Chronic Care Delivery
Call for Papers
Enhancements to Primary Care in the Treatment of
Chronic Disease
Chair: Morris Weinberger, Univesity of North Carolina,
Chapel Hill
Sunday, June 26 • 3:30 pm – 5:00 pm
●The Impact of Telephone-Based Care Management on
Mortality Risk of Frail Older Adults
Gretchen Alkema, MSW, George R. Shannon, Ph.D., Kathleen
H. Wilber, Ph.D.
Presented By: Gretchen Alkema, MSW, Doctoral Candidate,
Leonard Davis School of Gerontology, University of Southern
California, 3715 McClintock Avenue, Los Angeles, CA 900890191; Tel: (213)740-9685; Email: alkema@usc.edu
Research Objective: This analysis evaluated mortality risk
over 24 months for Medicare managed care members who
participated in the Care Advocate Demonstration Program
designed to link frail older adults to home- and communitybased services.
Study Design: Participants (N=704) were randomly assigned
to care management intervention and control groups, with the
intervention group receiving a telephonic social care
management intervention and 12 months of follow-up.
Proportional hazard modeling techniques were used to assess
the relative risk of death throughout multiple study periods.
Population Studied: Frail older adults (65+) enrolled in a
Medicare managed care plan who scored high on a health
services utilization algorithm.
Principal Findings: The control group had a significantly
greater risk of dying during the intervention (O/R = .480;
p=.007) whereas differential risk, which reduced in the postintervention period was not statistically significant (O/R =
.651; p=.101).
Conclusions: The findings suggest that social care
management affected mortality while the program was in
progress, but not after completion of the intervention phase.
Implications for Policy, Delivery, or Practice: By
highlighting the importance of formal social support for frail
older adults, this work broadens the knowledge base on the
connection between social support and mortality risk, and
suggests policy implications for targeted social care
management interventions.
Primary Funding Source: California HealthCare Foundation
●Group Visits Improve Compliance with Preventive and
Treatment Guidelines in Uninsured or Inadequately
Insured Patients with Type 2 Diabetes
Dawn Clancy, M.D., MSCR, Kathryn Magruder, MPH, Ph.D.
Presented By: Dawn Clancy, M.D., MSCR, Assistant Professor
of Medicine, Medical University of South Carolina, PO Box
250104, 326 Calhoun Street, Charleston, SC 29401; Tel: (843)
876-8986; Fax: (843)876-8980; Email: clancyd@musc.edu
Research Objective: To evaluate the effectiveness of group
visits in the management of uninsured or inadequately
insured patients with type 2 diabetes.
Study Design: One hundred eighty six patients with
uncontrolled type 2 diabetes were randomly assigned to
receive medical care in group visits or usual care for twelve
months. After twelve months, concordance with ten processof-care indicators recommended by the American Diabetes
Association (ADA) standards of care and three cancer
screening procedures recommended by the United States
Preventive Task Forces (USPTF) for general medical care were
evaluated through chart abstraction. The ten ADA 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. The three screening procedures
evaluated were: hemoccult cards for colon cancer screening,
mammograms for breast cancer, and papanicolaou (PAP)
smears for cervical cancer.
Population Studied: Predominantly African American
uninsured or inadequately insured patients aged >18 years
with uncontrolled type 2 diabetes defined as a HbA1c greater
than 8.0% without a primary diagnosis of substance abuse or
dependence, current pregnancy, dementia, or inability to
speak English.
Principal Findings: Patients receiving medical care in group
visits showed statistically significant improvement in
concordance with the ten ADA process-of-care indicators
(p<0.001). The proportion of intervention patients who had at
least five of the ADA standards met was at least twice the
number of control patients. Though colon cancer screening
was equivalent in the intervention and control patients (68%
and 65%, respectively; p=0.352), more than 80% of
intervention patients met the criteria for breast and cervical
cancer screening with mammograms and PAP smears as
compared to 68% in control patients (p=0.006, 0.019,
respectively). Though outpatient costs for patients in group
visits were greater, overall costs were less (p<0.05) due to
lower ER and inpatient costs.
Conclusions: Group visits proved more effective in
promoting concordance with ADA standards of care and two
of three cancer screening procedures than usual care in the
treatment of uninsured or inadequately insured patients with
type 2 diabetes with lower overall health services costs.
Implications for Policy, Delivery, or Practice: Offering group
visits to patients with uncontrolled type 2 diabetes may be a
cost-effective way of improving quality of care. Though
outpatient costs may increase, there should be an overall cost
savings.
Primary Funding Source: RWJF, AHRQ
●Assessment of Chronic Illness Care for Diabetes in
Primary Care Clinics
Amer Kaissi, Ph.D., Michael Parchman, M.D.
Presented By: Amer Kaissi, Ph.D., Assistant Professor, Health
Care Administration, Trinity University, One Trinity Place, #
58, San Antonio, TX 78212; Tel: (210)999-8132; Fax: (210)9998108; Email: amer.kaissi@trinity.edu
Research Objective: The majority of care provided to patients
with type 2 diabetes is provided in the primary care setting.
The Chronic Illness Care model suggests that there are six
structural dimensions of primary care teams that are
important in improving the quality of diabetes care. The
objective of this study is to assess the degree to which the six
structural dimensions of the Chronic Illness Care model are
implemented in primary care practices by comparing
responses given by caregivers, administrative staff and an
independent external observer, and to examine the
relationship of these responses with selected quality of care
process measures.
Study Design: The “Assessment of Chronic Illness Survey”
developed by Bonomi, Von Korff, Wagner and colleagues
includes 25 questions that constitute 6 structural dimensions:
organization, community linkages, self-management support,
decision support, delivery system design, and clinical
information systems. The wording of each question was
modified slightly to be specific to the care of patients with type
2 diabetes. The quality measures included were percentage of
patients in each clinic who had the following within the past 12
months: referral for dilated eye exam, foot exam, two blood
pressure measurements, one HbA1c measurement, one urine
micro albumin measurement, and one lipid
measurement.Means of scores given by two groups of
respondents and an external observer were compared using
one-way Analysis of Variance (ANOVA). To determine which
of these assessments were more related to actual quality
measures, Spearman correlation coefficients were calculated.
Population Studied: The survey was filled by 54 caregivers
(physicians and nurses), 77 administrative staff (medical
assistants, receptionists, office managers and other staff), and
one external observer in 20 primary care clinics in the South
Texas Ambulatory Research Network. Thirty patients in each
clinic were included in the study and their charts were
reviewed to assess the quality process measures.
Principal Findings: Overall, administrative staff were more
likely to rate their clinics higher on each structural dimension
in the ACIC than caregivers or the external observer, with the
differences being significant for three main dimensions:
delivery system design F=3.064; P<0.05, clinical information
systems F=8.301; P<0.05 and overall score that combines all
six dimensions F=5.247; P<0.05. The observer’s assessment,
and to a lesser degree the caregivers’ assessment were more
consistently correlated with quality of care measures than the
administrative staff assessments. For example, the observer’s
assessment on four structural dimensions (community
linkages, self-management support, decision support and
clinical information systems) were statistically related to the
percentage of patients with eye exam, while the caregiver’s
assessment of only one dimension (decision support) and
none of the administrative staff assessment were related to
that same measure.
Conclusions: Assessment of a primary care clinic’s structure
seems to be more accurate when conducted by an external
observer and by the caregivers that practice in the clinic, rather
than by the administrative staff in the clinic. Administrative
staff may tend to exaggerate the adequacy of the structures
that are present in their clinics.
Implications for Policy, Delivery, or Practice: The first step
toward redesigning primary care practices in order to improve
the quality of diabetes care is to accurately assess structures
that are directly related to quality measures. This study
suggests that a version of the ACIC tool that is tailored to
diabetes management can be used to examine structural
dimensions in primary care clinics, but may be more valid if
completed by caregivers or an independent observer. The next
step is to develop a profile of primary care clinics that provide
higher quality of care.
Primary Funding Source: AHRQ, Health Resource and
Service Administration
●Care Management for Elders with Chronic Conditions in
a Medicare Coordinated Care Demonstration
Cheryl Schraeder, RN, Ph.D., FAAN
Presented By: Cheryl Schraeder, RN, Ph.D., FAAN, Head,
Health Systems Research Center, Carle Foundation, 307 East
Oak #3, PO Box 718, Mahomet, IL 61853; Tel: (217)586-4164;
Fax: (217)586-2174; Email: Cheryl.Schraeder@carle.com
Research Objective: Does the Carle Medicare Coordinated
Care Demonstration improve self-management behaviors,
clinical health status, medication management for specified
health conditions, patient satisfaction, service utilization and
total Medicare cost of care compared to usual care?
Study Design: A prospective, 48 month randomized clinical
trial using an intent-to-treat approach. The Carle MCCD
includes a multi-modial intervention provided by primary care
teams (primary care physician, nurse partner and patient) and
is based on core components of the Chronic Care Model: selfmanagement support, decision support, delivery system
design, and clinical information systems.
Population Studied: 1,948 Medicare beneficiaries
(Treatment=980; Control=968) who enrolled in the Carle
MCCD between April 2002 and April 2003 who self-reported a
diagnosis of coronary artery disease, congestive heart failure,
atrial fibrillation, diabetes, or chronic obstructive pulmonary
disease and live in 11 counties in east-central Illinois or
western Indiana.
Principal Findings: There were no significant differences
between the treatment and control groups in baseline
characteristics, including demographics, health or functional
status, targeted diagnoses, hospitalizations or ED visits,
satisfaction, self-care behaviors or clinical health status
measures. At the end of the first 12 months, based on a
rolling enrollment period, there were significant differences
between the treatment and control groups. The treatment
group had higher scores in overall satisfaction with the health
care they received (9.0 vs 8.7) and higher satisfaction with
their nurse partner compared to their physicians' office nurses
(9.3 vs 9.0). Treatment group patients with diabetes had
higher rates of annual foot exams (52% vs 37%) and patients
with congestive heart failure had higher rates of daily weighing
(28% vs 17%). Treatment group patients had higher rates of
LDL (78% vs 64%) and triglycerides testing (79% vs 65%) in
accordance with the medical guidelines used in this study.
Treatment group patients with diabetes had highher rates of
HbA1c (81% vs 68%) and albuminuria testing (68% vs 34%).
The treatment group also had higher rates of hypertension
control (59% vs 45%).
Conclusions: These outcome trends are continuing in the
second evaluation period, 24 months after patient enrollment.
We are in the process of acquiring the Medicare claims data
through the end of 2003 to evaluate the economic impact of
the intervention on Medicare costs.
Implications for Policy, Delivery, or Practice: Early
evaluation results suggest that an intervention composesd of
primary care teams, using a combined case and disease
management approach, can significantly impact the
challenges older adults face in managing and living with multimorbid conditions.
Primary Funding Source: CMS
●CCM Implementation and Patient Perceived Selfmanagement Support for Their Chronic Illness
Shinyi Wu, Ph.D., Marjorie Pearson, Ph.D., Stephen Shortell,
Ph.D., Jill Marsteller, Ph.D., Michael Lin, MS, Emmett Keeler,
Ph.D.
Presented By: Shinyi Wu, Ph.D., Associate Engineer, Health,
RAND Corporation, 1776 Main Street, Santa Monica, CA
90401; Tel: (310)393-0411; Fax: (310)260-8155; Email:
shinyi@rand.org
Research Objective: Patient self-management is critical to
managing chronic illnesses. The Chronic Care Model (CCM), a
quality improvement (QI) framework, encourages
organizations to make system changes and work with patients
to support them in self-management. This study investigates
whether patients report more self-management support with
sites that do more to implement CCM.
Study Design: An observational study conducted by the
RAND/Berkeley Improving Chronic Illness Care Evaluation of
chronic care collaboratives. The QI changes undertaken by
participating organizations during the collaboratives were
collected by interviews and progress reports. The data were
then coded according to a hierarchical typology of CCM
intervention strategies, and rated on their “depth”, i.e.,
likelihood of impact, using predefined rating criteria. Each
organization received a summary rating for the overall
changes made to implement the CCM and a sub rating for
specific changes made to support patient self-management.
Patients from the study organizations were surveyed 10 to 18
months after the collaboratives had begun. The telephone
survey included questions on their perceptions of the selfmanagement support received from their healthcare providers
in nine areas. OLS regressions were used to examine the
relationships between patients’ ratings of their received selfmanagement support and the organizations’ implementation
performance as defined by the overall and self-managementspecific implementation depth rating, controlling for average
patient education, language, and disease type. Site variation in
implementation depth was evaluated by one-sample t-tests.
Population Studied: 1787 patients from 32 healthcare
organizations that participated in one of three QI
collaboratives to improve congestive heart failure, diabetes, or
asthma care.
Principal Findings: The organizations varied in the depth of
overall CCM implementation (p<0.01) and the depth of
changes to support patient self-management (p<0.01).
Despite that, on average, in six of the nine areas patients
perceived very good self-management support from providers
(score 70 or higher in a 0-100 scale). The three areas that
received lower ratings included proactive follow-up calls from
providers (average score of 33), receipt of self-management
plan copy (53), and appointment reminders (65). For these
three areas, the intensity of changes an organization made in
the area of self-management support was positively related to
the levels of support perceived by patients (p< .10). In
addition, patients from sites that had the best implementation
of CCM overall not only were more likely to receive a proactive
call but also were given greater confidence to control their
disease (p <. 10). Sites that served a higher percentage of
English speaking patients were rated higher.
Conclusions: In general, patients reported good selfmanagement support from providers. Greater implementation
of CCM changes, nevertheless, enhanced this critical factor of
chronic illness care, especially in giving patients a written plan,
appointment reminders, proactive follow-up calls, and overall
confidence to control their disease.
Implications for Policy, Delivery, or Practice: Successful
implementation of CCM, specifically in the area of selfmanagement support, increases patients’ tools and
confidence in managing their disease. . Organizations should
be encouraged to intensify CCM change efforts to improve
self-management support.
Primary Funding Source: RWJF
Call for Papers
Organizational Factors & Tools for Improving Practice
Chair: Shoshanna Sofaer, Baruch College
Tuesday, June 28 • 8:30 am – 10:00 am
●Relationship Between the Chronic Care Model and
Diabetes Outcomes
Laurie Hurowitz, Ph.D., Benjamin Littenberg, M.D., Charles D.
MacLean, M.D.
Presented By: Laurie Hurowitz, Ph.D., Research Assistant
Professor, General Internal Medicine, University of Vermont College of Medicine, 371 Pearl Street, Burlington, VT 05401;
Tel: 802-847-7937; Email: laurie.hurowitz@uvm.edu
Research Objective: As health care organizations consider
improvement to better manage chronic illness, the Chronic
Care Model has been promoted as a comprehensive model to
guide change. Various components of the Chronic Care
Model (CCM), such as use of clinical information systems and
patient/provider reminders, provider education on clinical
guidelines, and promotion of self-management techniques,
are currently under study for their relationship to patient
outcomes. To date, results have been mixed. However, few
data exist on the efficacy and validity of the CCM, as a whole,
and patient outcomes. The current study was designed to
examine the relationship between glycemic control for patients
diagnosed with diabetes and primary care practice
organization across all components of the CCM.
Study Design: This was a cross-sectional, observational study,
using lab measures of glycemic control for adult patients
diagnosed with diabetes at the baseline of a larger study on
diabetes care, the Vermont Diabetes Information System
(VDIS). Primary care practitioners (PCPs) responded to a
standard survey measuring practice conformance with the
CCM, the Assessment of Chronic Illness Care (ACIC). The
instrument was modified to be specific to diabetes care.
The ACIC survey, typically employed as a pre- and postassessment in quality improvement initiatives, includes 33
items, each on an 11-point scale. Higher scores are associated
with greater conformance with the CCM. All analyses were
conducted at the practice level. If more than one PCP
responded to the survey, their scores were averaged to
produce one practice level score. Glycosylated hemoglobin, as
measured by the A1C assay, was used to assess glycemic
control. A1C values were averaged at the practice level.
Population Studied: Of the 118 PCPs in the 57 rural practices
in Vermont and northern New York involved in the VDIS
study, 47 PCPs in 28 practices completed surveys assessing
practice conformance with the CCM. There were 3,701
patients with diabetes in these 28 practices.
Principal Findings: A simple linear regression of the
relationship between conformance with the CCM and average
glycemic control showed that greater conformance with the
CCM (higher scores) was associated with lower average A1C
(coefficient = -0.088 p=.122, 95% CI -0.201, 0.025). Adjusting
for age, gender, and panel size (number of patients with
diabetes in a practice), the relationship between the total
survey score and glycemic control had a coefficient of -0.091
(p=.055; 95% CI -0.184, 0.002).
Conclusions: Greater conformance with the Chronic Care
Model is related to better glycemic control among patients
with diabetes.
Implications for Policy, Delivery, or Practice: Absent
controlled trials demonstrating the validity and efficacy of the
CCM, these data are among the first to show a relationship
between overall conformance with the CCM and patient
outcomes.
Primary Funding Source: No Funding
●Asthma Patients and the Patient-Clinician Relationship: A
Qualitative Study of Continuity of Care
Margaret Love, Ph.D., Sarah B. Wackerbarth, Ph.D., Renee V.
Girdler, M.D., Arch G. Mainous, III, Ph.D., Dennis E. Doherty,
M.D.
Presented By: Margaret Love, Ph.D., Assistant Professor and
Research Director, Family Practice and Community Medicine,
University of Kentucky, K302 Kentucky Clinic, Lexington, KY
40536-0284; Tel: (859)323-6747; Fax: (859)323-6661; Email:
mlove@email.uky.edu
Research Objective: Previous research suggests that asthma
patients value an ongoing relationship with their doctors or
other health care professionals, seemingly more so than do
patients without chronic illness or with certain other chronic
illnesses. However, the reasons asthma patients value
continuity of care have not been explicated. The aim of this
study was to better understand asthma patients’ perceptions
of their relationships with health care practitioners, particularly
their reasons and priorities for continuity of care over time
with the same practitioners.
Study Design: In 2004 we conducted a qualitative focus
group study. Participants also completed a brief survey about
their asthma severity and demographic characteristics.
Prompts for the audiotaped focus group discussions asked
participants what they value in their relationships with health
care professionals, why seeing the same clinician would be
important to asthma patients, and how they develop and
manage relationships with one or more clinicians. We used
open coding of the focus group transcripts. Two researchers
independently identified themes regarding what patients liked
about their clinicians and relationships with them. Then the
researchers discussed and consolidated the themes.
Population Studied: Adult asthma patients were recruited
through the University of Kentucky Family Medicine clinic,
through the University of Kentucky Pulmonary Care clinic, and
through flyers posted at community grocery stores, public
libraries, and YMCAs. We conducted six focus groups with
three to seven participants each. Of the 26 patients that
participated, most were female, white, 41-60 years of age, and
had health insurance.
Principal Findings: Several themes emerged. Some themes
addressed positive health outcomes resulting from care:
clinician competence, successful diagnosis, and successful
treatment. Other themes addressed the interpersonal
process: the patient feels comfortable; the clinician talks,
listens, and explains; and the clinician is straightforward.
Many themes were about relationship qualities or information
that can only be developed or acquired over time: the
physician “knows me,” the patient trusts the clinician, the
clinician trusts the patient, the clinician is reliable and can be
depended on to help, the patient receives individualized care
that takes disease history and preferences into account, and
the physician cares about the patient. Also, patients wanted
to avoid “starting over” each visit.
Conclusions: Our results provide insight into what asthma
patients find valuable about continuity of care with the same
health care practitioner. Some of the patients’ concerns may
be considered typical indices of high quality care (e.g.,
improved health outcomes) or of positive interpersonal
interactions (e.g., listening). Their other concerns point to
relationship qualities and knowledge that require a shared
history (e.g., “knows me,” mutual trust, and avoid starting
over).
Implications for Policy, Delivery, or Practice: Better
understanding of what asthma patients value about continuity
can be used to develop practice systems that meet patients’
health care needs. Future research can evaluate whether
improving the aspects of health care delivery that asthma
patients value would improve their health care outcomes. In
the context of the current health care environment, in which
continuity of care with individual clinicians is diminishing, it
will be important to develop strategies to meet chronically ill
patients’ special concerns.
Primary Funding Source: National Heart Lung and Blood
Institute
●The Influence of Primary Care Practice Climate on
Medical Services Costs and Quality of Care
Douglas Roblin, Ph.D., David H. Howard, Ph.D., Edmund R.
Becker, Ph.D., E. Kathleen Adams, Ph.D., Sheldon Greenfield,
M.D.
Presented By: Douglas Roblin, Ph.D., Research Scientist,
Research Department, Kaiser Permanente Georgia, 3495
Piedmont Road NE, Building 9, Atlanta, GA 30305; Tel: (404)
364-4805; Fax: (404)364-7361; Email: Douglas.Roblin@KP.Org
Research Objective: Improved teamwork among clinical staff
has been cited as an opportunity for improving the quality and
safety of health care delivery in the United States. Little is
known, however, about: 1) whether primary care practices with
higher levels of teamwork, collaboration, and care
coordination (“practice climate”) are cost-saving or costgenerating compared with practices with lower levels, and 2)
how differentials in service delivery costs are associated with
variation in quality of care. We studied the influence of
practice climate on medical services costs per member per
month (PMPM) and diabetes quality of care among members
empanelled to 16 semi-autonomous and self-directed adult
medicine teams of the primary care delivery system in a group
model managed care organization (MCO).
Study Design: Member-level data (demographic, clinical,
financial) were organized into 2 cross-sections (2000 and
2002). Intermediate outcomes (glycemic, lipid, and blood
pressure control; ACEI and statin use) in the subsequent year
(2001 and 2003) were obtained for members with diabetes.
