care
approach should thus be based on alternative considerations,
such as cost, satisfaction, and longer term outcomes.
Primary Funding Source: UCLA Center for AIDS Research
Related Posters
Poster Session B
Tuesday, June 8 • 7:30 a.m.-8:45 a.m.
• Patient-Provider Communications Regarding Self-Care
Management During Medical Encounters: A Contextual
Assessment Framework
Nedal Arar, Ph.D., Juan Rosales, MA, Jackie Pugh, M.D.
Presented by: Nedal Arar, Ph.D., Ass. Professor, Medicine,
UTHSCSA, SA, TX 78229-3900; Tel: 210.567.0075; Fax:
210.567.4423; E-mail: ararn@uthscsa.edu
Research Objective: Self-care management (SCM) support is
an essential element for achieving high-quality chronic illness
care. Effective communication between providers and patients
remain at the center of health-care delivery. Our objectives are
to (1) describe the content and the process of patientphysician exchanges regarding SCM during outpatient primary
care encounters, (2) develop and test a tool to asses the
intensity of these exchanges, and (3) develop a framework that
considers the improvement of patient-provider
communications regarding SCM.
Study Design: Cross-sectional, observational study design.
Methods: 50 encounters involving six physicians at a Veterans
Health Care System in SA, TX. were videotaped, coded, and
analyzed for verbal content and process related to SCM.
Content analysis of these observations focused on patientphysician exchange regarding: awareness of symptoms
associated with a chronic illness and its complications,
monitoring activities (e.g. home glucose monitoring), use of
medications, management of emergencies, diet, exercise,
alcohol use, cigarette smoking, family support, and
management of illnesses’ psychosocial impact Data analysis
included both qualitative and quantitative approaches using
Atlas.ti and SPSS 9.0 software packages respectively.
Population Studied: Outpatient Veterans
Principal Findings: The average length of the encounter was
22.6 minutes, (range: 5-47, SD=8.9). The average number of
patient visits observed per physic was 8 (range: 3-12, SD=3.2).
The most common disease observed was diabetes (22, 44%),
followed by heart diseases (9, 18%), hypertension (8, 16%),
depression (6, 12%) and cancers (5, 10%). 35% (18) had one
disease, 14 (27%) two, 11 (22%) between 3 and 6 diseases.
We found that issues pertaining to different facets of self-care
management were discussed in every physician-patient
interaction. The total number of complete exchanges
regarding self-care management topics in all the 50
encounters was 484. The highest number of SCM exchanges
discussed was related to medication (195, 40.3%), followed by
disease symptoms (79, 16.3%), diet (58, 12%), exercise (47,
9.7%), monitoring activities (44, 9.1%), smoking (20,4.1%)
and family support (19, 3.9%). Community resources (30,
0.6%), management of emergencies (5, 1%) and drinking (8,
2.9%) were the least discussed issues. Using the Third Party
Assessment-Self-care Management (TPA-ScM) tool, we
measured the intensity of SCM communication between
patients and their physicians. Weighted kappa was calculated
using SAS (SAS Institute, Cary, NC) software, and it was
based on a four point ordinal scale: (0) indicated the evaluator
perceived that the item was not discussed (least desirable); (1)
indicated that item discussion was considered poor; (2)
indicated that item discussion was considered adequate; and
(3) indicated that item discussion was considered exceptional.
The overall Kappa for all subscales = 0.75. Patient-physician
exchanges regarding SCM were found to be barely adequate
(patients score= 1.9, physicians score=2).
We also present a new analytical framework: Contextual
Assessment Framework (CAF) that has informed the content
analysis presented herein. This framework allows for
comparing patients’ and physicians’ questions and responses
exchanged during the encounters concerning SCM. It views
the patients as being active in giving and receiving feedback
on their progress, and physicians as being instrumental in
helping patients within the context of patients’ experiences
with chronic illnesses.
Conclusions: In any given encounter, only a few aspects of
SCM were emphasized. Patient-physician exchanges regarding
SCM were barely adequate. The CAF contrasts patients’ and
providers’ concepts of illnesses, and considers the
improvement of communications within the dynamic process
of clinical interactions.
Implications for Policy, Delivery or Practice: Improving
SCM will enhance patients’ centeredness and foster a highquality chronic illness management. Further studies
evaluating the impact of patient-centered approach on
improving the care for chronically ill patients is justified.
Primary Funding Source: VA
• Are Clinical Measures of Quality Related to Consumer
Satisfaction and Reported Experience with Care? An
Analysis of Diabetic Medicare Beneficiaries in Medicare
Fee-for-Service
Shulamit Bernard, Ph.D., R.N., Erica Brody, M.P.H., Celia
Eicheldinger, M.S.
Presented by: Shulamit Bernard, Ph.D., R.N., Director,
Program on Health Care Quality and Outcomes, Health
Quality Program, RTI International, 3040 Cornwallis Road,
Research Triangle Park, NC 27709; Tel: 919.485.2790; Fax:
919.990.8454; E-mail: sbernard@rti.org
Research Objective: To examine whether consumer reports
and ratings of health care are correlated with clinical indicators
of quality.
Study Design: We used data from the 2000 National
Medicare Fee-for-Service (MFFS) CAHPS® survey, conducted
for the Centers for Medicare and Medicaid Services (CMS).
The sample of beneficiaries, drawn from a sampling frame
constructed from the CMS Enrollment Data Base (EDB)
resulted in 103,551 (64%) completed surveys. MFFS survey
data was merged with 1999-2001 Medicare claims data. This
analysis includes 16,532 diabetic beneficiaries identified by ICD
9 codes. Using ICD-9 and CPT codes, and data from the
twelve months preceding the survey response date, we
constructed 4 clinical indicators of quality including eye exam,
physiological test (including hemoglobin A1c, microalbumin,
and cholesterol), diabetic education and self blood glucose
monitoring, and disease progression. In addition, estimated
case-mix adjusted means for 5 CAHPSTM measures, were
constructed using the CAHPS Macro version 3.4. The casemix adjusted means were stratified by the clinical quality
indicators and two-sample tests for mean differences were
performed. Due to large sample sizes the Gaussian
distribution was assumed.
Population Studied: Diabetic beneficiaries enrolled in
Medicare fee-for-service during 2000.
Principal Findings: We found no differences in mean CAHPS
scores among beneficiaries experiencing disease progression.
Having a diabetes-related physiological exam (such as
Hemoglobin A1c) is associated with higher mean CAHPS
scores for the three composites estimated (Getting Care
Quickly, Good Communication, and Getting Needed Care) as
well as the two ratings estimated (Rate Plan and Rate Health
Care). Beneficiaries having an eye exam report higher mean
scores for the two ratings and the getting needed care
composite while the self care indicator is associated with
higher plan ratings but no other CAHPS measure.
Conclusions: Our findings suggest that overall, diabetic
beneficiaries receiving preventive services are more likely to
report higher levels of satisfaction and better experience with
the Medicare program. Diabetic beneficiaries experiencing
worsening of their disease do not differ in their reports of
satisfaction or experience suggesting that they do not attribute
disease progression to availability of services or the plan
performance.
Implications for Policy, Delivery or Practice: The findings
suggest that, among a chronically ill population, subjective
ratings and reports are correlated with quality of care as
demonstrated by process measures. Further, this analysis
suggests that ratings and reports are a direct result of the
quality of care received and may be used to monitor clinical
quality as well as satisfaction and experience with care.
Primary Funding Source: CMS
• Disease Management Success Stories: Chronic Disease
Management in Uninsured, Underserved and Rural
Populations.
Jane Nelson Bolin, Ph.D., J.D., R.N., Larry Gamm, Ph.D.,
Donna Zazworsky, R.N., M.S., Michael Reis, M.D., Paul
Shelton, Ph.D., Bita Kash, M.B.A.
Presented by: Jane Nelson Bolin, Ph.D., JD R.N., Assistant
Professor, Health Policy & Management, Texas A & M School
of Rural Public Health, 3000 Briarcrest Avenue, Suite 310,
Bryan, TX 77802; Tel: 979.862.4238; Fax: 979.862.8371; E-mail:
jbolin@srph.tamushsc.edu
Research Objective: To identify and examine outcomes of
chronic diabetes disease management efforts in uninsured,
underserved, and rural populations.
Study Design: Disease management outcomes data from
health plans offering Diabetes Disease Management in
Arizona, Texas and Illinois are examined. Statistical
comparisons and analyses are conducted to examine both
clinical and financial outcomes of diabetes disease
management members of the individual health plans. Key
dependent variables are (1)) Key laboratory tests acquired; (4)
Key exams performed; (5) Changes in costs for in-patient
charges, (6) Changes in total costs per-member per-year
(PMPY) and (7) Differences in outcomes across urban and
rural patient populations.
Population Studied: Adult participants of Diabetes Disease
Management programs in health plans in Arizona, Texas and
Illinois.
Principal Findings: In Arizona’s DM program for the
uninsured key clinical measures and exams were obtained
routinely, and a majority of the time, with improvement noted
in outcome measures for HgbA1c, LDL, urine proteins and
other key indicators. Health Plans in Texas and Illinois saw
significant improvement in both patient-level clinical
indicators as well as a reduction in patient costs. These health
plans serve underserved, uninsured and rural patients.
Conclusions: Diabetic disease management resulted in
improvement of key clinical and patient level indicators as well
as improved financial indicators such as in-patient costs and
overall per-member per-year costs.
Implications for Policy, Delivery or Practice: Managed care
plans, community health systems and private or public
insurers can cost-effectively support the treatment needs in
diabetic patients in underserved, uninsured and rural
populations.
Primary Funding Source: HRSA, Office of Rural Health Policy
• Use of Complementary and Alternative Medicine
Practitioners By People with Physical Disabilities:
Estimates from a National Survey
Matthew Carlson, Ph.D., Gloria Krahn, Ph.D., M.P.H., Phillip
Beatty, M.A.
Presented by: Matthew Carlson, Ph.D., Assistant Professor,
Sociology, Portland State University, P.O. Box 751, Portland,
OR 97207; Tel: 503.725.9554; Fax: 503.725.3957; E-mail:
carlsonm@pdx.edu
Research Objective: To estimate the prevalence and
determine symptoms and reasons for CAM practitioner use
among insured adults with physical disabilities.
Study Design: Panel survey data collected in 2000 and 2001.
Estmates are based on cross-sectional analysis of the 2001
survey and bivariate analyses of CAM practitioner use among
people with physical disabilities.
Population Studied: 830 persons with physical disabilities
obtained through a multi-modal sampling technique including
a random sample of members of disability organizations
(51%), a purposive sample recruited through disability
publications, websites, and provider practices, (40%), and a
snowball sample (9%).
Principal Findings: CAM practitioners were used by 19% of
the sample. CAM use was more prevalent among women
than men (24% vs. 10%), in the Western US (30%) compared
to the Midwest (20%) Northeast (14%), and South (10%) and
among prior users (62%) compared to non-users (8%).
