Issues in Improving Behavioral Health Care for
Children
Chair: Haiden Huskamp
Monday, June 29 * 11:30 a.m.–1:00 p.m.
♦ News Media Coverage of FDA Warnings on
Pediatric Antidepressant Use & Suicide Risk
Colleen Barry, Ph.D.; Susan Busch, Ph.D.
Presented by: Colleen Barry, Ph.D., Assistant Professor
of Public Health, Division of Health Policy &
Administration, Yale University School of Public Health,
60 College Street, #302, New Haven, CT 06510, Phone:
(203) 785-4956, Email: colleen.barry@yale.edu
Research Objective: In October 2004, after an 18month investigation, the Food and Drug Administration
(FDA) directed pharmaceutical manufacturers to add a
black box warning to antidepressants regarding an
increased suicide risk in children. Large declines in
pediatric antidepressant use occurred concurrent with
this investigation. Our research objective is to evaluate
the content of news coverage of pediatric antidepressant
use and suicide risk by major U.S. newspapers and
television networks.
Study Design: Content analysis of news reporting on
pediatric antidepressant use and suicide risk (N=167).
Two researchers coded all news articles using a nineitem instrument. Item inter-rater reliability was .84 or
greater. Main outcome measures were volume and
balance of news reporting, inclusion of key health
information, and reporting on uncertainty of risks and
benefits.
Population Studied: Lexis-Nexis, Factiva, and
newspaper online archives were used to collect a
census of news stories published in the ten highest
circulation U.S. newspapers and four television networks
in 2003 and 2004.
Principal Findings: News stories were unbalanced in
their greater emphasis on specific children harmed
versus children helped by antidepressants. When expert
sources were quoted, they were more likely to
emphasize the benefits of antidepressants over their
risks. Key health information highlighted in FDA safety
warnings was often absent from news coverage, even
during the periods immediately following FDA
announcements. News stories were 10 times more likely
to convey the overall impression that the risks of
antidepressant use outweighed the benefits in treating
children.
Conclusions: The FDA is largely dependent on the lay
press to communicate safety information to the public.
Findings suggest that including health information in
FDA advisories is not sufficient to ensure its
communication to the public. News reporting might have
been improved with more balanced reliance on
anecdotes of specific children being helped or harmed,
and in the overall impression conveyed about the risks
and benefits of antidepressants.
Implications for Policy, Delivery or Practice: Given
the news media’s emphasis on the risks of
antidepressant use over their benefits, the steep
declines that occurred in pediatric antidepressant use
are not surprising. Because depression is an undertreated disease with the potential for long term negative
consequences, these declines are troubling to the extent
that they represent an increase in unmet need.
Achieving balance in reporting may be particularly
challenging on an issue such as this one which involves
substantial scientific uncertainty. However, this case
suggests that quality and balance in news reporting on
risks and benefits may have important implications for
who does and does not get treated.
Funding Source(s): NIMH
♦ Does Private Insurance Adequately Protect
Families of Children with Mental Health Disorders?
Susan Busch, Ph.D.; Colleen Barry, Ph.D.
Presented by: Susan Busch, Ph.D., Associate
Professor, Health Policy, Yale Medical School, P.O. Box
208034, New Haven, CT 06520, Phone: (203) 7852927, Email: susan.busch@yale.edu
Research Objective: Although private insurance
typically covers most health care costs, the burden on
families of caring for a sick child is substantial. This
burden may be more severe for CSHCN with mental
illnesses than for other special needs children due to a
number of factors. Our objective is to determine whether
families of privately insured children needing mental
health care face different burdens than other families in
caring for their children.
Study Design: We use the 2005-2006 National Survey
of Children with Special Health Care Needs (NSCSHCN) to study privately insured children ages 6-17.
We compare CSHCN with mental health care needs
(N=4,918) to three groups: children with no SHCN
(N=2,346), CSHCN with no mental health care needs
(N=16,250), and a subset of the CSHCN with no mental
health care need group but a need for other specialty
services (N=7,902). We use weighted logistic
regression and study outcomes across four domains:
financial burden, health plan experiences, labor market
and time effects, and satisfaction with services. To
illuminate some causes of differences in burden, we
examine three subgroups of children: children living in
states with comprehensive mental health parity laws,
children living in states with an adequate supply of child
psychiatrists, and children not reporting a need for
prescription drug medication.
Population Studied: National Sample of Children with
Special Health Care Needs
Principal Findings: We find that families of children
with mental health care needs face significantly greater
financial barriers, have more negative health plan
experiences, and are more likely to reduce their labor
market participation to care for their child than other
families. Families of children with mental health care
needs are somewhat more likely to report dissatisfaction
with the services their child receives than other families,
although fewer significant differences are detected in this
domain. In absolute terms, this burden is substantial.
Forty-three percent spend over $1,000 out-of-pocket on
their child’s health care, indicating that private insurance
coverage does not protect families from the expenses
associated with mental health treatment.
Conclusions: Families of privately insured CSHCN
needing mental health care face a higher burden than
other families in caring for their children.
Implications for Policy, Delivery or Practice: Policies
are needed to aid families in obtaining affordable, high
quality mental health care for their children. While we
find that, under private insurance, CSHCN with mental
health care needs face greater barriers than other
special needs children, we are unable to definitely
determine the causes of these differences. Our results
do suggest that the shortage of child psychiatrists may
have some impact on patient satisfaction, and that the
out-of-pocket cost of psychotropic medications may play
a role in the high financial burden on these families.
More research needs to be done to better understand
the cause of these differences, and to develop policy
solutions that may ameliorate their effects.
Funding Source(s): NIMH
♦ Using CANS as a Placement Decision Support
Algorithm to Predict Clinical Outcome of Youth in
Child Welfare Placed in Residential Treatment
Ka Ho Brian Chor, B.S.; Gary McClelland, Ph.D.; Neil
Jordan, Ph.D.; John Lyons, Ph.D.
Presented by: Ka Ho Brian Chor, B.S., Doctoral Student
in Clinical Psychology, Department of Psychiatry &
Behavioral Sciences, Mental Health Services & Policy
Program, Northwestern University Feinberg School of
Medicine, 710 North Lake Shore Drive, Suite 1224,
Chicago, IL 60611, Phone: (617) 230-6422, Email: kchor@northwestern.edu
Research Objective: A transformation in the use of
residential treatment in child welfare is driven by two
forces, the enormous cost of treatment and the accepted
policy of “least restrictive setting.” In this context,
inappropriate placements resulting from the absence of
standard placement criteria have detrimental outcomes.
For this reason, placement decisions should be guided
by children’s needs and evidence-based guidelines. This
study compared placement decisions of two models: (1)
a model of placement decision support algorithm guided
by clinical ratings on the Child and Adolescent Needs
and Strengths (CANS) instrument, and (2) the traditional
team model based on the multidisciplinary Child and
Youth Investment Teams (CAYIT). Placement decisions
were classified as concordant when both algorithm and
teams recommended residential placements, and
discordant when the CANS algorithm recommended
lower levels of care. It was hypothesized that the
concordant group would achieve more clinical
improvement on the CANS, placement stability, and
hospitalization rates, than the discordant group.
Study Design: Hypothesis testing of improvement on
the CANS applied a 2 x (3 x 5) mixed design ANOVA
where Group (concordant vs. discordant) was the
between-subject factor, Time (pre-, at, and 6 months
post-placement), and 5 CANS Domain were the withinsubject factors. Additional hypotheses about placement
stability and hospitalization rates were tested with Cox
regression and Poisson regression, respectively,
controlling for demographic factors and baseline
functioning.
Population Studied: Our sample consisted of 544
residential wards of Illinois DCFS. Concordant (n = 449)
and discordant group (n = 95) displayed similar
demographic characteristics. Average age was 14 years,
60% African American and 60% male. On average, both
groups waited 80 days to get placed from the date of the
CAYIT assessment to residential placement, with length
of stay of one year.
Principal Findings: Concordant group had higher initial
scores on the CANS and significantly improved across
domains over time, especially on emotional and
behavioral symptomatology, while improvement in the
discordant group was less remarkable and consistent.
The concordant group showed somewhat better
placement stability. Although both groups reduced
hospitalization rates post-placement, the discordant
group was still less likely to be hospitalized controlling
for other factors.
Conclusions: Significant improvement on CANS scores
shows that positive outcomes follow when the
multidisciplinary team decisions were congruent with the
CANS algorithm. Less favorable outcomes in the
discordant group validate the superiority of the CANS
algorithm, and demonstrates negative consequences of
over-treatment. Outcomes using placement stability and
hospitalization rates were less supportive of our
hypothesis. Directions for future research are proposed.
As the concordant group, by design, had more room to
improve due to their higher baseline severity, regression
analysis incorporating other outcome measures is
recommended. Placement stability can be further
understood by distinguishing disruptions from proper
discharges.
Implications for Policy, Delivery or Practice: This
premise that residential treatment does not compromise
less severe wards in the discordant group should not
justify continuation of their placements. Rather, stepdowns to outpatient treatment are recommended. The
impact of concordant and discordant placements at other
levels of care should be examined to fully assess the
capacity of the CANS algorithm to inform clinical
judgment.
Funding Source(s): Northwestern University Feinberg
School of Medicine, Department of Psychiatry and
Behavioral Sciences, Mental Health Services and Policy
Program
♦ Concurrent Behavioral Health Specialty Care
Among Medicaid Enrolled Children Receiving
Antipsychotic Medications
Emily Harris, M.D., M.P.H.; Bradley Stein, M.D., Ph.D.;
Mark Sorbero, M.S.; Jane Kogan, Ph.D.; James
Schuster, M.D., M.B.A.; Bradley Stein, M.D., Ph.D.
Presented by: Bradley Stein, M.D., Ph.D., Associate
Professor, Psychiatry, University of Pittsburgh School of
Medicine, 3811 O'Hara Street, Pittsburgh, PA 15213,
Phone: (412) 454-8633, Email: steinbd@upmc.edu
Research Objective: Since the introduction of secondgeneration atypical antipsychotic medications in 1992,
studies have documented increased use in youth
[Cooper, et al., 2006; Olfson, et al., 2006] with a paucity
of information about concurrent behavioral health
services being received by these children [Olfson, et al.,
2006; Patel, et al., 2006]. In this study, we examine the
utilization of concurrent behavioral health specialty
services among Medicaid-enrolled youth in a large MidAtlantic state.
Study Design: Univariate and bivariate analyses, as
well as multiple logistic regression analyses were used
to examine the relationship between concurrent mental
health specialty care and race, Medicaid eligibility
category, age, gender, community of residence,
diagnosis, and prior psychiatric hospitalization.
Concurrent utilization was defined as receiving any care
from a behavioral health specialty provider in the 30
days prior to the first observed antipsychotic prescription
or at any point while receiving antipsychotic medication.
Population Studied: Using administrative data from the
largest Medicaid managed behavioral health
organization in a large mid-Atlantic state and state
provided pharmacy data, we identified 6311 Medicaidenrolled children less than 18 years of age who received
antipsychotic medications from January 1, 2007 through
December 31, 2007.
Principal Findings: Approximately twenty percent of
youth receiving antipsychotic medications did not receive
any concurrent behavioral health specialty care. Children
who were female, had recent inpatient psychiatric
hospitalization, received FDA-label or externalizing
disorder diagnoses, or who were Latino had significantly
higher rates of concurrent behavioral health specialty
care than other children controlling for other factors.
Children aged 12-17 receiving antipsychotic medication,
involved in the child welfare system, and children
Medicaid-enrolled due to disability were less likely to
have concurrent behavioral health specialty care.
Relatively few of the children receiving antipsychotic
medications had received diagnoses for which
antipsychotic medications had an FDA indication.
Conclusions: Approximately a quarter of youth
receiving antipsychotic medications have received a
diagnosis for which antipsychotic medications are
indicated, and a substantial number of youth receiving
antipsychotic medication (20%) do not appear to be
receiving concurrent behavioral health specialty care.
Implications for Policy, Delivery or Practice: Nonpharmacologic interventions are recommended as firstline treatment in externalizing and behavior disorders
[Jensen, 2008], which presents a potential opportunity to
improve the care being received by these youth. Such
efforts can involve outreach to families and primary care
providers to enhance access to appropriate specialty
behavioral health care through education and reducing
barriers to access, as well as working with psychiatrists
to consider clinically appropriate non-pharmacologic and
pharmacologic interventions for children receiving
antipsychotic medications.
Funding Source(s): Community Care Behavioral Health
Organization
♦ The Effect of Self-Esteem & Academic
Performance on Adolescent Decision-Making: An
Examination of Sexual Debut & Illegal Substance
Use
Stephanie Wheeler, M.P.H.
Presented by: Stephanie Wheeler, M.P.H., Research,
Ph.D. Student, Health Policy & Management, University
of North Carolina at Chapel Hill, McGavran-Greenberg,
Campus Box 7411, Chapel Hill, NC 27599, Phone:
(864) 376-0516, Email: stephanie_wheeler@unc.edu
Research Objective: The determinants of early initiation
of sexual intercourse and early illegal substance use
among youth remain largely unknown, but may be linked
to potentially mutable elements of self-worth and
knowledge. Psychosocial theory suggests that
individuals with poorly constructed self-esteem and poor
academic performance may be more likely to engage in
risky behaviors to help fill the void left by feelings of
social inadequacy and/or fear of failure.
Recognizing that early sexual debut and regular use of
illegal substances may have profound implications for
health, this study examined the effects of self-esteem
and academic performance on sexual debut and
substance use.
Study Design: This secondary analysis used panel data
from waves I, II, and III of the National Longitudinal
Study of Adolescent Health to assess the effects of selfesteem and academic performance in wave I (19941995) on self-reported sexual debut and illegal
substance use in waves II (1995-1996) and III (20012002). Sexual debut in wave II or III was defined as first
coitus, or first episode of intercourse, among virginal
youths from wave I. Illegal substance use was defined
as reporting regular use of any illegal substance,
including underage alcohol or tobacco use, as well as
use of marijuana, cocaine, injected drugs, inhalants, or
illegal prescription drugs. Separate models were
estimated for males and females at two different time
intervals for each dependent variable, controlling for
known confounders.
Population Studied: The population of interest was
American adolescents enrolled in the 7th through the
12th grades in 52 middle schools and 80 high schools
during the 1994-1995 academic years. Individuals not
available for sampling in all successive waves were
excluded.
Principal Findings: Among virginal males and females,
higher self-esteem at baseline had no effect on sexual
debut 6-7 years later; however, being an “A” student at
wave I, as compared to a student who averaged “C”
grades or lower, was significantly associated with
decreased odds of sexual debut one year later (OR:
0.41; p=0.001). In addition, higher standardized test
performance at baseline was associated with lower odds
of sexual debut among both males (p=0.002) and
females (p=0.0001) 6-7 years later. With respect to
substance use, contrary to hypothesis, higher selfesteem corresponded to slightly higher likelihood of
substance use (p<0.05). As expected, higher academic
performance and higher standardized test scores at
baseline were significantly associated with lower
likelihood of illegal substance use in subsequent waves
(p<0.05).
Conclusions: Efforts to enhance self-esteem and
academic performance among young people are clearly
important endeavors, and this study suggests that
bolstering self-esteem and improving academic
performance may have specific benefits in terms of
sexual decision making and substance-related risk
taking.
Implications for Policy, Delivery or Practice:
Continued emphasis on efforts to improve academic
performance and confidence among youth is warranted.
Future research should explore the mechanisms through
which self-esteem is constructed. Peer network
modeling could also provide additional insight into peermediated decision making among young people.
Funding Source(s): AHRQ
Identifying Ways to Improve Quality of Behavioral
Health Services
Chair: Colleen Barry
Tuesday, June 30 * 9:45 a.m.-11:15 a.m
♦ The Three-Headed Culprit for the Marginalization of
Depression Care
Seong-Yi Baik, Ph.D.; Junius Gonzales, M.D., M.B.A.;
Barbara Bowers, Ph.D.; Jean Anthony, Ph.D.; Jeff
Susman, M.D.
Presented by: Seong-Yi Baik, Ph.D., Associate
Professor, School of Nursing, University of Louisville,
555 South Floyd Street, Louisville, KY 40202, Phone:
(502) 852-8380, Email: s.baik@louisville.edu
Research Objective: The purpose of this research was
to understand the impact of co-morbid medical
conditions and behavioral health care system factors on
depression management in primary care settings. This
research was a part of a larger NIH-funded DEED
(Describing Enigma of Evaluating Depression) project
that investigates the depression care processes and
influencing conditions for primary care clinicians’
management of depression.
Study Design: Mixed method was used with seventy indepth, in-person individual interviews, three focus
groups (with 24 clinicians), two surveys (per clinician),
and the investigators’ field notes on office environments.
Individual interviews lasted 50 to 70 minutes (up to 120
minutes), and focus group interviews lasted
approximately two hours each. Interviews were
audiotaped and transcribed for the analysis. We used
Grounded Theory method to guide data collection and
analysis for the interview data and descriptive statistical
techniques (using SPSS) and Rasch Analysis to analyze
quantitative survey data.
Population Studied: Seventy primary care clinicians
from fifty-two primary care offices in the Mid-west: 28
general internists, 28 family physicians, and 14 nurse
practitioners; 47 men, 23 women; 38 White (54.3%), 22
African-American (31.4%), 9 Asian (12.8%), and 1
Hispanic (1.4%). The participants were recruited from
diverse primary care practice environments ranging from
private solo, group, to federally-funded community health
centers. The clinicians’ years of practice ranged from 1
to 30. Over 18 of 52 offices served African-American
patients as their primary population.
Principal Findings: The analysis indicated that today’s
acute-, productivity-oriented primary health care system
poses significant challenges to depression care, viewed
as a time-consuming, burdensome condition to manage.
A plethora of competing medical co-morbidities such as
diabetes and hypertension in the real-world practice
environment diminished the clinicians' ability to
effectively manage depression, resulting in the
marginalization of depression in primary care settings.
These findings were consistent among the three clinician
groups. Compared to other medical conditions, we
identified three major clinical, system, and societal
barriers that are unique to depression care: absence of
objective measurement (e.g., a blood test or blood
pressure), the disjointed nature of our current mental
health care system (administrative and financial carveouts, lack of accessibility of referral and educational
resources, inadequate reimbursement of primary care
clinicians’ time, and poor communication between
mental health specialists and primary care clinicians),
and societal stigma of depression (related to patient’s
willingness of accepting the diagnosis and prescribed
treatment). The clinicians reported that, compared to
depression care, medial co-morbid conditions can be
more easily addressed, and better fit within their
practice.
Conclusions: Primary care competing co-morbid
conditions, coupled with real-world clinical, system, and
societal barriers, lead to the marginalization of
depression care.
Implications for Policy, Delivery or Practice:
Interventions in improving depression care should focus
on creating cultural fit to implement and disseminate
sense-making depression care models. Understanding
the context of primary care clinicians’ depression
treatment decision-making in a real-world environment
provide strategies to effectively design and implement
depression care quality improvement interventions.
Bottom-up approaches in designing and implementing
such interventions may contribute to sustaining the
desirable effect of intervention strategies.
Funding Source(s): NIMH
♦ Do Evidence-Based Depression Care Management
Programs Help Patients with Lower Education More?
Evidence from a Randomized Controlled Trial
Yuhua Bao, Ph.D.; Thomas Ten Have, Ph.D.; Edward
Post, M.D., Ph.D.; Martha Bruce, Ph.D.
Presented by: Yuhua Bao, Ph.D., 411 East 69th Street,
New York, NY 10021, Phone: (212) 746-2734, Email:
yub2003@med.cornell.edu
Research Objective: This study aims to investigate if
depression care management (DCM) interventions, by
featuring care managers who take on a central role in
care coordination and patient follow-up, benefit the less
educated patients to a greater extent.
Study Design: The Prevention of Suicide in Primary
Care Elderly: Collaborative Trial (PROSPECT) study
was a randomized controlled trial of an evidence-based
DCM intervention. We used data from 6 assessments
over 2 years to examine how intervention effects on
clinical outcomes and antidepressant use differed by
patient education. Clinical outcomes included treatment
response (defined as a reduction in the Hamilton
Depression Rating Scale (HDRS) by more than 50%
compared to baseline) and depression remission
(HDRS<10 at the time of assessment). Guidelineconcordant antidepressant use was measured by 1) any
antidepressant use and any use with adequate dosage
at each assessment, 2) initiation of new antidepressant
within the first 8 months among baseline non-users, and
3) antidepressant use for at least 4 months by baseline
users or non-users who subsequently initiated treatment.
We estimated a logistic regression for each outcome at
each assessment as a function of intervention status (vs.
usual care), patient education (less than high school,
high school, some college or more) and interaction terms
of intervention status and education, controlling for
patient demographics including race/ethnicity and
baseline depression severity and co-morbidities. For
each outcome of each education group, we derived
intervention vs. usual care risk ratios (RRs), with
confidence intervals (CIs) based on bootstrap.
Population Studied: Five hundred and ninety-nine
patients aged 60+ and determined to have major or
clinically significant minor depression at baseline.
Principal Findings: For depression outcomes, while all
education groups saw greater improvement in the
intervention (vs. usual care) arm over time, the
intervention effect was larger and more sustained in the
less educated groups. At 12 months, among the “less
than high school” group, intervention patients were 1.89
times (95% CI: 1.11, 4.56) as likely as usual care
patients to have responded to treatment; corresponding
mean RRs were 1.21 and 1.19 for high school graduates
and college attendees, respectively, and were not
statistically significantly different from 1. At 24 months,
RRs associated with depression remission were 1.50
(CI: 1.03, 2.30) and 1.59 (CI: 1.08, 2.82) for the “less
than high school” and “high school” groups, respectively,
compared to 0.96 (CI: 0.73, 1.30) for college attendees.
For antidepressant outcomes, RRs associated with all
but one outcome were consistently larger in size and
more likely to achieve statistical significance at
assessments beyond 12 months. Minority (mainly
African American) patients were not statistically different
from whites in depression outcomes, but were less likely
to engage in or adhere to antidepressant therapy.
Conclusions: The PROSPECT intervention had a larger
and more sustained effect on depression outcomes and
antidepressant adherence among less educated
patients.
Implications for Policy, Delivery or Practice:
Evidence-based DCM interventions offer the promise of
narrowing socioeconomic disparities in depression
treatment by providing intensive care management and
thus compensating for poorer self-management among
those with less education.
♦ Impact of Financial Incentives for Publicly Funded
Alcohol & Other Drug Treatment on Waiting Time &
Length of Stay
Maureen Stewart, M.A.
Presented by: Maureen Stewart, M.A., Doctoral
Candidate, Heller School for Social Policy &
Management, Brandeis University, Mail Stop 035 415
South Street, Waltham, MA 02453, Phone: (781) 8566492, Email: mstewart@brandeis.edu
Research Objective: In 2001, in order to improve
quality of alcohol and other drug (AOD) treatment, the
Delaware Division of Substance Abuse and Mental
Health changed from paying outpatient AOD treatment
providers on a cost basis to a performance based
contract (PBC). The objective of this study was to
examine the Delaware PBC at the client and facility
levels to gain a better understanding of how incentives in
the PBC work and how the PBC impacts access to and
quality of AOD treatment services.
Study Design: This study used administrative data from
publicly funded outpatient AOD treatment facilities in
Delaware and Maryland. The study employed a quasiexperimental pre-post design with a control group. All
regression analyses were conducted using multilevel
modeling techniques.
Population Studied: The sample consisted of adults
receiving publicly funded outpatient AOD treatment in
Delaware between 1998 and 2006 (N = 13,789) and a
matched control group selected from adults receiving
outpatient AOD treatment in Maryland over the same
period (N = 300,976).
Principal Findings: Descriptive analyses of waiting time
from a client’s first contact with the treatment program to
admission to treatment in Delaware indicate average
waiting time decreased from 32 days to 10 days
between 2001 and 2006. Multivariate analyses
controlling for client demographic characteristics and
frequency and type of drug use indicate that on average,
clients admitted to Delaware facilities after the PBC
waited 17 fewer days for admission to treatment (p <
.001). Analyses of length of stay (LOS) for clients
admitted to publicly funded Delaware outpatient AOD
treatment indicate LOS increased from 104 days to 117
days between 2001 and 2006 while LOS in Maryland
declined from 97 days to 92 days over the same period.
Multivariate analyses indicate that clients admitted to
treatment in Delaware following implementation of the
PBC stayed in treatment an average of 23 days longer
than clients in Maryland over the same period (p < .001).
Analyses of changes in the population treated over time
in Delaware indicate facilities did not engage in selection
of patients, rather client severity increased over time.
Interviews conducted with CEOs of treatment facilities in
Delaware indicate that the performance contract
provided an incentive to improve quality of AOD
treatment and that it was important for facilities to have
assistance and guidance in order to make improvements
in quality of care.
Conclusions: The PBC is associated with
improvements in waiting time and LOS in publicly funded
outpatient AOD treatment programs in Delaware.
Implications for Policy, Delivery or Practice: State
agencies funding AOD treatment may be able to
incentivize provision of better quality treatment through
the use of PBCs. Performance contracts provide an
incentive to improve, but AOD treatment agencies also
need tools that help them learn how to improve.
Funding Source(s): NIAAA, NIDA
♦ Outcomes of Consumer-Operated Service
Programs as Adjuncts to Traditional Services
Gregory Teague, Ph.D.
Presented by: Gregory Teague, Ph.D., Associate
Professor, Mental Health Law & Policy, University of
South Florida, 13301 Bruce B Downs Blvd, MHC 2734,
Tampa, FL 33612, Phone: (813) 974-7185, Email:
teague@fmhi.usf.edu
Research Objective: The Consumer-Operated Services
Programs Multisite Research Initiative (COSP-MRI) was
funded by the Substance Abuse and Mental Health
Administration, Center for Mental Health Services to
investigate the outcomes of consumer-operated services
when offered as adjuncts to traditional mental health
services for persons with serious mental illnesses. The
primary hypothesis was that participants offered both
traditional and consumer-operated services would show
greater improvement in wellbeing over time than
participants offered only traditional mental health
services. Other outcomes examined included
empowerment, symptoms, hospitalization, and
socialization.
Study Design: The (COSP-MRI) used an experimental
design in eight separate sites across the country
representing a range of consumer-operated program
types, including drop-in centers and peer support and
education/advocacy programs, along with traditional
community-based mental health programs. Participants
were randomly assigned either to the experimental
condition of being offered use of consumer-operated
services (COS) as adjuncts to traditional services or to
the control condition of continuing their usual services. A
standardized interview protocol was administered at
baseline and at 4-month follow-up intervals over a 12month period. A common measure of program
ingredients was used to assess both consumer-operated
and traditional service programs. Outcomes were
evaluated using intent-to-treat analysis. Supplemental
as-treated analyses used propensity scores to address
possible selection effects. Experimental results were reexamined using program fidelity scores to reveal
program contributions to outcome.
Population Studied: Study participants were 1827
persons 18 years and older with serious mental
disorders receiving services in traditional, communitybased mental health programs.
Principal Findings: Although the level of use of
consumer-operated services offered was modest, the
experimental group showed significantly greater gains in
well-being, with greater gains associated with higher
use. Use of COS was also significantly associated with
increase in empowerment, decrease in symptoms, and
increase in perception of social inclusion, and there was
a marginal reduction in number and duration of
hospitalizations for the experimental group. Education
level was significantly related to gains in wellbeing and
empowerment and reduction in symptoms. Specific
program process ingredients – inclusion, choice &
respect, and opportunities for self-expression – were
strongly associated with outcomes when analyzed either
experimentally or observationally, independent of size of
experimental effect.
Conclusions: Consumer-operated programs were
effective in producing gains in recovery-related domains
over a 12-month period when offered as adjuncts to
traditional community-based services. Greater gains
were obtained for persons with greater social &
intellectual skills. Gains were strongly related to specific
program features that are stronger in COSPs but present
in traditional programs as well.
Implications for Policy, Delivery or Practice:
Consumer-operated services programs increase wellbeing and empowerment and foster symptom reduction.
These effects are both incremental and compensatory,
and discrete programs should be supported and offered
to consumers. Additionally, relationships between
outcomes and program ingredients specified for and
found in COSP exist independent of setting, and these
program features should be fostered within traditional
programs. More generally, the study findings support the
value of self/mutual help in recovery.
Funding Source(s): Substance Abuse and Mental
Health Administration, Center for Mental Health Services
♦ Payer Mix & On-Site Mental Health Service
Provision by Federally Qualified Community Health
Centers
Rebecca Wells, Ph.D., M.H.S.A.; I-Heng Lee, M.A.;
Andrea Radford, Dr.P.H.; Joseph Morrissey, Ph.D.
Presented by: Rebecca Wells, Ph.D., M.H.S.A.,
Associate Professor, Health Policy & Management,
University of North Carolina, 7411 McGavran-Greenberg
Building, Chapel Hill, NC 27514, Phone: (919) 9666961, Email: rwells@unc.edu
Research Objective: Federally funded community
health centers play an increasingly important role in
behavioral health care for the medically underserved.
This investigation sought to identify how both center
level payer mix and state Medicaid generosity affect onsite mental health service provision by community health
centers.
Study Design: Secondary data from the Health
Resources and Services Administration’s Uniform Data
System were combined with publicly available data on
county and state contexts. Three-level lagged random
intercept models were used to accommodate multiple
years of data for every center, which in turn made it
possible to test for enduring patterns. Key predictors
were the percentage of community health center patients
covered through Medicaid, state Medicaid spending per
person, and the percentage of health center patients
with private insurance. Logistic models predicted health
centers’ on-site provision of routine mental health
services and 24-hour/crisis mental health services. An
ordinary least squares model predicted the mean
number of mental health encounters per mental health
patient, controlling for patient population need, center
structure, rurality, alternative providers, and year.
Preliminary analyses had not found payer mix or patient
population attributes to be endogenous to service
provision
Population Studied: The sample included all US
federally funded community health centers between
2000 and 2004 with outcomes from 2001-2005 (n=3,788
center-years representing 862 centers). The majority
(70%) of health centers provided on-site specialty mental
health care. Far fewer (19%) provided 24 hour crisis
intervention services. The mean number of mental
health encounters per mental health patient reported by
health centers (not weighted by center size) was 2.43.
Principal Findings: The percentage of community
health centers’ patients covered by Medicaid was
positively associated with health centers’ odds of offering
routine mental health services (OR=1.054, p<0.001).
State Medicaid expenditures per person were positively
associated with crisis mental health service provision
(OR=1.626, p<0.001). The percentage of health centers’
patients covered through private insurance was
positively associated with both the odds of providing
routine mental health services (OR=1.055, p<0.001) and
the average number of mental health encounters per
person with a primary diagnosis of mental illness
(p<0.05).
Conclusions: Both health center payer mix and state
Medicaid expenditures per person may affect on site
mental health care provision.
Implications for Policy, Delivery or Practice: State
Medicaid eligibility thresholds may affect community
health centers’ provision of mental health care by
affecting the proportions of health center patients with
Medicaid coverage.The current analyses suggest that
states that provide Medicaid to more people may thereby
improve public mental health service availability. The
level of Medicaid funding states provide per enrollee also
appears to have ripple effects on access. Thus, policy
makers should be aware that sustaining Medicaid
expenditures may support crisis service provision that in
turn may prevent more expensive episodes of
hospitalization, as well as reduce the human costs of
mental illness. In other words, investments in Medicaid
may yield indirect benefits. Finally, health center
administrators already strive to attract privately insured
patients. Findings from the current study indicate that
doing so may enhance rather than detract from their
ability to serve the uninsured.
Funding Source(s): NIMH, UNC School of Public
Health
Factors Affecting Access to Behavioral Health
Services
Chair: Marisa Elena Domino
Tuesday, June 30 * 11:30 a.m.-1:00 p.m.
♦ Perceived & Personal Stigma as Barriers to Mental
Health Service Utilization
Daniel Eisenberg, Ph.D.; Marilyn Downs, M.S.W.; Ezra
Golberstein, Ph.D.; Kara Zivin, Ph.D.
Presented by: Daniel Eisenberg, Ph.D., Assistant
Professor of Health Management & Policy, Health
Management & Policy, University of Michigan, M3517
SPH II, MC 2029, Ann Arbor, MI 48109-2029, Phone:
(734) 615-7764, Email: daneis@umich.edu
Research Objective: The stigma of mental illness has
been identified by the Surgeon General and other
national policymakers as an important barrier to the
receipt of mental health care. The concept of stigma
takes many forms, some of which may be more
influential than others, but empirical evidence on these
distinctions is limited. We conducted the first study, to
our knowledge, of how mental health service utilization
independently relates to each of two important aspects
of stigma: perceptions of public stigma (“perceived public
stigma”) and one’s own stigmatizing attitudes (“personal
stigma”).
Study Design: We analyzed data from the 2007 Healthy
Minds Study, in which web surveys were administered to
random samples of students at 13 universities
nationwide. Mental health service utilization was
measured using questionnaire items adapted from the
Healthcare for Communities study. Perceived public
stigma and personal stigma were measured using
adaptations of the Discrimination-Devaluation scale
developed by Bruce Link and colleagues. Symptoms of
depression and anxiety were measured using the Patient
Health Questionnaire (PHQ). We accounted for survey
non-response bias using response propensity weights
based on administrative data, and we also assessed
potential response bias with a brief non-response survey
with key mental health measures. We estimated the
relationship between measures of stigma and helpseeking behavior using logistic regressions controlling
for a range of covariates.
Population Studied: The 13 schools in the study were
diverse in terms of geographic location (at least two from
each Census region), enrollment (ranging from 5,000 to
43,000), and racial/ethnic composition (ranging from 0 to
63% non-white). A total of 5,555 (43%) of recruited
students completed the survey. The sample was 54%
female and 74% undergraduate, and the racial/ethnic
composition was 10% Asian, 6% black, 6% Hispanic,
67% white, 5% multiple race/ethnicities, and 6% other
categories.
Principal Findings: We had three main findings: 1)
perceived public stigma was considerably higher than
personal stigma; 2) personal stigma was higher among
students with any of the following characteristics: male,
younger, Asian, international, more religious, or from a
poor family; and 3) personal stigma was significantly and
negatively associated with measures of help-seeking
(perceived need for help, and utilization of psychotropic
medication, therapy, and nonclinical sources of support),
whereas perceived stigma was not significantly
associated with help-seeking.
Conclusions: The sample in this study, which consisted
mostly of young adults, believes that the public
stigmatizes mental illness to a much greater extent than
they themselves report stigmatizing attitudes.
Stigmatizing attitudes were also higher on average
among certain groups of students. One’s own
stigmatizing attitudes appear to represent a more
significant barrier to mental health care utilization than
one’s concerns about others’ stigmatizing attitudes.
Implications for Policy, Delivery or Practice: Efforts to
reduce the role of stigma as a barrier to mental health
care may be most effective if they are tailored to: a)
focus on changing people’s own attitudes, which
requires going beyond addressing people’s concerns
about others’ attitudes; b) addressing certain groups that
have particularly high levels of stigma.
Funding Source(s): Other, Penn State Center for
Youth, Family, and Children; University of Michigan
Comprehensive Depression Center; and the colleges
and universities participating in the 2007 Healthy Minds
Study
♦ The Costs & Utilization of Behavioral Healthcare
Services Between CDHP Full Replacement & CDHP
Options
Nancy Hardie, M.P.H., M.S.; M.S.; Anthony LoSasso,
M.A., Ph.D.; Regina Levin, M.P.H
Presented by: Nancy Hardie, M.P.H., M.S., Senior
Health Services Researcher, Healthcare Product, United
Healthcare, 5901 Lincoln Drive, Edina, MN 55436,
Phone: (952) 992-5796, Email: nancy_hardie@uhc.com
Research Objective: Consumer-directed health plans
(CDHP) remain controversial in the ongoing health care
debate, yet CDH plans have attracted considerable
attention from employers, individuals, and policy makers.
However, as enrollment in CDHP continues to grow, our
goal is to use a unique dataset from a large national
health insurer to estimate the effects of CDHP on
behavioral health care cost and utilization.
Study Design: We compare utilization and costs of
health services between members with and without
behavioral disorders who either switch to a full
replacement consumer directed health plan (CDHP) to
those who had an option to choose a CDHP. A
retrospective pre-post cohort study design was
implemented to compare behavioral health utilization
and costs over the years 2005-2007, (one pre study year
and two years of follow-up).
Population Studied: A national cohort of employers 1)
switching entirely from traditional plan designs to
exclusively offering CDHP benefits beginning in 2006
(full replacement), or 2) offering the option of a CDHP
alongside traditional plans in 2006 for the first time
(option). From these groups there are 13,177 full
replacement enrollees, 10,345 option enrollees who
chose a CDHP, and 52,508 option enrollees who did not
choose a CDHP.
Principal Findings: The diagnosis rates of behavioral
disorders were 9.9 in 2005, 10.4 in 2006 and 9.8 in 2007
in the Full replace cohort; 7.4 in 2005, 7.4 in 2006 and
7.5 in 2007 in the Option-CDHP enrollees cohort; and
8.3 in 2006, 9.6 in 2006 and 9.4 in 2007 in the Option
Non-CDHP enrollees.
Conclusions: Our results are clearly consistent with the
widely noted favorable selection into CDHP, but thus far
we do not detect any significant evidence consistent with
reduced access to behavioral health treatment A distinct
advantage of our data is the ability to observe pre-CDHP
utilization patterns for all cohorts in our study.
Implications for Policy, Delivery or Practice: The
policy implications of our findings are potentially quite
significant as HSA legislation is subject to continuing
scrutiny by Congress and employers and consumers are
urgently looking for means of reducing their exposure to
high health insurance premiums. Learning about the
potential effects of CDHP benefit designs for chronically
ill subgroups such as those with behavioral health
disorders is a critical need. This study will provide
information about the impact of health insurance
offerings on behavioral health enrollment, utilization and
cost. Given the high incidence of these conditions,
understanding the impact of health insurance offerings
on behavioral health is critical to the goal of delivering
necessary behavioral health services.
♦ The Tradeoff Between Access to Community
Treatment & Acute Hospitalizations of the Severely
Mentally Ill
Richard Lindrooth, Ph.D.; Anouk Grubaugh, Ph.D.;
Walter Jones, Ph.D.; Anthony Losasso, Ph.D.;
Christopher Frueh, Ph.D.
Presented by: Richard Lindrooth, Ph.D., Associate
Professor, Center for Health Economics & Policy
Studies, Medical University of South Carolina, 77
President Street, MSC 700, Charleston, SC, Email:
lindrorc@musc.edu
Research Objective: Measure how access to
community care affects emergency psychiatric
admissions for severe mental illness (SMI) and
characterize locations where the inpatient cost offset is
greater than the cost of opening and maintaining
community services.
Study Design: We posit that spatial and temporal
variation in the number of ED admissions is due to
differences in the: prevalence and incidence of SMI and
access to community care. Four out of seven sample
states substantially reduced their state beds and thus
increased community prevalence. Access to community
services is measured as follows. First, we create
variables that equal one if the closest hospital ED has
specialty psychiatric emergency services; partial
hospitalization services; or none. Second, the supply of
outpatient psychiatric and psychiatric residential facilities
in the patient’s Health Service Area is measured. The
number of general and specialty hospital psychiatric
beds per capita in the patient’s Healthcare Referral
Region control for inpatient supply. We regress the
logged number of ED admissions per capita in a zipcode
on these measures (Access) plus the change in the
number of state beds per capita vis-à-vis 1997 (Beds).
Beds is interacted with Access yielding parameters that
measure how services perform in the wake of bed
closures. We show that Beds is exogenouslydetermined by changes in tax revenues and not statespecific clinical practice differences and that community
services didn’t increase after bed closures: eliminating
potential sources of bias. ED admissions for psychiatric
disorders uncommon in state hospitals are used as a
control group. The standard errors of the
heteroskedastic smearing-adjusted results are from a
block-bootstrap.
Population Studied: General hospital psychiatric
admissions (primary diagnosis: Psychotic, Mood, or
Cognitive Disorders) in AZ, CO, FL, NJ, NY, WA, and WI
between 1997-2005 in the HCUP-SID (n=1,098,592).
Facility information is from the American Hospital
Association Annual Survey; Medicare Cost Reports;
Census of Economic Activity; and state sources.
Principal Findings: The smearing-adjusted results
reveal that about 80-90% of the growth in ED
admissions for psychotic and mood disorders in CO, FL,
and NY was due to state closures. 33%-66% of this
increase could be prevented with access to community
alternatives. Preliminary cost estimates reveal that the
cost of 10-15 emergency psychiatric units in FL and NY
and 2-3 in CO would be offset by reduced inpatient
expenditures. Increased supply of residential services is
warranted in four states (all at least p<0.05).
Conclusions: Reductions in state beds in the last
decade have not been adequately offset by increases in
community services. There is potential for large (and
cost-effective from the state’s perspective) investments
in psychiatric emergency services and residential
services.
Implications for Policy, Delivery or Practice: As a
result of the recent economic downturn mental health
agencies in many states have to absorb another round
of substantial cutbacks. Agencies are charged with
difficult decisions about where to direct limited
resources. Preventing relatively expensive general
hospital inpatient stays is one way to make better use of
limited resources, and at the same time, potentially
increase the quality of care.
Funding Source(s): NIMH
♦ The Impact of a Medicaid Pharmacy Benefit
Change on Outcomes for Olanzapine-Treated
Patients with Schizophrenia or Bipolar Disorder
James Signorovitch, Ph.D.; Howard Birnbaum, Ph.D.;
Rym Ben-Hamadi, M.S.; Daniel Ball, Dr.P.H.; Yohanne
Kidolezi, B.A.; David Kelley, B.A.
Presented by: James Signorovitch, Ph.D., Associate,
Analysis Group, Inc, 111 Huntington Avenue, 10th Floor,
Boston, MA 02199, Phone: (617) 425-8258, Email:
jsignorovitch@analysisgroup.com
Research Objective: Atypical antipsychotics (AAs) are
often subjected to utilization management restrictions
with the goal of reducing pharmaceutical spending.
However the impact of such measures on medical
outcomes has not been well-characterized. This study
assesses the impact of a Florida (FL) Medicaid policy
announcement on acute care service utilization among
patients treated with the AA Zyprexa (olanzapine)
following diagnosis with schizophrenia or bipolar
disorder. The policy, effective on 7/11/2005 but
rescinded on 9/9/2005, re-classified olanzapine as nonpreferred and allowed current users 60 days to change
antipsychotics.
Study Design: Retrospective analysis of matched prevs. post-policy Florida Medicaid cohorts, using as a
reference cohort New Jersey (NJ) Medicaid, where
olanzapine maintained preferred status during the study
period. Conditional logistic regression was used to
assess the effects of year (2005 post-policy vs. 2004
pre-policy), state (FL vs. NJ) and state-by-year
interaction on the odds of switching from olanzapine to
other antipsychotics, inpatient hospitalization and
emergency room (ER) visits over a 6-month outcome
period.
Population Studied: Florida Medicaid patients
prescribed olanzapine following diagnosis with
schizophrenia or bipolar disorder. To adjust for patient
baseline (pre-policy change) characteristics, olanzapine
users on 7/11/2005 (the post-policy cohort) were
matched to comparable prior-year (7/11/2004) patients
(the pre-policy cohort). Parallel pre- and post-policy
cohorts were matched in NJ to describe trends in
olanzapine treatment and acute care in the absence of
the FL policy change for patients with schizophrenia or
bipolar diagnoses.
Principal Findings: Unmatched FL olanzapine users in
2005 (n=5,164) vs. 2004 (n=7,257) switched to other
antipsychotics more frequently (39.1% vs. 10.1%;
P<0.001) during the outcome period, but experienced
similar rates of inpatient hospitalization and ER visits
(increased by 1% and 3%, respectively, in 2005 vs.
2004; both P > 0.3). In the matched FL cohorts
(n=4,255), with balanced baseline characteristics
including acute care, switching from olanzapine to other
antipsychotics remained more frequent in 2005 vs. 2004
(38.6% vs. 9.0%), but, in contrast to the unmatched
results, inpatient hospitalizations and ER visits increased
significantly by 19.8% and 19.7%, respectively, in 2005
vs. 2004 (all P<0.001). Also in contrast to FL, in the
matched NJ cohorts (n=2,352) switching from
olanzapine was less frequent in 2005 vs. 2004 (10.7%
vs. 14.8%), and inpatient hospitalizations and ER visits
decreased by 8.3% and 19.9%, respectively, in 2005 vs.
2004 (all P<0.05). These rate decreases in NJ were
significantly different from the concurrent rate increases
in FL (all P<0.001).
Conclusions: FL Medicaid’s announced policy change
was associated with substantial disruption of olanzapine
therapy and an increased risk of inpatient hospitalization
and ER visits. In contrast, during the same period in NJ
Medicaid, where olanzapine’s status remained
unchanged, olanzapine-treated patients experienced
decreased rates of switching from olanzapine and a
decreased risk of inpatient hospitalization and ER visits.
Implications for Policy, Delivery or Practice: These
results are consistent with the 2008 National Association
of State Mental Health Program Directors
recommendations that “‘grandfathering’ is the
recommended practice for individuals stabilized on a
nonformulary antipsychotic medication to minimize risk
of relapse and support continuity of care.”
Funding Source(s): Eli Lilly and Company
♦ The Effect of the Privatization of the Inpatient
Psychiatric Care on the Jail System
Jangho Yoon, Ph.D., M.S.P.H.
Presented by: Jangho Yoon, Ph.D., M.S.P.H., PostDoctoral Scholar, The Nicholas C. Petris Center on
Health Care Markets & Consumer Welfare, University of
California at Berkeley, 2510 Shattuck Avenue, Suite 525,
Berkeley, CA 94704, Phone: (510) 642-9930, Email:
jhyoon@berkeley.edu
Research Objective: Despite the national interest in the
on-going transformation of the mental health system, an
important component of mental health service delivery
has received little attention. This study analyzes the
effect of the privatization of the inpatient psychiatric care
market, and tests its potential spill-over effect on local
jails. Private hospitals, particularly for-profit hospitals,
may be less inclined than traditional public safety-net
providers to serve indigent and costly patients. Thus, it is
postulated that a market shift from public to private
inpatient care increases the size of jail population
through the exacerbation of psychiatric symptoms and
subsequently increased contacts with criminal justice
authorities in this population.
Study Design: This study involves analysis of statelevel panel data from various administrative databases
on all 50 states and the District of Columbia for the years
1985 to 1998. Inpatient privatization was measured by
the ratio of private hospital psychiatric beds to total
psychiatric beds. The annual number of jail inmates was
regressed on the market share of private psychiatric
beds – first for total private beds and then separately by
ownership type including non-profit and for-profit. The
total supply of psychiatric beds and community mental
health expenditures were included in the empirical
specification to control for the capacity of the state
mental health system. The model also controls for
changes in demographic and socioeconomic
characteristics of each state as well as state and year
fixed effects. The empirical model was estimated using
weighted least squares with state populations as
weights. Standard errors were adjusted for clustering at
the state level. The instrumental variable generalized
method of moments (IV/GMM) estimator was calculated
to address the potential endogeneity of the supply of
private inpatient services.
Population Studied: US residents aged 18 and older
for the years 1985-1998.
Principal Findings: Holding fixed the total supply of
inpatient and outpatient mental health resources, a 1percentage point increase in the market share of private
psychiatric beds on average was found to increase the
annual number of jail inmates by about 7 percent
(p<.001). The effect of ownership was not
homogeneous. A 1-percentage point increase in the forprofit market share increased the number of jail inmates
by about 8.6 percent annually (p<.001); no significant
effect was found for the non-profit market share. This
finding suggests that the 4 percentage-point increase in
the for-profit market share between 1985 to 1998 is
responsible for an approximately 34 percent increase in
jail inmates.
Conclusions: The findings present strong evidence that
the privatization of the inpatient psychiatric care market,
especially toward for-profit ownership, has a negative
spill-over effect on local jails.
Implications for Policy, Delivery or Practice: The
inpatient psychiatric care market has been increasingly
dominated by private psychiatric facilities. Because this
structural change to the inpatient psychiatric care
delivery may significantly contribute to increasing
contacts with the criminal justice system among the
mentally ill, changes in the ownership composition of the
inpatient psychiatric care market should be an important
agenda for mental health policy.
Funding Source(s): NIMH
Understanding & Improving Child Health Care
Quality
Chair: Michael Seid
Sunday, June 28 * 2:30 p.m.- 4:00 p.m.
♦ Improving Timely Childhood Immunizations
Through Pay for Performance in Medicaid Managed
Care
Alyna Chien, M.D., M.S.; Zhonghe Li, M.S.; Meredith
Rosenthal, Ph.D.
Presented by: Alyna Chien, M.D., M.S., Instructor,
Pediatrics, Children's Hospital Boston, 21 Autumn Street
- Room 223, Boston, MA 02115, Phone: (857) 2184074, Email: alyna_chien@yahoo.com
Research Objective: Despite widespread use of pay for
performance by commercial and public payers, there
remains considerable uncertainty about how best to
design and implement these programs. We sought to
evaluate the effectiveness of pay for performance that
rewards providers for each child that was fully and timely
immunized and screened at age 2 in a Medicaid-focused
health plan. The incentive program offered practices
$100 for each fully immunized child and $200 for each
fully and timely immunized child. We also examined
levels and changes in racial and ethnic disparities in
immunization and screening.
Study Design: The study uses a pre/post comparison in
immunization and screening with an external comparison
derived from other Medicaid-focused health plans in the
same state. Patient-level claims data analysis is used to
complement aggregate trend comparisons between the
intervention and comparison health plans in publicly-
reported quality data, which reflect both claims and chart
review information.
Population Studied: 3,279 children who reached the
age of 2 during the study period (2003-2007) and were
continuously enrolled from birth to age 2 in the Hudson
Health Plan. All children were covered under either the
Medicaid or SCHIP program.
Principal Findings: Compared to children covered by
other Medicaid-focused health plans in New York,
immunization and screening for Hudson Health Plan’s
continuously-enrolled two-year-old population improved
by approximately 3 percentage points more after the
launch of the pay-for-performance program. Hispanic
children had higher baseline levels of immunization and
screening than non-Hispanic children. There were no
significant changes in racial and ethnic disparities after
pay for performance.
Conclusions: Paying physician practices and clinics a
bonus for every child fully or fully and timely immunized
and screened leads to significant but modest
improvements in recommended pediatric preventive
care. Racial and ethnic disparities in preventive care
that were observed at baseline were not affected by the
introduction of the bonus.
Implications for Policy, Delivery or Practice: Pay for
performance can lead to improvements in care, but may
need to be used alongside other mechanisms such as
patient outreach and education to achieve more
substantial gains.
Funding Source(s): CWF
♦ Asthma Care Quality for Children with MinorityServing Providers
Alison Galbraith, M.D., M.P.H.; Lauren Smith, M.D.,
M.P.H.; Barbara Bokhour, Ph.D.; James Glauber, M.D.,
M.P.H.; Irina Miroshnik, M.S.; Tracy Lieu, M.D., M.P.H.
Presented by: Alison Galbraith, M.D., M.P.H., Assistant
Professor, Department of Ambulatory Care &
Prevention, Harvard Medical School & Harvard Pilgrim
Health Care, 133 Brookline Avenue, 6th Floor, Boston,
MA 02215, Phone: (617) 509-9893, Email:
Alison_Galbraith@harvardpilgrim.org
Research Objective: Health care for minority children is
often concentrated among a small proportion of
providers. Studies of adults have raised questions about
whether minority-serving providers deliver worse quality
of care than other providers. However, few studies have
evaluated this issue for children, particularly for asthma
care, where racial/ethnic disparities are welldocumented. This study aimed to compare asthma care
quality for children who did and did not have minorityserving providers.
Study Design: We conducted a telephone survey of
parents of children with persistent asthma, linked to data
from a mailed survey of their providers. The primary
outcome measures were report of whether the child had:
1) ever received inhaled steroids; 2) received influenza
vaccination in the past season; and 3) received an
asthma action plan in the past 12 months. The primary
predictor was whether the child's provider was minorityserving (with >25% of patients black or Latino). We used
generalized linear mixed models to test the relationship
between each of the 3 outcomes and having a minorityserving provider.
Population Studied: We identified children aged 2 – 12
years with probable persistent asthma based on HEDIS
criteria using the claims and encounter data of a
Medicaid-predominant health plan and a multispecialty
provider group in Massachusetts. Children’s usual
providers were identified through the same claims and
encounter data, as well as by parent report in the survey.
Principal Findings: The study population included 563
children. Children were more likely to have never
received inhaled steroids if they had a minority-serving
provider (16.9%) than if they did not (10.7%) (p=0.034),
and if they were Latino (22.6%) rather than black
(10.5%) or white (9.9%) (p=.004). Differences by having
a minority-serving provider and by race/ethnicity were
not seen for influenza vaccination or asthma action
plans. After adjusting for patient and provider
characteristics, the odds of never receiving inhaled
steroids were not significantly different for children with
minority-serving providers (OR 1.29, 95% CI 0.63-2.64),
or for Latino (OR 1.76, 95% CI 0.74-4.18) or black (OR
1.07, 95% CI 0.43-2.66) vs. white children. However,
children had increased odds of not receiving inhaled
steroids if they received care in health centers (OR 4.88,
95% CI 1.70-14.02) or hospital clinics (OR 4.53, 95% CI
1.09-18.92) vs. multispecialty practices.
Conclusions: Children with persistent asthma were less
likely to receive inhaled steroids if they received care
from minority-serving providers or were Latino, but these
differences were attenuated after adjusting for other
patient and provider characteristics. Such differences
were not observed for influenza vaccination and asthma
action plans. Children receiving care from health
centers and hospital clinics were less likely to receive
inhaled steroids.
Implications for Policy, Delivery or Practice: Based
on the limited set of asthma measures studied, our
findings do not support the hypothesis that minorityserving providers deliver lower-quality asthma care.
However, insofar as practice setting may be associated
with lower prescribing of inhaled steroids, quality
improvement efforts in this area should consider
focusing on underperforming settings such as health
centers and hospital clinics, which disproportionately
serve minority children.
Funding Source(s): NICHD
♦ Increased Tympanostomy Tube Use Contrasts with
Fewer Ambulatory Visits for Otitis Media in the US:
1996 - 2006
Lawrence Kleinman, M.D., M.P.H.; Salomeh Keyhani,
M.D., M.P.H.; Leonardo Trasande, M.D., MPP
Presented by: Lawrence Kleinman, M.D., M.P.H., Vice
Chair for Research & Education, Health Policy, Mount
Sinai School of Medicine, One Gustav L. Levy Place,
New York, NY 10029-6574, Phone: (212) 659-9556,
Email: lawrence.kleinman@mssm.edu
Research Objective: Despite its incidence having been
reduced by pneumococcal vaccination of infants, otitis
media is the most common childhood illness in the US
and the most common indication for childhood surgery,
especially tympanostomy tube surgery. Recent
guidelines have encouraged increased use of watchful
waiting. While ambulatory medical visits are assessed
annually through the National Ambulatory and National
Hospital Medical Care Surveys (NAMCS, of physician
office visits and NHAMCS, of hospital clinical visits and
emergency department visits), the National Ambulatory
Surgery Survey (NSAS) was conducted in 2006 for the
first time since 1996. We set out to compare and
contrast patterns of utilization for ambulatory visits for
otitis media and ambulatory tympanostomy tube (TT)
surgery in the US from 1996 through 2006.
Study Design: Interrupted time series design, using
cross sectional data from NAMCS and NHAMCS to
assess the number of ambulatory visits with a diagnosis
of otitis media in 1994 through 1996 and 2002 through
2006, and NSAS to estimate the number of
tympanostomy tube surgeries for 1994 through 1996 and
2006, all for children < 16 years. Segmented regression
analysis measured the impact of the 9 years between
1996 and 2006 on utilization of each of these services.
We the rate of tympanostomy tube (TT) surgery per 100
otitis media visits (OMV). We further measured the per
capita use of tympanostomy tubes in 1996 and 2006
using US Census data to estimate the population of
children under 16.
Population Studied: Representative sample of all
ambulatory visits and ambulatory surgeries of children
through 16 years old cared for in non-federal facilities, as
estimated by NAMCS and NHAMCS from 1994-1996
and 2002-2006 and NSAS from 1994-1996 and 2006.
Principal Findings: In 2006, 668,245 TT were
performed on children < 16 in the US, compared to
493,219 in 1996 (up 35%). From 1996 to 2006 per capita
TT use increased 28% to 0.96 surgeries per 100
children. Since OMV fell by 27% during this time frame,
TT use per 100 OMV increased 85% from 2.1 to 3.8 TT,
implying that in 2006 there was one TT surgery for every
26.2 OMV. These patterns persisted across age groups.
Segmented regression confirms that a trend towards
fewer tympanostomies existed in the 1990s and was
reversed between 1996 and 2006.
Conclusions: Despite a consistent decrease in the
number of ambulatory visits for otitis media, childhood
tympanostomy tube use from 1996 to 2006 increased
substantially, reversing a prior trend.
Implications for Policy, Delivery or Practice: From
1994 to 1996, use of tympanostomies declined. Since
that time, despite documented overuse compared to
expert judgment or guidelines, their use has increased.
Recent policy has focused on reducing the use of
antibiotics for otitis media: these data lead to the
question of whether surgical overuse is an unintended
consequence of greater focus on managing the medical
treatment of otitis media. Our findings suggest the
urgent need for policy makers, researchers, and
practitioners to identify and to promote the optimal use of
tympanostomy tube surgery for the benefit of children.
♦ Child Mortality at Pediatric & Other Hospitals
John Moran, Ph.D.; Robert Kanter; Joseph Terza
Presented by: John Moran, Ph.D., Assistant Professor,
Health Policy & Administration, Penn State University,
604 Ford Building, University Park, PA 16802, Phone:
(814) 865-8893, Email: jrm12@psu.edu
Research Objective: Regionalization of pediatric
hospital care, in which high-risk patients are admitted to
regional comprehensive pediatric hospitals while other
patients are hospitalized closer to home, has been
advocated by the American Academy of Pediatrics and
the American College of Critical Care Medicine, among
others. However, evidence supporting these
recommendations is limited to small subsets of disorders
and hospitals. The evaluation of hospital quality is
complicated by the propensity of more severely-ill
patients to receive care at higher-quality hospitals, a
phenomenon that leads to the well known problem of
case-mix bias. We estimate the relative quality of care
provided by pediatric hospitals using an instrumental
variables approach that mitigates these biases.
Study Design: Comprehensive pediatric hospitals were
identified as those in the top decile statewide for both
clinical volume and diversity of diagnostic disorders, as
well as having an accredited pediatric residency. Eleven
of the 241 hospitals in our data met these criteria. Child
mortality rates were compared at pediatric hospitals and
other hospitals. Patient characteristics and diagnosisrelated groups (DRGs) were used to control for
observable case-mix variation. To account for
unobservable case-mix differences, we instrumented for
hospital choice using the differential distance from each
patient’s residence to the nearest pediatric hospital,
relative to the nearest hospital. Differential distance
partially affects treatment (choice of a pediatric or other
hospital) but does not directly affect outcome, thus
mimicking a randomization to the type of hospital.
Population Studied: All children age 14 years and
younger hospitalized in New York State during the
period 1996-2002, excluding neonates. Additional
analyses were performed for a subgroup of children with
an elevated risk of death. Our estimation samples
contained 903,388 and 355,571 children, respectively.
Principal Findings: The overall child mortality rate was
3.5 deaths / 1000 hospitalizations. Analysis controlling
only for patient characteristics indicates that pediatric
hospitals have an excess mortality rate of 7.7 / 1000
hospitalizations. Adding DRGs to the set of control
variables reduced the excess mortality at pediatric
hospitals to 3.0 / 1000. However, when the instrumental
variables estimator was employed, the mortality rate at
pediatric hospitals was lower than at other hospitals by
4.7 deaths / 1000. For high-risk patients, the mortality
reduction at pediatric hospitals was three times larger:
14 deaths / 1000.
Conclusions: Our estimates provide evidence that
pediatric hospitals treat sicker patients than nonpediatric hospitals, that part of the difference in illness
severity is unobservable, and that after adjusting for
case-mix differences, pediatric hospitals provide higher
quality care than other hospitals, especially for children
whose clinical characteristics heighten their risk of death.
Implications for Policy, Delivery or Practice: Our
findings support a role for regionalization of hospital
services for children and suggest that regulatory
interventions should balance the efficiency gains from
competition in hospital markets with the superior clinical
outcomes that arise when patients have appropriate
access to comprehensive pediatric hospitals.
♦ Explaining Variations in Quality of Mental Health
Care for Children: Do Organizational Characteristics
of Clinics Matter?
Susan Stockdale, Ph.D.; Bonnie Zima, M.D., M.P.H.;
Penny Knapp, M.D.; Michael Hurlburt, Ph.D.
Presented by: Susan Stockdale, Ph.D., Sociologist,
Semel Institute Health Services Research Center,
University of California, Los Angeles, 10920 Wilshire
Boulevard, Ste 300, Los Angeles, CA 90024, Phone:
(310) 794-3732, Email: sstockdale@mednet.ucla.edu
Research Objective: Although effective treatments
have been developed for many mental illnesses, serious
deficiencies persist in the quality of care received by
children in publicly-funded systems. This study explores
effects of organizational characteristics on child mental
health care quality.
Study Design: A multi-stage stratified random sample of
813 children from 62 mental health clinics in 21
California counties. Data from medical records for a 4month period from 2001-2002 were used to construct
outcome variables - quality of care indicators in 8
domains. Information about clinics obtained through
program administrator surveys was used to construct
organizational-level predictors, including county income
and population density, clinic ownership status, percent
of providers treating children, volume, number of
services, organizational climate/culture, staffing,
supports/incentives for QI, and clinic capacities for QI.
Child-level predictors included race/ethnicity, gender,
age, clinical severity and psychosocial complexity.
Hierarchical models and standardized predictions were
used to explore predictors of probable acceptable mental
health care, defined using operational definitions
developed from expert panel ratings through a modified
Delphi approach, and whether different organizational
characteristics are important for specific quality domains.
Population Studied: Children with a tracer condition
(ADHD, CD, or MD), aged 6 to 16.9 years.
Principal Findings: We found significant associations
between probable acceptable care and quality domain,
and a three-way interaction between population density,
ownership status, and quality domain. Younger children
and those with clinical severity were liklier to receive
acceptable care across all mental health quality
domains. For linkage to other services domain, children
in high population density counties received better care
in contract (62%) as compared with directly operated
clinics (40%); in low population density counties, a
similar but less dramatic difference was found. For the
basic treatment principles domain, 43% of children from
directly operated clinics in low population counties
received acceptable care, compared with 29% in
contract clinics. In high population counties, contract
clinics had better general medication monitoring (83% of
children) and specific medication monitoring (26%),
compared with directly operated clinics (51% and 5%,
respectively). In general, directly operated clinics in low
population density counties deliver better care than in
high population counties, while no trend was apparent
for contract clinics by population density.
Conclusions: Although organizational theory suggests
that clinic structure, resources, culture, and capacity for
QI are important determinants of quality, our results
suggest that clinic structure and the socio-environmental
context are associated with quality of care. In particular,
we found that children receiving care in contract clinics
in high population density counties were more likely to
receive acceptable care, as compared with their
counterparts in directly operated clinics, on some quality
domains, particularly those related to safety (general and
specific medication monitoring).
Implications for Policy, Delivery or Practice: Due to
health sector market forces, contract clinics in high
population density areas may have more resources than
directly operated clinics, resulting in better quality care.
Alternatively, directly operated clinics may be better at
“decoupling” quality control processes from patient
outcomes, and consequently quality measures may not
be good indicators of the actual effect of care received
upon improved mental health.
Funding Source(s): State of California
Resolving Disparities in Health Care Utilization
among Vulnerable Children
Chair: Gregory Stevens
Sunday, June 28 * 4:30 p.m.- 6:00 p.m.
♦ Adolescent Human Papillomavirus Vaccine
Utilization: Experience of the First Year
Amanda Dempsey, M.D., Ph.D., M.P.H.; Lisa Cohn,
M.P.H.; Vanessa Dalton, M.D., M.P.H.; Mack Ruffin,
M.D., M.P.H.
Presented by: Amanda Dempsey, M.D., Ph.D., M.P.H.,
Assistant Professor of Pediatrics & Communicable
Diseases, Pediatrics, University of Michigan, 300 North
Ingalls, Room 6E08, Ann Arbor, MI 48109-5456, Phone:
(734) 615-0398, Email: adempsey@umich.edu
Research Objective: Adolescents participate in
preventive care services less frequently than other
childhood age groups, raising questions about the
feasibility of successfully implementing adolescenttargeted vaccine recommendations. Of the adolescent
vaccines, the human papillomavirus (HPV) vaccine is
considered the most problematic because it requires
three doses for series completion. Understanding
adolescents’ HPV vaccine utilization patterns is
important for informing future interventions to improve
vaccination rates among this population. The objectives
of this study were 1) to determine the proportion of
adolescents initiating and completing the HPV
vaccination series within the first year of vaccine
availability at a university-based health care system; and
2) to determine if there were differences in adolescent
HPV vaccine utilization by medical specialty or by patient
characteristics such as race, age or insurance status.
Study Design: Electronic medical record data from 9-18
year old females seen in outpatient pediatric, family
medicine or obstetric/gynecology clinics from January
2007-March 2008 at the University of Michigan were
reviewed to determine the proportion initiating and
completing the HPV vaccination series. Patient and clinic
characteristics associated with vaccine receipt were
evaluated using the Chi-square test.
Population Studied: 9-18 year old females seen at
outpatient pediatric, family medicine or
obstetric/gynecology clinics in a university-based health
system.
Principal Findings: 28% of 10,082 eligible adolescents
initiated HPV vaccination - of those, 75% completed the
3-dose series. However, among adolescents overall,
including those who were eligible for but did not initiate
vaccination, series completion was only 15%. African
American adolescents were significantly more likely to
initiate the vaccination series than White adolescents
(34% vs. 28%, p<.01), but were less likely to complete
the 3-dose series (61% vs. 77%, p<.001). Similarly,
those with public insurance were more likely to initiate
vaccination that those with private insurance (35% vs.
27%, P<.05), but were less likely to complete the
vaccination series (63% vs. 78%, p<.01). As
adolescents aged, there was a significant trend for
increasing vaccine series initiation, but no differences by
age category in series completion. A significantly lower
proportion of adolescents seen in gynecology clinics
(17%) initiated HPV vaccination than those seen in
pediatric or family medicine clinics (29% each, p<0.05).
Series initiation was also significantly more common at
preventive care visits than at problem-focused visits
(55% vs. 28%, p<0.05).
Conclusions: A high proportion of adolescents initiating
the HPV vaccination series complete it. However, in the
first year of HPV vaccine availability, series initiation
among adolescents overall was low. There was
significant variability in HPV vaccine utilization by both
patient and medical practice characteristics.
Implications for Policy, Delivery or Practice: Our
results suggest that outreach to underserved minorities
and socio-economically disadvantaged adolescents will
be important for ensuring high HPV vaccine utilization
rates. In addition, understanding and addressing the
barriers to HPV vaccination faced by
obstetrician/gynecologists should be a focus of future
research.
Funding Source(s): University of Michigan Award
♦ Effect of Access to a Medical Home on Emergency
Department Use & Family Financial Burden in
Childhood Asthma in the United States
Abdoulaye Diedhiou, M.D., M.S., Ph.D.; Janice Probst,
Ph.D.; Amy Martin, Dr.P.H.; James Hardin, Ph.D.; Sudha
Xirasagar, M.D., Ph.D.
Presented by: Abdoulaye Diedhiou, M.D., M.S., Ph.D.,
Postdoctoral Fellow, Public Health Consortium,
University of South Carolina, 800 Sumter Street, Room
309, Columbia, SC 29208, Phone: (803) 545-4938,
Email: diedhiou@gwm.sc.edu
Research Objective: Asthma is the most common
chronic illness in children in the United States.
Accessing health services for children with asthma can
challenge families who often face numerous barriers to
care. As an integrative method of service delivery, the
medical home has been advocated as central in efforts
to address barriers to effective care for children with
chronic conditions, including children with asthma.
However, studies documenting both the presence of a
medical home and its benefits have faced the challenge
of measuring the concept using available survey or
administrative data. Care provided through a medical
home in which physicians and parents share
responsibility for ensuring that children and families have
access to all services needed, may improve child and
family outcomes for patients with asthma. This study
ascertains the effect of having a medical home on the
use of emergency services and families’ perceived
financial burden associated with care in childhood
asthma.
Study Design: Data from the 2005-2006 National
Survey of Children with Special Health Care Needs (NSCSHCN) was analyzed. Aday & Andersen’s expanded
behavioral model of health services use and the Center
for Medical Home Improvement’s model guided the
analysis. The predictor of interest was medical home
status, as defined by the American Academy of
Pediatrics. Outcome measures were the number of
emergency department (ED) visits in a year and families’
perception of financial burden due to care. An
instrumental variable, the propensity for a child to have a
medical home, was computed and included in
multivariate analyses to account for a set of
characteristics associated with having a medical home.
The analysis was performed with SAS Callable SUDAAN
to handle the complex design of the NS-CSHCN.
Adjusted odds ratios (OR) and 95% confidence intervals
of models controlling for child and parental
characteristics (models 1), and for the additional
instrumental variable (models 2) are presented.
Population Studied: Children with asthma.
Principal Findings: Approximately half of children with
asthma had a medical home. Having continuous
insurance coverage was associated with higher odds of
securing a medical home (OR=1.60 [1.19—2.15]).
Factors associated with lower odds of having a medical
home included being Black (OR=0.63 [0.53—0.74]),
Hispanic (OR=0.61 [0.48—0.78]) or non-English speaker
(OR=0.55 [0.31—0.95]); living in a household with
income between 0 and 100% FPL (0.75 [0.59—0.97]) or
between 101 and 200% FPL (OR=0.79 [0.64—0.96]);
rating the condition as moderate (OR=0.67 [0.58—0.77])
or severe (OR=0.40 [0.29—0.54]); and having a
behavioral-emotional-developmental co-morbidity
(OR=0.59 [0.51—0.69]). Children who had medical
homes had lower odds of ED visits in model 1 (OR=0.77
[0.68—0.87]) and model 2 (OR=0.75 [0.69—0.82]); their
families had markedly lower odds of reporting financial
burdens due to care (OR=0.49 [0.41—0.58] for model 1;
OR=0.51 [0.45—0.57] for model 2).
Conclusions: Access to a medical home may contribute
in reducing misuse of health services and family financial
worries in childhood asthma.