Practitioner and support staff surveys of practice climate were
conducted in 2000 (N=183, 80% response rate) and 2002
(N=227, 91% response rate). Practice climate is a multidimensional construct, encompassing 7 subscales (e.g.
delegation and collaboration, autonomy, and team ownership)
with good reliability (Cronbach’s alpha > 0.80). Medical
services costs PMPM were estimated as a function of team
practice climate, controlling for member characteristics (age,
gender, 7 major chronic diseases) using the 4-part modelling
strategy of the RAND HIE. Diabetes quality of care was
estimated as a function of average medical services costs
PMPM per team (adults with diabetes), controlling for
member characteristics. All models were estimated with fixed
effects per team; and, standard errors were adjusted for
clustering of members within team.
Population Studied: 166,209 and 167,664 members, and
10,472 and 12,710 adults with diabetes, empanelled to the
teams in 2000 and 2002, respectively.
Principal Findings: Primary care and ancillary services costs
PMPM were higher (p<0.05) on teams with more favorable
perceptions of practice climate in both 2000 and 2002. On
average, a member empanelled to a team with favorable
practice climate (75th percentile) incurred $5-$6 more PMPM
than a member empanelled to a with unfavorable practice
climate (25th percentile). Acute and specialist care costs
PMPM did not vary with practice climate. Teams with higher
primary care and ancillary services costs PMPM per diabetes
patient had greater likelihood of glycemic, lipid, or systolic
blood pressure control (p<0.05) among their diabetes
patients. For every 100 adults with diabetes, a team with $30
greater primary and ancillary services costs PMPM per
diabetes patient achieved 7 more patients with glycemic
control, 4 with lipid control, and 4 with blood pressure
control.
Conclusions: Primary care practices with higher levels of
teamwork, collaboration, and coordination among
practitioners and staff were associated with increased primary
care and ancillary services costs PMPM and better
intermediate outcomes among adults with diabetes.
Implications for Policy, Delivery, or Practice: In the shortterm (1-2 years), an MCO that invests in enhancing primary
care teamwork should not expect cost-savings because the
better intermediate quality of care that obtains from improved
teamwork may require increased services use (e.g. HbA1c
tests for monitoring glycemic control).
Primary Funding Source: AHRQ
●A Tale of Two Ownership Types: Implications for
Organizational Resources, External Incentives, and the
Implementation of the Chronic Care Model
Margaret Wang, Ph.D., MPH, Stephen M. Shortell, Ph.D.,
MPH, Thomas G. Rundall, Ph.D.
Presented By: Margaret Wang, Ph.D., MPH, Postdoctoral
Research Fellow, UCLA/RAND Health Services Research
Training Program, UCLA/RAND, 1776 Main Street, Santa
Monica, CA 90401; Tel: (310)393-0411 x6077; Email:
mcywang@berkeley.edu
Research Objective: To compare freestanding physician
organizations (Pos) with those affiliated with health systems
or owned by hospitals on the availability of organizational
resources; impact of external incentives on quality; and in turn
their performance on chronic care management.
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).
Multivariate regression analyses were performed to compare
PO ownership types while adjusting for organizational and
environmental characteristics.
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., excluding single specialty Pos
such as radiology, pathology, chiropractic, podiatry,
ophthalmology, anesthesiology, emergency medicine, and/or
imaging. Analyses were restricted to 966 Pos (58%
freestanding physician-owned and 42% systemaffiliated/hospital-owned) reported treating at least one of the
following chronic conditions: asthma, CHF, depression, or
diabetes.
Principal Findings: On the average, Pos adopted
approximately four of the eleven items in the Chronic Care
Management Index (CCMI), a composite measure reflecting
the extent to which the Chronic Care Model (CCM) is
implemented in Pos. System-affiliated/hospital-owned Pos
implemented the CCM to a greater extent (i.e., about five
items), compared to freestanding physician-owned Pos (i.e.,
about four items). In addition, Pos affiliated with health
systems or owned by hospitals were found to have more
sophisticated clinical information technology and offer more
comprehensive case manager services to physicians,
compared to Pos owned by physicians. PO receiving public
recognition (e.g., blue ribbon awards) as an external incentive
was found as a significant and robust factor positively
associated with CCM implementation in all Pos,
corresponding to a one-item increment in the CCMI. Subsample analyses revealed that the level of clinical information
technology adoption and PO receiving better contracts as an
external incentive for quality were both positively correlated
with CCM implementation in the freestanding physicianowned PO sub-sample, but not in the systemaffiliated/hospital owned sub-sample, suggesting that these
factors operate differently among these two PO ownership
types.
Conclusions: Results from this study indicate that Pos
affiliated with health systems or owned by hospitals have
implemented the CCM to a greater extent than Pos owned by
physicians. Further analyses suggest that this difference is
possibly due to system-affiliated/hospital-owned Pos having
more organizational resources for chronic care management.
Implications for Policy, Delivery, or Practice: This study
provides important comparative evidence on the quality of
chronic care management between system-affiliated/hospitalowned Pos and freestanding physician-owned Pos. These
findings underscore the need to develop collaborative efforts
between physician groups and health systems in order to
facilitate synergistic use of resources for chronic care delivery.
In addition, they highlight the importance for policy makers to
consider using a mixture of resource-based (e.g., pay for
performance) and institutional-based (e.g., blue ribbon
awards) incentives to motivate improvement in chronic care
delivery.
Primary Funding Source: RWJF, Health Research and
Education Trust Fellowship
●Factors Associated with Family Caregivers’ Experience of
End of Life Care
Anne Wilkinson, Ph.D., MS
Presented By: Anne Wilkinson, Ph.D., MS, Senior
Behavioral/Social Scientist, Health, RAND, 3720 Upton Street
NW, Washington, DC 20016; Tel: (202) 895-2659; Fax: (202)
966-5410; Email: annew@rand.org
Research Objective: Families and other informal caregivers
are essential in meeting an individual’s physical and
psychosocial needs and in accomplishing treatment goals.
Caregivers face a wide spectrum of emotional, physical, and
economic consequences as a result of their caregiving
responsibilities, including caregiver burden. We describe the
evidence base regarding care processes and interventions on
end of life caregiver burden to inform a research agenda for
palliative care.
Study Design: As part of a systematic review of the end-of-life
literature, we reviewed articles that evaluated caregiver
burdens related to end-of-life care.
Population Studied: We conducted a systematic review using
Medline, Database of Reviews of Effects, the National
Consensus Project bibliography, and recommendations of an
international expert panel. We augmented our search with
several systematic reviews from both Health Canada and
National Institute for Clinical Excellence, United Kingdom.
The searches were limited to published articles in the English
language (1990-2004), involving adult human subjects.
Principal Findings: From 24,423 total citations, we identified
18 systematic reviews, 23 intervention studies, and 134
observational reports addressing caregiver outcomes or
concerns, excluding bereavement. The final report included 8
high-quality systematic reviews, 13 intervention studies, and 17
observational studies of caregiving to patients with cancer,
dementia, and organ system failure. Outcomes included
burden, stress, depression, anxiety, satisfaction (e.g., with
care, life satisfaction, satisfaction with caregiving), caregiver
morbidity and mortality, unmet needs, institutionalization,
and place of death. Most articles involved interventions for
caregivers to dementia patients or palliative care interventions
for caregivers to advanced cancer patients. Dementia
caregiver interventions showed small benefits for caregivers.
Moderate positive effects were found for cancer patient
caregivers using palliative care services, especially home care.
However, the high levels of reported psychological morbidity
and unmet need indicate that not all caregiver needs were
being met. Families of younger, poorer, and more functionally
dependent patients were the most likely to report losses in
work hours, jobs, or the family’s savings. Caregivers to
patients with substantial unmet needs were more likely to
consider euthanasia or physician-assisted suicide, to have
depressive symptoms or anxiety, and to report that caring for
the patient interfered with their lives.
Conclusions: This systematic review identified a large and
diverse literature concerning caregiver burden. Interventions
had little consistent effect on caregiver outcomes and most
studies focused on dementia or cancer. Very few studies used
RCT design, outcome measures differed widely across studies,
and few studies examined palliative caregiving for nondementia, non-cancer deaths. Caregiver burden may be too
multidimensional to be described in a single scale, improved
by single component or short-term interventions, or
generalizable across diverse populations.
Implications for Policy, Delivery, or Practice: Informal
caregiving will be a critical component of care for the
increasing numbers of disabled elderly, yet research designs
have been weak, interventions limited, and outcome
assessment inadequate. Redesign of theoretical models,
measurement tools, and intervention designs is a priority.
Primary Funding Source: AHRQ, National Institute for
Nursing Research
Call for Papers
Do Physicians Appropriately Intensify Care for Patients
with Chronic Illnesses?
Chair: R. Adams Dudley, University of California,
San Francisco
Tuesday, June 28 • 10:30 – 12:00
younger or with comorbid COPD. Presence of hypertension
and diabetes increased the odds of initiation, but had no
significant effect on persistence among initiators.
Conclusions: For patients who start on beta-blocker and ACE
inhibitor therapies, there is a significant decline in use over
the course of two years.
Implications for Policy, Delivery, or Practice: Quality
improvement efforts have focused on prescription of betablockers upon hospital discharge for AMI. An important next
step is to focus on long-term persistence on these therapies.
Primary Funding Source: No funding source
●Refill Persistence with Beta-Blocker and ACE Inhibitor
Therapy after Acute Myocardial Infarction
Ayse Akincigil, Ph.D., John Bowblis, MA, Carrie Levin, Ph.D.,
Saira Jan, PharmD., Minalkumar A. Patel, M.D., Stephen
Crystal, Ph.D.
●National Spending on Bariatric Surgery and Bariatric
Medications
Didem Bernard, Ph.D., William Encinosa, Ph.D., Claudia
Steiner, M.D., MPH, Chi-Chang Chen, MS, Pharmacist
Presented By: Ayse Akincigil, Ph.D., Assistant Research
Professor, Institute for Health, Health Care Policy and Aging
Research, Rutgers, The State University of New Jersey, 30
College Avenue, New Brunswick, NJ 08901; Tel: (732) 9325348; Fax: (732) 932-8592; Email:
aakincigil@ihhcpar.rutgers.edu
Research Objective: In prevention of secondary heart attack,
the importance of beta-blocker and ACE inhibitor therapy is
greatly recognized. However, long-term adherence with this
recommendation is not well described. Our objectives are to
present rates and predictors of patient medication refill
persistence with beta-blocker and ACE inhibitor therapy within
the 24 months following an acute myocardial infarction (AMI).
Study Design: A retrospective, observational study using
linked medical and pharmacy claims from a large health plan.
Population Studied: 1,624 subjects aged 18 or older with an
inpatient claim for AMI (ICD-9-CM: 410.xx) between June 1,
2000 and May 31, 2001, continuously enrolled in the health
plan throughout the 24 months following AMI. 23% were in
point of service or HMO products; the remaining members
were in indemnity products.
Principal Findings: Among subjects with AMI and no
counterindication for beta-blockers, 23% never filled an
outpatient prescription for beta-blockers. Discontinuation is
defined as failure to fill a subsequent prescription within 60
days after exhausting the days supplied from prior
prescriptions. Among initiators, the discontinuation rate was
33% after a year, and 49% after 2 years (based on KaplanMeier estimates). Medication possession ratio (MPR) was
calculated as the ratio of number of days supplied to number
of days in the period. Persistence was defined as MPR > 0.75.
Multivariate models predicting initiation and persistent use
controlled for gender, age, income at zip-code level, plan type,
number of hospitalization days for AMI, and presence of
comorbid conditions. Odds of persistent beta-blocker use
were higher for patients living in high income areas, and for
those with chronic conditions that increase the risk of a
secondary AMI (i.e., diabetes, hypertension, dyslipidemia,
congestive heart failure, cerebrovascular and peripheral
vascular disease). Number of hospitalized days for AMI had a
positive effect on initiation, but not on long-term persistence.
The ACE inhibitor initiation rate was 60%. Of those who
initiated ACE inhibitor therapy, 30% discontinued therapy
within the first year, and 48% within two years. Odds of
persistent ACE inhibitor use were lower for patients aged 55 or
Presented By: Didem Bernard, Ph.D., Economist, CFACT,
AHRQ, 540 Gaither Road, Rockville, MD 20850; Tel: (301) 4271682; Email: dbernard@ahrq.gov
Research Objective: Due to the growing epidemic of obesity,
bariatric medicine is an emerging specialty of medicine
dealing with methods of weight loss among the obese. Very
little is known about the current use of bariatric surgery and
bariatric medicines and the potential demand for these
bariatric treatments.
Study Design: We examine insurance claims for bariatric
drugs and bariatric surgery among 5.1 million non-elderly
people covered by 45 large employers across the U.S. in 2002.
We also examine all inpatient discharges for bariatric surgery
in 36 states from the 2002 HCUP State Inpatient Databases,
representing 90% of all discharges from U.S. community
hospitals.
Population Studied: 5.1 million non-elderly people covered by
45 large employers across the U.S. in 2002 and
all inpatient discharges for bariatric surgery in 36 states from
the 2002 HCUP State Inpatient Databases.
Principal Findings: In 2002, 76% of bariatric surgeries were
covered by private insurance. Among the non-elderly
population in the U.S. with private health insurance in 2002,
there were 6.4 million morbidly obese adults clinically eligible
for bariatric surgery. We estimate that 79,276 bariatric
surgeries were performed on 78,336 adults (or 1.2% of those
eligible for the surgery) at a total spending of $1.62 billion.
Employers paid $1.56 billion of that expense. About 14% of the
$1.62 billion was paid to surgeons. While 31% of those eligible
for the surgery were men, only 16% of the surgeries were
performed on men. Moreover, men had an inpatient death
rate 7.75 times higher than women (0.80% vs 0.18%). In
2002, among a non-elderly sample of 5 million people with
drug coverage under 45 large employers across the country (a
3.2% sample of all employer-sponsored health insurance with
drug coverage in the U.S.), there were 1.14 million obese
adults clinically eligible for bariatric drug therapy. We found
that 22,119 adults (or 1.9% of those eligible) actually used
insurance-covered, bariatric prescription drugs, at a total
spending of $6.7 million, or $300 per user per year. Employers
paid $6 million of that total expense. While 49% of those
eligible were men, only 23% of those taking the bariatric
medications were men.
Conclusions: Less than 2% of the non-elderly adults with
private insurance who were clinically eligible for bariatric
treatments actually had bariatric drug use or bariatric surgery
in 2002. Thus, future demand for bariatric treatments may be
quite large.
Implications for Policy, Delivery, or Practice: Due to the
growing epidemic of obesity, not only Medicare but also
employers are considering whether they should cover bariatric
treatments. This study provides data on the cost and extent of
utilization of bariatric surgery and medications among the
privately insued population in 2002.
Primary Funding Source: AHRQ
●The Impact of Adverse Events on Warfarin Prescribing in
Atrial Fibrillation: a Matched-Pair Analysis
Niteesh K. Choudhry, M.D.
Presented By: Niteesh K. Choudhry, M.D., 1620 Tremont
Street, Suite 3030, Boston, MA 02446; Tel: (617)278-0930;
Email: choudhry@fas.harvard.edu
Research Objective: Warfarin is received by only 30-60% of
appropriate patients with atrial fibrillation (AF). Physicians’
experiences with warfarin-associated adverse events may be
an important determinant of warfarin use. Some adverse
events (i.e., major hemorrhage in an AF patient treated with
warfarin) may be more influential than others (i.e.,
thromboembolic stroke in an AF patient who did not receive
warfarin). Understanding the determinants of warfarin use
may help improve the quality of care for patients with AF.
Study Design: Using linked administrative data for 116,200
elderly patients with non-valvular non-transient AF, we
identified 3921 who were hospitalized for major hemorrhage
while on warfarin and 8720 hospitalized for thromboembolic
strokes while not on warfarin. We identified the physicians
responsible for the care of the patients that experienced
adverse events and selected pairs of patients treated by that
physician (one patient before and one patient after the adverse
event (i.e., exposure). Using this paired analysis we compared
the odds of warfarin receipt for pre- and post-exposure
patients after adjusting for stroke and bleeding risk factors
that also might influence warfarin use. We also evaluated a
comparison outcome -- the odds of angiotensin converting
enzyme (ACE) inhibitor prescriptions before and after
exposure -- that should not have been influenced by warfarinassociated adverse events.
Population Studied: Community dwelling elderly patients
(aged 66 and older) in Ontario, Canada
Principal Findings: For the 530 physician who were exposed
to an adverse bleeding event and treated other AF patients
during both the 90-day period before and the 90-day period
after exposure, the odds of warfarin prescribing was 21% lower
for post-exposure patients (adjusted OR 0.79, 95% CI: 0.621.00). Greater reductions in warfarin prescribing were found
in analyses using patients for whom more time had elapsed
between physician exposure and patient treatment. There
were no statistically significant changes in warfarin prescribing
after a physician had a patient experience a stroke while not on
warfarin or in the use of ACE inhibitors by physicians who had
patients with either bleeding events or strokes.
Conclusions: These results suggest that a physician’s
experience with warfarin-associated bleeding events can
influence warfarin use. In contrast, adverse events that are
likely associated with underuse of warfarin may not affect
subsequent prescribing.
Implications for Policy, Delivery, or Practice: Our findings
highlight the need for strategies to modify physicians’
perceptions of the risks associated with warfarin use and to
encourage warfarin prescribing for patients with AF.
Primary Funding Source: Harvard Pilgrim Health Care
Foundation and Canadian Institute for Health Research
●Evaluation of a Patient-Centered Care
Coordination/Home-Telehealth Disease Management
Program for Veterans with Diabetes
Neale Chumbler, Ph.D., W. Bruce Vogel, Ph.D., Mischka Garel,
MPH, Haijing Qin, MS, Rita Kobb, MS, ARNP, Patricia Ryan,
MS, RN
Presented By: Neale Chumbler, Ph.D., Research Health
Scientist, Assistant Professor, Department of Health Services
Research, Management and Policy, University of Florida, VA
HSR&D/RR&D Rehabilitation Outcomes Research Center
North Florida/South Georgia Veterans Health System, 1601
SW Archer Road (151B), Gainesville, FL 32608; Tel: (352)3761611 x4920; Fax: (352)271-4540; Email:
neale.chumbler@med.va.gov
Research Objective: To evaluate the effectiveness of a
patient-centered care coordination/home-telehealth (CC/HT)
program as an adjunct to treatment for veterans with diabetes.
This program consists of a care coordinator (RN or ARNP)
who uses disease management principles through the care
continuum, manages treatment for veterans with diabetes,
and equips the patient in self-management skills to reduce
costly health services (e.g., hospitalizations).
Study Design: This study evaluated a Department of Veterans
Affairs (VA) CC/HT program in a Florida, Puerto Rico, and
Georgia veteran population with diabetes. Care coordinators
monitored patient responses through an in-home messaging
device (called a Health Buddy). A total of 400 high-use
veterans with diabetes (two or more all-cause hospitalizations
or emergency department [ED] visits in the year prior to
enrollment) were enrolled in one of four VA CC/HT
programs. A matched comparison group of 400 veterans
with diabetes who met the same inclusion criteria was
randomly selected from VA administrative data. The matched
comparison group was similar in age, facility site, marital
status and service connected disability status. Propensity
scores were applied to improve the balance between the
treatment and comparison groups. Service use outcomes
were measured at 12 months before and after enrollment. A
difference-in-differences (DiD) approach was used in the
multivariable statistical models to measure the treatment
effect for patients in the programs.
Population Studied: High service use veterans with diabetes.
Principal Findings: One-year after enrollment, there was a
significant difference between the treatment and comparison
groups in the likelihood of one or more need-based primary
care visits (p < .01), increasing in the treatment group by 7.3
percentage points (from 45.6% to 52.9%) and decreasing in
the comparison group by 11.6 percentage points (from 40.8%
to 29.2%). Need-based primary care clinic visits are newly
scheduled visits that enable the veteran to be seen “just in
time” rather than “just in case” (traditional care---seeing
patients at regular intervals to catch problems). There was
also a significant difference between groups in one or more
emergency room visits (p < .0001); the comparison group
increased by 49.3% and the treatment group showed a
reduction of 17.4%, this finding may be the result of using
inclusion criteria as an outcome variable.
Conclusions: The Congressional Budget Office has indicated
that regression to the mean can bias the kinds of simple prepost studies of disease management programs that have
characterized the literature to date. The DiD design of the
present work, however, avoids this pitfall. The rigor of our
study design strengthens the finding that the CC/HT program
was effective in increasing new, need-based primary care
visits. The increase of such visits supports the notion of the
“just in time” care approach, where the veterans’ health status
was monitored and their clinical needs were met before their
health deteriorates.
Implications for Policy, Delivery, or Practice: Our results
are consistent with the CC/HT program improving the quality
of care for veterans through the incorporation of new patient
education and telecommunications technologies that involve
greater, more timely patient-clinician interaction. In this way,
the program supports greater access to care and improved
self-management for veterans with diabetes.
Primary Funding Source: VA
●Progress in Reducing Cardiovascular Risk in Diabetes: Is
it Enough?
Monika M. Safford, M.D., Katharine A. Kirk, Ph.D., Catarina I.
Kiefe, Ph.D., M.D.
Presented By: Monika M. Safford, M.D., Associate Director,
Deep South Center on Effectiveness, Medicine, Birmingham
VA Medical Center and University of Alabama at Birmingham,
1717 11th Avenue South, MT643, Birmingham, AL 35294-4410;
Tel: (205)934-6883; Fax: (205)934-7959; Email:
msafford@uab.edu
Research Objective: Hypertension (HTN) is a dominant
cardiovascular risk factor, especially among people with
diabetes (DM), at least as important as glycemic control. Yet,
many individuals with DM have uncontrolled blood pressure
(BP). National programs have recently emphasized
cardiovascular risk factor control in DM, and the Veterans
Administration (VA) has made HTN management and DM
part of its nationwide performance measurement system. We
studied nearly current patterns of BP medication management
in a VA medical center.