Common symptoms treated were pain (80%), decreased
functioning (43%), and lack of energy (24%). Common
reasons for using CAM practitioners included lifestyle choice
(67%) and because they are more effective (44%).
Conclusions: People with physical disabilities are a
heterogeneous group who use CAM modalities at similar or
higher rates than the general population, for similar
symptoms, and for reasons similar to the general population.
Implications for Policy, Delivery or Practice: Results from
the current survey suggest that CAM treatments represent a
substantial proportion of the medical care obtained by
Americans with chronic health conditions and highlight the
need for more consistent regulation as well as integration with
traditional medicine.
Primary Funding Source: US Department of Education,
National Institute on Disability and Rehabilitation Research
• Comorbid Physical Conditions and Quality of Depression
Care Among Elderly Medicare Beneficiaries
Usha Sambamoorthi, Ph.D., Stephen Crystal, Ph.D., Wenhui
Wei, M.A., M.S., Mark Olfson, M.D., Stephen Crystal, Ph.D.
Presented by: Stephen Crystal, Ph.D., Research Professor,
Institute for Health, Health Care Policy, and Aging Research,
Rutgers University, 30 College Avenue, New Brunswick, NJ
08901; Tel: 732.932.8579; Fax: 732-932-8592; E-mail:
scrystal@ihhcpar.rutgers.edu
Research Objective: This study evaluates the relationship
between comorbid physical conditions and depression care
among elderly persons using eight years of a large, nationally
representative survey of Medicare beneficiaries.
Study Design: We used merged survey and Medicare claims
data from the Medicare Current Beneficiary Survey. The
elderly with diagnosed depression were identified on the basis
of ICD-9-CM codes recorded in health care claims.
Pharmacological treatment for depression was derived from
detailed self-reports of prescribed medication use and
psychotherapy for depression was identified from Medicare
claims.
Population Studied: Medicare beneficiaries aged 65 and over
living in the community, enrolled in fee-for-service Medicare
throughout the year.
Principal Findings: Rates of diagnosed depression were
positively associated with increasing levels of physical
comorbidity overall and for all examined subgroups. However,
among those diagnosed with depression, treatment for
depression was not related to level of physical comorbidity.
Conclusions: These findings call into question the concept
that concurrent general medical conditions tend to impede
the management of depressive disorders.
Implications for Policy, Delivery or Practice: Access to
specialty care treatment needs to be expanded for elderly with
concurrent physical illness and depression.
Primary Funding Source: NIMH
• Patient Adherence: Lessons from Five Decades of
Research
Robin DiMatteo, Ph.D.
Presented by: Robin DiMatteo, Ph.D., Professor, Psychology,
University of California, 900 University Avenue, Riverside, CA
92508; Tel: 909.787.5734; Fax: 909.787.3985; E-mail:
robin@ucr.edu
Research Objective: A major limiting factor in the success of
chronic care delivery involves the reluctance of patients to
accept and follow through with recommendations from their
physicians and other health professionals. The literature on
patient adherence is very extensive, and although only about
10 percent of the published papers on this topic are empirical
articles, there are over 1000 studies. Summarizing what we
currently know about the causes and consequences of
nonadherence requires an analysis of the entire adherence
literature, and the building of data-driven models from metaanalyses. Issues of measurement are critically important, as
well. Researchers and clinicians have devised various
strategies for assessing patient adherence, yet how these
methods relate to each other, whether they over- or underestimate adherence, and how various factors affect adherence
research results need to be examined.
Study Design: This paper presents a coherent, data-driven
model of the results of multiple meta-analyses of the entire
literature on predictors, outcomes, and measurement of
patient adherence to chronic disease regimens. Moderating
variables included definitions of adherence, specific regimens
and diseases of concern, and methods of adherence
measurement.
Population Studied: All empirical articles on adherence
published in peer-reviewed, English language journals from
1948 through 2002 were included. Studies examined
adherence to exercise, diet, medication, health related
behavior, screening, vaccination, and appointments
(prescribed by a nonpsychiatrist physician). Each article was
coded according to: recency, disease condition of patient
sample; illness severity and health status; type of adherence
measurement method; type of treatment or recommendation
requiring adherence; operational definition of adherence;
sample size; percentage of patients adhering for each method
of adherence assessment, and “r” (correlation) effect size
between methods of adherence assessment, as well as
between adherence and the following variables: physician
humanistic and communication skill, patient beliefs, anxiety,
depression, practical and emotional social support, family
cohesiveness, and family conflict, and the outcome of medical
treatment
Principal Findings: Adherence to treatment relates
significantly to treatment outcomes. Adherence is positively
predicted by physician humanism, and by patients’ efficacy
beliefs, family cohesiveness, and social support. Adherence is
negatively predicted by family conflict and patient depression.
Conclusions: The strong effects in this research suggest that
in the context of limited resources, patient adherence to
chronic disease regimens can best be achieved by improving
health professional-patient communication and by insuring
that patients believe in the necessity and efficacy of treatment,
and have adequate support for adherence. Screening for, and
reducing, patient depression and family conflict likely can
improve patient adherence.
Implications for Policy, Delivery or Practice: Estimates
suggest that nonadherence costs the US health care system
several hundred billion dollars per year. Interventions to
improve adherence should be targeted to factors that are
known, from quantitative reviews of adherence research, to
relate to adherence with strong effects sizes.
Primary Funding Source: AHRQ
• Use of COX-2 Nonsteroidal Anti-Inflammatory Drugs in
Ambulatory Care, 2000-2001
Sheila Franco, Alan Cohen, M.A., Amy Bernstein, Sc.D.
Presented by: Sheila Franco, Staff Fellow, National Center for
Health Statistics, 3311 Toledo Road, Hyattsville, MD 20782;
Tel: 301.458.4331; Fax: 301.458.4037; E-mail: sfranco@cdc.gov
Research Objective: Since 1999, a new class of nonsteroidal
anti-inflammatory drugs (NSAIDs) has been introduced, the
so-called COX-2 NSAIDs. COX-2 NSAIDs are similar in
efficacy to traditional NSAIDs but were believed to have a
lower incidence of gastrointestinal side effects than traditional
NSAIDs. COX-2 drugs are also among the most heavily
marketed and are generally more expensive than traditional
NSAIDs. This paper examines the use of COX-2 NSAIDs in
ambulatory care visits by age, sex, and selected diagnoses.
Study Design: Using data from the National Ambulatory
Medical Care Survey (NAMCS) and National Hospital
Ambulatory Medical Care Survey (NHAMCS) Hospital
Outpatient Department Component, visit records were
examined to determine NSAID and COX-2 NSAID visits. Visit
records include up to six prescription and non-prescription
drugs ordered or continued during the ambulatory care visit.
Bivariate analyses and multivariate logistic regressions were
used to determine the predictors of the use of a COX-2 NSAID
among NSAID visits.
Population Studied: Visits by persons age 18 and over to U.S.
office-based physicians’ practices (NAMCS) and hospital
outpatient departments (NHAMCS) are included. Data years
2000 and 2001 are combined.
Principal Findings: In 2000-01, COX-2 NSAIDs accounted for
45 percent of NSAID ambulatory care visits among adults 18
years and older, almost equaling the use of traditional
NSAIDs. The use of COX-2 NSAIDs increases with age. For
visits for those aged 18-44, 29% of NSAID visits were for COX2, compared with 46% for those aged 45-64, 58% for those 6574, and 62% for those 75 and older. Patients with rheumatoid
(RA) or osteoarthritis (OA) often take NSAIDs on a long-term
basis, and therefore may be more prone to gastrointestinal
side effects. COX-2 use was more prevalent among visits with
a recorded diagnosis of rheumatoid or osteoarthritis, with
61% of NSAID visits with an OR or RA diagnosis including a
COX-2, compared to 43% of those without such a diagnosis
recorded. Logistic regression controlled for the effects of age,
sex, race, and a diagnosis of rheumatoid or osteoarthritis. Age
and a diagnosis of rheumatoid or osteoarthritis remained
significant predictors in the multivariate analysis of having a
COX-2 NSAID prescribed during an NSAID visit. Men were
more likely than women to have a COX-2 prescribed, after
controlling for other factors. Race was not significant
predictors of COX-2 use.
Conclusions: Since the introduction of the first COX-2
NSAIDs, they have dominated the market. COX-2 NSAID use
increases as age increases and is more common for men and
for patients with a diagnosis of rheumatoid or osteoarthritis.
Implications for Policy, Delivery or Practice: COX-2 NSAIDs
were heralded when introduced because it was believed they
offered analgesic and anti-inflammatory relief with fewer
gastrointestinal side effects. While some NSAID users do
develop GI complications, it is a small proportion of all
patients. Further, as COX-2 drugs are more widely used, the
evidence of their lower incidence of side effects has been
mixed and controversial. It is unclear if the increased use of
COX-2 NSAIDs is warranted given their substantially higher
cost.
• Diabetes Care Management Participation in a Primary
Care Setting and Subsequent Hospitalization Risk
Anthony Greisinger, Ph.D., Rajesh Balkrishnan, Ph.D., Rahul
Shenolikar, M.S., Oscar Wehmanen, M.S., Shahid
Muhammad, M.D., P. Kay Champion, M.D.
Presented by: Anthony Greisinger, Ph.D., Vice President for
Research and Development, Kelsey Research Foundation,
7800 Fannin, Suite 209, Houston, TX 77054; Tel: 713.442.1214;
Fax: 713.442.1229; E-mail: ajgreisinger@kelsey-seybold.com
Research Objective: There exists scant evidence examining
the impact of participation in primary care diabetes
management programs and their educational components on
the risk of subsequent significant patient morbidity. This
study examined the association between participation in a
diabetes management program in a primary care setting, and
the risk of subsequent hospitalization.
Study Design: In this cohort study, information in the year
preceding the hospitalization was obtained on several
demographic, clinical, and diabetes care management
participation related variables. Multivariate logistic regressions
were used to examine the relationship between primary care
diabetes management participation, as well as individual
educational components on the likelihood of subsequent-year
hospitalization.
Population Studied: 10,980 patients with diabetes mellitus
receiving some type of treatment in a large primary care clinic
network in Houston, TX were examined for incidence of
hospitalization in the year 2002.
Principal Findings: Patients participating in some type of
primary care diabetes management were 16% less likely to
have an incidence of hospitalization (p=0.05). When individual
educational components of the diabetes care management
program were examined, diabetes education sessions were
more beneficial than certified diabetes educator visits in
reducing the incidence of hospitalization. Patients with
controlled blood glucose levels and a diabetes education
session seemed to have the most significant hospitalization
risk reduction (Odds ratio (OR) =0.62, 95% CI: 0.40, 0.95).
Conclusions: There seems to be beneficial effects associated
with participation in primary care diabetes management
programs in terms of reduced hospitalization risk.
Implications for Policy, Delivery or Practice: Attendance in
diabetes educational sessions in primary care settings coupled
with maintenance of blood glucose control seems to be
associated with greatest risk reduction.