Implications for Policy, Delivery or Practice: Families,
practitioners, insurers, communities, and policymakers
should strive to secure a medical home for each child
with asthma. Particular attention is needed for children
facing changes in insurance eligibility.
♦ Dental Care Utilization Under the Los Angeles
Healthy Kids Program: Successes & Challenges
Sara Hogan, M.H.S.; Ian Hill, M.P., M.S.W.; Embry
Howell, Ph.D.
Presented by: Sara Hogan, M.H.S., Research
Associate, Health Policy Center, The Urban Institute,
2100 M Street, NW, Washington, DC 20037, Phone:
(202) 261-5407, Email: shogan@urban.org
Research Objective: To assess the utilization of dental
care services by children enrolled in the Los Angeles
Healthy Kids Program, a universal child coverage
initiative designed to extend comprehensive health
insurance to children in families with incomes below 300
percent of the federal poverty level who are ineligible for
California’s Medi-Cal and Healthy Families programs.
Study Design: A five-year evaluation, begun in 2004,
comprises multiple qualitative and quantitative
components, including case studies of implementation,
focus groups with parents, analysis of administrative
data, and a longitudinal household survey. This paper
draws on findings from each component and presents
new results from analysis of encounter data from
Safeguard Dental, the program’s dental plan.
Population Studied: Children in the Los Angeles
Healthy Kids Program, who are primarily undocumented
immigrants given the program’s eligibility rules.
Principal Findings: The coverage and delivery of
general and specialty dental services through Healthy
Kids has not gone entirely smoothly. Case studies found
that children were often assigned to different dentists
than their parents had selected at enrollment, leading to
confusion and delays in obtaining care. Accessing
dental specialists was reportedly also problematic, due
to shortages of these providers. In focus groups, most
parents reported that their children had seen a dentist,
that finding one was easy, and that appointments were
made quickly. However, many parents were unhappy
with their child’s dentist and felt compelled to find a
different one. Many parents also reported that their
dentists charged sizeable copayments for checkups and
fillings, a practice forbidden by program rules. Still, our
household survey revealed that enrollment in Healthy
Kids was associated with a significant 28 percentage
point increase in the likelihood of a child having a usual
source of dental care, a 14 point increase in likelihood of
having a dental visit, and a 9 point reduction in likelihood
of an unmet dental need. Analysis of dental plan
encounter data, however, indicates that only about 40
percent of enrollees received an annual visit in 2007, the
lowest rate among all Healthy Kids programs in
California.
Conclusions: Findings from the Healthy Kids Evaluation
show mixed results for the delivery of dental care to the
program’s nearly 40,000 enrollees. While core
measures show significant improvement in access for
enrolled children compared to their uninsured
counterparts, dental plan data indicate relatively low
rates of utilization, an outcome that could have been
caused by some of the program’s early implementation
challenges.
Implications for Policy, Delivery or Practice: Overall,
the Los Angeles Healthy Kids Evaluation has
demonstrated that the program has greatly succeeded in
improving coverage and access for low-income,
undocumented Latino children. Yet, like many public
insurance programs across the country, Healthy Kids’
ability to meet the dental care needs of children has
been hampered by various factors, including insufficient
supply of specialists and problematic assignment of
children to network dentists. Incomplete dental plan
encounter data also make precise measurement of
utilization difficult. Policymakers must address these
shortcomings to ensure that children have access to
high quality dental care.
Funding Source(s): First 5 LA and The California
Endowment
♦ Effects of an Integrated Care System on Children
with Special Health Care Needs
Caprice Knapp, Ph.D.; Vanessa Madden; Hua Wang,
M.S.; Phyllis Sloyer, Ph.D.; Elizabeth Shenkman, Ph.D.
Presented by: Vanessa Madden, Institute for Child
Health Policy, Universitty of Florida, P.O. Box 100147,
Gainesville, FL 32610, Phone: (352) 265-0111 ext.
85763, Email: VLM@ichp.ufl.edu
Research Objective: In 2006 Florida reformed its
Medicaid program in Broward and Duval counties. The
aims of Florida’s Medicaid reform were to improve health
care delivery through flexibility in benefit packages and
to promote competition. With few exceptions, all
Medicaid enrollees are allowed to choose the health plan
that best suits their individual health needs. Children
with special health care needs (CSHCN) can also
choose from a number of health plans including
Children’s Medical Services Network (CMSN). Prior to
the implementation of Medicaid reform, Medicaid
enrolled CSHCN in Broward and Duval Counties were
primarily enrolled in the MediPass program. After
reform, they were transitioned into an Integrated Care
System (ICS). The ICS differs from MediPass in that it
has a defined (meaning based on standards) and closed
network of providers (CSHCN had access to any
provider under MediPass); there is greater medical
management (administrators can better monitor
utilization and referrals) due to the use of a Third Party
Administrator that processes claims; and each child is
assigned a care coordinator. Our study is the first to
investigate how the outcomes of CSHCN have changed
due to the implementation of the ICS under Medicaid
reform.
Study Design: This study employs two methodologies.
First, we use a quasi-experimental design to determine if
expenditures (inpatient, outpatient, Emergency
Department, and total) have changed from the pre
(2006) to post (2007) periods of Medicaid reform. Both
control (Palm Beach and Alachua) and treatment
(Broward and Duval) counties are used in the analysis to
determine if changes in expenditures would have
occurred in the absence of Medicaid reform. Second,
we use cross sectional retrospective survey data to
determine if there are differences pre (2006) and post
(2007) Medicaid reform in customer satisfaction across
the same control and treatment counties. The
Consumer Assessment of Health Plans (CAHPS) survey
was used to measure consumer satisfaction.
Population Studied: Children with Special Health Care
Needs enrolled in Florida's Medicaid program from 2006
to 2007. These children resided in Broward and Duval
counties, which underwent Medicaid reform, and two
control counties.
Principal Findings: After controlling for confounding
factors (age, race, gender, and months enrolled in
Medicaid) our results from the multivariate models show
that CSHCN in Broward significantly spent less than the
control county on inpatient ($1,000), pharmacy ($300),
and total expenditures ($1,700). Comparatively, CSHCN
in Duval only spent significantly less on inpatient care
($3,000) than the control county. However, both
Broward and Duval spent more on Emergency
Department care following reform ($300 and $40,
respectively). Our results also show that consumer
satisfaction significantly increased (p<0.05) in five of 12
CAHPS categories in Broward and Duval compared to
their control counties. There were no significant
changes in two (Customer Service and Getting Needed
Information) of the CAHPS categories.
Implications for Policy, Delivery or Practice: Although
it could be a number of years before policymakers,
researchers, and advocates can declare if the
implementation of the ICS has been successful, it is still
crucial to analyze data in the early phase of
implementation. Our study is the first to provide a
comprehensive analysis of CSHCN enrolled in an ICS.
Moreover, our study is one of the first to estimate the
effects of Medicaid reform on a particularly vulnerable
population. Our results suggest that cost savings did
occur in the Medicaid reform counties and for the most
part, consumer satisfaction increased or remained
unchanged. While we do not suggest that these results
indicate success or lack thereof of the ICS, we again
emphasize the importance of interim data analysis.
Delaying data analysis until years after program
implementation prohibits policymakers from making
much needed adjustments throughout the program’s
continuum.
Funding Source(s): Florida's Department of Health,
Children's Medical Services Division
♦ Comorbidities among Children with Emotional,
Developmental & Behavioral Conditions
Timothy McBride, Ph.D.; Shirley Porterfield, Ph.D.; Katie
Stone, M.P.H.
Presented by: Timothy McBride, Ph.D., Professor,
Brown School, Washington University, One Brookings
Drive, Saint Louis, MO 63130, Phone: (314) 935-4356,
Email: tmcbride@wustl.edu
Research Objective: In the past two decades the
incidence of children with emotional, developmental, and
behavioral (EDB) conditions has grown rapidly
(Blanchard, Gurka & Blackman 2006). There also has
been increased focus on whether the use of a “medical
home” is one solution to meeting the needs of children,
especially chronically ill children. The growth in the
number of children with EDB conditions has raised
concerns about both the financial burden of these
conditions on their parents, and whether parents may
start reducing utilization of services as this burden gets
large, especially if the parents are low-income. This
research examines whether children with EDB
conditions and comorbidities reduce utilization of needed
services because they cannot afford to pay for them. In
other words, because of the severity of their conditions,
and the multiplicative costs associated with them, do
these families then cut back on utilization of services
because their family cannot afford these services?
However, are children who have a medical home more
likely to receive needed services?
Study Design: The empirical approach used includes
descriptive analysis and the estimation of multivariate
models that take into account medical condition and
comorbidities, while controlling for demographic,
economic, medical home, and family characteristics. The
multivariate approach estimates a two-part model with
the first stage estimating whether the person receives
any services or not, and the second stage estimating the
amount of services received. The estimation accounts
for both the number as well as the type of conditions the
child has, with a specific focus on the presence of EDB
conditions and children with multiple EDB conditions. An
innovation of this analysis is to model utilization and
medical spending not only based on the presence and
number of EDB and non-EDB conditions, but accounting
for the severity and types of conditions present, and in
what combinations, as well as the medical home.
Population Studied: Data are drawn from the 20002006 Panels of the nationally-representative Medical
Expenditure Panel Survey (MEPS).
Principal Findings: Approximately 18 percent of
children ages 0-17 are currently diagnosed with one or
more EDB conditions that is, those conditions that affect
mental functioning or behavior, including children with
mental retardation, autism spectrum disorders (ASD),
anxiety/depression, learning disabilities,
emotional/conduct disorders, attention
deficit/hyperactivity disorder (ADHD), and bipolar
disorder. The annual costs of medical care for children
with EDB conditions and comorbidities are estimated to
be almost three times higher than those for children with
EDB conditions and no comorbidities. The analysis finds
that low-income children with comorbid health conditions
reduce expenditures relative to children with higher
incomes, all else equal, and that the medical home is a
moderating factor.
Conclusions: From a policy perspective, if families with
children with multiple conditions reduce the use of
needed services, this could lead to even more medical
complications in the long run, and perhaps increased
expenditures, creating policy concerns. Since the
medical home can alleviate some of these problems,
policies can be adopted to help support introduction or
expansion of this aspect of pediatric care. Providers will
certainly need to be aware of these issues when treating
their patients.
Implications for Policy, Delivery or Practice:
Policymakers who control programs such as Medicaid or
other public health insurance programs need to be
cognizant of access issues created for children with EDB
conditions who are covered by these programs, or for
children not currently covered by public programs. This
study finds that the presence of a medical home
improves clinical outcomes and the quality of care for
EMB children, which should suggest to policymakers
that policies to encourage the medical home should be
encouraged.
Funding Source(s): AHRQ
Chronic Care Implementation Strategies Across
Different Patient Settings
Chair: Stephen Parente
Monday, June 29 * 11:30 a.m.-1:00 p.m.
♦ Growth & Diffusion of Antipsychotic Medicines for
Labeled & Off-Labeled Uses, 1994-2007
G. Caleb Alexander, M.D., M.S.; Sarah Gallagher, B.A.;
Anthony Mascola, M.D.; Rachael Moloney, B.A.; Randall
Stafford, M.D., Ph.D.
Presented by: G. Caleb Alexander, M.D., M.S.,
Assistant Professor, Medicine, University of Chicago,
5841 South Maryland Avenue (MC 2007), Chicago, IL
60637, Phone: (773) 834-9177, Email:
galexand@uchicago.edu
Research Objective: Antipsychotic drugs are widely
used and costly. However, little is known about how
antipsychotic use during the past decade has varied with
respect to specific clinical applications or levels of
supporting evidence. We sought to examine trends in
antipsychotic use with a focus on how the application of
these drugs has changed over time. Extending prior
research, our efforts used greater diagnostic detail than
previous investigators, examined whether usage was
supported by evidence of efficacy for a given indication,
and also explored possible physician and patient
characteristics accounting for the observed prescribing
patterns.
Study Design: We used the IMS Health National
Disease and Therapeutic Index to describe typical and
atypical antipsychotic use from 1994 through 2007. This
data, which is nationally representative and
prospectively collected cross-sectional data of outpatient
office-based physicians, includes physician-reported
diagnoses based on ICD-9 codes, which were then
matched to indications provided by the FDA and the
Drugdex® compendium to determine levels of evidence
and labeled approval status. We also obtained
promotional and prescription expenditures from IMS
Health Integrated Promotional Services and the National
Prescription Audit. Quarterly prescription expenditures
for typical and atypical antipsychotics were reviewed and
divided by the number of prescriptions to determine the
average cost per typical or atypical antipsychotic drug.
Principal Findings: Preliminary results suggest
aggregate annual antipsychotic use increased 262%
from 8 million physician visits (1994) to 21 million (2006),
then declined to 19 million (2007). The market share of
typical antipsychotics decreased from 86% to 8% over
this time period. Among increases in antipsychotic use
between 1994-2007, the majority occurred among
individuals 18-64 (234%) and less than 18 years of age
(559%), while increases were more modest among
those 65 years of age or older (131%). Antipsychotic
use for schizophrenia declined from 76% to 31% as a
share of all uses from 1994 to 2007, while substantial
increases in use occurred for bipolar affective disorder
(5% to 39%) and depression (8% to 15%). The fraction
of atypical antipsychotic use for indications with
insufficient evidence of efficacy increased from 32% in
1994 to 58% in 2007, representing 26 million
prescriptions and $7.3 billion dollars in expenditures in
2007. During 2007, primary care physicians accounted
for 21% of visits where an antipsychotic was used, as
compared with psychiatrists (77%) or physicians from
other specialties (2%). The frequency of antipsychotic
use in settings of insufficient evidence was similar
among primary care physicians and psychiatrists.
Conclusions: Substantial growth and change has
occurred in the clinical application of antipsychotic drugs
during the past decade, including increased use without
strong evidence.
Implications for Policy, Delivery or Practice: The
scope and costs of this expansion, due to both clinical
innovation and overuse, demonstrate the importance of
efforts to guide practice towards more effective and
evidence-based use of these commonly used drugs.
This is of particular importance for policy makers and
practitioners alike given recent evidence of similar
efficacy and important side effect profiles of both typical
and atypical agents.
Funding Source(s): AHRQ, RWJF
♦ The Importance of Persistency in Medication Use
among Medicare Beneficiaries with Diabetes
Bruce Stuart, Ph.D.; Amy Davidoff, Ph.D.; Ruth Lopert,
M.D.; Thomas Shaffer, M.S.; Jennifer Lloyd, M.S.; Lirong
Zhao, M.S.
Presented by: Bruce Stuart, Ph.D., Professor, Peter
Lamy Center, University of Maryland Baltimore, 220
Arch Street, Room 01-212, Baltimore, MD 21201,
Phone: (410) 706-5389, Email:
bstuart@rx.umaryland.edu
Research Objective: The importance of persistency in
medication use to prevent chronic disease sequelae is
well established in clinical trials and observational
studies of adult populations. Less is known about
factors related to persistency in medication use and its
consequences among chronically ill aged populations
over time. This study has 3 objectives: (1) measure
persistency in use of antidiabetic agents, ACE-inhibitors
and ARBs, and statins and other lipid lowering drugs for
a nationally representative sample of Medicare
beneficiaries with diabetes over 3 years, (2) identify
demographic, socioeconomic, and behavioral factors
associated with persistency in use of these medications,
and (3) to determine whether higher persistency is
associated with lower Medicare spending on traditional
Medicare services (a surrogate for better health status).
Study Design: We tracked annual self-reported
prescription fills for each drug class using Medicare
Current Beneficiary Survey (MCBS) data from 1997
through 2005. Persistency was defined as number of fills
per class over 3 years following a base year self-report
of diabetes. We used ordinary least squares regression
to identify predictors of persistency among users of each
medication class. The relationship between medication
persistency and Medicare spending (measured in
constant 2006 dollars) over the same 3-year period was
assessed using a generalized linear model with a
gamma distribution and log link. Covariates included a
rich array of personal characteristics, diabetes-related
behaviors (knowledge of diabetes, taken diabetes
management class, checked blood sugar, checked feet
for sores), and drug switching indicators.
Population Studied: Six cohorts of community-dwelling
Medicare beneficiaries inducted into the MCBS between
1997 and 2002 who reported a doctor telling them they
had diabetes. To assure complete data capture, only
survivors who contributed complete MCBS surveys for 4
years were included in the study. (N=2,187).
Principal Findings: The most commonly used
medications were older oral antidiabetic agents
(metformin and sulfonylureas) taken by 68% of the
sample with a mean 24 fills over 3 years, followed by
ACE-inhibitors/ARBs (67% and 18 fills), and statins
(50% and 15 fills). There was strong correlation in
persistency across drug classes. Baseline demographic
and socioeconomic characteristics were not consistently
associated with persistency. None of the diabetes
behavior variables was significantly related to
persistency. However, there was a strong inverse
relationship between cumulative 3-year Medicare
spending and persistency in use of older antidiabetic
agents and ACE-inhibitors/ARBs. Each additional
prescription fill of an older oral agent was associated
with $92 (p=0.01) lower Medicare spending. Each
added fill for an ACE-inhibitor or ARB was associated
with $220 (p<.001) lower spending. These predicted
reductions exceeded unit drug costs—$38 for older oral
agents, $58 for ACE inhibitors, and $71 for ARBs.
Conclusions: Medicare beneficiaries with diabetes
exhibit a wide range of persistency in use of
recommended medications. Higher persistency levels
for older oral antidiabetic agents and ACEinhibitors/ARBs are strongly associated with lower
Medicare spending.
Implications for Policy, Delivery or Practice: There is
a significant potential for improved health and lower
Medicare costs among Medicare beneficiaries with
diabetes who are persistent users of recommended
medications. However, more research is necessary to
discover actionable predictors of persistent drug use.
Funding Source(s): RWJF
♦ Implementing the Chronic Care Model in Academic
Settings: Stories from the Field
Donna Woods, Ed.M., Ph.D.; Julie Johnson, Ph.D.;
David Stevens, M.D.; Connie Sixta, Ph.D.; Judy Bowen,
M.D.; Ed Wagner, M.D.
Presented by: Donna Woods, Ed.M., Ph.D., Assistant
Professor, Institute for Healthcare Studies, Feinberg
School of Medicine, Northwestern University, 750 North
Lake Shore Drive, 10th Floor, Chicago, IL 60611,
Phone: (312) 503-5550, Email:
woods@northwestern.edu
Research Objective: The disease burden from chronic
conditions is increasing and now represents the majority
of care delivered. Despite improved understanding of the
mechanisms of chronic diseases, only about half of the
patients with chronic conditions receive the
recommended care and improvement in outcomes of
care have remained stagnant. The Chronic Care Model
is a method established to direct improvement of chronic
illness care. Learning collaboratives were convened
nationally and in California to assist the diffusion of the
Chronic Care Model into academic medical centers.
Study Design: An evaluation consisted of 60-90 minute
focus-groups of teams participating in the Academic
Chronic Care Collaborative (ACCC). The focus groups
were audio-taped, transcribed, and analyzed to identify
emergent themes. A standardized protocol was used to
ask participants to discuss: Changes in practice,
definitions of success, organizational support, strategies
for spread, integration into education, resulting changes
in team philosophy and approach, the experience of
making changes to chronic illness care, the experience
of work as these changes were underway, and the
impact of the collaborative. The focus groups were
conducted to the point of saturation, the point at which
no new information is generated.
Population Studied: Thirty-two academic medical
teams representing twenty-two institutions across the
country participated in the ACCC.
Principal Findings: Focus groups were conducted with
17 of the participating ACCC Teams. Emerging themes
consisted of the following: Value added by participating
in the ACCC; Provides a framework and expectations for
guiding the work; Framework = patient care model and
data collection; Expectations = reporting; Teamwork =
necessary to get it done; Learning Sessions;
Benchmarking experiences was as important as
benchmarking process and outcomes; Participation
leverages organizational support and moves teams
through inertia; Effect of the ACCC on philosophy and
approach; Breaking down traditional hierarchies;
Realizing the need for multidisciplinary teams;
Importance of re-aligning roles to match level of training;
Embracing the PDSA cycle; It’s one thing to read about
it, using it is something else; Rethinking education;
Redefinition of learners and teachers; Involvement of
residents in making change; Implementing the CCM
requires teaching teamwork; Rethinking patient care;
Group visits; Self management; Teamwork; The
developmental frontier; Reimbursement issues at the
local level; Recognition of quality improvement work as
worthy of publication and tenure; Strategies for spread
(social network theory vs. replication); Education
strategies; Significant contribution of teamwork to the
success of changes in practice; Both the Chronic Care
Model and the Collaborative each independently
contributed to teamwork; The teams described
transformative 2nd order change - 1st order change
occurs within the system but the system remains
unchanged, in 2nd order change the change changes
the system.
Conclusions: The findings from this qualitative
evaluation provide direction for academic medical
centers contemplating implementation of the Chronic
Care Model. The ACCC was a dynamic learning
environment that provided a framework for teams of
clinicians from academic medical centers across the
country to make substantive changes to the organization
and education of chronic illness care.
Implications for Policy, Delivery or Practice: The
magnitude of change required to implement the CCM
and improve chronic illness care involved 2nd order
systemic change that has implications for the
organization of care, healthcare financing, existing
clinical roles and teamwork, and education.
Funding Source(s): AAMC, RWJF, and California
Healthcare Foundation
♦ Disease Management Outcomes for TRICARE
Populations with Asthma, Congestive Heart Failure
& Diabetes
Wenya Yang, M.P.A.; Tim Dall, M.S.; David Arday, Ph.D.
Presented by: Wenya Yang, M.P.A., Senior Associate,
Federal National Security & Emergency Preparedness,
The Lewin Group, 3130 Fairview Park Drive, Suite 800,
Falls Church, VA 22042, Phone: (703) 269-5694, Email:
Grace.Yang@Lewin.com
Research Objective: Evaluate the financial outcomes of
asthma, congestive heart failure (CHF), and diabetes
disease management (DM) programs of TRICARE
Management Activity (TMA).
Study Design: A predictive model designed to calculate
expected medical costs for DM participants was built
based on the experience of a historical control group
(HCG). The HCG was identified from claims data using
the same criteria as DM candidates. Using the HCG, we
estimated health care costs in the year following
“identification” based on patient demographics, plan
coverage, risk profile, and medication compliance in the
year preceding identification. We estimated diseaserelated healthcare costs for asthma and CHF, and
overall costs for diabetes. The estimated regression
coefficients were then applied to DM participants to
predict the expected healthcare costs in the absence of
DM. Actual and expected costs were then compared to
quantify program impact. Generalized Linear Models
were compared with Ordinary Least Squares models
and the best fitting ones were chosen as final models
based on R2 and Root Mean Squared Error (RMSE).
The prediction accuracy of the final models was
validated using a split sample approach. Model
performance was estimated using prediction ratio and
correlation between actual and expected costs. The
predictive model approach removes regression-to-the-
mean bias because it measures DM impact relative to
changes in the outcomes for the control group. Since the
historical controls did not have the option to participate in
DM, it also minimizes potential bias due to patient
motivation and self-selection. Potential biases due to
secular trends are adjusted by inflating costs to 2008
dollars. Also, we compared the estimated financial
impact to DM impact on clinical and healthcare utilization
measures.
Population Studied: The population includes high
utilization young and adult asthma patients (n=21,361),
adult CHF patients (n=3,703) and diabetes patients
(n=25,786) under age 65 who had been in the DM
programs for at least six months. Candidates for DM
were identified using a healthcare utilization thresholdbased approach based on TMA eligibility and claims
files. The study time frame was one year prior to and two
years post identification for continuously eligible patients.
Principal Findings: Findings suggest that DM reduces
annual disease-related medical costs (actual vs.
expected) for asthma ($2,125 vs. $2,452) and CHF
($4,628 vs. $5,463), and reduces overall medical costs
for diabetes ($11,392 vs. $12,375). Cost savings come
primarily from reduced hospital days and reduced
emergency visits for the three diseases.
Conclusions: Average, annual medical savings
generated from DM after only 2 years of program
existence are modest, but are anticipated to continue
growing. Areas of continuing research are whether the
benefits of DM differ by patient characteristics (e.g.,
demographics, indication of uncontrolled diabetes [for
diabetes patients], and level of participation in the DM
program).
Implications for Policy, Delivery or Practice: These
findings, estimated using a large patient population, help
develop the business case for disease management—
especially among a younger (< age 65) population.
Funding Source(s): TRICARE Management Activity
New Strategies for Disseminationg & Sustaining
Chronic Care Services
Chair: Ming Tai-Seale
Monday, June 29 * 3:00 p.m.-4:30 p.m.
♦ Using Animation to Enhance Diabetes Health
Literacy in Vulnerable Populations
Jose Luis Calderon, M.D.; Richard Baker, M.D.; Magda
Shaheen, M.D., Ph.D., M.P.H.; Nisa Sangasubana,
Ph.D.; Patrick Hardigan, Ph.D.; Sylvia Rabionet, Ed.D.
Presented by: Jose Luis Calderon, M.D., Division of
Research, Charles Drew University of Medicine &
Science, 1731 East 120th Street, Los Angeles, CA
90059, Phone: (760) 521-5511, Email:
drcalderon@sbcglobal.net
Research Objective: National and international studies
have demonstrated that improving health literacy (an
understanding of disease, its consequences and its
care) is associated with better health outcomes and
improved health status. Since immigrant Latinos have
limited educational attainment, and face language and
literacy barriers they are less likely to benefit from written
health information about diabetes. Though animation
has been used as an educational tool its use as an
educational intervention targeting chronic diseases such
as diabetes has not been reported. We produced an
animated video, ‘What is Diabetes?’ in English and
Spanish and tested its efficacy when compared to easy
to read information available from NIDDK at enhancing
diabetes health literacy among Spanish speaking
immigrant Latino diabetics as measured by a modified
version of the Starr County Diabetes Knowledge
Questionnaire.
Study Design: This was a pretest, post test randomized
controlled trial. Posttest1 was conducted the day of the
intervention and posttest2 two weeks after. Outcome
variable was diabetes knowledge score calculated as the
proportion of items out of 30 answered correctly. We
used descriptive, non-parametric and logistic regression
to analyze survey data as needed. The Test of
Functional Health Literacy in Adults (TOFHLA) was
administered at baseline.
Population Studied: We studied a sample of 240
diabetic Latino diabetics who accessed healthcare at the
South Central Family Health Center and who were
without previous formal diabetes education.
Principal Findings: There were no significant
differences between the groups in demographic
characteristics, baseline diabetes knowledge and
TOHFLA scores. Paired t-test revealed significant within
group increase in knowledge scores in posttest1 and
posttest2 relative to baseline scores for both groups,
(p<0.05). Adjusting for baseline scores there was a
significant increase in diabetes knowledge in the
intervention group posttest1 (p=0.02) but not posttest2.
However, participants in the intervention group with
inadequate or marginal functional health literacy had
significantly higher knowledge scores posttest2 when
compared to participants in the control group with similar
TOFHLA scores (p<0.005). There was no between
group difference in knowledge scores at posttest2
among those with adequate functional health literacy.
Conclusions: Animated videos are an effective venue
for enhancing diabetes health literacy among persons
with limited literacy skills. Though diabetics with
adequate health literacy did not benefit as much as
those with inadequate health literacy they nevertheless
showed increases in knowledge scores. Though this
study tested animation among immigrant Latinos,
vulnerable populations in general (minorities, the elderly)
are in need of usable health information that does not
depend on the written word.
Implications for Policy, Delivery or Practice:
Animation may be effective at enhancing chronic
disease health literacy among other vulnerable
populations with limited literacy skills and has the
potential to contribute to lessening chronic disease
health disparities in this regard. As the population of
vulnerable persons policy mandating the use of nonwritten venues and public health campaigns using multimedia to promote chronic disease health literacy for this
population are needed. This is particularly important for
persons with cognitive decline resulting from chronic
disease and aging.
♦ The PRISM Project: Promoting Realistic Individual
Self-Management Among Urban & Rural Patients
with Diabetes
Elizabeth Ciemins, Ph.D., M.A., M.P.H.; Valerie Caton,
N.P.; Patrician Coon, M.D.
Presented by: Elizabeth Ciemins, Ph.D., M.A., M.P.H.,
Research Director, Center for Clinical Translational
Research, Billings Clinic, 2800 Tenth Avenue, P.O. Box
37000, Billings, MT 59107, Phone: (406) 238-5724,
Email: eciemins@billingsclinic.org
Research Objective: To evaluate the effectiveness of a
nurse practitioner-led multi-disciplinary team approach to
diabetes self-management on achieving established
ADA guidelines for diabetes disease control, patient
satisfaction and patient self-management in the urban
and rural primary care setting.
Study Design: A three-group pre-post cohort design
was utilized in this study to determine the effects of a
patient-centered multi-disciplinary team approach to
diabetes management. The team consisted of a nurse
practitioner, certified diabetes educator, registered
dietician and a Master’s level social worker who provided
intensive clinical, educational, and psychosocial patient
care, both face-to-face and through the use of
telemedicine. Urban control patients were compared, at
baseline and one-year post-intervention, to urban and
rural intervention patients on control of vascular risk
factors (HbA1C < 7%, BP< 130/80 mm Hg, and LDL
cholesterol < 100 mg/dL), patient satisfaction, and selfmanagement assessments.
Population Studied: Two hundred thirty-seven adult
patients with Type 2 diabetes seen by a primary care
provider in one urban and five rural clinics in Eastern
Montana were enrolled in the study, beginning in June
2005, and followed for one to three years postintervention.
Principal Findings: One year post-intervention, the
proportion of patients with two or more uncontrolled risk
factors decreased from 59% to 24% among intervention
patients compared to a decrease from 65% to 51%
among control patients (p<.05). Patient diabetes care
satisfaction rates increased 142% and 392% among
urban and rural intervention patients, respectively,
compared to a 50% increase among control patients
(p=.006) during the same time period. In the intervention
groups, there was greater improvement in reported selfmanagement habits, i.e., adherence to diet, exercise,
and blood glucose monitoring, compared with control
group patients. No significant differences were identified
between rural and urban intervention patients on clinical
outcomes suggesting that telemedicine is an effective
mode in which to provide diabetes care for rural patients.
Conclusions: A nurse practitioner-led multi-disciplinary
team approach to diabetes management had a positive
impact on improved risk factor control, patient
satisfaction, and diabetes patient self-management
among urban and rural patients with Type 2 diabetes.
Telemedicine proved to be an effective means of
communication for the provision of diabetes care to rural
patients. Further investigation is needed to determine
which types of patients benefitted most from this model
of care and its associated cost-effectiveness. Current
work is also under way to identify barriers to selfmanagement and to determine which barriers the
diabetes team was most effective in addressing.
Implications for Policy, Delivery or Practice: This
study demonstrates the effectiveness of an innovative
model of care in the management of an increasingly
prevalent chronic disease that can be implemented in
both urban and rural settings. The future of healthcare is
dependent on the development of effective strategies to
address increasing rates of chronic conditions in an
aging population. This model of care is a possible
alternative to the traditional one-on-one patient-provider
encounter and may be a viable strategy for addressing
the unique challenges faced by patients living in rural
communities.
Funding Source(s): NIDDK
♦ Assessing the Impact of a Chronic Care Registry
on the Quality of Care
Henry Fischer, M.D.; Sheri Eisert, Ph.D.; Josh Durfee,
M.S.P.H.; Susan Moore, M.S.P.H.; Andy Steele, M.D.,
M.S.P.H.; Tom Mackenzie, M.D.
Presented by: Sheri Eisert, Ph.D., Director, Health
Services Research, Internal Medicine, Denver Health,
777 Bannock Street, Denver, CO 80204, Phone: (303)
436-4072, Email: sheri.eisert@dhha.org
Research Objective: To assess whether diabetes
outcomes can be improved through using a registry to
support 1) report card mailings to patients 2) point-ofcare report card distribution to patients and 3) provider
performance feedback with patient-level data.
Study Design: This study utilized a mixed-methods
approach. Process and clinical outcomes were
examined quantitatively, adjusting for age, race/ethnicity,
gender and baseline outcome performance. Generalized
estimated equations (GEE) accounted for within-subject
visit correlation. Measures included: Mean HbA1c; % of
patients with controlled HbA1c, LDL, and BP; % of
patients with HbA1c, LDL, and BP tested in the past
year. Patient satisfaction was qualitatively evaluated
through unprompted response to self-administered
mailed surveys. Provider satisfaction was assessed
through guided interviews with key informants. Data
were inductively analyzed, with emergent themes
synthesized into a final interpretive assessment.
Population Studied: Patients selected from the
diabetes registry included 5,457 English or Spanish
speaking patients with a diagnosis of diabetes and a visit
within 18 months. The majority are female (59.3
percent) and Hispanic (61.5 percent), with a mean age
of 54. Sixty primary care providers treating diabetic
patients at community health centers were included, with
a purposive sample selected to participate in interviews.
Principal Findings: Initial clinical results indicate that
randomization to both point-of-care report card and
provider performance interventions significantly
increased the percentages of patients with HbA1c levels
lower than 7 (p < 0.01) and LDL levels under 100 mg/dl
(p<0.01) respectively, compared to patients randomized
to the control groups. Initial results also indicate no
significant improvement in diabetic outcomes for patients
that were mailed quarterly report cards. 347 surveys
were returned (6.5 percent). The majority of
respondents found the report cards to be clear (89.6
percent), correct (83.9 percent), and helpful (87.6
percent), and preferred to continue receiving them (83.9
percent). Most also felt that their providers helped them
understand (55.3 percent) and use (51 percent) the
report card. Many respondents indicated self-efficacy,
expressed by confidence in their ability to control their
diabetes (67.4 percent), and perceived improvement in
their diabetes as a result of the report cards (52.7
percent). Additional unstructured information contributed
to the identification of several themes, including cost,
time, information, and nutrition factors. Providers
indicated varying degrees of integration between the
patient report cards and their personal or clinic-based
treatment strategies. Satisfaction was mixed, with some
providers indicating difficulty accessing their
performance reports and others observing that
information presented without guidance is of limited
value. Themes of perceived competition, patient
population demographics, the importance of case
management, and patient coaching strategies emerged
during analysis.
Conclusions: A patient-centered approach to diabetes
management using chronic disease registries may
improve the quality of care and clinical outcomes.
Patients value receiving personalized health information
and being active participants in their own care.
Providers cited barriers to improving health outcomes
through provider performance feedback.
Implications for Policy, Delivery or Practice:
Nonadherence to guidelines for diabetes care is
pervasive and costly in both physical and financial terms.
As information systems increase in sophistication,
computerized disease registries can be used to improve
the quality of care both during and between visits.
Funding Source(s): AHRQ
♦ Educational Attainment Moderates the Effect of a
Brief, Telephone Delivered Diabetes SelfManagement Intervention on Hemoglobin A1c
William Sacco, Ph.D.; Kristi White, B.A.
Presented by: William Sacco, Ph.D., Professor,
Psychology, University of South Florida, PCD 4124,
Tampa, FL 33620, Phone: (813) 974-0375, Email:
sacco@cas.usf.edu
Research Objective: To determine whether educational
attainment moderates the effect of a brief, telephone
delivered diabetes self-management intervention. The
dependent variable, hemoglobin A1c is a measure of
average blood glucose level over the previous 60 - 90
days. Hemoglobin A1c is highly predictive of morbidity
and mortality in people with diabetes. Therefore,
reductions in hemoglobin A1c are the primary goal of
diabetes treatment. A prior study found that people with
lower educational attainment benefited more from
intensive supplemental interventions to facilitate
diabetes adherence. The present study examined
whether educational attainment moderates the effect of
a brief supplemental intervention.
Study Design: Randomized Clinical Trial. Sixty-two
adults diagnosed with type 2 diabetes were randomly
assigned to receive a brief, telephone delivered
“coaching” intervention along with treatment as usual, or
only treatment as usual. Baseline educational
attainment was examined as a moderator of the
intervention’s effects on hemoglobin A1c.
Population Studied: Participants were adult patients,
age 18 - 65, receiving medical care from the University
of South Florida Medical Center for type 2 diabetes.
Inclusion criteria included: able to read and speak
English, reachable by telephone, and the most recent
hemoglobin A1c level greater than 6.5%.
Principal Findings: A significant intervention by
educational attainment interaction effect, p < .05,
revealed that the intervention produced a greater
reduction in hemoglobin A1c in patients with higher
educational attainment than in patients with lower
educational attainment. In contrast, educational
attainment was unrelated to hemoglobin A1c in the
control group. The significant interaction effect was
found after controlling for the effects of age, gender,
income, and pretest diabetes knowledge. Moreover,
entering income instead of education as the moderator
did not produce a significant interaction effect.
Conclusions: Brief, telephone delivered interventions
for people with type 2 diabetes appear to be more
effective at lowering hemoglobin A1c levels in patients
with higher educational attainment. This finding
contrasts with an earlier finding that patients with lower
educational attainment benefited more from an intensive
self-management intervention.
Implications for Policy, Delivery or Practice: Diabetes
patients with higher educational attainment may benefit
the most from brief, telephone delivered interventions.
Patients with less educational attainment may require
longer, more intensive, self-management interventions.
Funding Source(s): American Heart Association
Strategies for Chronic Care Implementation in
Cancer, COPD & Nonadherent Patient Populations
Chair: Anthony Lo Sasso
Sunday, June 28 * 4:30 p.m.- 6:00 p.m.
♦ Psychosocial Risk Factors for Hospital
Readmission Among Community Based Adults with
Chronic Obstructive Pulmonary Disease: A
Prospective Study
Peter Coventry, Ph.D., M.Sc., M.A., B.Sc.
Presented by: Peter Coventry, Ph.D., M.Sc., M.A.,
B.Sc., MRC Research Fellow, School of Nursing,
Midwifery & Social Work, University of Manchester,
University Place, Manchester, M13 9PL, UK, Phone:
+44 161 306 7653, Email:
peter.a.coventry@manchester.ac.uk
Research Objective: Hospital readmission within 3months for acute exacerbation occurs in some 30% of
patients with chronic obstructive pulmonary disease
(COPD), leading to excess morbidity, poor prognosis
and high socio-economic burden for healthcare services.
Health related quality of life (HRQOL) is associated with
risk of readmission but the contribution of other
psychosocial factors is not well understood. This study
was designed to identify psychosocial risk factors for
readmission in community based older adults with
COPD.
Study Design: Prospective cohort study using routine
clinical data and patient self-report questionnaires at
baseline, 3-months, and 12-months follow-up. Data on
lung function (predicted FEV1 %), medical comorbidity,
previous hospital admissions, medications,
sociodemographics, HRQOL (St George’s Respiratory
Questionnaire [SGRQ]), anxiety and depression (HADS),
and perceived social support (ENRICHD Social Support
Instrument [ESSI]) were collected 1-week after
discharge to the community. Group means were
compared with t-tests. Univariable logistic regression
models were fitted to estimate whether baseline
psychosocial factors were independently associated with
readmission at p<0.20. Exploratory multivariable models
were then fitted to identify the best subsets of baseline
psychosocial factors associated with readmission.
Population Studied: 79 patients hospitalised for acute
exacerbation of COPD at 3 acute hospitals in Greater
Manchester, UK, and discharged to specialist nurse-led
community care. Patients’ first admission during the
study period was taken as the referent event for followup. Patients with known lung-reduction from other
causes were excluded.
Principal Findings: Mean age (SD) 65.3 (9.9) years,
predicted FEV1% 42.2% (18.4), 44 (56%) were male. In
keeping with previous studies of emotional distress in
COPD both anxiety and depression were highly
prevalent in this study population. Forty six (58.2%)
patients reported HADS-A scores =8 indicative of
anxiety, and 34 (43%) reported HADS-D scores =8
indicative of depression. HRQOL on the total SGRQ was
diminished, mean (SD) 58.8 (14.6). Patients reported
high levels of perceived social support on the total ESSI,
mean (SD) 26.5 (6.3); 20 (25.3%) patients were classed
as having low perceived social support. Twenty-seven
(34.2%) patients were readmitted to hospital within 3months. Only predicted FEV1% was significantly
different in the group readmitted, compared with those
who were not readmitted (mean difference = 9.9,
p=0.022). Univariable analysis showed that predicted
FEV1% was a significant predictor of readmission
(OR:0.96, 95%CI: 0.93 – 0.99). HRQOL on the total
score of the SGRQ (OR:1.03, 95%CI: 0.99 –1.06,) was
the only psychosocial variable associated with
readmission at p<0.20. No psychosocial variables were
significantly associated with readmission in the
multivariable models adjusted for predicted FEV1%.
Conclusions: COPD patients report high levels of
emotional distress and poor quality of life immediately
after discharge following hospital admission. The effects
of these psychosocial factors could be attenuated by
high levels of perceived social support. Lung function
appears to be the key driver of readmission, although
psychosocial factors might affect outcomes over the
longer term.
Implications for Policy, Delivery or Practice: Patients
with disabling COPD discharged to community care
have high levels of anxiety and depression and are at
high risk of rapid readmission. Causes of readmission
are complex but potentially modifiable, for example, by
wider provision of comprehensive pulmonary
rehabilitation programs.
Funding Source(s): UK Medical Research Council
♦ Impact of the National Breast & Cervical Cancer
Early Detection Program (NBCCEDP) on Breast
Cancer Morality: Estimating the Life-Years Saved in
Medically Underserved Populations
Donatus Ekwueme, Ph.D., M.S.; Thomas Hoerger, Ph.D;
Jacqueline Miller, M.D.; Ingrid Hall, Ph.D., M.P.H.;
Vladislav Uzunangelov, M.S.; Chunyu Li, M.D., Ph.D.
Presented by: Donatus Ekwueme, Ph.D., M.S., Senior
Health Economist, Centers for Disease Control &
Prevention, 4770 Buford Highway, Northeast, Atlanta,
GA 30341, Phone: (770) 488-3182, Email:
dce3@cdc.gov
Research Objective: The National Breast and Cervical
Cancer Early Detection Program (NBCCEDP) was
established in 1991 to provide free or low-cost breast
cancer screening to medically underserved low-income
women. To date, no study has evaluated the
NBCCEDP’s effect on breast cancer mortality, as
measured by life-years (LYs) saved. The objective of this
study was to estimate the LYs saved by NBCCEDP
breast cancer screening compared with no NBCCEDP
and with no screening.
Study Design: We applied the Stanford model - a
simulation model of breast cancer screening published
by the Cancer Intervention and Surveillance Modeling
Network – as the basic modeling framework for this
study. We modified the screening module to reflect
screening frequency for women participating in the
NBCCEDP. Using 1991-2005 data from the NBCCEDP
surveillance database, we estimated the age of first
mammography and intervals between mammograms for
women who participated in the Program. We used the
1990-2005 National Health Interview Survey data on
mammograms among uninsured women to represent
what would have happened in the absence of the
Program. We performed separate Monte Carlo
simulations for women who are eligible in the NBCCEDP
under 3 scenarios: 1) those who received screening in
the NBCCEDP, 2) women who potentially received
screening in the absence of the program (No Program),
and 3) women who received no screening at all (No
Screening). The effect of the NBCCEDP was estimated
as the difference in life-years saved between the
Program versus No Program, and the Program versus
No Screening.
Population Studied: Medically underserved low-income
women aged 40-64 years who have an annual income of
=250% of the federal poverty level.
Principal Findings: The total life-years saved by the
Program from 1991 through 2005 were 100,800 years
relative to No Program and 369,000 years relative to No
Screening. Per woman screened, the Program saved
0.056 life-years (or 20.45 days) relative to No Program,
and 0.205 life-years (or 74.88 days) relative to No
Screening. Based on the simulation, women participating
in the NBCCEDP will receive 17.16 screening
mammograms over the course of their lifetimes, versus
12.37 mammograms in the absence of the Program, and
by definition, 0 screens in the No Screening scenario.
Women who were eligible for the program during some
time of the period 1991-2005 were estimated to receive
3.85 screens with the Program vs. 2.25 screens with No
Program during these years.
Conclusions: We estimate that over 15 years,
mammography screening in the NBCCEDP saved over
one hundred thousand LYs. The estimated LYs gained
was larger for women whose breast cancer was
detected early through screening.
Implications for Policy, Delivery or Practice: These
estimates suggest that the collective efforts of
NBCCEDP grantees, policy-makers, and other national
partners to offer breast cancer screening to medically
underserved populations have significant health impact.
♦ Estimating Personal Costs Incurred by Women
Participating in the National Breast & Cervical
Cancer Early Detection Program
Donatus Ekwueme, Ph.D., M.S.; Ingrid Hall, Ph.D.,
M.P.H.; James Gardner, M.S.P.H.; Janet Royalty, M.S.
Presented by: Donatus Ekwueme, Ph.D., M.S., Senior
Health Economist, Centers for Disease Control &
Prevention, 4770 Buford Highway, Northeast, Atlanta,
GA 30341, Phone: (770) 488-3182, Email:
dce3@cdc.gov
Research Objective: The National Breast and Cervical
Cancer Early Detection Program (NBCCEDP) is the only
national screening program in the U.S., offering breast
and cervical cancer screening to medically underserved
populations. The Program covers direct costs of
screening for breast and cervical cancer and diagnostic
follow-up. However, personal costs measured by the
opportunity and transaction costs of participating in the
program are not covered. Opportunity costs included
travel time, waiting time, time spent receiving screening
services, and distance traveled to and from screening
location and transaction costs are out-of-pocket costs,
which include transportation, childcare and/or dependent
care, and parking. The aim of this study was to estimate
personal costs for women participating in the NBCCEDP
by race/ethnicity.
Study Design: We constructed and parameterized a
decision analysis model using data from a retrospective
cohort Survey of Mammography Re-screening (SMR) for
breast cancer among women aged 50-64 participating in
the NBCCEDP, data from the US Census, and from the
literature. Because the SMR data did not include
women aged 40-49 for breast cancer and aged 18-64 for
cervical cancer, we assumed that most characteristics of
women receiving mammography in the Program are the
same for those receiving Pap tests. However, in the
Program, 25% of women screened for breast cancer
were aged 40-49; 80% screened for cervical cancer
were aged 40-64; and 20% were aged 18-39. We used
these screening rates to adjust for the proportion of
women that responded to the survey. We constructed a
multiplier using the ratio of women currently being
screened for breast cancer to the ratio being screened
for cervical cancer. We used this multiplier to adjust for
the estimates for cervical cancer. We constructed four
mutually exclusive race/ethnicity categories (i.e., white
non-Hispanic, black non-Hispanic, Hispanic, and other
Non-Hispanic). All costs were standardized to 2005 US
dollars.
Population Studied: NBCCEDP participants, women
aged 18-64 years for cervical cancer and 40-64 years for
breast cancer who have an annual income =$25,000.
Principal Findings: We estimate that for all
races/ethnicities, a 1-year personal cost incurred by
women aged 40-49 participating in breast cancer
screening in the NBCCEDP was $91,530 (or $2.24 per
woman). For women aged 50-64, the total cost was
$1,209,476 (or $8.63 per woman). For cervical cancer,
women aged 18-39 incurred a 1-year personal cost of
$14,285 (or $0.35 per woman); $158,827 (or $1.72 per
woman) for those aged 40-49; and $188,335 (or $1.60
per woman) for those aged 50-64. In both breast and
cervical cancers and for all age-groups, white nonHispanic women incurred the highest cost. On the other
hand, non-Hispanic women of other races incurred the
lowest cost. For both breast and cervical cancers, >90%
of personal cost incurred was attributable to opportunity
costs.
Conclusions: Capturing and quantifying personal costs
will help ascertain the total cost (i.e., societal cost) of
providing breast and cervical cancer screening to
medically underserved, low-income women participating
in the NBCCEDP.
Implications for Policy, Delivery or Practice: The cost
estimates can provide useful information to assist policy
makers.
♦ The Effect of Nonadherence with Oral
Hypoglycemics on Potentially Avoidable
Hospitalizations among Medicare Part D Enrollees
with Diabetes
Yi Yang, M.D., Ph.D.; Vennela Thumula, B.S.; Patrick
Pace, Ph.D.; Benjamin Banahan, Ph.D.; Noel Wilkin,
R.Ph., Ph.D.; William Lobb, R.Ph., Ph.D.
Presented by: Yi Yang, M.D., Ph.D., Assistant
Professor, Department of Pharmacy Administration,
University of Mississippi, 234 Faser Hall, University, MS
38677, Phone: (662) 915-1062, Email:
yiyang@olemiss.edu
Research Objective: In 2007, the Agency for
Healthcare Research and Quality (AHRQ) developed
Prevention Quality Indicators (PQIs) for ambulatory caresensitive conditions (ACSCs), such as diabetes and
congestive heart failure, for which timely and effective
ambulatory care can potentially prevent the need for
hospitalizations. The PQIs were designed to be used
with hospital inpatient data to identify potentially
avoidable hospitalizations (PAHs) among patients with
ACSCs. The objectives of this study were to describe the
prevalence of PAHs among Medicare Part D enrollees
with diabetes and to identify patient characteristics that
can predict the risk for PAHs.
Study Design: Longitudinal retrospective cohort study.
Using Medicare Part D claims data from 01/01/2006 to
06/30/2006, we examined patient adherence with
prescribed oral hypoglycemic agents (OHGs). We
measured adherence using proportion of days covered
(PDC) and subsequently we classified patients as
adherent (PDC=0.8), poor adherent (0.5= PDC <0.8),
and very poor adherent (0< PDC <0.5). We also
evaluated Medicare Part A records from 07/01/2006 to
03/31/2007 to identify PAHs due to diabetes short-term
complications, long-term complications, uncontrolled
diabetes, and diabetes lower-extremity amputations.
Using multivariate logistic regression to adjust for patient
demographics (age, gender, and race) and comorbidity
(Charlson Comorbidity Index), we examined the
association between adherence and PAHs.
Population Studied: Medicare Part D enrollees with
diabetes from six states (Alabama, California, Florida,
Mississippi, New York, and Ohio) who had filled at least
one prescription for OHGs during the first six months of
2006 and who had continued Medicare enrollment from
10/01/2005 to 03/31/2007.
Principal Findings: Among 1,101,533 eligible patients,
64.9% were adherent, 11.2% were poor-adherent, and
24.0% were very poor-adherent with OHGs. Overall,
52,176 (4.74%) patients had at least one PAHs, 0.14%
had hospital admissions due to diabetes short-term
complications, 2.83% due to diabetes long-term
complications, 2.02% due to uncontrolled diabetes, and
only 94 PAHs were due to diabetes-related lowerextremity amputation. Multivariate regression models
show that the odds for PAHs was 22.6% (odds ratio:
1.226, 95% confidence interval: 1.192-1.261) higher for
poor-adherent patients and 18.8% (odds ratio: 1.118,
95% confidence interval: 1.164-1.213) for very pooradherent patients compared to patients who were
adherent with their oral hypoglycemic drugs. Age
younger than 65 or older than 75, female gender, black
or Hispanic race, and increased comorbidities were
significant independent predictors of PAHs in this
population.
Conclusions: The results suggest that nonadherence to
OHGs is relatively common and nonadherence
appeared to be associated with greater risks for PAHs.
Given the chronic nature of diabetes, it is very likely that
most patients were chronic medication users and had
started OHG treatment long before the study started.
The observed adverse health consequences probably
reflect the cumulative effect of medication nonadherence
over an extended period of time.
Implications for Policy, Delivery or Practice: Our
findings suggest that nonadherence with prescribed
therapy is associated with increased risk of PAHs among
Medicare enrollees with diabetes. Medicare prescription
drug plans should consider developing targeted
interventions to improve medication adherence among
patients with diabetes.
Funding Source(s): CMS
Chronic Care Communication & Evaluation
Strategies
Chair: Jane Nelson Bolin
Tuesday, June 30 * 11:30 a.m.-1:00 p.m.
♦ Pre-Visit Assessment of Patient Agendas on Their
Discussion in a Clinic
Betty Chewning, Ph.D.; Betsy Sleath, Ph.D.; Rich Van
Koningsveld, M.S.; Carolyn Bell, M.D.; Kevin McKown,
M.D.; Dale Wilson, M.S.
Presented by: Betty Chewning, Ph.D., Professor,
Pharmacy, University of Wisconsin, 777 Highland
Avenue, Madison, WI 53705 2222, Phone: (608) 2634878, Email: bachewning@pharmacy.wisc.edu
Research Objective: Substantial research documents
that patient agendas are often incompletely addressed
during their encounter with a physician. The goal of this
research was to identify whether an inexpensive, easily
transferrable intervention could increase the likelihood
that patient’s priorities would be discussed in a clinic
visit.
Study Design: A randomized controlled trial was
conducted where patients with rheumatoid arthritis were
enrolled at their clinic visits. Once enrolled, patients were
randomized within physician to one of 2 interventions: 1)
patients received a computerized lifestyle assessment in
the waiting room immediately before they entered the
exam room; or 2) patients received a computerized
assessment of what health domains they most wanted to
improve and discuss in the clinic visit (i.e., pain, mood,
etc.). The domains were drawn primarily from the
Arthritis Impact Measurement Scale (AIMS1).
Immediately after the assessment for both study arms,
patients received a printout summarizing their responses
and physicians received the printout placed at the front
of the patient’s medical record. Patient-physician
encounters were audiotaped and coded as to whether
the patient’s priority health topics were discussed. A 12
month longitudinal design was used with a preintervention baseline, initiation of the intervention at the
6 month visit, and follow-up intervention at the 12 month
visit.
Population Studied: 450 patients were enrolled from 6
rheumatology clinics in two states (Wisconsin and North
Carolina). Eighteen rheumatologists participated. All
patients had a recorded diagnosis of rheumatoid
arthritis. Ninety one percent of those approached
participated in the study. Eighty four percent of the
patients were retained for 1 year.
Principal Findings: Logistic regression was conducted
to test the apriori hypothesis that a computerized
assessment and printout increased the likelihood that
patients’ priority health topics would be discussed in a
visit. Ten AIMS dimensions and fatigue were examined.
The hypotheses were upheld for the following topics:
mobility, walking, hand and finger function, arm function,
housework, mood, socializing, work and fatigue. Only
pain (which is almost always discussed at the visit as a
clinical issue) and tension failed to show an increased
likelihood in that topic area being discussed given that it
was a patient priority. Self-care and support were so
rarely a topic area to patients, that we could not examine
the impact of the tool.
Conclusions: This study suggests that giving patients
and physicians visual cues of patients’ priority health
agendas helps to increase the likelihood that patient
health agendas will be more fully addressed.
Implications for Policy, Delivery or Practice: Pre-visit
identification of patient health priorities can help patients
direct clinic visit agendas. This is particularly important
for sensitive topics that physicians underattend to such
as patient mood.
Funding Source(s): NIA
♦ Patient Satisfaction, Empowerment & Health &
Disability Status Effects of a Disease ManagementHealth Promotion Nurse Intervention among
Medicare Beneficiaries with Disabilities
Bruce Friedman, Ph.D., M.P.H.; Brenda Wamsley,
Ph.D., M.S.W.; Dianne Liebel, Ph.D., M.S.Ed.; Zabedah
Saad, M.A.; Gerald Eggert, Ph.D., M.S.W.
Presented by: Bruce Friedman, Ph.D., M.P.H.,
Associate Professor, Community & Preventive Medicine,
University of Rochester, 601 Elmwood Avenue, Box 644,
Rochester, NY 14642, Phone: (585) 273-2618, Email:
Bruce_Friedman@urmc.rochester.edu
Research Objective: To report the impact on patient
and informal caregiver satisfaction, patient
empowerment, and health and disability status of a
primary care-affiliated disease self-management-health
promotion nurse intervention for Medicare beneficiaries
with disabilities and recent significant health services
use.
Study Design: The Medicare Primary and ConsumerDirected Care Demonstration was a 24-month
randomized controlled trial that included a disease selfmanagement-health promotion nurse intervention. The
intervention included monthly nurse home visits, disease
self-management using the Consumer Self-Care
Strategies and Healthwise for Life handbooks, the
PRECEDE health education planning model to organize
patient health behavior change and maintenance, and
physician-patient-family-nurse conferences reimbursed
by Medicare. The present study compares the Nurse
(n=382) and Control (n=384) groups. Generalized linear
models for repeated measures were used to compare
satisfaction scores at 10 months and 20 months. Linear
regression and ordered logit were employed.to evaluate
the effect of the intervention on five dependent variables
measuring empowerment and five measures of health
and disability status at 22 months postbaseline. The
regression models included variables for intervention
group, site, baseline value of the dependent variable
being estimated, age, gender, and the seven variables
that differed at p<.10 across the intervention groups at
baseline.
Population Studied: 766 persons age 65+ that
participated in the Medicare Demonstration. Study
participants resided in 19 counties in New York State,
West Virginia, and Ohio, and were required to need or
receive help with either 2+ activities of daily living (ADLs)
or 3+ instrumental ADLs (IADLs), and must have
received recent significant healthcare services use
(hospitalization, admission to a nursing home, or receipt
of Medicare home health care services within the
previous twelve months or 2+ ED visits within the past
six months). The sample had a mean age of 77.4 years,
31% were male, and 3% were non-white. The mean
number of ADL dependencies at baseline was 2.3 while
the mean number of IADL dependencies was 3.5.
Principal Findings: The patients whose ADL
dependencies were reported by the same respondent at
baseline and 22 months post-baseline had significantly
fewer dependencies at 22 months than did the Control
group (p=.038). This constituted the vast majority of
respondents. In addition, patient satisfaction significantly
improved for 6 of 7 domains while caregiver satisfaction
improved for 2 of 8 domains. However, the intervention
had no effect on empowerment, self-rated health, the
SF-36 physical and mental health summary scores, and
the number of dependencies in instrumental ADL.
Conclusions: This intervention improved patient
satisfaction and resulted in less ADL dependence as
compared with a Control Group at the end of a 22 month
treatment period.
Implications for Policy, Delivery or Practice:
Implications include that a multi-component health
promotion/disease self-management intervention can be
well received by Medicare beneficiaries with disabilities,
and that such an intervention holds the potential to delay
functional decline among these beneficiaries. Our
findings have implications for the design of the Medicare
Medical Home and other primary care demonstrations,
health promotion/disease management models, and
other interventions for high cost, high risk Medicare
beneficiaries.
Funding Source(s): CMS
♦ National Health Expenditures on Chronic Illness
Prevention and Treatment
Charles Roehrig, Ph.D.; George Miller, Ph.D.
Presented by: Charles Roehrig, Ph.D., Vice President,
Altarum Institute, 3520 Green Court, Ann Arbor, MI
48105-1579, Phone: (734) 302-4646, Email:
charles.roehrig@altarum.org
Research Objective: The purpose of this research is
development of annual estimates of national health
expenditures (NHE) on prevention and treatment of
medical conditions with emphasis on chronic illness.
Estimates cover the years 1996 through 2006 and
benchmark to totals from the National Health
Expenditure Accounts (NHEA). Prevention expenditures
are divided into primary prevention, screening, and other
secondary prevention. Treatment expenditures are
broken out by medical condition including all of the major
chronic diseases. This information provides a rich
framework for discussions about population
management of chronic diseases.
Study Design: This study builds upon two previous
efforts. In a paper that was just accepted for publication
in Health Affairs, we developed annual estimates of
national health expenditures by medical condition. In a
separate paper that was just published in Advances in
Health Economics and Health Services Research, we
developed annual estimates of national health
expenditures on prevention. We are now integrating
these results for the first time, extending them to cover
all years from 1996 through 2006, and providing type-ofservice detail.
Population Studied: Entire US population including
institutionalized.
Principal Findings: We present eleven year trends in
the shares of national health expenditures going to
prevention and to the treatment of the most important
chronic illnesses. For selected illnesses, we show
trends in spending by type of service including hospital
services, physician services, prescription drugs, home
health, and nursing homes. Our principal findings are:
(1) The share of NHE going to prevention has been
around 8 percent between 1996 and 2006. (2) About
half of prevention spending is for primary prevention but
this share has been declining due to slow growth in
public health spending. (3) Using disease
categorizations adopted by AHRQ, we find treatment of
mental disorders to be the most costly medical condition
in all years followed by heart conditions. (4)
Expenditures for treating chronic conditions often
associated with smoking show lower than average
growth rates.
Conclusions: The share of NHE going to prevention is
greater than the figure of 3 percent often cited in the
literature but is still relatively small and growth is
concentrated mainly in secondary prevention –
particularly treatments of hypertension and
hyperlipidemia for those who do not yet show symptoms
of cardiovascular disease. The low growth rates in
spending for cardiovascular disease and other chronic
conditions associated with smoking suggests that
primary prevention (reduced prevalence of smoking) and
secondary prevention (treatment of hypertension and
hyperlipidemia in pre-symptomatic individuals) may have
had beneficial effects.
Implications for Policy, Delivery or Practice: This
study provides for the first time an integrated times
series view of national health expenditures by medical
condition being treated and by type of prevention
intervention. It provides an essential context for the
study of prevention and treatment of chronic illness and,
within a panel discussion, would make an ideal lead-in
presentation.
Funding Source(s): Internal R&D
♦ Improving Access to Home-Based Palliative Care
for Patients with Advanced Chronic Illness
Penny Feldman, Ph.D.; Miriam Ryvicker, Ph.D.; Jennifer
Mongoven, M.P.H.; Beth Costello, M.A.; Marilyn Liota,
M.A., R.N.; Karol Dibello, A.P.N.; Geraldine Abbatiello,
A.P.N., Ph.D.
Presented by: Miriam Ryvicker, Ph.D., Research
Associate/Project Manager, Center for Home Care
Policy & Research, Visiting Nurse Service of New York,
5 Penn Plaza, 14th Floor, New York, NY 10001, Phone:
(212) 609-5775, Email: miriam.ryvicker@vnsny.org
Research Objective: Intense, acute care in advanced
stages of chronic illness frequently interferes with quality
of life for seriously ill patients and results in high
healthcare costs and potential resource misallocation.
Home health care provides a unique setting for testing
cost-effective models of advanced illness management.
Yet, few studies have employed randomized trials to test
such models. This study used a randomized design to
examine the impact of an interdisciplinary, team-based
intervention – Advanced Illness Management (AIM) – on
patients’ access to home-based palliative care in a large
urban home health organization. AIM was designed to
embed home-based palliative care into the routine
practice of homecare teams while developing a frontline
nurse clinical career path replicable by other agencies.
Study Design: Nine service delivery teams in one of the
organization’s largest, most diverse geographic regions
were randomly assigned to intervention (5 teams) or
control (4 teams) status. Eligible patients were identified
through an electronic screening algorithm, using data
from administrative records and the Outcomes and
Assessment Information Set (OASIS). A two-step model
was used to: 1) adjust for case-mix differences in
demographics, function and clinical status, and 2) test
AIM’s impact on hospice referrals and admissions
(reported here), hospitalization and symptom
management.
Population Studied: The study included patients
identified by the AIM algorithm, using life expectancy,
diagnosis, prognosis, and disease severity as assessed
at homecare admission. The algorithm identified
patients served by the intervention and control teams
during the 12-month trial. This paper reports on patients
admitted during the trial’s first 10 months (N=979).
Principal Findings: Patients meeting the AIM criteria
were clinically complex. Forty-eight percent had a life
expectancy of less than 6 months; the most common
diagnoses were cancer (26%), COPD (10%), and heart
failure (11%). On average patients had 4.3
comorbidities, took 8.4 medications, and needed
assistance in 10.3 out of 14 ADLs/IADLs. Case-mix
adjusted outcomes indicated that AIM had a statistically
significant, though modest, impact on both hospice
referrals and admissions.
Conclusions: This study advances current knowledge
on interdisciplinary approaches to advanced illness care
by employing a randomized design, which thus far is
rare in the expanding field of home-based advanced
illness management. The modest impact on hospice
referrals and admissions underscores the challenges of
improving access to high-quality, home-based palliative
care given healthcare silos and systems constraints.
Clinician feedback highlighted difficulties implementing
an AIM care plan with “short-stay” managed care
patients and clinically unstable patients who were quickly
re-hospitalized. Enlisting family and physician support
proved challenging without common understandings of
the illness trajectory and care goals. Finally, existing
reimbursement mechanisms made it difficult to establish
a payment structure for nurse practitioner consultations
and to adjust productivity expectations for specially
trained field nurses given the time involved in advanced
illness planning.
Implications for Policy, Delivery or Practice: Though
evidence reviews show that multidisciplinary, teambased interventions are key to promoting
comprehensive, person-centered advanced illness care,
current systems barriers may limit the ability to
effectively implement and replicate such models in home
care. Addressing these barriers is critical to improving
quality of life for patients/families coping with the
stressors and dilemmas of advanced chronic illness.
Funding Source(s): New York State Health Foundation
Nudging Consumer Behavior in a Choice
Environment
Chair: Kristin Carman
Tuesday, June 30 * 8:00 a.m.-9:30 a.m.
♦ To Test or Not to Test? The Role of Religious
Involvement, Knowledge & Attitudes Towards
Predictive Adult Genetic Testing in Forming Intentto-Test – A Structural Equation Modeling Approach
Anda Botoseneanu, M.D.; Jeffrey Alexander, Ph.D.;
Jane Banaszak-Holl, Ph.D.
Presented by: Anda Botoseneanu, M.D., Doctoral
Student, Health Management & Policy, University of
Michigan, 109 South Observatory Street, Ann Arbor, MI
48109, Phone: (734) 646-8199, Email:
andabm@umich.edu
Research Objective: This study explores factors that
influence consumers’ choices regarding acceptance and
participation in genetic testing for adult-life disease
susceptibility programs. Genetic testing for disease
susceptibility is increasingly feasible, and carrier-status
screening is increasingly marketed to healthy individuals.
Yet, little is known about the factors affecting consumers’
preferences and acceptance of genetic screening. The
particular distribution of certain genetic profiles (e.g.,
BRCA 1 and 2 genes) across religious groups, the use
of religious venues for dissemination of information
about genetic risk and for recruitment campaigns for
genetic screening, and ethical-religious considerations
highlight the significance of elucidating the role of
religion, among other factors, in consumer genetic
testing choices. We aim to test a model of direct and
indirect effects of consumer knowledge, religious
involvement, previous experience with and attitudes
towards genetic testing for disease susceptibility on
formation of intent to undergo genetic testing.
Study Design: This cross-sectional analysis uses the
publicly available survey titled United States Public
Knowledge and attitudes about genetic testing, 2000.
Structural equation modeling was used to test the total,
direct and indirect effects of knowledge, religious
involvement, experience and attitudes on intent-to-test
for cancer susceptibility.
Population Studied: The sample of 1,824 is
representative of adults in the U.S. aged 18 and over.
Principal Findings: Of the 1,824 adults surveyed, 77%
expressed willingness-to-test for curable disorders, and
only 52% expressed willingness-to-test for incurable
disorders. 17% had previous experience with a genetic
disorder, and 8% had previous experience with genetic
testing. Confirmatory factor analysis (CFA) established
the good fit of the proposed measurement model, and
SEM analysis revealed the following significant direct
effects on intent to undergo testing: attitudes (positive
effect; p=0.000), knowledge (negative effect; p=0.009),
and previous experience (positive effect; p=0.034).
Religious involvement had a significant indirect effect on
the intent to undergo genetic testing, because it had a
negative effect on attitudes towards testing (p=0.000)
and no direct effect on intent-to-test. Individuals with
high religious involvement were more likely to hold more
negative attitudes towards genetic testing. The model as
proposed explains 15% of the variance in intent-to-test.
Conclusions: A majority of respondents indicate
willingness to test for susceptibility to adult life genetic
disorders, especially for curable disorders. The ability of
genetic testing to identify those at increased cancer risk
can advance prevention, early detection and
prophylactic interventions only if it leads to
improvements in current screening and surveillance
behaviors. Our findings underscore the need to refine
outreach and intervention efforts, to account for multiple
influences (religiosity, knowledge, experience, attitudes)
on consumer willingness-to-test.
Implications for Policy, Delivery or Practice: Our
findings suggest that genetic testing policy initiatives
need to consider multiple factors affecting consumers’
decisions. Increasingly, health education and outreach
efforts are presented and promoted through religious
and faith-based venues, and efforts are made to
increase genetic counseling and testing in specific
religious groups with a high prevalence of cancer-related
genetic mutations (e.g., BRCA in Ashkenazi Jews). As
such, policy consideration should be given to the impact
of religious involvement on attitudes towards genetic
testing and ultimately, on consumers’ testing behavior.
♦ Experience with Health Coach-Mediated Physician
Referral in an Employed Insured Population
Karen Donelan, Ed.M., Sc.D.; Sowmya Rao, Ph.D.;
Robert Rogers, B.A.; Robert Galvin, M.D., M.B.A.; David
Blumenthal, M.D., M.P.P.
Presented by: Karen Donelan, Ed.M., Sc.D., Senior
Scientist in Health Policy, Institute for Health Policy,
Massachusetts General Hospital, 50 Staniford Street,
9th Floor, Boston, MA 02114, Phone: (617) 726-0681,
Email: kdonelan@partners.org
Research Objective: Given increasing interest in
helping consumers choose high-performing (higher
quality, lower cost) physicians, one approach chosen by
several large employers is to provide human assistance
in the form of a telephonic “health coach” – a registered
nurse who assists with identifying appropriate and
available providers. We seek to evaluate the health
coach’s influence on provider choice and the quality of
the user experience in the early introduction of this
service.
Study Design: We surveyed 3490 employees of a large
national firm that offered health coach services to all
employees beginning in September 2007. In AugustOctober 2008, we conducted a self-administered mail
survey of users and non-users of the health coach
service. We proportionately sampled 1750 employees
who used the services between October 2007 and
February 2008, and drew a sample of 1740 non-users
stratified by age and chronic condition. Token cash and
gift incentives were used through 5 waves of mailing,
alternating full survey and postcard reminders. The
response rate was 55%.
Population Studied: Adults (21-64) with employersponsored health insurance and their dependents.
Principal Findings: As compared to non-users of the
service, users had slightly higher measures of consumer
activation and were more likely to have changed PCPs,
consulted a medical specialist and been a hospital
inpatient in the past year.The primary reason for using
the service was to obtain provider referrals (73%). Fiftytwo percent of users sought a specialist referral, 33% a
PCP referral and 9% a hospital referral. Eighty-nine
percent of users seeking a provider referral were
referred in-network; 82% of those referred visited the
referred provider. Out-of-network referrals were
negligible. For measures of user satisfaction with
provider referrals, the percentage of users reporting
each of the following aspects of their experience as
“excellent” or “very good” is as follows: accuracy of the
information provided by the health coach about
physicians (65%), assistance from the health coach with
visit preparation (54%), ability to promptly schedule an
appointment with the referred physician (58%), quality of
care provided by the referred physician (59%), value of
consultation with the referred physician (56%). The
secondary reason for using the health coach was for
health information (60%). Twenty-six percent of users
called for general information on medical conditions, 8%
inquired about specific treatment options and 27%
inquired about both. Forty percent of users reported
using all of the information provided by the health coach;
44% reported using some of it. Satisfaction with health
information services was approximately 70%. Neither
type of usage nor satisfaction differed significantly by
age or chronic disease status. Significant differences
existed in reported user satisfaction between customers
of the two different vendors providing health coach
services.