Study Design: We defined a retrospective DM cohort in 20012, and assessed HTN and BP medications at 2 observation
periods: 2001-2 and 2003-4. We used the Veterans Health
Information Systems and Technology Architecture (VISTA) for
this study, an electronic medical record including all
pharamcy, utilization and lab test results. Diagnostic codes
and DM medications were used to define DM, and diagnostic
codes and BP levels to define HTN. BP medication was
“appropriately intensified” if dose was increased or a new BP
medication class added after the last eligible primary care visit
with SBP>=140mmHg (uncontrolled HTN). Separate logistic
regressions for each observation period included age, sex,
race/ethnicity, and SBP level.
Population Studied: All DM patients cared for at a VA
medical center in 2001-2.
Principal Findings: The 6810 DM patients had mean
(standard deviation) baseline age 64.7(10.8) years, 2.2% were
women and 19.4% were African American. In 2001-2, 5190
patients had DM and HTN; in 2003-4, 3711 patients had DM
and HTN, representing those who remained in care. Patients
had many opportunities for management: the mean number
of primary care visits was 6.1(3.7) in 2001-2 and 6.3(3.6) in
2003-4. The mean number of BP medications at last measure
was 2.2(1.4) in 2001-2 and 2.7(1.9) in 2003-4. HTN control
improved somewhat, but remained suboptimal: at last
measure, 59.0% had uncontrolled HTN in 2001-2, and 50.6%
in 2003-4. Of all the 2074 uncontrolled in 2001-2 who
remained in care in 2003-4, 57.3% remained uncontrolled. BP
management in those with uncontrolled HTN in the 2
assessment periods was more intense in 2003-4. For example,
in 2001-2, 20.8% were on >2 BP medications, and 40.3% in
2003-4. Similarly, medications were intensified at only 33.7%
of visits with uncontrolled HTN in 2001-2; this rose
considerably but was still only 49.3% in 2003-4. In
multivariable analysis, people of different ages, race/ethnicity
or sex had generally similar patterns of medication
intensification.
Conclusions: Two thirds of intensification opportunities were
missed in 2001-2. For those who remained in care, that
proportion improved to half in 2003-4, and overall BP control
improved modestly. Secular trends and the fact that the 20034 group represented a longer VA care period may have
contributed to the improvement. Nevertheless, care fell
considerably short of optimal in both observation periods.
Implications for Policy, Delivery, or Practice: Efforts to
improve HTN management in the very high risk group of
persons with diabetes are bearing fruit. However,
considerable room for improvement remains. Our data may
also reflect a beneficial effect of remaining in care in a large
healthcare system.
Primary Funding Source: VA
Related Posters
Poster Session A
Sunday, June 26 • 2:00 pm – 3:15 pm
●Utilization of Statin Therapy during the Two Years
Following Acute Myocardial Infarction.
Ayse Akincigil, Ph.D., John Bowblis, MA, Carrie Levin, Ph.D.,
Saira Jan, PharmD., Minalkumar A. Patel, M.D., Stephen
Crystal, Ph.D.
Presented By: Ayse Akincigil, Ph.D., Assistant Research
Professor, Institute for Health, Health Care Policy and Aging
Research, Rutgers, The State University of New Jersey, 30
College Avenue, New Brunswick, NJ 08901; Tel: (732) 9325348; Email: aakincigil@ihhcpar.rutgers.edu
Research Objective: Clinical trials have demonstrated the
survival benefits of long term and regular use of statins. We
describe rates and predictors of statin therapy utilization,
including initiation, refill persistence and discontinuation
within the 24 months following an acute myocardial infarction
(AMI).
Study Design: A retrospective, observational study using
linked medical and pharmacy claims from a large health plan.
Population Studied: 1,624 subjects aged 18 or older with an
inpatient claim for AMI (ICD-9-CM: 410.xx) between June 1,
2000 and May 31, 2001, continuously enrolled in the health
plan throughout the 24 months following AMI. 23% were
members of point of service or HMO products; the remaining
were in indemnity products.
Principal Findings: Forty percent of patients initiated the
therapy within the 30 days following AMI; 35% initiated after a
delay of 30 days or more; and 25% did not fill any prescription
for statins in the two-year follow up period. Discontinuation is
defined as failure to fill a subsequent prescription within 60
days after exhausting the days supplied from prior
prescriptions. Based on Kaplan-Meier estimates,
discontinuation rates were 12% after 3 months, 30% after a
year, and 46% after 2 years. Members of managed care
products were more likely to initiate the therapy and to be
persistent compared to members of indemnity plans. Patients
between 45 and 75 years of age were more likely to initiate the
therapy, and patients aged 55 or older were more likely to
persist. Length of hospital stay for AMI significantly affected
initiation and persistence rates. Odds of initiation increased
by presence of dyslipidemia and the number of chronic
conditions that increase the risk of a secondary AMI (i.e.,
diabetes, hypertension, congestive heart failure,
cerebrovascular and peripheral vascular disease); odds of
initiation decreased among patients living with renal disease.
Conclusions: Lack of long-term adherence to statin therapy
represents a source of missed opportunities for prevention of
second AMIs. Younger patients and those in indemnity plans
appear at particular risk for treatment dropout.
Implications for Policy, Delivery, or Practice: Secondary
prevention efforts need to focus not only on initiation but also
adherence to statin therapy.
Primary Funding Source: Other
Population Studied: Community-dwelling beneficiaries who
participated in the Medicare Current Beneficiary Survey during
2000-2002 and who were hospitalized and discharged home;
n=1351, representing 2,883,726 persons after weighting.
Principal Findings: Self-management ability was associated
with significantly reduced length of stay ranging between 1.62.0 days, in a multivariate model that adjusted for age, gender,
race, and self-reported health status. Unmet need was not
associated with length of stay in similar models. Fifteen
percent of the participants who were hospitalized were
readmitted within 60 days of discharge; n=202. Participants
who were readmitted were less likely to be married, more likely
to live alone, and had a greater number of self-reported
chronic conditions. Self-management was not associated with
readmission, but having an unmet need and being unmarried
increased the odds of readmission significantly; ORs=1.48 and
1.99, respectively, after adjustment for age, gender, race, selfreported health status, and length of stay of the initial
admission.
Conclusions: Improving older adults’ ability to self-manage
their health conditions may decrease the duration of their
stays in hospitals. Similarly, access to personal assistance for
functional deficits after hospital discharge may decrease the
likelihood of hospital readmissions.
Implications for Policy, Delivery, or Practice: These findings
could help health care providers target a vulnerable group of
older adults for intensive discharge planning and postdischarge assistance to improve continuity of care. These
data also suggest that self-management skills may be relevant
to Medicare coverage policy.
Primary Funding Source: RWJF
●The Effects of Self-Management and Home Help on
Older Adults' Use of Hospitals.
Alicia Arbaje, M.D., MPH, Jennifer Wolff, Ph.D., Neil Powe,
M.D., MPH, MBA, Gerard Anderson, Ph.D., Chad Boult, M.D.,
MPH, MBA
●Development of a Nutrition Quality of Life Survey to
Improve Patient-Centered, Chronic Nutrition Care
Judith Barr, Sc.D., Gerald Schumacher, PharmD, Ph.D.
Presented By: Alicia Arbaje, M.D., MPH, Robert Wood
Johnson Clinical Scholar, Medicine, Johns Hopkins University,
600 North Wolfe Street, Carnegie 291, Baltimore, MD 21287;
Tel: (410)614-4525; Fax: (410)614-9068; Email:
aarbaje@jhmi.edu
Research Objective: Older adults who transition from
hospital to home may experience lapses in continuity of care
and subsequent adverse events. Their ability to self-manage
their health conditions and obtain help with their functional
deficits may favorably affect their hospital utilization patterns
and minimize the risk of discontinuity of care. We examined
whether self-management skills and lack of help with
functional deficits are associated with the length of stay and
the likelihood of readmission among hospitalized communitydwelling Medicare beneficiaries.
Study Design: Cohort study in which beneficiaries were
interviewed at home and monitored through Medicare claims
for hospital use during the following year. Measures include
self-reported ability to manage one’s health conditions on a 4point scale, unmet need for functional deficits, that is, lack of
personal assistance for difficulty with 6 ADLs and 6 IADLs,
length of stay of first admission, and non-elective readmission
within 60 days of hospital discharge.
Presented By: Judith Barr, Sc.D., Director, NERCOA, National
Education and Research Center for Outcomes Assessment,
Northeastern University, 360 Huntington Avenue - 105DK,
Boston, MA 02115; Tel: (617) 373-4188; Fax: (617) 373-2968;
Email: j.barr@neu.edu
Research Objective: To develop a Nutrition Quality of Life
(NQOL)survey that can be used to improve patient-centered
care by identifying patient-reported areas of concern and to
target interventions to improve adherence to chronic
nutritional therapy.
Study Design: In Stage 1, we conducted 10 patient and 7
clinician focus groups in 6 geographically diverse US cities to
identify physical, psychological, and social factors affecting
NQOL following recommended dietary modifications. Each
session was transcribed and read by the investigators and
three content consultants. In Stage 2, we developed a 47-item
survey, written at the 5th-6th grade level, that included 6 item
clusters: food impact, self-image, self- efficacy, psychological,
interpersonal, and physical. In Stage 3, we mailed the draft
survey instrument to each of the focus group participants,
asking the patients to complete the survey and asking both
patients and clinicians to suggest improvements.
Population Studied: The 65 patients in the focus groups of
Stage 1 were 72/28% female/male; age range 18->65 years;
25/63/12% low/middle/high income; 66/22/11/1%
Caucasian/African-American/Hispanic/other; and included 7
medical conditions that led to seeking medical nutrition
therapy. The 46 dietitians in the focus groups were from
outpatient, inpatient, military, public health, and home care
practice sites.
Principal Findings: 37 patients, responding to the survey in
Stage 3, averaged 9 minutes to complete the instrument.
Only one of the 47 items had more than two missing
responses. Based on Stage 3 patient and clinician responses,
the survey was modified to add 4 questions, and improve
syntax and question order. A color format for visually scoring
the survey was also developed. 81% of the patients and 71%
of the clinicians said the survey would be helpful to assess the
impact of dietary modifications on quality of life.
Conclusions: Focus groups provide a forum for collection of
valuable patient-reported concerns which can be used in the
development of measures to support chronic care. Further
work on the 51-item NQOL, version 1.4, will involve
psychometric analyses based on larger population testing, and
validity/reliability studies.
Implications for Policy, Delivery, or Practice: Results from a
survey to identify patient-centered concerns during long term
nutritional therapy may assist care givers to target
interventions to improve adherence to chronic dietary changes
Primary Funding Source: American Dietetic Association
Foundation
●Care Coordination using Information Sharing Systems
for Children with Autism Spectrum Disorders
Christine Burns, EdM, MBA, Susan Taylor Brown, Ph.D.,
MSW, Megan MacWilliams, Shawn Ryan
Presented By: Christine Burns, EdM, MBA, Associate
Director, Pediatrics, Strong Center for Developmental
Disabilities, 601 Elmwood Avenue, Rochester, NY 14642; Tel:
(585) 275-6681; Fax: (585) 275-3366; Email:
Christine_Burns@urmc.rochester.edu
Research Objective: Children with autism have special health
care needs that require complex care provided by multiple
specialists that typically continue throughout their lifetimes.
Their care is often fragmented, and parents are challenged to
be sure their children are receiving all the necessary care.
Emerging electronic information sharing systems hold
particular promise for improving the coordination of care of
children with special needs. The purpose of this study was to
identify the characteristics of care coordination programs,
including family access to information, for children with
Autism Spectrum Disorder within the University Centers for
Excellence in Developmental Disabilities Education, Research,
and Service (UCEDD) network.
Study Design: A six-item telephone questionnaire was
conducted surveying national interdisciplinary programs
based in University Centers for Excellence in Developmental
Disabilities that serve children with autism spectrum disorder
who have special health care needs. Summary statistics for
frequency were calculated for the total survey sample to
describe comparisons between and among groups.
Population Studied: Sixty-one University Centers for
Excellence in Developmental Disabilities Education, Research,
and Service serving individuals who have developmental
disabilities.
Principal Findings: Of the 41% UCEDDs providing services
or supports for children with ASD 84% provide
diagnosis/evaluation, 84% behavioral consultation, 88%
educational consultation, 96% training for service providers,
88% training for parents, 72% parent support groups, 96%
technical assistance and 72% research. These supports are
provided in the Center and/or through collaboration with
community programs. 72% reported involvement with care
coordination for children with ASD. The number of disciplines
providing services or supports to children with ASD ranged
from 3 to 16. The majority of Centers involved 11 or more
disciplines. The primary discipline was Speech Language
Pathology followed by Psychology and OT. Respondents
indicated that the primary method for information exchange
was telephone followed by mail. Use of EIS by Centers
included 64% Internet, 52% intranet, 20% VPN. EMRs are
available in 32% of the Centers. Only 4% of Centers have
intersystem access by community-based agencies and 0%
allows direct access by parents.
Conclusions: Considerable variability in implementation
models for CC continues to exist. Patient and family
participation is quite limited and must be improved to assure
family-centered care. The majority of programs have
fragmented care coordination models. Improvement of care
coordination programs is needed to enhance health and
functional outcomes of children with ASD.
Implications for Policy, Delivery, or Practice: Models of care
delivery must include effective care coordination that includes
participation by consumers and families and utilizes efficient
information exchange methodologies. Initiatives such as the
Medical Home may be able to address these issues and
improve family-centered care using EIS. There will be a need
for TA for parents and care provides alike.
Primary Funding Source: HRSA
●How do Practice Characteristics Relate to Diabetes
Treatment Patterns Among Patients' Primary Care
Providers?
Catharine Burt, EdD, Jane E. Sisk, Ph.D.
Presented By: Catharine Burt, EdD, Chief, Ambulatory Care
Statistics Branch, CDC's National Center for Health Statistics,
3311 Toldeo Road, Hyattsville, MD 20782; Tel: (301)458-4126;
Fax: (301)458-4032; Email: cburt@cdc.gov
Research Objective: As the U.S. population ages and chronic
disease management becomes increasingly important,
policymakers are exploring methods to influence physicians’
management. This study analyzed whether selected
characteristics of physicians’ practices influenced
management of diabetes, a prevalent condition with growing
evidence of appropriate management.
Study Design: We examined whether management of
diabetes by a patient’s primary-care provider was related to
practice characteristics that might exert an influence through
internal processes or external guidelines: number of
physicians, type of practice (solo, single specialty group, multispecialty group), percentage of revenue from managed care,
percentage of revenue from selected payers (Medicaid,
Medicare, private insurance, other), and use of electronic
medical records. Using logistic regression, we analyzed
whether or not specific aspects of diabetes management,
specified as dependent variables, were associated with these
practice characteristics, with physician specialty and patient
age, gender, and race as additional independent variables. We
selected indicators recommended in evidence-based
guidelines: for all diabetics - recording blood pressure,
counseling for diet and nutrition, and counseling for exercise;
for diabetics with hypertension – prescribing medications
recommended by the Joint National Commission (JNC-VI).
We also included for all diabetics - prescription of an
angiotensin-converting-enzyme (ACE) inhibitor or angiotensin
II-receptor blocker (ARB). The study involved a secondary
analysis of encounter data from the 2001 and 2002 National
Ambulatory Medical Care Survey, a national probability survey
of office-based physicians with 65-70-% annual response rates.
We specified each dependent variable as the percentage of
visits with the specific aspects of management recoded, and
used SUDAAN to account for the complex sample in
determining statistical significance.
Population Studied: Physician office visits (n=1,110) to
primary care providers for adult patients (age = 18 years) with
diabetes (ICD-9-CM code = 250 for any of three possible
diagnoses).
Principal Findings: Among visits by diabetics, 86.5% of the
visits had recorded blood pressure, 38.1% had documented
counseling for diet and nutrition, 18.4% for had exercise
counseling recorded, and 21.3% had prescriptions for an ACEinhibitor or ARB. At visits by diabetics who were also
hypertensive, 48.9% of the visits had prescriptions for JNC-VIrecommended medications. Regression results found few of
the studied practice characteristics related to diabetes
management. Physicians in practices with electronic medical
records had higher odds of prescribing an ACE-inhibitor or
ARB at all visits (p<.01). General and family practitioners had
higher odds than cardiovascular specialists of documenting
dietary counseling (p<.05) and exercise (p=.06).
Conclusions: Management of diabetes varies little by
organizational and financial characteristics of diabetic
patients’ primary-care providers.
Implications for Policy, Delivery, or Practice: In all practice
settings, substantial room for improvement exists to improve
evidence-based management regarding counseling for diet
and exercise and prescribing appropriate medications for
hypertension.
Primary Funding Source: CDC
●Risk of Emergency Department Visits for Asthma:
Frequent Symptoms or Delay in Care
Neetu Chawla, MPH, Ying-Ying Meng, DrPH, Susan Babey,
Ph.D., E. Richard Brown, Ph.D., Elizabeth Malcolm, M.D.
MSHS, Yee Wei Lim, M.D., Ph.D.
Presented By: Neetu Chawla, MPH, Research Associate,
UCLA Center for Health Policy Research, 10911 Weyburn
Avenue, Suite 300, Los Angeles, CA 90024; Tel: (310)7948362; Fax: (310)764-2686; Email: nchawla@ucla.edu
Research Objective: To identify modifiable factors related to
Emergency Department visits for asthma among a diverse
non-elderly adult population in California.
Study Design: This study used data from the 2001 California
Health Interview Survey (CHIS). CHIS 2001 is a random-digit
dial (RDD) telephone survey of 55,428 households drawn from
every county in California and is the largest statewide health
survey conducted in the United States. The sample was
designed to provide estimates for California's overall
population, its major racial and ethnic groups, and a number
of ethnic subgroups. Logistic regression analyses were used to
determine factors associated with emergency department
(ED) visits for asthma. Factors studied include age, gender,
race/ethnicity, education, English proficiency, insurance
coverage, having a usual source of care, reasons for delaying
asthma-related care, self-reported health status, frequency of
asthma symptoms, rural/urban residence, and smoking
status. Our analysis employs a framework based on the
Anderson model of health care utilization.
Population Studied: The population studied was 4,359
California adults, ages 18 to 64, who reported that they had
been diagnosed with asthma and experienced asthma
symptoms in the past year.
Principal Findings: Overall 9.4% of adults with asthma
reported visiting the ED due to asthma in the past year. We
found that those with daily or weekly symptoms, with fair or
poor health status, and who delayed care for asthma due to
cost/insurance or other reasons were more likely to visit the
ED for asthma. Stratification of the study population into
those with daily/weekly symptoms and those with less
frequent symptoms revealed that delay in care due to cost and
health insurance coverage, delay in care for other reasons, and
fair/poor health status remained significant for both groups.
In addition, Latinos and women were more likely to visit the
ED in the severe asthma group while Asians, African
Americans, and the uninsured were more likely to visit the ED
in the less severe group.
Conclusions: To prevent ED visits for asthma, it is important
to control asthma symptoms and reduce delays in receiving
asthma care. In addition, racial and ethnic disparities exist in
ED visits for asthma.
Implications for Policy, Delivery, or Practice: ED utilization
for asthma has been increasing, but our findings support the
argument that this costly form of health care can be reduced.
Two important factors, frequent asthma symptoms and delays
in care for asthma, can be improved with effective
interventions. Providers, patients and their family members
could work in partnership to control asthma symptoms
through more effective monitoring and medications.
However, broader societal-level efforts are also needed, such
as efforts to control asthma triggers (e.g., air pollution) and to
improve health care coverage. Our findings also suggest that
in addition to financial barriers, racial and ethnic minorities
face other barriers to care, such as cultural or institutional
barriers.
Primary Funding Source: The California Endowment
●Sustainability of the Health Disparities Collaborative:
Incentives, Assistance and Barriers
Marshall Chin, M.D., MPH, Anne C. Kirchhoff, MPH, Jessica
E. Graber, Ph.D., NORC-MWCNPresented By: Marshall Chin, M.D., MPH, Associate
Professor, Department of Medicine, University of Chicago,
5841 South Maryland MC 2007, Chicago, IL 60637; Tel:
(773)702-4769; Fax: (773)834-2238; Email:
mchin@medicine.bsd.uchicago.edu
Research Objective: Quality improvement (QI)
collaboratives, typically using the Chronic Care Model (CCM),
are increasingly used as a way to improve chronic illness care.
In 1998, the Bureau of Primary Health Care (BPHC) started
the Health Disparities Collaborative (HDC) to improve chronic
disease management in community health centers (CHCs).
Little is known, however, about the practical issues involved in
sustaining QI programs over time and the help participants
need for maintaining these programs. Therefore, we aimed to
determine barriers to continued HDC success and to
understand what incentives and assistance are needed to
maintain improvements.
Study Design: The first year of the HDC initiative includes
learning sessions and conference calls where usually 10-20
teams at a time are trained in the CCM and rapid Plan-DoStudy-Act cycles to make changes focused on improving care.
After the first year, CHCs concentrate on continuing and
extending the improvements made in the initial year. In 2004,
we conducted a mail survey of 1,519 administrators, providers,
and staff from CHCs that had completed at least one year of
the HDC by July 2003; 1,029 responded for a response rate of
68%. We report here on the initial 702 respondents. CHCs
surveyed participated in the HDC on average approximately
3.5 years.
Population Studied: We surveyed health center
administrators, providers, and staff from 165 MidWest and
West Central collaborative health centers. Of respondents,
almost 20% were administrators (CEOs or Medical Directors),
66% were members of the QI teams, and 15% were other
staff.
Principal Findings: CHC administrators, providers and staff
generally believe the HDC is successful (83%) and improves
patient outcomes (88%) at their centers. However, CHC
administrators note that the HDC leads to increased costs per
patient (76%) and CHC costs (77%), but with no increased
patient care reimbursement (79%) or grant acquisition (71%)
to compensate for these costs. Respondents are somewhat
concerned about burnout and inequitable workloads resulting
from the HDC. Fifty-two percent of respondents believe that
there is not sufficient funding or staff to run the HDC at their
center. Also, they believe that sustaining the HDC would
benefit from increased resources and assistance from BPHC
and the CHC leadership for direct patient care, staff time for
data entry and QI activities, and leadership support.