Primary Funding Source: Kelsey Research Foundation
• A Qualitative Assessment of Best Practice
Implementation for Diabetes Management in Primary Care
Bryan Weiner, Ph.D., Christian Helfrich, M.P.H., Lucy Savitz,
Ph.D., M.B.A., Kathleen Swiger, M.S., M.P.H., Christian
Helfrich, M.P.H.
Presented by: Christian Helfrich, M.P.H., Doctoral candidate,
Health Policy and Administration, University of North Carolina
at Chapel Hill, CB #7411, Chapel Hill, NC 27599-7411; Tel:
919.968.6150; E-mail: helfrich@unc.edu
Research Objective: To examine how physician practices
adopt and implement strategies for Type 2 diabetes
management (DM). In particular, we explored how
organizational factors and strategy characteristics affect
adoption and implementation processes.
Study Design: Replicated, holistic case studies, using
qualitative interviews and quantitative surveys.
Population Studied: Six physician group practices
purposively sampled from a survey of 166 primary care
physicians affiliated with managed care organizations in the
state of North Carolina who provided care to ten or more
privately ensured diabetes patients in 2001.
Principal Findings: Two distinct phases were observed: 1)
adoption and 2) implementation. The adoption phase
included an "agenda setting" stage where parameters were
established for searching for and evaluating the DM strategy,
and a "matching" stage where the strategy was compared with
the organization's needs. The implementation phase included
a "redefining/restructuring" stage, where both the
organization and the strategy were mutually adapted and a
"routinizing" stage where the strategy ceased to have a
distinct identity and simply became part of the routine way
things were done.
All sites reported a routine forum for identifying problems,
opportunities, and strategies for improving diabetes care. In
some cases, a "performance gap" triggered the search for a
new strategy, and in all cases sites engaged in opportunistic
surveillance rather than routine, comprehensive scanning.
Sites did not vary in terms of the external sources of
information considered in the adoption of new DM strategies;
and all sites reported using their own practice experience to
“reality test” information gathered from external sources.
In all cases, the DM strategies underwent considerable
adaptation after they were adopted. Even “fixed” innovations,
such as an in-office HbA1c testing machine, were adapted as
physicians defined the appropriate frequency of testing and
optimal range of values for diabetes management.
Cases that succeeded in routinizing their DM strategy made
lasting changes to organizational policies and procedures
concerning factors such as appointment scheduling, office
workflow, and documentation. They did not require
institutional incentives or punitive measures.
Conclusions: A reasonably consistent innovation process was
observed across the six cases, which matches well with
organizational theory and previous empirical studies. While a
great deal of variation exists within the general process,
several specific factors emerged that may help other efforts
aimed at adopting and implementing innovative strategies in
primary care settings. Routine forums for identifying
problems, local tailoring, and ease of administration are
shared attributes of successful interventions. Further, an
innovation champion is essential for implementation of the
strategy.
Implications for Policy, Delivery or Practice: Understanding
the adoption and implementation process can help
researchers and policy makers identify key points for delivering
support to promote adoption and implementation of
evidence-based strategies.
Primary Funding Source: CDC
• Adherence to Clinical Guidelines for End Stage Renal
Disease Anemia Management: Implications for Cost and
Quality of Care
Denise Hynes, R.N., M.P.H., Ph.D., Kevin Stroupe, Ph.D.,
James Kaufman, M.D., Domenic Reda, Ph.D., Amy Peterman,
Ph.D., Margaret Browning, Ph.D.
Presented by: Denise Hynes, R.N., M.P.H., Ph.D., Senior
Health Scientist, Midwest Center for Health Services and
Policy Research, Edward Hines, Jr VA Hospital, P.O. Box 5000
(151V), Hines, IL 60141; Tel: 708.202.2413; Fax: 708.202.2415;
E-mail: hynes@research.hines.med.va.gov
Research Objective: Patients with end-stage renal disease
(ESRD) require chronic dialysis to replace lost kidney function,
using substantial healthcare resources. A costly component of
ESRD care is anemia management with erythropoietin (EPO).
National Kidney Foundation (NKF) clinical practice guidelines
recommend that EPO be administered subcutaneously (SC)
rather than intravenously (IV). Since reimbursement for EPO
differs for federal vs. private-sector dialysis centers we
hypothesize different use patterns by facility type. Using data
from a multi-site prospective observational study of patients
with ESRD, 1) we examined how well this guideline was
followed for hemodialysis patients in VA or private-sector
facilities; and 2) we determined implications of following this
recommendation for EPO dose, cost, and anemia
management.
Study Design: 1) We determined route of EPO administration
monthly over 6-12 months of patient follow-up and compared
the proportion of patients receiving SC versus IV
administration based on predominant route. 2) We compared
EPO dose for patients receiving predominantly SC EPO versus
IV, adjusting for baseline factors (age, race, comorbidities,
months on dialysis, baseline hemoglobin); we compared
average yearly EPO cost per patient for SC versus IV
administration, using the Medicare reimbursement rate of
$8/1000 units of EPO; we assessed anemia management by
comparing hemoglobin at closeout for patients receiving SC
EPO versus IV.
Population Studied: 332 ESRD patients receiving
hemodialysis enrolled in a study from 2001-2003.
Principal Findings: Of the 332 patients 183 received dialysis in
a VA facility and 149 in a private-sector facility. We found
greater adherence to the clinical guideline in VA facilities. SC
route of administration was used predominantly for 53% of
patients in VA facilities (97 patients) versus 16% in privatesector facilities (24 patients) (p < 0.001). Average weekly dose
was 35% lower for patients receiving SC EPO compared to IV,
adjusting for baseline clinical factors: 13,789 units for SC (95%
CI: 7,842 to 19,737) versus 21,064 for IV (95% CI: 15,660 to
26,467) (p < 0.01). Average weekly SC dose (adjusting for
clinical factors) did not differ between VA and private-sector
facilities (p = 0.91) nor did IV dose (p = 0.75). The average
yearly EPO cost per patient (adjusted for clinical factors) was
$3,027 lower for patients receiving SC EPO: $5,736 for SC
versus $8,763 for IV. Closeout hemoglobin was not different
between SC and IV groups: 11.85 gm/dL for both groups.
Conclusions: We found greater adherence to the NKF
guideline recommending SC use for administration of EPO
among patients treated at VA facilities compared to the private
sector. By following the guideline, we estimate that facilities
could use 35% lower doses at a savings of $3,027 per patient
annually without compromising anemia management.
However, overall adherence to this guideline is low.
Implications for Policy, Delivery or Practice: Given the high
costs of ESRD care, it is important to determine where costs
can be saved without compromising patient care. The NKF
recommendation for SC EPO was found to provide cost
savings without impacting anemia management. Future
research should investigate whether there are other clinical
outcomes associated with the use of SC administration of
EPO that might augment or offset these findings.
Primary Funding Source: VA
• Medication Related Factors Affecting Health Care
Outcomes and Costs in Patients with Psoriasis
Rajesh Balkrishnan, Ph.D., Amit Kulkarni, M.S., David
Richmond, M.S., Daniel Pearce, M.D., Steven Feldman, M.D.,
Ph.D.
Presented by: Amit Kulkarni, M.S., Doctoral Student and
Graduate Research Assistant, Management, Policy,and
Community Health, University of Texas School of Public
Health, 1200 Herman Pressler, Suite E-331, Houston, TX
77030; Tel: 713.500.9181; Fax: 713-500-9171; E-mail:
akulkarni@sph.uth.tmc.edu
Research Objective: Psoriasis is one of the most common
skin diseases. Owing to its non-life threatening nature,
psoriasis is not considered as serious as many other medical
conditions. However, the degree of morbidity faced by these
patients has been shown to be comparable to other major
chronic diseases. Approximately $1.6 to $3.2 billion is spent
annually in the United States for treatment of psoriasis, a large
portion of it on controller medications. Patients suffering
from psoriasis have low health status and a constant cost
associated with the treatment of psoriasis owing to its chronic
and recurring nature. This study examined the relationship
between factors related to medication use and associated
health status and costs associated with the treatment of
psoriasis in the United States.
Study Design: Cross sectional cohort study using the 2000
United States Medical Expenditure Panel Survey (MEPS)
Database. Estimates of health care service utilization and
costs, and demographic and clinical patient variables were
obtained from the database files. Self-reported health status in
the MEPS is measured using the EuroQoL (EQ-5D)
instrument.
Population Studied: Data for approximately 1.1 million
patients (weighted sample size) with psoriasis in the 2000
MEPS database was analyzed using multivariate weighted
analyses.
Principal Findings: Medications accounted for nearly 50% of
the psoriaisis-specific health care costs in patients. The
average number of annual psoriasis prescription refills was
3.8. 57.1% of patients were being treated with topical
corticosteroids, 27.5% with other medications, and 15.4% were
not receiving any pharmacological treatment. The multivariate
models examining predictors of health care costs and health
status (EQ-5D summary score) explained 61% and 50% of the
variance respectively. Among medication-related factors, use
of topical corticosteroid therapy was associated with a
decrease in psoriasis-specific health care costs (60% lower
costs among users compared to non users, p=0.036) and
better health status (29% improvement in EQ-5D summary
scores among users compared to non users, p=0.004). The
use of other medications was not associated with any
significant reduction in costs or improvements in health
status compared to patients receiving no pharmacological
treatment. Increased psoriasis prescription refill rates were
associated with an increase in psoriasis-specific health care
costs (p<0.001).
Conclusions: Use of controller medications such as topical
corticosteroids is the most important driver of reduced health
care costs and improved health status in patients with
psoriasis. Prescription costs are an important component of
total psoriasis-specific health care costs. There seems to be a
differential beneficial impact of topical corticosteroids
compared to other medications for treatment of psoriasis on
health care outcomes and costs.
Implications for Policy, Delivery or Practice: Controller
medication use is an important cornerstone of successful
psoriasis management. The availability of many inexpensive
topical corticosteroids should encourage payers and
physicians to encourage increased adoption of controller
medications in order to decrease patient costs, and improve
patient outcomes.
Primary Funding Source: The Center for Dermatology
Research is funded by a grant from Galderma Inc.
• Modifying the SF-36V Physical Functioning Scale For Use
with Persons with SCI
Stephen Luther, Ph.D., Debra Rosenberg, Ph.D., Jeffery
Kromrey, Ph.D., Gail Powell-Cope, Ph.D., AR.N.P, Audrey
Nelson, Ph.D, R.N., Patricia Quigley, Ph.D., R.N.
Presented by: Stephen Luther, Ph.D., Evaluation
Methodologist, Measurement & Evaluation Team, Veterans
Integrated Services Network 8, 11605 North nebraska Avenue,
(118M), Tampa, FL 33612; Tel: 727.580.7477; Fax: (813) 5583990; E-mail: steve.luther@med.va.gov
Research Objective: The purpose of this study was to modify
the SF-36V Physical Functioning (PF) Scale for use with Spinal
Cord Injured veterans.