Conclusions: Customers largely follow the provider
recommendation of the health coach. As users and nonusers are broadly similar in health status and information
needs, a market opportunity exists for health coach
services. Users express general satisfaction with
existing health coach services, but differences in
performance between vendors highlight the need for the
services to be well implemented.
Implications for Policy, Delivery or Practice: Health
coach services have the potential to guide consumers
towards high-performing physicians.
Funding Source(s): General Electric Corporation
♦ The Role of Cognition in Choice: The Case of
Medicare
Brian Elbel, Ph.D., M.P.H.; Sewin Chan, Ph.D.
Presented by: Brian Elbel, Ph.D., M.P.H., Assistant
Professor, New York University, 423 East 23rd Street,
15-120N, New York, NY 10010, Phone: (212) 263-4283,
Email: brian.elbel@nyumc.org
Research Objective: Governments are increasingly
turning to individual choice as a means of implementing
social policy. Many of these policy choices are complex,
particularly for individuals of advanced age. Medicare is
the prime example of this, where choices are notoriously
difficult. While some attention has thus far been paid to
how individuals make such choices, little to no attention
has been paid to the potential role of cognitive ability on
policy-related choices. This is a serious deficiency in the
choice literature, given a) that significant problems that
have been reported with some policy-oriented choices
and b) the significant role that cognition has shown in
other realms. To fill this gap, we use the Health and
Retirement Survey (HRS) to examine the role of
cognitive ability in the decision to enroll in Medicare
supplemental coverage versus going without coverage.
Study Design: We utilize 6 waves of the HRS (gathered
between 1996 -2006) to model the choice of Medicare
beneficiaries to enroll in either one of the available
Medigap or Medicare health plans versus nothing at all
as a function of cognition (utilizing multiple validated
scales and measures), health (self reported, # of chronic
conditions, recent hospitalizations), demographics
(education, age, sex, race, marital status) and financial
status (income and assets).
Population Studied: After excluding individuals who
gain coverage from their employer, union, spouse or
Medicaid (whose choice set is considerably simpler), we
consider the remaining 11,000 observations
(approximately 50% of our initial sample).
Principal Findings: Overall, 29% of our sample did not
choose to enroll in any Medicare supplemental
coverage. And, while health status was a significant
predictor of enrollment, cognition explained
approximately five times more of the variance than
health. These results appear to hold up even after
controlling for education and other demographics.
Generally, but not exclusively, those with greater
cognitive ability are more likely to be enrolled in
Medicare supplemental coverage.
Conclusions: Cognition is an important predictor of
Medicare choices and potentially more important than
health. Given the complexity of choice in today’s policy
environment, we must pay greater attention to the role of
cognition as a predictor of choice and begun to structure
policy with such findings in mind.
Implications for Policy, Delivery or Practice: In
structuring choice-based social policies, the cognitive
capabilities of consumers might need to be a more
prominent consideration.
Funding Source(s): NYU Wagner Research Fund
♦ Can Employees' Health Activation Levels Be
Improved?
Jinnet Fowles, Ph.D.; Paul Terry, Ph.D.; Min Xi, Ph.D.;
Judith Hibbard, Dr.P.H.; Yvonne Jonk, Ph.D.
Presented by: Jinnet Fowles, Ph.D., Senior Vice
President, Research, Health Research Center, Park
Nicollet Institute, 3800 Park Nicollet Boulevard,
Minneapolis, MN 55416, Phone: (952) 993-1949, Email:
jinnet.fowles@parknicollet.com
Research Objective: To test whether employees’
activation levels can be improved by either (a) a
traditional health promotion program or (b) an activated
consumer program compared with a control program.
Study Design: The ACTIVATE study (Activating
Consumers Through Information Versus Applying
Traditional health Education) is a 3-year, randomized,
controlled trial funded by the Centers for Disease Control
and Prevention. It compares a traditional worksite health
promotion program with an activated consumer
navigation program, using a personal development
education program as a control intervention. Both the
traditional health promotion program arm and the
activated consumer navigation arm include a coaching
option for employees at high risk for developing heart
disease. Primary data collection was conducted in two
waves: March-June 2005 and March-May 2006. The
traditional program intervention topics included physical
activity, nutrition, injury prevention, and stress
management. Coaching in this intervention group for
employees identified as being at high risk focused on
nutrition, physical activity, and disease management.
Topics in the activated consumer program included
evaluating sources of health information, choosing a
health benefits plan, and becoming familiar with
preventive service guidelines. Coaching for high risk
employees in the activated consumer intervention
focused on health care decision-making. Participants in
the personal development control program were offered
information on personal development topics, such as
time management, dealing with difficult people, and
hobbies, e.g., photography and quilting. The key variable
for this analysis is the Patient Activation Measure (PAM),
a scale assessing patient activation. Developed using
Rasch psychometric methods analysis, PAM is an
interval-level, unidimensional, Guttman-like measure. It
comprises 13 items that assess patient knowledge, skill,
and confidence for self-management. Items range from
“When all is said and done, I am the person who is
responsible for managing my health” to “I am confident I
can maintain lifestyle changes, like diet and exercise,
even during times of stress.” Each item has four
response options: “disagree strongly,” “disagree,”
“agree” and “agree strongly.” The PAM has a theoretical
range from 0 to 100. Higher scores indicate greater
activation. Comparative analysis was conducted at three
levels: the population level (all employees), for
employees at risk (whether or not they enrolled in
coaching), for employees at risk who enrolled in
coaching.
Population Studied: Two Minnesota employers
participated: a large integrated health system and a
national airline. At baseline (Spring 2005), we mailed
invitations, consent forms and questionnaires to
employees at their worksite (n = 1,628: 832 health care
workers, 796 airline reservationists). We gave
employees a $15 incentive for attending onsite health
screenings. At the screenings, we obtained employees’
clinical measures and collected their completed surveys.
Survey and clinical data were obtained from 631
employees, for a response rate of 39%. At follow-up,
two years later, we mailed surveys and invitations for
screening to 631 employees. Data were obtained from
320 employees, for a response rate of 51%.
Principal Findings: Average PAM scores increased
significantly in each of the intervention arms in each of
the three levels of analysis. The population mean PAM
score increased in the traditional arm from 68.5 to 73.2
(P = .0005) and in the activated consumer arm from 68.1
to 74.5 (P = .0001). The mean PAM score for individuals
at risk increased in the traditional arm from 67.2 to 72.1
(P = .002) and in the activated consumer arm from 66.1
to 73.0 (P = .0005). The mean PAM score for employees
at risk who enrolled in coaching increased in the
traditional arm from 65.7 to 70.2 (P = .009) and in the
activated consumer arm from 65.7 to 72.2 (P = .005).
There was no significant change in the mean PAM
scores in the control arm.
Conclusions: Patient activation is a malleable personal
characteristic that can be improved with intervention.
Previous analyses have shown that a gain of five points
on the PAM scale, such as observed in this study,
correlates with changes from unhealthy to healthy
behaviors, such as eating breakfast or exercising
regularly. Similar PAM increments are associated with
greater health information-seeking behaviors.
Implications for Policy, Delivery or Practice: Patient
activation is a key skill for people in today’s health care
environment in which the increasing burden of chronic
disease requires more self-management. The concept of
activation should not be restricted to people who already
have chronic conditions, but can be broadened to
include those at risk, and even the general population.
This study demonstrates that interventions can improve
this skill set leading to better health behaviors. Activation
can be improved with broad social campaigns, not just
with individual coaching. Activation can be changed
outside the delivery system, such as in places of
employment.
Funding Source(s): CDC
♦ Health Risk Appraisals in Employer-Sponsored
Insurance: A Meaningful Way to Engage Patients?
Haiden Huskamp, Ph.D.; Meredith Rosenthal, Ph.D.
Presented by: Meredith Rosenthal, Ph.D., Associate
Professor, Health Policy & Management, Harvard School
of Public Health, 677 Huntington Avenue, Boston, MA
02115, Phone: (617) 432-3418, Email:
mrosenth@hsph.harvard.edu
Research Objective: Health Risk Appraisals (HRAs),
which ascertain information about health status,
behavior, and health history, have been promoted as the
entry point for many behavioral interventions and an
element of consumer engagement. Our objective was to
explore the potential role of HRAs as a tool for managing
health care quality and costs in employer-sponsored
insurance using HRA responses and health care billing
data from a large insurer.
Study Design: We first estimated logistic regression
models to examine characteristics associated with
voluntary HRA completion among employees of firms
that offer but do not require employees to complete an
HRA. We then used generalized estimating equations
and a difference-in-difference framework to compare
health care use (office visits, prescription drugs,
emergency room (ER) visits), costs, receipt of
recommended care, and disease management (DM)
program participation for HRA completers and similar
individuals enrolled in plans that did not offer an HRA
(matched using propensity scores).
Population Studied: Three groups of employees that
contract with CIGNA: 1) 45,398 employees who
completed an HRA; 2) 108,327 employees of the same
firms who elected not to complete an HRA; and 3) a
random sample of 200,000 employees of firms that did
not offer an HRA.
Principal Findings: The average HRA participation rate
within firms was 68% (SD=41%). We found that women
(OR=1.48), individuals with fewer co-morbid conditions
(Charlson Index OR=0.94), and consumer-driven health
plan (CDHP) enrollees (OR=3.99) were more likely to
complete an HRA (all p=0.05). Use of office visits and
prescription drugs increased after HRA completion
relative to individuals not offered an HRA (3% and 4%,
respectively, p=0.05), as did cervical cancer screening
(OR=1.32, p=0.05). There was no change in DM
participation or use of ER visits.
Conclusions: Our analyses suggest that there are
discernable patterns of self-selection among HRAcompleters. In particular, women, CDHP enrollees (who
have financial incentives to make cost-conscious
utilization decisions), and individuals with fewer chronic
conditions are more likely to complete an HRA. We also
found evidence of short-term changes in utilization and
quality for HRA-completers, including increases in office
visits, prescriptions filled, and cervical cancer screening.
We are unable to assess whether the increased
prescription drug and office visit use represents needed
care and thus higher quality. While increases in office
visits and prescription drugs may not be unambiguously
good from the payer’s perspective, increases in services
such as cancer screening are clearly in line with the
goals of the HRA.
Implications for Policy, Delivery or Practice:
Employers are increasingly questioning the return on
investment for disease management and wellness
programs that they sponsor for employees in part
because of low participation rates in the programs. Our
results suggest that HRAs may influence some health
behaviors of employees, but employers may need to
identify alternative approaches to engage consumers
more actively in reducing their health risks.
Funding Source(s): RWJF
Consumers & Value-Based Health Care Choices
Chair: Jessica Greene
Tuesday, June 30 * 11:30 a.m.-1:00 p.m.
♦ A Multi-Employer Multi-Insurer Study of the Effects
of Consumer Directed Health Plans on Healthcare
Costs and Use
Melinda Beeuwkes Buntin, Ph.D.; Amelia Haviland,
Ph.D.; Neeraj Sood, Ph.D.; Roland McDevitt, Ph.D.
Presented by: Amelia Haviland, Ph.D., Statistician,
Health, RAND Corporation, 4570 Fifth Avenue, Suite
600, Pittsburgh, PA 15213, Phone: (412) 683-2300,
Email: haviland@rand.org
Research Objective: To evaluate the effects of different
consumer directed health plan (CDHP) designs on
changes in health care costs and use. Utilization and
costs are examined overall and for different types of
care; costs and use will be examined for different types
of households including those with high vs. low baseline
spending, those in different income groups, and those
with and without chronic diseases. They will also be
examined for people in plans with varying deductible
levels and personal health savings accounts.
Study Design: In order to address the limitations of prior
studies, which have looked at early CDHP designs
offered by a single employer or a single insurance
carrier, a new dataset was constructed with enrollment
and claims data, 2003-2005, from all employees and
dependents of 60 large or very large employers
distributed across the U.S. These employers offer health
insurance plans from a total of 129 different carriers.
The resulting analysis dataset includes 113,371 unique
families in CDHP plans and 2,492,257 comparison
families. Outcomes are examined at the household or
“insurance unit” level. Multiple methods are
implemented to address selection into different plan
designs and confirm model robustness including
differences in differences, instrumental variables, and
propensity score weighting. Control variables include
family structure, risk scores, diagnostic/disease
categories, geocoded household income, and actuarial
values of plans. Generalized linear models incorporating
log link functions are employed to fit the highly skewed
cost data, count models are employed for utilization data
including admissions, and quantile regressions are
employed to look at effects by level of spending.
Population Studied: Employees and dependents of 34
large firms offering high-deductible health plans and 26
controls firms offering only traditional HMOs and PPOs.
Employers were selected so as to yield a diverse sample
in terms of regions, industries, wage levels, and
insurance carriers; employers offering CDHPS were
sought with diverse CDHP attributes including deductible
levels, personal account offerings, employer
contributions, and penetration of high-deductible plans.
Principal Findings: Findings suggest that, depending
on specification, the growth in high-deductible plan
enrollees’ costs was between 8.8 and 17.3 percent lower
than that of comparable enrollees in control plans
(p<0.001). This difference was due to lower inpatient,
and slightly lower outpatient, expenses. There is also
some evidence of lower pharmaceutical expenditures,
but mixed results on emergency room costs. Results on
utilization and by specific CDHP and employee attributes
are in process.
Conclusions: High-deductible plans are associated with
lower cost growth in the first year an employee enrolls.
We will add findings regarding how the specific aspects
of CDHP plan designs affect spending and utilization,
including utilization of preventive care, and whether
certain enrollee groups are affected more than others.
Implications for Policy, Delivery or Practice:
Policymakers considering wide-reaching changes to the
structure of health insurance in the U.S. need to be
aware of how different plan designs will affect the costs
and use of care.
Funding Source(s): RWJF, and the California
HealthCare Foundation
♦ Success Rates & Consumer Learning in the Market
for In Vitro Fertilization
David Howard, Ph.D.; Gary Jeng, Ph.D.
Presented by: David Howard, Ph.D., Associate
Professor, Department of Health Policy & Management,
Emory University, 1518 Clifton Road, Northeast, Atlanta,
GA 30322, Phone: (404) 727-3907, Email:
david.howard@emory.edu
Research Objective: Proponents of market based
reforms in health care often assume that patients, if
given enough information, will make intelligent choices.
Critics charge that for many health care services,
patients only make a one-time purchase, and so they
cannot develop into informed consumers. In vitro
fertilization (IVF) offers a unique setting to test these
theories. Many patients make repeated choices, and
information on success rates is readily available. We test
whether patients consider success rates when choosing
clinics and whether the impact of success rates
increases as patients gain more experience in the
market.
Study Design: The data are from a universal IVF
registry at the CDC. They contain a 100% census of IVF
“cycles” received by patients who initiated treatment in
2004-2005. Each IVF attempt is called a cycle. Some
patients require only one cycle, others undergo multiple
attempts. The CDC uses these data to calculate clinic-
level success rates (i.e. the proportion of cycles that
result in pregnancy) (see http://www.cdc.gov/ART/). We
estimate Train’s mixed multinomial logit model for
repeated choices. For each patient, we construct a
choice set consisting of the clinics within a 100 mile
radius. We estimate the probability that a patient
chooses a clinic in her choice set as a function of the
clinic’s success rate, distance, and other clinic attributes.
Clinic attributes are interacted with patient
characteristics, including the number of previous cycle
attempts.
Population Studied: Women choosing IVF clinics who
initiated treatment in 2004 and 2004. We have data on
151,131 cycles, including 85,714 first cycles, 40,735
second cycles, 18,508 third cycles, 7,893 fourth cycles,
and 3,281 fifth cycles.
Principal Findings: About 10% of patients switched
clinics between cycles. Patients who initially chose
clinics with lower success rates were significantly more
likely to switch. On average, switching patients switched
to clinics with higher success rates. The final clinics had
success rates about 0.5 standard deviations higher than
the initial clinics. The mixed multinomial logit model
confirms these results. The coefficient on success rates
is positive and significant and the coefficient on the
interaction of success rates and cycle number – a
measure of patient learning – is also positive and
significant.
Conclusions: Patients, even those choosing for the first
time, appear to take success rates into account when
choosing clinics. However, we find evidence of patient
learning, suggesting that patients choosing for the first
time are not as familiar with clinic-level success rates as
patients with previous experience in the market. Clinics
with higher success rates may charge higher prices.
Failure to control for price will lead to estimates of the
impact of success rates on patient choice that are biased
downwards
Implications for Policy, Delivery or Practice: Critics of
market based reforms are correct in charging that
patients making one-time choice decisions may not be
fully informed. However, this does not imply that
provider-level demand is unresponsive to differences in
quality.
♦ The Impact of DTC Print & Television Advertising
on Antidepressant Use
Rosemary Avery, Ph.D.; Kosali Simon, Ph.D.; Matthew
Eisenberg, B.A.
Presented by: Kosali Simon, Ph.D., Associate
Professor, Policy Analysis & Management, Cornell
University, MVR Hall, Ithaca, NY 14850, Phone: (607)
255-7103, Email: kis6@cornell.edu
Research Objective: We test the hypothesis that
exposure to direct-to consumer (DTC) advertising for
antidepressants affects individual use of these
medications.
Study Design: We use individual level data from the
Simmons National Consumer Survey (NCS), a nationally
representative repeated cross-sectional marketing
survey from 2001-2004. This survey contains information
on individual use of antidepressants, as well as very
detailed information on an individual's magazine reading
habits (i.e. exact issues read of specific magazines, and
fractions of those issues). Using a unique database of
DTC print advertisements appearing in 26 of the top
read consumer magazines in the U.S. during time
period, we calculate the number of advertisements for
antidepressants that were contained in the specific
magazine issues read by the individual. We then
examine the causal impact of this advertising exposure
measure (we classify high exposure as more than 4 ads,
moderate as 1-4 ads) on the use of antidepressants. We
are able to circumvent endogeneity concerns (marketers
place more ads in magazines read by individuals with
higher demand for antidepressants) because the NCS
contains detailed demographic characteristics used by
marketers in targeting ads. A prior study using this study
design and these databases found that exposure to
smoking-cessation product advertisements causally
affected quitting behavior (Avery et al, Journal of Political
Economy, 2007). Using a logit, we study the probability
than an individual reports using antidepressants during
the year. The key regressor is the measure of
advertising exposure at the individual level. The model
includes demographic factors as well as magazine
specific fixed effects.
We also conduct an anti-test: we estimate a similar
model to see if exposure to statin product advertising,
when included as an additional regressor, impacts use of
antidepressants. We estimate models separately by
gender.
Population Studied: 85,188 adult respondents to the
NCS from 2001-2004
Principal Findings: In the print ad models for women
we find that high ad exposure results in a 23.6% greater
odds of using antidepressants, but that moderate
exposure results in a statistically insignificant effect on
the odds of usage. In our sample, 25.29% of women are
exposed to high levels and 28.87% to moderate levels of
print ads, compared to the control group of no exposure
(45.83%). Our results hold up even when we control for
individual exposure to another type of DTC product ad
(anti-cholesterol/statins) supporting the conclusion that
the effect we find comes only from exposure to the
relevant (antidepressant) ads. We find that male
exposure to DTC antidepressant ads in print media does
not appear to affect their antidepressant use in a
statistically significant manner. This gender difference in
ad exposure has not been tested in earlier studies that
use market level ad exposure, thus we are unable to say
whether this phenomenon is specific to antidepressant
use.
Conclusions: This is the first study to consider the
causal impact of individual-level exposure to DTC
advertising on use of antidepressants. Our findings are
that exposure to pharmaceutical print ads impact
women’s consumption of prescription antidepressant
products.
Implications for Policy, Delivery or Practice:
Understanding the impact of advertising on use of
pharmaceutical products in general and antidepressant
use specifically is policy relevant for several reasons.
Unfortunately, given the non-clinical nature of our data,
we are unable to discern whether women in this study
whose antidepressant use was affected by print ads are
indeed the untreated, or whether the ads are fueling
excessive demand for branded products through
consumer pressure on physicians. Future clinical work in
this area should attempt to address these causal links
more directly.
♦ Early Evidence of Consumer Response to a HighPerformance Physician Network.
Anna Sinaiko; Meredith Rosenthal, Ph. D.
Presented by: Anna Sinaiko, M.P.P., Student, Health
Policy, Harvard University, 351 Otis Street, West
Newton, MA 02465, Phone: (617) 467-5659, Email:
sinaiko@fas.harvard.edu
Research Objective: To analyze consumer awareness
and use of high-performance physician networks in
health plans, the sources consumers say they would
trust to determine which physician to see, and how
demographic and other characteristics affect these
results.
Study Design: We developed and fielded a survey to
assess consumer response to high-performance
physician networks included in health plans offered by
the Massachusetts Group Insurance Commission (GIC),
a quasi-independent state agency that provides and
administers health benefits to state employees. The
networks, in place for more than a year at the time of the
survey, are based on ratings for a standard set of
performance measures for individual physicians using
pooled data across all six of the GIC health plans. The
performance data include efficiency scores based on the
ETG methodology and quality scores based on
Resolution Health Inc. analysis. The survey asks about
knowledge and use of the high-performance network
over the past year, and about use of the health care
system, information-seeking behavior, demographics
and self-reported health status. The survey was
administered via US mail; responses were submitted via
mail or Internet. Data were collected from March 2008 –
June 2008.
Population Studied: We surveyed a stratified (based on
health plan) random sample of 4200 non-retired state
employees. There were 64 undeliverable surveys and
1,972 responses for an adjusted response rate of 48%.
Non-respondents were more likely from a zip code with a
high percentage of minority residents and to have
enrolled in an HMO. In comparison to the GIC
population of workers, respondents were more likely to
be older and female.
Principal Findings: 49.5% of respondents reported
prior knowledge of the tiered networks and only 19.0%
reported knowing which tier one of their doctors is in.
Respondents with prior knowledge of the networks were
more likely to trust an independent organization (e.g.
consumer reports) or a professional society to decide
which doctors should be in a preferred tier than their
health plan or their employer. Of respondents who knew
their doctor’s tier designation, 83.5% learned this
information at or after their first visit. Respondents who
learned their doctor’s tier before the first visit were more
likely to find this information very or moderately
important to their decision to see that physician. Findings
vary by demographics, self-reported use of the Internet
for health information and whether a consumer visited a
specialist in the last year. All findings are adjusted for
non-response and post-stratification weighting for age,
gender, plan, coverage type and minority population by
zip code.
Conclusions: The majority of Massachusetts state
employees are not aware of the high-performance
physician networks in their health plan, and do not use
the network designation in their choice of provider.
Implications for Policy, Delivery or Practice: This
early evidence suggests that using high-performance
physician networks to direct consumers to preferred
providers requires extensive consumer education to
increase awareness and trust in the employer and health
plan as a source for determining the tiers. Efforts
targeting consumers before they decide to see a
particular doctor may be more successful at achieving
the desired consumer response.
Funding Source(s): Harvard School of Public Health
Institutional Funds
♦ A Randomized Controlled Trial of Copayment
Reductions for Blood Pressure Medication: The
Collaboration in Hypertension to Reduce Disparities
(CHORD) Trial
Kevin Volpp, M.D., Ph.D.; Andrea Troxel, Sc.D.; Judith
Long, M.D.; Said Ibrahim, M.D.; Dina Appleby, M.A.;
Steven Kimmel, M.D., M.S.C.E.
Presented by: Kevin Volpp, M.D., Ph.D., Director,
Center for Health Incentives, Leonard Davis Institute of
Health Economics, Associate Professor of Medicine and
Health Care Management, University of Pennsylvania
School of Medicine and the Wharton School, Medicine &
Health Care Management, Center for Health Incentives,
Leonard Davis Institute of Health Economics; University
of Pennsylvania School of Medicine; the Wharton
School; CHERP, Philadelphia VA Medical Center, 1232
Blockley Hall, Philadelphia, PA 19104, Phone: (215)
573-0270, Email: volpp70@wharton.upenn.edu
Research Objective: Value-based insurance designs, in
which copayments are lowered for services of relatively
high benefit, are garnering widespread attention as a
way to improve adherence and patient outcomes. Nearly
two-thirds of Americans with hypertension (HTN) have
poorly controlled hypertension, which puts them at risk
for substantial morbidity and mortality. We undertook this
study to examine whether lowering patient copayments
for blood pressure medications among patients with
poorly controlled hypertension significantly improves
blood pressure control.
Study Design: We conducted two randomized trials of
interventions to improve blood pressure control. In the
first (COPAY ELIGIBLE, n=479), participants were
randomly assigned to receive incentives equivalent to
reductions in copayments from $8 per medication per
month to $0 for each anti-hypertensive prescription filled,
a computerized behavioral intervention (CBI), both
copay reduction and CBI, or usual care. In the second,
among patients who didn’t pay copayments (COPAY
EXEMPT, n=336) participants received rewards that
effectively lowered copayments from $0 per medication
per month to negative $8, a CBI, both copay reduction
and CBI, or usual care. In each trial, individual
participants were randomized evenly to the four arms
with stratification by site, systolic blood pressure (<160,
>=160), and income. The primary outcome was change
in blood pressure 12 months post-enrollment, and the
study was powered to detect a 10mm difference in
systolic blood pressure between arms.
Population Studied: 816 patients with poorly controlled
hypertension (SBP>140 non-diabetics, SBP>130
diabetics) from 3 Pennsylvania hospitals.
Principal Findings: There were no significant
interactions between the incentive interventions and the
CBI interventions. Blood pressure decreased among all
participants over the 12 months of the study, but there
was no significant difference in results between the
financial incentive groups and the control groups.
Among patients in the COPAY ELIGIBLE study, systolic
blood pressure within the incentive group dropped 13.2
mm on average, vs. 15.2 mm for the control group
(difference = 2.0, [95% CI = -2.3 to 6.3], p=0.36.) The
proportion of patients whose blood pressure was under
control at 12 months post-enrollment was 29.5% in the
incentive group vs. 33.9 in the control group (OR = 0.8;
[95% CI = 0.5 to 1.3], p=0.36). Within the COPAY
EXEMPT group, the results showed a mean 13.7 mm
drop for the incentive group vs. a 10.0 mm decline for
the control group (difference = -3.7 [95% CI = -9.0 to
1.6], p=0.17.) Blood pressure control was achieved by
35.6% of the incentive group vs. 27.7% of the control
group (OR = 1.4, [95% CI = 0.8 to 2.5]; p=0.19.)
Conclusions: Among patients with poorly controlled
blood pressure, neither financial incentives that
effectively eliminated copayments for blood pressure
medications or that paid patients for filling prescriptions
improved blood pressure control.
Implications for Policy, Delivery or Practice:
Reductions in copayments may be a less effective
means of improving intermediate outcomes than had
been anticipated by the architects of value-based
insurance design.
Funding Source(s): Commonwealth of Pennsylvania
Public Policies Affecting Coverage & Access
Chalir: Thomas Buchmueller
Sunday, June 28 * 11:00 a.m.- 12:30 p.m.
♦ Early Lessons from San Francisco’s Pay-or-Play
Employer Health Benefits Mandate
Carrie Hoverman Colla, M.A.; William Dow, Ph.D.;
Arindrajit Dube, Ph.D.
Presented by: Carrie Hoverman Colla, M.A., Ph.D.
Candidate, Health Services & Policy Analysis, University
of California, Berkeley, 1563 Lombard Street, San
Francisco, CA 94123, Phone: (917) 756-7666, Email:
carrieh@berkeley.edu
Research Objective: Implemented in early 2008, San
Francisco’s Health Care Security Ordinance has
received national attention as the most far-reaching local
health reform in the United States. The policy consists
of a pay-or-play health spending mandate per worker
hour on employers and the creation of a low-cost health
access plan by the county to strengthen the safety net.
Similar pay-or-play ideas have been incorporated into
many other reform proposals at the state and national
level in the U.S., but to date there is little evidence on
how such mandates would perform in practice. This
study evaluates employer-level responses to a pay-orplay mandate.
Study Design: The research design uses multiple
control groups to identify average treatment effects in
large San Francisco employers subject to the mandate.
The control groups include: 1) Bay Area employers
outside San Francisco not subject to the mandate, 2)
small employers in San Francisco not subject to the
mandate, and 3) employers in San Francisco whose
benefit offerings already met the mandate's
requirements. We present descriptive statistics and use
difference-in-difference estimators to estimate early
effects on employer insurance benefit offering and
employee take-up.
Population Studied: Employers interviewed for the
2008 Bay Area Employer Health Benefits survey. The
survey gathered data from firms about their health
benefit offerings and take-up in both 2007 and 2008,
thus both just before and just after implementation of the
pay-or-play mandate. The sample of approximately
1,000 firms includes San Francisco firms subject to the
mandate (20 or more employees), as well as comparison
firms not subject to the mandate (smaller firms and those
in surrounding counties).
Principal Findings: Most firms in San Francisco subject
to the mandate offered insurance to some employees
prior to the implementation of the pay-or-play mandate.
However, because the mandate applies for each
employee rather than as a percentage of total payroll,
almost all targeted firms changed their behavior. Only a
small portion of the firms were unaware of the mandate
six months after implementation. Employer changes
included covering more of the premium, revising
insurance offerings, as well as paying the city fee in lieu
of providing insurance. A notable portion of firms chose
to meet the mandate by paying into health
reimbursement accounts, as predicted, particularly in
this early period after implementation. There is no
significant evidence of employers dropping insurance
coverage.
Conclusions: We find evidence that employers behave
strategically in response to the incentives of the
mandate.
Implications for Policy, Delivery or Practice: Many
recent national and state health reform proposals have
included employer pay-or-play mandate provisions, but
modeling the expected effects of those provisions has
been difficult given little previous experience. The San
Francisco mandate differs substantially from those in
Hawaii and Massachusetts, and responses have differed
as well. Our research suggests that the details of such
mandates may indeed have crucial implications for the
effects of the mandate.
Funding Source(s): RWJF, California Program on
Access to Care, Labor and Employment Research Fund
♦ Free Mammograms for Low Income Women &
Breast Cancer Mortality Rates
David Howard, Ph.D.
Presented by: David Howard, Ph.D., Associate
Professor, Department of Health Policy & Management,
Emory University, 1518 Clifton Road, Northeast, Atlanta,
GA 30322, Phone: (404) 727-3907, Email:
david.howard@emory.edu
Research Objective: The National Breast and Cervical
Cancer Early Detection Program (NBCCEDP) is a joint
federal-state program that provides free mammograms
to uninsured, low income women. States instituted
NBCCEDP programs between 1991 and 1999. About
9% of women are eligible. We estimate the impact of the
NBCCEDP on breast cancer mortality rates. NBCCEDP
may reduce mortality by 1) shifting the stage at
diagnosis and/or 2) facilitating access to treatment
among women irrespective of stage (the program
covered treatment post-2000; before 2000 many women
were able to obtain free care).
Study Design: The data consist of observations for
each state and year (1990-2004). The outcome variable
is the breast cancer mortality rate for women 45-65.
Independent variables include the proportion of women
45-64 screened under NBCCEDP, the unemployment
rate, the Medicaid coverage rate, the unemployment
rate, and per capita income. We estimated the model
using least squares regression with state and year fixed
effects and heteroskedasticity-adjusted standard errors
(Stock and Watson, Econometrica, 2008). The impact of
the NBCCEDP is identified based on changes in
mortality within states, and each state serves as a
control for the other states. For example, West Virginia’s
program began in 1991 and Virginia’s in 1998. If the
program had an impact, we would expect a steeper
decline in breast cancer mortality rates in West Virginia
compared to Virginia in 1991 and a steeper decline in
Virginia compared to West Virginia in 1998. We
performed falsification tests by estimating the impact of
NBCCEDP on colon cancer, heart disease, and
homicide/suicide/accident mortality rates. A finding that
NBCCEDP is negatively related to mortality from these
other causes could indicate that our study design lacks
specificity or that results are biased by an omitted
variable.
Principal Findings: By 2004, 2% of women aged 45-65
were screened under NBCCEDP. The NBCCEDP
screening rate was significantly and negatively related to
breast cancer mortality. Results indicate that a 1%
increase in the NBCCEDP screening rate leads to a 1%
decline in the breast cancer mortality rate. NBCCEDP
was unrelated to mortality due to other causes (e.g.
heart disease). NBCCEDP was also unrelated to breast
cancer mortality among women >65 (who were
unaffected by the program).
Conclusions: We find -- somewhat surprisingly given
the “noisyness” of the outcome variable -- that
NBCCEDP is associated with a decline in breast cancer
mortality. It is unclear whether this is due earlier
detection or better access to treatment, or some
combination of thereof. Our study is based on state-level
data, and the usual caveats apply.
Implications for Policy, Delivery or Practice: The
results of this study and previous work suggest that
NBBCEDP did not simply crowd out free mammograms
with publicly funded mammograms. Rather, it led to an
increase in the mammography rate. More broadly, the
findings are consistent with the hypothesis
Funding Source(s): CDC
♦ Medicare Spending for Previously Uninsured
Adults
J. Michael McWilliams, M.D., Ph.D.; Ellen Meara, Ph.D.;
Alan Zaslavsky, Ph.D.; John Ayanian, M.D., M.P.P.
Presented by: J. Michael McWilliams, M.D., Ph.D.,
Assistant Professor of Health Care Policy & Medicine,
Department of Health Care Policy, Harvard Medical
School, 180 Longwood Avenue, Boston, MA 02115,
Phone: (617) 432-3290, Email:
mcwilliams@hcp.med.harvard.edu
Research Objective: To estimate the effects of
uninsurance in the near-elderly population on
subsequent Medicare spending using Medicare claims
data. Medicare spending may be higher for previously
uninsured adults with treatable conditions if poor disease
control leads to irreversible complications before age 65
or persistently elevated clinical needs after age 65.
Uninsured adults may also delay elective procedures
until they gain coverage.
Study Design: Longitudinal survey data from 1992-2006
were used to assess coverage patterns and other
sociodemographic and clinical characteristics before age
65 for an aging near-elderly cohort. Linked Medicare
claims data from 1996-2005 were used to assess
differences in utilization and spending after age 65
between previously uninsured and insured adults. We
used an inverse probability of treatment weighting
technique to adjust for observed baseline differences
between these comparison groups and account for
survey non-response that led to missing claims data.
Using this method, we also adjusted for time-varying
confounders such as health declines that could have
caused or resulted from uninsurance before age 65. We
estimated the contributions to differences in Medicare
spending for previously uninsured and insured adults
from hospitalizations for complications of cardiovascular
disease or diabetes, joint replacements, and
exacerbations of chronic obstructive pulmonary disease
(COPD).
Population Studied: Nationally representative cohort of
adults from the Health and Retirement Study (HRS),
including 2951 adults who were continuously insured
and 1616 adults who were continuously or intermittently
uninsured before age 65.
Principal Findings: Adjusted annual total Medicare
spending after age 65 was significantly higher for
previously uninsured ($4521) than previously insured
($3589) adults (difference: $932; P=0.04), particularly
among adults with cardiovascular disease or diabetes
(difference: $1398; P=0.04). Descriptive plots
suggested spending differences persisted through age
71 and diminished thereafter. Relative to other service
types, differences in annual spending were largest for
inpatient services ($524; P=0.07). Previously uninsured
adults with cardiovascular disease or diabetes were
more likely to be hospitalized for related complications
(adjusted annual rates: 7.3% vs 5.3%; P=0.04) and
those with arthritis tended to be hospitalized more often
for joint replacement surgery (2.4% vs 1.2%; P=0.08).
Together these condition-specific admission rates
accounted for 68.6% of the difference in total annual
Medicare spending between all previously uninsured and
insured adults. In contrast, previously uninsured adults
who reported lung disease or active smoking tended to
be hospitalized less often for COPD exacerbations than
previously insured adults (1.0% v. 1.7%; P=0.08).
Conclusions: Adjusted Medicare spending was
significantly higher for previously uninsured than
previously insured adults. Differences in spending were
explained largely by complications of cardiovascular
disease or diabetes and greater use of joint
replacements, but not by exacerbations of COPD, a
condition for which few treatments alter disease
progression. These differences appeared to narrow
after 7 years, suggesting persistent effects of being
uninsured before age 65 that were eventually
attenuated.
Implications for Policy, Delivery or Practice: The
costs of expanding coverage before age 65 may be
partially offset by subsequent reductions in Medicare
spending after age 65 for treatable chronic conditions
and elective procedures.
Funding Source(s): CWF
♦ Distribution of Out-of-Pocket Pharmacy Spending
among the Elderly Before & After Medicare Part D
Prescription Benefit
Yuting Zhang, Ph.D.; Joseph Newhouse, Ph.D.; Julie
Donohue, Ph.D.; Judith Lave, Ph.D.
Presented by: Yuting Zhang, Ph.D., Assistant
Professor, Health Policy & Management, University of
Pittsburgh, 130 DeSoto Street, A664 Crabtree,
Pittsburgh, PA 15261, Phone: (412) 383-5340, Email:
ytzhang@pitt.edu
Research Objective: Medicare Part D was enacted to
protect beneficiaries against catastrophic drug
expenditures and reduce beneficiaries’ financial burden.
This study evaluates Part D’s impact on the distribution
of out of pocket pharmacy payment among elderly
beneficiaries.
Study Design: Using a pre-post-with-comparison-group
design, we compared two groups of elderly beneficiaries
who were continuously enrolled in a large insurer that
offers Medicare Advantage Part D products: the majority
had no coverage or limited coverage (quarterly caps of
$150 or $350) who switched to Part D, while others had
generous employer-subsidized coverage that did not
change. We examined changes in total drug use and
out-of-pocket drug spending. We also evaluate whether
Part D resulted in a shift in the “risk” of out-of pocket
pharmacy spending in a way consistent with the goals of
insurance; that is, we determine whether the proportion
of payments made out of pockets decreased as overall
expenditures increased as a result of Part D.
Population Studied: We used a 40% random sample of
36,858 continuously enrolled members in the insurer
between 2004 and 2007. We excluded 1756 members
under age 65 who were eligible for Medicare because of
disability, 926 who had some low-income subsidies to
cover medications. We used the remaining cohort of
34,176 members to study the impact of Part D on
medication treatment patterns.
Principal Findings: In the two year post the
implementation of Part D, overall drug use increased
64.1% (95% CI, 59.5 – 68.7%), 19.9% (95% CI, 17.622.2%), and 11.2% (95% CI, 10.1-12.4%), among those
with no prior drug coverage, and quarterly caps of $150
and $350, relative to the comparison group. The
comparison group whose benefits were unchanged had
more stable monthly out-of-pocket drug spending around
$40 per month before and after Part D. Relative to the
comparison group, Part D reduced out-of-pocket
spending in the two treatment groups that began with no
or less generous drug coverage: out of pocket spending
decreased 13.4 percent among the group with no prior
coverage (95% CI, -17.1- -9.1 percent), and 15.9 percent
among those with a $150 quarterly cap (95% CI, -19.1 - 12.8 percent). In contrast, total out-of-pocket spending in
the $350 did not change. In the group without benefit
pre- Part D, the proportion of out-of-pocket spending
declined from 100% to less than half among those
whose drug spending higher than median. In general,
Part D reduced proportion of beneficiary payment more
among high drug spenders (6th deciles up) than low
spenders.
Conclusions: In general drug spending increases with
the generosity of drug coverage. Part D increased
overall drug use and reduced out-of-pocket spending.
Changes in overall drug spending and counts of
prescriptions followed the similar patterns, suggesting
that the cost per prescription was not much changed.
Implications for Policy, Delivery or Practice: Our
findings suggest that Part D reduced beneficiaries’
financial burdens of increasing high pharmacy costs,
especially among those high spenders.
Economic Determinants & Comsequences of Health
Insurance Coverage
Chair: Amy Davidoff
Sunday, June 28 * 2:30 p.m.- 4:00 p.m.
♦ The Effect of Parent’s Involuntary Job Loss on
Health Insurance Coverage of Children
Susan Busch, Ph.D.; William Gallo, Ph.D.
Presented by: Susan Busch, Ph.D., Associate
Professor, Health Policy, Yale Medical School, P.O. Box
208034, New Haven, CT 06520, Phone: (203) 7852927, Email: susan.busch@yale.edu
Research Objective: The U.S. economy lost 2.6 million
jobs in 2008. While it is well known that adults often lose
health insurance coverage in response to job loss, there
is little information on the effects of job loss on children.
While children may also lose coverage, expansions in
children’s eligibility for public coverage over the past
decade may result in children’s maintaining coverage by
enrolling in public insurance programs. Our objective is
to determine what share of children whose parents
experience involuntary job loss become uninsured.
Study Design: We use two recent panels of the Medical
Expenditure Panel Survey (MEPS) to examine the effect
of parent’s involuntary job loss on children’s health
insurance status. We exploit the longitudinal nature of
the MEPS, and examine changes in insurance status for
children at 3, 6 and 12 months post parent job loss. We
categorize insurance status into four categories (private
group, private non-group, public coverage and
uninsured). Because transitions in and out of insurance
coverage may occur in the absence of job loss, we
determine the net effect of job loss by using propensity
score matching to compare changes in insurance status
with a similar group of children whose parents did not
experience job loss. We randomly assign a ‘job loss’
date to children not experiencing parental job loss.
Population Studied: National sample of children less
than 17 years of age.
Principal Findings: We present findings for 6 months
post job loss, although declines in insurance coverage
are similar at other time periods. Preliminary findings
suggest that children whose parents experience
involuntary job loss are significantly more likely to lose
coverage. In the month prior to job loss, we find similar
rates of insurance coverage comparing children
experiencing and not experiencing parental job loss
(approximately 90 percent). Among children who were
insured in the month prior to job loss, significantly fewer
are insured six months later in the job loss group (81
versus 97 %). We find no significant change in public
coverage rates in either group. Among children who
were not insured in the month prior to job loss,
significantly fewer gain coverage in the job loss group
(24 versus 35 %). We find similar increases in public
coverage in the two groups (from 0 to approximately 18
percent). Somewhat surprising, we found no differential
effect on insurance status by whether the job loser was
the mother or father.
Conclusions: We find large declines in insurance
coverage among children whose parents experience
involuntary job loss. Additional analyses will examine
whether these effects result in declines in the receipt of
necessary care.
Implications for Policy, Delivery or Practice:
Consolidated Omnibus Reconciliation Act (COBRA)
health benefit provisions and the non-group market are
unaffordable to many families. Lacking routine and
preventive care, uninsured children may seek more
costly emergent and acute care at public health
institutions at a high cost to taxpayers and a great
burden to the public health system.
♦ Family Financial Pressures from Medical Bills:
Implications for Defining Affordability Standards in
Health Reform
Peter Cunningham, Ph.D.
Presented by: Peter Cunningham, Ph.D., Senior Fellow,
Center for Studying Health System Change, 600
Maryland Avenue, SW, Suite 550, Washington, DC
21043, Phone: (202) 484-4242, Email:
pcunningham@hschange.org
Research Objective: Several recent surveys have
found a substantial increase in the number of families
reporting problems paying medical bills. These trends
are usually attributed to increases in out-of-pocket costs
relative to family income, although it’s possible that the
affordability of medical care has decreased due to other
financial pressures on families, such as increases in
overall debt, home foreclosures, and the cost-of-living.
This study examines why family-defined affordability of
medical care decreased between 2003 and 2007.
Study Design: Analysis of two nationally representative
surveys from 2003 and 2007 (the 2003 Community
Tracking Study Household Survey and the 2007 Health
Tracking Household Survey, both conducted by the
Center for Studying Health System Change). Both
surveys were similar in design and included information
on out-of-pocket spending, self-reported problems
paying medical bills, health insurance coverage, health
status, and sociodemographic characteristics. Both
descriptive and multivariate analyses are used to
examine changes in the percent of people reporting
problems paying medical bills between 2003 and 2007,
and to examine the reasons for the increase in medical
bill problems.
Population Studied: A nationally representative sample
of persons less than age 65, including about 44,000
people in the 2003 survey and 16,000 people in the
2007 survey.
Principal Findings: The percent of nonelderly people in
families with problems paying medical bills increased
sharply, from about 16 percent in 2003 to 21 in 2007.
While out-of-pocket spending relative to family income
also increased during this period, increases in out-ofpocket costs were not the primary reason for the
increase in self-reported medical bill problems.
Changes in insurance coverage, as well as health and
socio-demographic characteristics of the population also
did not account for the increase in medical bill problems.
Further analysis suggests that other financial pressures
on families decreased the affordability of health care, as
indicated by an increase in the percentage of people
reporting medical bill problems at relatively low levels of
spending. The analysis also examines how other
economic factors, such as the cost-of-living in an area,
and home foreclosure rates (measured at the county
level) are associated with the percentage of people
reporting medical bill problems.
Conclusions: Rising out-of-pocket costs for medical
care are increasing the financial pressure on families.
However, other factors are likely contributing to financial
pressures resulting from medical bills, such as increases
in other forms of debt, the home foreclosure crisis, and
increases in inflation that occurred before 2008.
Implications for Policy, Delivery or Practice:
Affordability of medical care is central to health reform
efforts. Identifying uniform standards of affordability
upon which to base subsidies and coverage mandates is
a key concern among policymakers, although there is
little consensus over how these standards should be
defined. The findings from this study suggest that the
“affordability” of medical care is not static, but changes
over time in response to broader changes in the
economy and families’ economic circumstances.
Funding Source(s): RWJF
♦ Variation in Undiagnosed Health Problems among
Adults: What Difference Does Insurance Coverage
Make?
Linda Blumberg, Ph.D.; Genevieve Kenney, Ph.D.
Presented by: Genevieve Kenney, Ph.D., Principal
Research Associate, Health Policy Center, Urban
Institute, 2100 M Street, NW, Washington, DC 20037,
Phone: (202) 261-5568, Email: jkenney@urban.org
Research Objective: This study examines the extent of
undiagnosed hypercholesterolemia, hypertension, and
diabetes among non-elderly adults. We compare
diagnosis rates for adults with and without insurance
coverage and examine the role that observed
differences in the characteristics of the insured and the
uninsured play in explaining differences in the diagnosis
rates.
Study Design: We use National Health and Nutrition
Examination Survey data collected from 2001 to 2006.
Information on the insurance coverage of the
respondents, their demographic/socioeconomic
characteristics, and the extent to which they have been
told by a provider that they have hypercholesterolemia,
hypertension, and diabetes are drawn from the
household component of the survey. Information on
whether the respondent has hypercholesterolemia,
hypertension, and diabetes are based on results from
the physical examination and laboratory results that
were conducted as a follow-up to the household survey.
Our adjusted differences control for age, marital status,
income, nativity, race, education, and self-reported
health status. We conduct sensitivity analyses to assess
alternative approaches for defining the extent to which
people have health problems that are undiagnosed and
for controlling for differences between insured and
uninsured adults.
Population Studied: Adults ages 20 to 64.
Principal Findings: We find that uninsured adults who
have hypertension, hypercholesterolemia, or diabetes
are less likely than insured adults who have these
conditions to know that they have the given health
condition, whether or not we control for observed
differences between the uninsured and insured. We find
that uninsured adults with hypertension,
hypercholesterolemia, or diabetes are 1.2, 1.5, and 1.9
times, respectively, as likely as the insured to have the
condition and not be aware of it. We find that having
seen a physician in the past year lowers the likelihood of
having undiagnosed health problems, but that around 20
percent of adults with one of these conditions who have
seen a physician in the past year are not aware they
have the condition. We also find that the likelihood of
having seen a physician in the past year explains some,
but not all, of the differential in diagnosis rates by
insurance status.
Conclusions: This analysis demonstrates another
adverse consequence of lacking health insurance
coverage—namely, having undiagnosed health
problems. It also suggests that seeing a physician
lowers, but does not eliminate, the likelihood of having
undiagnosed conditions.
Implications for Policy, Delivery or Practice: These
findings suggest that significantly expanding health
insurance coverage through comprehensive reform
should lower the rates of undiagnosed health problems,
leading to earlier detection and treatment, and possibly
lowering subsequent health care costs. The findings also
highlight a need to increase the identification and
treatment of common chronic health problems among
adults being seen by physicians.
Funding Source(s): Kaiser Family Foundation
♦ For Richer or Poorer, In Sickness & in Health: Do
Same-Sex Marriage Bans Negatively Impact Health
Care Coverage?”
Ninez Ponce, M.P.P., Ph.D.; Susan Cochran, Ph.D.,
M.S.; Vickie Mays, Ph.D., M.S.P.H.
Presented by: Ninez Ponce, M.P.P., Ph.D., Associate
Professor, Health Services, University of California, Los
Angeles School of Public Health, 31-254B Center for the
Health Sciences, Los Angeles, CA 90095, Phone: (310)
206-4021, Email: nponce@ucla.edu
Research Objective: The recent heated public interest
on the legal recognition of same-sex marriages calls into
question a rethinking of the social framework of our
nation’s system of healthcare coverage. We focus on
California to explore the coverage disparities resulting
from a same-sex marriage ban. We use a large
population-based survey that contains information on
sexual-orientation, differentiates between partnered and
married relationships, and identifies all possible sources
of health insurance coverage, including dependent
employment-based health insurance (EBHI).
Study Design: Pooled cross-sectional analyses of the
California Health Interview Surveys 2001, 2003 and
2005 to increase the sample of sexual minorites. This
period pre-dates the short-lived state court legalization of
same-sex marriage, and thus approximates the effects
of the recent passage of the proposition banning samesex marriage in 2008. Employing weighted multivariate
multinomial logit estimation, we tested the effect of
sexual orientation on a 5-category variable of health
insurance: uninsured, public, own EBHI, dependent
EBHI and direct purchase in the nongroup market. To
identify the marriage ban coverage disadvantage levied
on gays/lesbians, we subsetted the data into
partnered/married nonelderly adults. We then estimated
the likelihood of gays/lesbians compared to
heterosexuals of falling into each of the 5 health
insurance categories by computing relative risks (RR)
with bootstrapped confidence intervals (CI). All models
were stratified by gender and adjusted for age,
race/ethnicity, and other covariates associated with
coverage.
Population Studied: California adults ages 18 to 64
who report being partnered or married.
Principal Findings: Among partnered /married women,
lesbians were much less likely than heterosexuals to
have dependent EBHI (RR=0.32; 95%CI[0.19, 0.44]),
but had greater likelhood of having coverage from own
EBHI (RR=1.37; 95%CI[1.08, 1.48]) and from public
programs (RR=2.06; 95%CI [1.01, 3.35]). However, own
EBHI and public coverage did not fully offset the penalty
in dependent coverage: lesbians were twice as likely to
be uninsured than heterosexuals (RR=1.99; 95%CI[1.43,
2.76]). We found similar results among
partnered/married men: gays had a lower likelihood of
dependent coverage than heterosexuals (RR=0.51; 95%
CI[0.34, 0.71]), had higher probaility of having public
coverage (RR=1.91; 95%CI[1.21,2.71]), and had higher
risk of being uninsured (RR=1.45; 95% CI[1.07, 1.93]).
Unlike lesbians who were more likely to have own EBHI,
gay men were just as likely to have own EBHI compared
to heterosexuals.
Conclusions: The common practice of US employers
setting dependent coverage eligibility rules that favor
legally married employees has direct impact on
partnered gay and lesbian adults in durable relationships
but who do not receive the same benefits compensation
as their married coworkers. Unmarried heterosexual
employees in partnered relationships also are affected,
but unlike their gay and lesbian counterparts, they are
not banned from entering into marriages that could
confer EBHI benefits.
Implications for Policy, Delivery or Practice: Bans on
same-sex marriages legitimize discriminatory employer
practices. Employers not offering coverage to same-sex
dependent spouses could lead to uninsurance and its
attendant societal costs when need is unmet, notably
increased preventable disease management costs and
premature mortality. Our study also suggests that lack of
dependent coverage for gay/lesbian adults crowds-out
public coverage.
Funding Source(s): NIDA, NCMHHD; NCI
The Market for Health Plans & Health Care:
Implications for Coverage & Access
Chair: Lisa Dubay
Monday, June 29 * 4:45 p.m.-6:15 p.m.
♦ Pricing & Welfare in Health Plan Choice
M. Kate Bundorf, Ph.D., M.B.A., M.P.H.; Jonathan Levin,
Ph.D.; Neale Mahoney
Presented by: M. Kate Bundorf, Ph.D., M.B.A., M.P.H.,
Assistant Professor, Health Research & Policy, Stanford
University School of Medicine, HRP Redwood Building,
Room 108, Stanford, CA 94305-5405, Phone: (650)
725-0067, Email: bundorf@stanford.edu
Research Objective: Whether competition in health
insurance markets leads to efficient outcomes is a
central question for health policy. Markets are effective
when prices direct consumers and firms to behave
efficiently. But in health insurance markets, the prices
consumers face typically do not vary by individual risk,
potentially causing consumers to make inefficient plan
choices. Our research objective is to examine the
effects of uniform pricing (community rating) of health
insurance premiums on how consumers choose among
different types of health plans.
Study Design: We demonstrate theoretically how
uniform pricing affects the efficiency of the matching of
consumers to health plans and develop a method to
quantify the welfare implications of uniform pricing. We
develop models of consumer choice of health plan,
health plan costs, and health plan pricing and estimating
them jointly using a Generalized Methods of Moments
estimator. The model allows us to identify the effects of
forecastable risk on plan costs as well as the effects of
observed risk and private information on household plan
choices. We then use the model to simulate the effects
of alternative contribution policies.
Population Studied: 11 small to medium-sized
employers during 2004 and 2005 who offered
employees a choice between an integrated HMO and a
more loosely managed PPO product.
Principal Findings: Particular plans did not
systematically experience unfavorable risk selection.
Instead, the different plans experienced unfavorable
selection based on different components of risk. We
also find that private information on risk affects
employee choices; observable risk scores explain about
2/3 of the health status information that factors into plan
choice. In our setting, consumer demand is relatively
price inelastic, although our estimate – that a $100
increase in the annual enrollee contribution decreases
market share by 7 to 9%- is in line with others. Finally,
our results indicate that integrated health plans generate
larger cost savings for high risk than for low risk
enrollees. Using the estimates from our models to
simulate the effects of alternative contribution policies,
we find that the welfare loss of current contribution
policies relative to a feasible, risk-rated alternative
represents about 2-11% of coverage costs. Risk-rated
pricing policies lead to substantial reallocation of
consumers among plans with high risks moving to the
integrated plan and low risks moving to the PPO.
Conclusions: Uniform pricing generates an
economically significant welfare loss through inefficient
matching of consumers to health plans in the setting we
examine. The inefficiency results from both differences
by enrollee risk in the cost structures of the plans and
differences among consumers in their preferences for
coverage.
Implications for Policy, Delivery or Practice: While
policies to address problems of adverse selection in
health insurance markets generally focus on risk
adjusting the payments made to insurers, our findings
indicate that the absence of risk rating of the prices
facing consumers is an additional potential source of
inefficiency. Our findings suggest that current pricing
institutions have impeded the dissemination of the
integrated model of health care delivery.
♦ The Effect of Plan Design on Utilization: A
Comparison of Traditional & Consumer-Driven
Health Plans
Caroline Carlin, Ph.D.; Robert Town, Ph.D.; Steve
Parente, Ph.D.
Presented by: Caroline Carlin, Ph.D., Assistant
Professor, Department of Applied Economics, University
of Minnesota, 1994 Buford Avenue, 249c COB, Saint
Paul, MN 55108, Phone: (612) 625-0216, Email:
ccarlin@umn.edu
Research Objective: The objective of this body of work
is to tease out the differences in plan utilization caused
by individual characteristics such as illness burden, from
utilization differences caused by plan-specific
characteristics such as provider reimbursement levels
and moral hazard. We examine the plans’ impact on
overall plan costs, as well as specific segments of care,
paying particular attention to differences in patterns of
access to preventive care.
Study Design: We use Bayesian inference to facilitate
joint models of plan choice and utilization levels.
Adapting work by Deb, Munkin & Trivedi (J of Bus and
Econ Stat, 2006) to a multinomial choice setting, we
include utility errors in the utilization models to capture
unobserved heterogeneity in choice that may also
influence utilization levels. We use a two-part censored
regression model with individual random effects to model
overall claims, and a series of correlated probit
equations with individual random effects to model
preventive care access. These health care utilization
models are estimated jointly with a multinomial probit
choice model with preference shocks having AR(1)
correlation across time.
Population Studied: We study the employee population
of a large Twin Cities employer, offering four different
plans (an HMO, two POS plans and a CDHP) to their
employees. We have access to detailed claims and
enrollment data for the years 2002-2005. This rich panel
dataset enables the development of sophisticated health
risk measures to control for differences in illness burden
across the plans, enhancing the accuracy of our model
and supplementing the econometric methods of
accounting for heterogeneity in utilization.
Principal Findings: We find significant adverse
selection across plans, and find that this selection is
economically meaningful. In addition, we find the
relative cost by plan changes as we move across the
health risk spectrum. In an attempt to separate the
impact of provider reimbursement levels from utilization
patterns, we model Medicare Resource-Based Relative
Value Units for each individual. We see little difference
by plan in the probability that the individual accesses any
care during the year, but find significant differences in
utilization, conditional on positive resource use. These
differences are less than the differences in overall cost,
suggesting that the plan-based cost differences are
driven by both resource use and provider reimbursement
levels. We also find significant differences in access to
preventive care, despite the fact that all plans waive
copayments for preventive care.
Conclusions: We find that significant differences exist
in cost and treatment patterns across plans, even after
adjusting for differences in the enrolled populations.
These differences are meaningful, and change as we
move across the health risk spectrum.
Implications for Policy, Delivery or Practice: The
differences in relative cost and resource use by plan, as
we move across the health risk spectrum, imply that no
one plan provides the greatest cost management for all
insureds. Greater knowledge of the interaction of
insured characteristics and the plan’s cost management
should inform policy as we work on the national level to
finance expanded health plan access.
Funding Source(s): AHRQ
♦ When Public & Private Plans Compete in a
Reformed HealthCare System: Comparing
Premiums, Financial Protection & Affordability
Jon Gabel, M.A.; Roland McDevitt, Ph.D.; Jeremy
Pickreign, M.S; Ryan Lore, M.P.P.; Heidi Whitmore,
M.P.P.
Presented by: Jon Gabel, M.A., Health Policy &
Evaluation, National Opinion Research Center, 4350
East West Highway, Bethesda, MD 20814, Phone: (301)
634-9313, Email: gabel-jon@norc.org
Research Objective: To analyze premiums, out-ofpocket medical spending, actuarial value and
affordability of Medicare, “Medicare Plus,” and the Blue
Cross-Blue Shield FEBHP plan when offered in an
“exchange” setting.
Study Design: Using medical claims data from
Thompson/Medstat MarketScan, we conduct simulated
bill-paying for Medicare plans and Blue Cross Blue
Shield (BCBS) Federal Employees Health Benefit Plan
(FEBHP) for a standard population. Through simulated
bill-paying, we estimate expected out-of-pocket
expenses, and percentage of the bill paid by insurance
(actuarial value). Medicare plans include: (1) Medicare
only (2) Medicare plus Part D (3) Medicare plus Part D
plus MedSup Plan F (4) “Medicare Extra” -- $250 single
deductible, 10 percent coinsurance, and no deductible
for drug coverage with 25 percent coinsurance. Building
up from the claims database, we estimate premiums for
BCBS-FEBHP and Medicare plans by applying an
administrative expense add-on. Greater discounts for
Medicare than BCBS are a key calculation. Affordability
is estimated as the percentage of income paid for out-ofpocket (oop) medical expenses and premiums by
persons earning 200 and 400 percent of poverty income.
Beneficiary contributions for health insurance are
calculated as premiums minus a fixed refundable tax
credit. In estimating administrative expenses, we
discuss the issue allocating joint costs.
Population Studied: The standard population is from
the MarketScan claims data base that includes 10 million
persons with employer-based insurance. We have
adjusted this standard population to reflect the high
percentage of early retirees in FEBHP.
Principal Findings: Actuarial value for the BCBS plan is
0.83. For the Medicare Plans, actuarial values range
from 0.67 for Medicare only, 0.78 for Medicare plus Part
D, 0.87 for Medicare Extra, to 0.90 for Medicare with
MedSup and Part D. For the top 10 percent of users,
expected average out-of-pocket expenses range from
$1,423 for Medicare with MedSup, $2,677 for BCBS,
and $5,703 for Medicare only. The major advantage in
pricing health insurance for Medicare is provider
discounts.
Conclusions: With an actuarial value three points
above the group insurance average, BCBS is a richer
than average plan. Standard Medicare offers
considerably less protection than an average plan. Sicklow-income persons, nonetheless, may regard even
BCBS coverage as “unaffordable.” After adjusting
Medicare administrative expenses to include the cost of
CMS employees and to standardize for the size of the
average claim, differences in administrative expenses
narrow considerably between private and public health
insurance.
Implications for Policy, Delivery or Practice: Pricing
Medicare will entail many highly-controversial and
arbitrary decisions. For example, should some share of
the cost of HHS central administration, the Congress,
GAO, CBO, OMB, and collection of premiums and taxes
be allocated to the Medicare plan? These decisions will
likely determine whether Medicare or private plans
become the dominant insurer in an exchange setting.
Funding Source(s): CWF
♦ Time is Money: The Value of Time Spent Waiting
for Healthcare in the United States
Julia Prentice, Ph.D.; Steven Pizer, Ph.D.
Presented by: Julia Prentice, Ph.D., Health Scientist,
Health Care Financing & Economics, VA Boston Health
Care System, 150 South Huntington Avenue (152H),
Boston, CO 02130, Phone: (857) 364-6057, Email:
Julia.Prentice@va.gov
Research Objective: The market for healthcare
services in the United States reconciles the demand for
services with existing supply in two ways. First, prices
for services can adjust, either directly or indirectly
through insurance premiums. In principle this
adjustment would be sufficient to produce equilibrium
except that there are limits on the flexibility of prices due
to fee schedules imposed by law. The resulting
imbalances between supply and demand are resolved
by waiting times. Lately, waiting times for a variety of
patient populations have significantly increased and the
Institute of Medicine highlights decreasing waiting times
as one of six ways to improve the quality of healthcare in
America. An important aspect of waiting times as an
allocation mechanism is that their burden is not
distributed evenly. Individual patients may choose to
pay more for care that is provided more quickly. This
study is the first to use data from the United States to
measure the sensitivity of health care financing choices
to waiting times. We use the results to calculate
premium elasticities of waiting for several important
subgroups, identifying a potentially important channel
through which disparities in the quality of healthcare
propagate.
Study Design: We use Medicare Current Beneficiary
Survey (MCBS) data, focusing attention on a sample of
veterans who face the choice of waiting for VA care or
paying more out-of-pocket for shorter waits in Medicare.
We supplement MCBS with VA waiting time data. Our
statistical model has two parts, estimated
simultaneously. The first part predicts how much
veterans rely on VA care as a function of VA wait times.
The second part models Medicare financing choices as
a function of VA reliance, Medicare premiums, and
coverage options. Medicare choices include: 1)
Medicare fee-for-service, 2) Medicare HMOs with or
without prescription drug coverage and 3) Medigap plans
with or without prescription drug coverage.
Population Studied: Veterans in 20001-2003 MCBS
data.
Principal Findings: There is a significant and negative
relationship between VA wait time and VA reliance.
Individuals who rely heavily on VA care are less likely to
choose Medicare choices with higher premiums and
better coverage. Non-disabled individuals and
nonwhites are more likely to continue to rely on the VA
as wait times increase.
Conclusions: Patients consider both time and money
when choosing among health care options and will pay
more for health care services to avoid long waits.
Depending on their needs, individuals prioritize the
time/cost tradeoff differently. For example, disabled
individuals in this study are willing to pay more for
shorter waits.
Implications for Policy, Delivery or Practice: Wait
times have been increasing for a variety of patient
populations. The rationing of health care through wait
times may increase further if new health care reforms
attempt to substantially reduce health care costs.
Certain sub-groups are at greater risk of experiencing
long wait times resulting in degraded quality of care.
Policymakers should consider the mix of public and
private financing options and the differential effects of
waiting times on vulnerable populations when assessing
the cost control components of health care reform.
Funding Source(s): RWJF
♦ The Geographic Distribution of Retail Clinics & the
Socio-Demographic Characteristics of the
Communities They Serve
Rena Rudavsky, B.S.; Craig Pollack, M.D.; Katrina
Armstrong, M.D.; Ateev Mehrotra, M.D.
Presented by: Rena Rudavsky, B.S., Research
Assistant, Policy Sciences, RAND Corporation, 1200
South Hayes Street, Arlington, VA 22202-5050, Phone:
(703) 413-1100, Email: rrudavsk@rand.org
Research Objective: As a rapidly growing new model of
care in the United States, retail clinics have been the
subject of much controversy. Located physically within a
retail store, retail clinics provide simple acute and
preventive care services for a fixed price and without an
appointment. It is hoped that retail clinics can improve
access to care for patients in general, and the
underserved in particular. To better understand their
potential to improve access, we describe (1) where retail
clinics have opened in the US, (2) examine variation in
clinic ownership, (3) identify what fraction of the
population live within a short driving distance of a clinic,
and (4) the determine socio-demographic characteristics
of the communities in which they operate.
Study Design: We created an inventory of all retail
clinics in the US and using geospatial imaging software
determined the proportion that are in medically
underserved areas and urban areas as defined by the
US Census. We defined a catchment area around each
clinic by mapping “service areas” of five and ten-minute
driving distances to the clinics. Using US Census data,
we compared the socio-demographic characteristics of
the population within and outside of these retail clinic
catchment areas.
Population Studied: As of August 2008, 41 different
organizations operated 982 retail clinics in 32 states.
Principal Findings: Over half of the retail clinic
operators (24) are existing physician and hospital
systems (e.g. Mayo Clinic, Intermountain Healthcare,
Geisinger) though they currently operate relatively few
clinics (109, 11%). Two operators, CVS and Walgreens,
dominate the market (operate 690 clinics, 70%). The
majority (88%) of retail clinics were located in an urban
area and we estimate that 13% and 36% of the US
urban population lives within a 5-minute and 10-minute
driving distance from a retail clinic. The fraction of the
population within a short drive of a retail clinic is much
higher in some urban areas such as Nashville (57% 5minute, 94% 10-minute) and Minneapolis-St. Paul (51%,
96%). The urban population living within 5-minute driving
distance from a retail clinic has a higher median
household income ($52,849 vs. $46,080) and is better
educated (33% vs. 25% with a college degree). In a
sub-analysis of chain drugstores (i.e. CVS, Walgreens)
in six counties, stores with a retail clinic were less likely
to be located in a medically underserved area compared
to stores without retail clinics.
Conclusions: As of August 2008 13% of the US urban
population lives within a 5 minute drive of one of the
almost 1000 retail clinics in the US and this fraction is
much higher in some cities. We find that relative to the
overall urban population, the population that can easily
access a retail clinic is less likely to be poor and
medically underserved.
Implications for Policy, Delivery or Practice: Already
a significant fraction of the US population can easily
access a retail clinic. The populations that can access a
clinic is less likely to be underserved and this will limit
the ability of retail clinics to improve access for those
most in need.
Disparities: Policy
Chair: Anne Beal
Sunday, June 28 * 2:30 p.m.- 4:00 p.m.
♦ Racial & Socioeconomic Health Disparities:
Investigating the Roles of Policy-Driven Inequities &
Chronic Stress
Holly Avey, Ph.D., M.P.H.
Presented by: Holly Avey, Ph.D., M.P.H., Senior
Research Associate, Georgia Health Policy Center,
Georgia State University, P.O. Box 3992, Atlanta, GA
30302-3992, Phone: (404) 413-0291, Email:
havey@gsu.edu
Research Objective: Disadvantaged racial and
socioeconomic groups have disproportionately higher
rates of many stress-related illnesses. This study used a
biopsychosocial model to investigate the a priori theory
that exposure to the persistent social stress of
institutionalized inequity affects the psychological
appraisal process, resulting in a biological stress
reaction that creates or exacerbates stress-related
illness. The study further investigated stress perceptions
of the policy-driven context to illuminate underlying
mechanisms of race and class discrimination, such as
social closure – when social and economic opportunities
are restricted for certain groups, and relative deprivation
– when certain groups perceive that they are relatively
deprived of resources compared to others.
Study Design: Surveys were administered to assess
the variance in stress scores accounted for by race and
SES and the variance in stress-related illness accounted
for by exposure to stressors and perceived stress. A
sub-set of each population used the photovoice
technique and participated in focus groups to assess
how mechanisms of discrimination are perceived to
contribute to chronic stress for different racial and
socioeconomic groups. Participants took pictures of their
sources of stress, then selected pictures to discuss
during focus groups. Participants were asked about their
psychological assessments of the stressors (perceived
control, task engagement, and perceived resources) and
how people from different racial/economic groups might
have answered the same questions. Multiple regression
analyses were conducted to analyze quantitative data,
while pile sorting and inductive analysis were used to
analyze qualitative data. Quantitative and qualitative
data were then triangulated.
Population Studied: A convenience sample of 310 lowand middle-SES Blacks and low- and middle-SES
Whites was recruited from doctor’s offices in a large
metropolitan area of the Southeast.
Principal Findings: Race was not found to have an
influence on stress scores or stress-related illnesses
previously known to display racial disparities for this
group. Low-socioeconomic status was associated with
higher exposure to traumatic events, higher total stress
exposures, and higher levels of perceived stress. Higher
perceived stress was further found to be associated with
higher stress-related illness burden, especially as it
relates to hypertension, depression, and anxiety.
Qualitative data revealed that differential exposures and
stress appraisals are a result of institutionalized class
discrimination which limits social and economic
resources for housing, transportation, physical and
behavioral health care, and legal representation for lowSES populations.
Conclusions: Results confirmed the a priori theory that
low-SES groups are exposed to more stressors and
have higher levels of perceived stress and stress-related
illness than middle-SES groups, but did not confirm the
same to be true for Blacks when compared to Whites. It
is possible that historical mechanisms of institutionalized
race discrimination have resulted in socioeconomic
circumstances that make SES more relevant as a
stressor for Blacks today. The policy-driven context of
social and economic resources results in perceptions of
social closure and relative deprivation for low-SES
groups.
Implications for Policy, Delivery or Practice: Policies
that limit or restrict social and economic resources or
result in inequitable opportunities for low-SES
populations can result in social closure and relative
deprivation. Such policies and the psychological
assessments they trigger may be a root cause of many
SES-related health disparities.