Respondents deem personal incentives, such as receiving
extra money for HDC work, somewhat less important than
increases in system resources; however, 46% of participants
who do not receive release time, indicate this is unacceptable.
Conclusions: CHC personnel perceive the HDC to be worth
the effort, but they also believe there are important financial
and personnel barriers to maintaining improvements.
Respondents indicate needing additional system support for
patient care, data entry, QI, and leadership cooperation for
sustaining the HDC.
Implications for Policy, Delivery, or Practice: QI
collaborative interventions, such as the HDC, are considered
helpful by participants for improving care and patient
outcomes; however, the sustainability of the HDC model and
other QI collaborative programs may require increased
resource support to maintain success over time.
Primary Funding Source: AHRQ
●Productivity Enhancement for Primary Care Providers
Using Care Management
David Dorr, M.D., MS, Cherie P. Brunker, M.D., Adam Wilcox,
Ph.D., Laurie Burns, PT, MS, Paul D. Clayton, Ph.D.
Presented By: David Dorr, M.D., MS, Assistant Professor,
Medical Informatics & Clinical Epidemiology, Oregon Health
& Science University, 3181 SW Sam Jackson Park Road,
Mailcode: BICC, Portland, OR 97219; Tel: (503) 494-4502; Fax:
(503) 494-4551; Email: davedorr@gmail.com
Research Objective: To determine the impact of a generalist
care management system on the productivity of primary care
providers.
Study Design: A prospective cohort design was used to
examine care management usage and productivity of primary
care physicians (PCPs) over 24 months. Intermountain
Health Care’s (IHC) generalist CM program consists of seven
primary care clinics where specialized information system
applications assist care managers and physicians in providing
collaborative care for patients with one or more chronic illness
or with psychosocial needs. Use of the system is voluntary
and referrals are physician driven. Percent of patient visits
who were care managed per physician per month was used to
predict changes in work relative value units (wRVUs)
generated over time. A mixed multivariable autocorrelation
model was used to adjust for multiple levels of factors that
might affect productivity, including time-based effects. Clinic
level effects included clinic location (urban vs. rural), specialty
mix, and team staffing levels. Patient panel effects included
aspects of the patient population treated by the physician such
as average case-mix as measured by the Chronic Disability
Payment System (CDPS), average population age, percent
married, and race. Physician factors examined included
gender and age of physician, time in system, time since
graduation, and specialty. Lag for time-based effects was
determined with spatial autocorrelation. Continuous
differences were tested with students' t and ANOVA, and
model significance was tested with the likelihood ratio
methods. Cost of the program was compared with revenue
from productivity changes.
Population Studied: 122 PCPs (53 internists; 69 family
practitioners) within IHC over 24 months in 7 intervention and
23 control clinics.
Principal Findings: The 122 primary care physicians saw
153,403 patients during 2,731 physician-months. In all, 4,898
(3.2%) patients were referred to CM. Unadjusted wRVUs were
377.9±104.3 for physicians with no/low CM use (67 control
and 11 intervention physicians with <2% of visits with care
managed patients) and 399.0±117.2 for those with higher care
management use (44 physicians; >= 2% of visits), a 5%
difference. Limiting the analysis to intervention physicians,
low users had 332.5±144.9 wRVUs per month and higher users
had 397.7±104.9 wRVUs (difference: 20%, p<.0001); this
difference is strongest in physicians who adopted use during
the study period. Specialty, average age (44.2), years in
system (5.3), and gender (11% female) of physicians all
influenced productivity at baseline and over time, as did
percent of patient panel married (55.6%), Caucasian (93.2%),
and average patient CDPS score (.79). Team staffing and
clinic location also were significant predictors of productivity
differences. After adjusting for these confounders, adjusted
wRVUs were 318.00 ± 98.8 for low users and 398.8 ± 107.1 for
high care management users. For physicians with access,
adjusted wRVUs were 368.0±108.8 and 398.2±115.2 for low
and high users (difference: 8%, p<.0001). Net cost of care
managers from a physician only perspective was $11,643 per
year.
Conclusions: Productivity increases for physicians who made
use of generalist care managers in our system were moderate
but stable in a multivariable model. Net costs were reduced
substantially in this limited perspective.
Implications for Policy, Delivery, or Practice: Amount and
accrual of benefits from CM programs have been hotly
debated. When a generalist, information technology intensive
program is used, provider productivity may increase and
reduce net costs. However, assessment of productivity
changes is challenging with many confounders.
Primary Funding Source: John A. Hartford Foundation
●Drug Adherence and Physiologic Outcomes in Medicare
Patients with Hypertension
Vicki Fung, BA, Jie Huang, Ph.D, Richard Brand, Ph.D, Joseph
Newhouse, Ph.D, Joseph Selby, M.D., MPH, John Hsu, M.D.,
MBA, MSCE
Presented By: Vicki Fung, B.A, Analyst, Division of Research,
Kaiser Permanente, 2000 Broadway, Oakland, CA 94612; Tel:
(510)-891-3527; Fax: (510)-891-3606; Email: Vicki.Fung@kp.org
Research Objective: The recent Medicare Modernization Act
of 2003 (MMA) aims to help Medicare patients pay for
chronic prescription drugs, such as blood pressure (BP)
drugs. Clinical studies suggest that regular use of BP drugs
decreases the risk of adverse cardiovascular events, but
patients might have limited adherence to therapy. We
examined levels of adherence to BP drugs, patient and
insurance characteristics associated with lower adherence,
and the association between adherence and physiologic
outcomes in a Medicare population.
Study Design: Using a large integrated delivery system’s
(IDS) automated clinical databases, we determined adherence
by calculating the proportion of days covered (PDC) by BP
medications (i.e. angiotensin converting enzyme-inhibitors,
angiotensin receptor blockers, beta blockers, calcium channel
blockers, or diuretics) in 2003. We considered PDC = 0.8 as
“adherent.” We used multiple logistic regression models to
assess patient and insurance characteristics associated with
lower adherence. We used logistic regression models to
assess the association between adherence and elevated
systolic blood pressure levels (SBP = 140mmHg) using the
last measurement of the year in 2003.
Population Studied: All subjects were members of the IDS
who were 65+ years old with Medicare insurance, and had a
diagnosis of hypertension and used a BP drug in 2002. The
85,099 subjects were an average age of 75.2 years old and
were predominantly female (61.9%) and of white
race/ethnicity (73.4%). In 2003, all subjects had at least some
prescription drug coverage: 79.3% had a $1,000 annual drug
benefit cap, and all subjects had a $10 generic and $20-35
brand drug copayment. 92.4% of subjects had at least one
SBP measurement in 2003.
Principal Findings: In 2003, 84.1% of subjects were adherent
to any BP drug. In multivariate models, subjects with a
benefit cap, who were male, had a higher comorbidity level,
and were of non-white race/ethnicity were less likely to be
adherent to BP drugs in 2003. Among all subjects, 37.9% had
elevated SBP levels in 2003. After adjusting for covariates,
adherence to BP medications was significantly associated with
lower odds of elevated SBP levels (OR=0.87, 95% CI: 0.840.91).
Conclusions: Over one in three Medicare patients in this
sample had elevated systolic blood pressure levels. Moreover,
many patients were not adherent to BP medications
throughout the year. Adherence was associated with favorable
clinical outcomes, as measured by non-elevated SBP levels.
Implications for Policy, Delivery, or Practice: Despite the
presence of relatively generous prescription drug coverage,
many hypertensive Medicare patients in this study had
elevated SBP and were not adherent to their drug regimen.
Drug adherence was significantly associated with non-elevated
blood pressure levels. These findings are particularly
concerning given the clinical trial evidence indicating the value
of lowering blood pressure for reducing adverse
cardiovascular events. More research is needed to assess drug
use, adherence, and clinical effects.
Primary Funding Source: AHRQ
●Measuring the Quality of Follow-up Pharmacotherapy
Management of Chronic Obstructive Pulmonary Disease
(COPD) Exacerbations.
Min Gayles Kim, MPH, Fernando Martinez, M.D., Russ
Mardon, Ph.D., Phil Renner, MBA
Presented By: Min Gayles Kim, MPH, Senior Health Care
Analyst, Quality Measurement, National Committee for
Quality Assurance, 2000 L Street NW Suite 500, Washington,
DC 20036; Tel: (202)955-1731; Fax: (202)955-3599; Email:
gayles@ncqa.org
Research Objective: To explore the potential for a
performance measure to assess the timely follow-up
pharmacotherapy management of COPD exacerbations.
Effective management of COPD exacerbations to shorten
recovery and prevent relapse can have a large impact to
reduce the economic and social burden and prevent
worsening health status.
Study Design: Observational study conducted in five health
plans. Utilization of emergency department (ED) and inpatient
services with a principal discharge diagnosis of COPD served
as proxy for moderate to severe COPD exacerbations. Two
indicators assessing the timely pharmacotherapy dispensing
were measured: dispensing of systemic corticosteroids within
7 days and bronchodilator dispensing within 21 days of
discharge from ED or inpatient visit. Pre-existing prescriptions
for steroids and bronchodilators were included.
Population Studied: Five health plans participated in the
study and were asked to provide patient data and claims data
(e.g. spirometry testing) from administrative data systems for
the entire eligible population. In addition, each plan was
asked to review medical records for a sample of 150 patients
in the eligible population. The enrollments of these plans
included commercial, Medicare, and Medicaid product lines
across several geographical regions of the U.S., and ranged in
size from 52,000 to over 820,000 members.
Principal Findings: Plan-specific frequency of patients with an
exacerbation ranged from 0.27 per 1000 to 1.35 per 1000
commercial plan members (avg: 0.65), and ranged from 7.56
per 1000 to 20.21 per 1000 Medicare members. Overall, 43%
of plan enrollees who were discharged home from an ED or
hospital visit received systemic corticosteroids within 7 days,
and 54% received a bronchodilator within 21 days. Planspecific rates ranged from 26% to 52% for steroid use and
29% to 55% for bronchodilator use. Steroid and
bronchodilator use rates were notably lower in the Medicare
population compared to commercial (36% vs. 47% steroid;
45% vs. 53% bronchodilator). There was no difference in
usage rates between men and women. 87% of all steroid
prescriptions were for prednisone, and 75% of bronchodilator
prescriptions were for Albuterol.
Conclusions: Despite guideline recommendations for shortterm use of systemic corticosteroids to reduce rate of relapse
and improve symptom management in moderate to severe
exacerbations, this study shows considerable room for
improvement. Similarly, bronchodilator therapy, which is a
key COPD therapy because of its capacity to alleviate
symptoms, decrease exacerbations, and improve health
status, was underutilized. Steroid and bronchodilator use was
much lower in the Medicare population reflecting possible
disparity of care in the older population.
Implications for Policy, Delivery, or Practice: Performance
measures for appropriate follow-up pharmacotherapy of
COPD exacerbations can be an important method for
encouraging physicians to manage COPD effectively thereby
decreasing the frequency of exacerbations by reducing the rate
of relapse and improving symptom management.
Primary Funding Source: Supported in part by educational
grant from Boehringer-Ingelheim & Pfizer
●Robustness of Diabetes Self-Management
Russell E. Glasgow, Ph.D., Lisa A. Strycker, MA, Diane K. King,
MS, OTR, Deborah J. Toobert, Ph.D., Alanna Kulchak Rahm,
MS, Marleah Jex, MPH
Presented By: Russell E. Glasgow, Ph.D., Senior Scientist,
Clinical Research Unit, Kaiser Permanente Colorado, 335 Road
Runner Lane, Penrose, CO 81240; Tel: (719) 372-3165; Fax:
(719) 372-6395; Email: russg@ris.net
Research Objective: To evaluate the "robustness" or
generalization of effects from a computer-assisted diabetes
self-management program on reach, implementation, and
efficacy attributable to a variety of factors below.
Study Design: RCT with stringent attention control condition.
Analyses were conducted of interaction or moderator effects
due to health plan, counselor, and variety of patient
characteristics.
Population Studied: 217 adult type 2 primary care diabetes
patients from both fee-for-service and HMO healthcare
settings.
Principal Findings: 41% patient participation, variable
adoption by physicians (76% HMO vs 18% non-HMO),
excellent implementation, and improvements in both dietary
and physical activity outcomes. Few significant interactions
between treatment condition and patient characteristics, type
of healthcare plan, or counselor experience.
Conclusions: Patients and (HMO) physicians were willing to
participate in this self-management intervention.
Interventionists from a variety of backgrounds delivered the
program successfully, and the results appear robust across a
variety of patient and delivery characteristics.
Implications for Policy, Delivery, or Practice: This
intervention applies generalizable across a variety of factors
related to public health and potential moderator variables.
More such research is needed to inform practice and policy
concerning the conditions under which chronic care programs
are and are not effective.
Primary Funding Source: NIDDK
●Patient Assessment of Chronic Illness Care: Application
in Diabetes Sample
Russell E. Glasgow, Ph.D., Candace C. Nelson, MA, Holly
Whitesides, BS, Diane K. King, MS, OTR, Barbara L. McCray
Presented By: Russell E. Glasgow, Ph.D., Senior Scientist,
Clinical Research Unit, Kaiser Permanente Colorado, 335 Road
Runner Lane, Penrose, CO 81240; Tel: (719)372-3165; Fax:
(719)372-6395; Email: russg@ris.net
Research Objective: To evaluate the characteristics and
usefulness of the Patient Assessment of Chronic Illness Care
(PACIC) survey among a sample of 355 type 2 diabetes
patients participating in a care improvement project. The
PACIC is designed to assess patient reports of the extent to
which they received care congruent with the Chronic Care
Model and can also be scored to produce subscales reflecting
the 5 As of behavioral counseling.
Study Design: Patient survey administration. Analyses of the
relationship of the PACIC to HEDIS-like measures of quality of
care received, measures of physical activity and eating
behaviors, and to a variety of patient characteristics.
Population Studied: 355 adult type 2 primary care patients of
52 physicians throughout Colorado. Respondent
characteristics generally matched those from BRFSS data from
Colorado for diabetes patients(e.g., 47% female, average age =
63, 42% had family incomes < $30,000.
Principal Findings: 1. These results generally replicated those
of an initial validation study on the PACIC, but with a much
larger diabetes sample. 2. The category of Chronic Care Model
congruent care reported most often was patient activation
activities. PACIC subscale activities reported to occur least
frequently were related to follow-up and coordination of care.
3. The new 5 As scoring for receipt of behavioral counseling
found that Agree activities were reported most often and
Arranging follow-up and community resources the least often.
4. The PACIC summary scores were significantly related to
both patient physical activity levels (r = .16, p <. 01) and to
receipt of HEDIS- related quality of diabetes care (r = .21-.27, p
<. 001). In contrast, and encouraging, very few patient
characteristics were significantly related to any of the PACIC
scale scores.
Conclusions: The PACIC appears to be a useful patient report
instrument that produces adequate variability and relates to
some patient outcomes such as level of physical activity and
quality of diabetes care received. The new items and 5 As
scoring for receipt of behavioral counseling also appears to be
useful.
Implications for Policy, Delivery, or Practice: The PACIC
scale offers promise as a practical way to assess patient
perceptions of receipt of primary care reflective of both
Chronic Care Model and USPSTF 5 As behavior change
counseling activities. It is recoimmended for use in
intervention studies to assess its sensitivity to change and to
evaluate quality improvement innovations.
Primary Funding Source: AHRQ
●Secondary Prevention Lipid Clinic: A Multidisciplinary
Approach
Anthony Greisinger, Ph.D., Ali Mortazavi, M.D., Kim Birtcher,
Ph.D., Haroonur Rashid, M.D., Madjid Tehrane, M.D., Oscar
Wehmanen, MS
Presented By: Anthony Greisinger, Ph.D., Vice President for
Research and Development, Kelsey Research Foundation,
7800 Fannin Street, Suite 209, Houston, TX 77054; Tel: (713)
442-1214; Fax: (713) 442-1229; Email: ajgreisinger@kelseyseybold.com
Research Objective: Numerous studies have demonstrated
that lipid clinics have outperformed usual care models in
improving patient outcomes related to achieving LDL goals,
increasing compliance with medication regimens, and
reducing costs. We developed and evaluated the impact of a
secondary prevention lipid clinic (SPLC) in improving
treatment outcomes (total cholesterol <200, HDL >40, LDL
<100, and triglycerides <150) for patients with a history of
cardiovascular and cerebrovascular disease (CV disease).
Study Design: Our multidisciplinary team approach includes
cardiologists, a pharmacist, nurses, and a registered dietician.
This approach uses a protocol based on the National
Cholesterol Education Project (NCEP) guidelines that provides
individualized patient and family education to promote
appropriate lifestyle changes (e.g., cholesterol reduction,
diet/weight management, exercise, medications, and tobacco
cessation). Patients with a history of CV disease from a large
multi-specialty medical organization were referred by a
physician or through self-referral to the SPLC and followed
prospectively. At the initial clinic visit, a pharmacist obtained
patients’ histories and baseline measures of height, weight,
dietary and exercise habits, and tobacco use. Customized
verbal and written instructions about diet, exercise, tobacco
cessation, and medications were provided to each patient.
Cholesterol goals were discussed and patients’ commitments
to making the recommended lifestyle changes were obtained.
A cardiologist reviewed all treatment plans before discussions
with the patient. At subsequent clinic visits, weight changes
and compliance with exercise, medication, and tobacco
cessation commitments were reviewed, revised as necessary,
and discussed with patients. Patients’ progress was
monitored at all subsequent clinic visits and clinical data were
entered in a database specifically designed for the SPLC.
Population Studied: Patients with a history of CV disease
were identified and treated at a large multi-specialty medical
organization. The organization has 21 clinics and more than
300 physicians serving the greater Houston, Texas
metropolitan area.
Principal Findings: Since the inception of the SPLC in
October 2001, 1,286 patients have been enrolled, with 28% of
these patients enrolled for 2 or more years. Data analyses
(October 2001 through December 2004) show significant
improvement in patient attainment of NCEP-recommended
goals for cholesterol management. Baseline data collected at
the initiation of the SPLC showed that 65.6% of patients had
total cholesterol <200mg/dl, 50% had LDL <100mg/dl, 56.9%
with HDL >40mg/dl, and 45.9% with triglycerides <150mg/dl.
In December 2004, 88% of enrolled patients achieved total
cholesterol of <200mg/dl, 71% were at goal for LDL
<100mg/dl, 79.5% were at goal for HDL >40mg/dl, and 65.9%
were at goal for triglycerides <150mg/dl.
Conclusions: Multidisciplinary lipid clinics can assist patients
in attaining NCEP-recommended goals for cholesterol
management and address modifiable risk factors to prevent
future cardiovascular events.
Implications for Policy, Delivery, or Practice: These findings
provide additional support for the effectiveness of
multidisciplinary lipid clinics in improving patient outcomes
and the quality of care. Future studies are needed to examine
adherence to lipid clinics over time, the cost-effectiveness of
these programs, and whether lipid clinics reduce the risk of
future CV events.
Primary Funding Source: Kelsey Research Foundation
●The Costs of Implementing the Health Disparities
Collobarative to Improve Diabetes Care: a Community
Health Center Perspective
Elbert Huang, M.D., MPH, Sydney E.S. Brown, AB, James X.
Zhang, Ph.D., NORC
Presented By: Elbert Huang, M.D., MPH, Assistant Professor
of Medicine, Section of General Internal Medicine, University
of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago,
IL 60637; Tel: (773) 834-9143; Fax: (773) 834-2238; Email:
ehuang@medicine.bsd.uchicago.edu
Research Objective: The Health Disparities Collaboratives
(HDC) is a national effort sponsored by the Bureau of Primary
Health Care (BPHC) to improve the quality of chronic illness
care in federally-qualified community health centers (CHCs).
The HDC includes training of CHC teams in implementing the
Chronic Care Model and techniques of rapid quality
improvement (QI). Teams then use these new skills to
develop QI projects. The HDC has been found to improve
diabetes care. As the HDC is disseminated, it is crucial to
understand the resources that are required to implement such
a program. We evaluate the costs of implementing the
Diabetes HDC program over time.
Study Design: We adopted a case study approach. Data
sources included: 1) a survey of center leadership in order to
obtain details regarding the time commitment of providers
and non-providers for HDC activities such as data collection,
data entry, team meetings, and conferences; 2)
comprehensive billing data for one center to calculate the
value of provider time; 3) and annual Uniform Data System
reports for descriptions of center clinical activity (i.e. unique
patients seen). We used these data to estimate our main
outcomes of interest: 1) the time commitment of providers
and non-providers to Diabetes HDC activities (HDC hours per
week, % provider time) and 2) the costs of implementing the
Diabetes HDC (Program costs in $/unique patient seen/year)
over time.
Population Studied: Four Midwestern CHCs with consistent
computerized financial records and involvement in the
Diabetes HDC for at least 3 years.
Principal Findings: The CHCs included two from Ohio (Ohio
1 and Ohio 2), one from Indiana, and one from Missouri. The
number of unique patients seen annually per CHC ranged
from 5729 to 28,451 in year one. All centers had growth in the
number of patients seen. For Ohio 1 and the Indiana center,
total HDC hours declined over time (Ohio 1: 24.8 hours/week
to 18.6 over 5 years; Indiana: 48.9 hours/week to 23.3 over 4
years). Similarly, the costs of the HDC declined (Ohio 1:
$3.57/patient/year to $2.22; Indiana: $10.52/patient/year to
$2.43). In contrast, hours devoted to the HDC increased for
Ohio 2 and the Missouri center. HDC costs declined for Ohio
2 ($15.40/patient/year to $11.15) but costs remained higher
than any other center. HDC costs for the Missouri center rose
($2.88/patient/year to $4.51). The initial percentage of HDC
time from providers varied by center, but generally declined.
Conclusions: The CHCs developed distinctive strategies for
implementing the Diabetes HDC that led to varied program
costs. The overall time commitment and the percentage of
time devoted by providers were important determinants of
program costs. The costs of the HDC per patient declined for
3 out of 4 centers.