Study Design:
The project consisted of two phases. In the first phase a focus
groups were conducted with veterans with SCI and their
caregivers to identify alternative wording for SF-36 PF items
that might be comparable to items that are worded
inappropriately (i.e. "Climbing one flight of steps") for persons
with SCI. The pool of alternative items was then included with
the original SF-36 items, measures of activities of daily living,
Information about level of injury, information about physical
functioning, and demographic information in a written
questionnaire. After pilot testing the questionnaire was
mailed to all persons with SCI who have the James A. Hailey
Veterans Medical Center as their medical provider (n=787).
Approximately 400 usable questionnaires were obtained
through this process. We employed Item Response Theory
strategies (as recommended by Ware) to compare the
psychometric properties of the original SF-36V items and the
new SCI sensitive items. The characteristic of the new items
across varying levels of function is also explored. Finally
convergent and divergent validity of the resultant scales are
described.
Population Studied:
A cross sectional survey of all veterans with SCI that receive
their care at the James A. Hailey Veterans Medical Center as
their medical home (n=787).
Principal Findings: Equivalent items employing wording
appropriate for persons with SCI were identified. A discussion
of modification to the scales to be appropriate for persons
with different levels of injury and function will be described.
Conclusions: A set of items with comparable psychometric
properties to those on the original PF scale but being more
appropriate for persons with SCI was identified.
Implications for Policy, Delivery or Practice: The SF-36V is
widely used by the Veterans Administration Healthcare
System monitor outcome of patient populations. A
appropriately worded and psychometrically sound version of
the SF-36V PF Scale will ensure that values for persons with
SCI will comparable to those of other patients.
Primary Funding Source: VA
• Success of Implementation and Maintenance of Quality
Improvement for Depression
Lisa Meredith, Ph.D., Peter Mendel, Ph.D., Marjorie Pearson,
Ph.D., Shin-Yi Wu, Ph.D., Emmett Keeler, Ph.D., Jurgun
Unutzer, M.D., M.P.H.
Presented by: Lisa Meredith, Ph.D., Senior Behavioral
Scientist, Health, RAND Corporation, 1700 Main Street, Santa
Monica, CA 90407-2138; Tel: 310.393.0411 Ext. 7365; Fax:
(310)451-7004; E-mail: seidel@rand.org
Research Objective: To describe the changes made and
examine factors associated with the success of
implementation, maintenance, and spread of practice-based
quality improvement (QI) efforts to put promising new
primary care practice models for depression into place locally.
Study Design: Cross-sectional analysis of qualitative data
coded from monthly progress reports completed throughout
QI implementation and telephone interviews conducted with
key team leaders 18 months following implementation.
Implementation success was evaluated using measures of
change activities, changes that teams rated a success,
maintenance of changes, and spread of changes. Other
variables evaluated were reported barriers and facilitators to
change, and organization and community characteristics.
Population Studied: We evaluated the QI process of 17 multidisciplinary QI teams (11 public community health centers and
6 private health care practices) participating in the Improving
Chronic Illness Care and Institute for Healthcare
Improvement's Breakthrough Series for depression in 2001.
Principal Findings: Implementation of change activities was
varied with some changes made by only 1 or 2 organizations
(planned visits, community linkages) while other changes
were made by all (proactive follow-up, patient education,
patient registry, and patient management information
systems). Organizations most commonly reported success
for changes to delivery and information system changes (59%
and 53%) and more sites sustained these changes over time
(59% and 94%). Organizational structure and leadership
support were the most common facilitators while staff
resistance, time, and information technology were the most
common barriers. Different strategies for success varied with
different sets of barriers
Conclusions: Despite the challenges associated with QI for
depression, we observed broad success across 17 different
multi-disciplinary teams.
Implications for Policy, Delivery or Practice: Detailed
findings about QI implementation such as these should be
helpful in guiding future efforts to improve chronic illness
care.
Primary Funding Source: RWJF
• How Often Do Patients with Chronic Illnesses Fail to
Receive Recommended Monitoring for Their Conditions?
James Reschovsky, Ph.D., Hoangmai Pham, M.D., M.P.H.
Presented by: Hoangmai Pham, M.D., M.P.H., Senior Health
Researcher, Center for Studying Health System Change, 600
Maryland Avenue, S.W., Suite 550, Washington, DC 20024;
Tel: 202.554.7571; Fax: 202-484-9258; E-mail:
mpham@hschange.org
Research Objective: To measure the extent that patients
diagnosed with common chronic conditions fail to receive
regular monitoring by a physician or other health professional
as recommended in prevailing clinical guidelines and to
assess factors associated with the receipt of regular
monitoring care.
Study Design: The study uses nationally representative survey
data from the Round 2 (1998-1999) Community Tracking
Study Household Survey. For a set of prevalent chronic
conditions, adult survey respondents were asked if they were
ever diagnosed with the condition. Diagnosed patients were
then asked if they saw a physician or other health professional
for that condition during the previous two years. We identify
chronic conditions for which regular monitoring (at least every
two years) is recommended by prevailing clinical guidelines.
The frequency of regular monitoring care is measured and
patient, insurance, and delivery system factors are assessed in
bivariate and multivariate analyses.
Population Studied: Adults ever diagnosed with
hypertension, hypercholesterolemia, or diabetes (n=15,592).
Principal Findings: A significant number of diagnosed
patients failed to receive regular care for their chronic
conditions over the preceding two years: 39% for
hypertension, 33% for hypercholesterolemia, and 15% for
diabetes. Multivariate factors associated with greater
monitoring generally are consistent across specific conditions:
diagnosis with multiple conditions, poorer self-reported health
status, greater age, African American race, self-reported risk
aversion, not being a smoker, being insured (especially by
Medicare), seeing the same provider at a usual source of care,
and having a physician as the regular provider. Patients’
educational level was only associated with receipt of
monitoring in bivariate analyses. Finally, patients who
reported their regular provider was good at explaining things
were more likely to get regular monitoring care.
Conclusions: Large proportions of diagnosed patients fail to
receive regular monitoring for chronic conditions, as
recommended by clinical guidelines. Patient characteristics
appear to be the most important factors, although continuity
of care and proper patient education by providers also are also
influential.
Implications for Policy, Delivery or Practice: Failure to
receive regular monitoring can potentially increase the
seriousness of chronic conditions, resulting in extra morbidity,
cost, and preventable hospitalization. We identify the types of
patients that are at greatest risk of not receiving regular followup care for chronic conditions. Providers should target these
patients with greater educational efforts. In addition,
administrative systems that permit the making of
appointments well into the future, systems to remind patients
to make appointments at times recommended by clinical
guidelines, and systems that remind patients to keep
appointments that have been made could all contribute to
greater compliance with guidelines for the treatment of
chronic conditions. These are likely to be key components for
successful disease management programs.
Primary Funding Source: RWJF
• Prescription Drug Benefit Dispensing Restrictions: A
Barrier to Managing Chronic Conditions and Costs?
Kathryn Phillips, Ph.D., Su-Ying Liang, Ph.D., Jennifer Haas,
M.D., Brian Alldredge, Pharm.D., Marilyn Stebbins, Pharm.D.
Presented by: Kathryn Phillips, Ph.D., Associate Professor of
Health Economics and Health Services Research, School of
Pharmacy & Institute for Health Policy Studies, University of
California San Francisco, 3333 California Street, Box 0613, San
Francisco, CA 94143; Tel: 415.502.8271; Fax: 415-502-0792; Email: kathryn@itsa.ucsf.edu
Research Objective: Chronic disease management is a major
issue for health care quality and costs. Adherence with longterm prescription drug regimens is central to disease
management. Although it is known that many health plans
limit prescriptions to a 30-day supply when filled at
community pharmacies, there is virtually no research on
dispensing patterns for these types of medications. The
objective of this research was to examine dispensing patterns
for five drug classes commonly prescribed for chronic
conditions.
Study Design: This study utilized data from the 1996 and
2000 Medical Expenditure Panel Survey. Drugs were chosen
based on following criteria: (a) typically used for chronic
conditions, (b) in most cases can be safely dispensed for
more than 30 days, (c) have consistent dosing patterns, and
(d) have variations by relevant populations: gender, age, and
how continuously taken. Five drug classes were examined:
anti-epileptic drugs (AED), beta -blockers (BB), hormone
replacement therapy (HRT), oral contraceptive pills (OCP),
and selective serotonin reuptake inhibitors (SSRI). Drug
names and quantity dispensed were reviewed and categorized
to indicate whether prescriptions were filled for <=30 days or >
30 days. We used chi-square tests to examine the
associations of insurance, use of mail order, and individual
characteristics with dispensing patterns.
Population Studied: The study population contained a
nationally representative sample with appropriate age and
gender groups for the drug classes analyzed (both genders
and all ages for AED and SSRI, ages 18+ for BB, female ages
50+ for HRT, female ages 18-35 for OCP).
Principal Findings: Almost three-quarters of prescriptions for
the drug classes examined were dispensed for 30 days or less
in both 1996 and 2000. Among the five drug classes, the
percentage of prescriptions dispensed for 30 days or less
varied widely from 66%-67% (BB and HRT) to 82%/84%/86%
(OCP, AED, SSRI) (p<.01). Individuals who were younger,
non-White, less educated, uninsured or publicly insured, or
with poorer access to care were more likely to obtain
prescriptions for <=30 days. Conversely, individuals with
Medicare coverage were more likely to obtain prescriptions for
>30 days. However, among privately insured individuals,
those with drug coverage were more likely to obtain
prescriptions for <=30 days than those without coverage. The
percentage of individuals who reported having ever used mail
order services, which is the most commonly used method to
obtain >30 day supplies, increased only slightly from 19962000 (from 8%-10%).
Conclusions: Almost three-quarters of prescriptions for five
commonly used drug classes for chronic conditions were
dispensed for <=30 days. Individuals who are more
disadvantaged were more likely to get prescriptions for <=30
days. Although there can be clinical and economic reasons to
dispense drugs for <30 days in selected instances, dispensing
> 30 day drug supplies is often more effective and less costly.
Implications for Policy, Delivery or Practice: Our results
suggest that dispensing restrictions are a potentially serious
challenge to more effective and less costly care. These results
have implications for debates over Medicare prescription drug
benefits, as benefit structure appears to influence whether
patients get <=30 day or > 30 day supplies. Further research is
needed to consider the influence of dispensing restrictions
and mail order prescription services on the costs and
outcomes of care.
Primary Funding Source: NCI, AHRQ
• Measuring the Quality of Care in Indian Health Diabetes
Education Programs
Yvette Roubideaux, M.D., M.P.H., Carolyn Noonan, M.S., Jack
Goldberg, Ph.D., Lorraine Prucha, M.P.H., Lorraine Valdez,
R..N., M.P.A., CDE, Kelly Acton, M.D., M.P.H.
Presented by: Yvette Roubideaux, M.D. M.P.H., Assistant
Professor, Mel and Enid Zuckerman Arizona College of Public
Health, University of Arizona, 500 N. Tucson Boulevard, #110,
Tucson, AZ 85716; Tel: 520.318.7280; Fax: (520) 318-7017; Email: yvetter@u.arizona.edu
Research Objective: The purpose of this study is to examine
the relationship between the level of diabetes education
program services and the quality of diabetes care.