♦ Medicare Managed Care & Primary Care Quality:
Examining Racial/Ethnic Effects Across States
Jayasree Basu, Ph.D., M.B.A.
Presented by: Jayasree Basu, Ph.D., M.B.A., Senior
Economist, Health & Human Services, Agency for
Healthcare Research & Quality, 540 Gaither Road,
Rockville, MD 20850, Phone: (301) 427-1579, Email:
jayasree.basu@ahrq.hhs.gov
Research Objective: Medicare Modernization Act of
2003 ushered in higher federal payments to managed
care companies and sparked a renewed interest in
Medicare managed care. Medicare spends about $10
billion more each year on beneficiaries enrolled in the
plans, known as Medicare Advantage (MA), but there is
little data to show added value worth the extra
investment. One key understudied topic in this area is
the program’s effectiveness in reducing racial and ethnic
disparities in quality of health care delivery and access.
The study will assess the role of MA plans in providing
quality primary care in comparison to FFS Medicare in
three states (NY, CA, FL) across three racial ethnic
groups (White, African American, and Hispanic). The
performance will be measured in terms of providing
better quality of primary care, as defined by lowering the
risks of preventable (ACSC) hospital admissions.
Managed care plans can directly reduce preventable
hospitalizations by making more primary and preventive
services available to their constituents. Accordingly, a
lower rate of preventable hospitalization has been
proposed as an indicator of better health plan
performance.
Study Design: Using 2004 hospital discharge data
(HCUP-SID) for three states, a multivariate cross
sectional design is used with individual admission as the
unit of analysis. ACSC admissions are compared with
“marker” admissions which are urgent and non-elective.
MA plan enrollment is used as a binary individual level
variable, with Medicare FFS as the default category. We
hold constant patient and area characteristics associated
with two types of hospital admissions so that we can
isolate the impacts of MA plan enrollment using
multivariate logistic regression models, estimated
separately for each state and by each of three racial
ethnic groups. Area characteristics are defined by local
area units known as primary care service area (PCSA)of
patient's origin, validated in previous research as natural
markets for primary care. To assess whether MA
enrollment made a statistically significant difference in
racial/ethnic disparities, a combined model across races
in each state is also used.
Population Studied: Elderly (65 and above) Medicare
enrollees hospitalized for prevantable and marker
conditions in three states.
Principal Findings: While MA plans were found to
reduce preventable hospitalizations relative to marker
admissions in all three states, the racial/ethnic effects
varied by state. Finding by racial and ethnic subgroups
by state indicate that in CA, white MA patients were 18%
less likely (p<.01) than white FFS patients to have a
preventable admission, while blacks and Hispanics were
respectively 30% and 29% (both p<.01) less likely than
their FFS counterparts to have preventable
hospitalizations. In FL, blacks and Hispanic MA patients
were, respectively, 18% and 25% less likely (Odds
ratio(OR)= 0.82,and 0 .75 ) than their FFS counterparts,
and relative to white MA versus white FFS patients(OR=
0.89). The combined model showed the differences
between whites and blacks to be statistically significant
in CA and between whites and Hispanics to be
statistically significant in both CA and FL. In NY, MA
enrollees in all three racial groups appeared to have had
fewer preventable hospitalizations (OR: whites=.93,
Black= .98, Hispanic.85), although differences across
racial groups were not statistically significant.
Conclusions: The study shows that MA plans had some
beneficial impacts in terms of improving quality of
primary care by reducing preventable hospitalizations.
The benefit also spilled over to different racial and ethnic
subgroups, and in some states, e.g. CA and FL, resulted
in significant reductions in racial and ethnic differences
in the risks of preventable hospitalizations.
Implications for Policy, Delivery or Practice: Since
many previous studies reported that minorities have
higher risks of preventable hospitalizations, a greater
reduction of such risks among minority subgroups than
among whites indicate a favorable role of MA plans in
achieving racial/ethnic equalities.
Funding Source(s): AHRQ
♦ Hospital Collection & Use of Patient Race,
Ethnicity & Language Data
Christal Ramos, M.P.H.; Karen Jones, M.S.; Marsha
Regenstein, Ph.D.
Presented by: Christal Ramos, M.P.H., Research
Assistant, Health Policy, The George Washington
University, 2021 K Street, NW, Suite 800, Washington,
DC 20006, Phone: (202) 994-8664, Email:
christal.ramos@gwumc.edu
Research Objective: The collection of race, ethnicity
and language data is important for hospitals to be able to
identify and address potential disparities among their
patients. This study examined the extent to which
hospitals collect and use these types of data and
whether over time collection has increased.
Study Design: Data were obtained and compared from
telephone surveys of hospital Chief Financial Officers
(CFO) for the years 2005 and 2007. The surveys were
developed by GW researchers and reviewed by external
experts in the field. Descriptive statistics were
generated on hospital characteristics (ownership,
teaching status, and bedsize) and on policies and
practices surrounding the collection and use of race,
ethnicity and language data.
Population Studied: In 2005, 501 hospital CFOs from
non-federal, acute care hospitals completed the survey
for a response rate of 46%, and 547 hospital CFOs
completed the survey in 2007 for a response rate of
52%. Hospitals were randomly selected from the
American Hospital Association database. Survey results
were weighted by hospital governance and teaching
status to reflect the make-up of the American hospital
industry.
Principal Findings: The majority of hospitals collect
information on the race of their patients and about half
collect ethnicity and/or language. The collection of race
and language data increased from 78% and 50% of
hospitals, respectively, in 2005 to 81% and 52% in 2007.
Neither increase was statistically significant. Collection
of ethnicity data was significantly lower over that period,
dropping from 51% in 2005 to 42% in 2007 (p=.005). In
2007, only 7% of hospitals that collected these data
reported using it to identify disparities by the race or
ethnicity of the patient and even fewer (3%) used it to
identify disparities by language spoken.
Conclusions: Hospital race, ethnicity and language
data collection did not significantly progress between
2005 and 2007. Although most hospitals have
information on the race, ethnicity and language of their
patients, very few hospitals have used this data to
identify disparities.
Implications for Policy, Delivery or Practice: Policies
and tools are needed to help hospitals progress in
collecting this important data, as well as in using the
data to identify and address disparities. Progress is
necessary for our nation’s hospital industry to move
towards providing more equitable care by targeting
areas for improvement and developing interventions that
are most appropriate for the patient populations.
Funding Source(s): RWJF
♦ Has Pay-for-Performance Decreased Access for
Minority Patients?
Andrew Ryan, M.A., Ph.D.
Presented by: Andrew Ryan, M.A., Ph.D., Postdoctoral
Fellow, Heller School of Social Policy & Management,
Brandeis University, 415 South Street, Mail Stop 035,
Waltham, MA 02454, Phone: (781) 736-3954, Email:
andrew@brandeis.edu
Research Objective: To examine whether the CMS and
Premier Inc. Hospital Quality Incentive Demonstration
(PHQID), a hospital-based pay-for-performance (P4P)
and public quality reporting program beginning in Q4 of
2003, caused participating hospitals 1) to avoid treating
minority (non-white) patients diagnosed with AMI, heart
failure, and pneumonia and 2) to avoid providing CABG
to minority patients diagnosed with AMI.
Study Design: We use 100% Medicare inpatient claims,
Denominator Files, and Provider of Service Files from
2000-2006. To evaluate the avoidance of minority
patients with AMI, heart failure, and pneumonia, we
identify hospital referral regions (HRRs) in which PHQID
hospitals operated and identify Medicare patients living
in these HRRs. Using individual-level logit models, we
model the probability that patients living in these HRRs
receive care at PHQID hospitals as a function of
beneficiary characteristics (including severity), minority
status, HRR fixed effects, an indicator for the PHQID
period (after Q3 in 2003), and an interaction between
minority status and the PHQID period indicator.
Separate models are estimated for each diagnosis. A
negative coefficient for the interaction term would
indicate that minority patients living in HRRs served by
PQHID hospitals became less likely to receive care at
these hospitals after the PHQID began.
To examine whether the PHQID led to a reduction in
CABG for minority patients diagnosed with AMI, using
individual-level logit models, we model the probability of
receiving CABG for all Medicare patients diagnosed with
AMI from 2000-2006. We estimate the conditional
probabilities that non-Hispanic white and minority
patients receive CABG (controlling for patient
characteristics and hospital fixed effects) in hospitals
participating, and not participating, in the PHQID before
and after the commencement of the PHQID.
Population Studied: For the AMI, heart failure, and
pneumonia analysis, 574,661 admissions from 335,450
Medicare beneficiaries diagnosed with these conditions
who lived in one of the 119 HRRs in which PQHID
hospitals operated between 2000-2006. For the CABG
analysis, 2,223,280 AMI admissions from 1,761,494
Medicare beneficiaries in 4,538 acute care hospitals
between 2000-2006.
Principal Findings: For minority patients living in HRRs
served by PHQID hospitals, the probability of being
treated in a PHQID hospital decreased by 3.0
percentage points for AMI (p < .05) but did not decrease
for heart failure or pneumonia. Results from the CABG
analysis indicate that, in the post-PHQID implementation
period, the probability of minority patients receiving
CABG increased by 0.31 percentage points at nonPHQID hospitals (p > .10) but decreased by 0.17
percentage points at PHQID hospitals (p > .10). The
difference-in-differences is 0.48 percentage points (p >
.10).
Conclusions: The PHQID appears to have resulted in
limited avoidance of minority patients with AMI but has
not resulted in the avoidance of minority patients with
heart failure or pneumonia and has not decreased the
provision of CABG to minority patients with AMI.
Implications for Policy, Delivery or Practice: The
predominately process-based performance measures
used in the PHQID may have limited the incentives of
hospitals to avoid minority patients.
Funding Source(s): Jewish Healthcare Foundation
Disparities: Methods
Chair: Ninez Ponce
Sunday, June 28 * 4:30 p.m.- 6:00 p.m.
♦ Conducting Multilevel Model Health Disparities
Research in Complex Survey Data with Design
Weights
Adam Carle, M.A., Ph.D.
Presented by: Adam Carle, M.A., Ph.D., Assisstant
Professor, Psychology, University of North Florida, 1
UNF Drive, Jacksonville, FL 32224, Phone: (904) 6203573, Email: adam.carle@unf.edu
Research Objective: Multilevel models offer health
services researchers a unique approach to
understanding individual and contextual health
disparities determinants. Large scale survey data offer
premier opportunities to conduct multilevel modeling
studies. However, little summarized guidance exists with
regard to fitting multilevel models in complex survey data
with design weights. Simulation work suggests that
analysts should scale design weights using two methods
and fit the multilevel models using unweighted and
scaled-weighted data. This research examines the
performance of this advice across a variety of multilevel
models and software programs and provides practical
summary advice for health services researchers seeking
to examine the influence of individual and contextual
variables on health disparities.
Study Design: Using data from the 2005-2006 National
Survey of Children with Special Health Care Needs (NSCSHCN) that collected data from children clustered
within states, I examine the performance of scaling
methods across outcome type (categorical vs.
continuous), model type (level-1 only: individual only;
level-2: contextual; or combined: individual and
contextual), and software (Mplus, MLwiN, and
GLLAMM).
Population Studied: The National Survey of CSHCN
provides state- and national-level data on the prevalence
of special health care needs and their impact on children
and their families. Children (n = 40,723) ranged in age
from 0 to 18 years. Design weights adjust for unequal
probability of selection and make the data representative
of children nationally and within states.
Principal Findings: Scaled estimates and standard
errors differed slightly from unweighted analyses,
agreeing more with each other than with unweighted
analyses. However, observed differences were minimal
and did not lead to different inferential conclusions.
Likewise, results demonstrated minimal differences
across software programs, increasing confidence in
results and inferential conclusions independent of
software choice. Scaled and unweighted estimates and
standard errors all differed from unscaled weighted
results.
Conclusions: If including weights, health services and
health disparities researchers should scale the weights
and use software that properly includes the scaled
weights in the estimation. Researchers should not
include raw, unscaled weights in any analyses.
Implications for Policy, Delivery or Practice:
Multilevel models let health disparities researchers
understand individual and contextual level predictors of
health disparities. They also allow researchers the ability
to partition variance in health disparities into individual
and contextual level components. Large scale surveys
offer health services researchers tremendous
opportunities to conduct multilevel modeling studies and
advance health disparities research and evaluate
effective policy and practice. However, in order to
properly use large scale survey data with design
weights, researchers must use the practices described in
this research. Otherwise, they will achieve erroneous
results.
♦ Comparing Methods of Racial & Ethnic Disparities
Measurement Across Different Settings of Mental
Health Care
Benjamin Cook, Ph.D., M.P.H.; Thomas McGuire, Ph.D.;
Kari Lock, M.S.; Alan Zaslavsky, Ph.D.
Presented by: Benjamin Cook, Ph.D., M.P.H.,
Instructor/Research Associate, Center for Multicultural
Mental Health Research, Harvard Medical School, 120
Beacon Street, 4th Floor, Somerville, MA 02143, Phone:
(617) 503-8449, Email: bcook@charesearch.org
Research Objective: Numerous studies document
racial and ethnic disparities in mental health access and
utilization. However, the ability to track improvement in
this area is hindered by the varying methods and
disparity definitions used in previous research. We use
the Institute of Medicine (IOM) definition of disparities,
and apply two “IOM-concordant” empirical methods, to
assess access and expenditure disparities in total,
outpatient, and prescription drug mental health
expenditure.
Study Design: Two IOM-concordant methods were
compared in the context of non-linear models: the rank-
and-replace and propensity score-based methods. The
first step in operationalizing the IOM methods was to
model expenditure distributions, using a two-part GLM to
account for the large number of zeros and skewness.
Second, the properties of rank and propensity scores
were used to create counterfactual distributions of
minority individuals with white mental health status.
Next, mean race/ethnicity group predictions were
generated using model coefficients and post-adjustment
covariate values, and disparities were calculated for both
the probability of having any expenditure and the level of
expenditure among those with positive expenditures.
Multiple imputation methods account for missing data.
Population Studied: A nationally representative study
population of non-Hispanic whites, Blacks, and
Hispanics was created from the five most recent years
(2002-2006) of the Medical Expenditure Panel Survey.
This dataset was merged with mental health status and
citizenship information obtained from the National Health
Interview Survey.
Principal Findings: Racial/ethnic disparities were
significant for all three expenditure variables. We found
that Black-White and Latino-White disparities were
significant for the probability of having any expenditure in
all dependent variables (the first part of the two-part
models) but, in almost all cases, not in the level of
expenditure given access to care. The exceptions were
that we found, among positive spenders, Latino-White
disparities in total and outpatient expenditures. Overall
predicted expenditures were similar among propensity
score-based and rank-and-replace methods, but
predictions differed (in compensating directions) in parts
one and two of the two-part models. This divergence
stems from the two methods’ differing treatment of racehealth interaction variables in the adjustment of mental
health status.
Conclusions: Using the IOM definition of healthcare
disparities, we find significant Black-white and Hispanicwhite disparities in mental health care expenditures.
Disparities in the probability of any use appear to be
driving overall disparities in overall mental health care,
outpatient mental health care, and prescription drug
expenditure.
Implications for Policy, Delivery or Practice:
Disparities in access to mental health care imply that
improved efforts are needed at outreach and
destigmatization of mental health services among racial
and ethnic minority populations. In these data, both the
propensity score-based method and the rank and
replace method were precise and adequate methods
implementing the IOM definition of disparity. However,
researchers using these methods should be aware of the
mathematical differences inherent in the methods.
Funding Source(s): NIMH
♦ Using Medicare CAHPS Data to Validate Indirect
Estimation of Racial/Ethnic Disparities
Marc Elliott, Ph.D.; David Klein, M.S.; Allen Fremont,
M.D.; Nicole Lurie, M.D., M.S.P.H.
Presented by: Marc Elliott, Ph.D., Senior Statistician,
Economics & Statistics, RAND Corporation, 1776 Main
Street, Santa Monica, CA 90407, Phone: (310) 3930411, Email: elliott@rand.org
Research Objective: To validate use of indirect
race/ethnicity data to assess racial/ethnic differences in
health care measures, using Medicare CAHPS data.
Study Design: Previous work has shown that Bayesian
methods of indirectly estimating race/ethnicity from
residential address and surname (utilizing publiclyavailable US Census files) provide highly accurate
estimates of race/ethnicity among commercially-insured
samples, with an average area under the ROC curve of
0.93. In the current study, we use nationally
representative 2007 Medicare CAHPS survey and
administrative data to replicate these commercial
evaluations and to validate the use of indirect estimates
to assess racial/ethnic differences in health care
measures. To measure racial/ethnic differences, we fit
linear models predicting 13 CAHPS measures of patient
experience from measures of Hispanic, Black, API,
AI/AN, Multiracial, or White race/ethnicity, using White
as the reference group. One series of these models
uses self-reported indicators of race/ethnicity; a second
series uses a vector of indirectly estimated probabilities
of race/ethnicity. Additional versions of these models
add sociodemographic covariates known to be related to
the CAHPS measures. Accurate indirect estimation of
racial/ethnic disparities requires that the errors in
predictions of race/ethnicity not be strongly correlated
with the health measures of interest. We evaluate the
extent to which this assumption holds, comparing
indirect racial/ethnic disparity estimates (using only
surname and address) to disparities estimated in the
same Medicare beneficiaries using a gold standard of
self-reported race/ethnicity.
Population Studied: 257,518 community-dwelling
Medicare beneficiaries participating in the 2007
Medicare CAHPS survey for whom surname, address,
and self-reported race/ethnicity was available.
Principal Findings: Performance of indirect methods in
predicting race/ethnicity was similar in this Medicare
population to what was previously found in commercial
populations. Indirect estimates of differences between
Blacks, Hispanics, and APIs and non-Hispanic Whites
on CAHPS measures were very close to estimates
based on self-reported race/ethnicity, with average
absolute differences of 0.4 for Black/White, 0.6 for
Hispanic/White, and 0.9 for API/White on a 0-100 scale.
The sign of the indirect disparity estimate was the same
as for self-report in 39 of 39 instances and statistical
significance at the 0.05 threshold was the same in 38 of
39 instances. Performance for estimating AI/AN/White
and multiracial/White disparities is markedly poorer.
Adding sociodemographic predictors of CAHPS
outcomes slightly reduces errors in indirect estimates of
racial/ethnic disparities.
Conclusions: Current Bayesian indirect estimation
methods predict race/ethnicity well in Medicare
beneficiary populations and can be used as reliable and
valid means of estimating racial/ethnic disparities for
Blacks, Hispanics, APIs, and Whites in patient
experience measures, yielding disparity estimates that
are very similar to estimates based on self-reported
data.
Implications for Policy, Delivery or Practice: Results
suggest that indirect estimation of health measures
using current Bayesian approaches to estimating
race/ethnicity may have utility in a variety of settings,
opening the door to estimating racial/ethnic disparities
for many different health outcomes and process
measures available in administrative data files where
self-reported race/ethnicity is not available.
Funding Source(s): CMS
♦ Are there Measurement Inconsistencies by Race
on the Massachusetts Youth Screening Instrumentversion 2 that Cause a Disparity in which Juvenile
Offenders Receive Mental Health Services?
Henrika McCoy, M.S.W., M.J., Ph.D.
Presented by: Henrika McCoy, M.S.W., M.J., Ph.D.,
Assistant Professor, Graduate School of Social Work,
Boston College, McGuinn 308, 140 Commonwealth
Avenue, Chestnut Hill, MA 02467, Phone: (617) 5522209, Email: mccoyh@bc.edu
Research Objective: The Massachusetts Youth
Screening Instrument – version 2 (MAYSI-2) is used
throughout juvenile justice systems in 47 states to
identify which youth need additional mental health
assessment. Research shows that courts are more likely
to refer African American youth to correctional facilities
and Caucasian youth to psychiatric services. Hundreds
of thousands of juveniles with psychiatric disorders,
many of whom are African American, enter the juvenile
justice system each year. Therefore, it is critical that
screening instruments, such as the MAYSI-2, be free of
racial bias. There is recent evidence that minority youth
interpret MAYSI-2 items differently, possibly resulting in
a disparity in referrals for service. This study uses mixed
methods to determine what factors may contribute to
those differences.
Study Design: Structured interviews were conducted to
assess the following variables that might mediate the
relationship between race and MAYSI-2 domains:
experiences with discrimination, reading level, mental
health service use history, and social desirability. Path
analysis, using MPLUS, was the analytic tool used to
assess mediation. Semi-structured cognitive interviews
were conducted to explore if there were differences, by
race, in how a juvenile’s cognitive processes influences
their responses to the MAYSI-2 items and administration
process. Using a grounded theory approach, interview
responses were separated by question, grouped by
race, and the relationships were examined to identify
potential themes.
Population Studied: Seventy African American and 20
Caucasian male juvenile detainees, ages 12 to 17, from
two Midwestern detention facilities participated. All 90
participants engaged in the structured interview; 16 of
the 90 participated in the semi-structured cognitive
interview.
Principal Findings: The effect of race on all six MAYSI2 domains was mediated by experiences with
discrimination, reading level, mental health service use
history, and social desirability; race had a direct effect on
the Somatic Complaints domain. The qualitative results
showed that African American and Caucasian youth
interpreted the concept of time and symptoms differently,
resulting in inaccurate responses.
Conclusions: There are measurement issues related to
race that result in different MAYSI-2 scores and impact
how juveniles interpret the MAYSI-2 items and
administration process. These issues can lead to racial
disparities in referrals for services and must be
considered when administering the MAYSI-2 and
interpreting scores.
Implications for Policy, Delivery or Practice: The
experiences of this population must be considered
because they may impact symptom presentation.
Complementing the MAYSI-2 with additional screening
tools, known to identify psychiatric concerns with the
general adolescent population, could also strengthen the
MAYSI-2’s results. During MAYSI-2 administration,
providing a specific time frame or landmarks and
alternative words or definitions could also potentially
increase reliability. MAYSI-2 administrators should be
made aware of possible suspicion by youth, provided
strategies for administration, and advised about what to
share with a juvenile about the MAYSI-2’s purpose.
Finally, practitioners must increase their awareness
about how symptoms may differ from expectations and
staff must increase their knowledge of mental health
needs.
Funding Source(s): Fahs Beck Fund for Research and
Experimentation
Disparities: Interventions
Chair: Hector Rodriguez
Monday, June 29 * 11:30 a.m.-1:00 p.m.
♦ Using Community Health Workers to Reduce
Disparities in Diabetes Care
Lee Hargraves, Ph.D.; Celeste Lemay, R.N., M.P.H.;
Joan Pernice, R.N.C., M.S.; Warren Ferguson, M.D.
Presented by: Lee Hargraves, Ph.D., Research
Associate Professor, Family Medicine & Community
Health, Univesity of Massachusetts Medical School, 55
Lake Avenue North, Worcester, MA 01655, Email:
lee.hargraves@umassmed.edu
Research Objective: Community health workers
(CHWs) have gained prominence as members of the
health care workforce, proliferate in communities of
racial and ethnic diversity, and serve as liaisons between
individuals and the health care system. This project
evaluates the impact of using formally trained CHWs in
community health centers (CHCs) to assist patients
living with diabetes in their efforts to improve glycemic
control and reduce risk of cardiovascular disease, as
measured by self management goal setting, number of
hemoglobin A1c per year, measurement of low-density
lipoprotien, and measure of blood pressure.
Study Design: This project selected 12 community
health centers and match paired them by population
served, geographic location, and progress in a statewide health disparities collaborative. Utilizing focused
groups and interviews, we evaluated CHW curriculum
and training activities. To assess CHWs activities with
patients, we used detailed encounter forms that can be
linked to patient clinical measures. Finally, to evaluate
CHW integration onto the health care team, we
conducted separate focus groups with CHWs and their
supervisors.
Population Studied: Six pairs of CHCs were
randomized to an intervention of enhanced patient
support by CHWs. Half the sites received the
intervention of a trained CHW. CHWs worked with
patients for 13 months to improve self-management of
diabetes, improve clinical outcomes, and reduce
disparities. Each CHC, which differed in racial and ethnic
population served, provided clinical data on patients
participating in the disparities collaborative.
Principal Findings: CHWs were more likely to have
encounters with patients that had been seen in the CHC
at least once a year in the previous 3 years than with
patients who were less connected to regular care.
Patients with a CHW were more likely to have a
documented self-management goal than patients
receiving care at Control sites. Patients that had
Encounters with CHWs were more likely to have one
HbA1c in the last year than patients that did not have an
Encounter, 93 versus 70 percent. Ethnic differences in
self-management goal setting were mixed at baseline,
with significant improvements among African American,
Latino, and Non-Hispanic white patients in centers with
CHWs.
Conclusions: Using CHWs to empower patients to set
culturally appropriate goals regarding self management
of their diabetes, as well as assisting patients in
navigating the health care system and accessing
resources, will help to reduce health disparities. CHWs
appear to be effective in assisting CHC patients to set
self management goals and in assisting patients with
routine testing regarding their diabetes care.
Implications for Policy, Delivery or Practice: CHWs
with enhanced training were integrated onto existing
health care teams to reduce disparities in care in a lowincome, racially/ethnically diverse population. Results
from this intervention support the use of trained CHWs to
assist in the reduction of health disparities and can
inform future efforts to reduce health disparities.
Funding Source(s): RWJF
♦ Changes in Healthcare Disparities Following the
Implementation of a Multifaceted Quality
Improvement Initiative
Muriel Jean-Jacques, M.D., M.A.; Stephen Persell, M.D.,
M.P.H.; Romana Hasnain-Wynia, Ph.D.; Jason
Thompson, B.A.; David Baker, M.D., M.P.H.
Presented by: Muriel Jean-Jacques, M.D., M.A.,
Assistant Professor, Internal Medicine, Northwestern
University Feinberg School of Medicine, 750 South Lake
Shore Drive, 10th Floor, Chicago, IL 60611, Phone:
(312) 503-9642, Email: mjean@nmff.org
Research Objective: To assess the impact of a
comprehensive, multifaceted quality improvement (QI)
project on disparities in the quality of care in a large,
ambulatory care practice.
Study Design: In February 2008, the UPQUAL project
initiated a comprehensive QI intervention that was
integrated into the electronic health record system
(EHRS) and targeted 18 measures of preventive and
chronic disease care. The intervention consisted of: 1)
point of care electronic alerts for providers; 2)
standardized ways for providers to enter medical and
patient reasons into the EHRS for why quality measures
were not met; 3) mailing monthly lists of patients not
receiving recommended medication to each provider;
and 4) focused outreach to patients who refuse or
cannot afford preventive services. For each measure, we
compared multivariate logistic regression models using
data from January 1, 2008 and December 1, 2008 to
identify which demographic or SES variables were
associated with quality deficiencies before and after the
QI initiative. For each model, the dependent variable
was the presence of a quality deficit and the
independent variables were race/ethnicity, gender, age,
insurance, and zip code-level SES. Race/ethnicity,
gender, age, and insurance are recorded in the EHRS
by registration staff. SES was imputed using U.S.
Census data from 2000 on the median household
income and proportion of high school graduates in the
patient’s zip code.
Population Studied: This study was conducted in an
academic general internal medicine practice with 37
attending physicians serving 43,900 patients.
Principal Findings: At baseline, we found 31 disparities
by at least one demographic or SES variable for 15 of
the quality measures. At follow up most disparities were
eliminated. For example, women were more likely than
men to have a deficiency in prescription of lipid lowering
therapy for coronary heart disease at baseline (OR 1.8,
95% CI 1.2-2.8, absolute disparity 7.1%), while there
was no disparity at follow up (OR 1.5, 95%CI 0.9-2.4,
absolute disparity 2.4%). Eight measures had at least 1
persistent disparity. For example, black patients were
more likely than white patients to have a quality
deficiency for osteoporosis screening or treatment at
baseline (OR 1.8, 95% CI 1.4-2.4, absolute disparity
14.1%), and this persisted at follow up (OR 1.6, 95% CI
1.2-2.2, absolute disparity 10.6%). Importantly, 6
measures had at least 1 new disparity emerge over time.
For example, race was not significantly associated with
the odds of having a quality deficiency in breast cancer
screening at baseline (OR 1.2, 95%CI 0.9-1.5 for black
versus white women, absolute disparity 5.1%) but was at
follow up (OR 1.5, 95% CI 1.3-1.9, absolute disparity
9.5%).
Conclusions: Though intended to achieve high quality
care for all patients, generalized QI initiatives are not
always sufficient to achieve healthcare equity.
Improvement may occur across groups, but baseline
disparities between groups may remain. Furthermore, QI
initiatives may affect population groups within the same
practice differently, and new disparities may emerge.
Implications for Policy, Delivery or Practice: In
evaluating quality improvement efforts, it is important to
continuously monitor for healthcare disparities in order to
identify areas where more targeted disparity reduction
interventions are needed.
Funding Source(s): AHRQ
♦ What are Physicians Doing to Address Racial &
Ethnic Disparities in Health Care?
James Reschovsky, Ph.D.; Claire Gibbons, M.P.H.,
Ph.D.; Ellyn Boukus, M.A.
Presented by: James Reschovsky, Ph.D., Senior Health
Researcher, Center for Studying Health System Change,
600 Maryland Avenue, SW, Suite 550, Washington, DC
20024-2512, Phone: (202) 484-4233, Email:
jreschovsky@hschange.org
Research Objective: The 2002 IOM report “Unequal
Treatment: Confronting Racial and Ethnic Disparities in
Health Care” found that--among other factors--bias,
stereotyping and clinical uncertainty among healthcare
providers contribute to racial/ethnic disparities. The
panel offered recommendations directed at providers for
addressing disparities, including increased use of
interpreter services where needed, use of
multidisciplinary patient education and treatment teams,
greater provider training in culturally competent care,
and collection and reporting of data by patient race,
ethnicity, SES and language. This paper provides a
report card on progress in meeting these
recommendations among U.S. patient-care physicians.
Study Design: Descriptive analysis of national survey
data using the 2008 HSC Health Tracking Physician
Survey (N=4,720).
Population Studied: U.S. non-federal, patient-care
physicians in 2008.
Principal Findings: Among physicians with non-English
speaking patients, 56% provide interpreter services.
Interpreter use increases with the percent of minority
patients served. Of those providing interpretation, 45%
offer it in only one language. Four in ten physicians
report having attended education sessions on minority
health. Only 16% of physicians report using IT systems
that provide information on patients’ preferred language,
while 23% of physicians receive reports on the race,
ethnicity, and preferred language of their patients and
only 12% receive reports on the quality of care provided
to their patients of different racial/ethnic backgrounds.
Among physicians treating common chronic conditions,
a minority provide multidisciplinary patient education and
treatment teams and between a half and two-thirds of
physicians supply written patient education materials,
depending on the condition. However, among
physicians providing patient education materials, only
one half offer these materials in languages other than
English. All measures designed to address racial and
ethnic disparities described in this analysis exhibit a
strong relationship with practice size and type. Solo
physicians are least likely to take such actions. The
likelihood increases with physician group size and is
greatest among physicians in group/staff HMO,
community health clinic, and in hospital/medical school
settings. In part reflecting differences in practice settings,
PCPS are less likely than specialists to be in practices
using interpreters, but are more likely to have received
continuing education on minority health.
Conclusions: Although practices that predominantly
serve minority patients are most likely to have taken
steps recommended by the IOM report to address
racial/ethnic disparities, a large portion of minority
patients receive care from physicians who have failed to
take recommended actions to address racial and ethnic
disparities.
Implications for Policy, Delivery or Practice: Financial
and other incentives to encourage physician practices to
address both language and cultural barriers to care in
the clinical setting and the potential disparate treatment
of racial/ethnic groups should be considered. In
particular, efforts should focus on smaller physician
practices, where the costs of interpreter services and
health information technology may be prohibitive.
Funding Source(s): RWJF
♦ Cultural Competency Training & Performance
Reports to Reduce Racial Disparities in Diabetes
Care: A Randomized Controlled Trial
Thomas Sequist, M.D., M.P.H.; Garrett Fitzmaurice,
Sc.D.; Richard Marshall, M.D.; Shimon Shaykevich,
M.S.; Dana Gelb Safran, Sc.D.; John Ayanian, M.D.,
M.P.P.
Presented by: Thomas Sequist, M.D., M.P.H., Assistant
Professor, Division of General Medicine, Brigham &
Women's Hospital, 1620 Tremont Street, Boston, MA
02120, Phone: (617) 525-7509, Email:
tsequist@partners.org
Research Objective: Racial disparities in the quality of
diabetes care are well documented. Increasing physician
awareness of disparities and improving communication
with patients of different backgrounds may improve
diabetes outcomes among black patients.
Study Design: We conducted a randomized controlled
trial of cultural competency training and performance
feedback at 8 ambulatory health centers. Primary care
teams consisting of physicians and nurse practitioners
were randomly assigned to receive two days of cultural
competency training consisting of small group facilitated
discussions, community tours, and patient feedback. For
the subsequent 12 months, intervention clinicians
received monthly race-stratified performance reports that
highlighted white-black differences in achieving clinical
control of HbA1c (<7%), LDL cholesterol (<100 mg/dL),
and blood pressure (<130/80 mmHg) across the 8 health
centers and within their own patient panels; they also
received educational materials regarding effective crosscultural diabetes care. Clinicians were surveyed pre- and
post-intervention to assess awareness of racial
disparities in diabetes care, with response rates of 88%
and 83%, respectively. Primary study outcomes
assessed at 12 months included: 1) physician
recognition of racial differences in diabetes care within
their medical group, health center and patient panel; and
2) rates of achieving clinical control targets among black
patients, adjusted for clustering within primary care
teams. The study had greater than 80% power to detect
differences as small as 7.6% between black patients in
the intervention and control groups in the three
measures of disease control.
Population Studied: Subjects included 122 primary
care clinicians (91 physicians and 31 nurse practitioners)
caring for 7,557 adults with diabetes, including 2,699
(36%) black patients and 4,858 (64%) white patients.
Principal Findings: Patients´ mean age was 62 years,
49% were male, 58% had commercial insurance, and
35% were covered by Medicare. Among 60 clinicians
randomized to receive the intervention, 60% attended
the cultural competency training and all received the
performance reports and educational materials. At
baseline, significant white-black differences were evident
in achieving HbA1c <7% (46% vs 40%), LDL cholesterol
<100 mg/dL (55% vs 43%), and blood pressure <130/80
mmHg (32% vs 24%) (all p<0.05). Intervention clinicians
were more likely than control physicians to acknowledge
the presence of racial disparities in the 8 health centers
as a whole (78% vs 57%, p=0.04) and also in their local
health center (70% vs 51%, p=0.06), but not with
reference to their own patient panel (60% vs 43%,
p=0.31). Among black patients of intervention and
control clinicians, no difference was noted in achieving
targets for HbA1c control (48% vs 45%, p=0.36), LDL
cholesterol control (48% vs 49%, p=0.68), or BP control
(23% vs 25%, p=0.73).
Conclusions: Cultural competency training combined
with race-stratified performance reports increased
clinicians´ awareness of racial disparities in diabetes
care within the medical group, but did not improve
clinical outcomes among black patients.
Implications for Policy, Delivery or Practice: Future
research is needed to understand what additional efforts
are needed beyond changing provider attitudes to
improve diabetes care for minority patients.
Funding Source(s): RWJF
♦ Race & Ethnicity Differences in Use of
Complementary or Alternative Medicine (CAM) & in
Communications with Medical Providers about CAM
Use
Sarah Laditka, Ph.D., M.B.A., M.A.; Manana Tsulukidze,
M.D., M.P.A., M.P.H.; James Laditka, D.A., Ph.D.;
Elizabeth Tait, M.H.S.
Presented by: Manana Tsulukidze, M.D., M.P.A.,
M.P.H., Doctoral Student & Research Assistant, Public
Health Science, University of North Carolina at
Charlotte, 9201 University City Boulevard, Charlotte, NC
28223, Phone: (704) 678-1951, Email:
mtsuluki@uncc.edu
Research Objective: Nearly 40% of adults in the U.S.
report using some form of complementary or alternative
medicine (CAM). Most research finds people in minority
groups are less likely to use CAM than whites. Much
less research has examined racial/ethnic differences in
reporting CAM use to medical providers. Reporting CAM
use is important because some CAMs are known to
affect conventional therapies. We examined
race/ethnicity differences in CAM use, and in
communication with providers about CAM use, using
data from a recently released nationally representative
survey of adults in the U.S.
Study Design: Data were from in-person surveys from
the 2007 National Health Interview Survey (NHIS), which
included a special detailed supplement on CAM use.
The NHIS, conducted annually in the U.S, collects
information about health status, use of medical care
services, and other measures. Data from the CAM
supplement were linked with the adult and person NHIS
files. Analyses, stratified by sex, included chi-square and
multivariate logistic regression, accounting for the
complex survey design and weighted for national
representativeness. Race/ethnicity groups were nonHispanic African Americans, Hispanics, non-Hispanic
Asian Americans, and non-Hispanic whites. Controls
included age, education, marital status, health
insurance, seven chronic health conditions, self-reported
health, changes in health status in the past 12 months,
health behaviors (smoking, body mass index) and region
of the country. We examined CAM use defined both
including and excluding vitamin use; reported results
include vitamins. Separate multivariate models
estimated the likelihood of telling a provider about CAM
use.
Population Studied: 18,539 adults aged 19 to 64 years
included in the 2007 NHIS adult survey and special CAM
supplement.
Principal Findings: In multivariate analyses, compared
with whites, people in minority groups were significantly
less likely to use CAMs: African Americans (odds ratio,
OR 0.63, 95% Confidence Interval, CI 0.55-0.72),
Hispanics (OR 0.62, CI 0.55-0.70), and Asian Americans
(OR 0.65, CI 0.54-0.79); race/ethnicity differences were
similar for women and men. Among all CAM users,
47.5% reported telling a provider; 44.6% of African
Americans, 37.9% of Hispanics, 39.2% of Asian
Americans, and 49.6% of whites told a provider
(p<.0001). In adjusted results, among women, African
Americans, Hispanics, and Asian Americans were less
likely to tell a provider than were whites (OR 0.76, CI
0.67-0.86; OR 0.74, CI 0.65-0.85; OR 0.64, CI 0.53-0.78,
respectively); results were similar for men. The results
for CAM defined without vitamins were analogous.
Conclusions: African Americans, Hispanics, and Asian
Americans are markedly less likely to use CAM than
whites. The majority of CAM users do not tell their
medical providers about this use; minorities are less
likely than whites to do so.
Implications for Policy, Delivery or Practice: There is
growing evidence suggesting that many CAM modalities,
e.g., practicing yoga and/or meditation, adopting plantbased diets, are healthy behaviors. Studies increasingly
support the role of such behaviors in preventing or
managing many chronic diseases. Our findings suggest
there may be opportunities to promote use of CAMs with
established health benefits among people in minority
groups. Because many CAMs, e.g., herbal
supplements, can interact with conventional therapies,
medical providers should inquire about CAM use,
particularly by minority patients.
Disparities: Subgroups
Chair: Joseph Sudano
Tuesday, June 30 * 8:00 a.m.-9:30 a.m.
♦ Health Risks, Chronic Diseases & Access to Care
among U.S. Pacific Islanders
Asaf Bitton, M.D.; Alan Zaslavsky, Ph.D.; John Ayanian,
M.D., M.P.P.
Presented by: Asaf Bitton, M.D., Clinical & Research
Fellow, Division of General Medicine & Primary Care,
Brigham & Women's Hospital, 75 Francis Street, Boston,
MA 02115, Phone: (617) 432-1134, Email:
abitton@partners.org
Research Objective: Asian Americans (AA) and Pacific
Islanders (PI) have typically been aggregated in federal
health surveys. Although the PI population in the US
includes nearly 1 million individuals, their health
outcomes and needs have been rarely reported and may
be masked by the greater numbers and relative good
health of Asian Americans. The purpose of this study
was to analyze the self-reported health risks, chronic
diseases, and access to health care for Pacific Islanders
using recently disaggregated US health survey data.
Study Design: We analyzed the 2007 Behavioral Risk
Factor Surveillance Survey (BRFSS), a nationally
representative state-based telephone survey of adults
across 54 US states, districts, and territories. The
BRFSS is one of the first nationally representative
surveys with sufficient samples to distinguish AA from
PI. Dependent variables included self-reports of health
risks (current smoking, BMI > 25, high alcohol intake,
inadequate physical activity, low fruit/vegetable intake),
chronic diseases (diabetes, hypertension, cardiovascular
disease (CVD), asthma, high cholesterol), and access to
care (insurance status, cost barriers to health care,
primary care physician, influenza and pneumonia
vaccination). We compared these outcomes for PI
relative to AA and whites with unadjusted chi square
analyses and odds ratios, and with logistic regression
models adjusted for age, sex, education, income, fixed
effects of states and territories with large PI populations,
smoking, and body mass index. The analysis adjusted
for the complex survey design using SUDAAN software.
Population Studied: This study cohort from the 2007
BRFSS included 1063 PI, 6420 AA, and 338611 whites.
Principal Findings: In bivariate analyses, PI were
significantly more likely than AA to be younger, current
smokers, not have a college degree, meet physical
activity recommendations, have a higher BMI, and have
asthma. In multivariate logistic regression models, PI
were significantly more likely than AA to report a BMI >
25 (Adjusted Odds Ratio (AOR) 2.11; 95% CI 1.44,
3.10), current smoking (AOR 2.51; 95% CI 1.45, 4.36),
high alcohol intake (AOR 9.68; 95% CI 3.42, 27.44),
hypertension (AOR: 1.86; 95% CI: 1.14, 3.04), CVD
(AOR: 5.79; 95% CI: 1.61, 20.84), diabetes (AOR: 1.95;
95% CI 1.01, 3.79), asthma (AOR: 2.37; 95% CI: 1.37,
4.10), and access to a primary care physician (AOR:
1.91; 95% CI: 1.21, 2.97). Relative to whites, PI were
more likely to report diagnoses of hypertension (AOR:
1.67; 95% CI: 1.05, 2.65) and diabetes (AOR: 2.43; 95%
CI: 1.39, 4.28). No significant differences were detected
for the other risk factors, chronic diseases, or access to
care measures.
Conclusions: PI are significantly more likely than AA to
report important health risks, including elevated BMI,
current smoking, and high alcohol intake, as well as
related chronic diseases including diabetes,
hypertension, asthma, and CVD. Compared to whites, PI
have higher odds of hypertension and diabetes. Access
to care appears to be similar or better among PI
compared to AA and whites.
Implications for Policy, Delivery or Practice: Future
surveys and health priority setting should disaggregate
data for PI and AA given the large sociodemographic
differences between these groups and significantly
increased rates of key health risks and chronic diseases
among Pacific Islanders.
Funding Source(s): HRSA
♦ Frequent Emergency Department Users: A
Comparison of U.S.-Born to Foreign-Born Patients
by Race & Ethnicity
Erin Carlson, M.P.H.; Fernando Wilson, Ph.D.
Presented by: Erin Carlson, M.P.H., Graduate
Research Assistant, Health Management & Policy,
University of North Texas Health Science Center, 3500
Camp Bowie Boulevard, Fort Worth, TX 76107, Phone:
(402) 305-3144, Email: ecarlson@hsc.unt.edu
Research Objective: This study examines the effects of
race/ethnicity and U.S. nativity on frequent emergency
department (ED) utilization.
Study Design: The 2005 National Health Interview
Survey (NHIS) provides data. Stata/IC 10.0 software is
used for analyses. “Frequent” ED use is defined as
having used the ED at least two times in the past year.
Bivariate analyses provide sample description.
Multivariate logistic regression models race/ethnicity and
nativity as predictors of frequent ED use, adjusting for
uninsurance, poverty, age, marriage, education, gender,
having a usual source of care, and self-reported health
status. Post-estimation analyses are stratified by White,
Black, and Hispanic race/ethnicity and by U.S. and
foreign nativity. Odds of frequent ED utilization are
calculated comparing foreign to U.S.-born by
race/ethnicity, and comparing Blacks and Hispanics to
Whites by nativity status.
Population Studied: Only respondents who reported
race/ethnicity as non-Hispanic White, non-Hispanic
Black, or Hispanic, and were aged 18 years or older are
included in the study. The study sample consists of
68,540 respondents, including 44,225 non-Hispanic
Whites, 9,234 non-Hispanic Blacks, and 15,081
Hispanics. Among U.S. natives, 41,810 are non-Hispanic
Whites, 8,221 are non-Hispanic blacks, and 10,255 are
Hispanic.
Principal Findings: Logistic regression reveals
Hispanics are significantly less likely [OR=0.76 (95%CI
0.67,0.86)] to utilize the ED frequently relative to nonHispanic Whites, while Blacks have greater odds
[OR=1.31 (95%CI 1.16,1.47)] of frequent ED utilization.
Poor health status is associated with the highest odds of
frequent ED utilization compared to those reporting fair
or good health status [OR=3.33 (95%CI 2.21,5.04)].
Bivariate results show Blacks report poor health status
one-third more often than Whites and at twice the rate of
Hispanics. Post-estimation stratification finds ED
utilization among foreign-born compared to U.S. natives
is significantly lower for all race/ethnicities [White
OR=0.63(95%CI 0.45,0.81); Black OR=0.63(95%CI
0.42,0.84); Hispanic OR=0.63(95%CI
0.46,0.80)].Compared to foreign-born Whites, foreignborn Blacks are significantly more likely to be frequent
ED users [OR=1.68 (95%CI 1.13,2.24)] and Hispanics
are not associated with frequent ED use [OR=1.05
(95%CI 0.77,1.33)]. Among U.S. natives, AfricanAmericans are significantly associated with greater odds
of frequent ED use compared to Whites [OR=1.68
(95%CI 1.37,1.99)] and Hispanics have lower odds of
frequent ED use [OR=0.66 (95%CI 0.49,0.84)].
Conclusions: Foreign-born individuals are less likely to
be frequent ED users than U.S. natives. While there are
greater odds of frequent ED utilization among both U.S.and foreign-born Blacks relative to Whites, Hispanics are
as likely or less likely to have frequent ED utilization
depending on nativity status. Those reporting poor
health status have the greatest odds of frequent ED
utilization regardless of race, ethnicity, or nativity.
Implications for Policy, Delivery or Practice: Efforts to
mitigate ED use among frequent users should not be
based on the assumption that foreign-born persons use
the ED at a higher rate than U.S.-born persons. Rather,
the underlying causes of health disparities responsible
for poorer health status in Blacks compared to other
groups should be identified. Policies should focus on
primary care interventions to mitigate the need for
frequent emergent care.
Funding Source(s): RWJF, University of Kentucky
PHSSR Dissertation Grant
♦ Racial & Ethnic Differences in Mental Health
Service Use among High-Need Subpopulations in
Clinical & School-Based Settings
Janet Cummings, B.A.; Ninez Ponce, Ph.D.; Vickie
Mays, Ph.D.
Presented by: Janet Cummings, B.A., Health Services,
University of California, Los Angeles School of Public
Health, 11839 Goshen Avenue, #7, Los Angeles, CA
90049, Phone: (310) 948-7154, Email: jrc12@ucla.edu
Research Objective: Higher rates of unmet need for
mental health services have been documented for
minority adolescents. Prior studies, however, have often
examined racial/ethnic differences in mental health
service use among adolescents without examining
differences separately across settings. By examining
differences in “any service use”, differences or the lack
thereof within specific settings, such as the medical
sector or schools, may be masked. When service use
across settings has been examined separately, the
differential role of race/ethnicity in the help-seeking
process for specific mental health problems was not
examined. This study examines whether there are higher
levels of unmet need among blacks, Hispanics, and
Asian/Pacific Islander adolescents in clinic-based and
school-based settings among three high-need
populations: (1) those with high levels of depressive
symptoms, (2) those with suicidal thoughts, and (3)
those with high levels of delinquent behaviors.
Acculturation is examined as a mediating factor for
observed racial/ethnic differences in service use.
Study Design: Using data from Wave I of the National
Longitudinal Survey of Adolescent Health (Add Health),
weighted logistic regressions are estimated to examine
racial/ethnic differences in clinic-based and schoolbased service use among three high-need populations.
Regression models control for predisposing, enabling,
and need-related factors. Acculturation (measured as
language other than English spoken at home) was
tested as a mediating factor.
Population Studied: 18,847 adolescents in grades 7 to
11 from a national school-based sample.
Principal Findings: No racial/ethnic differences were
observed for school-based service use in any high-need
group. Blacks were less likely than whites to receive
services in a clinical setting across all three high-need
groups, with odds ratios ranging from 0.35 (95% CI =
0.19, 0.63) among those with high levels of delinquent
behaviors to 0.64 (95% CI=0.39, 1.07; p<0.10) among
those with high levels of depressive symptoms.
Asian/Pacific Islanders were less likely than whites to
receive clinic-based services among those with high
depressive symptoms (OR=0.19, 95% CI=0.06, 0.65)
and those with suicidal thoughts (OR=0.32, 95%
CI=0.12, 0.87). Hispanics were less likely than whites to
receive clinic-based services for suicidal thoughts
(OR=0.52, 95% CI=0.33, 0.82), which was mediated by
language spoken at home.
Conclusions: There were no racial/ethnic differences in
school-based service use across populations. The
existence of racial/ethnic differences in clinical service
use are contingent on the mental health problem at
hand. Acculturation mediates relationship between
Hispanic ethnicity and lower service use in a clinical
setting among those with suicidal thoughts, but does not
mediate any of the findings for other minority groups.
Implications for Policy, Delivery or Practice: Results
underscore the important role that schools may be able
to play in addressing racial/ethnic differences in unmet
need for mental health care. The lack of racial/ethnic
differences in school-based service use contrasted with
significant differences in clinic-based service use among
high-need populations suggests that policy makers may
wish to consider investing resources in school-based
mental health programs to help reduce racial/ethnic
differences in unmet need for mental health care.
Funding Source(s): NIMH
♦ Understanding Barriers to High Quality Health Care
in the Indian Health Service
Thomas Sequist, M.D., M.P.H.; Theresa Cullen, M.S.;
Kenneth Bernard, B.A.; Shimon Shaykevich, M.S.; E.
John Orav, Ph.D.; John Ayanian, M.D., M.P.P.
Presented by: Thomas Sequist, M.D., M.P.H., Assistant
Professor, Division of General Medicine, Brigham &
Women's Hospital, 1620 Tremont Street, Boston, MA
02120, Phone: (617) 525-7509, Email:
tsequist@partners.org
Research Objective: Native Americans experience a
significantly higher disease burden and shorter life
expectancy than the general US population. The Indian
Health Service (IHS) provides health care for most
Native Americans, yet there is limited information
regarding physicians´ perceptions of health care delivery
and clinical performance within this system.
Study Design: We surveyed all 873 federally employed
physicians working within the IHS during October 2007.
Physicians used a 5-point Likert scale ranging from
“almost always” to “never” to report on the availability of
high-quality subspecialists, nonemergent hospital
admissions, diagnostic imaging services, and outpatient
mental health services; as well as availability of three
specific preventive services: 1) screening
mammography, 2) diabetic eye exams, and 3) influenza
vaccination. We further assessed primary care
physicians´ comfort with the complexity of conditions
being managed without specialty consultation using a
similar scale. Clinical performance on the three
preventive services was measured using automated
extracts from the IHS national electronic medical record
system in 2006. These extracts included performance of
biennial screening mammography for women 52-64
years old, annual dilated eye exams for adult patients
with diabetes, and annual influenza vaccinations for
adults 65 years and older. We calculated Spearman
correlation coefficients between the clinical performance
rates and proportion of primary care physicians reporting
each of these 3 services were “almost always” available
at the level of the individual clinics (n=59).
Population Studied: 873 federally employed physicians
within the IHS, as well as patients eligible for three
measures of preventive health care.
Principal Findings: The overall survey response rate
was 68%, including 426 primary care physicians (257
family practice, 71 general internal medicine, 86
pediatrics, 12 combined internal medicine-pediatrics).
Among primary care physicians, the proportion reporting
that essential services were “almost always” available
was low for subspeciality care (33%), hospital admission
(39%), imaging services (37%), and mental health care
(15%). More than half of primary care physicians
reported being expected to manage conditions without
specialty consultation for which the complexity was
either much greater than it should be (15%) or
somewhat greater than it should be (43%). The
proportion of primary care physicians reporting that
preventive services were “almost always” available was
relatively low for screening mammography (55%) and
diabetic eye exams (54%), but higher for influenza
vaccination (83%). Clinical performance was low for
biennial mammography (40%) and annual dilated eye
exams (49%), and somewhat higher for annual influenza
vaccinations (59%). While clinical performance rates
were slightly higher at sites where preventive services
were reported as "almost always" available (46% for
mammography, 52% for diabetic eye exams, and 63%
for influenza vaccinations), the correlations were small in
magnitude and not statistically significant.
Conclusions: Primary care physicians report substantial
barriers accessing a wide range of essential services
within the IHS, though correlations with clinical
performance are limited for specific preventive
measures.
Implications for Policy, Delivery or Practice: Future
research is needed to understand the impact of these
substantial barriers to accessing essential health
services on the health of the Native American
population, as well as the factors other than access that
affect delivery of preventive services within the IHS.
Funding Source(s): RWJF
Disparities: Insurance/Coverage
Chair: Laurence McMahon
Tuesday, June 30 * 9:45 a.m.-11:15 a.m
♦ Disparities in the Availability & Use of
Mammography
Elena Elkin, Ph.D.; Nicole Ishill, M.S.; Jacqueline Snow,
B.A.; Fahui Wang, Ph.D.; Peter Bach, M.D., M.A.P.P.;
Deborah Schrag, M.D., M.P.H.
Presented by: Elena Elkin, Ph.D., Assistant Attending
Outcomes Research Scientist, Epidemiology &
Biostatistics, Memorial Sloan-Kettering Cancer Center,
1275 York Avenue, Box 44, New York, NY 10065,
Phone: (646) 735-8141, Email: elkine@mskcc.org
Research Objective: Research Objective: Geographic
and racial disparities in rates of screening
mammography may be related to variation in access.
We assessed the impact of county-level mammography
capacity on the use of screening mammography.
Study Design: Study Design: Information on the
number and location of all mammography facilities and
machines in 2004 was obtained from the US Food and
Drug and Administration’s Center for Devices and
Radiological Health. Population estimates were obtained
from the US Census Bureau. Inadequate mammography
capacity was defined at the county level as fewer than
1.2 machines per 10,000 women age 40+. This
threshold represents the capacity required to meet the
Healthy People 2010 goal of a 70% screening rate.
Mammography utilization was evaluated in two national
samples: women age 40+ who participated in the 2006
Behavioral Risk Factor Surveillance System survey
(BRFSS) and a 5% random sample of female Medicare
beneficiaries age 65+. In both samples the primary
outcome measure was receipt of a mammogram within a
two-year period. The impact of inadequate
mammography capacity on utilization was estimated
using multivariable logistic regression, in each sample
and in subgroups by race, controlling for measured
demographic and health care characteristics.
Population Studied: US women age 40 and older.
Principal Findings: County mammography capacity in
2004 varied from 0 to 27 machines per 10,000 women,
with a median of 1.7. Thirty-six percent of counties had
fewer than 1.2 machines per 10,000 women, accounting
for 12% of all US women age 40+. In the BRFSS
sample, 77% of women reported a mammogram in the
past two years, while 40% of the Medicare cohort had a
claim for mammography in 2004-2005. In both samples,
residence in a county with inadequate mammography
capacity was associated with lower of odds of a recent
mammogram, controlling for measured demographic and
health care characteristics; adjusted odds ratios (AORs)
for inadequate mammography capacity were 0.89 (95%
CI 0.80 – 0.98, p<0.05) in the BRFSS cohort and 0.86
(95% CI 0.84 – 0.87, p<0.0001) in the Medicare cohort.
In the BRFSS sample, black women were more likely
than white women to report a recent mammogram, and
inadequate mammography capacity was not associated
with utilization in black women. In the Medicare sample,
black women were significantly less likely to have had a
mammogram, but inadequate capacity had a similar
impact on utilization in women of all races.
Conclusions: In US counties with few or no
mammography machines, limited availability of imaging
resources is a barrier to breast cancer screening. While
the impact of capacity on utilization was robust to
differences between survey-based and claims-based
studies, evidence of racial disparities was mixed.
Implications for Policy, Delivery or Practice:
Geographically targeted enhancement of mammography
capacity may boost breast cancer screening rates in the
most underserved areas while optimizing limited health
care resources. About one-eighth of all women age 40+
live in areas with inadequate mammography capacity.
Efforts to increase capacity in these areas may reduce
geographic and racial disparities in screening
mammography.
Funding Source(s): NCI
♦ Racial/Ethnic Disparities in Medicare Part D
Experiences: Findings from the 2008 Medicare
CAHPS Survey
Amelia Haviland, Ph.D.; Marc Elliott, Ph.D.; Katrin
Hambarsoomian, M.S.; Robert Weech-Maldonado,
Ph.D.
Presented by: Amelia Haviland, Ph.D., Statistician,
Economics & Statistics, RAND Corporation, 4570 Fifth
Avenue, Suite 600, Pittsburgh, PA 15213, Phone: (412)
683-2300, Email: haviland@rand.org
Research Objective: To determine the extent to which
Medicare beneficiaries of different racial/ethnic groups
report different experiences with Medicare Part D
prescription drug coverage.
Study Design: This study used data from 258,714
beneficiaries 65 and older with a stand-alone
Prescription Drug Plan (PDP) or who obtained Part D
coverage through their managed care (Medicare
Advantage) plan (MA-PD) who responded to the
nationally representative 2008 Medicare CAHPS survey.
We compared Hispanic, Black, Asian or Pacific Islander,
American Indian, and non-Hispanic White beneficiaries
with respect to three prescription drug coverage
measures: an overall 0-10 rating of their prescription
drug plan/coverage, and two composite measures: ease
of getting needed prescription drugs and ease getting
information on prescription drug coverage, all rescaled to
0-100. We fit weighted linear models predicting these
measures from race/ethnicity (using a nonHispanicWhite reference group) case-mix adjusting for
age, education, self-reported general and mental health
status, proxy assistance, Medicaid dual-eligibility, and
Low Income Subsidy eligibility.
Population Studied: Medicare beneficiaries 65 and
older with Part D coverage who participated in the 2008
Medicare CAHPS survey.
Principal Findings: Preliminary analyses suggest that
all racial/ethnic groups report significantly greater
difficulty getting needed drugs than non-Hispanic White
beneficiaries; with disparities ranging from 8 points for
Asian/Pacific Islanders to 2 points for American Indians
(means for these three groups are 91, 83, and 89,
respectively; p<0.001 for all vs. non-Hispanic White). All
groups other than American Indians also report
significantly greater difficulty than non-Hispanic Whites
with getting information about their prescription drug
coverage, with disparities ranging from 7 points for
Asian/Pacific Islanders to 3 points for African American
and Hispanic beneficiaries (means for these four groups
are 81, 74, 78, and 78, respectively with p< 0.001 for
each, p>0.05 for Native Americans). In contrast, no
racial/ethnic group provides lower overall ratings of their
prescription drug plan/coverage than non-Hispanic
Whites, with Hispanics, African Americans, and Native
Americans ratings averaging 3, 3, (both with p < 0.001)
and 1 point (p < 0.05) higher, respectively (means for
these four groups are 83, 86, 86, and 84, respectively).
Conclusions: Hispanic, African American, Asian/Pacific
Islander, and Native American beneficiaries reported
greater difficulties with obtaining information regarding
coverage and obtaining needed prescription drugs via
their Medicare Part D coverage than did non-Hispanic
Whites, with the greatest disparities observed for
Asian/Pacific Islander beneficiaries. Consistent with
other evidence of racial/ethnic differences in 0-10 scale
use, the 0-10 Part D rating showed a very different
pattern.
Implications for Policy, Delivery or Practice: Results
suggest that quality improvement efforts are needed to
reduce racial/ethnic disparities in beneficiary experience
with new Part D prescription drug coverage. Cultural and
language barriers in navigating Medicare’s Part D
program may partially explain the observed disparities.
Cultural competency training of providers, access to
interpreter services, and translation of materials into
non-English languages are some of the strategies that
can be used to improve the experiences of vulnerable
beneficiaries.
Funding Source(s): CMS
♦ Racial Disparities in Obesity Related Health Care
Expenditures
Sai Ma, Ph.D.; Lisa Dubay, Ph.D.; Kevin Frick, Ph.D.
Presented by: Sai Ma, Ph.D., Assistant Scientist,
Population, Family & Reproductive Health, Johns
Hopkins School of Public Health, 615 North Wolfe
Street, E4153, Baltimore, MD 21205, Phone: (410) 5029317, Email: sma@jhsph.edu
Research Objective: In the U.S., there is considerable
variation between African American and Caucasian
health care access, utilization, and spending for a
number of diseases and conditions. Such variation is
also reported in health care expenditures associated
with obesity: compared to whites, blacks not only have a
higher obesity rate in both obese classes, but also
higher average Body Mass Index (BMI) and lower health
care expenditures in each weight category. The primary
objective of this study is to investigate the reasons why
African Americans spend less on health care than their
white counterparts in each weight category (obese class
II/III, obese class I, overweight and normal weight), after
adjusting for socioeconomic factors.
Study Design: This study uses data from the House
Component of the Medical Care Expenditure Survey
(MEPS-HC, 2002-2005). The MEPS-HC provides
detailed information on total medical expenditure
including both insurance and out-of-pocket spending, as
well as abundant information on individual health
conditions (such as BMI) and socio-demographic status
(such as health insurance coverage, race/ethnicity, age,
education and poverty status).
Population Studied: The study population includes all
non-institutionalized American adults in 2002-2005. Our
sample excluded pregnant women and was also
restricted to Whites, Blacks and Hispanics. The final
analysis sample includes 56,912 adults age 18 or above.
Principal Findings: Using a standard two-part model
approach, controlling for a set of covariates including
SES and types of insurance, we found obese and
overweight people were significantly more likely to utilize
any health care than people in the normal weight
category. However, blacks are drastically less likely than
whites to utilize any health care (OR=0.487); they also
spend 10% less than whites when they do utilize care.
Blacks in obese class II/III and class I spend $824 and
$732 less, respectively, than whites in each weight
category. We then examined types of health care
services, including inpatient care, outpatient care,
ambulatory visits, ER visits and prescription medications.
We found that the only statistically significant differences
in types of service between whites and blacks existed for
inpatient hospital stay and length of stay: blacks in
obese class II/III are 58% less likely to use inpatient
service and stay 42% fewer nights than whites in the
same weight class; blacks in obese class I are 34% less
likely to use inpatient service and stay 12% fewer nights
than white counterparts.
Conclusions: Based on these preliminary results, we
conclude that obese blacks use expensive care, namely,
inpatient services, less frequently than white
counterparts, and the disparities in overall spending can
be explained by this difference.
Implications for Policy, Delivery or Practice: Blacks
already have a higher obesity rate as well as higher
average BMI in each weight category than whites. Their
health may further exacerbate due to underutilization of
inpatient care.
Funding Source(s): The PEW Charitable Trusts &
NCMHD: # P60MD000214-01
♦ Racial/Ethnic Disparities in Health Care
Expenditures of Chronically Ill Medicaid
Beneficiaries
Nadereh Pourat, Ph.D.; Gerald Kominski, Ph.D.; Dylan
Roby, Ph.D.; Ying-Ying Meng, Ph.D.; Allison Diamant,
M.D., M.P.H
Presented by: Nadereh Pourat, Ph.D., Associate
Professor, Health Services, University of California, Los
Angeles Center for Health Policy Research, 10960
Wilshire Boulevard, Suite 1550, Los Angeles, CA 90024,
Phone: (310) 794-2201, Email: pourat@ucla.edu
Research Objective: Racial/ethnic disparities in health
status may be alleviated by directing interventions
towards chronically ill low-income populations. The
purpose of this study is to determine if significant
racial/ethnic disparities exist at baseline among fee-forservice Medicaid beneficiaries eligible for a disease
management pilot demonstration program in California.
Information on the magnitude and direction of significant
baseline disparities may be useful in targeting
interventions to reduce such disparities. Failure to
understand the magnitude of baseline disparities could
also bias findings regarding the effectiveness of disease
management programs across different racial/ethnic
groups.
Study Design: Cross-sectional California Medicaid
claims data from September 2006 through August 2007
were analyzed. We examined total Medicaid
expenditures of Latino, African American, Asian and
Pacific Islander (AAPI), Armenian, and other white
populations. We then examined racial/ethnic differences
using a pooled linear regression model with logtransformed expenditures and controlling for specific
chronic condition, whether a comorbid condition was
present, severity of disease, and other demographic and
utilization covariates. In addition, we stratified the
regression analyses by chronic condition to examine
potential disparities within specific diseases.
Population Studied: California Medicaid enrollees ages
22 and older enrolled in fee-for-service care with one or
more of the following six chronic illnesses: asthma,
atherosclerotic disease syndrome (ADS), congestive
heart failure (CHF), diabetes, coronary artery disease
(CAD), and chronic obstructive pulmonary disease
(COPD). Fee-for-service beneficiaries in aged, disabled,
and blind aid codes who had full scope coverage without
share of cost, who did not receive Medicare, and resided
in two pilot counties were included.
Principal Findings: The population was relatively
evenly distributed among whites (25%), Armenians
(21%), Latinos (19%), and African Americans (22%) with
AAPIs constituting the smallest group (11%). Whites had
the highest level of unadjusted total expenditures
($10,220), followed by African Americans ($8,921),
Latinos ($7,504), Armenians ($7,364), and AAPIs
($5,986). Differences in total expenditures persisted after
controlling for specific disease and other covariates.
Armenians and AAPIs had significantly higher
expenditures and Latinos and African Americans had
significantly lower expenditures than whites. Stratifying
by specific chronic disease revealed that disparities were
not uniform across diseases. Armenians with ADS and
CAD, African Americans with CHF, and AAPI with
asthma, ADS, COPD, and diabetes had significantly
higher expenditures than whites. In contrast, African
Americans with asthma and ADS had significantly lower
expenditures than whites.
Conclusions: Our findings indicate significant
racial/ethnic disparities among Medicaid fee-for-service
beneficiaries, but no consistent patterns across chronic
disease category emerged. Higher adjusted
expenditures among Armenian, African Americans, and
AAPI populations for certain disease may indicate
shortcomings in management of chronic conditions
among these groups. On the other hand, lower adjusted
expenditures among Latinos overall and among African
Americans for other specific diseases may indicate
access barriers to appropriate services.
Implications for Policy, Delivery or Practice: Disease
management programs are proposed as a way to
improve patient outcomes and reduce costs of
chronically ill populations. Such programs may require
more specific targeting to help reduce racial/ethnic
disparities among chronically ill low-income patients.
Funding Source(s): Calfornia Department of Health
Care Services
Disparities: Site/Context
Chair: Lisa Gary
Tuesday, June 30 * 11:30 a.m.-1:00 p.m.
♦ Ten Best Practices of High Quality Minority
Serving (HQMS) Hospitals
Darrell Gaskin, Ph.D.; Thomas LaVeist, Ph.D.
Presented by: Darrell Gaskin, Ph.D., Associate
Professor, African American Studies, University of
Maryland, 2169 Lefrak Hall, College Park, MD 20724,
Phone: (301) 405-1162, Email: dgaskin@aasp.umd.edu
Research Objective: This study identified best practices
of high quality minority serving hospitals (HQMS).
Specifically, we identified how they achieve high quality
care to your minority patients.
Study Design: Using state inpatient discharge data from
13 states, we identified 166 minority serving hospitals.
Minority serving hospitals were defined as those
hospitals where more than 50 percent of their discharges
were African American, Hispanic or Asian patients. We
defined high quality hospitals based on their
performance according to the AHRQ inpatient quality
indicators (IQIs) and patient safety indicators (PSIs). For
each hospital, we computed composite quality scores for
the IQI and PSI. To be designated high quality, a
hospital had to score in the top quartile on either
composite score. We identified 31 HQMS hospitals
based on the IQI composite score and 47 HQMS
hospitals based on their PSI composite score. From
these hospitals, we selected 6 HQMS hospitals. We
conducted a site visit at each HQMS hospital.
Population Studied: We interviewed the CEO, CFO,
medical director, quality improvement officer and head of
nursing at each hospital to discuss the challenges they
face in providing high quality care to their minority
patients. The interview instrument covered five domains:
quality improvement initiatives, cultural competency,
workforce diversity, the adoption of IT and other new
technologies, and financial issues.
Principal Findings: 1) HQMS hospitals have consistent,
stable, committed leadership who demand excellence
from their senior managers and staff. They articulate a
vision that there will be not disparities. They provide
incentives for staff at all levels to innovate around quality
and efficiency. 2) HQMS hospitals have quality
improvement efforts that incorporate unit staff by
providing them with information and real time feedback
on performance. 3) HQMS hospitals are keenly aware of
their patients’ needs. In particular they are sensitive to
unique language and cultural needs of patients. HQMS
hospitals have developed ways to communicate these
needs to all units in their hospitals and incorporate them
in their training and patient care materials. 4) HQMS
hospitals invest their limited resources wisely. They
know how to set spending priorities. Despite limited
resources, they managed to invest in their physical plant
to meet current and future patient care needs. 5) HQMS
hospitals know how to leverage their funds with other
sources to better serve their patients and communities.
6) HQMS hospitals do not view their patients as minority
patients but rather just their patients. 7) HQMS hospitals
use health information technology to help their
physicians and staff manage their patients’ care. 8)
HQMS hospitals maintain strong support from political
leaders in their state and city. They know how to
communicate with political leaders to ensure their
hospitals have sufficient resources. 9) HQMS hospitals
practice family centered medicine. 10) HQMS hospitals
aggressively approach meeting quality standards set by
CMS, Joint Commission and other quality organizations.
They develop capabilities to measure, document, and
track their performance on these quality improvement
standards.
Conclusions: HQMS hospitals have developed effective
strategies to deliver high quality care to their patients
despite fiscal pressure and the unique needs minority
patients.
Implications for Policy, Delivery or Practice: Best
practices of HQMS hospitals can be replicated in other
hospitals, particular those serving minorities.
Funding Source(s): CWF
♦ Neighborhood Disadvantage, Race & Prostate
Cancer Presentation, Treatment & Mortality
Judith Long, M.D.; Nicole Lurie, M.D.; Jose Escarce,
M.D., Ph.D.; Chantal Montagnet, M.A.; Katrina
Armstrong, M.D., M.S.E.