Implications for Policy, Delivery, or Practice: This study
provides the BPHC and CHCs with estimates of the initial and
follow-up costs of implementing the Diabetes HDC. Further
study to identify the most cost-effective approaches to
implementing the HDC at the center level may help guide
future funding mechanisms of federal QI programs.
Primary Funding Source: AHRQ
●Identifying Medicare-Enrolled Veterans with Multiple
Chronic Conditions – Using Medicare, or VA or Both?
Michael Johnson, Ph.D., Margaret Byrne, Ph.D., Jennifer
Hasche, MS, Nora Osemene, PharmD, Laura Petersen, M.D.,
MPH, Raji Sundaravaradan, BS, Iris Wei, DrPH, Robert
Morgan, Ph.D.
Presented By: Michael Johnson, Ph.D., Assistant Professor of
Medicine, Houston Center for Quality of Care and Utilization
Studies, Baylor College of Medicine, 2002 Holcombe
Boulevard, Houston, TX 77030; Tel: (713)794-8608; Fax:
(713)748-7359; Email: mjohnson@bcm.tmc.edu
Research Objective: As the U.S. population ages and
healthcare costs continue to escalate, there is increasing
emphasis on studying elderly individuals with multiple chronic
conditions. Elderly veterans are a unique population with dual
eligibility for care from the VA and Medicare systems. Co-use
of VA and Medicare services has implications for both quality
and costs of care. Our objective was to identify Medicareenrolled veterans with multiple chronic diseases from both
systems of care. We chose to identify enrollees with diabetes
mellitus (DM), ischemic heart disease (IHD), or chronic heart
failure (CHF), as these are prevalent, comorbid chronic
conditions with a large burden of healthcare use and cost.
Study Design: A retrospective cohort study.
Population Studied: VA utilization records and Medicare
claims records for over 5 million unique veterans enrolled in
Medicare fee-for-service plans were separately searched for at
least one occurrence of ICD-9-CM diagnosis codes indicating
any of the 3 conditions for calendar years 1999-2002.
Principal Findings: A total of 3,226,922 enrollees (63.4%)
were identified as having at least one of these conditions. Of
these individuals, 52.7% had DM, 74.8% had IHD and 39.4%
had CHF. Among the DM group, 57.0% were identified in VA
records, 74.9% were identified in Medicare claims, and 42.5%
were found in both sources of records. Similarly, among the
IHD group 54.3% were in VA, 74.7% in Medicare, and 38.8%
were in both; among CHF, these percentages were 37.9%,
79.2% and 21.6% respectively. Of the DM patients identified
in Medicare only (n=731,676 or 43% of all DM), 13.3%
(n=97,415) were also found in either CHF or IHD cohorts
identified in the VA. In other words, over 97,000 patients were
found to have DM in Medicare records, but not in the VA,
where they were found to have CHF or IHD. Eleven percent of
IHD patients identified in Medicare only were in a non-IHD
VA cohort, and 32.1% of CHF patients identified in Medicare
were in a non-CHF VA cohort.
Conclusions: The prevalence of these chronic diseases in
isolation or in combination differs depending on which
healthcare system is searched. These findings suggest that
coding differences alone do not explain the variation in
identification of these conditions. Substantial numbers of
patients with a given chronic disease may not seek treatment
in both healthcare systems for that condition, though they
may receive other care in both systems. Thus, providers in the
VA may be unaware their patients have certain conditions, or
Medicare providers may be unaware their patients use the VA.
If providers are aware, this information is not being captured
in the administrative databases.
Implications for Policy, Delivery, or Practice: Further
research is needed to examine determinants in variation in
coding or use patterns leading to differential ascertainment of
disease conditions across the Medicare and VA systems.
Researchers should use caution in determining disease
cohorts based on either system alone.
Primary Funding Source: VA
●Characteristics and Predictors of Multiple Complicated
Transitions Thirty Days after Hospitalization for Acute
Stroke
Amy Kind, M.D., Maureen Smith, M.D., MPH, Ph.D., Jennifer
Frytak, Ph.D., Michael Finch, Ph.D.
Presented By: Amy Kind, M.D., Geriatric Fellow, Geriatrics,
Univeristy of Wisconsin and William S. Middleton VA Hospital
- GRECC, 2500 Overlook Terrace, William S. Middleton VA
Hospital - GRECC, Madison, WI 53705; Tel: (608)280-7000;
Fax: (608)280-7291; Email: ajh.kind@hosp.wisc.edu
Research Objective: In our current system of
compartmentalized healthcare, patients with complex health
conditions like acute stroke often require care across multiple
settings with numerous care transitions. Some of these
patients will undergo “complicated” transitions, i.e. transitions
from lower to higher care levels such as from home to the
hospital. Patients who undergo multiple complicated
transitions within a short time period indicate a potential
failure of the health care system and represent a potential
target for improved quality of care. The objective of this
analysis is to define the characteristics and predictors of
patients with multiple complicated transitions in the thirty
days after hospitalization for acute stroke.
Study Design: This study utilized Medicare claims and
enrollment data from 11 regions in the United States.
“Complicated transition” was defined as movement from a
less intense to a more intense care setting (i.e., lower to
higher level of care) with hospital being the highest on the
care spectrum, then emergency room (ER), skilled nursing
facility (SNF)/rehabilitation center/nursing home, home with
home health care, and home without home health care (the
lowest). Multivariable logistic regression was used to analyze
the relationship between multiple complicated transitions and
explanatory variables including socio-demographics, comorbidities, stroke severity, and HMO membership.
Population Studied: Medicare beneficiaries aged 65 years
and older discharged with acute ischemic stroke during 19982000, including 4,816 Medicare health maintenance
organizations (HMO) patients from 422 hospitals and 39,283
Medicare fee-for-service (FFS) patients from the same
hospitals. This analysis was restricted to 8,100 patients who
had at least one complicated transition.
Principal Findings: Among stroke patients with complicated
transitions over the initial thirty days after hospital discharge,
84% experienced only one complicated transition while 16%
(n = 1,266) experienced more than one complicated transition
(1,087 patients experienced two complicated transitions, 156
experienced three, and 23 experienced four or more). The
majority of complicated transitions (93%) involved ER visits or
hospital readmissions. When compared to those with a single
complicated transition, patients with multiple complicated
transitions (>1) were more apt to be African American (Odds
Ratio (OR) = 1.44, 95% Confidence Interval (CI) = 1.18-1.76),
have a history of fluid or electrolyte disorder such as
dehydration in the year prior to or during the index
hospitalization (OR = 1.28, 95% CI = 1.12-1.47) and experience
residual neurological deficits on discharge (OR = 1.27, 95% CI
= 1.08-1.50).
Conclusions: A significant number of stroke patients
experience multiple complicated transitions thirty days after
index hospitalization. This population could be distinguished
from patients undergoing a single complicated transition by
several socio-demographic and clinical factors available at the
time of hospital discharge.
Implications for Policy, Delivery, or Practice: The
distinguishing factors in this population are remarkable for
their potential to be influenced by socioeconomic and
environmental pressures. This may point to a potential
breakdown in our post-stroke system of health care for
vulnerable populations. Further investigation should focus on
the role that socioeconomic and environmental factors play in
patients with multiple complicated transitions.
Primary Funding Source: NIA
●Improving Primary Prevention for People with Chronic
Disabling Conditions: Focus Group and Internet Poll
Findings
Thilo Kroll, Ph.D., Melinda T. Neri, BA, Gwyn C. Jones, Ph.D.,
Matthew E. Kehn, BA, Sally Michaels, BA, Marcie Goldstein,
MA
Presented By: Thilo Kroll, Ph.D., Senior Research Associate,
Research Division, NRH Center for Health and Disability
Research, 102 Irving Street, NW, Washington, DC 20010; Tel:
(202) 877-1031; Email: thilo.kroll@medstar.net
Research Objective: There is increasing evidence that people
with chronic disabling conditions are less likely to receive
primary preventive care services recommended by the U.S.
Preventive Service Task Force than the general population.
They are also at greater risks for an earlier onset of secondary
conditions such as cardiovascular disease. This study’s
objective was to determine the experiences of people with
chronic disabling conditions with accessing and utilizing
primary preventive services. Further, we sought community
input for the development of strategies that could enhance
access to these services.
Study Design: The study combines in-depth focus groups
with a national consumer poll.
We conducted five focus groups with 36 adults (20 male, 16
female; Mdn ‘age’=46 years) with various chronic disabling
conditions. Interview questions focused on experiences with
primary preventive services, barriers to receiving timely and
correct services, strategies to improve the service experience,
and to address unmet information needs among health care
professionals and consumers. We further conducted an
Internet poll between August and November 2004 with n=518
(335 female; 183 male) adults from diverse racial/ethnic
backgrounds with various self-reported conditions (e.g. spinal
cord injury, cerebral palsy, post-polio, arthritis, diabetes) from
47 U.S. states and the District of Columbia. The research team
worked with independent living specialists throughout the
study.
Population Studied: People with chronic disabling
conditions. The largest subgroups were people with spinal
cord injury, multiple sclerosis, cerebral palsy and stroke.
Principal Findings: Focus group respondents reported
several environmental, provider-side and personal barriers
compromising primary preventive service access and
utilization. Primary barriers include inaccessible provider
facilities, equipment and procedures; insufficient support
during appointments, lack of provider knowledge about the
need for primary prevention, inappropriate professional
behavior towards individuals with communication and
mobility impairments, lack of reliable transportation to and
from providers, and personal motivation to seek preventive
care services. Suggested strategies involved careful planning
for physician appointments, improved scheduling techniques,
disability awareness education for primary care providers, and
advice on practical assistance needs during appointments.
Results from the Internet poll show that one-third (34.7%)
reported negative experiences in the receipt or primary
preventive services; while nearly three quarter (71.2%) of the
respondents said they believed they are receiving correct
services. There were no significant differences with regard to
age, gender, race/ethnicity. The only significant difference was
found for race/ethnicity with regard to perceived correct
services. Significant more Non-Caucasian participants
reported that they did not receive correct services. One-third
of all respondents said that they had not received a routine
physical exam, about half said they had not had a diabetes or
cholesterol test. Only 42% of the men over age 51 had
received a prostate exam; while only around half of the female
respondents over age 51 had received a mammogram, pap
smear or breast exam.
Conclusions: Adults with chronic disabling conditions face
multiple environmental and personal barriers in their access
to primary preventive services. Based on our findings we will
develop information resources for disabled consumers and
health care professionals.
Implications for Policy, Delivery, or Practice: Primary care
providers need to become more knowledgeable about access
barriers and adapt clinical practice to better address the
primary prevention needs of people with chronic disabling
conditions.
Primary Funding Source: CDC
●Evaluating Best Practice Patterns Using Commercial
Insurance Claims Data
Sylvia Kuo, Ph.D, Susan Miller, MBA, Ph.D, Jim Burrill, M.D.
Presented By: Sylvia Kuo, Ph.D, Investigator, Center for
Gerontology and Health Care Research, Brown University, Box
G-STZ, Providence, RI 02912; Tel: (401) 863-2060; Fax: (401)
863-9219; Email: Sylvia_Kuo@brown.edu
Research Objective: With the decline of managed care,
insurers are increasingly interested in promulgating evidencebased practices to improve the quality of care and reduce
unnecessary health care utilization among their beneficiaries.
Blue Cross & Blue Shield of Rhode Island (BCBSRI) covers
approximately 80 percent of the commercial market in the
state of Rhode Island. Through an analysis of BCBSRI’s claims
data, our objective was to examine deviations from acute
coronary symptom (ACS) best practices by describing the
extent to which recommended coronary procedures were
performed as well as by documenting the rate of duplicate
procedures. (word count = 487)
Study Design: Using BCBSRI claims data, rates of coronary
procedures performed within 4 weeks from the initial onset of
coronary symptoms as well as the rate of duplicate procedures
were calculated among a cohort of all commercially insured
adults. Procedures examined included coronary artery bypass
grafts (CABGs), angioplasties (PTCAs), cardiac
catheterizations and angiographies, stress echocardiograms,
nuclear stress tests, stress EKGs, and echocardiograms. ICD9, CPT and HCPCS codes identified ACS diagnoses and
associated coronary procedures. Procedure rates were also
stratified by patient and provider characteristics.
Population Studied: The population was a cohort of all adults
enrolled in BCBSRI commercial products who experienced
coronary symptoms for the first time between July 1 and
December 31, 2003. A first-time experience was defined as not
having had a previous claim associated with coronary
symptoms or treatment procedures in the year preceding the
study period; individuals also had to be continuously enrolled
at BCBSRI for this period. During the last half of 2003, a total
of 1,570 subscribers experienced initial coronary symptoms.
Principal Findings: There was some duplication for the
noninvasive diagnostic stress tests (about 5 percent of 720
who had initial test), and none for CABGs and PTCAs.
However, 12 percent (2 of 17) of adults who had an
angioplasty in the 4 week period had initially received a cardiac
catheterization at a hospital without revascularization
capabilities, while 40 percent (2 of 5) receiving a CABG had
also undergone a prior catheterization. The majority of
duplication in the stress tests occurred within the first 7 days
of the initial test; duplicate tests were performed by the same
physicians and concentrated among a small number of
physicians.
Conclusions: Although little duplication of coronary
procedures is evident among BCBSRI enrollees, there may be
unnecessary use of invasive services, particularly in receiving
cardiac catheterization at one location but treatment at
another. The concentration of duplicate stress tests among a
few physicians illustrates variations in physician practice
patterns, which suggest deviations from best practices.
However, these findings should be confirmed using a larger
cohort of BCBSRI enrollees.
Implications for Policy, Delivery, or Practice: Inefficiencies
due to the duplication of invasive procedures may not be
problematic for insurers although further research should be
conducted. However, the concentration of duplicate stress
testing among a few physicians may suggest the practice of
defensive medicine and variations in physician practice
patterns rather than problems with poor initial test quality or
inadequate information sharing across providers.
Primary Funding Source: Blue Cross & Blue Shield of Rhode
Island
●Achieving NCEP Goals in Patients with Diabetes: Results
from the VDIS Trial
Charles MacLean, MDCM, Amanda Kennedy, PharmD,
Benjamin Littenberg, M.D., Richard G Pinckney, M.D., MPH,
Phillip Ades, M.D.
Presented By: Charles MacLean, MDCM, Associate Professor,
Primary Care Internal Medicine, University of Vermont College
of Medicine, 371 Pearl Street, Burlington, VT 05401; Tel:
(802)847-8268; Fax: (802)847-0319; Email:
charles.maclean@vtmednet.org
Research Objective: Cholesterol management is essential in
the preventive care of patients with diabetes. Recently, the
National Cholesterol Education Program (NCEP) released a
report providing updated treatment recommendations. It
includes an optional LDL goal of <70 mg/dL for patients who
are at very high risk for coronary heart disease (CHD). It is
unknown how feasible this may be for very high risk patients
with diabetes. Our goal is to assess the feasibility of attaining
both the standard and the new optional LDL goals using
currently available medications.
Study Design: We performed a cross sectional analysis of
laboratory data from the Vermont Diabetes Information
System (VDIS), a large randomized trial of a decision support
system for patients with diabetes. Medication lists were
obtained by direct observation during a home interview.
Patients were categorized into high and very high risk CHD
status, based on NCEP criteria. For patients not at LDL goal
we estimated the changes in therapy necessary to achieve
goals, based on best evidence regarding medication
effectiveness from the literature. We used optimistic
assumptions regarding adherence and tolerability of
medications.
Population Studied: Adults with diabetes enrolled in the
Vermont Diabetes Information System (VDIS),under care by a
primary care provider in 47 practices in Vermont and northern
New York (N=650).
Principal Findings: The median age of the subjects was 66
years (range 25-93), the median duration of diabetes was 7.4
years (SD 10.1), and the mean A1C 7.1% (SD 1.3). Of the entire
cohort, 49.4% (321/650) had an LDL < 100 mg/dL. 29.4%
(191/650) of patients were at very high risk for CHD and,
according to the NCEP, have an optional LDL goal of < 70
mg/dL. Only 15.7% (30/191) of very high risk patients had an
LDL < 70 mg/dL. Of high risk patients, 17/459 (3.7%) would
require more than two lipid-lowering drugs to achieve an LDL
< 100 mg/dL. In the very high risk group, we estimate one
quarter (50/191; 26.2%) of patients would require at least
three drugs to reach an LDL < 70mg/dL.
Conclusions: In many patients with diabetes at very high
CHD risk, it will be difficult to attain an LDL goal of < 70
mg/dL. Approximately one quarter of patients will require
more than two lipid lowering drugs at maximal doses to attain
this goal, even assuming 100% tolerability of and adherence
to lipid therapy.
Implications for Policy, Delivery, or Practice: Given that
three-drug lipid lowering therapy has not been tested in
clinical trials, the latest recommendations from the NCEP
regarding lipid lowering therapy for patients with diabetes may
be overly aggressive.
Primary Funding Source: National Institute of Diabetes,
Digestive and Kidney Diseases
●Evaluation of an Interactive Voice Recognition (IVR)
Disease Management Intervention on Outcomes of Care
for Adults with Persistent Asthma
David Mosen, Ph.D., MPH, William Vollmer, Ph.D., Elizabeth
O'Connor, MS, Dawn Peters, Ph.D., Michael Kirshner, DDS,
MPH, Sonia Buist, M.D.
Presented By: David Mosen, Ph.D., MPH, Program
Evaluation Consultant, Care Management Institute, Kaiser
Permanente, 500 NE Multnomah, Suite 240, Portland, OR
97236; Tel: (503)813-3827; Fax: (503)813-2428; Email:
david.mosen@kp.org
Research Objective: Interactive Voice Recognition (IVR)
technologies offer a cost-effective method to deliver
automated, low intensity outreach for persistent asthmatics.
This technology can be used to not only provide useful
asthma health education, but can alert health providers when
a patient’s asthma is poorly controlled. Despite these
apparent benefits, little research has evaluated the impact of
such interventions on outcomes of care. The primary objective
of this study is to evaluate the impact of an IVR Disease
Management Intervention on medication use, asthma-related
hospital and emergency department (ED) utilization, asthma
control, quality of life assessment (QOL), and satisfaction with
care.
Study Design: Using an intent-to-treat study design, we
randomized 6948 adults with persistent asthma to receive
usual care (UC, n = 3367) or an asthma outreach program
(AOP, n = 3581). The AOP consisted of 3 calls spaced evenly
over 11 months. Computerized calls were made using IVR
technology. Each call lasted 5-10 minutes and asked about
recent acute care, patterns of medication use, and current
asthma control, followed by tailored feedback. Calls were
documented in the medical record, and high risk patients were
flagged for further follow-up. Random sample of the identified
population completed surveys at baseline and follow-up to
assess asthma control, QOL, and satisfaction with care.
Electronic medical data were obtained for all and used to
assess asthma related medication use and Hospital/ED
utilization. Appropriate bivariate statistical tests (e.g. chisquare, t-tests) were used to assess differences in outcomes
of care between the UC and AOP groups.
Population Studied: Adults with asthma enrolled in large
staff model HMO located in the Pacific Northwest.
Principal Findings: A total of 47% of AOP participants
completed >=1 call. Those responding were significantly likely
to: be older and female, report worse QOL, and have used
more inhaled corticosteriods during the baseline year.
Overall, we found no significant (p < .05) differences at followup between UC and AOP for key study outcomes. However at
follow-up, the subset of AOP patients who completed calls,
compared to UC, use significantly more controller
medications, and reported significantly better QOL on
symptom and emotional scales and significantly greater
satisfaction with their asthma care, and tended (p=.11) to
report fewer asthma control problems.
Conclusions: Although we did not find a difference in
outcomes using the original intent-to-treat design, post hoc
analysis of actual AOP users suggests a possible benefit in
asthma-related health outcomes for the AOP intervention,
among those respondents that completed 1 or more calls.
Implications for Policy, Delivery, or Practice: Further
research is needed to evaluate the effectiveness of IVR
technologies as a medium to provide health education and
modify behavior change among persistent asthmatics. Such
research will provide needed information to health providers
on how to best modify these strategies to improve their
effectiveness.
Primary Funding Source: CDC
●Localizing Cancer: Community-Based Approaches
Toward Cancer Control in Georgia
Christopher Parker, MBBS, MPH, Karen Minyard, Ph.D.
Presented By: Christopher Parker, MBBS, MPH, Research
Associate II, Georgia Health Policy Center, 14 Marietta Street,
Atlanta, GA 30303; Tel: (404)463-9346; Fax: (404)651-3147;
Email: chrisparker@gsu.edu
Research Objective: A review and assessment of the progress
of a regional statewide initiative designed to allow for greater
cancer control at the local level.
Study Design: Qualitative program metanalysis and case
studies utilizing document review, interviews and focus group
sessions.
Population Studied: Participants in nine statewide regional
coalitions (N~1500)
Leadership representatives (N=36)
Principal Findings: 1) There was unprecedented
collaboration. The success in building these hitherto
unachievable local coalitions strengthened the local health
care sectors and paved the way for inter-regional synergism to
be formalized. 2) The groups demonstrated significant overlap
in regional thinking and program design. Many anticipated
that the greatest return on investment would likely be seen
from programs designed to address cancer prevention, early
detection and the management of access to treatment. 3)
Data acquisition was invaluable in the planning stages.
Community specific information unearthed the depth of
issues related to cancer control facing each region. This has
resulted in a greater sense of a moral duty and ethical
obligation to move toward implementation. 4) The regional
programs perceived themselves to be the ideal vehicles by
which ‘the science is taken to the people, and the people are
taken to the science’. 5) Most regions have limited research
capacity. The capacity for bench research is limited given the
lower educational levels of rural Georgia and the relative
paucity of tertiary academic institutions in many of the
regions. 6) Business involvement is an untapped potential. To
date most regions have reported only the polite involvement
of the business community in their planning.