Study Design: Cross-sectional study of the quality of diabetes
care among patients in the Indian Health Service. Diabetes
programs were invited to participate in the IHS Integrated
Diabetes Education and Care Recognition Program and rank
the level of comprehensiveness of their services into one of
three groups ranging from the lowest (developmental) to the
highest (integrated). The quality of care was determined
using the 2001 IHS Diabetes Care and Outcomes Audit, which
is a systematic random sample of medical records of 8274
patients with diabetes seen in the 86 participating programs.
The quality indicators included recommended yearly
examinations, education, and laboratory tests. Results were
compared among programs of differing comprehensiveness
of services.
Population Studied: American Indians/Alaska Natives
Principal Findings: In the 86 participating programs, the
mean age of patients with diabetes was 54.21 years and the
mean duration of diabetes was 8.26 years. The majority of
programs were classified at or below the developmental level
of program comprehensiveness and only 9 programs (10%)
were at the higher program levels (educational and
integrated). After adjustment for patient characteristics,
program factors and clustering of data within programs, more
comprehensive programs were associated with greater
completion rates of diet education, yearly cholesterol tests,
and a1c tests (p< 0.05). Other quality of care indicators such
as yearly foot and eye exams, routine laboratory tests and
immunizations showed better outcomes for the higher level
programs but these differences were not statistically
significant after adjustment for data clustering, patient and
program characteristics.
Conclusions: System-wide improvements in diabetes
education are associated with better diabetes care outcomes.
Implications for Policy, Delivery or Practice: This study
provided information for the Indian Health National Diabetes
Program and suggests that development of more
comprehensive diabetes education programs can improve
care and could reduce morbidity for patients with diabetes.
The results of this study could help inform the development of
diabetes education programs in minority and non-minority
populations.
Primary Funding Source: AHRQ
• Predictors of Risk Status of Managed Care Patients with
Chronic Conditions: Implications for Chronic Care
Disease-Management
Jayashri Sankaranarayanan, M.Pharm., Ph.D. Candidate, Holly
Mason, Ph.D.
Presented by: Jayashri Sankaranarayanan, M.Pharm., Ph.D.
Candidate, Graduate Research Assistant, Pharmacy Practice,
Purdue University, Heine Pharmacy Building, 575 Stadium
Mall Drive, West Lafayette, IN 47907-2091; Tel: 765.743.2423;
Fax: 765.494.7880; E-mail: jysan@purdue.edu
Research Objective: Patient-risk status prediction in chronic
conditions has implications for designing efficient and
effective self-management education programs and guiding
management-decisions. In the context of limited empirical
data, the objective was to study the association of patientreported demographic, clinical, psychosocial, health-behavior
and health-outcome factors with the risk-status of managedcare patients in chronic conditions. Particularly, association
between patient’s readiness to adopt self-management
behavior and patient risk-status was also studied, controlling
for clinical, health-behavior and health-outcome variables.
Study Design: Randomized cross-sectional mail survey.
Population Studied: Enrollees (n=4730) from a centralIndiana (U.S.A) based health plan were surveyed (JuneSeptember 2003). Inclusion criteria: Adult patients, 18 years
or older with at least one of four chronic conditions (asthma,
diabetes, high-cholesterol or hypertension) using ICD-9-CM
codes. Based on Andersen’s conceptual behavioral utilization
framework (1995,2002), measures of demographics (gender,
age, people per household, marital-status, employment-status,
and insurance-status, number of information-support sources,
income), clinical (disease-type, duration), psychosocial
(stress, coping, self-efficacy, goal-setting, patient readiness),
health-behavior (summated score of a 22-item selfmanagement behavior inventory) and health-outcomes [ShortForm 12 physical and mental health summary scores(PCS,
MCS), 1-item satisfaction with care] were examined for their
associations with patient risk-status. Patients with high
medical service use and medical care costs were defined as
“high-risk.” Patient readiness for each of four selfmanagement domains was derived from a patient-reported
transtheoretical model-based staging-algorithm. This was the
checked stage response (1=pre-contemplation,
2=contemplation, 3=preparation, 4=action or 5=maintenance)
for each of four 1-item self-management domains:
participation with doctor; general self-management; lifestylemanagement; and medical care. Stress, coping, self-efficacy,
and goal-setting were measured by summated-scale scores.
Principal Findings: Usable response rate: 12.9% [High-risk
(n=102), low-risk (n=507)]. Gender, age, people per
household, education, marital-status, employment-status,
insurance-status, income, patient readiness to adopt lifestylemanagement, total medical conditions, maximum duration of
the four conditions, stress, coping, self-efficacy, goal-setting,
and PCS were significant for patient risk-status [univariate
logistic-regressions, p=0.05]. Six variables were significant
predictors of low-risk patient-status [stepwise multiple logisticregression, p=0.05]: Increased number of persons per
household (OR=1.6, 95%CI=1.02-2.62) and health-status score
(PCS-OR=1.1, 95%CI=1.07-1.16), and being full-time employed
than retired (OR=4.5, 95%CI=1.36-14.73) increased odds of
being low-risk. Having multiple-provider insurance compared
to private insurance only (OR=0.1, 95%CI=0.04-0.38), having
low information-support sources (OR=0.7, 95%CI=0.59-0.90)
and being in precontemplation compared to maintenance
stage in terms of patient-readiness for participation with
doctor (OR=0.1, 95%CI=0.02-0.62) decreased odds of being
low-risk. Being in action compared to maintenance stage for
patient readiness to adopt lifestyle-management increased
odds of being low-risk (OR=2.6, 95%CI=1.37-5.09), controlling
for clinical variables (total medical conditions, maximum
duration of the four conditions), self-management behavior,
and health outcomes.
Conclusions: Demographic (people per household,
information-support sources), enabling (insurance,
employment), psychosocial (patient-readiness for
participation with doctor), and health-status outcome (PCS)
factors were important predictors of patient risk-status.
Patient readiness to adopt lifestyle-management was
significant for patient risk-status, controlling for clinical,
health-behavior and health-outcome measures.
Implications for Policy, Delivery or Practice: Other than
demographic and enabling factors, this study highlights the
implications for considering psychosocial (patient readiness)
factors in patient risk-stratification to aid health-providers in
appropriate targeted self-management education interventions
for optimal chronic disease-management.
Primary Funding Source: Purdue Research Foundation,
Purdue University
• An Evaluation of an Adult Asthma BTS Collaborative:
Process of Care and Outcomes
Matthias Schonlau, Ph.D., Rita Mangione-Smith, M.D., Mayde
Rosen, R.N., B.S.N., Kitty Chan, Ph.D., Shan Cretin, Ph.D.,
Emmett Keeler, Ph.D.
Presented by: Matthias Schonlau, Ph.D., Statistician,
Statistics, RAND, 1700 Main Street, Santa Monica, CA 90407;
E-mail: matt@rand.org
Research Objective: To examine whether a collaborative to
improve asthma care positively influences process and
outcomes of care in adult asthmatics.
Study Design: Post-intervention evaluation of 11 sites that
chose to participate in the evaluation of the Institute for
Healthcare Improvement Breakthrough Series (BTS)
Collaborative for asthma care. Control sites were identified for
four of these sites.
Population Studied: 185 adults with asthma with at least one
asthma related visit in the prior 12 months in one of
15 primary care clinics: 11 collaborative participants and 4
control clinics.
Principal Findings: Patients in the intervention group were
more likely than patients in the control group to monitor their
peak flow (57% vs 24%, p=0.04) and to have a written action
plan (43% vs 27%, p=0.047). Patients in the BTS collaborative
were significantly more likely to be satisfied with provider
communication (62% vs 39%, p=0.02).
Conclusions: The intervention improved some aspects of
process of care. Patients benefited through increased
satisfaction with communication. Follow-up of patients who
participated in the intervention may have been too brief to
detect significant improvement in the other health-related
outcomes examined.
Primary Funding Source: RWJF
• Medicare Beneficiaries with Alzheimer’s Disease: Access
to Mental Health Services
Chandrakala Ganesh, B.S. Pharmacy, Dennis Shea, Ph.D.
Presented by: Dennis Shea, Ph.D., Department Head and
Professor, Health Policy and Administration, The Pennsylvania
State University, 104C Henderson Building, State College, PA
16802; Tel: 814.863.5421; Fax: 814.863.2905; E-mail:
dgs4@psu.edu
Research Objective: The objectives of this research are: (1) to
describe patterns of psychotropic drug use, physical and
mental co-morbidities, mental health visits and prescription
drug coverage among Medicare beneficiaries with AD; (2) to
determine the factors responsible for differences in
psychotropic drug use and visits to mental health providers
among Medicare beneficiaries with AD.
Study Design: The research uses data from the 1999
Medicare Current Beneficiary Survey (MCBS). Odds ratios are
calculated using logistic regression. Two dependent variables
are prescription of donepezil and mental health visit by
Medicare beneficiaries. The independent variables include self
report or claims diagnosis of mental health conditions, comorbid physical health conditions, age, census, race and
gender.
Population Studied: The study sample includes community
based Medicare beneficiaries who reported AD in the survey
or claims records of the 1999 MCBS.
Principal Findings: Over 70% of beneficiaries with AD had
atleast one other chronic health condition (50% arthritis, 43%
hypertension, 38% heart disease & 11% depression). Less than
20% of beneficiaries visited a mental health specialist for
mental health care. Beneficiaries more likely to visit a mental
health specialist are white, over 75 years and live in the
Northern or Western census regions. Only 16% of
beneficiaries with AD are prescribed donepezil. The key
predictors of a prescription are age over 75 years, diagnosis of
mental illness, from the South census region South and being
African American.
Conclusions: A significant number of Medicare beneficiaries
with AD do not receive mental health services. They have
lower levels of treatment, especially the use of acetyl
cholinesterase inhibitors.
Implications for Policy, Delivery or Practice: There are 4
million Americans suffering from AD. Though AD can be
effectively managed with pharmacological and behavioral
therapy, there is an underutilization of mental health services
by Medicare beneficiaries with AD. Medicare policy should
emphasize appropriate diagnosis and treatment guidelines for
this vulnerable population.
Primary Funding Source: NIMH, Summer Training in Aging
ResearchTopics- Mental Health (START-MH) 2003
• Making the Business Case to Employers for
Cardiovascular Health Benefits: A Summary of the
Worksite Literature and Selected Case Studies
Karen Shore, Ph.D., Steven Garfinkel, Ph.D., Dyann Matson
Koffman, Dr.PH, Victoria Anwuri, M.P.H., Diane Orenstein,
Ph.D., Lori Agin, B.A.
Presented by: Karen Shore, Ph.D., Senior Research Scientist,
American Institutes for Research, 1791 Arastradero Road, Palo
Alto, CA 94304; Tel: 650.843.8121; Fax: 650-858-0458; E-mail:
kshore@air.org
Research Objective: CDC’s cardiovascular health (CVH)
program provides public health leadership to improve
cardiovascular health for all, and reduce the burden of and
eliminate disparities associated with heart disease and stroke.