Presented by: Judith Long, M.D., Assistant Professor of
Medicine, Internal Medicine, VA Cenet for Health Equity
Research & Promotion, 1201 Blockley Hall, 423
Guardian Drive, Philadelphia, PA 19104, Phone: (215)
898-4311, Email: jalong@mail.med.upenn.edu
Research Objective: The burden of prostate cancer is
substantially greater among African American (AA) men
than White men in incidence, stage of presentation, and
mortality. Although most prior research has focused on
the contribution of individual biological, behavioral and
socioeconomic characteristics to prostate cancer
disparities, these individual characteristics comprise only
one part of the picture. Each of these individuals is
nested within a social and physical environment and
because neighborhood characteristics differ by race in
the US, these pathways may also contribute to racial
disparities in prostate cancer presentation and survival.
In this study we investigate the relationship between
neighborhood disadvantage, race, and prostate cancer
presentation, treatment, and mortality.
Study Design: We used SEER-Medicare data from
1991-1999 for data on prostate cancer presentation,
treatment, and mortality. Neighborhood disadvantage
was defined at the census tract level using a composite
index developed by RAND. The index uses interpolated
census data assigning each individual a neighborhood
disadvantage index value for the year they were
diagnosed. We used logistic regression to evaluate
stage at presentation (metastatic versus non-metastatic),
multinomial logit models to evaluate treatment received
among those without metastatic disease (prostatectomy
or radiation versus no treatment), and cox regression to
determine the hazard of death among those without
metastatic disease. The main predictors of interest were
the neighborhood disadvantage index quartile and race.
Other covariates included age, marital status,
comorbidities, grade at presentation, block group
income, and SEER site.
Population Studied: Our sample included 5,952 AA
and 47,639 White men with prostate cancer. The mean
age was 74 years, and the mean block group income
was 56k.
Principal Findings: Of those living in neighborhoods
with greatest disadvantage, 38% were AA compared to
only 1% in neighborhoods with least disadvantage. Both
greater neighborhood disadvantage and AA race were
independently associated with worse stage at
presentation (most disadvantaged versus least 1.18
95%CI 1.05-1.09: AA versus White 1.45 95%CI 1.311.40), less active treatment , and higher mortality (most
disadvantaged versus least 1.29 95%CI 1.07-1.54: AA
versus White 1.18 95%CI 1.01-1.37). The odds of
radiation versus no treatment was 0.74 95%CI 0.65-0.83
for living in the most disadvantaged neighborhoods
versus least and 0.79 95%CI -0.88 for AA versus White
race. The odds of prostatectomy versus no treatment
was 0.70 95%CI 0.58-0.82 for living in the most
disadvantaged neighborhoods versus least and 0.61
95%CI 0.49-0.73 for AA versus White race. In stepped
analysis, neighborhood disadvantage did little to explain
racial disparities in stage at presentation and mortality
but did explain to some extent treatment disparities (10%
for radiation versus no treatment and 17% for
prostatectomy versus no treatment).
Conclusions: Neighborhood disadvantage is associated
with prostate cancer stage of presentation, treatment,
and mortality and helps to explain racial disparities in
prostate cancer treatment for AA men.
Implications for Policy, Delivery or Practice: It is
possible that patients from disadvantaged neighborhood
and AA men may be receiving cancer care from
providers or sites of care where less aggressive
treatment is pursued. If this is the case targeting care at
these sites may be a means to ameliorating disparities in
prostate cancer care.
Funding Source(s): NIH
♦ Why Didn’t That Hip Get Fixed? Race & Variations
in Operative & Non-Operative Treatment for Hip
Fracture
Mark Neuman, M.D.; Lee Fleisher, M.D.; Orit EvenShoshan, M.S.; Lanyu Mi, M.S.; Jeffrey Silber, M.D.,
Ph.D.
Presented by: Mark Neuman, M.D., Clinical Scholar,
Robert Wood Johnson Foundation Clinical Scholars
Program, University of Pennsylvania, 423 Guardian
Drive, 13th Floor Blockley Hall, Philadlphia, PA 19104,
Phone: (215) 573-3983, Email:
neumanm@mail.med.upenn.edu
Research Objective: Efforts to examine variations in
the utilization of surgical services have historically been
limited by the inability to observe the full population of
patients eligible for a given surgical procedure, and have
focused primarily on patients receiving the procedure of
interest. Hip fracture offers unique advantages for the
study of surgical care; ICD-9-CM codes reliably identify
patients with hip fracture, providing detailed information
on fracture characteristics and the procedures used for
treatment. Operative repair is the standard of care for
medically stable patients with hip fracture; however, a
fraction of the 340,000 individuals who break their hips
each year in the U.S. undergo non-operative treatment.
This is associated with increased pain, functional
disability, and greater mortality. We examined the
influence of comorbidity, race, income, and hospital on
the odds of non-operative treatment for hip fracture.
Study Design: We identified patients over age 65 with
first-time femoral neck, intertrochanteric, or
subtrochanteric fractures by the following ICD-9-CM
codes: 820.00-09, 820.21-22, and 820.8. We excluded
patients with prior hip fracture, identified by a 3-month
look-back, patients admitted for rehabilitation, and those
with pelvic fractures. Patients were classified as having
undergone surgery within one month of admission by
104 ICD-9-CM procedure codes corresponding to
operations involving the femur or hip joint. The logistic
regression model predicting operative or non-operative
treatment for hip fracture included 14 variables for
fracture characteristics, 33 variables for comorbidities,
variables for patient sex, age, source of admission,
income, and 21 significant interactions. We also fit a
conditional logistic model, fixing on the individual
hospital, to examine differences in care delivered within
the same hospital.
Population Studied: Inpatient Medicare claims for
167,892 hip fracture admissions from 2002-2006 in New
York, Illinois, and Texas.
Principal Findings: 10,360 patients (6.17%) underwent
non-operative treatment for hip fracture. After adjusting
for patient factors, the odds of non-operative treatment
were 81% higher for black patients compared to whites
(95% CI 66%, 96%), P< 0.0001. This did not change
with adjustment for income. After adjusting for individual
hospitals, the odds of non-operative treatment remained
57% higher for blacks compared to whites, (95% CI =
42%, 73%), P<0.0001. 7-day mortality in patients
receiving non-operative care was 7.89% among blacks
vs. 20.0% among whites (p<0.0001), suggesting a lower
severity of concurrent illnesses among black patients
receiving non-operative care.
Conclusions: Black race is highly associated with nonoperative treatment for hip fracture.
Implications for Policy, Delivery or Practice: Nonoperative treatment for hip fracture may be acceptable
for the few patients in whom severe concurrent illnesses
make surgery inappropriate. However, our analyses
point to a strong association between black race and
increased odds of non-operative treatment for hip
fracture; this occurs despite controlling for income and
individual hospital effects, and despite a dramatically
lower rate of 7-day mortality among black patients
receiving non-operative treatment. These findings should
prompt providers and policy makers to seek a better
understanding of the causes underlying this potential
disparity in surgical care.
Funding Source(s): NIDDK
♦ Are There Racial/Ethnic Disparities in Mortality
Rates & Surgical Procedure Use in the Veterans
Health Administration?
Stephanie Shimada, Ph.D.; Amy Rosen, Ph.D.; Priscilla
Chew, M.P.H.; Ann Borzecki, M.D., M.P.H.
Presented by: Stephanie Shimada, Ph.D., Research
Health Scientist, Center for Health Quality, Outcomes &
Economic Research, Dept of Veterans Affairs, 200
Springs Road (152), Bedford, MA 01730, Phone: (781)
687-2000 x 6698, Email: shimada@bu.edu
Research Objective: Minorities often experience
reduced access to care, poorer quality of care, and
worse outcomes. The Agency for Healthcare Research
and Quality (AHRQ) has developed the Inpatient Quality
Indicators (IQIs) to screen for potential inpatient quality
problems using discharge data. The IQIs include: a)
mortality rates from specific procedures and conditions
where high mortality may be associated with poorer
care, and b) utilization rates of procedures where
concerns exist about over-/under-, or misuse. AHRQ
has reported disparities in IQI rates between whites and
minorities in the National Healthcare Disparities Report.
We examined whether there were racial/ethnic
disparities in IQI rates within the Veterans Health
Administration (VA).
Study Design: We utilized 2004–2007 inpatient
discharge data from 123 VA hospitals (N=2,272,894
hospitalizations) and AHRQ IQI Software Version 3.1 to
calculate risk-adjusted IQI rates by race.
Population Studied: Veterans who received inpatient
care at one of 123 VA hospitals between 2004 and 2007
and met the inclusion criteria for each IQI (N=388 88,874 hospitalizations, depending on the IQI).
Principal Findings: There were no significant
racial/ethnic differences in risk-adjusted mortality or
utilization rates for 17 out of 22 IQIs. The congestive
heart failure (CHF) mortality rate was significantly lower
for African-Americans (3.7%, 95% CI 3.4-4.0%) than for
whites (4.4%, 95% CI 4.2-4.6%). The pneumonia
mortality rate was significantly lower for Latinos (4.5%,
95% CI 3.2-6.1%) than for whites (6.4%, 95% CI 6.26.6%), African-Americans (6.9%, 95% CI 6.4-7.4%), or
patients of unknown/unreported race (6.7%, 95% CI 6.27.1%). Utilization indicators showed that Latinos were
significantly more likely (79.6%, 95% CI 73.0-85.6%) and
Native Americans were significantly less likely (58.3%,
95% CI 45.5-70.9%) to have a laparascopic
cholecystectomy compared with white (65.1%, 95% CI
63.9-66.4%) and African-American (64.2%, 95% CI 61.167.3%) patients. Incidental appendectomies were
performed at lower rates for African American patients
(0.82%, 95% CI 0.55-1.17%) and patients of unknown
race (0.83%, 95% CI 0.59-1.13%) than for white patients
(1.35%, 95% CI 1.19-1.53%). Bilateral cardiac
catheterizations were performed at significantly higher
rates among patients of unknown race (9.7%, 95% CI
9.2-10.2%) than for white (7.6%, 95% CI 7.4-7.8%),
African-American (8.2%, 95% CI 7.7-8.7%), or Native
American (5.9%, 95% CI 3.6-8.9%) patients.
Conclusions: We found variation in mortality and
utilization rates across racial/ethnic groups, with no one
racial/ethnic group consistently having higher or lower
rates. There was also large variation between groups in
utilization rates for laparascopic cholecystectomy,
suggesting significant underuse for Native American
veterans. Although we did not find significant
differences for many IQIs, small numbers in the
denominator for some racial/ethnic groups may have
prevented us from detecting some disparities in VA.
Implications for Policy, Delivery or Practice: There is
evidence that high mortality from the conditions
assessed by the IQIs are associated with poorer quality
care. Racial/ethnic disparities in IQI rates suggest that
inpatient care quality may not be uniform across all
racial/ethnic groups in VA, especially in terms of surgical
procedure use. Future research should examine
patient-, hospital-, and system-level factors that might
explain variation in IQI rates within the VA and between
the VA and non-VA settings.
Funding Source(s): VA
Informing Health Policy Through a Gender Lens
Chair: Alina Salganicoff
Tuesday, June 30 * 8:00 a.m.-9:30 a.m.
♦ Neighborhood SES & Incident CHD among Women
Chloe Bird, Ph.D.; Christine Eibner, Ph.D.; Beth Ann
Griffin, Ph.D.; Mary Slaughter, M.S.; Eric Whitsel, M.D.;
Shih, Ph.D.
Presented by: Chloe Bird, Ph.D., Senior Sociologist,
Health Unit, RAND, 1776 Main Street, P.O. Box 2138,
Santa Monica, CA 90407-2138, Phone: (310) 393-0411
ext. 6260, Email: chloe@rand.org
Research Objective: We assessed the relationship
between neighborhood socioeconomic status (NSES)
and incident coronary heart disease (CHD) among
women, adjusting for individual sociodemographic
characteristics, baseline health status and health
behaviors.
Study Design: Using 2-level hierarchical Cox
proportional hazard regression models (e.g. shared
frailty models), we analyzed the Women’s Health
Initiative Clinical Trial (WHI CT) data, merged with tractlevel Census data on neighborhood sociodemographic
characteristics. Participants were recruited at 40 clinical
centers and 36 satellite locations. Participants ages 5079 at baseline, were enrolled between 1993 and 1998,
and followed until at least March 2005. We examined 3
outcomes: time until first CHD event (myocardial
infarction (MI), revascularization, and hospitalized
angina), time until CHD death or first MI, and time until
CHD death. The NSES index included 6 educational
and economic measures for the Census tract of
residence.
Population Studied: The sample (n= 68,132) was
81.7% nonHispanic white, 10.3% nonHispanic black,
4.2% Hispanic, and 3.8% other; 60.9% were married at
baseline, 94.3% had at least a high school education,
and 66% had household incomes between $20,000 and
$75,000 (categories ranged from <$10,000 to
=$150,000).
Principal Findings: After controlling for a number of key
individual-level sociodemographic characteristics
including age, race, education, income, martial status,
region, family history of MI, and study arm, we found that
women residing in lower NSES census tracts
experienced higher risk for each of the outcomes and
shorter time to first CHD event or death by CHD. The
relationship between NSES and incident CHD was
mediated by baseline health status (BMI, waist hip ratio,
self-reported history of diabetes, hyperlipidemic
medication use and/or self reported high cholesterol,
hypertension) and health behaviors (smoking pack-
years, alcohol use, hormone use). After controlling for
these baseline measures in addition to
sociodemographic variables, the effect of NSES
decreased but remained statistically significant for all
outcomes except time to CHD death.To illustrate the
effect size of NSES on our outcomes, we compared the
hazard ratios for our outcomes for a women living in
Anacostia and northwest DC (neighborhoods which
represent the bottom and top quartiles of NSES in the
US), controlling for both demographics and baseline
health measures. Compared to the same woman living
in northwest DC, one living in Anacostia has a 1.20
times greater risk for first CHD event (CI:1.01,1.42) and
1.28 times greater risk for CHD death or MI
(CI:1.02,1.62). There is no significant difference
between the risk of these two women for CHD death (HR
1.28, CI:0.86,1.92). Propensity analyses confirmed that
these effect sizes were not sensitive to selection on
observed characteristics.
Conclusions: Living in a lower SES neighborhood was
independently associated with greater CHD risk, above
and beyond individual-level baseline characteristics.
Implications for Policy, Delivery or Practice: Our
findings suggest that the observed effects operate in part
through health behaviors and diseases which increase
cardiovascular risk. This study is part of a larger effort
aimed at assessing whether and how neighborhood
characteristics affect women’s health and understanding
whether changing neighborhood features could improve
health and reduce health disparities.
Funding Source(s): National Heart, Lung, and Blood
Institute
♦ Impact of Medicaid Family Planning Waivers on
Internatal Coverage & Birth Intervals of Low-Income
Women
Susan Haber, Sc.D.; Norma Gavin, Ph.D.
Presented by: Susan Haber, Sc.D., Senior Economist,
Division for Health Services & Social Policy Research,
RTI International, 1440 Main Street, Suite 310, Waltham,
MA 02451, Phone: (781) 434-1721, Email:
shaber@rti.org
Research Objective: Many low-income women do not
qualify for Medicaid until they become pregnant; they
then lose coverage 60 days after delivery. CDC has
recommended expanding insurance coverage for lowincome women to increase receipt of preconception and
internatal health care, which can improve neonatal
outcomes and reduce perinatal disparities. Twentyseven states, including Florida, have obtained federal
approval for Medicaid Family Planning Waivers (FPWs)
to provide family planning and primary care services to
women who otherwise would not qualify for Medicaid.
This study investigates the impact of Florida’s FPW on
continuity of post-partum Medicaid coverage and the
interval between Medicaid-covered deliveries, comparing
outcomes in Florida with a control state (Georgia)
without a FPW.
Study Design: We compared women in Florida and
Georgia who had a Medicaid-covered delivery during
FY2000-FY2001. We compared three eligibility groups
that differ in their Medicaid eligibility and risk of
subsequent pregnancies – teens (age<19), adults with
AFDC-related eligibility, and adults with poverty-related
eligibility. We used Medicaid data for 1999-2001 to
create a record for each woman that included
demographic characteristics, monthly Medicaid eligibility,
and dates of all deliveries. We used Kaplan-Meier
survival analysis to examine retention of Medicaid
following an index delivery and time to second delivery,
accounting for censoring due to differences in the time
observed after the index delivery.
Population Studied: All women with a Medicaidcovered delivery in FY2000-FY2001 in Florida
(n=120,414) and Georgia (n=113,584).
Principal Findings: Within 24 months after the index
delivery, 14% of women in Georgia and 10% of women
in Florida had a second delivery. Teens were the most
likely to have a second delivery (14% in Florida and 21%
in Georgia). Florida and Georgia differ substantially in
retention of Medicaid coverage following a delivery.
Although over 90% of women in both states have
Medicaid coverage 2 months after the index delivery,
coverage diverges substantially after this. Twenty-three
months after delivering 86% of women in Florida, but
only 10% in Georgia, still have Medicaid. Most of the
women in Florida are covered through the FPW; only
13% are still eligible for full Medicaid 23 months after
delivery. 89% of women in Florida with two deliveries
had uninterrupted Medicaid coverage (either full or
limited) between their deliveries, compared to 40% in
Georgia. They also were more likely to have Medicaid
coverage 9 months prior to their second delivery (95% in
Florida compared to 56% in Georgia).
Conclusions: Florida’s FPW substantially increases the
likelihood that low-income women will remain attached to
Medicaid following delivery and will have access to
Medicaid-covered services at the start of a subsequent
pregnancy. The longer interval between deliveries is
consistent with better access to family planning services
in Florida, but further study is needed to determine if this
is due to the waiver.
Implications for Policy, Delivery or Practice: Medicaid
FPWs can be an effective vehicle for extending Medicaid
coverage and providing access to care during the
interpregnancy period. Future research will examine
their impact on service use, particularly among women
at risk of poor outcomes.
♦ A Longitudinal Analysis of Total Workload &
Women’s Health after Childbirth
Patricia McGovern, Ph.D., M.P.H.; Rada Dagher, Ph.D.;
Heidi Roeber-Rice, M.D., M.P.H.; Dwenda Gjerdingen,
M.D., M.P.H.; Bryan Dowd, Ph.D.; Ulf Lundberg, Ph.D.
Presented by: Patricia McGovern, Ph.D., M.P.H.,
Professor, Division of Environmental Health Sciences,
University of Minnesota School of Public Health, Mayo,
MMC 807, 420 Delaware Street, SE, Minneapolis, MN
55455, Phone: (612) 625-7429, Email: pmcg@umn.edu
Research Objective: To investigate the association of
total workload, including paid and unpaid work, and
personal and work-related factors with women’s health
during the first year after childbirth.
Study Design: This study employs a prospective cohort
study design and utilizes theoretical perspectives from
health economics to examine the effects of total
workload, job satisfaction and stress, social support,
breastfeeding, and infant behavior on women’s mental
and physical health, and childbirth-related symptoms.
Eligible women were enrolled in-person, while
hospitalized for childbirth in the Minneapolis and St. Paul
seven county metropolitan area of Minnesota in 2001.
Telephone interviews were conducted at 5 weeks, 11
weeks, 6 months, and 12 months after delivery with
response rates of 88% (N=716), 81% (N=661), 76%
(N=625), and 70% (N=575), respectively. General
mental and physical health were measured at each time
period using the SF-12 version 2, and childbirth-related
symptoms were measured with a previously validated
instrument. Panel data analyses and econometric
methods were used to estimate the research models.
Population Studied: The study population included all
women delivering at selected hospitals ages 18 or older.
State birth statistics data revealed that the study
population was representative of all birth mothers
delivering at non-study hospitals on important
demographic and birth factors. Sample selection criteria
included: speaking English, being employed, and having
had a live, singleton birth.
Principal Findings: Women’s health improved with
time; total average daily workload ranged from 14.4
hours (6.8 hours of paid work; 7.1% working at 5 weeks
postpartum) to 15.1 hours (7.8 hours of paid work; 97%
working at 12 months postpartum). Longitudinal
analyses revealed an increased total workload over time
was associated with poorer mental health (beta
coefficient = -0.304; 95% CI: -0.432, - 0.175), and
increased symptoms (beta coefficient = 0.070; 95% CI:
0.017, 0.124). Increased perceived control and social
support were associated with better mental health (beta
coefficients = 0.886; 95% CI:0.482,1.29; and 0.397; 95%
CI:0.242,0.552, respectively), and fewer symptoms (beta
coefficients= -0.262; 95% CI: -0.415, -0.109; and -0.085;
95% CI: -0.134, -0.036, respectively).
Conclusions: Study findings on total workload reveal
that these new mothers had heavy workloads with very
limited sleep and personal time. Given the positive
association seen here between better postpartum health
and social support, and the inverse association between
health and total workload, providers and employers need
to explore options that enhance social support and
promote a better balance between work and rest
throughout the postpartum year.
Implications for Policy, Delivery or Practice: Study
findings suggest a need to investigate the role of paid
leave policies or flexible work arrangements to provide
the resources needed to keep total postpartum
workloads manageable, and facilitate mothers’ recovery
from childbirth and successful integration of family and
work commitments.
Funding Source(s): National Institute for Occupational
Safety and Health
♦ Cost & Barriers to Care: Impact on Women’s
Health Care Access, 2001 & 2008
Usha Ranji, M.S.; Alina Salganicoff, Ph.D.
Presented by: Usha Ranji, M.S., Principal Policy
Analyst, Women's Health Policy Program, Kaiser Family
Foundation, 2400 Sand Hill Road, Menlo Park, CA
94025, Phone: (650) 234-9257, Email: uranji@kff.org
Research Objective: To analyze the impact of barriers
on women’s access to care and use of services and
examine changes in access and costs barriers between
2001 and 2008.
Study Design: Data are from the 2001 and 2008 Kaiser
Women’s Health Surveys, nationally representative
samples of women ages 18-64 living in the continental
U.S. Data was collected using a stratified random-digit
sample of telephone numbers in the U.S. with a
disproportionately large sample of African-American,
Latina, uninsured, low-income and women on Medicaid.
Samples were weighted to provide nationally
representative estimates, using the Census Bureau’s
most recent Annual Social and Economic Supplement.
Population Studied: Findings are presented for women
ages 18 to 64 in the U.S. in 2001 and 2008. Sample
sizes were 3,966 in 2001 and 2,015 in 2008.
Principal Findings: In 2008, 24 percent of non-elderly
adult women reported they had delayed or gone without
needed care in the prior year because of costs,
23percent did not fill a prescription due to cost and 18
percent skipped or took smaller doses of medicines to
make them last longer. Among women with incomes
below 200 percent of poverty, 40 percent delayed or
went without needed care, 35 percent did not fill a
prescription, and 28 percent skipped or took smaller
doses because of costs. Among the uninsured, 55
percent skipped or delayed care because of the costs,
as did 31percent with Medicaid and 14 percent with
employer-sponsored insurance. Uninsured women also
had substantially lower rates of preventive screenings.
Among low-income women with different insurance
types, rates of barriers were often twice as high among
uninsured women compared to their insured
counterparts. Affordability barriers were also twice as
frequent among women in poorer health compared to
those in better health. While most estimates were stable
between 2001 and 2008, uninsured women had longer
spells of uninsurance, and among the uninsured, 21
percent reported not being able to see a specialist in
2008, compared to 15 percent in 2001. Women were
more likely to express concerns about quality in 2008 26 percent compared to 23 percent in 2001.
Conclusions: Cost pressures continue to be a
significant barrier to women’s access to care, with large
shares of women delaying needed care and prescription
medicines as a result. Uninsured and low-income
continue be at considerably higher risk, as are women in
poorer health. Alleviating cost burdens for women is an
important aspect to reducing barriers faced by women.
Implications for Policy, Delivery or Practice: This
study focuses on the cost barriers that women face in
obtaining health care, and quantifies their sizable impact
on access and the sizable impact on some groups of
women. As policymakers undertake national health
reform debates under deteriorating economic conditions,
these findings underscore the critical role that
affordability will play in promoting and expanding access,
particularly to populations that are already at risk of poor
access.
Funding Source(s): Kaiser Family Foundation
♦ Women's & Men's Health: Use & Expenditures for
Health Care Over the Life Cycle
Amy Taylor, Ph.D.; Lan Liang, Ph.D.
Presented by: Amy Taylor, Ph.D., Senior Economist,
Committee For A Constructive Tomorrow, Agency for
Healthcare Research & Quality, 540 Gaither Road,
Rockville, MD 20859, Phone: (301) 427-1660, Email:
ataylor@ahrq.gov
Research Objective: It has been well documented that
women are more likely to use health care services than
men and also to report high medical expenses. In a
1996 Medical Expenditure Panel Survey (MEPS)
Research Findings, a higher percentage of women
reported having any medical expenses than did men
(Cohen et al., 2000). However, average expenditures for
those with an expense did not vary significantly between
men and women. The purpose of this analysis is to
examine the pattern of medical care utilization and
expenditures over the lifetime of women, and to
compare it to that of men. Medical care utilization and
expenditures will be examined within and across age
groups, for women and men, by socio-economic and
demographic characteristics. Four age groups—young
adults (aged 18-29 years), adult (30 – 44 years), mid-life
(45 – 64 years), and elderly (65 years and older) will be
studied. In addition, we will compare treatment patterns
by gender for various chronic diseases, such as
diabetes, arthritis, and cardiovascular disease.
Study Design: Full year data from the 2005 Medical
Expenditure Panel Survey are used in this analysis. The
analysis examines men and women’s health status, use
of medical care, types of services used, and health care
expenditures within subgroups of the populations. The
paper will present tables showing expenditures for
different types of health services, including ambulatory
care, inpatient stays, emergency room, home
healthcare, and prescription drugs. For each age group,
multivariate analyses will be used to study how other
factors such as self-reported health and mental health,
health insurance status, race/ethnicity, education,
income and poverty status moderate the gender effect.
The proposed analyses will also study how health care is
financed and the financial burden of out-of-pocket
medical care expenditures as a percent of income.
Population Studied: A nationally representative sample
of non-institutionalized women and men, age 18 and
over, in the MEPS-Household survey, 2005.
Principal Findings: Preliminary data show that women
age 18 – 64 are more likely to have a doctor visit or use
preventive services than are men in this age group,
although by age 65 men’s utilization of these services is
not significantly different from women’s. Expenditures
for health care are higher for women aged 18 – 44 than
for men, but are comparable for those age 45 and
above. Over 20 percent of older women (age 65+)
spend more than 10 percent of their income on medical
care, compared to 9.4 percent of older men.
Conclusions: Women in younger age groups have a
higher probability of using medical services than men,
although men’s rate of utilization of most services
catches up with that of women by age 65. Out-of-pocket
medical expenditures as a percent of income are very
high for both women and men age 65 and over,
particularly for women in this age group.
Implications for Policy, Delivery or Practice: Health
policies that affect financial and non-financial access to
health care services have an important gender
component. To improve the quality of health care for
both men and women, it is important for policy makers
to understand the factors that influence both groups’
utilization and expenditures for medical care.
Funding Source(s): AHRQ
Gender & The Practice of Care
Chair: Emily Shortridge
Sunday, June 28 * 11:00 a.m.- 12:30 p.m.
♦ Burden of Gestational Diabetes Mellitus in 2007
Juliette Chen, M.P.A.; William Quick, M.D., F.A.C.P.,
F.A.C.E.; Wenya Yang, M.P.A.; Yiduo Zhang, Ph.D.;
Alan Baldwin, M.S.; Jane Moran, M.D.
Presented by: Juliette Chen, M.P.A., Senior Associate,
The Lewin Group, 3130 Fairview Park Drive, Suite 800,
Falls Church, VA 22042, Phone: (703) 269-5709, Email:
juliette.chen@lewin.com
Research Objective: Estimate national health care use
and medical costs associated with gestational diabetes
mellitus (GDM) in 2007.
Study Design: We used an attributable risk approach
that estimates the proportion of national health care
resource use associated with GDM. We constructed
etiological fractions that combine GDM prevalence rates
with rate ratios that reflect the impact of GDM on per
capita health care use controlling for other determinants
of health care use. We estimated the rate ratios using
multivariate Poisson regression analysis with medical
claims for 32,735 continuously enrolled (from January 1,
2004 through December 31, 2006) mothers and their
newborns in a longitudinal database – the Ingenix
Research Data Mart. We analyzed the 2003-2005
National Hospital Discharge Survey to estimate national
prevalence of GDM. We then multiplied the etiological
fractions by estimates of national health care use and
costs from analyses of 2005 Nationwide Inpatient
Sample, 2000-2005 National Ambulatory Medical
Survey, 2000-2005 National Hospital Ambulatory
Medical Survey, and 2003-2005 Medical Expenditure
Panel Survey. Estimates were extrapolated to 2007
based on Census Bureau population estimates. We
analyzed national health care use and costs associated
with GDM for the following complication categories: 1)
direct treatment of GDM, 2) eight categories of maternal
outcomes, and 3) ten categories of perinatal outcomes.
Population Studied: This analysis focuses on
pregnancies that result in delivery (including both live
births and stillbirths). Mother’s GDM status is determined
by the presence of ICD-9-CM diagnosis code 648.8.
Analysis of new mothers’ health care use covers the
period 9 months preceding delivery through 12 months
following delivery. The newborn analysis covers
perinatal outcomes and associated health care use
during the 12 months following delivery.
Principal Findings: GDM prevalence increases with
maternal age, rising from 1.3% of women under 21 to
8.7% of women over 35. For the estimated 180,000
GDM pregnancies resulting in delivery, average
expenditures increased $3,305 per GDM mother plus
$209 in the newborn’s first year of life. GDM increased
national medical costs by $636 million in 2007—$596
million for maternal costs and $40 million for neonatal
costs. Approximately $230 million (36%) of GDM related
medical costs are carried by government programs
(primarily Medicaid), $355 million (56%) are covered by
private insurers, and $51 million (8%) consists of self
pay and charity care.
Conclusions: GDM imposes a significant economic
burden. These estimates of the economic burden of
GDM likely are conservative because we focus on nearterm medical costs, omitting the increased risk for longterm sequelae.
Implications for Policy, Delivery or Practice: This is
the first study that uses an attributable risk method to
quantify the economic burden of GDM. These findings
are suggestive of potential savings from reducing GDM,
which information can be used to help develop the
business case for interventions to reduce GDM
prevalence and improve management of glucose levels
among women diagnosed with GDM.
Funding Source(s): National Changing Diabetes
Program
♦ Gender Equity & Access to Angiography in
Canadian Hospitals Between 2003 & 2005
Carey Levinton, M.Sc.; Adalsteinn Brown, Ph.D.; Brenda
Tipper, M.H.Sc.
Presented by: Carey Levinton, M.Sc., Department of
Health Policy, Management & Evaluation, University of
Toronto, 155 College Street, 4th floor, Toronto, M5T
3M6, CA, Phone: (416) 779-1510, Email:
carey.levinton@utoronto.ca
Research Objective: To determine whether women
have equal access to angiography following admission
to hospital with a diagnosis of an acute myocardial
infarction (AMI).
Study Design: Retrospective analysis of Canadians
who participated in the Canadian Community Health
Survey (CCHS) between 2003 and 2005. Linked to the
national Health Person Oriented Information database, a
database capturing all admissions to acute care
hospitals. All results were population weighted.
Classification and regression tree (CART) analysis was
employed to partition the population into disparate health
states ordered into groups ranging from individuals who
are healthy to those having debilitating chronic
conditions. Subsequently the health groups were
adjusted for socio-economic determinants including level
of education and family income. Econometric
techniques, including the Gini coefficient, were employed
to assess differences in access to angiography between
men and women which are attributable to socioeconomic factors. Finally the analysis was stratified into
two well-defined geographical regions which we denote
by 1 and 2.
Population Studied: All men and women participating
in the CCHS survey, over the age of 15, who had
previously been admitted to a Canadian hospital with a
diagnosis of an AMI.
Principal Findings: We identified 273,451 (population
weighted) individuals who met criteria for entry, 188,911
of which were male (69.1%) and 84,540 females
(30.92%). Unadjusted 45.1% of men and 40.6% of
women received angiography following an AMI. After
accounting for differences in health status, the relative
inequity in access to angiography between men and
women, attributable to socio-economic determinants,
ranged from 1.3% in region 1 to 2.6% (P < 0.05) in
region 2.
Conclusions: Despite carefully controlling for health
status, significant inequities in access to angiography, an
important diagnostic tool, remain between men and
women. Moreover these disparities vary across regions
as well.
Implications for Policy, Delivery or Practice:
Equitable access to important diagnostic procedures,
such as angiography may result in women incurring a
lower burden of morbidity and mortality.
Funding Source(s): Canadian Institutes of Health
Research
♦ Sex Differences in Prescription Drug Utilization: An
Analysis of Population-Based Data from British
Columbia, Canada
Steve Morgan, Ph.D.; Jamie Daw, B.H.Sc.; Natasha de
Sousa, M.A.; Gillian Hanley, M.A.; Devon Greyson,
M.L.I.S.; Barbara Mintzes, Ph.D.
Presented by: Steve Morgan, Ph.D., Associate
Professor, Centre for Health Services & Policy
Research, University of British Columbia, #201 - 2206
East Mall (LPC), Vancouver, BC, V6T 1Z3, CA, Phone:
(604) 822-7012, Email: morgan@chspr.ubc.ca
Research Objective: A variety of ad hoc analyses of
surveys and insurance company data indicate that there
are potentially important sex differences in the rates of
prescription drug utilization. These differences may have
important implications for health care quality, safety,
efficiency and equity. We sought to produce a
comprehensive view of such differences across
therapeutic areas for the entire population of British
Columbia, Canada.
Study Design: We drew on unique databases that
provide patient-specific information about prescription
drug use, health system use, and socio-demographics.
We computed crude and adjusted rates of prescription
utilization for women and men. Adjusted models
accounted for age, health status, income and region.
Analyses were computed for overall prescription drug
use and for use of prescription drugs within 20 leading
therapeutic categories. We estimated adherence to
treatments for select chronic conditions.
Population Studied: Year-2006 administrative data
were obtained for virtually every resident of BC. To
ensure complete data capture, we excluded residents
who lived outside of the province for more than 90 days
(e.g., students who study outside of province or retirees
who spend winter in warmer climates). This left us with a
sample of 4.1 million individuals (approximately 96% of
the provincial population).
Principal Findings: Across all treatment categories,
boys under age 14 were more likely than girls of the
same age to receive at least on prescription drug. Boys
were nearly 4 times more likely to receive psychostimulants or other treatments for ADHD than girls.
Beyond age 14, women were more likely than men to
receive at least one prescription drug. Significant sex
differences existed in the use of treatments for which sex
is a relevant clinical consideration: e.g., bone density,
contraceptives, erectile dysfunction, and cardiovascular
risks. In other categories, root causes of sex differences
are less clear. Women were far more likely than men to
receive treatments from neurological drug categories:
i.e., benzodiazepines and antipsychotics (beyond age
40). Most significantly, adult women were nearly twice as
likely as adult men to receive prescribed
antidepressants. Women were more likely than men to
persist with treatments in most chronic treatment
categories.
Conclusions: There are significant sex differences in
the rates of prescription drug use. Overall, and across a
majority of the largest therapeutic categories of drug
treatment, women are more likely than men to receive
prescription drugs. Significant sex differences in
likelihood of prescription drug use from some therapeutic
classes appear to be driven, in part, by gendered norms
and behaviours--from health seeking, to diagnosis and
prescription, through to prescription filling.
Implications for Policy, Delivery or Practice:
Developing a better understanding of sex differences in
utilization of medicines is critically important for the
safety, efficiency and equity of this important component
of the health care system. Differences in behaviour
(among patients and providers) may be resulting in sex(and gender-) related under or over use of medicines.
Notably, because women are less likely than men to be
subjects in pre-market clinical trials, higher rates of
utilization of medicines may be putting some women at
unnecessary risk of medicine-related harms.
Funding Source(s): Canadian Institutes of Health
Research - CIHR
♦ Decomposing Gender Differences in Low Density
Lipoprotein Cholesterol among Patients with or at
risk for Cardiovascular Conditions
Usha Sambamoorthi, Ph.D.; Sophie Mitra, Ph.D.;
Leonard Pogach, M.D., M.B.A.; Ranjana Banerjea, Ph.D.
Presented by: Usha Sambamoorthi, Ph.D., Professor,
Department of Psychiatry, University of Massachusetts
Medical School, 11 Bartram Road, Englishtown, NJ
07726, Phone: (732) 972-6232, Email:
ushasambamoorthi@gmail.com
Research Objective: Maintaining healthy lipid levels are
essential for men and women. Prior research suggests
gender differences in low density lipoprotein cholesterol
(LDL-C) levels. In national surveys, age-adjusted nonHDL cholesterol concentrations were lower in women
than men; however, among women with or at risk for
cardiovascular diseases women were less likely to attain
optimal lipid control. The objective of the study is to
identify and measure the extent to which gender
differences in lipid control among persons at risk for
cardiovascular diseases could be explained by
modifiable factors.
Study Design: Secondary data analyses of merged
Veteran Health Administration (VHA) and Medicare
claims data for the fiscal years (FY) 2002 and 2003.
Veteran clinic users with diabetes or heart disease or
hypertension in FY2002 were identified with ICD-9-CM
codes. FY2003 LDL-C values were obtained from the
VHA laboratory files. Gender differences were
examined using several measures of LDL-C (mean
values, LDL-C percentiles and binary indicator for poor
LDL-C control). Poor LDL-C control was defined as
LDL-C values >= 130mg/dl. Multivariate techniques
consisted of least squares, quantile and logistic
regressions. The independent variables were
demographics, socio-economic characteristics, health
status, mental health and medication use. Based on the
parameter estimates and distribution of individual
characteristics, we performed traditional and extended
decomposition techniques to analyze the drivers behind
the gender differences in lipid control.
Population Studied: Veterans using VHA facilities
diagnosed with diabetes or heart disease or
hypertension during FY 2002 and recorded LDL-C
values in FY2003 (N = 537,191). There were 10,747
women and 526,444 men veterans.
Principal Findings: Overall, more women (30.4%) than
men (18.7%) had poor LDL-C control. Quantile
regressions at .10, .25, .50, .75 and .90 percentiles
suggested that women had higher LDL-C values
compared to men at all points of the distribution. Even
after controlling for many observable characteristics,
women were more likely to have poor LDL-control. The
adjusted odds ratio was 1.62 with 95% CI = 1.55, 1.69.
While medication use decreased the likelihood of poor
LDL-C control, presence of depression and anxiety were
associated with increased likelihood of poor LDL-C
control. Nearly one third of the 12 percentage point gap
in poor LDL-C control was explained by variables
included in the model. Most of the gender gap in poor
LDL-C control could be explained by differences in type
of cardiovascular condition, age distribution, depression
and anxiety prevalence. Modifiable factors included
medication use for lipid control.
Conclusions: Gender differences in lipid control exist
and nearly one third of the difference could be explained
by differences in patient characteristics some of which
are modifiable.
Implications for Policy, Delivery or Practice: These
findings suggest gender differences in lipid control could
be partially reduced by increasing the use of lipid
lowering drugs among women. Our study findings
suggest the need for integrating mental health
management among women to reduce cardiovascularrelated morbidity and mortality.
Funding Source(s): VA
♦ Impact of Practice Structure on Quality of Care
among Women Veterans
Elizabeth Yano, Ph.D.; Bevanne Bean-Mayberry, M.D.;
Michael Mitchell, Ph.D.; Ismelda Canelo, M.P.A.; Andy
Lanto, M.A.; Donna Washington, M.D.
Presented by: Elizabeth Yano, Ph.D., Research Career
Scientist, VA Greater Los Angeles Health Services
Research & Development Center of Excellence, VA
Greater Los Angeles Healthcare System, 16111
Plummer Street (152), Sepulveda, CA 91343, Phone:
(818) 895-9449, Email: elizabeth.yano@va.gov
Research Objective: In sharp contrast to other U.S.
health care settings, women are a numerical minority in
VA facilities, which creates challenges to delivering
quality care in a system historically focused on care for
men. To address their needs, many VAs have
developed women’s clinics, designated providers to see
women to concentrate expertise in a few, and/or refer to
community providers. Our objective was to evaluate on
a national scale the impact of different practice
structures on the quality of care women veterans
receive.
Study Design: We merged results from a national key
informant survey assessing the organization and
management of women’s health (WH) services at
geographically distinct VA facilities with 2001-03 patientlevel data from chart-based chronic disease and
prevention quality indicators and survey-based patient
ratings of care. Organizational variables included clinic
structure, practice arrangements, scope of services,
staffmix, availability of WH clinical expertise, and
resource sufficiency. Patient-level measures included
HEDIS-like measures of diabetes processes, breast and
cervical cancer screening, and previously-validated
survey scales of accessibility, continuity and
coordination.
Population Studied: We surveyed senior VA WH
clinicians at all VA facilities serving 300+ women
veterans (N=166), obtaining an 82% RR (n=136)
representing all VA regions and networks. Centralized
performance data from annual random samples of
eligible women veterans were obtained and then
combined across years to yield sufficient sample sizes
(from 2,000-20,000) for each measure.
Principal Findings: Gender-focused practice features
(e.g., women’s clinics) did not predict variations in
women veterans’ chronic disease quality for genderneutral conditions (diabetes). However, they were
significantly related to gender-specific indicators and
patient ratings of care. Breast cancer screening rates
were better in facilities with any type of women’s clinic
(p<.05), while higher cervical cancer screening rates
were achieved in VAs with more comprehensive staffing
(gynecologists, other MDs, social workers) (p<.05) and
worse in those staffed by trainees and non-MDs (p<.05).
Accessibility was better in facilities with women’s PC
clinics (p<.0001), budgetary control (p<.005), local WH
clinical experts (p<.05), capable of providing WH training
(p<.05), active WH QI programs (p<.05), and onsite
bone scan equipment, endometrial biopsy and IUD
placement capabilities (each p<.05). Accessibility was
worse in facilities where most women were seen in
general PC clinics (p<.05) or had designated WH
providers (p<.05). Findings for continuity were highly
similar. Coordination was better in facilities with
women’s PC clinics, WH-focused QI programs, more
onsite WH services, and higher WH resources (clinical
expertise, staffing levels) and greater local authority over
WH staffing arrangements (each p<.05), and worse in
facilities having to refer women to other VA facilities for
WH specialty care.
Conclusions: Separate women’s primary care clinics
provide focused attention and resources for delivering
guideline-concordant care to women veterans, however,
the design and scope of care that they deliver is key.
Implications for Policy, Delivery or Practice: The VA
health care system is experiencing changes in its patient
mix, requiring policymakers and planners to reconsider
how VA care is organized in the short and long terms.
More research is needed to determine the attributes and
design of clinical programs that better address genderneutral conditions.
Funding Source(s): VA
Delivering High Quality Health Care: Learning from
Internation Experience
Chair: Ellen Nolte
Monday, June 29 * 4:45 p.m.-6:15 p.m.
♦ Application of Patient Safety Indicators in 16 OECD
Member Countries Using Administrative Hospital
Data
Saskia Droesler, M.D.; Niek Klazinga, M.D., Ph.D.;
Daniel Tancredi, Ph.D.; Patrick Romano, M.D., M.P.H.
Presented by: Saskia Droesler, M.D., Professor, Health
Care, Niederrhein University of Applied Sciences,
Reinarzstrasse 47, Krefeld, 47805, DE, Phone:
+0114921518226643, Email: saskia.droesler@hsnr.de
Research Objective: As part of the Health Care Quality
Indicator project of the Organization for Economic CoOperation and Development (OECD), we explored the
potential for international comparison of patient safety by
evaluating Patient Safety Indicators (PSIs) originally
published by the US Agency for Healthcare Research
and Quality (AHRQ). A previous pilot with seven
participating countries showed the feasibility of the
method. The objectives of the 2008 calculation round
were to investigate the feasibility of calculating 15 PSIs
and to explore the validity of the results across a larger
number of participating countries. Furthermore, we
evaluated potential impacts of variation in the distribution
of age and gender, length of hospital stay, and medical
or surgical treatment on country-specific PSI rates.
Study Design: We performed a retrospective crosssectional study using hospital administrative data.
Population Studied: The study population consisted of
adults discharged from acute care hospitals in Belgium,
Canada, Denmark, Finland, France, Germany, Italy,
New Zealand, Norway, Portugal, Singapore, Spain,
Sweden, the Netherlands, the United Kingdom, and the
United States of America (US) in 2006 or 2007 (except
that Belgian cases were from 2004). The number of
eligible discharges across the 16 countries varied
between 0.45 and 32.98 million.
Principal Findings: Pearson’s correlations were
performed among all countries. As the US is the most
experienced country in using hospital administrative data
for quality measurement, high correlations with US rates
are interpreted as a test of construct validity. Pearson’s
correlation coefficients were statistically significant
between the US and 14 other countries with values
between 0.634 and 0.993. No correlations were found
for data from two countries due to technical problems in
PSI calculation and marked underreporting. There was
substantial systematic variation in PSI rates across all
countries, ranging from a 6-fold difference for “foreign
body left in during procedure” (coefficient of variation
[CV] =48.1) and a 17-fold difference for “obstetric trauma
- vaginal delivery without instrument” (CV=57.8) to a
111-fold difference for “birth trauma - injury to neonate”
(CV=96.6) and a 644-fold difference for “postoperative
respiratory failure” (CV=100.7). Analysis of age, gender,
and medical-surgical stratified data did not reveal
notable differences in PSI rates after direct
standardization, whereas the mean number of
secondary diagnoses was highly correlated with countryspecific PSI rates. As the definitions of 12 PSIs were
identical in the 2007 and 2008 calculation rounds,
reliability analysis was performed. We found strong
concordance between mean population rates from 2007
and 2008 (Pearson correlation coefficient r=0.998, p =
0.01).
Conclusions: This study supports our previous findings
that AHRQ PSIs can be applied to international hospital
data. Although all 16 participating countries use DRGs
for hospital reimbursement, data quality and
completeness vary. Underreporting may be a systematic
problem in some countries.
Implications for Policy, Delivery or Practice: Based
on these findings and existing literature on PSI validity,
the OECD expert group selected 7 PSIs for regular
biannual reporting, starting in 2009. In addition,
recommendations for national governments were
formulated to enhance the potential of administrative
databases through coding and registration practices to
provide the information for internationally comparable
PSI rates.
Funding Source(s): OECD
♦ Drugs, Sex, Money & Power: A Potent Mix for
Health Policy
Marion Haas, Ph.D.; Toni Ashton, Ph.D.; Elena Conis,
Ph.D.; Margaret MacAdam, Ph.D.; Terkel Christiansen,
Ph.D.; Luca Crivelli, Ph.D.
Presented by: Marion Haas, Ph.D., Associate
Professor, Centre for Health Economics Research &
Evaluation, University of Technology, Sydney, P.O. Box
123, Broadway, Sydney, 2007, AU, Phone: +61 2 9514
4721, Email: marion.haas@chere.uts.edu.au
Research Objective: From the perspective of seven
countries, to examine the debate about the introduction
of the Human Papilloma Virus (HPV) vaccination, the
actors who influenced the debate and the outcome.
Study Design: Case studies drawn from survey reports
and additional information provided by members of the
International Network Health Policy and Reform to
examine similarities and differences between the policy
processes and outcomes for the countries.
Population Studied: We studies the experiences of
Australia, Canada, Denmark, Germany, New Zealand,
Switzerland and the USA in considering the
effectiveness and cost-effectiveness of the HPV vaccine
and making a decision about its introduction and/or
funding.
Principal Findings: The level of uncertainty about
effectiveness and uptake, as well as other dimensions
such as duration of immunity and cost-effectiveness,
creates the space for "struggle" between interested
parties. Countries with different decision making
processes can make similar decisions about the value of
subsidizing a program even when the influence of
supporters and opponents seems disparate. in the case
of the HPV vaccine, a number of countries seemed to
divert from their usual decision-making processes. Few
of the countries included in this study subjected the
vaccine to a systematic process of review, and there
seemed to be a degree of urgency among decision
makers to approve the vaccine and/or provide funding
for an organised program. Open discussion about the
relative cost-effectiveness of the vaccine compared with
other health interventions has been conspicuous by its
absence from this debate.
Conclusions: The speedy introduction of a subsidized
HPV vaccination program across a number of developed
countries can be seen as representing a successful
convergence of interests, whether motivated by profit or
public health. Increasing pressure to cover new drugs
while maintaining coverage of the existing basket of
products and services requires policy-makers to use
transparent and robust guidelines in making funding
decisions. Those guidelines should remain at armslength from political processes. That is, it is up to
decision makers (both bureaucratic and political), to
remain as firm as possible in their adherence to the
agreed processes.
Implications for Policy, Delivery or Practice: There is,
as yet, no direct scientific proof of the effect of the HPV
vaccine on morbidity and mortality and it will take
significant time and resources to obtain such evidence.
In addition, there is no evidence about the effect the
introduction of a vaccination program will have on the
rate of screening for cervical cancer (ie the uptake of
Pap tests). Ongoing research is needed to build the
evidence base for the effectiveness of the HPV vaccine;
it will also be important to monitor the rate of uptake of
both the vaccination and Pap tests. Delivering a “doublebarrelled” public health message (ie have this
vaccination AND (continue to) have regular Pap tests)
may be less effective than the previous simple public
health message about having regular Pap tests
Funding Source(s): Bertelsmann Foundation
♦ Accounting for the Cost of U.S. Health Care: A New
at Why Americans Spend More
Eric Jensen, M.S., M.B.A.; Diana Farrell, M.B.A., B.A.;
Bob Kocher, M.D., B.S., B.A.; Fareed Melhem; Lenny
Mendonca, M.B.A., B.A.; Nick Lovegrove, M.B.A.,
M.P.P., M.A.
Presented by: Eric Jensen, M.S., M.B.A., Fellow,
McKinsey & Company, 600 14th Street, Suite 200,
Washington, DC 20005, Phone: (202) 662-0954, Email:
eric_jensen@mckinsey.com
Research Objective: To understand the size and
growth of health care costs in the U.S. within the context
of health systems in other developed OECD countries.
Study Design: This is a comparative study of healthcare
spending and utilization data in the United States and 13
OECD countries. We used as our primary data source
health care data published by the OECD that allows for
cross-country comparability across its 30 member
countries. We then selected 13 countries for
comparison, using only those countries for which current
data was available across the entire spectrum of the
health systtem. For the U.S., we used MEPS (disease
prevalence and health care cost) and NHE (health care
costs) to calculate the cost impact of disease mix
differences.
Population Studied: Citizens in the US, with
comparisons to citizens in the 13 OECD countries.
Principal Findings: Of the $2.1 trillion the US spent on
health care in 2006, $650 billion in costs are above what
one would expect based on the nation's wealth and the
experience of other OECD countries. Outpatient care
accounts for nearly two-thirds of the excess spending or
$436 billion on account of structural and practice pattern
differences as well as strong incentives promoting
continued growth.
Conclusions: Any health reform efforts that do not
address the large and growing cost of outpatient care
(and the incentives underpinning that growth) are
unlikely to materially change the health care trajectory in
the United States.
Implications for Policy, Delivery or Practice: Health
care policy must focus on addressing the size and
growth of outpatient care costs if cost containment is
determined to be an objective. There is unlikely to be a
"silver bullet" in such an effort. Rather, it is likely to
require a comprehensive effort that addresses the
supply, demand and financing of care and the
interrelationships of the three.
Funding Source(s): self-funded
♦ Pharmaceutical Innovation in an International
Context--Is the U.S. Exceptional?
Salomeh Keyhani, M.D., M.P.H.; Paul Hebert, Ph.D.;
Steven Wang, M.D.; Daniel Carpenter, Ph.D.; Gerard
Anderson, Ph.D.
Presented by: Salomeh Keyhani, M.D., M.P.H.,
Assistant Professor, Health Policy, James J. Peters VA
Medical Center/Mount Sinai School of Medicine, 1
Gustave L. Levy Place, New York, NY 10029, Phone:
(212) 659-9563, Email:
salomeh.keyhani@mountsinai.org
Research Objective: Patients in the US pay more for
prescription drugs than patients in other developed
countries. The US is the only developed country that
does not employ a form of drug price regulation to
control pharmaceutical spending. We explored whether
the US is responsible for the development of a
disproportionate share of new molecular entities (NMEs).
Study Design: We identified the earliest patent filed for
each drug using the FDA´s Orange Book and the United
States Patent and Trademark Office´s website and
assigned each NME to an inventor country. Total
prescription drug spending, gross domestic product and
health related research spending for each country was
determined using OECD data and published reports.
First, we examined the relationship between the
proportion of total NMEs developed in each innovator
country and the proportion of total prescription drug
spending and GDP each country represented. Second,
we used a Poisson model to estimate the relationship
between the cumulative number of NMEs developed
from 1992-2004 and percent of GDP spent on
prescription drugs after adjusting for percent of GDP
devoted to health related research and the logarithm of
gross domestic product. We bootstrapped the standard
errors using 1000 replicates. We compared countryspecific actual and predicted NMEs for each country
from this model.
Population Studied: NMEs approved between 1992
and 2004.
Principal Findings: We identified 346 human
therapeutic NMEs. Fifty-eight (16.7%) NMEs did not
have patents in force at the time of approval. 36.4% of
all NMEs (including those without patents) were
developed in the US. The United Kingdom was the next
largest source of NME development (10.4%). Twenty
countries contributed to the development of 288 NMEs
with patents at time of approval. Among NMEs with
patents at the time of approval, the US accounts for
roughly 42.7% of prescription drug spending, 40% of
GDP among drug-developing countries and is
responsible for 43.7% of NME development. Using this
measure, Switzerland, the United Kingdom and Belgium
innovated proportionally more than their contribution to
GDP or prescription drug spending and South Korea,
Japan, Spain, and Australia innovated less. The
regression results revealed that pharmaceutical
innovation has a positive and statistically significant
relationship with the logarithm of GDP (p<0.007) and a
non significant relationship with percent of GDP spent on
prescription drugs (p=0.20) and percent of GDP devoted
to health related research (p=0.72). There was no
substantial difference between actual (n=126) and
predicted (n=127.1) NME development in the US as a
function of prescription drug spending after accounting
for other variables. The development of NMEs for most
countries is within the model´s standard error of
prediction. However, using this measure Switzerland and
France appear to develop NMEs statistically significantly
more than expected and South Korea, Australia and
Spain less than expected.
Conclusions: Pharmaceutical innovation is an
international enterprise. US pharmaceutical innovation
appears to be roughly proportional to its national wealth.
Implications for Policy, Delivery or Practice: Drug
spending in the US does not disproportionately privilege
domestic innovation, and many countries with national
health systems and drug pricing regulation were
significant contributors to pharmaceutical innovation.
Funding Source(s): Dr. Keyhani is Funded by a VA
HSRD Career Award
♦ Regulating Access to Health Care Providers &
Inequalities of Utilization in European Countries
Claus Wendt, M.A., Ph.D.; Nadine Reibling, M.A.
Presented by: Claus Wendt, M.A., Ph.D., Senior
Research Fellow, Mannheim Center for European Social
Research, University of Mannheim, A5, 6, Mannheim,
CA 68159, Phone: (617) 495-4303 ext 274, Email:
wendt@fas.harvard.edu
Research Objective: Regulating patients’ access to
healthcare has been used in several countries as a way
of controlling patients’ consumption levels. In some
countries, provider choice is directly limited through legal
regulations such as gatekeeping, whereas in other
countries patients’ behavior is primarily governed by
financial incentives like co-payments to doctor visits.
However, empirical studies, mostly conducted in the
United States, do not provide a clear answer whether
institutional access regulations actually accomplish a
reduction of used health services. The objective of this
paper is to assess the impact of access regulations on
healthcare utilization in a cross-national framework
comparing eleven European countries.
Study Design: The empirical test of our hypotheses is
based on the combination of macro-level institutional
indicators and micro-level survey data of the first wave of
SHARE. First, the theoretical relation between
institutional access regulations and utilization is outlined.
Second, an overview of instruments of access
regulations, evidence of effects on utilization and a
description of our measurement of legal regulations is
given. Next, data, variables and method are described
followed by a presentation of the effects of access
regulations on utilization levels and within-country
differences of utilization. Implications of our research
regarding effects of access regulations as well as for
cross-national research in this area are discussed in the
final part of the presentation.
Population Studied: SHARE provides data for a
comparative study of people over 50 conducted in 11
European countries in 2004. Looking at the elderly is of
special relevance for healthcare issues because higher
age increases the probability of both acute and chronic
diseases. These higher need levels make older people
use healthcare most frequently of all population groups.
Consequently, the effect of access regulations on
utilization levels and costs depends very much on how
older people react to or are affected by those.
Principal Findings: The results show that access
regulations and especially gatekeeping systems are
associated with a lower level of overall service usage.
Gatekeeping systems also reduce inequity in specialist
visits across groups with different levels of education.
Contrary to theoretical expectations but in line with
earlier studies cost sharing could not be related to
inequity patterns across income groups.
Conclusions: Looking at country-specific regressions
showed that access regulations influence the inequity of
care across population groups. We investigated inequity
in specialist care both across groups with different
income and educational level. While income inequity is
not related to the degree of cost sharing as would be
hypothesized, educational inequity is associated with the
degree of access regulation and especially the
establishment of a gatekeeping system. Finally, we
could show that a higher degree of regulation decreases
the probability of a doctor visit for people with low need
levels indicated by a good health status. This could be a
sign for increased efficiency of these access regulations
since the take up rate of medical services by people in
good health is lower.
Implications for Policy, Delivery or Practice: The
results indicate that access regulations can contribute to
a reduction of health services used. However, the
regulations mostly affect whether people have a first
doctor visit. This shows that an effective control of
consumption levels has also to influence provider
behavior. For instance, gatekeeping arrangements can
be designed in a way that encourage efficient provider
behavior such as fundholding schemes in Great Britain.
In addition, putting the locus of responsibility in the GP
also seems to have beneficial results in terms of
increased equity across groups with different educational
level.
Funding Source(s): CWF
Are Market Forces Beneficial? Effects of
Competition & Incentives on Provider Finances,
Costs & Quality
Chair: Laurence Baker
Tuesday, June 30 * 9:45 a.m.-11:15 a.m
♦ Effects of Competition in Post-Acute Care Markets
on Resource Intensity & Outcomes
Carrie Hoverman Colla, M.A.; Neeraj Sood, Ph.D.;
Melinda Beeuwkes Buntin, Ph.D.; Jose Escarce,
M.D.,Ph.D.
Presented by: Carrie Hoverman Colla, M.A., Ph.D.
Candidate, Health Services & Policy Analysis, University
of California, Berkeley, 1563 Lombard Street, San
Francisco, CA 94123, Phone: (917) 756-7666, Email:
carrieh@berkeley.edu
Research Objective: To analyze the effects of
competition in the Medicare post-acute care market on
resource use, length of stay, and outcomes of care in
inpatient rehabilitation facilities and how that relationship
responded to changes in payment systems.
Study Design: We use the introduction of prospective
payment for rehabilitation hospitals in 2002 as a natural
experiment to assess how changes the payment system
modify the effects of competition on resource use and
health outcomes. We constructed competition measures
for each patient based on predicted patient flows to
skilled nursing and inpatient rehabilitation facilities.
These predictions are generated from a model of facility
choice based on distance from the patient’s home,
facility type and characteristics, and patient
characteristics, which are exogenous sources of
.variation. Using predicted patient flows, we constructed
patient-level Herfindahl indices (HHIs) based on
probabilistic facility of admission. We estimated
resource intensity and length of stay from Medicare
claims and cost reports using a 60-day inpatient
rehabilitation facility episode. We used Medicare data
and the MDS to classify patients into two health outcome
categories: returning to the community versus dead or
institutionalized. The relationships between log of
resource use, log of length of stay, the competition
measures, and reimbursement environment were
estimated using ordinary least squares, while effects on
outcomes were measured using logistic regression.
Population Studied: We examined episodes of IRF
care for two groups of Medicare patients discharged
from acute care hospitals between 1 January 2001 and
30 June 2003 and admitted to inpatient rehabilitation:
stroke patients (N=84,649) and hip fracture patients
(N=63,480).
Principal Findings: After controlling for a broad array of
patient demographics, patient clinical characteristics,
facility characteristics, and a quarterly time trend,
greater competition in the post-acute care markets under
cost-based reimbursement has no significant effect on
IRF resource use, but has a significant positive effect on
length of stay. The switch to prospective payment in
2002 reduced resource intensity and length of stay.
Under prospective payment, greater competition
mitigated the effect of prospective payment on resource
use and length of stay. Finally, it appears that postacute care market competition has an adverse effect on
death/institutionalization, such that patients who reside
in more competitive areas have a greater probability of
death or institutionalization. The introduction of
prospective payment had no effect on the effects of
competition on this outcome.
Conclusions: We find that post-acute market
competition has no effect on resource intensity but
increases length of stay in rehabilitation hospitals.
Competition from other providers may mitigate the
negative effects on resource use and length of stay
caused by the introduction of prospective payment, but
may worsen outcomes in post-acute care.
Implications for Policy, Delivery or Practice:
Policymakers contemplating payment reforms to
increase efficiency must take into account the
competitive environment faced by providers. In the case
examined, competition was not associated with better
outcomes under cost-based reimbursement, but
competition and payment reform seem to have acted in
concert to produce greater efficiency without further
degradation in outcomes.
Funding Source(s): NIA
♦ Health Care Specialization & Asymmetric
Competition: The Dynamics of Surgery Center &
Hospital Exit
Michael Housman, A.M.
Presented by: Michael Housman, A.M., Doctoral
Candidate, Health Care Management Department, The
Wharton School, University of Pennsylvania, 3641
Locust Walk, Philadelphia, PA 19104, Phone: (215)
681-6955, Email: housman@wharton.upenn.edu
Research Objective: The recent emergence and rapid
growth of specialty hospitals and ambulatory surgery
centers (ASCs) represent a growing trend towards
specialization within the health care marketplace.
Although we know very little about how ASCs and
hospitals compete with one another, there are several
reasons to believe that ASCs benefit from the presence
of nearby hospitals. Hospitals tend to produce higher
rates of procedure demand and attract a higher supply of
physicians while allowing ASCs to cherry pick the most
profitable procedures and the healthiest patients. Yet
hospitals don’t necessarily benefit from the presence of
competing ASCs. To that end, this study aims to
understand how ASCs influence market exit by general
hospitals and how hospitals influence market exit by
ASCs.
Study Design: We explored this relationship within the
context of the market for outpatient surgery by using
1997 to 2006 patient data from the state of Florida. By
manipulating these patient-level datasets to produce
quarterly procedure counts at the county- and facilitylevel, we were able to measure competition, procedure
demand, and firm entry/exit with exact precision and to
directly model the relationship between them. We broke
down our explanatory variables by facility type (ASC vs.
hospital) and geographic location (local vs. diffuse), and
utilized Cox proportional hazard models to evaluate the
different impact of each factor on: (1) ASC exit; and (2)
hospital exit.
Population Studied: Our patient datasets represent a
complete census of all inpatient and outpatient surgical
procedures occurring within the state of Florida from
1997 to 2006. By generating quarterly procedure counts
from the facility IDs associated with those records, our
study sample includes all hospitals and ASCs operating
in the state during that time.
Principal Findings: Although ASCs do tend to exit
markets in which there are high levels of competition
from other ASCs, we found only weak evidence to
support the hypothesis that ASCs exit rates are lowest in
markets with high hospital density. On the other hand,
hospitals not only tend to exit markets with high levels of
competition from other hospitals, but we also found
evidence to support the hypothesis that they experience
high exit rates in markets with high ASC density. These
effects appear to be strongly influenced by geographic
location.
Conclusions: Our results suggest that ASCs benefit
from the presence of nearby hospitals while hospitals
are hurt by the presence of competing ASCs.
Implications for Policy, Delivery or Practice: These
findings have major implications since hospital closures
may affect patient access to care. Moreover,
competition with ASCs may prevent hospitals from
treating vulnerable populations and cross-subsidizing
less profitable lines of service (e.g., ER, mental illness).
Additional research should assess the welfare
implications of these findings and explore whether they
apply to other specialized facilities entering the market
for cardiac catheterization, lithotripsy, and diagnostic
imaging services.
♦ The Relationship of Financial Self-Interest in
Imaging to Economic & Medical Outcomes
Danny Hughes, Ph.D.; Mythreyi Bhargavan, Ph.D.;
Jonathan Sunshine, Ph.D.
Presented by: Danny Hughes, Ph.D., Senior
Researcher, American College of Radiology, 1891
Preston White Drive, Reston, VA 20191, Phone: (703)
716-7542, Email: dhughes@acr.org
Research Objective: Recent research suggests that
physicians with a financial self interest (FSI) in imaging
generate much more imaging than physicians who refer
patients outside of their practice for imaging. The
behavior of the former is widely viewed as driving
medical costs higher and increasing patients’ exposure
to harmful radiation. However, the research has not
addressed whether patients of physicians with FSI have
better outcomes than patients of physicians without FSI.
For example, physicians with FSI may generate higher
imaging costs per illness episode, but lower total
episode costs, or reduced illness duration, resulting in a
net health benefit. Our objective is to compare the
outcomes of episodes of care delivered by physicians
with FSI to episodes delivered by physicians without FSI.
We will compare economic and medical outcomes, such
as episode duration, total episode cost, annual patient
costs, total number of episodes, and probability of
surgical intervention, using suitable controls.
Study Design: Using the Medicare 5% Research
Identifiable File (RIF) for 2004-2006, episodes of care
will be constructed using the Symmetry Episode
Treatment Grouper. We study episodes of 12 medical
conditions, including cancers, injuries, major diseases
(such as heart disease), and signs and symptoms (such
as headache). For each condition, we will study one or
more imaging techniques (such as CT, MRI, and
ordinary X-ray). For episodes of the conditions of
interest, we will identify whether the main treating
physician for the episode had a financial self-interest
(FSI) in imaging. Physician FSI will be identified
separately for each imaging modality based on whether
a physician self-referred an imaging procedure in that
modality during the year. Alternate definitions from the
literature will be used to test sensitivity of findings to
definition of FSI. Using episodes of care as the unit of
analysis, we will evaluate the effects of whether the
treating physician has FSI in imaging on imaging volume
and each outcome. The analysis will control for patient
characteristics (such as age, gender, comorbidities, and
medical risk) and disease severity. Measures of patient
risk and disease severity are generated by the episode
grouper.
Population Studied: Medicare enrollees 2004-2006
Principal Findings: Results are not yet available. At
this time, data on ~2.5 million Medicare beneficiaries
and 157 million claims have been grouped into 6.05
million complete episodes of care that have been
appropriately mapped into the 25 combinations of
medical conditions and imaging modalities we have
previously studied. Large sample sizes for each
combination should allow us to effectively address the
effects of physician FSI on patient outcomes. For
example, we have approximately 291,000 distinct
complete episodes of heart disease and 108,000
complete episodes of genitourinary cancer for 2005.
Conclusions: Analysis results will permit us to
determine whether higher imaging utilization is offset by
other outcomes.
Implications for Policy, Delivery or Practice: Findings
on outcomes will inform policy-makers and payers on
whether utilization management or regulatory controls on
financially self-interested imaging are desirable from a
patient or health plan perspective.
♦ Does the Entry of an Ambulatory Surgery Center
Affect Hospital Surgical Output & Hospital Profit?
Michael Plotzke, Ph.D.; Charles Courtemanche, Ph.D.
Presented by: Michael Plotzke, Ph.D., Associate, Abt
Associates Inc., 55 Wheeler Street, Cambridge, MA
02138, Phone: (314) 387-8988, Email:
Michael_Plotzke@abtassoc.com
Research Objective: Ambulatory Surgery Centers
(ASCs) are small (typically physician owned) healthcare
facilities that specialize in performing outpatient
surgeries and therefore compete against hospitals for
patients who require those services. Since ASCs
perform a limited range of services in comparison to a
hospital, it is unclear how large an impact an ASC
entering into a hospital’s market would have on that
hospital. It’s conceivable that a large hospital performing
a wide range of services may not be impacted by the
entry of a small competitor (in this case an ASC) into
one of its lines of business. However, hospital
administrators claim that outpatient surgery is one of a
hospital’s most profitable lines of business and
competition in this area could cause significant harm to
the hospital. This paper examines whether the entry of
an ASC into a hospital’s market impacts either that
hospital’s surgical volume or its profit margins.
Study Design: Our primary datasets include: the
Centers for Medicare & Medicaid Services (CMS)
Provider of Services (POS) file for information on
characteristics of ASCs, the American Hospital
Association annual survey for information on
characteristics of hospitals, and the CMS Medicare Cost
Report for information on hospital profit margins.
Numerous other data sources were used to collect
information on the characteristics of the market where an
ASC or hospital was located. ASCs were assumed to be
located in a hospital’s market if they were within the
radius where the hospital admitted 75% of their patients
(as calculated by Gresenz, Rogowski, and Escarce
[2004]). We use a fixed effects model to estimate the
impact of the entry of an ASC into a hospital’s market on
the hospital’s surgical volume and profit margin.
Population Studied: 2,269 urban hospitals in the United
States from 1997 through 2004.
Principal Findings: We find on average a 1.71%
decline in a hospital’s annual outpatient surgeries and no
significant change in its annual inpatient surgeries after
an ASC enters that hospital’s market. However, for
hospital markets with 2 or fewer ASCs, an additional
ASC entrant is associated with a decline in hospital
outpatient surgery of 6.9%. ASC entry is not associated
with any changes in hospital profit margins for either a
hospital’s outpatient or inpatient department.
Conclusions: Even if ASCs treat a hospital’s most
profitable patients, ASC entry on average does not seem
to be associated with any financial harm to the hospital
nor a large loss of hospital surgical volume.
Implications for Policy, Delivery or Practice: Since
most urban US hospital markets already contain several
ASCs, the entry of an additional ASC would not seem to
cause harm to a hospital based on these results. The
entry of an ASC may have more of an impact in rural
markets where there are a limited number of healthcare
facilities.
Promoting & Studying HER Adoption & Use
Chair: Karen Murphy
Sunday, June 28 * 2:30 p.m.- 4:00 p.m.
♦ The Impact of Implementing Electronic Health
Records on the Occurrence of Medical Errors in
Hospitals
Ann Chou, Ph.D., M.P.H., M.A.; Robert Wild, M.S.;
Steve Mattachione, J.D.; Robn Green, M.P.H.; Robert
Roswell, M.D.
Presented by: Ann Chou, Ph.D., M.P.H., M.A.,
Assistant Professor, Health Administration & Policy,
University of Oklahoma, 801 Northeast 13th Street, CHB
355, Oklahoma City, OK 73104, Phone: (405) 271-2115
x4, Email: ann-chou@ouhsc.edu
Research Objective: The Institute of Medicine (IOM) in
1999 estimated that 44,000 to 98,000 Americans die
each year as a result of preventable medical errors. The
expanded use of health information technology (HIT)
would lend great opportunities in improving the quality of
health care, but there has been little information to
empirically assess the relationship between HIT use and
the rate of medical errors. The goal of this study is to
understand the impact of electronic health record (EHR)
implementation on the likelihood of medical error
occurrence.