Conclusions: In Georgia, cancer control has a real potential
to catalyze and engage local community collaborations for the
greater good of the state’s health care system. The
collaborations will nonetheless need tangible state and
business support to effectively implement these programs.
Implications for Policy, Delivery, or Practice: No other state
has previously attempted to “regionalize or localize” cancer
care and control in this way. Georgia’s experiment may
provide lessons for other interested states and policy makers
may consider these local collaborations as yet another prong
in the attack against cancer, that is a powerful adjunct to the
more research-oriented, and academic Centers of Excellence.
These local initiatives represent significant opportunities for
public-private partnerships that may well realize the resources
necessary to reduce the economic burden of cancer on local
communities and eventually states.
Primary Funding Source: Georgia Cancer Coalition
●Initial Non-Traumatic Lower Extremity Amputations
Among Veterans with Diabetes
Usha Sambamoorthi, Ph.D., Chin-lin Tseng, Dr.Ph., Mangala
Rajan, MBA, Patricia Findley, Dr.Ph., Leonard Pogach, M.D.,
MBA
Presented By: Usha Sambamoorthi, Ph.D., Health Scientist,
Center for Healthcare Knowledge Management, Department
Of Veterans Affairs, NJ Health Care System, 385 Tremont
Avenue, East Orange, NJ 07018; Tel: (973) 676-1000 x1512;
Fax: (973) 395 - 7111; Email: ushasambamoorthi@gmail.com
Research Objective: Non-traumatic lower extremity
amputations (LEA) occur at a markedly higher rate among
persons with diabetes. The objective of the study was to
identify initial (ILEA) and describe correlates of ILEA among
veterans with diagnosed diabetes.
Study Design: Secondary data analyses of merged Veteran
Health Administration (VHA) and Medicare claims data for
the fiscal years 1997 through 2000. ILEAs in FY 2000 were
identified using a two-step algorithm. In the first step,
amputations were identified using a comprehensive list of
status post-amputation codes and lower limb prosthetic codes
in addition to the actual procedure codes indicating
amputations. In the second step we initiated a backward
search of claims (look-back) to ensure that the observed
amputation is indeed an ILEA. To measure the extent of leftcensoring bias due to varying length of look-back period, we
estimated ILEAs by restricting the look-back period to 12, 18,
24 months and all years (between 3 and 10 years) of available
prior data.
Population Studied: Veterans using VHA facilities and
diagnosed with diabetes during FY 1997-1998. There were
436,080 VHA patients with diabetes in FY 2000.
Principal Findings: Overall, 2% (n = 9,617) had an LEA in FY
2000. ILEA estimates varied based on the look-back period
and the use of post-amputation codes and lower limb
prosthetic codes. ILEAs ranged from were from 4.6 per 1000
for the complete look-back period and 5.4 per 1000 for 12
months look-back period. Non-use of post-amputation and
prosthetic codes increased these estimates to 8.4 per 1000
and 13.8 per 1000 respectively. Multiple logistic regressions
revealed significant gender, race/ethnicity, age, foot-risk
factors (such as peripheral vascular disease, and ulceration)
and comorbid effects on the odds of having an ILEA. Veterans
who used both Medicare and VHA systems were more likely
to have an ILEA. However, this association was not
consistent across different look-back periods.
Conclusions: ILEA can be effectively identified using
administrative data. Using status post-amputation codes and
lower limb prosthetic codes in addition to actual procedure
codes considerably reduces the estimate (~62%). However,
the precision of ILEA estimates varied minimally as the lookback period increased.
Implications for Policy, Delivery, or Practice: These findings
highlight the usefulness of administrative data in identifying
individuals with ILEAs. Accurate identification of ILEAs is
critical to devise appropriate targeted interventions to reduce
amputations among individuals with diabetes.
Primary Funding Source: VA
●Practice Systems for Improving the Quality of Care for
Chronically Ill Persons
Sarah Scholle, Dr.PH., MPH, Greg Pawlson, M.D., MPH, Leif
Solberg, M.D., Sarah Shih, MPH, Steve Asche, MA, Merry Jo
Thoele, MPH
Presented By: Sarah Scholle, Dr.PH., MPH, Assistant VP,
Research and Analysis, NCQA, 2000 L Street, NW Suite 500,
Washington, DC 20036; Tel: (202)955-1726; Fax: (202)9553599; Email: scholle@ncqa.org
Research Objective: To perform feasibility, reliability, and
validity testing on the Practice Systems Assessment Survey
(PSAS), a self-report survey developed by the National
Committee for Quality Assurance to measure the presence,
scope, and function of organized systems in office practice. A
widely cited reason for poor performance in ambulatory care is
the finding that physician office systems and processes are
not optimally designed to address the care of persons with
chronic diseases or preventive needs. The goal of this
instrument is to provide a relatively simple way to identify
such systems for quality improvement, public accountability,
and pay-for-performance.
Study Design: The PSAS was developed with input from an
expert panel and assesses key components of practice
systems identified in the Chronic Care Model: continuity of
care, clinical information systems, systematic monitoring,
clinician reminders, performance tracking and feedback,
quality improvement, care management, and patient
education and support. After pretesting and subsequent
refinements of items, a stratified sample of clinical personnel
was surveyed. Trained nurse reviewers conducted on-site
audits to verify the presence and use of the practice systems
addressed in the survey. The surveys were compared to audit
data in order to determine which staff position could provide
the most accurate information about each section of the
PSAS.
Population Studied: Eleven medical groups in Minnesota,
including primary and multi-specialty groups located in
metropolitan and non-metropolitan areas.
Principal Findings: A total of 328 surveys were completed by
varying personnel in participating medical groups. Response
rates by medical group ranged from 61% to 94% with a mean
of 76%. Among the 11 groups, one had a fully integrated
electronic medical record (EMR), three had EMRs with freestanding systems, six had paper records supplemented with
electronic systems, and one had only paper-based records.
Agreement between the audit and the survey responses on the
functional capacity of the electronic systems varied by function
and was highest for the most commone functions. For
example, agreement was high (89.2% to 98.6%) regarding the
ability of electronic systems to do scheduling, medication
order entry, and alerts on drug-drug interactions. Agreement
was lower for functions such as laboratory order entry and
ability to search for patients based on diagnosis, with nurses
having better agreement with the audit than physicians.
Further analyses will assess interrater reliability and validity for
the remaining PSAS domains.
Conclusions: The degree of agreement on the capability of
information systems varies by medical personnel and the type
of system. Additional analyses and findings will report which
respondents most accurately reflect local reality on other
systems such as care management, quality improvement and
performance monitoring.
Implications for Policy, Delivery, or Practice: Information
from this study will identify which medical personnel can most
accurately report on the presence and function of practice
systems relevant to quality care for patients with chronic
conditions. The PSAS could help identify which systems
should be targeted for improvement and potentially serve as a
standardized metric for assessing and benchmarking office
systems for public accountability and pay-for-performance
efforts.
Primary Funding Source: RWJF
●Internet-based, Personalized, Patient Activation Feedback
to Improve Hypertension Guideline Adherence Does not
Harm Patient Perceptions of Care
Christopher Sciamanna, M.D., MPH, Edgar R. Miller, M.D.,
Ph.D, Michael Manocchia, Ph.D, Sarah Mui, B.S., Anthony N.
Sciamanna, B.S., Christopher J. Pignatelli, B.S.
Presented By: Christopher Sciamanna, M.D., MPH, Associate
Professor, Health Policy, Jefferson Medical College, 1015
Walnut Street, Suite 115, Philadelphia, PA 19107; Tel: (215)9554376; Fax: (561)892-0511; Email:
chris.sciamanna@jefferson.edu
Research Objective: To improve blood pressure control rates,
we developed a patient activation website to provide
computer-tailored hypertension feedback. The website asks
questions and provides feedback that highlights areas where
their care adheres to guidelines and areas where their care
does not, and encourages patients to ask questions during
doctor visits that would lead to changes in their hypertension
care.
Study Design: The study was designed as a randomized
controlled trial with a delayed treatment control, to measure
the effect of using the website on a patients’ perception of the
quality of their high blood pressure care.
Population Studied: Subjects (121) with a history of
hypertension and with access to the Internet were recruited to
use the website and to answer questions about their health
and health care before or after using the website.
Principal Findings: The mean age of participants was 46.8
years and the mean duration of high blood pressure was 8.2
years. On average, participants received 8 corrective feedback
paragraphs, which recommended a change to their care. Most
participants rated the website as “excellent” or “very good”.
Satisfaction with hypertension care was generally high, scoring
a 3.8 out of 5. Subjects who answered the satisfaction with
hypertension care questions before (59) and those who
answered the questions after (62) using the website had
similar responses with no significant differences in overall
care or in any of the 4 dimensions of satisfaction with
hypertension care or with their hypertension provider.
Conclusions: Though our web-based, patient activation
program identified gaps in the quality of hypertension care,
the feedback did not adversely effect patient’s perceptions of
the quality of their hypertension care.
Implications for Policy, Delivery, or Practice: Concerns that
providing physician-specific performance data to patients will
harm the doctor-patient relationship may be overestimated.
Primary Funding Source: NHLBI
●Effects of a Website Designed to Improve Patientprovider Interactions for the Management of Migraines.
Christopher Sciamanna, M.D., MPH, Robert A.Nicholson,
Ph.D., Jennifer H. Lofland, Ph.D., Michael Manocchia, Ph.D.,
Sarah Mui, BS, Christine W. Hartmann, Ph.D.
Presented By: Christopher Sciamanna, M.D., MPH, Associate
Professor, Health Policy, Jefferson Medical College, 1015
Walnut Street, Suite 115, Philadelphia, PA 19107; Tel: (215)9554376; Fax: (561)892-0511; Email:
chris.sciamanna@jefferson.edu
Research Objective: To improve migraine care, we developed
a patient activation website to provide computer-tailored
migraine feedback. The website asks questions and provides
feedback that highlights areas where their care adheres to
guidelines and areas where their care does not, and
encourages patients to ask questions during doctor visits that
would lead to changes in their migraine care.
Study Design: This study was conducted to examine the
effect of using the program on care that patients with
migraine report receiving during a visit with their migraine
care provider. Fifty-three migraine patients from a managed
care organization were recruited and randomized to use the
website before a doctor visit or to a delayed treatment control
condition.
Population Studied: Managed Care Organization patients
with at least two visits coded for headache or migraine in the
previous year.
Principal Findings: Overall, the mean age was 42.0 years,
most patients were female (86.5%), all were white, and 58.5%
saw a headache specialist during their visit. Most (75.0%)
reported having headaches at least once per week and 48.1%
rated their headaches as “severe”. After the intervention,
satisfaction with the visit was generally high (3.9 out of 5.0)
and a mean of 5.0 topics were discussed during the visits.
These differences were only significantly, however, for the
report of discussing “whether you had migraine headaches or
some other type of headache” (89.3% v. 54.5%; p < 0.01) and
“whether or not there may be a more serious cause of your
headaches” (50.0% v. 13.6%; p < 0.01). Among patients in the
intervention condition, most (78.6%) printed the feedback
from the website, though far fewer (28.6%) brought the
feedback during their visit. Most (64.3%) reported asking
questions that were suggested by the website.
Conclusions: The patient activation website led to significant
differences in migraine-related topics addressed during visits.
Future studies are planned to understand the effects of the
intervention on migraine-related outcomes.
Implications for Policy, Delivery, or Practice: Patient
activation interventions hold promise for improving the quality
of care for chronic medical conditions.
Primary Funding Source: NHLBI, NIAMS
●Reliance on VA/Medicare by Dually Eligible Veterans with
Diabetes
Yujing Shen, Ph.D., Mangala Rajan, MBA, Donald Miller,
Sc.D., Steven Crystal, Ph.D., Leonard Pogach, M.D., MBA
Presented By: Yujing Shen, Ph.D., Assistant Research
Professor, Institute for Health, Health Care Policy and Aging
Research, Rutgers University, 30 College Avenue, New
Brunswick, NJ 08901; Tel: (732)932-8148; Fax: (732)932-6872;
Email: yshen@ihhcpar.rutgers.edu
Research Objective: Many older U.S. veterans are eligible for
health care from both the Veterans Administration (VA) and
from other providers with Medicare coverage. In order to
better understand what influences choice for health services,
we assessed reliance on VA and Medicare care by dually
eligible veterans with diabetes and explored the factors
associated with their reliance.
Study Design: This is a cross-sectional analysis using data
from the 1999 VA Diabetes Epidemiology Cohort (DEpiC)
which includes VA and Medicare medical encounter files and
the 1999 Large Health Survey of Veterans. We studied patients
with Medicare fee for service in 1999. We identified those with
inpatient care in VA only as VA reliant, those with inpatient
care in Medicare only as Medicare reliant, and those with both
VA and Medicare inpatient care as dual reliant. For those with
outpatient but no inpatient, we grouped them into VA,
Medicare and dual reliant also based on the source of their
outpatient care. For multivariate analysis, we integrated both
inpatient and outpatient groups together. Logistic regression
was used to test the association between reliance on
VA/Medicare (VA, dual, and Medicare reliant) and a number
of factors including veterans' VA eligibility (priority) status,
health status (by SF 36), travel distance to the closest VA and
non-VA hospitals, and age, sex, race, education, and marital
status.
Population Studied: VA-Medicare dually eligible veterans with
diabetes who had Medicare fee-for-service coverage in 1999
(N=90,193).
Principal Findings: Overall, 13.9% used VA inpatient care
only, 16.1% used Medicare inpatient only, 3.5% used both
system for inpatient care, and 66.6% had no inpatient care
(30.3% had VA outpatient only, 2% had Medicare outpatient
only, 34.1% had outpatient care in both system). Those who
were more likely to be VA reliant were: 50%+ service
connected-disabled (VA priority 1) or catastrophically disabled
(VA priority 4), younger age, smoker, non-white, less
educated, unmarried, worse physical health status. Travel
distance to VA or non-VA hospitals affected their use of care.
For example, 10 extra miles of traveling to VA hospital
decreased the chance of being VA reliant by 9% while 10 extra
miles of traveling to non-VA hospitals decreased the chance of
being Medicare reliant by 9%.
Conclusions: Slightly more dually eligible VA patients with
diabetes relied on Medicare for inpatient care, but the vast
majority relied on either VA or both systems for outpatient
care. Many factors in addition to access to traveling distance
to care were associated with reliance on VA/Medicare care.
Implications for Policy, Delivery, or Practice: Given that
care is split between both systems in those with dual
eligibility, strategies for care coordination across systems
should be developed.
Primary Funding Source: VA
●Barriers and Adaptations of Rural Diabetes Management
Programs
Anne Skinner, BS, RHIA, J. Patrick Hart, Ph.D., Roslyn Fraser,
BA
Presented By: Anne Skinner, BS, RHIA, Health Data Analyst,
Preventive and Societal Medicine, University of Nebraska
Medical Center, 984350 Nebraska Medical Center, Omaha, NE
68198-4350; Tel: (402) 559-8221; Fax: (402) 559-7259; Email:
askinner@unmc.edu
Research Objective: To inform the development of
appropriate policy and programmatic responses to the
widespread need for diabetes care management in rural
settings. This objective addresses the high proportion of
diabetes cases combined with lack of resources that exists in
rural areas.
Study Design: An initial list of agencies, foundations, and
associations involved in chronic disease management was
compiled through discussions with key policy and practitioner
informants. The list led to an internet search of websites and
publications to identify, review, and describe rural chronic
disease management initiatives throughout the United States.
Next, we conducted interviews of representatives of diabetes
programs at the national, state, and local levels across the five
major diabetes initiatives in a geographically stratified sample
of six states. We asked questions dealing with organizational
and program characteristics, partnerships, barriers,
effectiveness of the program, and considerations made for
rural facilities. Interviews were transcribed and analyzed using
NVivo software.
Population Studied: National, state, and local level diabetes
management programs across five major diabetes initiatives:
CDC Diabetes Prevention and Control Programs, Health
Disparities Collaboratives, Quality Improvement
Organizations, Certified Rural Health Clinics, and the Office of
Rural Health Policy Outreach and Network Programs.
Principal Findings: At the time of this submission, interviews
are complete and analysis is scheduled to be finished by
February 1st. Preliminary findings indicate that several barriers
to successful diabetes management programs are inherent in
rural communities. Barriers include travel distances and
isolation, low health literacy, cultural and linguistic diversity,
lack of data registry management resources, time demands of
collaborative activities, absence of locally controlled media,
and challenges of integrated technology. Important
adaptations that contribute to the success of diabetes
management programs in rural areas include the
development of formal and informal networks and
collaborative efforts to overcome the isolation of the rural
setting. Appropriate communications through the use of
multicultural literature, media that cater to many literacy
levels, and the hiring of bilingual and culturally competent
staff have also shown to increase the effectiveness of
programs as well as increase patient satisfaction. A systematic
approach through the implementation of an electronic disease
management system combined with data sharing also
appears to improve process and outcome measures.
Conclusions: In rural settings where high proportions of
chronic disease exist in combination with few resources,
additional basic support and locally appropriate adaptations
create successful chronic disease programs.
Implications for Policy, Delivery, or Practice: Our goal is to
produce and disseminate findings on the policy implications
of the relationship between current approaches to diabetes
care management and their appropriateness, effectiveness,
affordability and sustainability in rural service delivery settings.
Primary Funding Source: Office of Rural Health Policy
(ORHP)
●Nephrologists Care Reduced One-Year Mortality for
Diabetic Patients with Chronic Kidney Diseases
Chin-Lin Tseng, Dr.PH., Anjali Tiwari, M.D., MS, Elizabeth
Kern, M.D., Donald Miller, Sc.D., Leonard Pogach, M.D., MBA
Presented By: Chin-Lin Tseng, DrPH, Health Research
Scientist; Assistant Professor, Center of Health Care
Knowledge and Management, New Jersey Health Care systemEast Orange VA Medical Center; University of Medicine and
Dentistry of New Jersey, 385 Tremont Avenue; #129, East
Orange, NJ 07018; Tel: (973)676-1000 x2028; Fax: (973)3957114; Email: tseng@njneuromed.org
Research Objective: There has been scant information
available regarding the quality of care provided to patients
with chronic kidney diseases in the US. Our objective was to
evaluate the provision of nephrology specialist care among
diabetic veterans with chronic kidney diseases (CKD) and its
association with mortality when age, gender, race, medical
and psychiatric comorbidities, and ACEI/ARB/statin usage are
controlled for.
Study Design: This study was a retrospective study. We used
the 4 variable MDRD formula to determine eGFR (adjusted for
age, sex, race, and creatinine levels). Multiple logistic
regression was used to assess the impact of nephrologists
care on one-year dialysis free mortality while controlling for
age, gender, race, ACEI/ARB/statin medication, medical and
psychiatric comorbidities.
Population Studied: We used the Diabetes Epidemiology
Cohort (DEPIC) dataset from our prior work to identify
561,088 veterans with diabetes in Fiscal year (FY) 1999
without a diagnosis of end stage renal disease or dialysis in FY
1997 or 1998 and were alive as of 9/30/1998. A total of
263,730 (64.73%) diabetic veterans could definitely be
classified into one of the five stages according to K/DOQI
criteria. Death outcome was obtained within 365 days from
the initial eGFR during the study period. Further removal of
1,356 veterans who had dialysis prior to death during the
follow-up resulted in 261,507 veterans.
Principal Findings: The percentages of diabetic veterans by
CKD stages were 21.5% (CKD 1), 47.5% (CKD 2), 28.7% (CKD
3), 2.2% (CKD 4), and 0.2% (CKD 5), respectively. The overall
one year mortality rate in the study population was 3.6%.
About 6.4% of the entire CKD population had at least one
nephrologist visit after their initial eGFR during the study
period. The percentages of nephrologist visit markedly
increased at the more severe/later CKD stages: 1.1% (CKD 1),
1.9% (CKD 2), 13.5% (CKD 3), 54.8% (CKD 4), and 59.9%
(CKD 5). Our multiple logistic regression models showed that
older age, men, non-white racial groups, and more
comorbidities were all significantly (p<0.001) associated with
greater odds of death. Having nephrologist visits, on the other
hand, reduced the odds of death, but only for patients in the
later CKD stages. For patients in CKD stage 3, the odds ratio
(OR) was 0.62 (95% confidence interval (CI)=(0.56, 0.69)).
For patients in CKD stage 4 and 5 combined, the odds ratio
was 0.39 (95% CI=(0.33, 0.47)). The results were similar when
ACEI/ARB/statin usage was controlled for.
Conclusions: A low percentage of diabetic veterans with CKD
had any nephrologist visit after their initial eGFR. Nephrology
specialist care was associated with reduced one year mortality
among diabetic veterans with chronic kidney diseases,
especially for patients in devastating CKD stages.
Implications for Policy, Delivery, or Practice: Our data
suggest compliance with roposed “quality of care measures”
according to the K/DOQI and VA-DOD Guidelines needs to
be improved for diabetic veterans with chronic kidney
diseases. The health care systems need to make efforts in
delivering nephrology specialist care to patients with chronic
kidney diseases and patients are encouraged to seek such
specialist care.
Primary Funding Source: VA
●Decreased Mental Health Functioning is Associated with
Increased Risk of Amputations Among Veterans with
Diabetes
Chin-Lin Tseng, Dr.PH., Mangala Rajan, MBA, Anjali Tiwari,
M.D., Leonard Pogach, M.D., MBA
Presented By: Chin-Lin Tseng, Dr.PH., Health Research
Scientist; Assistant Professor, Center of Health Care
Knowledge and Management, New Jersey Health Care
System-EAst Orange VA Medical Center; University of
Medicine and Dentistry of New Jersey, 385 Tremont Avenue,
#129, East Orange, NJ 07018; Tel: (973)676-1000 x2028; Fax:
(973)395-7114; Email: tseng@njneuromed.org
Research Objective: Among individuals with diabetes, a
lower extremity amputations (LEA) is often a catastrophic
complication leading to poor quality of life, higher mortality
rates, more hearth care costs. Whether adverse mental health
is associated with increased risk of lower extremity
amputations (LEAs) has not been well defined. Our objective
was to evaluate the association between self reported mental
health functioning upon risk of LEAs in veterans with diabetes
using patient level administrative data as well as the 1999
Large Veterans Health Survey data (LVHS).