In support of those goals, we developed a Cardiovascular
Health and Business Toolkit. State health department staff will
use the Toolkit to influence employers to purchase prevention
related benefits and services for their employees to prevent
heart disease and stroke. Through a literature review, expert
panel recommendations, and worksite case studies, we
identified interventions that improve health and reduce costs
associated with heart disease and stroke among employees.
Study Design: We conducted a literature review of worksite
efforts to reduce heart disease and stroke, specifically by
controlling high blood pressure and high blood cholesterol
risk factors. We also gathered extensive background
information on the programs of multiple companies from the
literature and from expert panel recommendations. Using a
list of criteria such as successful risk factor outcomes, we
selected six companies for detailed telephone case study
interviews. We gathered information on various aspects of the
organization, CVH program components, and efforts to
evaluate the CVH program.
Population Studied: The six case study organizations ranged
in size from 225 to over 1 million employees and had locations
throughout the U.S. Industries represented were direct
marketing/distribution, manufacturing (health care, clothing,
automotive), higher education, and poultry processing.
Principal Findings: The literature review suggested that for
those at risk for heart disease and stroke, 1) a minimal
screening and referral program offered at the worksite will
positively affect about 25% of those at-risk, 2) individual
follow-up counseling will significantly improve risk factor
outcomes, and 3) plant-wide environmental interventions
show a small positive effect on outcomes, but aren’t
comparable to individual follow-up counseling and education.
The case studies revealed a variety of promising practices
employers are currently implementing to reduce heart disease
and stroke. Programs ranged from general health promotion
programs (for the smaller employers) to CVH-specific
programs, and all were designed to reduce blood pressure
and/or cholesterol. Health program components included
HRAs, feedback, and follow up; newsletters; and interactive
websites. Specific approaches to address high risk employees
include disease management programs, telephone and inperson counseling, and vouchers to pay for physician office
visits.
Conclusions: Case study interviewees identified senior
management support and a culture supporting wellness and
CVH, as well as resourceful and committed program staff as
key organizational components of an effective program.
Consistent with the literature review, interviewees identified
HRAs and screenings, follow up counseling, plantwide/environmental changes (cafeteria foods, fitness centers),
plant-wide policy changes (non-smoking facilities), health
education information and classes, financial or other
incentives (gift cards, lower health insurance premiums),
efforts to reach populations “where they are”, and consistent
yet frequent communication with simple messages as key
program components.
Implications for Policy, Delivery or Practice: This study
identified interventions that had the most impact for
preventing heart disease and stroke, are cost-effective, and can
be implemented in all sizes and types of worksites.
Primary Funding Source: CDC
• Patient Satisfaction and Utilization of VA versus PrivateSector Healthcare Services by Veterans
Kevin Stroupe, Ph.D., Denise Hynes, Ph.D., Anita GiobbieHurder, M.S., Eugene Oddone, M.D., Morris Weinberger,
Ph.D., William Henderson, Ph.D.
Presented by: Kevin Stroupe, Ph.D., Research Scientist, ,
Midwest Center for Health Services and Policy Research, PO
Box 5000 (151H) 5th Avenue and Roosevelt Road, Bldg 1B260,
Hines, IL 60141; Tel: 708.202.3557; Fax: 708-202-2316; E-mail:
stroupe@research.hines.med.va.gov
Research Objective: Chronically ill patients who are not
satisfied with their care may change healthcare providers or
systems, which could disrupt continuity of care and impede
management of their conditions. In this study, we determined
the VA and private-sector healthcare utilization of veterans
with chronic conditions, and we tested the hypothesis that
veterans who were less satisfied with their care were more
likely to use private-sector services. Additionally, we examined
this hypothesis among a sub-group of veterans with greater
access to private-sector care: those who were Medicareeligible.
Study Design: Data came from a multi-center randomized
trial of increased access to primary care. We assessed patient
satisfaction along 11 dimensions prior to randomization, and
we determined VA and private-sector utilization over the
subsequent 6 months, using VA and Medicare administrative
data, private-sector billing data, and patient interviews. We
used multivariable logistic regression analyses to examine
whether baseline patient satisfaction was associated with
private-sector inpatient or outpatient use over the 6-month
period following baseline. Because the 11 satisfaction
subscales were correlated, we estimated separate regression
models for each satisfaction subscale. We conducted the
same analyses for the subgroup of Medicare-eligible veterans.
Population Studied: Patients hospitalized on the General
Medicine Service of 9 VA medical centers between 1992 and
1994 were eligible if they had a diagnosis of diabetes mellitus,
chronic obstructive pulmonary disease, and/or congestive
heart failure.
Principal Findings: Of the 1,375 study patients, 174 (13%)
used private-sector healthcare. Patients with private-sector
healthcare use were older and lived farther from a VA medical
center. Ninety-five percent of patients with private-sector use
continued to receive some VA healthcare. For 6 of the 11
satisfaction subscales, the odds of private-sector use
decreased as patient satisfaction increased, ranging from a
21% decrease (OR = 0.79; 95% CI: 0.63, 0.99) to a 32%
decrease (OR = 0.68; 95% CI: 0.53, 0.87) (p < 0.05). Findings
were even stronger among the sub-group of Medicare-eligible
veterans. For 8 of the 11 satisfaction subscales, the odds of
private-sector use decreased as satisfaction increased, ranging
from a 29% decrease (OR = 0.71; 95% CI: 0.53, 0.94) to a 39%
decrease (OR = 0.61; 95% CI: 0.40, 0.92) (p < 0.05). In
contrast, among Medicare-ineligible veterans, greater
satisfaction at baseline was associated with lower odds of
private-sector use for only 2 of the 11 satisfaction subscales (p
< 0.05)
Conclusions: Higher baseline satisfaction was associated
with less subsequent private-sector healthcare use. Moreover,
the association between patient satisfaction and private-sector
use was strongest among Medicare-eligible veterans.
Implications for Policy, Delivery or Practice: Patient
satisfaction was associated with private-sector, particularly
among Medicare-eligible veterans. While availability of
Medicare gives these veterans greater flexibility in response to
patient satisfaction, differences in VA and Medicare benefit
structures (such as the previous lack of a Medicare drug
benefit) might encourage dissatisfied veterans to continue
receiving some VA care. Indeed, 95% of private-sector users
continued receiving some care at the VA. This dual use of VA
and private-sector care may impede efforts to ensure
continuity of care for their chronic conditions. Thus,
improvements in patient satisfaction may lead to enhanced
continuity of care.
Primary Funding Source: VA
• VA and Medicare-Covered Private-Sector Healthcare Use
by Veterans with End Stage Renal Disease
Kevin Stroupe, Ph.D., Denise Hynes, Ph.D., Kristen Koelling,
M.S.
Presented by: Kevin Stroupe, Ph.D., Research Scientist,
Midwest Center for Health Services and Policy Research, PO
Box 5000 (151H) 5th Avenue and Roosevelt Road, Bldg 1B260,
Hines, IL 60141; Tel: 708.202.3557; Fax: 708-202-2316; E-mail:
stroupe@research.hines.med.va.gov
Research Objective: Veterans with end stage renal disease
(ESRD) need chronic dialysis to replace lost kidney function,
requiring substantial healthcare resources. Many VA users
also obtain private-sector healthcare. Such dual use may
enhance flexibility; however, it can potentially make
comprehensiveness and continuity difficult to achieve. Dual
use may be particularly prevalent among ESRD patients
because most become Medicare eligible after initiating
dialysis, regardless of age. To determine which ESRD patients
are most likely to have continuous rather than fragmented
care, we examined the financial, geographic, sociodemographic, and health status factors that predict exclusive
use of VA care. We hypothesized that patients with better
financial and geographic access to VA were more likely to use
VA exclusively.
Study Design: We submitted Social Security Numbers (SSNs)
of the 6.1 million VA users or eligible users in 1999 to the US
Renal Data System (USRDS), a national repository for
Medicare and other information for ESRD patients. USRDS
identified all ESRD veterans and provided their Medicare
claims and demographic data, which we linked with VA
administrative data. We obtained local healthcare market
factors from the Area Resource File. We performed
multivariable logistic regression analyses with regional fixed
effects to examine the effect of financial (e.g., whether patients
were subject VA copayments and whether patients were
eligible for Medicaid), geographic (e.g., whether patients lived
<10 miles from VA or non-VA hospitals), socio-demographic
(e.g., age, race, and gender), and health status factors on
exclusive VA healthcare use. Health status was measured
using Hierarchical Condition Categories (HCC) where higher
scores indicate worse health status.
Population Studied: Our study included all veterans with
ESRD in 1999 who were eligible for both VA and Medicarecovered private-sector care.
Principal Findings: There were 25,667 veterans with ESRD in
1999 eligible for VA and Medicare-covered private-sector
services. Fifty-nine percent were >= 65 years old. Ten percent
used VA services only, 32% used private-sector services only,
and 58% used both. Exclusive VA use increased for patients
without VA medical copayments (OR = 6.5) but decreased for
Medicaid-eligible patients (OR = 0.28). Exclusive VA use
increased when VA hospitals were <10 miles from patients
(OR = 2.15) but decrease when non-VA hospitals were <10
miles (OR = 0.71). Exclusive VA use decreased among
patients >= 65 (OR = 0.67) and decreased as HCC scores
increased (e.g., scores above the fourth quartile OR = 0.08).
Conclusions: Patients with greater financial (e.g., no VA
medical copayment) and geographic access (e.g., VA hospitals
<10 miles) to VA were more likely to use VA exclusively.
Patients with greater financial (e.g., Medicaid eligibility) and
geographic access (e.g., non-VA facilities <10 miles) to privatesector services were less likely to use VA exclusively. Older
patients with worse health status were less likely to use VA
exclusively.
Implications for Policy, Delivery or Practice: ESRD patients
require extensive healthcare and may benefit from
improvements in continuity and coordination of care.
Financial factors were found to affect exclusive VA use.
Consequently, it might be useful to examine whether altering
financial incentives (such as copayments) and benefit
structures in VA and Medicare might promote healthcare use
in a single system.
Primary Funding Source: HRSA
• Using Claims Data to Estimate the Burden of Mood
Disorder Services among Women Diagnosed with Tubal
Infertility
Guoyu Tao, Ph.D., F. Chowdhury, M.D., T. Chorba, M.D., G.
Fricchione, M.D., K. Irwin, M.D.
Presented by: Guoyu Tao, Ph.D., Health Scientist, Division of
STD, cdc, 1600 Clifton Road, MS-E80, Atlanta, GA 30333; Tel:
404.639.8180; Fax: (404)639-8607; E-mail: gat3@cdc.gov
Research Objective: Tubal infertility is one of the sequelae of
untreated bacterial STD infection. Little is known about the
use of medical services for mood disorder by women with
tubal infertility. Infertility may result in common mood
disorders (e.g., depression and anxiety) if reproductive efforts
fail, and mood disorders may reduce the frequency of
intercourse, thereby reducing fertility. The objective of this
study is to determine if an excess of medical services for
mood disorders is observed before and after the diagnosis of
tubal infertility.