Study Design: An analytic dataset was compiled with
discharge data from 50 ambulatory surgery centers,
inpatient hospitalizations from 137 hospitals, outpatient
discharges from 96 hospitals, and facility characteristics
from the Annual Cooperative Hospital Survey in the state
of Oklahoma. Hierarchical generalized linear modeling
estimated with Generalized Estimating Equations that
allowed for the clustering of observations within hospitals
was used to investigate associations between the
occurrence of medical errors and HIT implementation,
controlling for patient and hospital level characteristics.
Errors were defined using ICD-9 codes.
Population Studied: The total study population included
3876 patients from 113 hospitals, with 969 reported
errors defined as cases and 2907 randomly selected
controls for each case. The sample contained 60%
females, 13.5% were age 19 and younger, 23.4% were
between 20-44, 26.5% were between 45-64, and 35.6
were 65 and older. Forty-percent of the hospitals in the
sample were for-profit, 28.8 were nonprofit, and 32.2%
were government controlled.
Principal Findings: Patients who used facilities with a
fully implemented EHR were less likely to have a
medical misadventure (OR=0.50, 95% CI: 0.26, 0.98)
comparing to those who were in facilities with a paperbased system. However, no statistical differences were
observed among patient who used facilities with a
partially implemented EHR and those that relied on
paper records. Moreover, an increase in age and
comorbid conditions, weekday admission, and length of
stay were positively correlated with the occurrence of
medical errors.
Conclusions: Findings showed that medical errors were
less likely to occur if an EHR has been fully implemented
in comparison to a paper-based system. Although the
capital costs have often been cited as a primary barrier
for HIT implementation, the reduction in errors presents
a business case of return on investments in support of
wider HIT adoption and use.
Implications for Policy, Delivery or Practice: A
systems approach to prevent medical errors is
warranted, with the implementation of clinical information
systems serving as a key strategy to reduce these
errors.
♦ The Relationship Between the Use of Electronic
Health Records & Quality of Care in U.S. Hospitals
Catherine DesRoches, Dr.P.H.; Eric Campbell, Ph.D.;
David Blumenthal, M.D.; Christine Vogeli, Ph.D.; Karen
Donelan, Sc.D.; Ashish Jha, Ph.D.
Presented by: Catherine DesRoches, Dr.P.H.,
Instructor in Medicine, Institute for Health Policy,
Harvard Medical School/Massachusetts General
Hospital, 50 Staniford Street, Boston, MA 02115,
Phone: (617) 724-6958, Email:
cdesroches@partners.org
Research Objective: To determine whether hospitals
that have adopted an electronic health record (EHR)
provide higher quality care.
Study Design: We collaborated with the American
Hospital Association on a national survey of US
hospitals, fielded as a supplement to the AHA’s annual
survey between March and September 2008. We
received responses from 3,049 hospitals (63.1%
response rate). Data on hospital EHR adoption was
linked with those from the Hospital Quality Alliance and
Medicare Provider Analysis and Review (MedPar). With
input from a federally-chartered Expert Consensus Panel
(ECP), we defined the clinical functionalities necessary
for a hospital to be designated as having a basic or
comprehensive EHR. The functionalities fell into four
categories: clinical documentation, results viewing,
computerized provider order entry, and clinical decision
support. Hospitals were designated as having a
comprehensive system if they had all key functionalities
implemented widely, whereas they were listed as having
a basic system if they had a sub-group of 12
functionalities implemented in at least one clinical unit.
We examined performance on individual and summary
process measures and 30-day mortality and readmission
rates for acute myocardial infarction (AMI), congestive
heart failure (CHF), pneumonia, and surgical infection
prevention.
Population Studied: All acute care general hospitals in
the United States.
Principal Findings: We found, after adjusting for size,
region, teaching status, location, and the presence of
advanced technologies, EHR availability was associated
with small but consistently better quality of care for all
conditions examined, although it was statistically
significant for only AMI and surgical infection prevention.
For example, hospitals with an EHR provided the right
care more often for AMI (95.3% versus 94.5%, p=0.009).
Hospitals with EHR systems had modestly better
mortality rates for AMI (14.9% versus 15.8%, p=0.007)
but the mortality rates for CHF and pneumonia were
comparable between adopters and non-adopters. We
found modestly better 30-day readmission rates among
EHR adopters for all three conditions, although it was
statistically significant only for pneumonia (19.0% versus
20.2%, p=0.046). When we examined the impact of
adoption of individual clinical decision support
functionalities on HQA process measures, we found a
similar pattern: hospitals with these functionalities had
small but consistently better performance on standard
metrics compared to hospitals that did not.
Conclusions: We assessed the association between
EHR adoption and quality of care provided in U.S.
hospitals and found consistent, small effects on process
measures and patient outcomes. Whether the small
effects are due to the fact that these measures may not
be sensitive to EHR adoption or because adoption alone
may not be adequate to affect quality is unclear.
Implications for Policy, Delivery or Practice: EHR
adoption has become a priority of policymakers across
the nation, due in part to its potential to improve the
quality and outcomes of care. Our findings suggest that,
as currently adopted, these systems have a small effect
on improving care. Finding ways to ensure effective use
of these systems will be critical if we are to realize the
potential of EHRs to improve the health and healthcare
of all Americans.
Funding Source(s): Office of the National Coordinator
for Health Information Technololgy
♦ An Interactive Preventive Healthcare Record to
Promote Delivery of Patient-Centered Preventive
Care
Alex Krist, M.D., M.P.H.; S. H. Woolf, M.D., M.P.H.; D.
R. Longo, Sc.D.; S.R. Rothemich, M.D., M.S.; J.E.
Peele; A. Kuzel, M.D., M.H.P.E.
Presented by: Alex Krist, M.D., M.P.H., Assistant
Professor, Family Medicine, Virginia Commonwealth
University, 3825 Charles Stewart Drive, Fairfax, VA
22033, Phone: (703) 391-2020, Email: ahkrist@vcu.edu
Research Objective: On average, Americans receive
only half of indicated preventive services due to a host of
patient, clinician, and health care system barriers. While
multiple informatics-based interventions can each
improve use of preventive services, combining them in
an effective package could optimize effectiveness. We
sought to create and test a highly sophisticated personal
health record, an Interactive Preventive Healthcare
Record (IPHR), designed to promote 18 U.S. Preventive
Services Task Force (USPSTF)-endorsed screening
tests, counseling services, preventive medications, and
immunizations. The IPHR gives patients direct access to
the personal health information stored in the electronic
record of their primary care physician, displays tailored
prevention recommendations, provides links to online
educational resources, and generates patient and
clinician reminders.
Study Design: As part of a randomized controlled trial,
we compared IPHR use among intervention patients,
who received a mailed invitation to access the IPHR,
with controls who received no invitation. Electronic
medical record and IPHR data were used to calculate
the proportion and characteristics of patients who used
the IPHR. We conducted focus groups with patients and
providers to study their experience with the IPHR.
Population Studied: Eight primary care practices in the
Virginia Ambulatory Care Outcomes Research Network
(ACORN) participated in the study. From these
practices, 2750 intervention and 2750 control patients,
who were ages 18-75 years, were selected randomly for
participation.
Principal Findings: Within six weeks of being mailed
the invitation, 292 (11%) patients had established an
account and used the IPHR (updated usage rates will be
presented). IPHR-users were more often male (52% vs.
49%, p<0.001) and older (mean age of 55 vs. 48 years,
p<0.001) than non-users. Although 76% of users had
attended a wellness or chronic care visit within the past
year, only 3% were up-to-date, with risk factors under
control, for all 18 preventive services. Among the IPHR
users, 49% and 56% were due for screening tests and
vaccinations, respectively; 91% and 55% needed
counseling for unhealthy behaviors and preventive
medications, respectively; and 35% had inadequate
control of chronic conditions. Alerts to clinicians issued
by the IPHR led practices to update 59% of patients’
records and to contact patients to schedule a wellness
visit (80 patients), chronic care visit (49 patients), or an
appointment for a specific preventive service (56
patients). Additional data on IPHR use, focus group
insights, and the delivery of preventive care will be
presented.
Conclusions: Despite having had a recent wellness or
chronic care visit, the vast majority of established
primary care patients required additional preventive
care. The IPHR served as a catalyst both to promote
patient self management and to extend clinician care
outside of standard office encounters.
Implications for Policy, Delivery or Practice: The
feasibility and use of the IPHR by patients and practices
underscores the potential multiplier effect of integrating
patient-centered and clinician-based information
systems. Marrying the two can improve the efficiency of
information systems and their service to patients,
enhance health outcomes for both prevention and
chronic disease care, and control costs by promoting
evidence-based guidelines.
Funding Source(s): AHRQ
♦ HIT Implementation in Critical Access Hospitals:
Extent of Implementation & Business Strategies
Supporting IT Use
James Bahensky, M.S.; Marcia Ward, Ph.D.; Kwame
Nyarko; Pengxiang Li, Ph.D
Presented by: Marcia Ward, Ph.D., Professor, Health
Management & Policy, University of Iowa, 200 Hawkins
Drive E210GH, Iowa City, IA 52242, Phone: (319) 3845131, Email: marcia-m-ward@uiowa.edu
Research Objective: While hospitals are increasing
their efforts to use health information technology (HIT) to
improve the care patients receive, small rural hospitals in
particular face considerable financial and personnel
resource shortages which hinder their efforts to
implement complex HIT systems. Few studies to date
have examined the extent of HIT implementation in rural
hospitals, and especially in Critical Access Hospitals
(CAHs).
Study Design: A survey was created to review the use
of HIT. The first part of the survey profiled the hospitals
on technology resources and capacity, especially in
terms of staffing, use of external resources, and
purchasing information system influences. The second
part of the survey focused on the use of 46 different
types of HIT applications.
Population Studied: Surveys were mailed to the 82
CAHs in Iowa and 70 returned completed surveys for a
85% response rate. Case studies and focus groups
were conducted to follow-up on research findings.
Principal Findings: Among CAHs, 29% have
implemented electronic medical record (EMR) systems,
of which 12% have implemented computerized provider
order entry (CPOE) and clinical decision support
systems (CDSS). Analyses indicate that the number of
IT staffing in CAHs is a barrier to implementing HIT
solutions; 34% do not have any IT staff and 50% only
employ 1 to 2 IT staff. Analyses indicated that CAHs
with fewer staff tend to employ alternative business
strategies - 91% use external consultants and 85% use
outsourcing to support their HIT needs. In contrast, only
38% use application service providers (ASP). CAHs
with fewer IT staff use outsourcing more (r=.72). There
is a clear relationship between the number of IT staff at a
CAH and the types of technologies used. In particular,
CAHs with no IT staff were significantly less likely to use
a variety of communication technologies and patientcare devices (p<.05) and were less likely to have EMR
systems installed (p<.06). Over half (53%) of the CAHs
are part of a formalized network (owned or managed by
a multi-hospital organization). For those within a
network, 42% indicated that the network influenced their
IT purchasing decisions a great deal, while a third
indicated the network influenced them slightly (14%) or
not at all (17%).
Conclusions: As shown here, a third of CAHs operate
with no IT staff. CAHs appear to use external
consultants and outsourcing to compensate for lack of
in-house IT staff. Of those that have implemented EMR
systems, many CAHs report they are having trouble
expanding upon functionalities due to the difficulty of
finding IT staff with healthcare expertise.
Implications for Policy, Delivery or Practice: These
findings help to develop an understanding of technology
complexities and labor resource constraints in the
implementation and ongoing support of HIT systems in
rural environments. While CAHs have basic business
and communication systems operational, most are in the
transition point of planning for or beginning
implementation of complex clinical information systems
including EMR with CPOE and CDSS. Strategies for
addressing these challenges will need to evolve as the
HIT investments by rural hospitals race to keep pace
with the goals for the nation.
Funding Source(s): AHRQ
♦ A Qualitative Study of the Electronic Medical
Record
John Windle, M.D.; Lisa Grabenbauer, M.S., M.B.A.;
Anne Skinner, B.S.
Presented by: John Windle, M.D., Chief of Cardiology,
Internal Medicine, University of Nebraska Medical
Center, 982265 Nebraska Medical Center, Omaha, NE
68198-2265, Phone: (402) 559-9268, Email:
jrwindle@unmc.edu
Research Objective: To understand the physicians’
perspective on the benefits and limitations of current
Electronic Medical Records (EMR) by comparing the
Veteran’s Administration Medical Center (VAMC)
paperless system (Vista and CPRS) with the Nebraska
Medical Center’s (TNMC) GE Centricity Enterprise
system.
Study Design: Focus groups were conducted with
physicians who practice at both institutions. Participants
were asked open-ended questions about their interaction
with EMR systems and the systems perceived benefits
and limitations. Each EMR has been in use for over 10
years at their respective institution. Small focus groups
sessions took place in November and December 2008.
Sessions lasted 1 hour. Group proceedings were audiorecorded and transcribed. Data elements were
systematically coded and analyzed based on frequency,
convergence and intensity using NVivo v8.0 software.
Sampling continued until saturation was achieved.
Investigators (LG and JW) independently reviewed
transcripts and identified themes unique and similar
across all groups. Themes were verified by a third
investigator (AS). Using an iterative process, themes
were revised until consensus was achieved.
Population Studied: A convenience sample of 19
internal medicine physicians; 10 residents and 9 faculty
members participated. As a group they were very
sophisticated users of the EMR.
Principal Findings: The analysis produced two major
themes – workflow and communication. Each EMR had
perceived strengths but also significant limitations and
neither was felt to satisfactorily address their needs.
Workflow benefits focused on the availability of patient
data both spatially and temporally within the
organization. The costs of workflow related to the
retrieval of select patient information were high (the VA
system was more comprehensive but very difficult to
search, the University system was better organized but
less comprehensive). Information input and retrieval
was felt to significantly compromise time spent with
direct patient care. The use of templated notes saved
time and improved documentation but at the expense of
readability and comprehension. The benefits of
communication included the ability to share patientcentric information, with other physicians and with
patients. However, especially at the VAMC reduced
direct communication between health care providers was
noted. Neither system could interact with each other or
any other outside EMR, a frequently noted weakness.
Conclusions: The physicians interviewed were
committed to the potential of the EMR but expressed
concerns about functionality, trade-offs between patient
care and the requirements imposed by the EMR which
includes the significant time required to search for
information and input data. The VAMC system was
applauded for its comprehensive nature but was nonintuitive and labor intensive. The University system was
noted for its logic organization but lacked the
comprehensiveness of the VAMC system. A significant
concern was raised that each EMR shortcuts the
development of cognitive processes essential to medical
decision-making.
Implications for Policy, Delivery or Practice:
Sophisticated users were frustrated by cumbersome
system interfaces and processes, yet remained
optimistic about the potential for systematic collection of
data to improve patient care. EMR must provide
seamless and flexible interfaces across system
boundaries, for data input as well as data retrieval. The
study explores the sources of resistance to EMR
adoption by the physician community.
Drilling Down: Applied Informatics & Health
Information Technology
Chair: Margo Edmunds
Sunday, June 28 * 4:30 p.m.- 6:00 p.m.
♦ Chronic Disease Management Medication
Adherence of Medicaid Patients in the Primary Care
Information Project Cohort
Samantha De Leon, Ph.D.; Tod Mijanovich, Ph.D.;
Sarah Shih, M.P.H.; Farzad Mostashari, M.P.H., M.D.
Presented by: Samantha De Leon, Ph.D., City
Research Scientist, Healthcare Access - Primary Care
Information Project, New York City Department of Health
& Mental Hygiene, 161 William Street, New York, NY
10038, Phone: (212) 788-5686, Email:
sdeleon@health.nyc.gov
Research Objective: The objective of this study is to
determine the impact of an Electronic Health Records
(EHR) functionality that allows providers to obtain 90 day
patient medication histories to improve chronic disease
management, and quality of care.
Study Design: New York City has a citywide initiative to
implement EHRs with a health prevention focus to
reduce health disparities and improve population health.
The Primary Care Information Project (PCIP) has
developed, with the EHR vendor, the ability for providers
to review 90 days of a patients medication history
derived from Medicaid state claims. Using New York
State Medicaid prescription claims data, Medication
Possession Ratios (MPRs) were tabulated for each
patient as the number of days of medication supply
dispensed divided by the interval between the first and
last prescription purchase dates. The MPR was
tabulated for each category of medication recommended
by the CDSS logic for chronic disease panel
management. Regression analyses will be used to
study patient characteristics that affect medication
adherence, such as number of unique medications per
patient, co-morbidity status, and whether patients
receive care through a single provider, or multiple
providers, for a given chronic condition.
Population Studied: Patients were selected based on
having been treated by at least one of the 2,000
providers in the PCIP provider cohort, and with at least
four months of continuous prescription claims
documented in the system during the baseline study
period (2005), before any of the providers implemented
the EHR. Approximately 6,400 patients were available
to establish the baseline.
Principal Findings: Preliminary results suggest that
among patients that have at least four months of
continuous prescription claims data, medication
adherence across chronic disease categories is fairly
high. Average MPR ± standard deviations were
estimated for: Asthma control (0.85 ± 0.16); Diabetes
Mellitus A1c management (0.86 ± 0.15); Blood pressure
management (0.84 ± 0.15); LDL/ Cholesterol/
Antithrombotics (0.85 ± 0.16); Depression management
(0.80 ± 0.15); and smoking cessation treatment (0.76 ±
0.15). For a given treatment category, most patients
were treated by a single provider (average= 73.6%).
Conclusions: While most patients were observed to be
in compliance with their treatment medications, these
patients had a substantial period of time with continuous
paid prescription claims. Disparities in adherence are
expected upon further breakdown and analyses of subpopulations such as those with varying periods of
documented prescription claims, those that are on a
single or multiple chronic disease management
medications, and those that see a single provider versus
multiple providers.
Implications for Policy, Delivery or Practice: The
EHR implemented as part of the PCIP citywide initiative
will allow providers to obtain, in real-time, 90-day patient
medication histories through Medicaid claims data;
thereby, putting them in a better position to coordinate
care between providers and potentially have a
substantial impact on reducing redundancy of treatment
or increasing patient safety. Ultimately, comparing
baseline medication adherence before and after EHR
implementation will help determine whether EHRs with
point-of-care medication history reconciliation can
positively impact patient medication adherence.
♦ Factors Influencing EHR Use in Small Physician
Practices: Case Studies in Four States
Suzanne Felt-Lisk, M.P.A.; Christopher Fleming, M.P.H.;
Rachel Shapiro, M.P.P.; Brenda Natzke, B.A.; Lorraine
Johnson, Sc.D., M.P.H.
Presented by: Suzanne Felt-Lisk, M.P.A., Senior Health
Researcher, Mathematica Policy Research, 600
Maryland Avenue, SW, Suite 550, Washington, DC
20024, Phone: (202) 484-4519, Email: sfeltlisk@mathematica-mpr.com
Research Objective: This paper describes barriers and
facilitators to adoption of health information technology
(HIT) as reported by physicians and staff in selected
primary care practices participating in the ongoing
Medicare Care Management Performance (MCMP)
Demonstration. MCMP, which began July 1, 2007, is a
pay-for-performance demonstration to encourage use of
HIT to improve quality of care to chronically ill fee-forservice Medicare beneficiaries.
Study Design: The MCMP demonstration provides an
annual financial incentive to approximately 640 practices
in 4 states: Arkansas, California, Massachusetts, and
Utah. A bonus is based on performance on 26 clinical
measures, with an additional bonus if the data are
submitted via a CCHIT certified EHR. A practice can
earn up to $192,500 over three years; incentives more
likely to have an impact won't be available until later in
the demonstration. In summer/fall 2008, a two-person
research team met in-person with practitioners and staff
from eight participating practices in each of the four
states. A semi-structured protocol was used; detailed
notes were coded to identify themes.
Population Studied: Visited practices were selected to
vary on urban/rural location (72 percent urban), number
of physicians (mean 5.7, with 28 percent solo), number
of fee-for-service Medicare beneficiaries with chronic
conditions (mean 448) and experience with EHRs (72
percent used an EHR).
Principal Findings: The most common year-one
response to the demonstration was improving
documentation (18 of 32 visited practices), followed by
changes to the EHR itself and/or use of the EHR (7).
After implementing their EHRs, about one-third of the
visited practices began heavier use of medical assistants
for entering data to complete patient electronic records,
interviewing patients as a first step in the visit, and/or
conducting outreach to patients needing tests or
appointments. Factors facilitating better use of EHRs
included customizing EHR products and being owned by
a larger organization. Factors limiting use of EHRs
included system limitations, day-to-day pressures, cost,
autonomous sub-cultures within the practice, and lack of
a strong motivator to improve system use. Practices in
one state, participating in pay-for-quality programs and
tiered provider networks, appeared to be moving more
aggressively to improve system use than practices in
other states.
Conclusions: In year one, participation in the MCMP
demonstration appears to have prompted modest
operational responses in a large subset of targeted
practices, though the types of responses appear more
foundational—documentation and systems being
foundations for improvement—than transformational.
Early findings from the site visits may support the theory
that financial incentives for quality and system use are a
relevant tool for influencing practice change and system
improvement, with the overall payment environment
appearing more important than incentives from any
single payer, although it is too early to know whether this
will result in measurable quality improvements.
Implications for Policy, Delivery or Practice: The fact
that many visited practices are using medical assistants
to leverage EHRs for care improvement while increasing
practice efficiency suggests this is a critical area for
future study. The system difficulties that small,
independent practices face suggests that improving EHR
use will require attention to improving products and
implementation assistance to better meet clinicians’
needs.
Funding Source(s): CMS
♦ The Cost-Effectiveness of Bar Code Medication
Administration Systems for Preventing Adverse
Drug Events in the Community Hospital Setting
Julie Sakowski, Ph.D.; Alana Ketchel, M.P.P., M.P.H.;
Tom Leonard, R.N., M.P.A.
Presented by: Julie Sakowski, Ph.D., Senior Health
Services Researcher, Sutter Health Institute for
Research, 345 California Street, Suite 2000, San
Francisco, CA 94104, Phone: (415) 296-1808, Email:
sakowsj@sutterhealth.org
Research Objective: Medication errors are a significant
source of avoidable health care costs and patient harm.
It’s estimated 400,000 preventable drug related injuries
occur in hospitals annually, each resulting in $4,700 of
additional health care costs. Hospitals have been
turning to information technologies such as
Computerized Order Entry (CPOE), automated
dispensing systems, and Bar Code Medication
Administration Systems (BCMA) as tools to prevent
medication errors. This paper focuses on one of these
technologies: BCMA. BCMA utilize barcodes entered on
each dose delivered to a patient to electronically
compare the drug being administered with the order and
alert the user to any discrepancies. Studies have shown
that BCMA can be effective in preventing medication
errors, but these systems are expensive and little is
known about their cost-effectiveness The purpose of
this study is to estimate the cost-effectiveness of BCMA
for preventing adverse drug events (ADEs) from hospital
inpatient medication errors that cause patient harm.
Study Design: This is a retrospective cost-effectiveness
study. Cost information was collected from financial
records, project management documents and key
informant interviews. Costs include software licensing,
hardware purchases and personnel time for planning,
implementation, education and monitoring. Capital
investments such as construction, pharmacy
management systems and drug repackaging equipment
were included if these capital expenses were incurred as
part of the BCMA project. Information on the number of
adverse drug events prevented was gathered from our
previous studies examining BCMA effectiveness.
Sensitivity analyses were performed to evaluate the
impact of our cost and prevented ADE estimates on the
cost-effectiveness calculations.
Population Studied: We evaluated the costs incurred
for implementing and operating a commercially available
BCMA system implemented in adult, non-critical care
inpatient units at several community hospitals affiliated
with a large hospital network.
Principal Findings: Preliminary estimates suggest that
implementing and operating a hospital inpatient BCMA
system for 5 years costs $2,300 per ADE prevented.
Sensitivity analyses indicate significant variations in our
assumptions about the BCMA operating costs and ability
to prevent medication errors still produce costeffectiveness estimates less than the projected costs of
preventable medication injuries. For example,
increasing our BCMA cost estimates by 25% increases
the cost per ADE prevented estimate to $2,900. A 25%
reduction in the presumed number of ADEs prevented
produces a cost-effectiveness calculation of $3,000 per
ADE prevented.
Conclusions: BCMA may be a cost-effective tool for
preventing the morbidity and mortality associated with
preventable medication errors.
Implications for Policy, Delivery or Practice: The
cost-effectiveness of BCMA compares favorably with
other information technologies. For example, the costeffectiveness of CPOE has been estimated to be
$12,700 per ADE prevented and bar-code dispensing
systems are $1,573 per ADE prevented. Sensitivity
analysis suggests that how the system is used and the
effectiveness of the BCMA system in preventing
medication error related ADEs has a more pronounced
effect on the cost-effectiveness estimate than the cost
assumptions. This may suggest that the cost per
adverse drug event may be even more favorable if
BCMA is implemented in settings where the risk of
adverse events from medication errors is highest.
♦ Priorities & Preferences of Potential Ambulatory
Trigger Tool Users
Stephanie Shimada, Ph.D.; Peter Rivard, Ph.D.;
Jonathan Nebeker, M.D. M.S.; Lucy Savitz, Ph.D.;
Christopher Shanahan; Stephan Gaehde, M.D.; Amy
Rosen, Ph.D.
Presented by: Stephanie Shimada, Ph.D., Research
Health Scientist, Center for Health Quality, Outcomes &
Economic Research, Dept of Veterans Affairs, 200
Springs Road (152), Bedford, MA 01730, Phone: (781)
687-2000 x 6698, Email: shimada@bu.edu
Research Objective: Trigger methodology -- the
application of IT-based surveillance rules or algorithms
to patient data -- is used retrospectively to detect
adverse events or concurrently to intervene in and
improve patient care in real time. However, few trigger
tools are available for ambulatory care. As part of a
larger study to develop trigger tools for the ambulatory
setting, we sought to understand the priorities and
preferences of potential trigger users by obtaining input
from front-line clinicians and workers in ambulatory care
sites with varied electronic medical record (EMR)
systems and patient populations. We also queried their
perceptions of the relative prevalence and importance of
different adverse events (AEs) in the ambulatory setting.
Study Design: Focus groups of 5-8 participants each
were conducted at three organizationally and
geographically diverse healthcare systems in the U.S.
Participants were given a brief overview of trigger
methodology and then asked to discuss specific triggers
in terms of their clinical relevance and utility, identify
potential implementation issues, and suggest priority
areas for trigger development.
Population Studied: Participants represented a
diversity of professionals, including internists,
emergency physicians, surgeons, clinical pharmacists,
infection control and quality improvement nurses, and
informaticists. Focus groups were held at three sites: a
Veterans Health Administration hospital in the Northeast,
a large, urban safety-net hospital serving a diverse and
underserved patient population in the Northeast, and a
large integrated health care system serving both urban
and rural patients in the Western United States.
Principal Findings: Participants preferred triggers that
were (1) indicative of a specific causal agent and/or an
AE that was both prevalent and preventable, (2) not
redundant with ongoing quality, safety, or performance
tracking, (3) concurrent rather than retrospective, with a
clearly defined process as to who would receive the data
and who would intervene in the appropriate time frame,
(4) easy to implement given existing computer systems
and care processes, and (5) capable of preventing some
degree of harm to patients, making the effort and cost of
implementation worthwhile. Some of the top priority
areas for trigger development, based on frequency and
importance of prevention, were adverse drug events,
failure to follow-up on abnormal test results, wrong
diagnoses, wrong site procedures, and surgical site
infections.
Conclusions: Participants responded positively to
trigger tools. Practicing clinicians preferred concurrent
triggers that appeared most likely to help intervene
effectively to prevent or mitigate harm from AEs.
Participants identified areas in which triggers could
improve care, but were concerned about a number of
implementation issues.
Implications for Policy, Delivery or Practice:
Understanding user preferences is critical in guiding
future trigger development and implementation work.
Although development is ongoing with trigger tools for
adverse drug events and surgical adverse events,
further research is needed on triggers addressing loss to
follow-up and wrong diagnoses.
Funding Source(s): AHRQ
♦ Unforeseen Consequences: Internal Discrepancies
in Electronic Medication Prescriptions
Alexander Turchin, M.D., M.S.; Elizabeth Fang,
Pharm.D.; Janet Cygielnik, B.S.; Matthew Labreche;
Maria Shubina, Sc.D.; Matvey Palchuk, M.D., M.S.
Presented by: Alexander Turchin, M.D., M.S., Assistant
Professor of Medicine, Division of Endocrinology,
Brigham & Women's Hospital, 221 Longwood Avenue,
Boston, MA 02115, Phone: (617) 732-5661, Email:
aturchin@partners.org
Research Objective: Many e-prescribing systems
include both structured (e.g. dose, frequency) and freetext components in the prescriptions. We conducted this
study to determine the prevalence of internal
discrepancies between structured and free-text
components in electronic medication prescriptions and
the incidence of related potential adverse drug events.
Study Design: De-identified medication records
randomly selected from among all outpatient electronic
prescriptions written at Partners HealthCare between
01/01/2007 and 03/31/2007 were analyzed for internal
discrepancies between a) the structured fields and b) the
free-text Instructions field. Only medication records with
a non-empty Instructions field were analyzed. The
following structured fields were analyzed: medication
name, dose, dose units, strength, form, route, frequency,
and whether the medication was prescribed as needed
(prn). For each discrepancy, a potential for leading to an
adverse drug event (ADE) was assessed as follows: 0
(no potential for an ADE), 1 (potential for an ADE not
leading to a hospital admission) or 2 (potential for a
severe ADE, leading to a hospital admission or death).
Each record was independently rated by two
pharmacists. Records on which the raters disagreed
were re-reviewed by the original raters and a boardcertified internist to achieve a consensus rating.
Population Studied: A random selection from among all
outpatients at Partners Healthcare System in Boston,
MA.
Principal Findings: More than two out of five (43.0%) of
all medication records included a free-text Instructions
field. Out of 2,914 medication records with an
Instructions field we analyzed, 470 (16.1%) contained a
discrepancy between structured and free-text
components. Most (83.8%) discrepancies identified
could potentially lead to an ADE, and 79 (16.8%) to a
severe ADE. The most common discrepancy (137/470 =
29.1%) was between a complex regimen (frequencies /
doses changing over the course of treatment) outlined in
the free-text instructions and fixed dosing (e.g. “tid”) in
the structured component. Dose mismatch, route
mismatch and complex regimen mismatch were the
most likely to potentially lead to a severe ADE at the
average rate of 23.7%. On the other hand, imprecise
conversion of daytime and round-the-clock frequencies
(e.g. “bid” vs. “every 12 hours”) and dosage form
mismatches were never deemed to have the potential for
a severe ADE (p = 0.0001 for the comparison with the
highest risk mismatch types) Discrepancies were
particularly common among medications previously
reported to carry the highest risk for ADEs (warfarin,
insulin, digoxin). The rate of discrepancies that could
potentially lead to patient harm in this medication group
was 24.1% vs. 13.3% among the rest of the medications
(p = 0.03).
Conclusions: Internal discrepancies are common in
electronic medication prescriptions – an unforeseen
consequence of e-prescribing. They are particularly
common among high-risk medications and many could
potentially lead to ADEs.
Implications for Policy, Delivery or Practice: The
frequency of internal electronic medication prescription
discrepancies must be reduced to decrease the risk of
patient harm. Further interventional studies are needed
to determine whether this can be accomplished by
improving provider training and / or redesigning eprescribing software.
Funding Source(s): Partners HealthCare IS Research
Council
The Latest in Health Information Exchange
Chair: Patricia MacTaggert
Tuesday, June 30 * 11:30 a.m.-1:00 p.m.
♦ Regional Health Information Organizations:
Progress, Challenges & Viability
Julia Adler-Milstein, A.B.; Ashish Jha, M.D., M.P.H.;
David Bates, M.D., M.S.
Presented by: Julia Adler-Milstein, A.B., Doctoral
Candidate, Ph.D. Program in Health Policy, Harvard
University, 176 Upland Road #3, Cambridge, MA 02140,
Email: jadlermilstein@hbs.edu
Research Objective: There is broad consensus that a
nationwide health information infrastructure that allows
patients’ health information to electronically follow them
to any care delivery setting has the potential to improve
the quality and reduce the cost of care. Most policy
makers have focused on Regional Health Information
Organizations (RHIOs) as the model to achieve this. As
a follow-up to our 2007 national survey of RHIOs, we
sought to examine RHIO progress to help inform
policymakers on whether our current approach to
nationwide health information exchange (HIE) is likely to
be successful.
Study Design: We identified all existing RHIOs in the
U.S. using multiple sources and fielded a web-based
survey that asked respondents to report their level of
progress in facilitating HIE, organization demographics,
types of data exchanged and functionalities supported,
funding sources and financial viability, and barriers to
development.
Population Studied: All RHIOs in the US pursuing
electronic health information exchange between
independent entities in a defined geographic region
between 1/1/07 and 6/1/08.
Principal Findings: Our response rate was 78%
(131/167). Fifty-five RHIOs (42%) were operational and
actively exchanging clinical data as of June 2008, 12 of
which were newly operational in the 17 months since our
last survey. Forty-two RHIOs (32%) were planning for
clinical data exchange and the remaining 34 (26%) had
pursued clinical data exchange in the past but were no
longer pursuing it. Of the 45 RHIOs in the planning
stage from our prior survey, 15% had become
operational, 30% were still planning, while 55% had
stopped pursuing HIE. Among all RHIOs examined, the
failure rate between January 2007 and June 2008 was
20%. Among large operational RHIOs (those that
exchanged data for at least 5,000 patients), test results
were the most common type of data exchanged (84% of
RHIOs), followed by inpatient data (70%) and medication
history (66%). Eleven percent of planning RHIOs and
41% of operational RHIOs met our definition of selfsustaining: able to cover operating costs with revenue
from data exchange participants. Among those not yet
self-sustaining, we found large differences between
planning and operational RHIOs in their optimism: while
61% of planning RHIOs reported that they were likely to
eventually become self-sustaining, only 28% of
operational RHIOs ever expected to do so.
Conclusions: We found forty-four large operational
RHIOs that exchanged clinical data between
independent entities, nearly twice the number we found
in early 2007. Most RHIOs continue to focus on test
results and inpatient data such as discharge summaries.
However, we found a high failure rate, narrow scope of
data exchanged, and a minority of RHIOs financially
viable with a high degree of pessimism among many
organizations about future viability.
Implications for Policy, Delivery or Practice: The
current approach to spur growth in the number of RHIOs
appears to have produced more organizations actively
exchanging data. However, the narrow scope of activity
and significant financial challenges suggest that this
model may not lead to the vision of nationwide HIE.
Policymakers have to consider new financial incentives
for a broader set of activities or alternative models, such
as treating these entities as public goods, in order for
RHIOs to enable all Americans ubiquitous access to
their medical information.
Funding Source(s): Selma G. Usdan Fund for Studying
Market-Based Reforms at the Harvard School of Public
Health
♦ Characteristics of Hospitals Participating in
Regional Health Information Organizations
Julia Adler-Milstein, A.B.; Ashish Jha, M.D., M.P.H.;
Catherine DesRoches, Dr.P.H.; Eric Campbell, Ph.D.;
David Blumenthal, M.D., M.P.P.
Presented by: Julia Adler-Milstein, A.B., Doctoral
Candidate, Ph.D. Program in Health Policy, Harvard
University, 176 Upland Road #3, Cambridge, MA 02140,
Email: jadlermilstein@hbs.edu
Research Objective: The approach to achieving
nationwide health information exchange in the US
currently relies on the emergence of local and regional
efforts known as Regional Health Information
Organizations (RHIOs). The success of the RHIO model
depends heavily on the participation of organizations like
hospitals, which have the clinical data required for
exchange. We examined factors that differentiate
hospitals that choose to participate in RHIOs from those
that do not.
Study Design: We used data from the newly available
IT supplement to the annual American Hospital
Association (AHA) survey, which asked hospitals
whether they participate in a RHIO and exchange data.
We compared hospitals participating in data exchange
via a RHIO to those not doing so along a set of predefined characteristics.
Population Studied: All acute-care U.S. hospitals that
are members of the AHA were surveyed.
Principal Findings: We received responses from 3,488
(63.1%) acute-care hospitals. There were 561 hospitals
participating in data exchange via a RHIO (16% of all
acute care hospitals) while 2,833 (81%) affirmed that
they did not. The remaining 3% of hospitals did not
respond. Comparing hospitals that participate and
exchange data with those that reported they did not,
non-profit hospitals were more likely to participate than
for-profit hospitals (17% versus 12%, p=0.005). Large
hospitals (400+ beds) were more likely to participate
than small (6-99 beds) and medium (100-399 beds)
hospitals (22% versus 16% for both small & medium,
p=0.04). Urban hospitals were as likely to participate as
non-urban hospitals (16% versus 17%, p=0.49).
Participating hospitals did not differ significantly on the
proportion of Medicare admissions (47% versus 48%,
p=0.64) or Medicaid admissions (17% versus 16%,
p=0.49). Hospitals with more advanced clinical systems
were more likely to participate. For instance, those with
electronic clinical documentation of physician notes were
more likely to participate than hospitals that did not have
this functionality (22% versus 15%, p<0.001). Other
clinical functionalities associated with higher participation
rates included electronic clinical documentation of
patient demographics (18% versus 11%, p<0.001),
problem lists (20% versus 14%, p<0.001), and
medication lists (18% versus 14%, p=0.003) as well as
viewing of lab reports (18% versus 10%, p<0.001),
radiology reports (18% versus 11%, p<0.001), radiology
images (18% versus 12%, p<.001), diagnostic test
results (19% versus 13%, p<.001), diagnostic test
images (20% versus 14%, p<.001), and consultant
reports (19% versus 13%, p<.001).
Conclusions: In a nationally-representative survey of
acute-care hospitals, we found relatively low rates of
data exchange via RHIOs. Larger, non-profit hospitals
were more likely to participate, although even their rates
of participation were relatively low. Specific hospital IT
system functionalities related to clinical documentation
and results viewing were also associated with a higher
likelihood of RHIO participation.
Implications for Policy, Delivery or Practice: Low
overall rates of RHIO participation suggest that current
efforts to engage hospitals in clinical data exchange
have not had broad penetration. The dramatically low
rates of participation among for-profit hospitals suggest
that competition and fear of loss of market share may be
holding some institutions back. Incentives, whether
financial or regulatory, are likely needed to garner
greater enthusiasm among institutions to actively
exchange clinical data with other providers. Greater
adoption and use of specific IT functionalities, such as
results viewing, are likely to further spur participation as
hospitals realize greater gains from availability of
electronic clinical data.
♦ Electronic Exchange of Clinical Laboratory
Information: Issues & Opportunities
Prashila Dullabh, M.D.; Adil Moiduddin, M.P.P.; James
Sorace, M.D.
Presented by: Prashila Dullabh, M.D., Health IT
Program Manager, Health, National Opinion Research
Center, Email: dullabh-prashila@norc.org
Research Objective: In 2008, the Assistant Secretary
for Planning and Evaluation (ASPE) contracted with the
National Opinion Research Center (NORC) to conduct a
study to enhance understanding of the current
processes, issues and opportunities involved in the
electronic exchange of laboratory information in
ambulatory care settings, with a focus on safety-net
clinics and federally qualified health centers. Specific
areas covered in this paper include 1) an overview of the
current approaches used for electronic exchange of
clinical lab data between provider EHR systems (for
safety net providers in particular) and clinical
laboratories; 2) a review of the key stakeholders involved
in lab exchange; 3) a review of the use of standards to
facilitate a more systematic and consistent approach to
lab exchange; and 4) a review of issues and challenges
facing wide-spread participation in electronic lab
exchange
Study Design: To gather comprehensive information on
electronic exchange of laboratory data, NORC
conducted a scan of the available literature using
PubMed to search for peer reviewed publications. We
also conducted Internet searches to identify government
reports and articles from trade publications relevant to
electronic clinical laboratory data exchange. NORC also
conducted a series of phone discussions with major
stakeholders representing providers with EHRs currently
interfaced with clinical laboratories, their national and
regional lab partners, and EHR vendors.
Population Studied: This study focuses on the
challenges faced by federally supported health centers
and other safety-net clinics. Closely related to the health
center experience is a broader understanding of the
issues involved in moving to the use of consistent data
exchange standards and implementation approaches for
lab information exchange in other ambulatory care
settings.
Principal Findings: Limited use of standards: There is
limited evidence that clinical laboratories or EHR
vendors have moved towards greater use of standards
recommended by the Health Information Technology
Standards Panel (HITSP) or used, as criteria, the
Certification Commission of Health Information
Technology (CCHIT).
Limited understanding of best practices in interface
development. Due to the various business interests and
the relative inexperience of most providers with EHR
systems, there is little evidence that the health care
sector has developed clearly defined best practices
around interface development. Relationship between
use of standards and regulatory compliance. Key
regulatory issues relevant to lab exchange include CLIA
compliance as well as the privacy and security
regulations specific to CLIA, HIPAA and individual State
medical information privacy statutes. Cost
considerations. There are numerous challenges
associated with calculating interface costs because there
are a number of highly variable factors contributing to
the total. Additionally, messaging standards will
influence this expense. The major drivers of the costs of
establishing the interface, and those associated with
validation and ongoing maintenance, are not entirely
clear. Limited EHR adoption and availability to HIE
systems. The most recent research indicates that fewer
than one in four physician offices are using EHRs. Other
opportunities for interoperable lab exchange include
HIE-based platforms. However, most ambulatory care
providers do not have access to information or data
applications supported by HIEs.
Conclusions: To promote broader exchange of lab
information, it is important to develop a better
understanding of the costs involved and how benefits
accrue to various participants. Additionally, there needs
to be evidence of strong linkages between EHR adoption
and quality improvement initiatives. To support broader
standards adoption, current standards will need to be
expanded to include all types of lab information; also,
there will be need for detailed implementation guides to
ensure a more uniform approach to implementation.
Finally, a careful examination of some of the CLIA
requirements and certification processes will need to be
undertaken to assess how these can be revised to
promote lab information exchange. This study was
funded under a contract with ASPE. However the views
expressed represent only those of the authors and do
not necessarily reflect those of ASPE or HHS.
Funding Source(s): ASPE
♦ Using a Community Health Information Exchange
to Identify & Stratify Uninsured & Underinsured
Frequent Users of Emergency Department
Anjum Khurshid, Ph.D., M.B.B.S., M.P.A.; Tate Erlinger,
M.D., M.P.H.; Sandy Coe Simmons, M.A.
Presented by: Anjum Khurshid, Ph.D., M.B.B.S.,
M.P.A., Director, Clinical Research & Evaluation,
Integrated Care Collaboration, 2101 South IH-35, Suite
500, Austin, TX 78741, Phone: (512) 804-2090, Email:
akhurshid@gmail.com
Research Objective: To identify and stratify, using a
community health information exchange, uninsured and
underinsured patients who become frequent users (FUs)
of emergency departments (ED).
Study Design: This is a longitudinal study of encounter
data using a master patient index called the I-Care
database. The I-Care database receives encounter data
from all major providers in the 3-county region
comprising Hays, Travis, and Williamson in Central
Texas, if the patient is identified as uninsured or
underinsured. FUs of ED are defined as patients with =6
visits to ED in previous three months. We identified FUs
in the I-Care database within any quarter starting from
May 2006 to July 2008. Change in patient-lists from one
quarter to the next was calculated over a two-year
period.
Population Studied: The population included uninsured
and underinsured patients in I-Care database who have
had any encounter in the ED between May 2006 and
July 2008.
Principal Findings: 1,348 unduplicated patients were
identified as FUs over the 2-year period. The number of
FUs in any quarter ranged from 178 to 251 (mean=215;
SD= 24.1). In 2007, 9% of FUs were aged 0-17 years,
68% were aged 18-44 years, 25% 45 and above. 56%
were white, 17% African Americans, and 14% Hispanics.
There were slightly more females (56%) than males
(44%). Only 20-26% of patients who were FUs in one
quarter also became FUs in the next quarter. Over a
period of two years (8 quarters) only 2% (n=5) of
patients in a quarter appeared as FUs in all 8 quarters.
The profile of these frequent-FUs was quite different
from that of other FUs. We also found that if a similar
analysis was done using any of the individual hospital
system’s data, where we could only see FUs within the
same hospital system, the number of patients identified
as FUs was only a fraction of the ones identified through
the I-Care database. For instance, in May-July 2008
quarter, the total number of FUs identified in I-Care
database was 205, while FUs to each of the hospital
system in the region ranged from 2 to 55 and their
combined total was only 128.
Conclusions: Uninsured and underinsured FUs of ED
are not a homogenous or static group. A communitywide health information exchange can significantly
improve the capacity of the local healthcare system to
identify and stratify high users of emergency department
and thus help in development of focused strategies for
care coordination and case management for these
patients. Individual hospital systems are only able to
identify a smaller sample of this population when relying
on their own information systems instead of a community
health information database such as I-Care.
Implications for Policy, Delivery or Practice: This
study shows the benefits of collaboration through health
information technology at a community level to address
the needs of the uninsured and underinsured
populations. Systematic data analysis using such a
shared information database can help the healthcare
system and individual members develop focused
interventions to help vulnerable populations who may be
frequent users of healthcare services.
♦ Providers Perceptions about EHR in a Community
EHR Project
Armine Lulejian, M.S., M.P.H., C.H.E.S.; Sarah Shih,
M.P.H.; Farzad Mostashari, M.D., M.S.
Presented by: Armine Lulejian, M.S., M.P.H., C.H.E.S.,
Research Scientist, Primary Care Information Project,
New York City Department of Health & Mental Hygiene,
161 William Street, New York, NY 10038, Phone: (212)
788-5680, Email: alulejia@health.nyc.gov
Research Objective: More widespread adoption of
Electronic Health Record (EHR) systems is a national
priority and described as a key component of improving
the quality and efficiency of medical care and prevention.
The Primary Care Information Project (PCIP) is the
largest community EHR project in the United States and
helped over 1,000 providers serving underserved
communities in disparate practice settings to adopt an
EHR. We conducted surveys of providers before and 6
months after EHR adoption to better understand their
expectations and the perceived impact of EHR adoption.
Study Design: Two cross-sectional (unmatched)
surveys of providers were sent to providers via email or
mail prior to-- and six months after--EHR implementation
(prior to implementation of clinical decision supports for
preventive care).
Population Studied: Medicaid primary care providers
implementing EHRs in NYC. Preliminary findings
described here include 403 providers for baseline and 97
providers for the follow-up study; response rates were
57.4% and 63.0%, for baseline and follow-up surveys
respectively.
Principal Findings: At baseline, over 50% of the
providers noted satisfaction with documenting physical
exams, histories, and allergies, with lower rates of
satisfaction for keeping problem lists and medication
lists, keeping track of and providing preventive services,
and monitoring medication safety. The post-adoption (6month) surveys found that most providers thought that
the EHR had improved their ability to keep problem lists
and medication lists, and monitor drug safety. However,
less than half thought that the EHR had improved their
ability to monitor medication adherence or deliver
appropriate preventive care. Most providers (76%)
would recommend the EHR to other providers.
Conclusions: EHRs can improve the quality of medical
documentation and monitoring for medication safety.
However, without specific functionality and training,
preventive care is unlikely to improve.
Implications for Policy, Delivery or Practice: Health
Information Technology investments must require more
advanced functionalities including medication adherence
monitoring and decision support tools for preventive
care.
Funding Source(s): New York City Department of
Health and Mental Hygiene
Quality of Care in Nursing Homes
Chair: R. Tamara Konetzka
Sunday, June 28 * 11:00 a.m.- 12:30 p.m.
♦ Commonality in Nursing Home Quality: Medicaid
Payment & Re-Hospitalization of Post-Acute
Medicare Residents
David Grabowski, Ph.D.; Zhanlian Feng, Ph.D.; Orna
Intrator, Ph.D.; Vincent Mor, Ph.D.
Presented by: David Grabowski, Ph.D., Associate
Professor, Health Care Policy, Harvard Medical School,
180 Longwood Avenue, Boston, MA 02115, Phone:
(617) 432-3369, Email: grabowski@med.harvard.edu
Research Objective: Nursing homes care for two
distinct populations: custodial, predominantly Medicaidfinanced residents and post-acute, predominantly
Medicare-financed patients. Despite important
differences in the needs of these two populations, quality
of care within a facility has characteristics of a “common
good” shared across all nursing home residents. The
central implication of this observation is that policies
directed at improving care for one group of residents
may spillover to other residents. Indeed, recent work has
found that the adoption of Medicare prospective
payment for skilled nursing home care was associated
with lower quality of care for long-stay (i.e.,
predominantly Medicaid) residents. Other work has
shown that the generosity of Medicaid payments has
implications for the quality of care received by all nursing
home residents, including Medicare residents. The
objective of this paper is to directly analyze the effects of
Medicaid payment generosity and bed-hold policies
(whether the state pays nursing homes to hold a
Medicaid resident’s bed during acute hospital admission)
on the re-hospitalization of Medicare post-acute nursing
home patients.
Study Design: We examined the pre-post difference in
Medicare re-hospitalizations in states that changed their
Medicaid policies relative to those states that did not
undergo a change in these policies. Specifically, we
used differences-in-differences regression model to
control for potential selection biases.
Population Studied: Based on Medicare inpatient
claims for 2000- 2004, we identified all discharges to
nursing homes during each calendar year, as indicated
by an available Minimum Data Set (MDS) assessment or
a skilled nursing facility (SNF) Medicare claim within 30
days of hospital discharge. We tracked all SNF and MDS
records to define a cohort of newly admitted nursing
home residents within 30 days of hospital discharge in
each year, with one record per person. The total
number of observations (base discharges) annually was
approximately 900,000. We identified 30 day rehospitalizations following discharge from the initial
hospital stay from whence they entered a nursing home.
Principal Findings: Our initial analyses indicate that
Medicaid bed-hold policies are related to Medicare rehospitalizations. In particular, states that adopted a more
generous Medicaid bed-hold payment policy had lower
re-hospitalization rates among Medicare short-stay
patients. However, the generosity of Medicaid payment
was not significantly related to Medicare rehospitalizations.
Conclusions: These results suggest a connection
between Medicaid bed hold policies for nursing home
care and the delivery of care for Medicare residents.
Implications for Policy, Delivery or Practice: In spite
of our findings, neither Medicaid nor Medicare has an
incentive to enact nursing home payment policies that
recognize the welfare of residents covered by the other
program. This lack of coordination may lead to increased
program costs, a lack of care management, and poor
quality of care.
Funding Source(s): NIA
♦ The “Nursing Home Compare” Measure of
Urinary/Fecal Incontinence: Cross-Sectional
Variation, Stability Over Time & Impact of Case Mix
Yue Li, Ph.D.; John Schnelle, Ph.D.; William Spector,
Ph.D.; Laurent Glance, M.D.; Dana Mukamel, Ph.D.
Presented by: Yue Li, Ph.D., Center for Health Policy
Research, University of California, Irvine, 111 Academy,
Suite 220, Irvine, CA 92697, Phone: (949) 824-5929,
Email: yli11@uci.edu
Research Objective: The current “Nursing Home
Compare” report card publishes multiple outcome
measures derived from resident health assessments.
These measures are designed to inform consumer
choices of facilities based on “quality”, and could also
serve as objective evidence of performance and enable
future pay-for-performance programs to reward facilities
with superior outcomes. The intended effectiveness of
these quality measures (QMs) assumes that they reflect
true performance variations between competing
facilities. However, recent studies have suggested that
because these QMs are only minimally risk adjusted for
resident frailties and comorbidities, comparison of QM
rates may largely reflect cross-sectional variations in
case mix rather than performance between facilities. In
addition to the need for improved validity in crosssectional comparisons, another desired, although less
tested, property of the QMs is that they should be
relatively stable (or highly correlated) when calculated
and updated in the “Nursing Home Compare” publication
over a short period of time (eg, 3 months). Generally,
although QM rates may change in the longer term as a
result of altered care practices or staff turnover, the
short-term stability of QMs is expected and bears
important implications for relevant and reliable outcome
comparisons. It is unknown, however, whether and how
facility case mix affects the short-term stability of
published QMs. This study was designed to determine 1)
short-term stability of the published QM; 2) the potential
impact of facility case mix on cross-sectional variations
and short-term stability of the QM; and 3) whether
multivariate risk adjustment for resident characteristics
can minimize this impact. This study focused on one of
the 19 QMs currently published – urinary/fecal
incontinence for long-term care residents.
Study Design: Retrospective analyses of the 2005
national Minimum Data Set (MDS). Resident-level mixed
logistic regression was used to construct the riskadjusted QM. Facility-level ordinary least squares
models and adjusted R-squares were used to estimate
the impact of case mix on both currently published and
risk-adjusted QMs.
Population Studied: Over 600,000 long-term care
residents in 10,437 nursing homes.
Principal Findings: Both incontinence QM rates and
case mix vary substantially across facilities but in
general show relatively high stability over the short term.
At least 50% of the cross-sectional variation of the
published QM is explained by that of facility case mix
(adjusted R-square=0.50), and over 25% of the shortterm variation of the published QM is due to that of case
mix. In contrast, the cross-sectional and short-term
longitudinal variations of the risk-adjusted QM are much
less susceptible to case mix variations (adjusted Rsquare<0.10), even for facilities with more extreme or
more unstable outcome.
Conclusions: Current “Nursing Home Compare”
incontinence QM reflects considerably case mix
variations across facilities and over time, and therefore
may be biased. This issue can be largely addressed by
multivariate risk adjustment using risk factors available in
the MDS.
Implications for Policy, Delivery or Practice: This
study examined the impact of case mix on 2 aspects of
the incontinence QM – its cross-sectional variation and
longitudinal stability in the short run. Both properties are
important because they together determine how the
report card can be used as a valid tool to support
outcome comparisons. The findings suggest
considerable impacts of case mix on the 2 important
properties. Multivariate risk adjustment on this QM can
minimize the overall impact of case mix, and therefore,
make the QM more likely to reflect a facility’s crosssectional standing and short-term stability in continence
care practice. The multivariate risk-adjusted QM is more
appropriate than unadjusted QM for use as a report card
measure.
Funding Source(s): NIA
♦ The Costs of Turnover in Nursing Homes
Dana Mukamel, Ph.D.; William Spector; Rhona
Limcangco; Ying Wang; Zhanlian Feng; Vince Mor
Presented by: Dana Mukamel, Ph.D., Professor, Center
for Health Policy Research, University of California
Irvine, 111 Academy Way, Suite 220, Irvine, CA 926975800, Phone: (949) 824-8873, Email:
dmukamel@uci.edu
Research Objective: Turnover rates in nursing homes
have been persistently high for decades, ranging
upwards of 100%. While prior studies have shown
associations between turnover and poor quality, there is
no empirical evidence about the costs associated with
turnover. In this study we estimated the net costs
associated with turnover of direct care staff in nursing
homes.
Study Design: Data included Medicaid cost reports, the
Minimum Data Set (MDS), Medicare enrollment files,
Census and Area Resource File (ARF). We estimated
variable cost functions, which in addition to exogenous
outputs and wages, included the facility turnover rate.
Instrumental variable (IV) limited information maximum
likelihood techniques were used to account for the
endogeneity of turnover and costs.
Population Studied: 902 nursing homes in California in
2005.
Principal Findings: The average nursing home turnover
rate was 62%, and it was highly variable, with a
coefficient of variation of 65%. The average nursing
home variable cost was $5.3 million. The cost functions
exhibited the expected behavior, with initially increasing
and then decreasing returns to scale. The ordinary least
square estimate did not show a significant association
between costs and turnover. The IV estimate of the
marginal cost of turnover was negative and significant
(p=0.033). The marginal cost savings associated with a
10 percentage point increase in turnover for an average
facility was $168,610 or 3.2% of annual variable costs.
A nursing home choosing between operating at the 25th
percentile versus the 75th percentile of turnover, i.e.
between 38% and 78%, would experience a cost saving
of $674,440 (in 2005 dollars), ceteris paribus.
Conclusions: The net savings associated with turnover
offer an explanation for the persistence of this
phenomenon over the last decades, despite the many
policy initiatives to reduce it.
Implications for Policy, Delivery or Practice: This
study has implications for both research and policy. The
research related implication is the demonstrated
importance of endogeneity of turnover. Studies of the
impact of turnover in nursing homes, on both costs and
quality, should investigate the potential for endogeneity
bias. The policy implications derive from the estimated
negative net cost impact of turnover. Future policy
efforts need to recognize that the relationship between
turnover and costs is complex and may need to be
addressed with financial incentives.
Funding Source(s): NIA
♦ Design for Nursing Home Compare Five-Star
Quality Rating System
Alan White, Ph.D.; Michael Plotzke, Ph.D.; Louise
Hadden, B.A.; Terry Moore, M.P.H., B.S.; Allison Muma,
M.H.A., B.S.; Michael Plotzke, Ph.D.; Christianna
Williams, Ph.D.
Presented by: Michael Plotzke, Ph.D., Associate,
Domestic Health, Abt Associates Inc., 55 Wheeler
Street, Cambridge, MA 02138-1168, Phone: (314) 3878988, Email: Michael_Plotzke@abtassoc.com
Research Objective: In December 2008, the Centers
for Medicare & Medicaid Services (CMS) launched an
enhanced version of its Nursing Home Compare public
reporting site (http://www.medicare.gov/NHCompare/)
that includes a set of quality ratings for each facility that
participates in Medicare or Medicaid. For each facility,
the site reports multiple “star” ratings that measure
different dimensions of the facility’s quality. The primary
goal in launching the rating system is to give consumers
an easy way to evaluate the quality of a facility. In the
process of designing this rating system, numerous
potential measures were considered, as were different
methods of using the measures to calculate the ratings.
This presentation provides a description of the
methodology and results from the application of the
rating system.
Study Design: Each facility receives a quality rating for
three separate domains (health inspections, quality
measures, and staffing) as well as an overall composite
rating. Ratings range from one through five stars, with
one star indicating “much below average” and five stars
indicating “much above average.” Rankings are updated
monthly. The health inspections domain rating is based
on deficiencies identified during facility surveys,
including complaint and revisit surveys. The quality
measure (QM) domain rating is based on 7 “long-stay”
QMs (e.g. percent of long-stay residents who have/had a
catheter inserted and left in their bladder) and 3 “shortstay” QMs (e.g. percent of short-stay residents with
delirium) which are measured using the Minimum Data
Set. Constructing the QMs uses a methodology identical
to that used for the measures posted on Nursing Home
Compare. The Staffing domain rating is based on
casemix adjusted RN and total nursing hours per
resident day, with the casemix adjustment based on the
distribution of facility residents by RUG-III group. A
facility’s overall composite rating is based primarily on its
rating from the health inspection domain, but can
increase or decrease depending on the facility’s ratings
in the other two domains.
Population Studied: Facilities that participate in
Medicare or Medicaid.
Principal Findings: About 12% of the nation’s nursing
homes received a 5-star overall rating, while 22% had a
1-star rating. The remaining facilities were distributed
evenly among the two, three and four star ratings.
Overall composite ratings tended to be higher for smaller
facilities, as did ratings for the health inspections
domain. Hospital-based facilities tended to have higher
ratings on the staffing domain but lower ratings on the
QM domain.
Conclusions: The goal of the rating system is to give
consumers meaningful information that makes it easier
to compare nursing facilities. It provides a
straightforward assessment of quality that can
distinguish low and high performing facilities. The rating
system is intended to be a first step in researching
nursing home options.
Implications for Policy, Delivery or Practice:
Disseminating quality information about facilities aids
consumers in making informed decisions and also
provides a way for an individual facility to evaluate its
quality relative to other facilities. The availability of this
information may motivate facilities to improve quality if
they receive low star ratings.
Funding Source(s): CMS
♦ Effect of Nursing Home Work Environment on
Deficiency Citations
Helena Temkin-Greener, Ph.D.; Nan Zheng; Shubing
Cai; Hongwei Zhao, Sc.D.; Dana Mukamel, Ph.D.
Presented by: Helena Temkin-Greener, Ph.D.,
Associate Professor, Community & Preventive Medicine,
University of Rochester, Box 644, 601 Elmwood Avenue,
Rochester, NY 14642, Phone: (585) 275-8713, Email:
Helena_Temkin-Greener@urmc.rochester.edu
Research Objective: A number of studies have
suggested that such work environment attributes as job
design, work effectiveness, and teamwork influence
quality of care, but few have actually tested these
relationships empirically in nursing homes (NHs). This
study investigates the effect of these work environment
attributes on quality of care measured by facility-level
regulatory deficiencies. Deficiencies are issued to NHs
by state surveyors as part of the federal survey process.
Study Design: Data on work environment are derived
from survey responses obtained from 7,418 direct care
workers in 162 NHs. The surveys were collected in
2006-2007. Data on facility deficiencies and other facility
characteristics were obtained from the On-Line Survey
Certification and Reporting System (OSCAR). For each
facility, survey and OSCAR data were linked. We
examined the number of health-related deficiencies (192
specific standards) and quality of care deficiencies (25
specific standards).
Population Studied: The analytical sample includes
162 nursing NHs in NYS. The analysis is based on
facility-level data. Three dependent variables were
constructed: number of health-related (HR) deficiencies;
total number of quality of care (QC) deficiencies; and
presence/absence of high severity QC deficiencies (level
G-L, i.e. causing actual harm or immediate jeopardy).
Independent variables of primary interest include: work
effectiveness (a score based on a 5-point Likert scale
composed of 7 items); percent of direct care staff
working in interdisciplinary teams; and percent of direct
care staff with primary assignment. These variables
were constructed from survey responses obtained from
direct care workers. The measure of work effectiveness
has been demonstrated, in a prior published study, to be
psychometrically reliable and valid. Other independent
variables include staffing, occupancy, facility case-mix,
and ownership. Multivariate linear regression and logistic
regression models with random effects to account for the
survey region were estimated. Probability weights were
used to correct for higher than expected proportion of
non-profit facilities in the sample.
Principal Findings: An average NH had 5.00 HR and
1.68 QC deficiencies; 19.75% of QC deficiencies were
severe, categorized as G-L. Consistent with our
hypotheses we found significantly fewer HR deficiencies
in NHs with higher work effectiveness (p<0.001) and
greater penetration of self-managed teams (p=0.013).
Controlling for other factors, one standard deviation
(0.216) increase in work effectiveness results in 1.73
decline in the number of HR deficiencies; one standard
deviation (0.065) increase in proportion of self-managed
teams results in 0.323 decline in HR deficiencies. We
also found significantly fewer QC deficiencies in facilities
with better work effectiveness (p=0.019), higher
prevalence of self-managed work teams (p=0.046), and
higher proportion of primary assignment (p=0.030).
Similar relationships hold for QC deficiencies with G-L
severity.
Conclusions: Consistent with our hypotheses we find
that work environment attributes impact quality of care in
NHs. Facilities in which staff report higher work
effectiveness, greater prevalence of self-managed
teams, and primary assignment have consistently and
significantly fewer health and quality of care deficiencies,
even of the highest severity.
Implications for Policy, Delivery or Practice: These
findings provide important insights for NH administrators
and regulators in their efforts to improve quality of care
for residents.
Funding Source(s): NIA
Issues In Community & Institutional Long-Term Care
Chair: Helena Temkin-Greener
Sunday, June 28 * 4:30 p.m.- 6:00 p.m.
♦ Facility & Market Factors Affecting Transitions
from Nursing Home to Community
Greg Arling, Ph.D.; Kathy Abrahamson, Ph.D.; Valerie
Cook; Teresa Lewis; Robert Kane, M.D.
Presented by: Greg Arling, Ph.D., Associate Professor,
Indiana University Center for Aging Research, Indiana
University School of Medicine, 410 West 10th Street,
Suite 2000, Indianapolis, IN 46202-3012, Phone: (317)
423-5634, Email: garling@iupui.edu
Research Objective: Individual, facility, and community
characteristics likely combine to influence transitions
from nursing home to community. Yet much of the
previous transitions literature has focused upon
individual characteristics, excluding the contextual
nature of the discharge decision. Our objectives were
to: (1) determine the influence of facility and market
characteristics on community discharges from Minnesota
nursing facilities; (2) apply findings to design of a
statewide intervention promoting transitions from nursing
home to community.
Study Design: We developed multilevel models
predicting community discharge within 90 days of
admission for a cohort of annual nursing home
admissions. In the first stage we used resident
preferences and health and functional conditions to
predict community discharge. In the second stage we
used facility characteristics and market factors to predict
residual variance in facility discharge rates after
controlling for resident-level factors. Markets consisted
of individual or contiguous counties with homogeneous
admission patterns. Resident variables came from the
Minimum Data Set (MDS); facility and market
characteristics came from state administrative systems
and the Area Resource File. Facility characteristics
included size, ownership type, occupancy rate, Medicare
and Medicaid percentage, acuity-adjusted nursing hours,
and rate of admissions from hospitals. Market
characteristics included population size, average
occupancy, market concentration (HHI), home and
community-based service (HCBS) expenditures, and
ratio of HCBS recipients to nursing residents.
Population Studied: Annual first-time nursing home
admissions (24,648) to 378 Minnesota nursing facilities
in 2005-2006 followed for 12 months after admission.
Principal Findings: After adjusting for resident
characteristics, the proportion of admissions preferring
or having support for returning to the community was
greatest in facilities with higher average acuity, more
Medicare and fewer Medicaid days, and higher nurse
staffing and in markets having higher average facility
occupancy levels. Community discharge rates were
highest in facilities with more residents preferring
community discharge, more Medicare and fewer
Medicaid days, higher nurse staffing, higher occupancy,
and in markets with a greater ratio of Medicaid HCBS
recipients to nursing home residents
Conclusions: Community discharges from nursing
homes is influenced not only by resident health and
functional status and care preferences but also by facility
and market contexts. Nursing home admissions are
more likely to be discharged to the community and less
likely to become long-stay if they enter facilities that
maintain higher occupancy rates (despite their high
discharge rates) and are located in markets with high
occupancy, concentrate on the Medicare or private pay
admissions, invest in nurse staffing, recognize the
potential and encourage residents to return to the
community, and are located in markets with greater
availability of HCBS.
Implications for Policy, Delivery or Practice: The
community discharge intervention we are designing for
Minnesota has thus far focused on residents who would
be candidates for community discharge, i.e., residents
preferring discharge and having low care needs. This
study suggests that for the intervention to be successful
we need additional policy tools to encourage facilities to
reduce their unused bed capacity, balance their mix of
payers, invest in nurse staffing, and take other steps to
develop business models consistent with state goals for
long-term care re-balancing. Additionally, the state
should expand HCBS funding, particularly in markets
with lowest adjusted community discharge rates.
Funding Source(s): State of Minnesota
♦ State Long-Term Care Policies & Practices & the
Use of Hospice Care in Nursing Homes
Susan Miller, Ph.D.; Julie Lima, Ph.D.; Pedro Gozalo,
Ph.D.; Nathilvar Venkatesh, M.S.
Presented by: Susan Miller, Ph.D., Associate Professor
of Community Health (Research), Center for
Gerontology & Health Care Research, Brown University,
121 South Main Street, Providence, RI 02912, Phone:
(401) 863-9216, Email: Susan_Miller@brown.edu
Research Objective: This study aimed to extend our
understanding of how a state’s LTC policies and its
nursing home (NH) reimbursement practices are
associated with a NH’s rate of hospice use and its use of
higher (and more costly) levels of hospice care.
Study Design: Using a “residential history file,” this
cross-sectional study merged resident assessment data
(MDS) with Medicare Part A claims data to determine
whether the NH was the site of death, if hospice care
was provided within a NH stay, and the proportion of
total hospice days at continuous home care or general
inpatient care levels. To control for provider and market
characteristics, a NH-level file was linked with NH survey
data (i.e., OSCAR), the hospice provider of service file
and the area resource file; to that linked file was added
state LTC policy and NH reimbursement data. We used
a multivariate linear regression with clustering on
counties and state fixed effects to examine NH rates of
hospice use and a multinominal logit model to examine
whether the proportion of hospice days at higher levels
of care was above the median of 0, or at or above the
top decile of 10%.
Population Studied: Nursing homes across the 48
contiguous US states who had any resident deaths in
2000 (N=16,580) were included in state descriptive
analyses. To study NH-level hospice use, we included
NHs with any hospice use (N= 11,709).
Principal Findings: In 2000, we identified 491,384 NH
deaths in the 48 contiguous U.S. states. Of NH
residents who died, 15.7% enrolled in hospice. In
multivariate analyses, while Medicaid NH case-mix
payment (versus no case-mix) was not significantly
associated with the rate of hospice use, in case-mix
states removing hospice residents from a NH’s per diem
rate calculation (N=6) there was lower hospice use
(coefficient -12.6; 95% CI -7.6,-17.6). Conversely, in
these states NHs had twice the odds of using higher
levels of general inpatient and continuous care hospice
days (odds ratio [OR] 2.2; 95% CI 1.8, 2.7 for being in
the top decile of use). NHs in states adhering to
Medicaid per diem “pass-thru” regulations for hospice
residents (i.e., hospice receives payment and pays NH)
had lower rates of hospice use (coefficient -5.8; 95% CI -
1.55, -9.97). Last, the presence of any hospice certificate
of need regulations was associated with both lower rates
of hospice use (coefficient -6.9; 95% CI -0.33, -13.4) and
substantially lower odds of the NH using the highest
proportion (top decile) of general inpatient and
continuous hospice care (OR -18.4; 95% CI -17.5, 19.2).
Conclusions: Many state LTC policies and
reimbursement practices do not appear to promote
equitable access to the Medicare hospice benefit, and
one such policy may actually result in some overuse of
the costliest levels of Medicare hospice care.
Implications for Policy, Delivery or Practice: These
and previous research findings suggest payment reforms
should consider potential Medicare-Medicaid cross
subsidies to encourage state policies and practices that
promote equitable hospice access while aligning
provider incentives to increase the likelihood of
combined Medicare/Medicaid savings.
Funding Source(s): AHRQ, National Institute on Aging
♦ State Support for Home & Community-Based
Services & Elderly Well-Being
Naoko Muramatsu, Ph.D., M.H.S.A.