Study Design: This study was a retrospective longitudinal
cohort design. The outcomes were amputations in FY2000.
Minor (toe or transmetarsal) or major (transtibial or
transfemoral) amputations were determined from hospital
discharges using the highest-level amputation. Mental
Component Summary (MCS) from SF36 questions available
from LVHS was used as a measure of mental health
functioning. Other independent variables included selfreported demographics, foot risk factors(peripheral vascular
disease, infections, ulcers and deformities), medical
comorbidities, health behaviors (smoking and alcohol
drinking), social support (being married, not living alone, and
someone available to take to see a doctor) and physical
component score (PCS) from SF36. All independent variables
as measured in FY1999 were entered into a multinomial
(polytomous) logistic regression model; variables with pvalues less than 0.05 were removed from the model. We
reported odds ratios (OR’s) and 95% confidence intervals
(CI’s).
Population Studied: We analyzed 305, 218 veteran clinical
users with diabetes who were dually enrolled in Medicare feefor service in fiscal year (FY) 1999 and FY2000 alive at the end
of FY2000. A total of 97,652 completed the LVHS. We limited
our analyses to those that had no recorded amputations in
FY1998 or FY1999; it resulted in 96,242 veterans with diabetes
for the statistical analysis.
Principal Findings: Of the study cohort 96,242 diabetic
veterans, 98.5% were men and the average age was 69.3
(±8.5) years old. There were 346 (3.6 per1000) minor and 366
major (3.8 per 1000) amputations in FY2000. The average
MCS score was 43.4 (±13.4). MCS was significantly related to
major amputations with decreased mental functioning per five
points related to 7% increase in the risk of major amputations
(Odds ratio=1.07, 95% confidence interval=(1.03, 1.11)), but
was not related to risk of minor amputations. All independent
variables except for foot deformity and having someone to
take to the doctor were significantly associated with LEAs.
Conclusions: Decreased mental health functioning was
associated with a higher risk of amputations, especially major
amputations in veterans with diabetes when age, race, foot
risk factors, medical comorbidities, social support, and
physical functioning were controlled for.
Implications for Policy, Delivery, or Practice: Individuals
with foot risk factors and lower mental health functioning may
be candidates for foot care coordination programs that
incorporate physical and mental health assessment and care.
Mechanisms through which mental health affects amputation
outcomes will need further study.
Primary Funding Source: VA
●Glycemic Control and Labor Market Participation
Kaan Tunceli, Cathy J. Bradley, Jennifer Elston-Lafata, Manel
Pladevall, Allen Goodman, George Divine, Deneil M. Kolk,
Hugo Xi, Kemeng Li
Presented By: Kaan Tunceli, Ph.D., Research Scientist, Center
for Health Services Research, Henry Ford Health Systems, 1
Ford Place, Suite 3A, Detroit, MI 48202; Tel: 313-874-5485; Fax:
313-874-1883; Email: ktuncel1@hfhs.org
Research Objective: To examine the effect of glycemic control
measured by HbA1c on labor market outcomes among
patients with diabetes aged 30-64.
Study Design: We used automated data sources available
within a large multi-specialty medical group, to identify eligible
study participants with diabetes and their glycemic control
status in 2003. Data from a telephone survey administered to
a random sub-sample of 423 eligible patients stratified by
glycemic control level was used to solicit information
regarding employment status, working hours, and
absenteeism in 2004. Glycemic control was defined by
average HbA1c during 12 months prior to interview date and
classified into five categories (< 7%, 7-7.9%, 8-8.9%, 9-9.9%, •
10%). We estimated the effect of glycemic control on the
probability of working using a multivariable probit model
(N=415). Among those who are working, we estimate the
effect of diabetes on usual weekly hours worked, and work-loss
hours in the last week using multivariable ordinary least
squares regressions (N=210). Age, gender, race, marital
status, education, comorbidities, body mass index (BMI), and
insulin usage were controlled.
Population Studied: Study participants were drawn from the
patients of a non-profit large multi-specialty salaried medical
group providing care to the residents in southeastern
Michigan, including Detroit and its surrounding metropolitan
area. Patients with diabetes were identified according to their
hospital discharge diagnosis, outpatient encounters,
prescription drugs dispensed, and outpatient laboratory
results in 2003. In addition, we restricted the sample to
patients who were aged 30-64 at the time of the interview and
who had at least one HbA1c test result during the one year
before the interview.
Principal Findings: The interview participation rate was
57.9%, with a lower rate (50.6%) among those with HbA1c •
10. No HbA1c category was statistically associated with
employment status cross-sectionally. Among those who work,
relative to patients with HbA1c < 7, patients with 9% • HbA1c
< 10% and patients with HbA1c • 10% had 4.8 (p < 0.05) and
4.3 (p < 0.10) more work-loss hours per week respectively.
HbA1c levels were not significantly associated with usual
weekly hours worked.
Conclusions: There might not be a systematic relationship
between glycemic control and employment when observed
cross-sectionally. It seems that poor glycemic control among
employees with diabetes increases absenteeism, and thereby
leads to productivity losses. Our analyses suggest that
interventions designed to improve glycemic control are likely
to yield labor economic benefits in addition to preserving
health status and quality of life of individuals with diabetes.
Future research is needed to explore the effect of changes in
glycemic control on employment and productivity losses
longitudinally.
Implications for Policy, Delivery, or Practice: Information
on the effect of glycemic control on labor market outcomes
will be useful for evaluating the cost-effectiveness of
interventions aimed toward glycemic control among patients
with diabetes.
Primary Funding Source: Wayne State University
●Development and Preliminary Evaluation of a
Computerized Adaptive Assessment for Asthma
(ASTHMA-CAT)
Diane Turner-Bowker, Ph.D., Renee N. Saris-Baglama, Ph.D.,
Milena D. Anatchkova, Ph.D., David Mosen, Ph.D., MPH, John
E. Ware, Jr., Ph.D.
Presented By: Diane Turner-Bowker, Ph.D., Senior Scientist,
Director of Grants & Research Administration, QualityMetric
Incorporated, 640 George Washington Highway, Lincoln, RI
02865; Tel: (401)334-8800 x230; Fax: (401)334-8801; Email:
dtbowker@qualitymetric.com
Research Objective: To develop and field test a prototype
patient-based system for assessing asthma impact and
control (ASTHMA-CAT) that combines asthma-specific and
generic health-related quality of life (HRQOL) measures in a
single administration, and that yields user-friendly aggregate
reports likely to enhance care management and improve
decision-making.
Study Design: The ASTHMA-CAT system was programmed
for administration via the Internet and included: (a) either the
DYNHA Asthma Impact Survey (AIS) [a dynamic survey which
uses item response theory (IRT) models and computerized
adaptive testing (CAT) methods to provide practical and
precise measurement at the individual patient level] or a static,
full-length Asthma Impact Survey (AIS); (b) the Asthma
Control Test (ACT), a static short-form measure of asthma
control; (c) the SF-8 Health Survey, a static short-form generic
health status measure; (d) a socio-demographic survey; and
(e) a patient User’s Evaluation Survey. This new short, yet
comprehensive Internet-based dynamic health assessment
was then pilot tested in a small sample of clinician-diagnosed
asthma sufferers to evaluate the feasibility, efficiency, and
accuracy of the ASTHMA-CAT. Participants were randomly
assigned to complete either the dynamic AIS (n=55) or a fulllength static AIS (n=59). All participants completed the ACT,
SF-8, socio-demographic and User’s Evaluation Survey.
Finally, a prototype aggregate (or group-level) report was
developed and evaluated by clinician providers in disease
management.
Population Studied: Participants were 114 adults with current
asthma randomly sampled from a population of 10,000 adult
members with chronic disease in Kaiser Permanente’s (KP)
Care Management Institute (CMI). The sample was drawn
from 16 metropolitan statistical areas (MSA) across six
regions: Northern California (6 MSAs), Southern California (6
MSAs), Colorado (1 MSA), Georgia (1 MSA), Hawaii (1 MSA),
and the Northwest (1 MSA). The final working sample was
primarily comprised of White, non-Hispanic, educated women
with mild to moderate asthma, reporting an average age of 45
years.
Principal Findings: Response burden, measurement
precision, discriminant validity, and users’ evaluation of the
dynamic and static full-length Asthma Impact Surveys (AIS)
were compared using t-test and ANOVA. The dynamic AIS
was completed in significantly less time (M=50.4 seconds)
than the static full-length AIS (M=387.4 seconds) [t(112)=-9.84,
p=.00]; and achieved equally precise score estimation
[t(109)=1.18, p=.24] with substantially fewer items (M=5 items)
than the full-length survey. The dynamic AIS discriminated
those with mild (M=40.0), moderate (M=52.0) and severe
(M=66.1) asthma [F(2,51)=29.17, p=.00]. The dynamic AIS
was also significantly easier to complete than the static fulllength survey [t(104)=2.10, p=.04]. 100% of those who took
the dynamic AIS indicated that the survey was appropriate in
length, compared with 67.8% of those who took the full-length
static survey. Generally, very positive feedback was gained
from providers regarding the format, relevance, and
usefulness of the prototype aggregate report in asthma care
evaluation and planning.
Conclusions: ASTHMA-CAT is a comprehensive, yet efficient
measurement system for adults with asthma.
Implications for Policy, Delivery, or Practice: Enhancing the
accessibility and interpretability of HRQOL tools and other
patient-based assessments will make asthma management
more effective in meeting patient care needs.
Primary Funding Source: NIH: National Heart, Lung, and
Blood Institute
●Primary Care Provider Concerns about Treatment of
Chronic Pain
Carole Upshur, EdD, Judith Savageau, MPH, Roger
Luckmann, M.D.
Presented By: Carole Upshur, EdD, Professor, Family
Medicine and Community Health, University of
Massachusetts Medical School, 55 Lake Avenue North,
Worcester, MA 01655; Tel: (508)334-7267; Fax: (508)856-1212;
Email: carole.upshur@umassmed.edu
Research Objective: To identify the scope, concerns and
barriers to chronic pain treatment by primary care providers in
community-based health centers serving a diverse population
in terms of ethnicity and socioeconomic status.
Study Design: Survey of all PCPs at 6 federally qualified
community health centers and two primary care clinics who
had a primary care patient panel
Population Studied: Primary care providers, including
attendings, residents and nurse practitioners.
Principal Findings: The overall response was n=111, or 62.3%.
The mean percent of reported patients on the PCP’s schedule
from a randomly selected week with a current chronic pain
compliant was 37.5%. Providers ranked patient factors, such
as lack of self-management, psychological issues, lack of
compliance, and occupation as the four highest as barriers to
achieving adequate pain management; and ranked such
provider and health care system factors as difficulties
coordinating care among multiple chronic conditions, lack of
evidence based guidelines, time for careful diagnosis, lack of
tracking systems, and difficulties assessing patients as less
frequent barriers than patient factors. PCPs also reported they
were only minimally likely to prescribe opioids for chronic pain
Fear of the patient becoming addicted, and fear of the patient
selling the opioids were ranked as the highest concerns, with
uncertainty about the appropriateness of opioid use ranked
third, followed by patients becoming a target for illegal drug
users, and worries about side effects. Ranked last was worries
about safety. Worriers about law enforcement oversight were
surprisingly ranked 6th. Providers report moderate use of
some patient centered-care techniques, however provision of
patient education materials is ranked last among 12 options
for assisting patients to manage their pain. Finally, providers
ranked their satisfaction with treating their patients with
chronic pain as quite low, M= 1.9 (SD=.81) on a scale where
0=not at all satisfied and 4= very satisfied. In addition, overall
rankings of the level of pain management education received
in medical or professional school, post graduate medical
education, continuing education or on the job experience were
extremely low. On a scale of 0=insufficient, 1=adequate,
2=good and 3= very good, the mean ranking was .5 (SD=.8),
for medical school,.35 (SD=.67), for post-graduate medical
education .7 (SD=.84), and for continuing education .9
(SD=.82).
Conclusions: Patients with chronic pain complaints represent
a large proportion of primary care visits in a typical week.
Providers report overall insufficient training on chronic pain
management throughout their educational experiences and
very low levels of satisfaction in their ability to treat these
patients. At the same time, they tend to identify patient
barriers as more troublesome than provider or health care
practice structures in adequately addressing patient pain
complaints or in prescribing opioids. They do not use some
common patient-centered interventions, such as educational
materials very frequently.
Implications for Policy, Delivery, or Practice: Provider
training on managing chronic pain needs to be improved
dramatically, including how to appropriately use opioid
therapy and how to engage in more patient-centered care. In
addition, practice delivery systems using chronic care models
need to be developed for chronic pain patients similar to other
chronic conditions.
Primary Funding Source: AHRQ
●Implementing a Chronic Care Model for Depression
Management in an Adult Medicaid Population
Carole Upshur, EdD, Linda Weinreb, M.D.,
Presented By: Carole Upshur, Ed.D., Professor, Family
Medicine and Community Health, University of
Massachusetts Medical School, 55 Lake Avenue North,
Worcester, MA 01655; Tel: (508)334-7267; Fax: (508)856-1212;
Email: carole.upshur@umassmed.edu
Research Objective: To implement a chronic care model of
management for adults with depression insured by
Massachusetts Medicaid managed care programs, measure
outcomes, and identify systems and economic barriers to
sustainability.
Study Design: A longitudinal, nonexperimental design in six
primary care practices. Practices systematically screened all
MassHealth adults in their patient panels for depression using
the PHQ-9 instrument and implemented chronic care
management for major depression.
Population Studied: Adults ages 18-64 enrolled in four
managed care plans in the Massachusetts Medicaid program.
Principal Findings: A total of 1025 adults were screened. The
sample included 49% white, 38% Latino, 9% Black, and 5%
other, with a mean age of 41 years, 75% female. A mean rate
of 30.8% achieved screening scores indicating possible major
depression, while an additional 17.2% had moderate
depressive symptoms. 30.1% of patients entered care
management, which consisted of periodic supportive phone
calls and visits with either a nurse or social worker. 59% of
patients remained in active care management for 6 months.
Patients referred to care management had high rates of
comorbid medical illness (60% had one or more of
hypertension, diabetes, asthma etc.), and comorbid
psychiatric symptoms (e.g. panic, anxiety, history of physical
or sexual abuse) at baseline. Mean care manager telephone
contacts (3.8),and in -person visits (1.6) over the 6 months
were modest, while significant clinically improvement was
found in 39% of cases at follow up (PHQ-9 <10 points or 50%
improvement). Analysis revealed that Hispanic ethnicity, lack
of prior depression treatment, absence of bipolar or psychotic
symptoms, and absence of tobacco use explained outcome
scores at 6 months. In addition, preliminary analyses of
health care utilization, independent of absolute level of care
management, calculated in PMPM units one year prior to
enrollment in care management and one year after referral to
care management, revealed significant decreases in acute
primary care visits, significant increases in behavioral health
office visits, and a trend to increased antidepressant
medication prescribing. Rates of hospitalization were
extremely low in both periods and not significantly different.
Conclusions: Chronic care approaches to identification and
management of depression can be successfully implemented
in primary care practices serving Medicaid adults. The
prevalence of major depression is high, approximately 6 times
the level in the general population, and is accompanied by
multiple medical and psychiatric comorbidity. Nevertheless, a
relatively modest level of care management support over a
period of 6 months assisted in helping a large percentage of
the patients achieving clinically significant relief of their
depression symptoms. At the same time, implementation of
a chronic illness management intervention in this sample is
associated with redistribution, rather than overall increases, in
health care utilization.
Implications for Policy, Delivery, or Practice: Major
depression rates are extremely high among Medicaid-insured
adults and it is often unrecognized or under treated, in part
because symptoms of depression are confused with natural
reactions to difficult life circumstances. There is potential for
significant reduction in morbidity and more appropriate health
and behavioral health care utilization.
Primary Funding Source: RWJF
●Risk Indices for Adverse Outcomes After Surgery For
Small Bowel Obstruction
Katherine Virgo, Ph.D., MBA, Julie A. Margenthaler, M.D.,
Walter E. Longo, M.D., Frank E. Johnson, M.D., Tracy L.
Schifftner, MS, William G. Henderson, Ph.D.
Presented By: Katherine Virgo, Ph.D., MBA, Professor,
Surgery, Saint Louis University & St. Louis VAMC, 3635 Vista
at Grand Boulevard, Saint Louis, MO 63110-0250; Tel: (314)
289-7023; Fax: (314) 289-7038; Email: virgoks@slu.edu
Research Objective: The study objectives were to identify risk
factors for adverse outcomes following surgical treatment of
small bowel obstruction (SBO) and develop an easy-to-use
tool for clinicians to improve patient care.
Study Design: Using prospectively collected data,
independent variables examined included 68 pre-surgical and
12 intra-operative clinical risk factors; dependent variables
were 21 specific adverse outcomes including death. Stepwise
logistic regression analysis was used to construct models
predicting 30-day morbidity and mortality rates and to derive
risk index values. Patients were then divided into risk classes.
Population Studied: The Veterans Affairs (VA) National
Surgical Quality Improvement Program (NSQIP) contains
prospectively collected and extensively validated data on
>1,000,000 patients. All patients undergoing either
adhesiolysis only or small bowel resection with anastomosis
for SBO from 1991-2002 were selected for study.
Principal Findings: Of the 2,002 patients identified, 1,650
underwent adhesiolysis only and 352 underwent small bowel
resection. The adhesiolysis only group had a significantly
lower frequency of three co-morbid conditions (alcohol use,
disseminated cancer, weight loss; p<0.05); those undergoing
small bowel resection had a lower frequency of congestive
heart failure (p<0.05), but the groups were otherwise
comparable. Thirty-seven percent of patients undergoing
adhesiolysis only and 47% of patients undergoing small bowel
resection had >1 complications (p<0.001). Pneumonia,
prolonged ileus, failure to wean from the ventilator, unplanned
intubation, superficial wound infection, urinary tract infection
(UTI), systemic sepsis, and wound dehiscence were among
the most frequently reported complications for both groups.
The overall 30-day mortality rate was 7.7%. The mortality rate
associated with small bowel resection did not differ
significantly from the mortality rate for adhesiolysis only. The
odds of death were highest for patients who had infected
wounds, American Society of Anesthesiologists (ASA) class 4
or 5, age 80+, dyspnea at rest, and dirty wounds. Totally
dependent functional health status, age 80+, dirty wounds,
history of congestive heart failure (CHF), cerebrovascular
accident (CVA) with neurological deficit, history of chronic
obstructive pulmonary disease (COPD), and ASA class 4 or 5
were associated with a greater risk of complications.
Morbidity rates ranged from 22%, among patients with 0-7
risk points, to 62% for those with 19+ risk points. Mortality
rates ranged from 2%, among patients with 0-12 risk points,
to 28% for those with 31+ risk points.
Conclusions: Morbidity and mortality rates after surgery for
SBO in VA hospitals are comparable to those in other large
published series. In the current study, the morbidity rate, but
not the mortality rate, was significantly higher in patients who
required small bowel resection compared to those requiring
adhesiolysis only (p<0.001). The risk indices presented here
provide an easy-to-use tool for clinicians to predict outcomes
for patients undergoing surgery for SBO.
Implications for Policy, Delivery, or Practice: The calculated
postoperative risk indices for 30-day morbidity and mortality
may be useful in targeting peri-operative testing and
supportive care to high-risk patients. While it is true that
some patient risk factors are not modifiable, such as steroid
use, health status, disseminated cancer, and chronic
obstructive pulmonary disease, many of the preoperative and
intraoperative factors identified by the NSQIP may be altered.
Preoperative fluid resuscitation in patients with high serum
creatinine levels, platelet and fresh frozen plasma transfusions
for patients with low platelet levels or prolonged prothrombin
times, and prevention of intra-operative wound contamination
are some of the factors identified as important in preventing
morbidity and mortality.
Primary Funding Source: VA
●Complications from Affective Psychosis: What Are the
Implications of Different Patterns Across Diverse
Ethnicities?
Elmer Washington, M.D., MPH, Jay J. Shen, Ph.D.
Presented By: Elmer Washington, M.D., MPH, Medical
Director, Aunt Martha’s Youth Service Center, 233 West Joe
Orr Road, Chicago Heights, IL 60411; Tel: (708) 709-7610; Fax:
(708) 747-3497; Email: ewashington@auntmarthas.org
Research Objective: To evaluate patterns of care for affective
psychosis across diverse ethnicities over time and to
determine potential environmental effects on patterns of care
and severity of disease.
Study Design: Comorbidities across all populations were
evaluated and included personality disorders and all medical
conditions that may have an impact on the clinical outcomes.
In addition, complicating conditions; defined as complications
resulting potentially from inadequate access to timely care;
were evaluated. These conditions included overdose or
medication error resulting from carelessness (codes 960969), drug or alcohol abuse or dependence (codes 303 - 305),
suicide attempt or self inflicted injury (E950-E959), homicide
or injury inflicted upon another (E960-E969), legal
intervention contributing to an injury (E970-E978), and
physiologic malfunctioning caused by a mental disorder (306).
Discharges with the diagnostic code 296 for all categories of
affective psychosis were abstracted and analyzed for
differences in comorbidities and complicating conditions
across diverse ethnicities.
Population Studied: Data was obtained on patients admitted
with a diagnosis of affective psychosis to hospitals that
participated in the National Inpatient Sample during 1995,
1997, 1999, 2000, and 2001. Sample sizes were 73,745 in
1995, 85,840 in 1997, 83,105 in 1999, 91,551 in 2000, and
95,260 in 2001. Ethnicities included white (79.3%), African
American (13.8%), Hispanic (5.9%), and Asian-Pacific Islander
(.9%)
Principal Findings: White patients were older with higher risk
of having comorbid conditions (RR ranging from 1.02 to 1.19)
compared to the other minority groups. Compared to both
African Americans and whites, Hispanics and Asians had
lower risk of experiencing complicating conditions (RRs
ranging from 0.77 to 0.89 for Hispanics and from 0.43 to 0.69
for Asians).