Study Design: Using the MarketScan database for the years
1998 to 1999, we examined medical claims for women
enrolled in health plans of large U.S. employers. ICD-9 codes
were used to identify patients with tubal infertility and mood
disorders (major depressive disorder, anxiety, phobic
disorders, neurotic depression, brief or prolonged depressive
reaction, or adjustment reaction with anxious mood or mixed
emotional features).
Population Studied: women who had tubal infertility or mood
disorders.
Principal Findings: More than 335,000 women aged 19-44
years were continuously enrolled in these health plans from
1998 through 1999; 105 (0.2%) had claims for tubal infertility
and mood disorder. Of these, 51 (49%) were diagnosed with a
mood disorder before being diagnosed with infertility, and 54
(51%) were diagnosed with infertility before being diagnosed
with a mood disorder. The percent with a mood disorder was
significantly higher among enrollees with infertility claims than
among enrollees without infertility claims (16% versus 12%)
(p<0.001).
Conclusions: Services for mood disorders may be more
common in patients with infertility because of the possible
causal effects of infertility on mood disorders or mood
disorders on reduced fertility. Alternatively, enrollees with
coverage for infertility services may be more likely to have
mental health coverage that allows generation of mood
disorder claims because more costly health plan products
tend to cover both more comprehensive infertility and mental
health services. Among women diagnosed with infertility and
mood disorder, about half were diagnosed with a mood
disorder before their infertility diagnosis. Analyses that
attempt to estimate the degree to which tubal infertility causes
mood disorders must consider that both diagnosed and
undiagnosed mood disorders may precede infertility
diagnoses and represent pre-existing conditions rather than
outcomes of infertility per se.
Implications for Policy, Delivery or Practice: Clinicians who
care for infertility patients should be aware that many infertility
patients receive mood disorder services before or after their
infertility diagnosis and should consider mental health risk
assessment and management for infertility patients.
Primary Funding Source: CDC
• Evaluation of the Quality Payment Demonstration
Program for Increasing the Cure Rate of Tuberculosis
Wen-Chen Tsai, Dr.PH, Pei-Tseng Kung, Sc.D.
Presented by: Wen-Chen Tsai, Dr.PH, Assistant Professor,
Health Services Management, China Medical University, 11
Ln16 Sec.3 Chungching Road, Taya, Taichung, 428; Tel:
886.4.25603149; Fax: 886-4-25603149; E-mail:
wtsai@mail.cmu.edu.tw
Research Objective: The tuberculosis is one of leading
causes of death in Taiwan and the annual number of death of
tuberculosis is the the highest among all infectious diseases.
In order to increase cure rate of tuberculosis, improve
treatment quality, and give more health care responsibilities to
health care providers, the Bureau of National Health
Insurance (BNHI) has implemented the "quality payment"
demonstration programs for tuberculosis in Taiwan since
2001. The BNHI hopes to furnish the patients with
comprehensive health care services that emphasize health
care outcomes and quality. The purpose of this study was to
evaluated the tuberculosis demonstration program of quality
payment. This study evaluated the differences of cure rates,
treatment times, treatment expenditures, and patient
satisfaction for tuberculosis patients between the
demonstration program and current fee-for-services payment
programs. The factors influencing the successful treatment to
tuberculosis, were analyzed. The physicians' attitudes and
opinions to the demonstration program were surveyed.
Study Design: This study is a retrospective study. It consists
of two parts. In the first part, the study used the structured
questionnaire to interview tuberculosis patients, and we also
used questionnaire to survey the relative physicians’ opinions
for the demonstration program. The descriptive statistics were
used to compare patients’characteristics, treatment
expenditure, satisfaction of medical services, treatment times,
and cure rate between the demonstration programs and feefor-services program. Multiple regression analysis was
conducted to explore the relative factors that influenced the
patients’ satisfaction with treatment process and outcomes,
and logistic regression analysis was applied to examine the
factors that significantly affected tuberculosis patients if they
could be cured within 9-month treatment. In the second part,
based on NHI medical claim data this study conducted
statistical analyses for comparing the spending, cure rate, and
treatment time for tuberculosis patients between
demonstration program and fee-for-service program.
Population Studied: The study period was from January 2001
to December 2002. The samples comprised all tuberculosis
patients who were new cases and were cured in
demonstration program or fee-for-services program in 2002,
and those who were new tuberculosis patients and were also
cured in 2001 before the implementation of demonstration
program.
Principal Findings: The results showed that tuberculosis
patients in the demonstration program indeed had shorter
treatment times. According to the consequences of analyzing
NHI medical claim data, there was 83.81% cure rate in terms
of 9-month treatment for those participating in the
demonstration program, and 57.60% cure rate for nonparticipants. The average treatment time for cured patients
under the demonstration program was 224 days, which was
shorter than that of non-participants. The demonstration
program had higher average treatment expenditure for one
cured tuberculosis patient in terms of 9-month treatment, but
had similar average treatment expendiutre in terms of 18month treatment. The patients in the demonstration program
felt more satisfaction with treatment services. The main
problems for many tuberculosis patients were a long period of
medication and the side effects of medicines. For physicians,
most physicians believed the demonstration program is
helpful to increase cure rate, but they showed less satisfaction
with claim procedures and payment structures.
Conclusions: The quality payment demonstration program
was significantly helpful to increase the cure rate of
tuberculosis. The study results recommend the BNHI entirely
implements the quality payment program for tuberculosis
treatment.
Implications for Policy, Delivery or Practice: Health care
payment policy for increasing the successful tuberculosis
treatment
Primary Funding Source: Center of Disease Control, Taiwan
• Effect of Services in Drug Treatment Clinics on
Emergency Department Use
Christine Laine, M.D., M.P.H., Barbara Turner, M.D., MSEd,
Walter Hauck, Ph.D
Presented by: Barbara Turner, M.D., MSEd, Professor,
Medicine, University of Pennsylvania, 1123 Blockley Hall, 423
Guardian Drive, Philadelphia, PA 19104-6021; Tel:
215.898.2022; Fax: 215.573.8779; E-mail:
bturner@mail.med.upenn.edu
Research Objective: To examine the relationship of medical
care and other health care services in drug treatment clinics
with repeated emergency department (2+ ED) visits.
Study Design: A survey of a stratified random sample of drug
treatment clinic directors (N=125)in New York linked to
Medicaid claims for clinic patients. Survey in 1998 asked about
services in 1997 and addressed: linkage to medical care,
staffing, available drug and alcohol treatment, accessibility,
on-site medical preventive services, social support services,
HIV services, and academic affiliation. The dependent variable
was 2+ ED visits in 1997 and models adjusted for clustering of
patients.
Population Studied: 8,397 Medicare-enrolled patients who
received regular (6+ months) drug treatment at a surveyed
clinic in 1996-97
Principal Findings: Repeated ED use occurred for 14.4%.
Drug treatment clinics with on-site medical services had lower
odds of 2+ ED visits (0.79 [95% CI 0.68, 0.91]. After
adjustment, an interaction between onsite medical services
and the weekly number drug users seen (grouped by quartile)
revealed showed that this benefit occurred only for smaller
volume clinics: lowest quartile (0.64 [0.47, 0.88]), middle two
quartiles (0.79 [0.64, 0.97]) but top quartile (1.27 [0.81, 1.97]).
Offering more medical preventive services such as PAP
smears was the only other clinic characteristic associated with
less ED use (0.62 [0.44, 0.88].
Conclusions: Onsite provision of medical services in small
and moderate sized drug treatment programs is associated
less demand for ED care. The additional protective association
of preventive services may indicate clinics with more
comprehensive medical services.
Implications for Policy, Delivery or Practice: To reduce ED
use by drug users in treatment, policymakers should consider
supporting a more complete array of medical services in drug
treatment clinics. Lack of benefit of onsite medical services in
large drug treatment programs may indicate poorer ability to
manage patient demand or poorer quality care.
Primary Funding Source: NIDA
• Long Term Survival Post Treatment of a Nationwide
Cohort of Elderly Veterans with Colorectal Cancer
Katherine Virgo, Ph.D., M.B.A., Mary Valentine, M.P.H., Lucille
Dauz, M.A., Lan Marietta, M.A., Sangita Devarajan, M.P.H.,
Frank Johnson, M.D.
Presented by: Katherine Virgo, Ph.D., M.B.A., Professor,
Department of Surgery, Saint Louis University & St. Louis
VAMC, 3635 Vista at Grand Boulevard, Saint Louis, MO 631100250; Tel: 314.289.7023; Fax: 314.289.7038; E-mail:
virgoks@slu.edu
Research Objective: The research objective was to identify a
nationwide cohort of patients diagnosed with colorectal
cancer and follow them from the period pre-diagnosis through
diagnosis, initial curative intent treatment, adjuvant therapy,
post-treatment follow-up, to the final endpoint of
either death or loss to follow-up using a merged VA-Medicare
database. This permits the researcher to capture a more
complete picture of patient management, disease recurrence,
and outcomes than possible in studies which do not account
for patients utilizing multiple systems of health care.
Study Design: A retrospective analysis of 13 years of
nationwide Medicare and VA inpatient and institutional
outpatient data beginning with the three years pre-diagnosis
(1986-1990) through a minimum of five years post-diagnosis
(1994-1998) was conducted. Death data were available
through December 2003. Data were also extracted from
tumor registry files, Computerized Patient Record System
Files, and paper medical records at each VA.
Population Studied: The population studied included all VA
patients diagnosed with colorectal cancer and surgically
treated for cure during the five-year period 1989-1993, who
were Medicare-eligible at diagnosis, and survived the index
admission.
Principal Findings: Of the 6612 patients treated with curative
intent during the five-year period, 4902 (74%) could be
staged. Of these, 4535 (93%) were deemed eligible for the
study. Of the eligible patients, 77% were diagnosed with
colon cancer and 23 percent with rectal cancer. The majority
(88%) had adenocarcinoma. The histopathologic grade was
moderately differentiated for 54% and well differentiated for
19%. As of December 2003, 74% had died. Including all
stages (0- IV), the average survival in months after treatment
was 75 (median=61). Survival by stage was also calculated.
Identification of significant predictors of survival is underway.
Conclusions: This rich database provides a wealth of data for
subgroup analyses of survival, recurrence patterns, and
particularly, of health services utilization patterns within and
across
systems of care.
Implications for Policy, Delivery or Practice: Continuity of
care may be lacking for users of multiple systems of care. In
addition, diagnostic tests may be repeated needlessly further
increasing costs both the patient and to society.
Primary Funding Source: VA
• Congestive Heart Failure Care Management: Utilization
and Factors Associated with Its Implementation in
Physician Organizations
Margaret Wang, M.P.H., Thomas Bodenheimer, M.D., Robin
Gillies, Ph.D., Stephen Shortell, Ph.D.