Presented by: Naoko Muramatsu, Ph.D., M.H.S.A.,
Associate Professor, School of Public Health, University
of Illinois at Chicago, 1603 West Taylor Street, Chicago,
IL 60612, Phone: (312) 996-5679, Email:
naoko@uic.edu
Research Objective: The United States has made
significant progress towards expanding Home and
Community-Based Services (HCBS). However, states
vary greatly in their support for these services that are
intended to help disabled seniors live in the community
and avoid institutionalization. The purpose of this paper
is to examine how states’ generosity in providing HCBS
is associated with the well-being of the elderly,
especially their psychological well-being and chance of
remaining in the community
Study Design: Using the five-wave panel data (19932002) of Health and Retirement Study (HRS)
respondents born in 1923 or earlier, we examined their
depressive symptoms, timing of first and permanent
nursing home admissions, community discharges among
nursing home residents, and chance of dying in the
home (versus in an institution). The person-level data
were merged with state- and county-level data including
data on state HCBS support measured annually by two
proxy variables: total HCBS expenditures divided by the
65+ population, and percentage of long-term care (LTC)
expenditures going to HCBS rather than nursing homes.
We captured HCBS efforts funded not only by Medicaid
but also by other sources (Older American Act Title III
moneys, State Social Services Block Grants, and
programs funded with state-only revenues). We
conducted multilevel repeated measures analysis of
depressive symptoms, discrete-time survival analysis of
nursing home admission and discharge, and multilevel
logistic regression for the chance of dying at home. All
the statistical analyses took into consideration
respondents’ demographic, social, economic, health and
caregiving resources that change over time.
Population Studied: National representative samples of
non-institutionalized adults living in the United States
aged 70 and older as of 1993.
Principal Findings: Living in a state with higher HCBS
support moderated the effects of stress associated with
declining physical and mental function on depressive
symptoms, especially among those with little family
support. Living in a state with higher levels of HCBS
support was associated with a lower risk of nursing
home admission among seniors, especially those with
limited family availability, and thus higher chance of
dying at home rather than in an institution. However,
state HCBS support had no statistically significant
effects on seniors’ chance of returning to the community
after entering nursing homes.
Conclusions: Where seniors live matters for their wellbeing: living in a state with higher HCBS support was
associated with greater well-being of communitydwelling elderly, especially for those with limited family
support.
Implications for Policy, Delivery or Practice: This
study provides evidence for the importance of continued
state and federal efforts to sustain and increase HCBS
funding at this time of economic hardship. LTC
expenditures are one of the "largest uninsured financial
risks" in the United States. The number of people 65
and older will double between 2000 and 2030. With the
aging of baby boomers who generally have less children
than their predecessors, the proportion of those who lack
family caregivers and the role of HCBS will continue to
grow. Political will is needed to prepare society for
increasing LTC needs.
Funding Source(s): NIA
♦ The Use of Medicaid Claims Data to Describe
Patterns of Antipsychotic Prescribing in U.S.
Nursing Homes
Sam Simon, Ph.D.; James Verdier, J.D.; Christal Stone,
M.P.H.
Presented by: Sam Simon, Ph.D., Senior Researcher,
Mathematica Policy Research, 955 Massachusetts
Avenue, Suite 801, Cambridge, MA 02139, Phone:
(617) 301-8982, Email: ssimon@mathematica-mpr.com
Research Objective: A growing body of literature has
raised safety concerns about adverse events associated
with antipsychotic drug use in nursing home populations.
Our objectives were to determine the feasibility of using
Medicaid claims data to operationalize indicators of
inappropriate antipsychotic prescribing and to describe
the prevalence of inappropriate antipsychotic prescribing
patterns in U.S. nursing facilities.
Study Design: To identify indicators of potentially
inappropriate antipsychotic use, we conducted a review
of peer-reviewed literature and nursing-home-specific
federal guidelines and quality indicators. We prepared
from these sources a list of potential measures that
could be operationalized using federal Medicaid Analytic
Extract (MAX) claims data. A panel of three psychiatrists
with expertise in nursing home psychiatric practice and
research reviewed and commented on our list of
measures. We chose a subset of measures (N=7)
based on input from the panel members. We created a
summary measure to aggregate information from the set
of seven measures at the facility level. Online Survey
Certification and Reporting (OSCAR) data were merged
with the MAX data to provide facility characteristics. We
used logistic regression to test the independent
association between facility characteristics and
questionable antipsychotic prescribing practices.
Population Studied: Medicaid enrollees with at least six
months of contiguous nursing home claims in 2002
(N=1,013,990) in 14,208 facilities in 49 states.
Principal Findings: The median prevalence of
antipsychotic prescriptions among nursing home
residents was 36 percent during 2002, with an
interquartile range of 27 to 44 percent. Among the seven
measures evaluated, use of an antipsychotic without an
appropriate diagnosis was the most commonly triggered
measure with 99 percent of facilities having at least one
resident meeting this condition in 2002. In facilities that
triggered this measure, the average rate of triggering
was 28 percent of residents over the one-year study
period. The least commonly triggered measure of
inappropriate antipsychotic prescribing was the use of
conventional antipsychotics among residents with a
diagnosis of Parkinson’s disease, with 21 percent of
facilities triggering this measure, and 1.9 percent of
residents. Using the summary measure to aggregate
overall facility performance, where a score of zero
represented best practice and a score of seven indicated
worst practice, nearly one-third of facilities had a score
of zero and ten percent had a score of four or higher,
the threshold we used to identify poor facility prescribing
practice. We found that small facility size, for-profit
ownership, presence of an Alzheimer’s disease special
care unit, and relatively low staffing levels were
independently associated with poor prescribing
practices.
Conclusions: While our findings are subject to the
quality of the MAX data, which have somewhat limited
information on diagnoses, we found that these
administrative data identified a wide range of facility
antipsychotic prescribing practices. Further, we found
evidence linking poorest antipsychotic practices with low
levels of skilled and unskilled nurse staffing.
Implications for Policy, Delivery or Practice:
Evidence from our study indicates that MAX data can be
used to create a sensitive measure of nursing home
antipsychotic prescribing and may provide policymakers
and regulators a viable alternative to the MDS-based
antipsychotic use quality indicator to identify facilities in
need of closer evaluation.
Funding Source(s): Substance Abuse and Mental
Health Services Administration
♦ Caring for Mom & Neglecting Yourself? The Health
Effects of Caring for an Elderly Parent
Norma Coe, Ph.D.; Courtney Harold Van Houtven,
Ph.D.; Courtney Harold van Houtven, Ph.D.
Presented by: Courtney Harold Van Houtven, Ph.D.,
Assistant Professor, Health Services Research &
Development & General Internal Medicine, VA & Duke
University, 509 Fulton Street, Durham, NC 27705,
Phone: (919) 286-6936, Email:
courtney.vanhoutven@duke.edu
Research Objective: The evidence is clear that
providing informal care can cause adverse emotional
and physical health effects on elderly spousal
caregivers. Less is known about the health effects of
caregiving on adult children, who will become
increasingly important sources of informal care as the
baby boomer generation ages and the number of
divorcées increase. This paper tests whether caregiving
by adult children has adverse effects on their health.
Study Design: For this observational study, we examine
both the short-run and the persistence of caregiving
health effects by observing adult children over 14 years
using dynamic panel methods. We account for the
endogeneity of the length of the caregiving spell and
initial selection into caregiving. Death of the care
recipient is used as an instrumental variable for the end
of caregiving. This approach allows us to disentangle the
health effects of aging or bereavement from the health
effects of informal caregiving. Information about intrafamily caregiving behavior is exploited to control for the
endogenous decision to become a caregiver. The main
outcomes are self-rated health, Center for Epidemiologic
Studies Depression Scale (CES-D8), and diagnosed
heart conditions. We carefully control for baseline health
and work status of the adult child using fixed effects and
Arellano-Bond estimation techniques.
Population Studied: We use data from 8 waves of the
HRS (1992-2006). The sample consists of noncoresiding respondents with a mother alive who were
observed in at least three waves. There are 2557 and
8,092 initial non-caregivers. We also split the sample by
marital status and gender of the caregiver.
Principal Findings: We find that continued caregiving
leads to a 47% increase in the CES-D8 for married
women and an 83% increase for married men. There is
persistence in the depressive symptoms effect for men,
still significant and negative two years later, although
slightly lower in magnitude. Paradoxically, married
women caregivers experience a protective health effect
of continued caregiving, being less likely (10%) to report
a heart condition. Robustness checks confirm that the
increase in depressive symptoms and decrease in
likelihood of heart conditions can be directly attributable
to caregiving behavior, and not due to a direct effect of
the death of the mother. The initial onset of caregiving,
by contrast, has no immediate effects on health for any
subgroup.
Conclusions: Caregiving health effects among
caregivers of elderly mothers were substantial, whereas
no health effects of initial caregiving were found.
Whereas the mean CESD8 score of these samples is
below the clinical cut-off for probable depression at a
score exceeding 4 or 5, a half-point increase in the CESD8 score is large in magnitude. The protective health
effect of continued caregiving for married women could
be due to increased treatment of heart conditions over
time.
Implications for Policy, Delivery or Practice:
Clinicians and policy makers need to recognize that the
negative health effects of informal caregiving are not
limited to spousal caregivers. Focusing policy supports
on adult children and other informal caregivers who are
caregiving for long-periods of time would have the
biggest health benefits.
Funding Source(s): Network for the Study of Pensions
and Aging; Hartford Foundation
Medicaid Costs: Searching for Silver Bullets
Chair: Stephen Zuckerman
Monday, June 29 * 4:45 p.m.-6:15 p.m.
♦ Impact of Expansion of Specialty Consultation
Practice on Use of Specialty Care for Medicaid High
Risk Pregnancies
Janet Bronstein, Ph.D.; Songthip Ounpraseuth, Ph.D.;
David Fletcher, M.B.A.; Judith McGhee, M.D.; Richard
Nugent, M.D., M.P.H.; Curtis Lowery, M.D.
Presented by: Janet Bronstein, Ph.D., Professor, Health
Care Organization & Policy, University of Alabama at
Birmingham School of Public Health, 1665 University
Boulevard, Birmingham, AL 35294-0022, Email:
jbronstein@uab.edu
Research Objective: We assess the initial impact of a
State of Arkansas funded intervention that developed
practice guidelines, expanded continuing education and
improved access to telephone and video consulting
between community based maternity care providers and
university-based maternal fetal medicine (MFM)
specialists (the ANGELS program).
Study Design: Using linked Medicaid claims and vital
records for births occurring between April 2001 and
December 2005, we identify cases with high risk
conditions targeted for increased specialty consults. We
use time series analysis to examine whether (1) the
probability of diagnosis with the high risk conditions, (2)
the probability of a billed specialty consult during the
prenatal period, and (3) the probability of delivery at a
neonatologist-staffed hospital increased over the time
period as the interventions were implemented.
Population Studied: We examine records for over
62,000 Medicaid covered pregnancies in the time period
for women living 12 or more miles from the university
based MFM practice. We assess care for 23 of the 36
targeted conditions which could be identified with claims
and vital records data.
Principal Findings: Taking demographics and
gestational age of infants at delivery into account, we
observe a marked increase in the probability of
diagnosis with the targeted conditions and the probability
of delivery at a neonatology staffed hospital over the
time period. We observe a decline in the probability of a
billed specialty consult for the less severe targeted
conditions, and no change for the more severe
conditions. Pregnancies with earlier prenatal care starts
were more likely to have diagnosed risk conditions and
to receive specialty consults, but less likely to have
deliveries in specialty settings. Where care was partially
provided by nurse-practitioner staffed health
departments the likelihood of MFM consult was greater,
although fewer cases were diagnosed and fewer
referred at delivery.
Conclusions: Increased interaction between community
based maternity care providers and university based
specialists appears to have increased screening and
detection of risk conditions in the prenatal period and
specialty care at delivery for this high risk patient
population. However, in this initial implementation
period, community based physicians did not intensify
their use of specialty consulting services. Barriers to use
of consultation, including patient travel difficulties and
physician uncertainty about the actual value of the
specialty consult for patient management still need to be
addressed.
Implications for Policy, Delivery or Practice: The
highly localized nature of medical practices and the
absence of formalized perinatal regionalization systems
can limit access to specialty maternity care for high risk
pregnant women. State support for a voluntary
expanded specialty care presence is an alternative to a
more proscriptive approach to managing care for this
major component of states’ Medicaid beneficiary
populations. Given the rural nature of Arkansas and the
limited supply of both local maternity care providers and
neonatology staffed delivery settings, enhanced
interactions between existing specialty providers and
community based providers is essential. Early findings
on the impact of the ANGELS intervention are
encouraging, but barriers to appropriate use of specialty
maternity care remain.
Funding Source(s): State contract
♦ A Longitudinal Examination of Health Care
Spending & Service Use Among High-Cost Medicaid
Beneficiaries
Teresa Coughlin; Sharon Long
Presented by: Teresa Coughlin, Principal Research
Associate, Health Policy Center, Urban Institute, 2100 M
Street, NW, Washington, DC 20814, Phone: (202) 2615639, Email: tcoughlin@urban.org
Research Objective: To examine longitudinal spending
and service use patterns for the national Medicaid
population, with a particular focus on high-cost
beneficiaries.
Study Design: Using program administrative data,
Medicaid Statistical Information System (MSIS)
Summary File, we examine Medicaid spending and
utilization patterns for all program services (acute and
long-term care provided in both the community and in
institutions) for the national Medicaid population over a
three-year period, from 2002 to 2004. To account for the
transient nature of Medicaid enrollment, spending
estimates are presented as mean spending per month
enrolled over the study period. Descriptive analyses are
conducted.
Population Studied: The base sample is the 2002
national Medicaid population, for which we track
program spending between 2002 and 2004. Our final
study sample is 42 million individuals.
Principal Findings: We find high-cost Medicaid
beneficiaries to be a diverse population comprised of
individuals with various service use and spending
patterns. A high degree of spending persistence is
observed: Among top 10 percent of spenders in 2002,
65 percent remain in the top 10 percent of spenders in
the subsequent two years. Persistence can be attributed
largely to the use of institutional long-term care, but
other services play important roles, notably, communitybased long-term care and hospital inpatient care. We
also find that persistently high cost beneficiaries have
distinct personal characteristics: They are more likely to
be aged or disabled (including those dually enrolled in
Medicaid and Medicare), female and white. Additionally,
for the select medical conditions examined, we observe
that diabetes and mental illness were especially
prominently among persistently high cost beneficiaries.
Conclusions: We find Medicaid spending is heavily
concentrated among relatively few program beneficiaries
and, moreover, many have persistently high medical
costs.
Implications for Policy, Delivery or Practice: Medicaid
spent a total of $166.8 billion on the persistently highcost population (as we defined it) between 2002 and
2004. If strategies could be developed that reduce
spending on the population by even a modest amount,
say 10 percent, substantial program savings could be
realized. Given this is a high-need, medically-complex
group, such strategies would have to carefully and
thoughtfully developed so as not to compromise
beneficiaries’ health.
Funding Source(s): Kaiser Commission on Medicaid
and the Uninsured
♦ Medicaid Chronic Care Management - Saving
Lives?
Beverly Court, Ph.D., M.H.A.; Alice Lind, B.S.N., M.P.H.
Presented by: Beverly Court, Ph.D., M.H.A., Research
Manager, Office of Quality & Care Management,
Washington State Department of Social & Health
Services, P.O. Box 45530, Olympia, WA 98504-5530,
Phone: (360) 725-1643, Email: courtb@dshs.wa.gov
Research Objective: To determine the cost, utilization
and mortality impact of offering chronic care
management services to high-cost, high-risk Medicaid
clients.
Study Design: Three separate pretest/posttest
randomized control trials, focused on different chronic
care management interventions, implementing
organizations and geographic areas. The study was
designed to test for the population effect of “offering
chronic care management”. The target Medicaid
population was randomized into treatment and abeyance
group - those randomized to treatment were asked if
they wanted to participate. Analysis of the March/April
2007 – December 2007 implementation period
(compared to March/April 2006- December 2006 pretest
period) followed intent-to-treat and compared
proportional difference-in-differences.
Population Studied: Each study shared common
population characteristics: adult clients who were eligible
for aged/blind/disabled Medicaid benefits in Washington
State, not receiving Medicare or comparable private
insurance, and who fell in the top 20% at risk of having
future high medical expenses (as defined by their
ImpactPro™ risk score). Two programs targeted those
not receiving in-home long-term care services; 1.) a
face-to-face intervention for those in King County who
had used a specified network of providers in the past
(treatment n=839, abeyance n=862) and 2) a largely
telephonic intervention which covered all Washington
counties except King County (treatment n=3536,
abeyance n=3483). The third program (face-to-face)
focused on those receiving in-home long-term care
services also required clients to meet one of five further
risk factors: living alone in their own home, experiencing
isolating moods and behaviors, self rating of health as
fair or poor, deteriorated self-sufficiency, or having more
than 8 medications (treatment n=182, abeyance n=608).
Principal Findings: None of the programs showed
statistically significant net decreases in Medicaid medical
per member per month expenditures in the first 9-10
months of operation, however the two face-to-face
programs did show statistically significant differences in
mortality rate (p=.03, p=.04, respectively). Participation
rate of those assigned to the treatment group was 18%
(King County, face-to-face), 45% (statewide, telephonic),
and 43% (in-home long term care, face-to-face).
Conclusions: While the post-period time frame was
short, several things became evident.
If you build it, they will not necessarily come. Clients not
already receiving in-home long term care services were
difficult to find. Care management programs had to work
to gain confidence from the provider community. Low
participation rates within the treatment groups watered
down overall cost-savings from those who did
participate. Telephonic interventions did not appear to
have much effect on average costs or mortality, but faceto-face interventions showed promise for cost savings
and striking results on mortality.
Implications for Policy, Delivery or Practice: In these
days of tight state budgets, legislators yearn to have
quick fixes to contain Medicaid costs. Chronic care
management of those at highest risk for incurring future
costs is appealing, but few state experiments have
shown to deliver significant short-term savings. This
study suggests that face-to-face interventions may have
significant short-term impacts on mortality rates. Rather
than arguing for chronic care management as a costsavings tool, the legislative message could be reframed
as a step towards significantly improved short-term
quality with a potential for long-term cost savings.
Funding Source(s): Washington State Department of
Social and Health Services
♦ An Assessment of the Impact of an Educational
Pharmacy Management Intervention on Prescribers
to Medicaid Beneficiaries
Dominick Esposito, Ph.D.; James Verdier, J.D.
Presented by: Dominick Esposito, Ph.D., Senior
Researcher, Mathematica Policy Research, Inc., 600
Alexander Park, Princeton, NJ 08540, Email:
desposito@mathematica-mpr.com
Research Objective: To examine whether educational
mailings to prescribers of psychotropic medications to
Medicaid beneficiaries improve patient quality of care
and reduce drug costs.
Study Design: Prescribing behavior was compared to
pre-intervention behavior and, where available, to the
behavior of prescribers who were not sent mailings.
Medicaid pharmacy and eligibility data from April 2003
through September 2007 were used, as well as data on
intervention mailings and deviations from clinical
guidelines. Two prescriber focus groups provided
qualitative information that supplemented the claims
data analysis. The intervention identified clinical
deviations in psychotropic prescribing from claims data.
Mailings were sent to prescribers identified as having the
highest psychotropic drug costs associated with
deviations and to any prescribers whose patients were
identified as filling the same medications from multiple
prescribers or as discontinuing therapy. Primary
outcome measures included clinical deviations,
psychotropic claims, and psychotropic costs as a
percentage of total psychotropic claims or costs.
Intervention effects were estimated with generalized
linear regression models controlling for prescriber-level
fixed effects and a time trend, including sensitivity
analyses for various prescriber subgroups (for example,
by months of exposure to mailings or by number of
patients).
Population Studied: Prescribers of psychotropic
medications to Medicaid beneficiaries in Utah who were
mailed intervention letters and those who were not
mailed letters but were identified as deviating from
clinical guidelines. The intervention encompassed two
distinct phases. In Phase I (March 2004 to November
2005) mailings were sent monthly to qualifying
prescribers (297; 221 in comparison group) and in
Phase II (March 2006 to January 2007) mailings were
alternated between prescribers to children (89; 82
comparison) and prescribers to adults (145; 354
comparison).
Principal Findings: Impacts on prescribing behavior
were small and generally not statistically significant.
Prescribing behavior targeted by the letters in Phase I
and for prescribers to adults in Phase II was not different
from existing trends (p > 0.10 for all outcomes). For
prescribers to children, intervention period trends for all
outcomes were statistically different from pre-existing
prescribing; however, trends were not favorable when
compared with comparison group prescribers. For
example, targeted claims as a percentage of total claims
for treatment group prescribers were slightly lower than
for comparison group prescribers, but the average
difference was less than 1 percentage point (p = 0.12)
and not statistically significant until 12 months into the
intervention. In both phases, there were more instances
of prescriptions from multiple prescribers and less
therapy discontinuation after the intervention than
before. However, therapy discontinuation represented
only about 2 percent of all clinical deviations.
Conclusions: Mailings had very small impacts on
prescribing behavior that were generally not measurably
different from either fluctuations in behavior prior to the
intervention or from the behavior of prescribers who
were not mailed letters.
Implications for Policy, Delivery or Practice:
Psychotropic medications are commonly prescribed to
Medicaid beneficiaries. Concerns have been raised
about both their costs and appropriate use, especially for
young children. An educational intervention used in
many states consisting only of mailings to prescribers is
likely not sufficient to improve the quality of patient care
or reduce psychotropic drug costs.
Funding Source(s): U.S. Department of Health and
Human Services, Substance Abuse and Mental Health
Services Administration
♦ North Carolina Medicaid's Community Care of NC
as a Medical Home: New Evidence on Performance
Barbara Ormond, Randall Bovbjerg, J.D.
Presented by: Barbara Ormond, Senior Research
Associate, Health Policy Center, The Urban Institute,
2100 M Street, NW, Washington, DC 20037, Phone:
(202) 261-5782, Email: bormond@urban.org
Research Objective: Assess cost and quality
performance of Community Care of North Carolina, the
state’s medical home model, as the state looks to
expand application of the CCNC medical homes model
from Medicaid to Medicare and private insurance;
generate new information with external credibility to
augment available, mainly descriptive information from
within NC.
Study Design: 1. Comparisons of Medicaid spending
per enrollee by category and growth over time between
CCNC areas and others, including: (a) NC vs.
neighboring states and vs. US totals, using six years of
data from the Medicaid Statistical Information System
(MSIS) (2000 to 2005); (b) variation by NC county
according to CCNC implementation date (unlagged and
lagged), using 2003-2005 MSIS data that included
county of residence; (c) variation between select
counties known to be thoroughgoing implementers of
CCNC vs. other categories of counties (2003-2005). 2.
Multivariate analysis of 2004 and 2005 practice-level
measures of diabetes-related outcomes and processes
to assess CCNC membership’s impact on care for
diabetics. 3. Comparison and contrast with other, preexisting evidence on performance.
Population Studied: All Medicaid recipients (spending
aggregated by eligibility category) in NC and in US; NC
Medicaid recipients with diabetes.
Principal Findings: The new analyses of Medicaid
spending data and diabetes process and outcome
measures did not find differences between CCNCinfluenced and non-CCNC populations. These
inconclusive findings are in sharp contrast to earlier
findings that State Medicaid costs have been contained
according to actuarial and case comparison analyses of
early, small initiatives on asthma and diabetes, as well
as qualitative evidence from key informants and
observation of the state’s budgetary history.
Conclusions: Lack of savings over time compared with
other states might reflect the state’s maintenance of its
Medicaid eligibility rules and its high provider payment
rates during the early 2000s, when others were cutting
back--but not the lack of savings found across NC
counties. Within NC, the county may not be the best
level of analysis, and assessments of other forms of
quality could well be positive; access is certainly known
to be good, with high physician participation. More
intensive work might yet find past spending impacts
within more particularized areas. Alternatively, 2005
might have been too soon to see impacts, as CCNC was
then still recent in many counties and many practices,
and diabetes initiatives have only since then been
extended to Medicaid adults outside of pilot areas.
Another possibility is that CCNC was until very recently
focused more on network construction and provider buyin than on management for results.
Implications for Policy, Delivery or Practice: The
creation of a medical home or any other management
tool does not assure that it will be used to its full
capacity. It may well be that to improve performance as
intended CCNC needs to improve data monitoring and
feedback capabilities, enhance traditionally limited
support for care coordination across provider sites, or
move to forms of pay for performance.
Funding Source(s): CWF
Medicaid & SCHIP Coverage Expansions & Their
Consequences
Chair: Sharon Long
Tuesday, June 30 * 11:30 a.m.-1:00 p.m.
♦ The Effect of HIFA Medicaid Waivers on the Rate of
Uninsurance
Adam Atherly, Ph.D.; Bryan Dowd, Ph.D.; Robert
Coulam, Ph.D., J.D.
Presented by: Adam Atherly, Ph.D., Associate
Professor, Health Policy & Management, Emory
University, 1518 Clifton Road, Northeast, Atlanta, GA
30322, Phone: (404) 727-1175, Email:
aatherl@sph.emory.edu
Research Objective: To evaluate the effect of the
Health Insurance Flexibility and Accountability (HIFA)
demonstrations on the rate of uninsured. The policy
purpose of the HIFA demonstrations is to encourage
“new comprehensive state approaches” that will increase
the number of insured individuals within Medicaid, State
Children's Health Insurance Program (SCHIP), and
public-private partnerships that include premium
assistance programs and development of new health
plan products. HIFA interventions include changes in
benefit packages, eligibility rules for public programs and
states subsidization of private health insurance
premiums. Some states emphasized private insurance
(premium assistance), while others placed greater
emphasis on expanded eligibility for public insurance.
Study Design: The estimation approach was a
difference-in-difference model. We compared changes
in insurance status for individuals in the target population
to three control groups: individuals residing in states that
did not implement a HIFA demonstration during the
period of observation; individuals residing in states that
implemented a HIFA demonstration and who would have
been eligible for the HIFA demonstration had it been in
place, but who were drawn from pre-implementation
years; and individuals who were “nearly eligible” for the
HIFA demonstration in their state (e.g., those who fell
just outside the income eligibility limits) in the preimplementation and post-implementation time periods.
Data was drawn from the Current Population Survey
from 2000-2007. The sample sizes in our analyses
depended on the way in which the control groups were
defined and ranged from 672,923 to 23,561. The
results of the study were validated using data from the
Behavioral Risk Factor Surveillance System.
Population Studied: HIFA is targeted at individuals with
incomes below 200 percent of the federal poverty level
(FPL). The types of individuals in the target populations
ranged from adults to children, depending on the state.
Principal Findings: In the three-way model that
distinguishes public and private insurance, we find that
HIFA demonstrations reduced the probability of
uninsurance by 5.3 percentage points while increasing
the probability of public insurance by almost seven
percentage points. We did not find a statistically
significant effect of the HIFA demonstrations on the
probability of private insurance. The effect size varied
by state, with Maine having the largest effect and Illinois
the smallest. The results were robust to different
specifications of the control group.
Conclusions: Taken together, these findings provide
weak evidence of some crowd-out of private insurance
by HIFA because the increase in public insurance
exceeds the decrease in uninsurance and so some of
the newly publicly insured people must have come from
private insurance.
Implications for Policy, Delivery or Practice: Data
from the CPS indicate that 1.857 million individuals were
eligible for HIFA in 2006. Our estimate is that HIFA
increased the rate of insurance coverage by 5.73 to 9.44
percentage points. Thus, we estimate that between
105,849 and 174,558 adults gained health insurance
coverage due to HIFA. CMS reports that total HIFA
enrollment in was 280,739. Thus, our analysis suggests
that approximately one-third of enrollment in the HIFA
programs may have come from individuals who already
had health insurance in the pre-implementation period.
Funding Source(s): CMS
♦ Working Healthy: A Medicaid Buy-In Success Story
Jean Hall, Ph.D.; Michael Fox, Sc.D.; Noelle Kurth, M.S.;
Emily Fall, B.A.
Presented by: Jean Hall, Ph.D., Assistant Research
Professor, CRL - Division of Adult Studies, University of
Kansas, 1122 West Campus Road, Room 517,
Lawrence, KS 66045-3101, Phone: (785) 864-7083,
Email: jhall@ku.edu
Research Objective: Medicaid Buy-In programs
currently operate in 39 states, with several more states
in the development and implementation phases. Buy-Ins
allow participants to earn more and, often, accumulate
more assets while retaining eligibility for Medicaid
coverage. We sought to document the characteristics of
participants in a Medicaid Buy-In program, using multiple
data sources to track long-term health care utilization
patterns and health and economic outcomes.
Study Design: Using multiple data sources, we
conducted a longitudinal study of Buy-In participants and
a comparison group from 2002 to the present. Data
sources included Medicaid and Medicare claims, state
administrative data such as earnings and tax payments,
and self-reported survey data from individuals.
Population Studied: The study population included
participants in the Kansas Medicaid Buy-In program,
Working Healthy, and a comparison group. Participation
is limited to individuals age 16 to 64, with a Social
Security disability determination, who are competitively
employed. About 90% of Kansas participants are dually
eligible for Medicaid and Medicare; nationally about 75%
of Buy-In participants are dual-eligibles. More than two-
thirds of Kansas participants pay a premium to the state
for their Medicaid coverage. At the end of 2008, total
enrollment in Kansas was 1089; total national Buy-In
enrollment was approximately 105,000 at the end of
2007.
Principal Findings: Individuals who remain
continuously enrolled in the Kansas Medicaid Buy-In
show increased earnings and decreased medical
expenditures over time. Findings related to earnings are
self-reported by participants and confirmed through
administrative data. Decreases in medical expenditures
are seen in both Medicare and Medicaid claims over
time. Participants also self-report improvements in
mental health status, overall quality of life, and financial
status. Nevertheless, participants are mindful that
working above the substantial gainful activity (SGA)
threshold will result in loss of SSDI cash benefits; many
report turning down raises or increased hours in order to
avoid this loss. Administrative earnings data confirm that
participants tend to work just below the SGA income
threshold.
Implications for Policy, Delivery or Practice: Even
though state Medicaid programs may currently be
experiencing severe budget challenges, our study
indicates that expanding coverage to the optional
population of working people with disabilities may
actually result in long-term savings. Not only do the
majority of Kansas Buy-In participants pay monthly
premiums to help offset their costs, but continued
enrollment in the program is associated with decreases
in both Medicare and Medicaid expenditures over time.
Because many of these dually-eligible individuals were
only sporadically covered by Medicaid through a
spenddown process prior to Buy-In enrollment,
participation in the Buy-In not only allowed increased
income, but more consistent access to Medicaid
coverage and services. Moreover, as participants’
earnings increased over time, so did their state and
federal payroll taxes paid.
Funding Source(s): CMS, State of Kansas
♦ SCHIP Buy-In Programs: How Do Case Mix &
Utilization Compare Between Full-Pay & Subsidized
Enrollees?
Jill Boylston Herndon, Ph.D.; W. Bruce Vogel, Ph.D.;
Elizabeth Shenkman, Ph.D.
Presented by: Jill Boylston Herndon, Ph.D., Research
Associate Professor, Institute for Child Health Policy,
University of Florida, P.O. Box 100177, Gainesville, FL
32610-0177, Phone: (352) 265-7220, Email:
jbh@ichp.ufl.edu
Research Objective: States are increasingly
considering buy-in programs to fill in the gaps in
children’s health insurance coverage. These programs
allow families who do not qualify for subsidized Medicaid
or SCHIP coverage to buy into public coverage at the full
premium amount. However, little is known about the
characteristics of the children who participate in these
programs and to what extent adverse selection occurs.
This study compares the demographic characteristics,
case mix, and health care utilization of children enrolled
in Florida’s SCHIP buy-in program to children enrolled in
the subsidized program.
Study Design: Our data sources included person-level
administrative enrollment files containing information
about the children’s demographic characteristics,
premium amounts, and monthly enrollment. The
enrollment files were matched to health care claims and
encounter databases containing inpatient, outpatient,
and pharmacy files. The Clinical Risk Groups, which
uses ICD-9-CM diagnosis codes from health care
encounters, was used to assign children to hierarchically
defined health status groups (healthy, significant acute,
minor chronic, moderate chronic, and major chronic).
Bivariate tests were used to compare the demographic
and health characteristics of the buy-in and subsidized
populations. Negative binomial regression models were
used to compare utilization rates for buy-in and
subsidized enrollees for outpatient encounters, inpatient
discharges, and prescription drugs after adjusting for the
children’s demographic characteristics and health status.
Population Studied: Children ages 5-18 enrolled in
Florida’s SCHIP for at least one month in 2007. The
study sample included 293,994 children representing
2,456,096 months of coverage.
Principal Findings: (1) Buy-in enrollees were less likely
to be classified as healthy (65%) compared to
subsidized enrollees (71%) and more likely to have
significant acute or chronic conditions (p<.0001). (2)
Unadjusted utilization rates were 31% higher for
outpatient encounters, 27% higher for inpatient
discharges, and 59% higher for prescription drugs
among buy-in enrollees. (3) After controlling for
demographic characteristics and health status,
outpatient and prescription drug utilization rates
remained higher among buy-in enrollees (p<.0001).
However, statistically significant differences in inpatient
utilization rates were no longer detected.
Conclusions: Descriptive comparisons of utilization
rates for buy-in versus subsidized enrollees suggest
substantial adverse selection in the buy-in group. For
inpatient services, such adverse selection seems to be
associated with children’s health status and
demographics. For outpatient and prescription drug use,
however, utilization rates remained higher among buy-in
enrollees even after controlling for health status and
demographics, suggesting that unmeasured effects
underlie the higher utilization of full-pay enrollees for
these services.
Implications for Policy, Delivery or Practice: Our
findings indicate that states’ concerns with adverse
selection in buy-in programs are valid. A program
design that mitigates selection effects while effectively
expanding coverage is essential to successful
implementation. Our finding of variation in the relative
utilization of buy-in and subsidized enrollees by service
category has implications for premium rates, copayment
structures, benefit packages, and other program design
options such as waiting periods.
♦ How Community Health Centers Were Affected by
Massachusetts' Health Reform
Leighton Ku, Ph.D., M.P.H.; Emily Jones, M.P.P.; Peter
Shin, Ph.D., M.P.H.; Bradley Finnegan, M.P.P.; Sara
Rosenbaum, J.D.
Presented by: Leighton Ku, Ph.D., M.P.H., Professor,
Health Policy, George Washington School of Public
Health & Health Services, 2021 K Street, NW,
Washington, DC 20010, Phone: (202) 416-0479, Email:
leighton.ku@gwumc.edu
Research Objective: Prior research has shown that
Massachusetts' health reform led to a substantial
reduction in the number of uninsured. This study is
designed to assess the effects on community health
centers, which provide primary care to uninsured and
low-income patients.
Study Design: We analyzed administrative data about
health centers' caseloads, revenues and expenditures
for federally-funded health centers in Massachusetts
from 2005 to 2007, augmented by analyses of other
survey data. We conducted case study interviews of
health center directors and other experts in 2008.
Population Studied: Community health centers in
Massachusetts and their patients.
Principal Findings: The number of uninsured patients
served at health centers fell in 2007 and the number with
public insurance rose. After health reform, health
centers served about 50,000 more people than they had
before. But the reduction in uninsured served at health
centers was less steep than in the overall population.
Thus, health centers served about one-fifth of the
statewide uninsured in 2006 but more than one-third in
2007. Health centers' revenues rose 14% in 2007, but
their expenditures grew 15%, so there was no net gain in
their financial margins. About half the centers had
positive margins in 2007 and half had negative margins.
Centers had to accommodate a number of administrative
changes as they implemented changes under health
reform. Health centers had to take special actions to
recruit and retain primary care physicians and staff
during this period.
Conclusions: The expansion of insurance coverage in
Massachusetts was not accompanied by a statewide
expansion of primary care physicians. Health centers
became even more critical as care providers for newly
insured and the remaining uninsured populations.
Supplemental funding for the health centers played an
important role in their ability to remain viable during this
period.
Implications for Policy, Delivery or Practice:
Insurance expansions must also plan for expansions of
the health care delivery system, especially primary care
providers. Supplemental funding mechanisms, such as
uncompensated care funding, enhanced funding for
health centers or the National Health Service Corps,
need to be considered to ensure that health care is
accessible.
Funding Source(s): Kaiser Commission on Medicaid
and the Uninsured and RCHN Community Health
Foundation
♦ The Effects of SCHIP Expansion on Family
Insurance & Out-Of-Pocket Medical Costs: New
Results From the SIPP
H. Luke Shaefer, Ph.D.; Colleen Grogan, Ph.D.; Harold
Pollack, Ph.D.
Presented by: H. Luke Shaefer, Ph.D., Assistant
Professor, School of Social Work, University of
Michigan, 1080 South University, Ann Arbor, MI 48109,
Phone: (734) 936-5065, Email: lshaefer@umich.edu
Research Objective: During the reauthorization
debates for the State Children’s Health Insurance
Program (SCHIP) in 2007, the most prominent and
consistent concern focused on crowd-out: the possibility
that expansions of public health insurance for children
have substantially displaced private coverage. Many
policymakers believe crowd-out represents a policy
problem. However, we know almost nothing about the
implications of crowd-out for families. This paper
hypothesizes that child’s health status may play an
important predictive role in determining who crowds out,
and that crowd-out may reduce a family’s out-of-pocket
medical expenditures and premium payments.
Study Design: We use a pooled sample from the 2001
and 2004 panels of the Survey of Income and Program
Participation (SIPP), a nationally representative
longitudinal survey administered by the U.S. Census
Bureau. We begin by estimating the extent of crowd out.
We draw on Gruber and Simon’s (2007) method for
calculating crowd-out to produce estimates for the time
period 2001-2005. Next we consider the effects of
crowd-out. We begin by operationalizing a definition of
crowd-out that exploits the SIPP’s longitudinal design.
We present descriptive statistics comparing those who
crowded-out to those who did not. Next, using an
instrumental variable, two-stage-least-squares approach
to address the endogeneity of family coverage decisions,
we estimate the effects of crowd-out on out-of-pocket
medical expenditures and family premiums. Using the
simulated eligibility instrument constructed for the crowdout estimates, we estimate the probability of crowdingout in the first stage. In the second stage, the predicted
crowd-out variable has a significant impact on out-ofpocket medical expenditures and family premiums.
Population Studied: Our study utilizes a nationally
representative longitudinal sample of children, ages 0-18
from 2001 through 2005. We also access data on the
families of these children. Special attention is paid to
children in poor health status, as reported by parents.
Principal Findings: According to our estimates, children
and families who crowd-out are a vulnerable population,
and a child’s health is highly predictive of crowd-out. As
hypothesized, crowd-out appears to provide a large
financial benefit to affected families. Our estimates
suggest that SCHIP provides a cash-equivalent transfer
of $2,500 annually to families who crowd-out.
Conclusions: Our findings suggest that for the marginal
crowded-out family, substitution of public for private
insurance resulted in a substantial cash transfer,
providing resources for other important family
investments. Contrary to current public policy debates—
which generally presume that crowd-out is a societal
cost—our results suggest that reducing the private cost
of health coverage may bring important social benefits.
Implications for Policy, Delivery or Practice: Families
in the 300 percent of poverty range have a much higher
likelihood of dropping their private coverage for public
than families under the 200 percent of poverty range.
This income effect leads to the concern that expanded
public insurance for children may be inefficient because
it expends resources on higher-income families who
already have private coverage, perhaps at the expense
of support targeted at lower-income, uninsured families.
Yet many studies have shown that middle-income
families in poor health status are often made poor by
medical expenses, whereas healthy low-income families
can be defined as “medically middle-income.” Given that
Medicaid and SCHIP enrollment for families earning less
than 200 percent FPL is still voluntary, it may prove
difficult and inefficient for states to reach 95 percent
coverage of eligible children. Meanwhile families above
the income cutoff may have significant medical needs
even if just one member of the family is in poor health.
For these families, crowding-out may mean the
difference between financial hardship and financial
stability.
Funding Source(s): Other Govt, National Poverty
Center at the University of Michigan with funds provided
by the U.S. Census Bureau, Housing and Household
Economics Statistics Division
Medicare Part D
Chair: Patricia Neuman
Monday, June 29 * 9:45 a.m.-11:15 a.m.
♦ The Impact of Medicare Part D on MedicareMedicaid Dual-Eligible Beneficiaries' Prescription
Utilization & Expenditures
Anirban Basu, Ph.D.; G. Caleb Alexander, M.D., M.S.;
Wesley Yin, Ph.D.
Presented by: G. Caleb Alexander, M.D., M.S.,
Assistant Professor, Medicine, University of Chicago,
5841 South Maryland Avenue (MC 2007), Chicago, IL
60637, Phone: (773) 834-9177, Email:
galexand@uchicago.edu
Research Objective: The Part D drug benefit,
implemented on January 1, 2006, reflected a significant
change in prescription drug coverage for over six million
beneficiaries dually eligible for Medicare and Medicaid.
We examined the effect of Part D on dual eligibles’
prescription drug usage, out-of-pocket costs, and total
drug expenditures.
Study Design: We selected a 5% random sample of
unique pharmacy customers who filled at least one
prescription both in the 2005 and the 2006 calendar
years at any retail or mail order member of a national
pharmacy chain. For these, we obtained claims data for
every prescription filled between January 1, 2005 and
April 31, 2007. We divided the 28 months of data into 3
periods: pre-Part D, transition post-Part D, and stable
post-Part D. To identify Medicaid subjects, we looked for
at least one prescription that was reimbursed by
Medicaid during the entire pre-Part D period of January
1, 2005 to December 31, 2005. Our “treatment” group
consisted of dual-eligibles between 65-78 years on
January 1, 2005 and our “control” group consisted of
near-elderly patients with Medicaid coverage between
60-63 years on January 1, 2005. We used generalized
estimating equations (GEE) to examine the experience
of the treatment group with that of the control group
during the first 18 months after Part D implementation.
We focused on four pharmaceutical outcomes: (1) total
number of prescriptions per month, (2) pill-day – a
prescription utilization measure similar to medication
possession ratio that counts the number of days with a
pill summed across all prescriptions, (3) monthly out-ofpocket costs, and (4) total prescription expenditures.
Principal Findings: There were no significant changes
in trends in the dual-eligibles’ out-of-pocket
expenditures, total monthly expenditures, pill-days, or
total number of prescriptions due to Part-D.
Expenditures for the treatment and control groups
tracked each other closely in the pre-Part D period,
suggesting that the near-elderly suffices as a
comparison group. Immediately following the
implementation of Part D, expenditures for both groups
decreased and then leveled off. The proportions of
medications initiated, continued, or discontinued among
the treatment and control groups pre- and post-Part D
were almost identical, suggesting that part D did not
meaningfully impact patterns of prescription usage.
Findings were similar for the other outcomes examined.
Conclusions: We find no evidence that Part D
adversely affected pharmaceutical utilization or out-ofpocket expenditures during the transition period, nor
during the 18 months subsequent to Part D
implementation.
Implications for Policy, Delivery or Practice: Part D
represents a policy change of enormous proportions.
Particularly during the transition period in the first few
months of the benefit, there was considerable concern
about the impact of the transition on dual eligibles.
Many of these challenges were anticipated, and efforts
by numerous stakeholders were made to address those
that weren’t anticipated. Our results suggest that these
efforts, in aggregate, were successful in preventing
decreased access to prescription drugs among dual
eligibles.
Funding Source(s): AHRQ, RWJF
♦ Who Chooses? Enrollment of Dually Eligible
Beneficiaries in Medicare Part D Plans
Christine Bishop, Ph.D.; Cindy Parks Thomas, Ph.D.;
Daniel Gilden, M.S.; Joanna Kubisiak, M.S.
Presented by: Christine Bishop, Ph.D., Atran Professor
of Labor Economics, Heller School for Social Policy &
Management, Brandeis University, 410 South Street,
Mailstop 035, Waltham, MA 02454-9110, Phone: (781)
736-3942, Email: bishop@brandeis.edu
Research Objective: To identify factors associated with
plan-switching for dually eligible beneficiaries
autoassigned to Medicare Part D drug insurance plans.
Study Design: Dually eligible beneficiaries are
automatically assigned to low-cost prescription drug
plans (benchmark PDPs). Beneficiaries newly eligible
for Part D as duals (about 50,000 per month) and
continuing dual Part D enrollees whose plans fall above
benchmark in a new year (22% of duals in stand-alone
plans in December 2006) are randomly reassigned to
benchmark plans unless they actively choose a plan.
Some beneficiaries may be satisfied with their
autoassigned plans, and beneficiary choice allows those
not satisfied to switch. However, some duals may be
less able to make informed plan choices. Beneficiary
characteristics and monthly enrollment from the Part D
Prescription Drug Plan (PDP) Contract File and the
Medicaid Dual Eligibility File for 2006-2007 were linked
with health status indicators from 2005 Medicaid claims
and PDP characteristics. Multinomial logistic regression
was used to estimate impacts of demographic, health,
eligibility, and location factors on the probability that a
beneficiary chooses a plan rather than being passively
autoassigned.
Population Studied: 7.1 million beneficiaries who were
dually eligible for both Medicare and Medicaid for at
least one month between January 2006 and December
2007.
Principal Findings: 33% of the 1.1 million beneficiaries
who entered dual eligibility between February 2006 and
December 2007 chose a PDP by their first dual month
rather than accepting the autoassigned plan. Choice was
more likely for older duals and for those with income
greater than the Federal poverty level (FPL) (OR=1.27);
with the exception of those under 21 (OR=1.22), choice
was less likely for disabled duals (age less than 65,
OR=.55-.63) and for institutional residents (OR=.81).
23% of Part D dual enrollees whose plan moved above
benchmark in January 2007 chose different plans rather
than being autoassigned; an additional 15% chose to
remain in their above-benchmark plans. Choice was
more likely for duals with income greater than FPL (OR=
1.23) and for institutional residents (OR=2.11). Dual
beneficiaries in some states were more likely to make
active plan choices. Prior health status was also
associated with choice.
Conclusions: Medicare beneficiaries who enter dual
eligibility by becoming eligible for Medicaid may have
more experience with Medicare Part D than duals who
enter from Medicaid, and are thus more likely to make
active PDP choices. Beneficiaries residing in institutions
may have support from staff to choose a PDP when their
plan moves above benchmark. State of residence and
health and disability status affect plan choice.
Implications for Policy, Delivery or Practice: Although
PDPs enrolling dually eligible beneficiaries must meet
coverage standards, formularies vary. While individual
choice allows beneficiaries to match their PDPs to drug
needs, duals who are less able to make choices may
experience gaps in access. Patterns of duals’ choice
behavior can suggest policies for state Medicaid
programs and others to support choice. Results are also
a first step in research to assess whether failure to
choose is associated with health outcomes.
Funding Source(s): CMS
♦ Crossing the Doughnut Hole: The Effects of the
Medicare Drug Coverage Gap for Patients Who
Require High-Cost Medications
Dominick Esposito, Ph.D.; Margaret Colby, M.P.P.;
Daniel Ball, Dr.P.H.; Susan Garavaglia, Ph.D.; Eric
Meadows, Ph.D.; Martin Marciniak, Ph.D.
Presented by: Dominick Esposito, Ph.D., Senior
Researcher, Mathematica Policy Research, Inc., 600
Alexander Park, Princeton, NJ 08540, Email:
desposito@mathematica-mpr.com
Research Objective: To examine the effects of the
Medicare Part D doughnut hole and patient
characteristics on patients with conditions that are
treated with high-cost medications.
Study Design: Using 2007 pharmacy claims, we
examined the likelihood that patients had drug spending
reaching the Part D doughnut hole ($2,400) or
catastrophic coverage ($5,451), or total drug spending
equivalents, for prescription drug plan (PDP) and Retiree
Drug Subsidy (RDS) enrollees. RDS beneficiaries
served as a comparison group for PDP enrollees who
had varying levels of coverage gap exposure. Logistic
regression analyses were used to estimate the likelihood
of reaching each spending level. Key benefit design
variables included plan type (standard PDP, enhanced
PDP, Medicare Advantage [MA]-PDP, RDS) and
coverage gap exposure (no, partial, or standard
coverage gap). Key beneficiary characteristics included
primary medical condition and medication, other chronic
conditions, demographic characteristics, and low-income
subsidy (LIS) eligibility.
Population Studied: Analyses included Medicare
beneficiaries enrolled in PDP or RDS plans managed by
Medco Health Solutions, Inc. who had claims for cancer
(N=32,625), osteoporosis (N=331,337), or RA (N=5,712)
medications in 2007. A comparison group of enrollees
with other chronic conditions (N=368,784), but not the
three study conditions, was matched to the study
population by age, gender, geographic distribution,
number of chronic conditions, and LIS eligibility.
Principal Findings: Compared to patients with other
chronic conditions (56%), patients with cancer (84%),
RA (91%), or osteoporosis (59%) had higher odds of
reaching the doughnut hole (Odds Ratios [OR] = 19.3,
32.1, and 2.1, respectively, p<0.01 for all). Similar odds
were observed for the likelihood of reaching catastrophic
coverage (OR cancer =5.2, RA =34.5, osteoporosis
=1.4, p<0.01). LIS eligible beneficiaries were slightly
more likely to reach the doughnut hole and much more
likely to reach catastrophic coverage (OR = 1.2 and =
11.7, respectively, p < 0.01) than PDP or RDS patients
residing in areas where median household income was
between 200% and 300% of the federal poverty level.
Compared to standard PDP enrollees, enhanced PDP
enrollees were more likely (OR=1.12, p<0.01), MA-PDP
enrollees were less likely (OR=0.77, p<0.01), and RDS
beneficiaries were as likely (OR=0.99, p=0.88) to reach
the doughnut hole spending threshold. Relative to
enrollees without a coverage gap, beneficiaries who
faced one were somewhat less likely to have total drug
spending that reached $2,400 in 2007 (OR = 0.87, p <
0.01); however, their odds of reaching catastrophic
coverage were three times as great (OR = 3.0, p < 0.01).
Conclusions: Medicare Part D enrollees with cancer,
RA, or osteoporosis are more likely to have annual drug
spending that reaches the doughnut hole or catastrophic
coverage than patients with other chronic conditions.
Beneficiaries with these conditions often face expensive
drug regimens; despite high costs many spend through
the doughnut hole to reach catastrophic coverage.
Implications for Policy, Delivery or Practice: Although
LIS supports have reduced financial barriers to treatment
for the lowest income beneficiaries, hurdles remain for
many whose conditions require treatment with high-cost
medications. To ensure continued access to critical drug
therapies, policymakers should consider whether
additional supports may be needed for these
beneficiaries.
Funding Source(s): Eli Lilly and Company
♦ Direct Marketing Strategies Can Enhance
Enrollment of Low-Income Beneficiaries Into the
Low Income Subsidy (LIS)
Frank Funderburk; Christopher Koepke; Adam Burns;
Laura Salerno; Kevin Simpson; Lisa Wilson
Presented by: Frank Funderburk, Director, Division of
Research, Office of External Affairs/SRCMG/Division of
Research, Centers for Medicare & Medicaid Services,
7500 Security Boulevard, Baltimore, MD 21244, Phone:
(410) 786-1820, Email: frank.funderburk@cms.hhs.gov
Research Objective: This is an experimental study of
factors influencing enrollment of low-income
beneficiaries into LIS using direct marketing approaches.
Study Design: Data are derived from an experimental
study of the effectiveness of direct marketing strategies
for LIS outreach. This report focuses on a subgroup of
beneficiaries (n=2,079) whose incomes were < $21,000
per year. Study participants (n=20,000) were randomly
selected from an internal CMS list of beneficiaries
thought to be without creditable prescription drug
coverage and living in census block-defined areas with
median incomes in lowest 30%. Additional inclusion
criteria included residence in a state without a
comprehensive SPAP and in counties with active SHIPs.
Participants were randomly assigned to receive one of
five treatments that varied along a dimension of outreach
intensity: Control, CMS Letter, Custom designed SelfMailer+BRC (business reply card pre-populated with
address of local SHIP), Invitation-Style Mailer+BRC+prerecorded calls, and an Invitation-style
Mailer+BRC+Personal Enrollment Assistance Call. The
CMS letter was informed by qualitative research
findings, and the more intensive interventions were
further informed by psychographic profiles of the target
population. A telephone survey, with an overall
response rate of 25%, measured self-reported campaign
awareness, benefit awareness, and actions taken
related to LIS, including submitting an application for the
benefit. Logistic regression analyses, using robust
estimation procedures to account for clustering effects
related to geographic location, were used to evaluate the
effects of the various strategies. Covariates in the
models included awareness of the LIS benefit, age,
marital status, education, race, gender, and consumer
engagement in health care.
Population Studied: Medicare beneficiaries with selfreported incomes < $21,000 per year.
Principal Findings: People exposed to the active
outreach interventions were more likely to have reported
taking some action related to applying for the LIS (e.g.,
gathering information, talking with others, submitting an
application) than those in the control group (OR > 4.8, p
< .006). Those receiving the official CMS letter and
those in the two most intensive interventions (which
involved telephone contact and personal enrollment
assistance) were more likely to have taken some action
than those in the Self-Mailer+BRC condition (OR > 1.9, p
< 0.030). Using a more stringent criterion, more of those
receiving the official CMS letter or one of the two most
intensive intervention reported applying for the LIS after
the intervention than did those in the control group (OR
> 11.29, p < 0.021). Those in the Self-Mailer+BRC
condition did not differ from the control group (p =
0.159). Other factors that were associated with taking
action or applying were awareness of the LIS program
and age less than 65.
Conclusions: Direct marketing can be an effective
approach to encouraging application for the LIS benefit
among this difficult-to-reach audience. The effects of the
interventions were over and above that attributable to
awareness of the benefit.
Implications for Policy, Delivery or Practice: Tailored
messaging informed by target-beneficiary attitudes and
beliefs can effectively enhance LIS enrollment, but the
effect is not linearly related to outreach intensity.
Funding Source(s): CMS
♦ The Effect of the Part D Coverage Gap on Medicare
Beneficiaries using Antidepressants
Mary Price, M.A.; Jie Huang, Ph.D.; Richard Brand,
Ph.D.; Vicki Fung, Ph.D.; John Hsu, M.D., M.B.A.,
M.S.C.E.
Presented by: Mary Price, M.A., Senior Consulting Data
Analyst, Division of Research, Kaiser Permanente, 2000
Broadway, Oakland, CA 94612, Phone: (651) 246-0608,
Email: Maggie.Price@kp.org
Research Objective: The standard Medicare Part D
program requires substantial amounts of patient costsharing, including a coverage gap. Individuals who
require chronic treatment regimens may be at
particularly high risk for reaching the coverage gap
threshold. We investigated the impact of the coverage
gap in 2006 on drug consumption, adherence, and
mental health related emergency department (ED) visits
in a cohort of Medicare beneficiaries using an
antidepressant, compared with a concurrent control
group of patients without a gap in their drug coverage.
Study Design: We used regression models with a GEE
approach to estimate monthly levels of total and
antidepressant drug consumption (in dollars),
adherence, and mental health related ED use. We
defined patients with an adequate drug supply for more
than 80% of the year as being adherent. We adjusted
for individual characteristics and time.
Population Studied: All 47,008 subjects were 65+
years with Medicare insurance, were members of an
integrated delivery system, and had received an
antidepressant in 2005; 57% of subjects had a coverage
gap.
Principal Findings: On average, subjects had $154 in
drug costs ($15 for antidepressants) each month. In
multivariate models, subjects with a gap had lower
consumption of antidepressants and drugs overall than
subjects without a gap (difference=$4.12; 95% CI:
$3.48-$4.75 and difference=$46.37; 95% CI: $41.80$50.95, respectively). Overall, only 56% of subjects
were adherent to their antidepressants during the study
period, but subjects with a gap were less adherent than
subjects without a gap (OR=0.87; 95% CI: 0.84-0.89)
and had higher mental health related ED visit rates
(RR=1.28; 95% CI: 1.02-1.61).
Conclusions: In patients with Medicare insurance
receiving antidepressants, the coverage gap was
associated with decreased antidepressant and total drug
consumption, decreased adherence, and increased
rates of mental health related ED visits.
Implications for Policy, Delivery or Practice: These
findings suggest that limitations on drug coverage, such
as the coverage gap in the standard Medicare Part D
benefits, may have unintended clinical consequences for
beneficiaries on treatment regimens for depression or
other chronic conditions. Additional study is needed on
changes in clinical event rates and outcomes among this
vulnerable population.
Funding Source(s): NIA
Medicare Advantage
Chair: Melinda Beeuwkes Buntin
Monday, June 29 * 11:30 a.m.-1:00 p.m.
♦ Medicare Managed Care & Quality of Primary Care:
A Comparison Across Hospitalization Types
Jayasree Basu, Ph.D., M.B.A.; Lee Mobley, Ph.D.
Presented by: Jayasree Basu, Ph.D., M.B.A., Senior
Economist, Agency for Healthcare Research & Quality,
540 Gaither Road, Rockville, MD 20850, Phone: (301)
427-1579, Email: jayasree.basu@ahrq.hhs.gov
Research Objective: The Medicare Modernization Act
(MMA)of 2003 ushered in higher federal payments to
managed care companies and sparked a renewed
interest in Medicare managed care (MMC). Medicare
spends about $10 billion more each year on
beneficiaries enrolled in the plans, known as Medicare
Advantage (MA), but there is little data to show added
value worth the extra investment. One key understudied
topic in this area is the MA plan’s effectiveness in
increasing quality of primary care through better
management of preventive care and chronic illness.
The study will evaluate the performance of MA plans in
comparison to FFS Medicare in 2004 in three states
(NY, CA, FL) chosen explicitly for their historically high
Medicare managed care penetration. Although MMA
promoted new types of managed care recently – the
PPO and the PFFS – which have less care management
than traditional HMOs, these plans were not successful
in the period we study. The performance of MA plans
(predominantly HMOs) will be measured in terms of
providing better quality of primary care, as defined by
lowering the risks of preventable (ACSC) hospital
admissions. Managed care plans can directly reduce
ACSC hospitalizations by making more primary and
preventive services available to their constituents.
Accordingly, a lower rate of preventable hospitalization
has been proposed as an indicator of better health plan
performance. ACSC admissions are compared with
“marker” admissions, a control group of admissions
which are urgent and relatively insensitive to primary
care. In order to allow for broader comparisons, we also
include another group of admissions known as ‘ReferralSensitive’ (R-S), which usually require referrals from
primary care providers to specialists and thus could
increase with better primary care services provided in
managed care plans. The main hypothesis of the study
is that, compared to marker admissions, MA plans will
reduce preventable hospital admissions, while possibly
increasing referral-sensitive admissions.
Study Design: Using 2004 hospital discharge data
(HCUP-SID) of Agency for Healthcare Research and
Quality for three states, a multivariate cross sectional
design is used with individual admission as the unit of
analysis. Each state is modeled separately because of
differences in socio-demographic, insurance market, and
Medicare managed care penetration conditions. MA plan
enrollment is used as a binary individual level variable,
with Medicare FFS as the default category. Area
characteristics are defined by a local area units known
as primary care service area (PCSA), validated in
previous research as natural markets for primary care. A
multivariate multinomial logistic regression approach
compares ACSC and R-S admissions relative to marker,
using a common set of individual and area parameters,
with appropriate adjustments for area clusters. All three
admission types have been validated in previous
research.
Population Studied: Elderly (65 and above) covered
with Medicare insurance (both FFS and HMO)
hospitalized for preventable, marker, and referralsensitive conditions in three states.
Principal Findings: Relative to marker admissions,
enrollees in MA plans were found to be significantly less
likely to have preventable hospitalization than FFS
enrollees, in all three states. The magnitudes of the
average difference in CA, FL, and NY were respectively,
22%, 18%, and 7% (p<.01). The likelihoods of R-S
admissions were, however, 32% and 36% higher,
respectively, among enrollees in MA plans than in FFS
plans in NY and FL, while 12% lower in CA, relative to
marker admissions.
Conclusions: The study shows that MA plans had
beneficial impacts in terms of improving quality of
primary care for their enrollees, by reducing preventable
admissions (relative to traditional Medicare FFS
enrollees) in all three states. The effects on referralsensitive admissions varied across states, with CA
experiencing reductions in both preventable and referralsensitive admissions relative to marker, possibly
indicating the greater maturity of MA plans and higher
utilization control mechanisms operating in that state.
Implications for Policy, Delivery or Practice: The
findings indicate that that MA plans have added value to
the quality of primary care to the elderly by reducing
preventable hospitalizations, while having mixed impacts
on referral-sensitive admissions across states.
Funding Source(s): AHRQ
♦ Quality & Variation in Medicare FFS & Medicare
Advantage
Mark Shepard, B.A.; Niall Brennan, M.P.P.
Presented by: Niall Brennan, M.P.P., Senior Research
Associate, Engelberg Center for Health Care Reform,
Brookings Institution, 1775 Massachusetts Avenue, NW,
Washington, DC 20036, Phone: (202) 797-6068, Email:
nbrennan@brookings.edu
Research Objective: Despite a growing focus on
measuring and improving quality in Medicare, little
research reports on the quality of care received by the
Medicare fee-for-service (FFS) population, which
comprises 77 percent of Medicare enrollment. And
despite growing congressional interest in reforming the
Medicare Advantage (MA) program, little published
research explicitly compares measures of quality in the
FFS and MA populations. This study provides a
contemporary snapshot of quality in the FFS program,
compares quality in the FFS and MA programs, and
analyzes geographical variation in the quality of care.
Study Design: We use newly released data from the
Generating Medicare Physician Quality Performance
Measurement Results (GEM) project covering all
continuously enrolled FFS beneficiaries in 2006. We use
national and state performance rates for 14
administrative HEDIS measures covering preventive
screenings and medication management. We estimate
national and state-level rates for the same measures
and time period in the MA population, using quality data
publicly reported by MA plans. Because we study
process measures that are rarely contraindicated, FFS
and MA rates can be compared meaningfully without risk
adjustment. National and state quality measure rates
and the variance across states are compared for the
FFS and MA populations.
Population Studied: Medicare FFS and MA
beneficiaries continuously enrolled during 2006.
Principal Findings: Quality in the FFS population
during 2005-06 showed improvement from published
estimates for earlier in the decade, though the pace of
improvement appears to have slowed. Quality was
substantially higher in MA than in FFS for most of the 14
measures studied. MA beneficiaries were 6 to 16
percentage points more likely to receive appropriate care
on eight measures, including breast cancer screening,
antidepressant medication management, cholesterol
screenings for cardiovascular disease patients, betablockers after a heart attack, and four measures of
diabetes care. MA and FFS beneficiaries received
similar rates of appropriate care on two more measures.
Only the four measures related to monitoring of patients
on persistent medications were consistently higher in
FFS. Both MA and FFS show significant variation across
states in the quality of care, with substantial state-level
correlations across measures.
Conclusions: The GEM data provide a means of
measuring quality in FFS Medicare and comparing
quality between MA and FFS. The rate of FFS
beneficiaries receiving appropriate preventive
screenings and medication management continues to
improve, though significant gaps persist. MA plans
generally deliver higher quality care on these measures.
Interstate variation in quality of care is significant in both
FFS and MA for each measure and is correlated across
measures so that some states tend to be high or low
performers across the board.
Implications for Policy, Delivery or Practice:
Significant gaps in basic quality of care standards for
Medicare beneficiaries persist, and more consistent
measurement and accountability is needed to improve
the rate at which beneficiaries receive appropriate care.
Funding Source(s): RWJF
♦ Medicare Advantage Benefit Design & Beneficiary
Choice
Marsha Gold, Sc.D.; Maria Cupples Hudson
Presented by: Marsha Gold, Sc.D., Senior Fellow,
Mathematica Policy Research Inc., 600 Maryland
Avenue, SW, Suite 550, Washington, DC 20024, Phone:
(202) 484-4227, Email: MGold@Mathematica-MPR.com
Research Objective: Medicare beneficiaries have an
expanded range of private Medicare Advantage (MA)
plan choices but we know little about how they are
navigating this terrain and what choice means for
enrollee benefits, out of pocket costs, and financial
protection. Our analysis addresses this gap, asking
three questions: (1) What do enrollment choices show
about beneficiary preferences and the plan features
considered in selecting among available choices?; (2)
Does MA benefit design protect beneficiaries financially
and how does MA compare to other available options in
this respect?; and (3) What do findings suggest about
potential policy changes that might simplify or better
support beneficiary choice and minimize risks?
Study Design: Using descriptive statistical techniques,
we analyze files created from merging downloadable
data from CMS's 2008 and 2009 MA Plan Finder with
July 2008 MA enrollment at the contract/plan/county
level. Such enrollment data have not publicly been
available previously to support this kind of analysis.
Population Studied: The unit of analysis is the MA
plan, defined by unique benefit/premium packages
offered in aggregations of counties within the contract
service area. Our analysis is limited to plans available for
individual enrollment in 2008 (N=3,307) and 2009
(N=3,354). (SNPs were excluded because of unique
features). Unweighted estimates characterize the
features of plans available and enrollment weighted
estimates the benefits enrollees receive given their
enrollment preferences among those choices.The
analysis accounts for county level variation in available
choices and the specific plans in which beneficiaries
enroll.
Principal Findings: Our analysis to date shows a strong
beneficiary preference for plans with lower premiums
and enhanced Part D coverage but less apparent
attention to the impact of benefit design on beneficiary
out-of-pocket spending hospital and physician services
even though analysis shows such spending can be
substantial, especially if medical need is high. About
350,000 enrollees had to switch plans in 2009 because
their plan was no longer available, with PFFS and MSA
enrollees most affected. Changes in 2009 appear to
make PFFS benefits less competitive with HMOs on
some dimensions than in 2008.
Conclusions: The average beneficiary appears price
sensitive but not necessarily well informed about the full
impact of their choice on out of pocket spending. The
challenges we have encountered interpreting Plan
Finder data show its use but also limitations as a source
of beneficiary information for choice.
Implications for Policy, Delivery or Practice: The
current structure of the MA program is very demanding
of beneficiaries. We anticipate that when our analysis is
complete we will be able to identify measures which may
reduce demands and enhance beneficiary protections.
Funding Source(s): AARP Public Policy Institute
♦ Unintended Consequence of Increasing Outpatient
Cost-Sharing on Hospital Use in the Elderly
Amal Trivedi, M.D., M.P.H.; Vincent Mor, Ph.D.
Presented by: Amal Trivedi, M.D., M.P.H., Assistant
Professor, Community Health, Brown University, Box G,
S121-6, Providence, RI 02912, Phone: (401) 270-7281,
Email: amal_trivedi@brown.edu
Research Objective: In response to higher copayments
for outpatient physician visits, elderly patients may
forego important ambulatory care leading to increased
risk of hospitalization. We assessed longitudinal
changes in inpatient and outpatient utilization among
Medicare enrollees in health plans that increased
ambulatory cost-sharing compared to enrollees in
matched control plans where such cost-sharing was
unchanged.
Study Design: We reviewed insurance benefits for all
Medicare health plans from 2001 to 2006 and identified
18 plans that increased ambulatory copayments without
altering prescription drug benefits. We matched these
plans to 18 controls on the basis of census region,
model type, and tax status. Using a difference-indifferences (DID) design, we assessed annual outpatient
visits, inpatient days, and inpatient admissions in case
and control plans in generalized linear models adjusting
for age, sex, race, area-level SES, inpatient costsharing, comorbid conditions, clustering by plans, and
repeated measures of enrollees. To account for
selection out of plans in response to increased costsharing, we separately estimated utilization trends
among continuously-enrolled beneficiaries.
Population Studied: 752,030 Medicare managed care
enrollees age 65 or older.
Principal Findings: In case plans, mean copayments
approximately doubled from $7.38 to $14.38 for primary
care, $12.66 to $22.05 for specialty care, and $148.33 to
$329.17 for hospital stays. In control plans, primary care
($8.33) and specialty care ($11.38) copays were
unchanged, and inpatient copays increased from
$111.11 to $177.08. Annual inpatient admissions per
100 enrollees increased from 25.3 in the year prior to
raising ambulatory copayments to 27.6 in the year after
the copayment increase among case plans; in control
plans the concurrent increase was from 25.8 to 26.1
(adj. DID 2.3; 95%CI 1.8-2.7). Annual inpatient days per
100 enrollees increased from 133.5 to 145.9 in case
plans and from 125.6 to 126.7 in control plans (adj. DID
13.7; 95%CI 10.4-16.9). In contrast, annual rates of
outpatient visits/100 enrollees were reduced in case
plans relative to controls (adjusted DID -16.2; 95%CI 13.0 to -19.5;p<0.001). The DID estimates for inpatient
days were increased by factors of 1.6-2.2 for black
enrollees, persons with diabetes and prior myocardial
infarction, and those in the lowest area-level income and
education quartiles (P<0.01 for all interactions). These
estimates were consistent among the cohort of
continuously enrolled beneficiaries.
Conclusions: Increased ambulatory copayments
reduce use of outpatient care among elderly managed
care enrollees, but this decline is offset by substantial
increases in inpatient utilization, particularly among
vulnerable groups with low SES and chronic disease.
Implications for Policy, Delivery or Practice: Raising
ambulatory cost-sharing for the elderly may increase
total health care spending and have adverse clinical
consequences.
Funding Source(s): Pfizer Health Policy Scholars
Award
♦ Comparison of 8-year Trends (1998-2006) in
Primary Care Performance for Fee-for-Service vs.
Managed Medicare
Ira Wilson; William Rogers, Ph.D.; Hong Chang, Ph.D.;
Dana Gelb Safran, Sc.D.
Presented by: Ira Wilson, Professor of Medicine,
Institute for Clinical Research & Health Policy Studies,
Tifts Medical Center, 800 Washington Street, Boston,
MA 02111, Phone: (617) 636-8672, Email:
iwilson@tuftsmedicalcenter.org
Research Objective: In March 2008, MEDPAC
estimated that payments to Medicare Advantage plans
(MA) were 13% higher than costs for equivalent fee-forservice Medicare (FFS) beneficiaries, raising the
question of whether the “value” these plans deliver is
worth their higher cost. Herein we compare the primary
care performance of FFS and MA in 13 states between
1998 and 2006.
Study Design: Beneficiaries in MA were randomly
sampled, then a random sample of FFS beneficiaries
matched for age, gender, and zip code was drawn (2
MA: 1 FFS). Surveys administered in 7 years between
1998 and 2006 included a CG-CAHPS forerunner with
validated measures of organizational access,
longitudinal continuity, visit-based continuity, financial
access (1 item each for visit cost and medication cost),
integration, communication, and interpersonal treatment.
To maximize the information available, we analyzed the
dataset in terms of baseline values and changes
observed between successive questionnaires in which
the beneficiary stayed with the same doctor and same
system (FFS/MA). The linear regression analysis
controlled for age, gender, race, education in years and
count of chronicle disease conditions and accounted for
clustering within patient.