Conclusions: Further research is needed to determine the
factors underlying lower risk of complicating conditions
among Asians and Hispanics. Several hypotheses including
levels of group cohesion, the role of extended family, and
various culturally based explanations merit further
investigation.
Implications for Policy, Delivery, or Practice: Public policy
should encourage formation of support systems in areas
where unemployment levels increase significantly given the
existing body of research demonstrating the effectiveness of
such systems.
Primary Funding Source: AHRQ
●Recurrences of Non-Specific Occupational Low Back
Injuries: Relative Contributions to Related Costs and Work
Disability
Radoslaw Wasiak, Ph.D., JaeYoung Kim, M.D., Ph.D., Glenn
Pransky, M.D.
Presented By: Radoslaw Wasiak, Ph.D., Research Scientist,
Center for Disability Research, Liberty Mutual Research
Institute for Safety, 71 Frankland Road, Hopkinton, MA 01748;
Tel: (508)497-0242; Fax: (508)435-8136; Email:
radoslaw.wasiak@libertymutual.com
Research Objective: Previous studies have not measured the
proportion of care-seeking and work disability that are
associated with recurrences in claims for work-related LBI.
The objective of this study was to examine whether
recurrences, defined as repeated episodes of work disability or
medical care, substantially contribute to total medical and
indemnity costs and total duration of work disability.
Study Design: Retrospective analysis of detailed workers’
compensation (WC) claims data for non-specific low back
injuries (LBI) in a single jurisdiction. Three years of detailed
follow-up data, starting at the beginning of the first episode
were collected. Previously-validated definitions of recurrence
were used to identify new episodes of care and new episodes
of lost work time (work disability). Total duration of work
disability, total medical costs, and total indemnity costs were
investigated. For individuals with recurrences, outcome
variables were separated into first-episode and recurrent
period duration and costs.
Population Studied: All persons with new lost-time claims for
non-specific LBI reported in New Hampshire to a large WC
provider from 1996 to 1999 were selected (N=1867).
Principal Findings: The rate of recurrent work disability was
17.2% and the rate of recurrent care seeking was 33.9%.
Individuals with recurrence had significantly higher total
length of work disability and higher medical and indemnity
costs. For those with recurrent work disability, 69% of total
lost time from work, 71% of associated indemnity costs, and
84% of total medical costs occurred during the recurrent
period. For those with recurrence of care, the respective
values were 48%, 47%, and 42%.
Conclusions: Recurrence of LBI contributes substantially to
the total burden of work-related non-specific LBI, through both
additional care-seeking and work disability. Results support
the contention that non-specific LBI is episodic in nature.
Although individuals may learn to live with their conditions,
ongoing care and time away from work occur in a substantial
proportion in work-related LBI.
Implications for Policy, Delivery, or Practice: The study
findings indicate that prevention of repeated episodes may
lead to substantial cost savings and increase the rate of
sustained return to work.
Primary Funding Source: No Funding Source
●Dispersion of Care and Cardiovascular Outcomes; Does
More Matter?
Brook Watts, M.D., David Litaker, M.D., Ph.D.
Presented By: Brook Watts, M.D., Quality Scholar, Education,
Louis Stokes Cleveland VA Medical Center, 10701 East
Boulevard, Cleveland, OH 44106; Tel: (216)791-3800 x4110;
Email: wattsbrook@yahoo.com
Research Objective: Dispersion of care (DOC) is viewed as a
potential barrier to delivery of coordinated, comprehensive
primary care. DOC has become even more salient given recent
mandatory restrictions on the workweek of resident
physicians. Disruptions introduced by these restrictions may
result in unanticipated and/or undesirable effects on patient
care, especially in the long-term risk management of chronic
diseases. The purpose of this study was to examine the
relationship of DOC to cardiovascular treatment outcomes in
VA patients assigned a resident as their primary care provider.
Study Design: In this retrospective cohort study, we assessed
whether patients had attained nationally recommended riskfactor specific treatment goals for blood lipids, blood pressure
(<140/90 or <130/80 in diabetics), and glycemic control
(hemoglobin A1C <7%). We also assessed presence of poor
blood pressure control (=160/100). DOC was determined
using system-assigned numbers to identify the provider at
each visit in the 12 months preceding the lipid profile. An
established index of DOC was dichotomized to reflect either
complete continuity vs. some degree of DOC. Multivariable
logistic regression adjusted for patient demographics, clinical
characteristics, and the nesting of patients within resident
practices to assess the independent association of DOC with
each outcome.
Population Studied: Using the clinical database at the study
site we identified 473 patients with a lipid profile obtained
between January 2003 and October 2004 whose PCP was a
1st, 2nd, or 3rd year resident.
Principal Findings: Of the 473 patients, 363 patients (76.7%)
had DOC (range 2-5 providers). Although the DOC group
included more women (5.8% vs. 0.9%; p=.04) and had more
PCP visits (mean 3.3 +/-1.3 vs. mean 2.4 +/-0.63; p<.01), no
other significant differences in patients’ age, cardiovascular
disease, hypertension (HTN), disease burden, current tobacco
abuse, and diabetes mellitus (DM) were present. Attainment
of LDL goal was similar in the two groups (65.8% vs. 64.6%;
p=.80), yet adequate blood pressure control in those with
HTN or DM was lower in the DOC group (42.6% vs. 56.7%;
p=.01) and the proportion of patients with poor blood
pressure control (=160/100) was greater (14.6% vs. 6.4%;
p=.02). In 148 DM patients, significantly fewer patients in the
DOC group achieved desirable glycemic control (44.6% vs.
71.4%; p=.01). Using multivariate models, DOC remained
associated with less frequent attainment of appropriate HTN
control (OR 0.51; CI 0.30-0.87), an increased likelihood of
having poor HTN control (OR 2.52; CI 1.11-5.75), and a lower
likelihood of glycemic control in DM patients (OR 0.33; CI .12.93). We found no significant association between DOC and
lipid control.
Conclusions: The association between DOC and treatment
outcomes does not appear uniform and may more negatively
affect outcomes such as HTN and glycemic control that
involve complex management and a greater familiarity with a
patient’s comorbidities, medical history, and compliance.
Implications for Policy, Delivery, or Practice: In residents’
clinics where DOC is common, developing systems to
coordinate efforts at risk factor management may be useful.
Our data also suggest that caution is needed when selecting
outcomes to examine the impact of continuity on patient care.
Primary Funding Source: VA
●Linking Provider Attitudes and Self-Efficacy to Secondary
Cardiovascular Prevention
Brook Watts, M.D., David Litaker, M.D.
Presented By: Brook Watts, M.D., Quality Scholar, Education,
Louis Stokes Cleveland VA Medical Center, 10701 East
Boulevard, Cleveland, OH 44106; Tel: 216-791-3800 x4110;
Email: wattsbrook@yahoo.com
Research Objective: Patients with modifiable cardiovascular
(CVD) risk factors may benefit from preventive care, yet health
care providers frequently fail to provide this important service
consistently. Conceptual models have identified provider
attitudes and self-efficacy as potentially important barriers to
provision of preventive care. The purpose of this study was to
examine the association of these provider characteristics to
CVD risk factor management and outcomes in high-risk
patients.
Study Design: In this cross-sectional study, data on provider
attitudes and self-efficacy were measured using a standardized
instrument and were linked with patient-level laboratory and
pharmacy data to evaluate the association with the following
CVD prevention process measures: lipid screening and
treatment for dyslipidemia. We also examined the association
between provider attitudes, self-efficacy, and self-report of
services delivered with patients’ attainment of risk-adjusted
nationally recommended treatment goals for low density
lipoprotein (LDL). Multi-level models adjusted for the
following covariates: 1) patients– age, gender, number of
visits, and count of medical illnesses/health burden, and 2)
providers– age, gender, and professional status (i.e., physician
trainee, staff physician, non-physician provider).
Population Studied: Thirty-seven primary care providers at
various levels of professional training at a large VA outpatient
clinic and 522 patients, each of whom had been seen at least
twice in 2003 by a provider in our survey group and who had a
diagnosis of coronary heart disease (CHD) or CHD equivalent
condition and no contraindication to lipid-lowering therapy.
Principal Findings: Of the 37 providers in our sample, 25
(67.6%) were interns or residents, 6 (16.2%) were staff
physicians, and 6 (16.2%) were advanced practice nurses or
pharmacists. The importance of CVD prevention was reported
as high or very high by 32 providers (88.9%) and individual
self-efficacy in CVD prevention was reported as high or very
high by 15 providers (40.5%). Of the 522 high-risk patients
identified, 361 (69.2%) had lipid screening during the study
period; among screened patients, 202 (56.0%) were at the
recommended treatment goal. Multi-level models showed no
significant association between provider self-efficacy or selfreported service delivery in this area and process or outcomes
related to CVD prevention.
Conclusions: Although nearly all providers in our sample
agreed with the importance of CVD risk factor management,
we identified many missed opportunities for secondary CVD
prevention. Favorable provider attitudes and high self-efficacy
alone may be necessary, but they do not appear to be
sufficient in guaranteeing delivery of recommended care or
achievement of desirable outcomes.
Implications for Policy, Delivery, or Practice: Factors other
than attitudes and self-efficacy may be better targets for
interventions to improve preventive CVD care. Systems which
address outcome expectations, goals, facilitators and
impediments may be necessary.
Primary Funding Source: VA
●The Impact of Visit Interval on Blood Pressure Control
and Management
Mark Weiner, M.D., BJ Turner, M.D., Craig A. Umscheid,
M.D., Christopher Hollenbeak, Ph.D., Yi-Ting Lin, MS, Simon
Tang, MPH, Suchin Virabhak, Ph.D.
Presented By: Mark Weiner, M.D., Assistant Professor,
Division of General Internal Medicine, University of
Pennsylvania, 423 Guardian Drive -- Room 1116, Philadelphia,
PA 19104; Tel: (215) 898-5721; Fax: (215) 573-8779; Email:
mweiner@mail.med.upenn.edu
Research Objective: The appropriate interval in which to
follow-up a patient with hypertension (HTN) has little support
from empiric data. This study examines the association
between the time interval since the prior visit for a patient with
HTN and blood pressure (BP) control and physicians'
management decisions regarding patients presenting with
elevated BP.
Study Design: We studied a retrospective cohort of
hypertension (HTN) patients aged >= 18 with at least three
visits from 1/1/03 to 8/01/04 in one of 8 primary care
practices in Philadelphia urban and suburban settings.
Clinical, laboratory, pharmacology and health care data came
from electronic medical records and administrative billing
data. The dependent variable was a finding of appropriate
management for each visit. Management was appropriate if
BP was normal or, if high, the dose of a current BP med was
increased, a new BP med was started, or a med was renewed
if expired >1 month. Since the unit of analysis was the visit,
random effects multiple logistic regression was used to adjust
for clustering of patients.
Population Studied: HTN was defined using hierarchical
criteria: 1) a prescribed BP medication (med); 2) ICD-9-CM
diagnosis of HTN and >=1 visit with a high BP defined as
systolic BP (SBP) >= 140 or diastolic BP (DBP) >= 90; or 3)
high BP on >=2 visits. For each prescribed BP med, we
determined the daily dose and duration of treatment. High BP
based on JNC VI for patients without diabetes was SBP>=140
and DBP>=90 and for patients with diabetes, a more stringent
threshold of SBP>=130 or DBP>=85 was set. Patients with
diabetes (DM) were identified from diagnosis codes or HbA1C
>7. Patients with and without DM were analyzed separately.
Principal Findings: In 22,472 visits made by 3,597 HTN
patients with DM, BP was controlled in 43%. In 48,718 visits of
10,086 patients without DM, BP control was achieved in 61%.
Adjusting for demographic, clinical, and health care factors
and using a visit interval of < 3 months as the reference, the
adjusted odds ratio (AOR) of having uncontrolled BP was 1.10
(CI 1.04-1.16) for an visit interval of 6-9 months, 1.18 (CI 1.101.27) for an interval of 9-12 months and 1.25 (CI 1.17-1.33) for
an interval over one year. In the DM patients, the associations
were even stronger: AOR 1.11 (CI 1.02-1.22), AOR 1.38 (CI 1.211.58) and AOR 1.36 (CI 1.19-1.55). Inappropriate management
was less likely (AORs ranging from 10 to 20% lower, p < 0.05)
for longer visit intervals versus <3 months.
Conclusions: Longer intervals between visits of patients with
HTN, especially over 6 months, are associated with a greater
risk of presenting to the visit with uncontrolled HTN.
Physicians were more likely to modify HTN treatment in
patients seen less frequently.
Implications for Policy, Delivery, or Practice: Physicians are
reacting appropriately to the elevated blood pressure readings
that are associated with longer visit intervals. However, a
more preventative and proactive strategy would set visit
intervals of no more than 3-6 months for patients with HTN,
especially those who also have DM.
Primary Funding Source: Pfizer
●Identification of Subgroups of Medicare Beneficiaries
with Diabetes: Segmentation to Inform Targeted Outreach
and Tailored Education Strategies
Sunyna S. Williams, Ph.D.
Presented By: Sunyna S. Williams, Ph.D., Social Science
Research Analyst, Office of Research, Development, and
Information, Centers for Medicare & Medicaid Services, 7500
Security Boulevard/Mail Stop: C3-20-17, Baltimore, MD 21244;
Tel: (410)786-2097; Email: sunyna.williams@cms.hhs.gov
Research Objective: The purpose of this research was to
identify subgroups or segments of Medicare beneficiaries with
diabetes, to inform the development of targeted outreach and
tailored education strategies.
Study Design: This research involved secondary data analysis
of the 2001 Medicare Current Beneficiary Survey (MCBS)
Access File Community Questionnaire. The MCBS is an
ongoing household panel survey conducted by the Centers for
Medicare & Medicaid Services (CMS), of a representative
national sample of Medicare beneficiaries. The Access File
includes data on beneficiaries continuously enrolled for the
year. The Community Questionnaire is administered by faceto-face interview with community-dwelling beneficiaries or
their designated proxies, and assesses a wide range of healthrelated variables. The data files include a sample weight
variable and variables to permit adjustment for the complex
cluster sample design. Segmentation was achieved by
conducting k-means cluster analysis on four knowledge and
attitudes variables—global perceived knowledge about the
Medicare program, self care self-efficacy composite, health
information-seeking composite, and satisfaction with
information received regarding health problems. Comparisons
were conducted among the cluster segments, using chisquare (for categorical variables) and univariate general linear
model with sequential sidak to control for Type I error (for
continuous variables).
Population Studied: Of the 15,246 in the community sample,
2,814 (19%) reported ever having been told by a doctor that he
or she had diabetes. Of that diabetic subsample, 2,495 (90%)
were self-respondents to the interview. The analytic sample is
those 2,495 diabetic self-respondents. This sample is 15%
disabled and under 65 years, 55% female, 72% white, and 77%
overweight or obese.
Principal Findings: The four-cluster solution was selected
based on interpretability, separation, and distribution. Savvy
beneficiaries (42%) are highest on all four knowledge and
attitudes clustering variables. They are also the most
educated, the healthiest, the least likely to have only basic
Medicare fee-for-service, and engage in the most healthful and
preventive behavior. Passive beneficiaries (23%) are lowest on
self-efficacy and information-seeking, and moderate on
knowledge and satisfaction. They are also the most likely to
have only basic Medicare fee-for-service and engage in the
least healthful and preventive behavior. Uninformed
beneficiaries (29%) are lowest on knowledge, and moderate
on the remaining clustering variables. They are also the least
educated. Dissatisfied beneficiaries (6%) are lowest on
satisfaction, and moderate on the remaining clustering
variables. They are also the youngest, the most overweight
and obese, the most depressed, the most likely to smoke, and
the least satisfied with their healthcare. Additional analyses
showed that, for tailoring purposes, those in the four
segments can be identified using three single screening items.
Conclusions: These analyses identified four segments of
Medicare beneficiaries with diabetes that vary with regard to a
range of health-related variables.
Implications for Policy, Delivery, or Practice: These findings
can be used to promote informed healthcare and self care
decision-making among Medicare beneficiaries with diabetes.
Outreach targeted to the different segments should consider
differences in education and health status. For tailoring
purposes, those in the four segments can be identified using
the screening items. Education tailored for the different
segments should also consider differences in knowledge,
attitudes, and health behavior.
Primary Funding Source: CMS
●Understanding Global Transition Ratings
Kathleen Wyrwich, Ph.D., Vicki M. Tardino, MA
Presented By: Kathleen Wyrwich, Ph.D., Assistant Professor,
Research Methodology & Health Services Research, Saint
Louis University, 3750 Lindell Boulevard, Room 230, St. Louis,
MO 63108; Tel: (314)977-8192; Fax: (314)977-1616; Email:
wyrwichk@slu.edu
Research Objective: Several methods currently used for
determining meaningful or important change in health-related
quality of life (HRQoL) are based on patients' responses to
global transition assessments. It can be empirically
demonstrated that patients' responses to these gold
standards for change do not adequately incorporate the prior
condition, yet these transition items play an influential role in
patient-clinician communications and cannot be disregarded.
This follow-up study queried patients to better understand
how they ascertained their transition assessments
Study Design: We used face-to-face cognitive interviews to
obtain qualitative clues for
understanding patient reports
of HRQoL changes over time. Interview transcripts were
coded using the components of the Rapkin-Schwarz HRQoL
Model.
Population Studied: Prior to their qualitative interviews, the
41 chronic disease patients in this study had completed one
year of enrollment in a clinical study with bi-monthly HRQoL
telephone interviews that included the SF-36 and a diseasespecific (asthma, COPD, or heart disease) HRQoL instrument,
as well as global transition assessments for each instrument's
domains.
Principal Findings: Patients' explanations for determining
global transition assessments in HRQoL domains often
focused on current mobility and fatigue patterns, physicians'
statements about their conditions, comparisons of their
current states with the prior health conditions, and strong
personal convictions that reflected a resistance to voicing any
emotional changes. Patients also expressed primary health
concerns, like back pain, that were not related to the chronic
conditions (asthma, COPD or heart disease) under
investigatio
Conclusions: Quantitative studies that incorporate GT
assessments to anchor the interpretations of HRQoL changes
should also consider additional relevant items identified by
this qualitative investigation to inform researchers of the
potential framework that patients use to assess and report
their transitions.
Implications for Policy, Delivery, or Practice: In addition,
patient-clinician communications that incorporate global
transition assessments to anchor the interpretations of
HRQoL changes should also consider additional relevant
questions identified by this qualitative investigation to
understand the process each patient uses to appraise and
report changes in HRQoL.
Primary Funding Source: AHRQ
●The Effect of Evidence-Based Cardiac Medication Use on
Hospital Readmission
Zhou Yang, Ph.D., MPH Ade Olomu, M.D., William Corser,
Ph.D., David Rovner, M.D., David Sheps, M.D., MPH,
Margaret HolmesRover, Ph.D.
Presented By: Zhou Yang, Ph.D., MPH, Assistant Professor,
Health Services Research, Management and Policy, University
of Florida, 101 South Newell Drive, Room 4141, Gainesville, FL
32610-0195; Tel: (352)273-6081; Fax: (352)273-6075; Email:
zyang@phhp.ufl.edu
Research Objective: The importance of outpatient cardiac
medication use for patients has been widely recognized, and
is a primary focus of quality improvement. While previous
research has suggested that hospital discharge is a critical
time to promote the initial and continued use of cardiac
medications for Acute Coronary Syndrome (ACS) patients,
little research has investigated the effects of ongoing
outpatient drug use patterns after hospital discharge. Our
objective was to analyze patterns of outpatient cardiac
medication use after initial hospitalization for ACS, and
investigate the impact on the probability of subsequent
hospital readmissions.
Study Design: This is an observational study using secondary
data. Chart reviews are merged with data from post
hospitalization surveys about health care utilization and health
outcomes conducted at 3 time points: immediately after
discharge, 3 months, and 8 months after discharge. We
conducted a descriptive analysis to examine the dynamic
feature of post-acute ACS patient care, particularly changing
patterns of outpatient prescription drug use, post-discharge
hospital readmissions, and Emergency Department (ED)
visits. Series of multivariable logistic regression models were
used to estimate the association between post ACS
medication use and hospital readmission and ED visits by the
3 and 8 months telephone surveys.
Population Studied: 433 patients prospectively identified with
ACS in five mid-Michigan community hospitals during the
period January 2002 to April 2003
Principal Findings: Most changes to medication regimens
use occurred within 3 months after discharge, with fewer
changes in the subsequent 5 months. Taking Beta-Blockers
(odds ratio, 0.46 [95% CI, 0.21 to 0.99]) or AngiotensinConverting Enzyme Inhibitors (ACEI) (odds ratio, 0.31 [95%
CI, 0.13 to 0.77]) significantly reduced the probability of
hospital readmission within 3 months after discharge
(P<0.05). Higher adherence to ACEI after discharge
contributed to even lower hospital readmission rate (odds
ratio, 0.55 [95% CI, 0.34-0.89], p<0.1). Re-hospitalized within 3
months after discharge was a strong predictor of later hospital
readmission up to 8 months after discharge (odds ratio 0.74
[95% CI 0.73 to 1.74] p<0.05)
Conclusions: In addition to the prescription of effective
discharge medications, timely and appropriate medication
adjustment in outpatient settings appears to improve health
outcomes in ACS patients.
Implications for Policy, Delivery, or Practice: Time interval
shortly after discharge could be a good opportunity to initiate
and promote drug therapy for post ACS patients, which
indicates the important role of outpatient care physicians.
More research, especially longitudinal studies are expected to
be conducted at outpatient clinical settings to investigate the
effect of physician-patients relationships on continuity of
health care as well as subsequent health outcomes of post
ACS patients.
Primary Funding Source: AHRQ