Presented by: Margaret Wang, M.P.H., Doctoral Candidate,
Health Services and Policy Analysis, University of California,
Berkeley, 1340 Arch Street, Berkeley, CA 94708; E-mail:
mcywang@uclink.berkeley.edu
Research Objective: Existing literature provides evidence that
multi-disciplinary care management processes (CMPs) for
patients with congestive heart failure (CHF) improve clinical
outcomes and reduced healthcare costs. However, little is
known about the utilization of these processes or factors
affecting their implementation in physician organizations
(POs). This study aims (1) to assess the use of CMPs to
manage CHF patients; and (2) to identify organizational and
environmental factors affecting the extent of their
implementation in POs. Four types of CMPs are examined:
(a) case management; (b) provider feedback; (c) clinical
practice guidelines; and (d) disease registry.
Study Design: This study analyzed data collected by the
National Study of Physician Organizations (NSPO), a crosssectional census survey (response rate = 70%) of POs in the
U.S. (September 2000 through September 2001). CMP
implementation was assessed by asking the PO how many of
the four CMPs does the PO employ to manage CHF patients.
Multivariate linear regression was performed to determine
how environmental and organizational factors affect the extent
to which POs implement these CMPs.
Population Studied: The studied population consisted of
1,104 POs (67% medical groups and 33% IPAs) employing 20
or more physicians in the U.S. Analyses were restricted to
those POs report treating CHF patients, resulting in a sample
size of 798 POs.
Principal Findings: On the average, POs report implementing
approximately one CMP to manage CHF patients.
Multivariate linear regression results indicate that
environmental factors including external incentives to improve
quality, percentage of county HMO penetration, and
percentage of hospital financial risk assumed by the PO are all
positively associated with the extent to which CMPs are
utilized to manage CHF patients. In addition, a PO’s
participation in CHF quality improvement activities, the
sophistication of clinical information technology
infrastructures, systematic assessment of patient satisfaction,
having an appointment scheduling system to allow for patient
group visits and follow-up, IPA-status (MG as referent group),
and being single specialty (multispecialty as referent group),
all have positive relationships with the degree of CMP
implementation.
Conclusions: Even though CMPs for CHF have been shown
to improve outcomes and reduce costs, we found that POs
have adopted these CMPs to only a minor extent. In addition,
our results suggest that the extent to which POs implement
CMPs to manage CHF patients is affected by a combination of
environmental incentives and organizational structural
capabilities. Consistent with prior findings, most noteworthy
of these facilitators include the presence of incentives to
improve quality in the PO’s external environment and the
sophistication of clinical information technology adopted by
the PO.
Implications for Policy, Delivery or Practice: This study
provides the first national assessment of CMPs implemented
by POs to manage CHF patients, as well as factors associated
with the extent of their use in POs. Given that CHF has been
the most common discharge diagnosis for Medicare
beneficiaries and has significant healthcare cost and resource
implications, it is crucial to elucidate environmental and
organizational factors associated with CMP implementation.
A deeper understanding provides policy makers and
practitioners information on how to facilitate CHF care
management, thereby improving the healthcare quality for
CHF patients.
Primary Funding Source: RWJF
• Using the Ecology Model to Assess Healthcare in
Asthma
Barbara Yawn, M.D. M.Sc., George Fryer, Ph.D., Robert
Phillips, M.D., Susan Dovey, Ph.D., David Lanier, M.D., Larry
Green, M.D.
Presented by: Barbara Yawn, M.D. MSc., Director of
Research, Research, Olmsted Medical Center, 210 Ninth
Street, S.E., Rochester, MN 55904; Tel: 507.287.2758; Fax:
507.287.2722; E-mail: yawnx002@umn.edu
Research Objective: To test the value of the ecology model in
assessing changes in the patterns of healthcare contact in
people with asthma. Explicitly, to assess the ability of the
ecology model to reveal changes in patterns, identify specific
populations who experience barriers to care and describe how
asthma affects healthcare contacts.
Study Design: The ecology model was used as the analytic
framework to display the health care contacts of case and
control subjects. Risk ratios were used to compare the
healthcare contacts of cases and controls across multiple
settings and combinations of settings.
Population Studied: Children and adults who participated in
the 1999 U.S. Medical Expenditure Panel Survey. Cases were
school-aged children (6 to 17 years) and young adults (18 to
44 years) with self-reported asthma. Controls were people
from the same age groups who have no self-reported asthma
or other chronic conditions.
Principal Findings: In 1999, the presence of asthma
increased the likelihood of an ambulatory care visit (risk
rations 1.2 and 1.3 for children and adults respectively) and
more than doubled the likelihood of making one or more visits
to the emergency department (risk ratios >2.7). The ecology
models highlights the 18.8% of children and 14.5% of adults
with asthma who had no ambulatory care visits for asthma in
1999. In addition, about one quarter of this group (5.2% of
children and 3.69% of adults with asthma) were seen in the
emergency department or hospital but had no ambulatory
care during the year. These Americans were more likely to be
uninsured, have no usual source of care and live in
metropolitan areas.
Conclusions: The ecology model confirmed that asthma
increases contact in all health care settings but also
demonstrated a change in the pattern of contacts. More
importantly, the ecology model identified an uninsured, urban
subgroup of people with no usual source of care but with
asthma who sought emergent or hospital services but appear
to have barriers to ambulatory care access.
Implications for Policy, Delivery or Practice: The ecology
model identified people with apparent access barriers to care
that would be missed in reviews of HMO data, emergency
room records and medical records of large health care
organizations. The ecology model can provide the necessary
context for policy and practice evaluation and modification
related to care of chronic diseases.
Primary Funding Source: AHRQ
• Practical Quality Indicators for Asthma Management
Barbara Yawn, M.D., M.Sc.
Presented by: Barbara Yawn, M.D. MSc., Director of
Research, Olmsted Medical Center, 210 Ninth Street, S.E.,
Rochester, MN 55904; Tel: 507.287.2758; Fax: (507) 287-2758;
E-mail: yawnx002@umn.edu
Research Objective: Asthma is common and management
guidelines are availble, yet many reviews of asthma care
suggest that the care provided does not meet the
recommended standards. Most of the currently used quality
measures and report cards directed back to physicians provide
little information on how to improve compliance with the
quality standards assessed. This study is designed to develop
quality measures that relate directly to care functions in the
primary care physicians office.
Study Design: Retrospective medical records of an entire
county population. A set of quality measures that assess
basic history and physical functions for asthma care were
compared to the docmented care for all asthma visits in the
two community health care systems for a one year period.
Quality measures had to be present or met at only one visit
during that year to be counted as completed.
Population Studied: The clincians caring for all children and
adults making an asthma related visit to any health care facility
in Olmsted County in 2000.
Principal Findings: The quality measures developed and
studied and the percent meeting the indictor (%) are as
follows. 1. Percent of visits with an asthma ICD-9 code
(493.xx) that had a written diagnosis other than asthma such
as RAD or wheezy bronchitis in people > 3 years of age (24%).
2. Percent of visit notes with daytime symptoms documented
(54%). 3. Percent of visits with nighttime symptoms
documented (33%). 4. Percent of charts with absteenism or
reduced activity days recorded (12%). 5. Percent of visits with
triggers or allergies mentioned or evaluated (9%). 6.Percent
of patients with non-urgent visit in a year (11%). and 7.
Percent of patients with an ambulatory follow-up visit within
one month after emergency department visit or a
hospitalization (75%). The goal for measure 1 was 0% and
was 100% for all of the rest of the indicators.
Conclusions: Many medical records do not contain the
information necessary to assess asthma severity, asthma
control or triggers that may effect control. Without these
basic pieces of data it is difficult to believe that current
guidelines can be followed. Each measure has a direct
solution that can be incorporated into the care system of
people with asthma.
Implications for Policy, Delivery or Practice: These quality
measures may facilitate translation of guidelines into practice
more effectively than current guidelines that have such
outcomes as the ratio of rescue to controller prescriptions or
the percent of people on controller medications, neither of
which suggest immediate and simple solutions.
Primary Funding Source: AHRQ
• Risk Adjustment for Children with Special Health Care
Needs
Hao Yu, M.Sc., Andrew Dick, Ph.D, Peter Szilagyi, M.D.,
M.P.H.
Presented by: Hao Yu, M.Sc., Ph.D Candidate, Community
and Preventive Medicine, University of Rochester, 601
Elmwood Avenue, Box 644, Rochester, NY 14642; Tel:
585.275.3432; Fax: 585.461.4532; E-mail:
hao_yu@urmc.rochester.edu
Research Objective: While most studies of risk-adjusted
capitation focused on Medicare’s reimbursement to managed
care plans, few risk-adjustment models have been estimated
separately for children. This study aims to fill the information
gap by estimating risk-adjustment models for children,
especially for children with special health care needs
(CSHCN), and examining the potential profit that plans could
hypothetically gain by using additional information to select
low-cost enrollees under different risk-adjusted capitation
rates.
Study Design: The data were extracted from the Medical
Expenditure Panel Survey (MEPS), a nationally representative
survey of health services use and cost. This study tested five
sets of adjustors using a modification of the RAND two-part
model, in which the first part used logistic regression to
estimate the probability of using health services in 2000, and
the second part used a generalized linear model with gamma
distribution to estimate the total expenditures in 2000. Crossvalidation of the estimated models was performed using a
split-sample method with bootstraping.
Plan’s revenue was defined as the sum of risk-adjusted
capitation payment, and its profit as the difference between
the revenue and the actual health expenditures in 2000. The
profit rate was the profit divided by the revenue. We quantify
plans’ incentive for risk selection by assuming that plans could
use additional information to exclude individuals whose
predicted expenditures were higher than the capitation rate
under each of the estimated models.
Population Studied: The study included 4,896 children less
than 18 years old, who were screened using the CSHCN
Screener through the MEPS 2000 Parent Administered
Questionnaire. The sample was linked with MEPS 1999 to
obtain information about health services use and expenditure
in 1999.
Principal Findings: Socio-demographic factors explained 2%
of the variance in annual expenditure. Together with sociodemographic factors, CSHCN status explained 6%; the five
detailed questions of CSHCN Screener explained 12%; health
status measures explained 14%; and prior year use and
expenditures explained 20%. All the adjusters together
explained 22%.
If the socio-demographic factors were used to adjust
capitation rates, plans could use CSHCN status as additional
information to enroll only the profitable individuals whose
expected expenditures were not higher than the adjusted
capitation payment, and could achieve a profit rate of 45%. In
the extreme case of favorable selection, the profit rate would
be 50%.
Conclusions: Each of the risk adjustment models explained
only a small proportion of the variance of annual total
expenditure. Adding CSHCN status as an adjuster tripled the
proportion explained by socio-demographic factors alone. The
five questions of CSHCN Screener had explained the variation
similarly to health status. The CSHCN information could help
reduce discrimination facing CSHCN in a competitive health
plan market. The plans’ incentive to select low-cost children
was substantial.
Implications for Policy, Delivery or Practice: Further
research in the area of adjustment models for children is
needed. Given the imperfection of risk-adjustment capitation
system, future studies need to focus on a mix of capitation
payment and cost-based reimbursement system to reduce
selection incentives.
Primary Funding Source: The Maternal Child Health Bureau