Population Studied: The Study of Choice and Quality in
Senior Health Care is a longitudinal observational study
of non-institutionalized Medicare beneficiaries aged 65
and older in AZ, CA, CO, FLA, IL, MA, MN, NM, NY, OR,
PA, TX, and WA.
Principal Findings: In 1998, financial access favored
MA over FFS, but FFS performance was higher on all 6
other measures (all comparisons p<0.001). Between
1998 and 2002 there were significant declines is most
measures, followed by a stabilizing or return toward the
1998 baseline between 2002 and 2006. Visit-based
continuity showed marked (p<0.001) declines for both
FFS (-6.6) and MA (-7.2) between 1998 and 2002, then
stablized. Similar, though more moderate changes were
seen in integration, communication, and interpersonal
care. Changes were greatest, and most divergent by
system, for financial access. In MA, visit affordability
ratings declined by 5.9 points (p<0.001) between 1998
and 2002, then stayed flat between 2002 and 2006;
while medication affordability ratings dropped by 12.7
points, then rebounded by 7.6 points (both p<0.001).
Financial access was unchanged for FFS. In 2006, FFS
performance remained significantly better than MA on 6
of 7 primary care measures, while MA’s advantage on
financial access narrowed due to diminished affordability
of both visits and medications.
Conclusions: Overall, primary care performance for the
Medicare beneficiaries declined between 1998 and
2002, then stabilized between 2003 and 2006, with FFS
and MC maintaining their relative position on all
measures. The fact that MA enrollment waned from
1998 to 2003 during a period of substantially increased
cost-sharing, and then rebounded from 2004 to 2006
when cost-sharing decreased, suggests that out-ofpocket costs figure importantly in many beneficiaries’
enrollment decisions.
Implications for Policy, Delivery or Practice: While
MA provides better financial access, the care received
by beneficiaries in MA does not appear to be more
coordinated or more patient-centered, suggesting that
the higher costs of MA do not deliver better value in
primary care settings.
Funding Source(s): AHRQ, NIA
Medicare Costs & Quality
Chair: Sharon Arnold
Monday, June 29 * 4:45 p.m.-6:15 p.m.
♦ Diffusion of Computer-Aided Mammography
Following Congressionally Mandated Medicare
Coverage
Joshua Fenton, M.D., M.P.H.; Susan Bartlett Foote, J.D.,
M.A.; Pamela Green, Ph.D.; Laura-Mae Baldwin, M.D.,
M.P.H.
Presented by: Joshua Fenton, M.D., M.P.H., Assistant
Professor, Family & Community Medicine, University of
California, Davis, 4860 Y Street, Suite 2300,
Sacramento, CA 95817, Phone: (916) 734-3164, Email:
joshua.fenton@ucdmc.ucdavis.edu
Research Objective: Medicare can provide preventive
services only if specifically authorized by Congressional
legislation, which may be subject to political influence.
In 2000, a heavily lobbied Congress mandated that
Medicare pay a premium for the use of computer-aided
detection mammography technology (CAD) despite
uncertainty about whether CAD yielded better clinical
outcomes in community settings than routine screening
mammography. The effort to include the CAD provisions
was spearheaded by Congresswoman Anna Eshoo,
whose district in California’s Silicon Valley is the home of
the dominant worldwide CAD manufacturer, R2, Inc.
After passage of the legislation, the CAD industry made
reimbursement a central theme of its marketing strategy.
The objective of this study is to characterize the diffusion
of CAD technology within the Medicare population during
the initial three years of coverage.
Study Design: We performed serial cross-sectional
analyses of Medicare claims for screening
mammography. From 2001 to 2003, we determined the
prevalence of CAD use during screening mammography
by assessment of claims procedure codes. We
estimated prevalence overall, by study year, within
patient subpopulations (stratified by age, race/ethnicity,
median household income, and rural vs. urban
residence), and by geographic region.
Population Studied: We identified 5% annual random
samples of women aged 67 to 89 years who were
enrolled in fee-for-service Medicare and received
screening mammography (N=66,125 women who
received an average of 1.7 mammograms). Women
resided in Surveillance, Epidemiology, and End Results
(SEER) regions in 13 U.S. states, representing 25% of
the U.S. population.
Principal Findings: Prevalence of CAD use increased
from 4.8% in 2001 (95% CI: 4.6-5.1%) to 26.9% in 2003
(95% CI: 26.5%-27.4%). The adjusted prevalence of
CAD use in 2003 was between 21-38% lower among
black, Asian/Pacific Islander, and Hispanic women
relative to white women (p<0.001 for each comparison);
32-49% lower among women residing in nonmetropolitan vs. metropolitan counties (p<0.001 for each
category of non-metropolitan county); and significantly
lower among women residing in ZIP codes with median
annual household incomes of <$30,000 vs. greater
median incomes (p for trend<0.001). The prevalence of
CAD use in 2003 varied widely by SEER region, ranging
from 3.5% in Rural Georgia to 42.6% in Connecticut.
Conclusions: A novel, industry-developed preventive
technology of potential but uncertain clinical benefit,
CAD disseminated rapidly within the Medicare
population following Congressionally-mandated
coverage. More rapid diffusion of CAD to white women,
urban residents, and women residing in higher income
areas may have stemmed from the greater market
appeal of CAD technology to these subpopulations.
Implications for Policy, Delivery or Practice: Because
Congress is ill-equipped to develop evidence-based
coverage policies for new preventive technologies
absent political or interest group pressures, Congress
should broaden Medicare’s mandate to encompass the
prevention of illness. A broader mandate would allow
the Medicare program itself to apply rigorous methods of
technology assessment to weigh the clinical and fiscal
consequences of covering new preventive services.
Funding Source(s): American Cancer Society
♦ Unintended Consequences: Higher Coinsurance
Burdens for Beneficiaries at Critical Access
Hospitals
Kathleen Dalton, Ph.D.; Sara Freeman, M.S.
Presented by: Sara Freeman, M.S., RTI International
Research Objective: We assess differences in
Medicare Part B coinsurance at cost-based Critical
Access Hospitals (CAHs) versus PPS hospitals.
Beneficiaries receiving outpatient CAH care pay
coinsurance based on 20% of charges, which is higher
than coinsurance on equivalent OPPS services. We
review CAH claims volume, costs, charges, payments
and coinsurance over time to evaluate the excess
coinsurance burden, and consider policy options to
mitigate it.
Study Design: Retrospective two-period review of
16,211,209 claims matched to 2,109 cost reports for
1,115 facilities.
Population Studied: Medicare beneficiaries receiving
outpatient services at CAHs with cost reports in
2005/2006 (Period 2) and three years earlier (Period 1).
One third of study facilities were PPS hospitals in Period
1.
Principal Findings: In hospitals under outpatient PPS in
Period 1, coinsurance was 9.3% of covered charges
compared to 15.4% after becoming a CAH in Period 2.
Patient liabilities as a share of total payments increased
from 30.9% to 36.4%, due both to the change in
reimbursement rules and higher price mark-up. In
hospitals that were CAHs in both periods, the patient
liabilities share rose from 27.9% to 30.4%, with the
increase due primarily to higher mark-up. Cost-tocharge ratios (CCRs) for Medicare ancillary services
dropped 13% over the 3-year period, equating to higher
price mark-up and leading to greater charge-based
coinsurance. For all 1,115 CAHs, coinsurance amounts
in Period 2 totaled more than 40 percent of the
estimated cost of applicable services. This figure varies
widely by type of service because of variation in pricing
policy. For services with typically low CCRs (e.g.
cardiology and imaging), beneficiaries at many CAHs
pay more in coinsurance than Medicare allows for that
the service itself.
Conclusions: The coinsurance burden for CAH
Medicare outpatients is significantly higher than the
burden for other Medicare outpatients, and is increasing
more rapidly. Two options to reduce the burden are to
limit coinsurance to 20% of estimated costs, or to require
CAHs to code outpatient claims for ambulatory patient
classification and compute coinsurance equal to that
assigned under OPPS. We estimate the first option
would have reduced beneficiary coinsurance by 55% in
Period 2, resulting in an offsetting increase of $445
million in Medicare CAH payments. Effects of the OPPSequivalent option cannot be directly modeled without
additional procedure codes. If Period 2 OPPS
coinsurance were at the observed pre-conversion level
of 9.3 percent of covered charges, the amount of the
transfer from beneficiary to Medicare liability would have
been slightly less than the transfer under the 20%-ofcost option.
Implications for Policy, Delivery or Practice: Special
reimbursement for CAHs arose from policy decisions to
protect rural health access by subsidizing rural
providers. The added out-of-pocket burden is an
unintended consequence arising from subsequent
changes in pricing and payment, and possibly simple
oversight. MedPAC estimates that 14% of rural
beneficiaries in 2005 had no supplemental insurance
coverage, and this group is particularly penalized for
living in a CAH community. In spite of the cost to the
Medicare program, CAH coinsurance should be adjusted
such that beneficiaries are not harmed by a policy
intervention and are protected from the effects of
increasing hospital mark-up.
Funding Source(s): MedPAC
♦ Medicare High-Cost Beneficiaries in Community
Versus Long-Term Care Settings
Gretchen Jacobson, Ph.D.; Juliette Cubanski, Ph.D.;
Tricia Neuman, Sc.D.; Anthony Damico
Presented by: Gretchen Jacobson, Ph.D., Senior Policy
Analyst, Medicare Policy Project, Kaiser Family
Foundation, 1330 G. Street, NW, Washington, DC
20005, Phone: (202) 347-5270, Email:
gjacobson@kff.org
Research Objective: A small number of Medicare
beneficiaries account for a large proportion of the
program’s cost. In 2005, the costliest 10 percent
accounted for more than 60 percent of Medicare
spending (excluding spending by other payers) and the
costliest 25 percent accounted for more than 85 percent
of spending. The purpose of this study is to describe the
characteristics and use of medical care services by
Medicare’s highest-cost beneficiaries, with a focus on
comparing people living in long-term care facilities
versus in the community.
Study Design: This analysis used longitudinal data from
the Medicare Current Beneficiary Survey (MCBS) Cost
and Use files to examine the characteristics and
utilization experience of Medicare high-cost
beneficiaries, focusing on a comparison of those living in
long-term care facilities versus in the community. Data
were linked for survey years 2003 to 2005 to distinguish
between individuals who were high-cost cases over
multiple consecutive years versus for one year only.
Mean demographics, health status, insurance coverage,
and the use of medical care services were compared
between beneficiaries with Medicare expenditures above
and below the 75th percentile, above and below the 90th
percentile, and multi-year versus single year high-cost
beneficiaries. The analysis used bivariate and
multivariate statistics to identify characteristics
associated with high expenditures.
Population Studied: Medicare beneficiaries in the
MCBS Cost and Use samples for 2003 to 2005,
including community dwelling and long-term care facility
residents.
Principal Findings: High-cost beneficiaries were more
likely than others to have multiple chronic conditions
(including cognitive impairments), be end-stage renal
disease (ESRD) beneficiaries, or be dually covered by
Medicare and Medicaid. High-cost beneficiaries for
multiple successive years, as compared to high-costs in
one year only, were more likely to be in poor health,
have a cognitive impairment, be ESRD beneficiaries, be
dually covered by Medicare and Medicaid, or live in a
long-term care facility, such as a nursing home. Among
high-cost beneficiaries, those residing in nursing homes
had higher average Medicare expenditures than those
living in the community. High Medicare spenders living
in nursing homes were more likely to use inpatient
hospital, skilled nursing facility, and hospice services,
and had longer and costlier stays at these facilities.
Conclusions: This analysis shows that the high-cost
beneficiaries who account for a large share of the
Medicare expenditures are more likely to live in nursing
homes, have cognitive impairments, and be poorer and
sicker than other Medicare beneficiaries. Among highcost Medicare beneficiaries, those residing in nursing
homes had higher Medicare expenditures, used more
acute care services, and were more likely to be multiyear high-cost beneficiaries than those residing in the
community.
Implications for Policy, Delivery or Practice: The
finding that high-cost beneficiaries residing in nursing
homes have higher Medicare expenditures and use
more acute care services than those residing in the
community suggests a point of intervention for
controlling Medicare costs.
Funding Source(s): Henry J. Kaiser Family Foundation
♦ Prevalence & Costs of Chronic Conditions among
Medicare Fee-for-Service Beneficiaries &
Beneficiaries with Diabetes
Nancy McCall, Sc.D.; Amanda Honeycutt, Ph.D; Joel
Segal; Galina Khatutsky; Wendy Funk; Laura Hopkins,
Presented by: Nancy McCall, Sc.D., Chief Scientist,
Division for Health Services & Social Policy Research,
RTI International, 701 13th Street NW, Suite 750,
Washington, DC 20005, Phone: (202) 728-1968,
Email: nmccall@rti.org
Research Objective: To examine trends in the
prevalence and costs of chronic conditions among
Medicare fee-for-service (FFS) beneficiaries.
Study Design: The CCW database contains
beneficiary-level information on Medicare populations
with one or more selected chronic conditions, including
their claims data, survey data, and patient assessments
that span across the continuum of care. The CCW has
been populated with data from 2001 to 2006 and this
paper examines longitudinal trends in prevalence rates
of the CCW chronic conditions, Medicare expenditures
and utilization patterns for beneficiaries with chronic
diseases, and an econometric assessment of the
economic burden of diabetes to the Medicare program.
Population Studied: Medicare fee-for-service
beneficiaries with one or more chronic conditions from
2001 through 2006.
Principal Findings: In calendar year 2001, 59% of all
Medicare FFS beneficiaries had none or only one of the
studied chronic conditions. By 2006, the prevalence rate
had dropped to 54% or almost three-quarters of one
million beneficiaries had developed more than 1 chronic
condition. In contrast, less than 3% of beneficiaries had
6 or more conditions in 2001, but by 2006, almost 4%
had 6 or more conditions translating into an additional
350,000 beneficiaries with serious comorbid disease. A
similar pattern of increasing frequency of prevalence
rates for the presence of 2, 3, 4, or 5 multi-comorbid
conditions is also observed. The increasing prevalence
of multi-comorbid disease has dire implications for the
quality of life for Medicare FFS beneficiaries as well as
economic burden on the Medicare program. In 2006,
the annual rate of hospitalization was 5.6 per 100
Medicare FFS beneficiaries with no chronic conditions,
16 per 100 beneficiaries with 1 chronic condition and an
astonishing 203 per 100 beneficiaries with 6 or more
chronic conditions. The admission rate for beneficiaries
in the highest level of co-morbidity is 63% higher than
observed for beneficiaries with 5 chronic conditions,
145% higher than observed for beneficiaries with 4
chronic conditions, and over 300% higher observed for
beneficiaries with 3 chronic conditions. Total Medicare
expenditures mirror these grim statistics. In 2006,
Medicare program expenditures were $257 billion with
6% of expenditures devoted to the 30% of Medicare FFS
beneficiaries with no chronic conditions. In contrast, 18%
of expenditures were for the 3.6% beneficiaries with 6 or
more chronic conditions. This translates into average
annual total Medicare expenditures for beneficiaries with
no chronic conditions of $1,792, $4,299 for beneficiaries
with 1 chronic condition, and $40,982 for beneficiaries
with 6 or more chronic conditions. Diabetes is one of the
most rapidly growing chronic conditions. Between 2000
and 2006, the prevalence of diabetes increased from
18.2% to 23.9% among FFS Medicare beneficiaries. As
a result of the increasing prevalence of diabetes and the
high rates of comorbidities among persons with
diabetes, Medicare payments have also risen
dramatically among FFS beneficiaries with diabetes.
Total Medicare payments for claims with a diagnosis of
diabetes among FFS beneficiaries rose from $22.5
billion in 2000 to $38.4 billion in 2006. Because so many
of the Medicare beneficiaries with diabetes are likely to
also have chronic kidney disease, heart disease, or
some other chronic condition, an analysis of diabetes
costs that adds up costs for services with a primary or
secondary diagnosis of diabetes would ignore the
diabetes-attributable costs that arise because treatment
of other chronic conditions is made more difficult by the
presence of diabetes. In this analysis, we use the full
2006 5% sample and apply a multivariate regression
analysis approach to examine the Medicare payments
that are attributable to diabetes. We use results from this
regression analysis to predict diabetes-attributable
Medicare payments by age group, by sex, and by the
presence of other chronic conditions (1, 2, 3, or 4 or
more).
Conclusions: The increasing prevalence of multicomorbid disease has dire implications for the quality of
life for Medicare FFS beneficiaries as well as economic
burden on the Medicare program.
Implications for Policy, Delivery or Practice: This
paper provides a foundation for assessing the direct and
indirect economic costs of the development of chronic
conditions.
Funding Source(s): CMS
Issues for VA Health Care: Dual Use & Women’s
Health
Chair: Ciaran Phibbs
Tuesday, June 30 * 9:45 a.m.-11:15 a.m
♦ Do Reductions in VA Psychiatric Services Lead to
Increased Private Hospital ED Utilization?
Anouk Grubaugh, Ph.D.; Richard Lindrooth, Ph.D.
Presented by: Anouk Grubaugh, Ph.D., Assistant
Professor, Department of Psychiatry & Behavioral
Sciences, Medical University of South Carolina &
Charleston VA Medical Center, 67 President Street, 4
South, P.O. Box 250861, Charleston, SC 29425, Email:
grubaugh@musc.edu
Research Objective: We examine how changes in the
supply of VA psychiatric beds affect the number of
emergency psychiatric admissions at non-VA hospitals
within the same Healthcare Referral Region (HRR).
Emergency psychiatric admissions measure how well
the system of community care is functioning. While
there is convincing evidence that the presence of
alternative outpatient services (both VA and non-VA) will
mitigate the effects of VA inpatient psychiatric hospital
closures on access to care (Rosenheck et al., 2001;
Rosenheck et al., 2000). Little is known about utilization
of private hospitals changes the wake of a reduction of
VA beds.
Study Design: We model the number of psychiatric
admissions to private acute care hospitals as a function
of the number of VA psychiatric beds in a given HRR;
existence of VA psychiatric unit closure; access to
private inpatient and VA and private
outpatient/community treatment; percent veteran
zipcode residents; year and HRR fixed effects. We
estimated the model using a conditional zipcode fixed
effect negative binomial regression model (conditioned
on zipcode-level admissions) thus the results utilize
within HRR variation conditional upon the level of
zipcode admissions. This allows us to measure how
access to community services interacts with the
downsizing or closure of beds.
Population Studied: Analyses are based on admissions
(between 1998 and 2005) of patients with primary
psychiatric diagnoses common among Veterans to nonVA acute care hospitals in AZ, CO, FL, NJ, NY, WA, and
WI in the HCUP-SID database. Facility information is
from the American Hospital Association Annual Survey;
Medicare Cost Reports; Census of Economic Activity;
and state sources.
Principal Findings: Our results suggest that reductions
in the number of VA psychiatric beds in an HRR leads to
a statistically significant increase in psychiatric
admissions at private hospitals within the same HRR.
Downsizing leads to a measurable shift to non-VA
hospitals but the effect of a unit closure is entirely due a
reduction in beds not other unmeasured characteristics
associated with a closure. The effect of closure is
mitigated by access to community treatment options.
The potential for endogenous closure in which closures
only occur in areas that have sufficient community
services is also considered but this portion of the
analysis is ongoing.
Conclusions: Increased ED admissions are a symptom
of constraints on access to psychiatric care. Veterans
who would have had access to inpatient psychiatric care
at VAMCs are now admitted in neighboring hospitals
through the ED. However, the effect of bed closures can
be mitigated with increased access to outpatient and
community services.
Implications for Policy, Delivery or Practice:
Understanding the interplay of VA and non-VA facilities
has growing importance as the number of veterans with
mental health difficulties continues to increase due to
recent war deployments. It is often the case that
increased access to outpatient and community services
for Veterans is a cost-effective way mitigate the need for
more inpatient capacity.
Funding Source(s): NIMH, Department of Veterans
Affairs
♦ Policy & Cost Implications of VA & Medicare Dual
Use for Colon Cancer
Denise Hynes, R.N., M.P.H., Ph.D.; Elizabeth Tarlov,
Ph.D., R.N.; Todd Lee, Pharm.D., Ph.D.; Thomas
Weichle, M.S.; Ramon Durazo-Arvizu, Ph.D.; Ruth
Perrin, M.A.
Presented by: Denise Hynes, R.N., M.P.H., Ph.D.,
Research Career Scientist/Professor, VA Information
Resource Center, Department of Veterans Affairs, 5000
South 5th Avenue (151V), Hines, IL 60141, Phone:
(708) 202-2413, Email: denise.hynes@va.gov
Research Objective: To examine and compare
healthcare use and costs for colon cancer patients
treated in the Veterans Health Administration (VA) and
Medicare
Study Design: This study linked clinical data from eight
National Cancer Institute Surveillance and Epidemiology
and End Results (SEER) Programs with VA and
Medicare workload and claims data for a retrospective
cohort of colon cancer patients who were at least 66
years old and eligible to use both VA and Medicare
healthcare between 1999 and 2003. We characterized
and compared healthcare use and costs in terms of
patient demographics, prior health care use, clinical
characteristics and geographic factors. We examined
healthcare use and costs in the VA and Medicare for the
twelve month period following colon cancer diagnosis
and compared diagnosis setting (VA vs. Medicare) and
use of both VA and Medicare for treatment of colon
cancer (CC Dual Users). All costs were adjusted to 2004
dollars.
Population Studied: Elderly veterans with colon cancer
eligible to use both VA and Medicare healthcare
Principal Findings: Among the 1,962 veterans
identified with colon cancer, 95% were male; 14% were
African American; 21% were diagnosed at a VA facility;
38.9% received any services in both VA and Medicare
settings and 12% were CC Dual Users. Mean twelve
month costs were similar for CC Dual Users diagnosed
under Medicare, non-CC Dual users diagnosed under
Medicare, and non-CC Dual Users diagnosed in VA
($45,010 vs. $45,599 vs. $44,908 respectively); however
costs were significantly higher for patients diagnosed at
the VA who were CC Dual Users ($67,520).
Multivariable regression analyses showed that after
adjustment for differences in demographics, stage at
diagnosis, colon cancer surgery, comorbidity score,
geographic factors, and prior health care use, healthcare
costs were 37% higher among VA diagnosed CC Dual
Users than veterans who were diagnosed in a Medicare
setting and treated for their colon cancer exclusively
under Medicare (non-CC Dual Users) (Incident Rate
Ratio (IRR) 1.37; 95% CI 1.07-1.75). In contrast, for
veterans who were diagnosed in the Medicare setting
and were CC Dual Users, total costs were 12% lower
compared to veterans who were diagnosed and treated
exclusively under Medicare (IRR 0.88. ; 95%CI: 0.790.98).
Conclusions: Veterans who are dual users of VA and
Medicare services for colon cancer care experience
significantly different overall healthcare costs depending
in part on where they begin their cancer care.
Differences in the course of treatment, quality of care
and costs attributable to colon cancer warrants further
study.
Implications for Policy, Delivery or Practice: The
differential increase on healthcare costs for those colon
cancer patients diagnosed in the VA and using both VA
and Medicare for treatment of their colon cancer is
important to understand as policymakers consider new
health coverage benefits aimed at improving efficiency
and quality of care across and within VA and Medicare
programs. Whether these cost differences translate into
differences in quality of cancer care deserves urgent
attention.
Funding Source(s): VA
assessment in VA. These effects may be more
significant for CBOC patients.
Funding Source(s): VA
♦ Use of Outpatient Care in VA & Medicare among
VAMC & CBOC Patients
Chuan-Fen Liu, Ph.D., M.P.H.; Michael Chapko, Ph.D.;
James Burgess, Jr., Ph.D.; Christopher Bryson, M.D.,
M.S.; John Fortney, Ph.D.; Matthew Maciejewski, Ph.D.
♦ Women’s Experiences with War in Iraq &
Afghanistan Women Veterans Coping with Combat
Exposure & Military Sexual Trauma
Kristin Mattocks, Ph.D.; Sally Haskell, M.D.; Amy
Justice, M.D., Ph.D.; Cindy Brandt, M.D.
Presented by: Chuan-Fen Liu, Ph.D., M.P.H.,
Investigator, Health Services Research & Development,
VA Puget Sound Health Care System, 1100 Olive Way,
Suite 1400, Seattle, WA 98101, Phone: (206) 764-2587,
Email: chuan-fen.liu@va.gov
Presented by: Kristin Mattocks, Ph.D., Associate
Research Scientist, Medicine, Yale University, 4 Frazier
Road, Hamden, CT 06518, Phone: (203) 494-0100,
Email: kristin.mattocks@va.gov
Research Objective: VA established community-based
outpatient clinics (CBOCs) to improve veterans’ access
to primary care. Previous studies document that
veterans going to CBOCs have lower VA outpatient care
utilization than veterans going to VAMC primary care
clinics. This study examines whether lower VA outpatient
care by Medicare-eligible CBOC and VAMC patients is
offset by more Medicare outpatient care.
Study Design: This study was a retrospective analysis
of utilization of VA and Medicare health care services.
We obtained data on primary care, specialty care, and
mental health visits from 2001-2004 VA administrative
datasets and Medicare claims.
Population Studied: The study included 8,964 CBOC
and 6,556 VAMC primary care users who were also
eligible for Medicare in FY2000.
Principal Findings: Over 30% of CBOC and VAMC
patients used primary care in Medicare. CBOC patients
had fewer VA primary care visits (2.3 versus 2.8) than
VAMC patients but more Medicare primary care visits
(1.4 versus 1.0), and similar total primary care visits (3.8
versus 3.9) in 2001. Over 60% of CBOC and VAMC
patients used specialty care in Medicare. CBOC patients
had fewer specialty care VA visits (4.1 versus 5.7) but
more Medicare specialty care visits (7.1 versus 6.0) than
VAMC patients, and similar total specialty care visits
(11.2 versus 11.6) in 2001. There was no difference in
the likelihood of Medicare mental health services use
between the two groups, but overall CBOC patients were
less likely to mental health care and had fewer total
mental health care visits than VAMC patients (1.1 versus
1.9) in 2001, with majority of visits occurred in VA for
both groups (0.9 versus 1.6). Similar patterns were
observed in subsequent years and regression results
were consistent with these descriptive results.
Conclusions: Significant proportions of CBOC and
VAMC patients use Medicare outpatient services. CBOC
patients appear to be offsetting lower use of VA primary
care and specialty care with greater use of Medicare
services.
Implications for Policy, Delivery or Practice: Dual use
of VA and Medicare services may impact continuity of
care, chronic disease management and performance
Research Objective: The wars in Iraq (Operation Iraqi
Freedom, OIF) and Afghanistan (Operation Enduring
Freedom, OEF) have engendered a growing population
of female veterans, with women now comprising 15% of
active duty military personnel. Women serving in the
military come under direct fire and experience combatrelated injuries and trauma, and are also often subject to
in-service sexual assaults and sexual harassment.
However, little is known regarding how women veterans
cope with these combat and military sexual trauma
experiences once they return from deployment, or
whether they feel comfortable sharing their combat or
sexual trauma experiences with health providers.
Therefore, the objectives of this study were to: 1)
explore women veterans’ experiences with combat and
military sexual trauma in Iraq and Afghanistan; 2)
understand what mechanisms women veterans use to
cope with combat and sexual trauma experiences, and
3) understand whether women veterans share combat
and military trauma experiences with their healthcare
providers.
Study Design: Focus group interviews were conducted
with OEF-OIF women veterans living in Connecticut.
Interviews were digitally recorded and transcribed to a
VA encrypted server. Data were analyzed using
grounded theory methods.
Population Studied: Research participants included 20
women veterans, ranging in ages from 23-58.
Participants were culled from the OEF/OIF roster
provided by Defense Manpower Data Center (DMDC)—
Contingency Tracking System Deployment file. The
OEF/OIF roster contained military discharges from
10/1/2001-11/30/2007. The roster only included
discharged veterans deployed for OIF/OEF who were
physically located within the OIF/OEF combat zones or
areas of operation or specifically identified by his/her
Service as ‘directly supporting’ the OIF/OEF mission
outside the designated combat zone.
Principal Findings: Analyses revealed two major
domains of stressors for women veterans: war-related
stressors (combat exposure and military sexual trauma)
and post-deployment stressors (returning to
family/friends, societal stigma aimed at veterans, and
personal finances). To cope with these stressors,
women veterans relied on isolation, overeating, and
excessive spending. Few women relied on the VA
system to help them cope with their traumatic
experiences, and some women reported a distrust of the
VA system in keeping their military sexual trauma
information confidential. None of the women interviewed
endorsed alcohol or drug use as a coping mechanism for
traumatic military experiences.
Conclusions: Women veterans have significant
experiences with combat exposure and military sexual
trauma. Women veterans must cope with these
experiences, along with the stress of re-entering into
society after deployment, and rely on various coping
mechanisms to handle these experiences. Women
veterans may not share their combat and sexual trauma
experiences with health providers, and yet may need
treatment for health problems related to these
experiences.
Implications for Policy, Delivery or Practice: Despite
efforts by the VA to address women veterans’ health
issues, some women do not feel comfortable using the
VA for issues related to military sexual trauma. The VA
must ensure that it creates an environment where
women veterans are comfortable disclosing their combat
and military sexual trauma experiences. State medical
associations should also work to educate their providers
regarding women’s combat and military sexual trauma
experiences.
Funding Source(s): VA
♦ Pregnancy & Mental Health Care among Women
Veterans Returning from Iraq & Afghanistan
Kristin Mattocks, Ph.D.; Melissa Skanderson, M.S.; Amy
Justice, M.D.; Joseph Goulet, Ph.D.; Sally Haskell, M.D.;
Cynthia Brandt, M.D.
Presented by: Kristin Mattocks, Ph.D., Associate
Research Scientist, Medicine, Yale University, 4 Frazier
Road, Hamden, CT 06518, Phone: (203) 494-0100,
Email: kristin.mattocks@va.gov
Research Objective: Women veterans who have
served in Operation Enduring Freedom (OEF) and
Operation Iraqi Freedom (OIF) comprise a growing
proportion of new patients in the Veterans Administration
(VA) Healthcare system. Given that 85% of these
women are under age 40, many may require
reproductive health services, including care for
pregnancy. Many pregnant women veterans may also
require ongoing mental health services for combatrelated trauma, and yet little is known regarding the
mental health needs of pregnant women veterans.
Under the Uniform Benefits package, the VA finances
pregnancy care for all eligible veterans, yet little is
known regarding how many women utilize the VA or its
affiliated providers for obstetrical care. This study aims
to investigate the occurrence of pregnancy, and
concurrent mental health problems, among OEF-OIF
women veterans who utilize VA health services.
Study Design: Cross-sectional analyses of OEF-OIF
veteran women who have enrolled in VA health care.
ICD-9 codes were used to identify pregnant women
receiving services in the VA.
Population Studied: Research subjects included
44,264 women who served in OEF-OIF and enrolled in
VA health care after return from deployment.
Participants were culled from the OEF/OIF roster of
military discharges from 10/1/2001-11/30/07 provided by
the Defense Manpower Data Center (DMDC)—
Contingency Tracking System Deployment file.
Principal Findings: Of the 44,264 women on the OEFOIF roster, 940 women (2%) requested military
separation due to pregnancy. Of these women, 88 (9%)
sought pregnancy care in the VA. Overall, during the sixyear study period, there were 2036 pregnancies among
OEF-OIF female veterans in VA care. Of these
pregnancies, 102 (5%) ended in miscarriage or
spontaneous abortion, while another 46 (2%) were
ectopic or molar pregnancies. Compared to nonpregnant OEF-OIF women veterans utilizing VA care,
pregnant women were more likely to have a diagnosis of
PTSD (16% vs 12%, p<.0001), major depression (7.5%
vs. 5.7%, p<.001), and mild depression (15% vs. 11%,
p<.0001). Only 54% of all pregnancies had any
documentation of VA payment through VA fee basis
mechanisms, either as an inpatient or outpatient.
Conclusions: Pregnancy is common among OEF-OIF
women veterans, and many pregnant women seeking
care in the VA have concomitant mental health
problems.
Implications for Policy, Delivery or Practice: There
are three major implications of our findings: 1) Given that
a majority of obstetrical care is provided through fee
basis or contract providers at non-VA facilities, the VA
must implement systems to ensure women veterans
receive quality obstetrical care from community-based
providers. 2) Since mental health conditions associated
with military duty are especially common in this group of
veterans, coordination of mental health services offered
within VA and pregnancy related services outside the VA
will be a special challenge. VA mental health providers
must ensure that medications given to treat mental
health conditions are not contraindicated for pregnant
women. 3) Many returning women veterans may not
know that the VA will cover pregnancy related
healthcare, and the VA must ensure that women know
that pregnancy care is a covered benefit for women
veterans.
Funding Source(s): VA
The Prevention, Identification & Treatment of
Obesity
Chair: Lisa Simpson
Monday, June 29 * 9:45 a.m.-11:15 a.m.
♦ Variation in Provider Identification of Obesity by
Patient-Level & Neighborhood-Level Characteristics
among an Insured Population
Sara Bleich, Ph.D.; Jeanne Clark, M.D., M.P.H.;
Suzanne Goodwin, M.P.H.; Mary Margaret Huizinga,
M.D., M.P.H.; Jonathan Weiner, Ph.D.
Presented by: Sara Bleich, Ph.D., Assistant Professor,
Health Policy & Management, Johns Hopkins Bloomberg
School of Public Health, 624 North Broadway, Room
451, Baltimore, MD 21205, Phone: (410) 502-6604,
Email: sbleich@jhsph.edu
Research Objective: To identify variation in provider
identification of obesity by patient-level and
neighborhood-level characteristics among an insured
population. The central hypothesis is that members living
in lower socioeconomic status neighborhoods with a
higher percent of minority residents will have a lower
likelihood of receiving an obesity diagnosis from their
provider.
Study Design: Analysis of Blue Cross Blue Shield
(BCBS) claims data linked to member Health Risk
Assessment (HRA) surveys and ZIP code level
neighborhood characteristics (e.g., percent black,
percent Hispanic, percent with high school degree,
median household income) from the 2000 Census.
Patient height and weight (obtained from the HRA) was
self-reported. Also included in the HRA were patient
gender and age as well as lifestyle behaviors (e.g.,
smoking, alcohol, exercise, healthy diet). The ZIP code
was based on the member ZIP code of enrollment.
Logistic regression, adjusted for potential clustering of
risk factors by neighborhood and possible correlation
among observations, was used to model the outcome
variable of interest (obesity diagnosis). Individuals were
considered to have an obesity diagnosis if indicated by
The International Classification of Diseases, Ninth
Revision (ICD-9) diagnostic codes (259.9, 278.0, 280.1,
783.1, 783.6, V77.8, V85.0-V85.54). Because Blue
Cross Blue Shield is the largest insurer in the country,
and the BCBS dataset is the largest and most current
that has been used for this type of analysis, we are able
to more accurately characterize variation in provider
identification of obesity.
Population Studied: The study population was a cohort
of BCBS enrollees from several plans with claims data
linked to HRA data from that same year, 2002-2005 (N =
71,074). Individuals were excluded from the sample if
they were enrolled less than 6 months in the year in
which their HRA was completed, were less than 18
years old or their data was missing, had a pregnancy
and/or delivery claim during the study period, had a body
mass index (BMI) less than 10 kg/m2 or greater than
100 kg/m2, or were missing height or weight needed to
calculate their BMI.
Principal Findings: Rates of provider identification of
obesity were low. Based on self-reported BMI, 22.7
percent of the study population was obese. Only 24
percent of these obese individuals were identified as
obese by their provider. The mean BMI for obese
patients with an obesity diagnosis was significantly
higher than the mean BMI for those without an obesity
diagnosis (38.4 kg/m2 vs. 34.5 kg/m2, p < 0.001). At the
individual-level, increased odds of obesity identification
were significantly associated with female gender (OR =
1.73, 95% CI: 1.49, 2.00) and younger age (age 18-29 –
OR = 2.97, 95% CI: 2.12, 4.14; age 30-44 – OR = 2.53,
95% CI: 1.94, 3.30; age 45-64 – OR = 1.57, 95% CI:
1.23, 2.01) as compared to the elderly (65+), after
controlling for neighborhood-level covariates. Obese
individuals with comorbid conditions had a higher
likelihood of being identified as obese as compared to
obese individuals without comorbidities, after adjusting
for covariates (hypertensive – OR = 2.78, 95% CI: 2.28,
3.41; diabetes – OR = 1.29, 95% CI: 1.08, 1.55;
dyslipidemia – OR = 1.88, 95% CI: 1.48, 2.39). We did
not observe a relationship between lifestyle behaviors
and provider identification of obesity. At the
neighborhood-level, members in neighborhoods with a
higher percent black population were less likely to have
an obesity diagnosis (OR = 0.98, 95% CI: 0.98, 0.99),
whereas those in neighborhoods with a higher
percentage of high school graduates (OR = 4.05, 95%
CI: 1.24, 13.23) or a higher quintile of household income,
as compared to the 1st quintile, where more likely to
receive an obesity diagnosis (4th quintile – OR = 1.63,
95% CI: 1.14, 2.34; 5th quintile – OR = 2.46, 95% CI:
1.64, 3.67) after controlling for individual-level
covariates.
Conclusions: Most insured obese patients, particularly
the moderately obese (BMI >= 30 & < 35), were not
appropriately diagnosed as obese by their provider.
Rates of obesity identification were strongly related to
patient age and gender as well as neighborhood-level
sociodemographic characteristics.
Implications for Policy, Delivery or Practice: Our
findings suggest considerable missed opportunities in
the diagnosis of obesity, particularly for members at
higher risk and members living in socially deprived
neighborhoods. A key contribution of this paper is the
examination of the relationship between neighborhood
characteristics and obesity diagnosis, which has
received little attention to date. More research is needed
to understand which neighborhood characteristics, such
as available resources or cultural norms, most influence
provider identification of obesity.
Funding Source(s): Department of Health Policy and
Management
♦ Collaborative System Modeling to Develop
Childhood Obesity Prevention Policies
Rachel Ferencik, M.P.A.; Heather Devlin, M.A.; Chris
Soderquist; Ken Powell, M.D., M.P.H.; Heather Devlin,
M.A.; Mary Ann Phillips, M.P.H.; Karen Minyard, Ph.D.
Presented by: Heather Devlin, M.A., Research
Associate II, Georgia Health Policy Center, Georgia
State University, 14 Marietta Street, Suite 221, Atlanta,
GA 30303, Phone: (404) 413-0292, Email:
hdevlin@gsu.edu
Research Objective: Obesity among school-age
children has tripled in recent decades. Promising
interventions are available, but comprehensive, policydriven approaches will be required to reverse this
complex epidemic. This project’s objective was to
provide policymakers with a systemic perspective on
childhood obesity and to enable more rigorous
discussions of policy alternatives. Toward that end, a
diverse team developed a simple system dynamics
model of childhood obesity for legislators.
Study Design: The collaborative system modeling team
included state legislators, legislative staff, and experts in
nutrition, exercise physiology, epidemiology, pediatric
medicine, and system dynamics. The model relied on
epidemiological data and structure from a similar tool
previously developed by the Centers for Disease Control
and Prevention. The modeling team extracted the sector
of the CDC model pertaining to children, incorporated
state-specific information and assumptions where
available, and added policy interventions. Six policy
areas were modeled: 1) ensuring safe routes to school,
2) improving school food options, 3) improving school
physical education, 4) improving nutrition/physical
activity education in preschool programs, 5) improving
nutrition/physical activity education in after school
programs, and 6) reimbursing Medical Nutrition Therapy
for obese children insured by Medicaid. In the model,
children are classified as normal weight, overweight,
obese or severely obese. As they grow older, children
can move between adjacent weight categories based on
energy balance assumptions for the “base case” or
intervention conditions. A simple user interface enables
policymakers to explore policy interventions, alone or in
combination and at varying intensities, in terms of their
impact on obesity and associated health care costs over
the coming decade. The model is designed for real-time,
hands-on exploration in a learning lab environment.
Participants are encouraged to predict outcomes,
articulate theories and inquire into any differences
between their expectations and the model’s outcomes.
Population Studied: The model included data for
children ages 0-18 years.
Principal Findings: Consistent with recent
epidemiologic evidence, model results suggested a
“base case” future in which childhood obesity prevalence
levels off at an unacceptably high rate of about 25%. No
single policy had a large impact on future rates of
obesity. However, some policy combinations lowered the
prevalence of obese children to 10%, effectively
returning prevalence to 1970 rates. Time lags were
observed for all interventions, but significant reductions
could be seen within 5 years by maximizing a coherent
set of policies, particularly those affecting the school
environment.
Conclusions: Model results suggest there is no “magic
bullet” for reducing childhood obesity, but coherent
policy combinations hold promise, provided that they are
implemented intensively and sustained over time.
Implications for Policy, Delivery or Practice: Using a
collaborative system modeling process and a systemic
perspective, this project brought together legislators and
content experts to develop a set of actionable policy
options. The resulting model provides a framework, a
common language and a credible and engaging tool that
has already begun enabling state legislators to engage
in more rigorous discussions about effective and feasible
policy options for reducing childhood obesity. The
approach also shows promise for other complex policy
issues.
Funding Source(s): Georgia Health Foundation
♦ First-Year Results of an Obesity Prevention
Program at the Dow Chemical Company
Ron Goetzel, Ph.D.; Xiaofei Pei, Ph.D.; Kristin Baker,
M.P.H.; Meghan Short, M.P.H.; Xiaofei Pei, Ph.D.;
Ronald Ozminkowski, Ph.D.; Shaohung Wang, Ph.D.
Presented by: Xiaofei Pei, Ph.D., Economist,
Healthcare, Thomsonreuters, 4301 Connecticut Avenue,
Washington, DC 20008, Phone: (703) 825-3771, Email:
xiaofei.pei@thomsonreuters.com
Research Objective: Our objective was to test the
hypothesis that employees exposed to workplace
environmental weight reduction interventions in addition
to usual individual interventions would have lower weight
and body mass index (BMI), and that the prevalence of
overweight and obesity, and other weight-related health
risk factors would be lower in these worksites compared
to worksites where employees receiving standard care
(individual interventions) only.
Study Design: Twelve Dow Chemical Company
worksites were included in this 12-month, pre-post
quasi-experimental study. Environmental interventions
included increased access to physical activities, such as
walking paths, healthier foods in vending machines and
on-site cafeterias, and weight management tools. Nine
sites were assigned to the intervention condition
(environmental plus individual weight reduction
methods). Employees at three additional sites received
individual weight loss interventions only (control sites).
Intervention sites were further randomized to two levels
of intervention intensity: moderate (4 sites), or intense (5
sites). Moderate interventions introduced an array of
inexpensive environmental changes focused primarily on
the physical environment, and intense interventions
required a higher level of commitment especially among
site leaders. Employees at intervention and control sites
were compared at baseline and 12 months postenvironmental program implementation for self-reported
health habits from a standard health risk assessment
(HRA) survey, weight and BMI. Changes in employees’
weight, body mass index (BMI), and other health risks
were examined using chi-square and t-tests. We used
propensity score weighting techniques to control for
potential confounders, including employee
demographics and underlying health status. Differencein-differences (DID) analyses were used to compare the
trends over time between treatment and control groups.
Population Studied: A total of 10,281 employees
(intervention sites = 8,013; control sites = 2,268)
participated in this study. Analyses were based on the
cohort of employees (n=3,152) who completed both
baseline and year-one HRAs. Of these, 2,518 (79.9%)
were at treatment sites and 634 (20.1%) at control sites.
Principal Findings: One year post intervention, a
modest treatment effect was observed for weight and
BMI largely because the control group subjects gained
weight and the intervention group maintained their
weight; however, no effect was observed for overweight
and obesity prevalence. Other risk factors (tobacco use,
high blood pressure, and systolic and diastolic blood
pressure values) decreased significantly, although blood
glucose (high risk prevalence and values) increased.
Conclusions: Environmental changes to the workplace
can achieve modest improvements in employees’ health
risks, including weight and BMI measures.
Implications for Policy, Delivery or Practice: It
probably takes longer to introduce environmental
interventions that exert a positive health impact than
individual interventions. It is likely that introducing
changes to the environment by, for example, altering
vending machine contracts, introducing new cafeteria
menus, posting signs, updating company policies,
engaging leadership, setting health goals, and revising
recognition programs may be more cumbersome and
administratively burdensome compared to providing
individual coaching and counseling programs. Layers of
approval are needed to design new programs and
management buy-in has to be negotiated before
programs are accepted and implemented. Thus, newly
introduced environmental programs may need additional
time to achieve their desired effect.
Funding Source(s): National, Heart, Lung and Blood
Institute (NHLBI)
♦ A Touch of Life for Health & Wellness: A
Complementary Alternative Healthy Lifestyle Change
to Decrease the Nutritional Deficiencies Associated
with Overweight & Obesity
Akmal Muwwakkil, Ph.D.
Presented by: Akmal Muwwakkil, Ph.D.,
President/C.E.O., The Energy Institute of the Healing
Arts Foundation, 12911 Woodmore Road, Mitchellville,
MD 20721, Phone: (301) 249-2445, Email:
akmalmuwwakkil@yahoo.com
Research Objective: The objective of the research was
to promote complementary, alternative, and healthy
lifestyle changes to address the prevalence of obesity
and its associated health disparities.
Study Design: The project involves twelve weekly
sessions. Each session was held for two-hour durations
with approximately 30 to 40 participants per group.
Lectures and didactic sessions were provided
introducing healthy lifestyle changes, micronutrients and
phytonutrients protocols along with Qi Gong exercises.
During each of the sessions participants were weighted
and their blood pressures were recorded. They also
would self report on the changes in medications and
physicians visits.
Population Studied: 896 African Americans age
ranging from 20 to 67 who lived in the under-served
communities of Prince George's County Maryland
participated in the project.
Principal Findings: Over the seven years of the project,
findings where based on program evaluations and self
reporting, which indicated that the participants reduced
their blood glucose levels by 60 to 90 percent and 42
participants where taken off their medication by their
physicians. Another 20% of the participants medications
where reduced by their physicians. Through weighting
participants, we found that 789 participants
demonstrated a 40 to 60% rate of weight loss by the end
of the project and 35% of them maintained the weight
loss. By the conclusion of the project there had been a
significant decrease in cholesterol levels of 60 to 85% of
the participants with elevated cholesterol. Hypertensive
participants show a decrease it their blood pressure by
45% and 25 hypertensive participants was taken off of
their medication by their physicians. The greatest impact
is participant willingness to maintain the protocol as their
blood sugar levels decrease, reduction in weight and
HDL’s increase as LDL’s decrease.
Conclusions: The study demonstrated through
education, healthy dietary life style changes,
micronutrient and phytonutrients protocols along with
exercises participants lost significant weight and reduced
and/or eliminated their high glucose levels, hypertension,
and cholesterol.
Implications for Policy, Delivery or Practice:
The study shows the importance of integrating
alternative methods in healthy lifestyle and micronutrient
protocols in consumer-based programs. Such efforts will
potentially enhance the outcomes of obesity, diabetic,
hypertensive, and cholesterol research and
interventions.
Funding Source(s): Consumer Foundation, and Kaiser
Permanente.
♦ Relationship Between Hospital Volume &
Postoperative Complications for Laparoscopic
Gastric Bypass Surgery: Results from the 2005
Nationwide Inpatient Sample
Wendy Weller, Ph.D.; Carl Rosati, M.D.
Presented by: Wendy Weller, Ph.D., Assistant
Professor, Health Policy, Management, & Behavior,
University at Albany, State University of New York,
School of Public Health, One University Place, Room
167, Rensselaer, NY 12144, Phone: (518) 402-0302,
Email: wweller@albany.edu
Research Objective: The objective of this study was to
use nationally representative data to examine the
relationship between hospital volume and postoperative
complications among persons undergoing a
laparoscopic gastric bypass procedure in 2005.
Study Design: This is a cross-sectional study based on
data from the 2005 Nationwide Inpatient Sample (NIS).
Population Studied: The study population was
comprised of adults (18 years or older) who had a
principal diagnosis code for obesity (ICD-9-CM codes
278.0, 278.00, 278.01, 278.1) and a primary procedure
code for laparoscopic gastric bypass surgery (ICD-9-CM
code 44.38). The final study population consisted of
14,180 discharges (weighted n=68,810).
Principal Findings: There was an inverse relationship
between postoperative complications and hospital
volume after controlling for patient and hospital
characteristics. The adjusted odds of a postoperative
complication decreased from 1.66 (95% confidence
interval [CI] 1.40-1.97) for the 25th quartile to 1.28 (95th
CI: 1.07-1.54) for the 75th quartile compared to the
highest volume quartile. Likewise, for three of four
binary hospital volume cutpoints (100, 125, 200), there
was a significantly higher likelihood of postoperative
complication in the lower volume hospitals.
Conclusions: This study demonstrates that the
likelihood of postoperative complications from
laparoscopic gastric bypass procedures is greater for
patients in low-volume hospitals.
Implications for Policy, Delivery or Practice: The
results of this study suggest that existing minimum
volume thresholds that have been adopted by several
organizations in attempts to improve quality of care for
bariatric surgery patients may be warranted. In some
cases these thresholds do not distinguish between
laparoscopic or open procedures or were established
prior to the proliferation of laparoscopic procedures.
Given that laparoscopic gastric bypass now accounts for
the majority of bariatric procedures in the United States,
voluntary "Center of Excellence" programs and others
should take these procedures into consideration when
establishing minimum volume thresholds.
The Causes & Consequences of Obesity
Chair: Christina Economos
Tuesday, June 30 * 8:00 a.m.-9:30 a.m.
♦ The Influence of Calorie Labeling on Food Choice
Brian Elbel, Ph.D., M.P.H.; Rogan Kersh, Ph.D.; Victoria
Brescoll, Ph.D.; L. Beth Dixon, Ph.D.
Presented by: Brian Elbel, Ph.D., M.P.H., Assistant
Professor, New York University, 423 East 23rd Street,
15-120N, New York, NY 10010, Phone: (212) 263-4283,
Email: brian.elbel@nyumc.org
Research Objective: Obesity is a major public health
problem, yet few true population-level solutions have
been implemented. The first such policy meant to
impact obesity at a large scale is the mandatory labeling
of the caloric content of menu items in fast food
restaurants. The legislation has been passed or
considered in over 25 cities and states, yet we have no
evidence of its effectiveness. New York City was the
first location to implement mandatory calorie labeling in
the summer of 2008. The objective of our study is to
examine the influence of calorie labeling on food choice
in low-income communities.
Study Design: We utilized this natural experiment via a
difference-in-difference design to study the influence of
labeling in New York City, utilizing Newark, NJ as a
control group. We collected 1,100 receipts from adults
outside of fast food restaurants both before and
approximately 1-month after labeling was introduced.
When entering the restaurants, subjects were
approached by study staff and asked to bring us their
receipt and answer a short survey upon leaving. The
methodology is similar to a street intercept survey.
Calories purchased were calculated using the
information on the receipt and each restaurant's
corporate website.
Population Studied: Restaurants from the largest fast
food chains in low-income, largely racial and ethnic
minority areas in NYC were matched to those similar
areas in Newark. Subjects were sampled outside of
these restaurants.
Principal Findings: We did not observe a change in the
number of calories purchased from the pre- to postlabeling period in NYC or Newark. However, the
percentage of people that noticed and reported utilizing
the information increased to approximately 15% in the
NYC, post-labeling period. We are also exploring and
will report on the influence of labeling on adolescents
and families and why labeling was effective (or not).
Conclusions: While these results do not imply that
providing caloric information is ineffective in the long
term, it does show the need for greater research before
labeling is introduced on a wide scale. The provision of
information alone to change behavior could have limits
that must be explored. Findings from behavioral
economics could be helpful.
Implications for Policy, Delivery or Practice: This
study could inform policy makers that are currently
planning to implement labeling.
Funding Source(s): RWJF
♦ The Impact of Obesity on Office-Based Physician
Visits
William Pearson, Ph.D., M.H.A.; Kavitha Bhat-Schelbert,
M.D., M.S.; Earl Ford, M.D., M.P.H.; Ali Mokdad, Ph.D.,
M.P.H.
Presented by: William Pearson, Ph.D., M.H.A.,
Epidemiologist, Division of Adult & Community Health,
Centers for Disease Control & Prevention, 4770 Buford
Highway NE, MS K-66, Atlanta, GA 30341, Phone:
(770) 488-5429, Email: wpearson@cdc.gov
Research Objective: Obesity is associated with
morbidity, mortality, and increased healthcare costs.
Indeed, these costs are seen at both a societal and a
clinical level. However, relatively few studies have
examined the impact of obesity on outpatient office
visits. The objective of this study was to determine if
visits made to office-based physicians by obese persons
required more time with the provider and more
prescription medications compared to visits made by
non-obese persons.
Study Design: We conducted a cross-sectional analysis
of data from the 2006 National Ambulatory Medical Care
Survey. The obesity status (BMI > 30.0 kg/m2 ) for
patient visits made by persons aged 18 years or older
was identified based on height and weight
measurements taken from the patient encounter form or
from diagnosed obesity on the patient record.
Time spent with the provider and the number of
prescription medications mentioned at each visit were
compared between visits made by obese and non-obese
patients. We used logistic regression models to examine
the association between obesity status of the patient and
time spent with the provider as well as the number of
prescription medications mentioned at the visit, while
controlling for potential confounders such as age, sex,
race and number of chronic conditions for the patient, as
well as payment source, and major reason for the visit.
Population Studied: We studied a total of 24,239
nationally-representative patient visits made to
outpatient physician offices in the United States during
2006.
Principal Findings: Obese patients had a significantly
higher duration of time spent with the provider and a
significantly higher number of medications prescribed
compared to non-obese patients. On average, visits
made by non-obese patients lasted for 20.8 minutes
compared to 22.8 minutes for visits made obese
patients. Visits made by non-obese patients had on
average 2.2 prescription medications listed for each visit.
Alternatively, visits made by obese patients had, on
average, 3.1 prescription medications listed for each
visit. Adjusted logistic regression models showed that
visits made by obese persons were significantly more
likely to last more than 20 minutes as compared to visits
made by non-obese patients (O.R. 1.17, 95% C.I. 1.021.36) and that visits made by obese patients were
significantly more likely to have more than two
prescription medications as compared to visits made by
non-obese patients (O.R. 1.83, 95% C.I. 1.57-2.14).
Conclusions: Our study revealed that obese patients
require longer treatment time during visits to officebased physicians and that these patients receive more
medication during these visits compared to non obese
patients. Increased time for treatment and increased
numbers of medications prescribed translate into
increased costs for our healthcare system. These
findings document the impact of obesity among US
adults on our medical community.
Implications for Policy, Delivery or Practice: Our
findings have great implications on medical care cost
and planning in that they demonstrate how obese
patients require greater resources in the office setting.
Therefore, incentives for weight loss and exercise would
be beneficial in reducing healthcare costs from obesity.
Funding Source(s): CDC
♦ The Impact of Participation in the Supplemental
Nutrition Assistance Program on Child Obesity
Maximilian Schmeiser, Ph.D.
Presented by: Maximilian Schmeiser, Ph.D., Assistant
Professor, Consumer Science, University of WisconsinMadison, 1300 Linden Drive, Madison, WI 53706,
Phone: (608) 262-2831, Email: mschmeiser@wisc.edu
Research Objective: This study investigates the impact
of participation in the Supplemental Nutrition Assistance
Program (formerly Food Stamps Program) on the Body
Mass Index (BMI) and obesity status of children.
Expanding on previous research, this paper examines
the effect of general participation in the Supplemental
Nutrition Assistance Program (SNAP) on BMI and
obesity, as well as the marginal effect on BMI and
obesity of an additional dollar of SNAP benefits.
Study Design: This study identifies the causal effect of
SNAP participation and changes in benefit value on the
BMI and obesity status of children, using an instrumental
variables (IV) individual fixed-effects estimation strategy.
In order to identify the effect I use the exogenous
variation in state and federal EITC eligibility and the
value of EITC benefits as an instrument for SNAP
participation. Changes in the EITC program generate
exogenous variation in eligibility for the SNAP, as the
EITC program has a significant impact on welfare
participation, earned income, and employment, which
are all correlated with SNAP participation. Tests of this
hypothesis based on data from the NLSY79 confirm that
these instruments have a first-stage F-statistic that
exceeds the weak instruments threshold of 10 (Staiger
and Stock, 1997). This IV approach corrects for the
biases in previous estimates of the effect of SNAP
participation on BMI.
Population Studied: The population studied is children
ages 6 through 14 drawn from the National Longitudinal
Survey of Youth 1979 Children and Young Adults
sample.
Principal Findings: Preliminary results indicate that
participation in the SNAP program actually lowers the
BMI and probability of obesity for children. There does
not appear to be a differential effect on male or female
children.
Conclusions: Increasing SNAP benefits may be an
effective means of combating child obesity, while also
supporting low-income families.
Implications for Policy, Delivery or Practice:
Congress is considering an expansion of SNAP benefits
as part of the economic stimulus package. In addition to
the economic stimulus provided by increased SNAP
benefits, the results of this research suggest that
increased benefits may also reduce child obesity.
Funding Source(s): USDA
♦ Cigarette Smoking & Abdominal Obesity: A MetaAnalysis
Lu Shi, Ph.D.; Jeroen van Meijgaard; Esa Eslami
Presented by: Lu Shi, Ph.D., Senior Analyst,
Department of Health Services, University of California,
Los Angeles, 3271 Sawtelle Boulevard, Unit 106, Los
Angeles, CA 90066, Phone: (315) 395-8025, Email:
lushi.pku@gmail.com
Research Objective: A substantial proportion of
smokers, especially female smokers, perceive their
cigarette smoking behavior as a way of weight control,
although various studies have shown that cigarette
smoking is positively associated with abdominal obesity
as measured by waist-to-hip circumference ratio (WHR).
The main objective of this meta-analysis is to evaluate
the magnitude and significance of the association
between cigarette smoking behavior and WHR, while
exploring the possible moderating effects of age and
gender on this association.
Study Design: Database searches of MEDLINE and
Google Scholar were conducted. Citation list searches
were also used. Studies that have tested the association
between current cigarette smoking behavior and
abdominal obesity (as measured by the continuous
variable of WHR) were sought for the purpose of this
review. Studies that have not controlled for age and
gender in their estimation of the associations were
excluded from this review. Studies that have examined
the association between current cigarette smoking and
the categorical outcome of abdominal obesity (e.g.,
WHR>0.8) were not included in this meta-analysis. Data
were analyzed using the SPlus/R function of MiMa
(Viechtbauer, 2006).
Population Studied: This meta-analysis includes
83,962 people aged 18 and above, which include
various racial and ethnic groups of different countries in
Europe, North America and South America.
Principal Findings: Of the 14 studies analyzed, all find
significant and positive associations between WHR and
current cigarette smoking. One study reported significant
and positive association in its male sub-group but no
significant association in its female sub-group, and one
study reported a positive and significant association in its
female sub-group but no significant association in its
male sub-group. Current cigarette smoking is associated
with a pooled effect size of 0.015 (95%CI: 0.008-0.022,
p<0.001) increase in the waist-to-hip circumference
ratio. Age and gender of the study populations are not
significant moderator variables for the effect size.
Conclusions: Our result shows that cigarette smoking is
very significantly associated with abdominal obesity
across different age and gender groups. This
paradoxical body shape of low BMI and high WHR
among smokers could come from the fact that they
typically have more sugar and fat in their food (a
possible result of the low taste sensitivity among
smokers) than never-smokers, despite the fact that
nicotine suppresses the smoker’s overall appetite. More
empirical studies are needed to examine the association
between abdominal obesity and cigarette smoking in the
adolescent population, an important age group for the
society’s smoking reduction efforts.
Implications for Policy, Delivery or Practice: The
popular notion that smoking could effectively prevent
obesity might encourage smoking initiation among
never-smokers, discourage quitting among current
smokers, and increase relapse behavior among quitters
who often find a short-term weight gain after quitting.
Therefore, people working on anti-smoking campaigns
and smoking cessation interventions may find it effective
to emphasize the message that cigarette smoking could
significantly contribute to the smoker’s abdominal
obesity, a consistent pattern that has been found in
different age, gender, racial and ethnic groups
worldwide.
♦ The Role of Midlife Obesity in Late Life Health
Outcomes
Brenda Spillman, Ph.D.
Presented by: Brenda Spillman, Ph.D., Principal
Research Associate, Health Policy Center, Urban
Institute, 2100 M Street, NW, Washington, DC 20037,
Phone: (202) 261-5846, Email: bspillman@urban.org
Research Objective: To examine the relationship
between midlife obesity and late life health, disability,
longevity, and Medicare spending.
Study Design: The study uses data from the 1999
National Long Term Care Survey merged with Medicare
claims and other administrative data. The survey
collects both information on current height and weight
and weight at age 50. These data were used to construct
the key explanatory variables, which are indicators of
longstanding obesity, former obesity, and obesity
occurring after age 50, using a standard criterion of Body
Mass Index of 30 or higher. Models were developed to
estimate the relationship between these key explanatory
variables and the probability of three chronic diseases
associated with obesity, 5-year survival, and chronic
disability, as well as Medicare spending. Controls were
included for demographic and socioeconomic
characteristics, Medicaid enrollment, region, and local
health care market characteristics. Probit regression
was used to estimate models for dichotomous outcomes.
Two-part models using probit and GLM were used to
estimate expected spending over a 5-year followup
period.
Population Studied: A nationally representative sample
of Medicare enrollees age 65 or older living in
community settings.
Principal Findings: Both persons obese at midlife or
becoming obese after midlife are significantly more likely
than those who were never obese to be black and to
have less than a high school education. Those obese at
midlife are also significantly more likely to be poor.
Being obese in midlife, regardless of current weight, is a
strong predictor of arthritis, diabetes, and heart disease,
whereas becoming obese after midlife is significantly
associated with arthritis and diabetes, but not heart
disease. Only former obesity predicted reduced 5-year
survival, but both longstanding, former, and current
obesity were strong predictors of chronic disability. After
controlling for chronic conditions and other
characteristics, neither longstanding, former, nor current
obesity was significantly associated with higher
Medicare spending. Average predicted 5-year spending,
however, was more than 40 percent higher for persons
who were obese at age 50 and about 8 percent higher
for persons who became obese after age 50, relative to
persons who were never obese.
Conclusions: Obesity in midlife is an important
predictor of serious chronic disease and disability in late
life and appears to be a better predictor than late life
obesity alone. Estimated outcomes are uniformly worse
for persons who were obese in midlife, regardless of
current weight, than for persons who became obese only
after midlife.
Implications for Policy, Delivery or Practice: Relying
solely on current obesity among the elderly to forecast
the implications of the current obesity epidemic in the
younger population may understate its importance for
old age health and other outcomes. These results
provide support for the increasing focus on primary
prevention initiatives in midlife and earlier to prevent the
negative consequences of obesity in later life. The
results with respect to the higher rate of poverty and
lower education among those who are obese in midlife
or later also suggests that such interventions may have
a greater impact among these disadvantaged groups.
Funding Source(s): DHHS/ASPE
Changes & Challenges in Primary Care
Chair: Diane Rittenhouse
Monday, June 29 * 11:30 a.m.-1:00 p.m.
♦ Improving the Primary Care-Specialty Care
Interface Through eReferrals
Alice Chen, M.D., M.P.H.; Margot Kushel, M.D.; Ellen
Keith, B.A.; Ryan Kimes, M.S.; Yeuen Kim, M.D.; Hal
Yee, Jr., M.D., Ph.D.
Presented by: Alice Chen, M.D., M.P.H., Assistant
Clinical Professor, Medicine, University of California San
Francisco, DOM Box 1364, San Francisco, CA 94143,
Phone: (415) 206-4049, Email:
achen@medsfgh.ucsf.edu
Research Objective: We conducted a series of
evaluations to assess the impact of a novel electronic
referral system (eReferral) whose salient characteristic is
centralized review and triage of referrals by a specialist
clinician reviewer, with the opportunity for iterative
communication between referring and specialty
providers.
Study Design: We measured median wait times for
seven adult medical subspeciality clinics before and after
the implementation of eReferral. We also tracked the
percentage of avoided and expedited clinic visits for
each clinic. Referring provider acceptability was gauged
through a web-based survey of primary care provider
experience. Impact on specialists was assessed
through an encounter-based survey of new patient
appointments comparing patients referred using the prior
(paper and fax based) referral process and those
referred through eReferral.
Population Studied: eReferral was implemented at a
public hospital with over 500,000 outpatient visits
annually, 28% of which are specialty care visits. The
core referral network is comprised of 27 primary care
clinics (a combination of county funded and independent
community clinics) with access to the hospital EMR. A
total of 368 primary care providers were surveyed, with
an 81% response rate. For the subspecialist survey, a
total of 413 encounters were assessed.
Principal Findings: Median wait times declined
between 13% and 81% in 6 of 7 clinics. The percent of
referrals that were “never scheduled” (defined as no
appointment 180 days after the last exchange between
the referring provider and specialist reviewer) ranged
from 12.9% to 53.2%. The percent of referrals that were
expedited (defined as an appointment scheduled before
the routinely next available appointment) ranged from
2.2% to 46.4%. Among primary care providers, 71% felt
that eReferral improved clinical care, 71% felt that
eReferral provided improved guidance for pre-visit
evaluation, and 89% felt that eReferral improved their
ability to track referrals. Medical subspecialists
experienced a nearly 50% decrease in the percentage of
referrals rated as “somewhat” or “very difficult” to identify
the consultative question, from 19% to 10% (p=0.003).
Conclusions: Using a specialist clinician reviewer to
provide clinical guidance and triage through an
electronic interface can both reduce wait times and
increase specialist efficiency, with high levels of primary
care provider acceptability.
Implications for Policy, Delivery or Practice: The use
of an electronic referral system informed by specialist
clinical intelligence allows for the identification and
avoidance of unnecessary or premature visits while
expediting urgent cases. When guided by evidencebased medicine, such a system can increase access
and improve quality while controlling costs. An
additional benefit is the ability to track and analyze
referral volume and patterns. Payers such as Medicaid
and Medicare could invest in such a system as a way to
ensure the provision of timely, appropriate care. For
safety net settings across the country that are struggling
with poor access to specialty care, this type of
centralized screening, triage, and education system
should be highly appealing. It remains to be seen
whether this system can be applied in other settings in
which patient demand for specialty care may trump
rational system design.
Funding Source(s): San Francisco Health Plan
♦ Does Patient-Centered Access to Care Increase
Utilization & Costs among Patients with Diabetes?
David Grembowski, Ph.D., M.A.; Melissa Anderson,
M.S.; James Ralston, M.D., M.P.H.; Diane Martin, Ph.D.,
M.A.; Robert Reid, M.D., Ph.D.; Julia Hecht, Ph.D.
Presented by: David Grembowski, Ph.D., M.A.,
Professor, Health Services, University of Washington,
Box 357660, Seattle, WA 98195-7660, Phone: (206)
616-2921, Email: grem@u.washington.edu
Research Objective: In 2002 Group Health Cooperative
(GHC) launched a patient-centered Access Initiative (AI)
to improve quality by increasing enrollee access to
physicians and information through the following system
reforms: 1) enrollee Web site, MyGroupHealth (MyGH),
with access to enrollee-physician secure messaging,
electronic medical records and health promotion
information; 2) advanced access to primary care (same
day appointments); 3) direct access to specialists
(removal of gatekeeping); 4) primary care redesign to
control costs; and 5) changes in primary and specialty
physician compensation. Objective is to compare
utilization and costs before versus after the Initiative
among enrollees with diabetes and comorbid conditions.
Study Design: Single (one-group) interrupted time
series design. Repeated measures generalized
estimating equation (GEE) models were used to
compare quarterly utilization and costs in the Rollout
(2002-2003) and Full-Implementation (2004-2006) of the
AI with utilization in the pre-Initiative years (1998-2002).
Covariates included age, gender, indicators for last two
quarters of life, outpatient and pharmacy copayment
amounts, Group Health wellcare waiver, market segment
(type of health insurance), and severity of illness,
measured by eight ADGs with significant morbidity that
do not overlap with diabetes and the four comorbid
conditions.
Population Studied: 9,871 GHC members continuously
enrolled 1997-2006 with type 1 or 2 diabetes in all years
(including deaths) in western Washington state and
entered in GHC Diabetes Registry, stratified into six
comorbidity groups: 1) no comorbid conditions (diabetes
only); 2) hypertension and/or coronary artery disease
(CAD); 3) congestive heart failure (CHF); 4) depression
only; 5) depression and hypertension and/or CAD; and
6) depression and CHF. Models included interaction
terms between time period and comorbidity group to
estimate different AI effects by group.
Principal Findings: Compared to pre-Initiative years,
primary care visits decreased in Full-Implementation
(rate ratio (RR) range across comorbid groups: 0.780.87), likely offset by growth in secure messaging
between enrollees and primary providers. About 32%
enrollees completed ID verification to access MyGH, and
of those, 75% messaged providers at least once.
Specialty visits and inpatient care did not change across
most comorbid groups. Emergency visits increased for
all groups (RR range: 1.56-3.58). Prescriptions
increased for enrollees without comorbid depression.
Total costs increased for most groups (RR range 1.091.46), although specialty, laboratory and radiology costs
decreased for most comorbid groups.
Conclusions: In a continuously-enrolled cohort of
members with diabetes and comorbid conditions, the AI
did not increase in-person utilization of primary and
specialty care as expected. Primary care visits
decreased, likely offset by growth in secure messaging.
Specialty visits did not change while emergency visits
and total costs increased.
Implications for Policy, Delivery or Practice: In
implementing a patient-centric model of care, the AI
required clinic staff to adapt simultaneously to several
changes in care delivery, which may have reduced
attention to management of chronic illness that
otherwise might have averted some visits to emergency
departments. The increase in emergency department
use may be a consequence of the increased burden
placed on primary care physicians, which reduced time
spent with patients in managing diabetes and comorbid
conditions. Future initiatives to improve access should
implement policies to reduce emergency visits.
Funding Source(s): AHRQ
♦ Organizational Context & New Clinical Practice
Adoption
Louise Parker, M.A., Ph.D.; Jacqueline Fickel, Ph.D.;
Elizabeth Yano, Ph.D.; Carol Simons, M.A.; Mona
Ritchie, M.S.W.; JoAnn Kirchner, M.D.
Presented by: Louise Parker, M.A., Ph.D., Independent
Consultant, Veterans Health Administration, 1 Warwick
Park, Unit 1, Cambridge, MA 02140, Phone: (617) 4974952, Email: parkerlouise@earthlink.net
Research Objective: There is substantial evidence that
achieving clinical practice change is often difficult.
Further, even when healthcare organizations do achieve
practice changes, they often fail to sustain them. Many
health service researchers have argued that a
healthcare organization’s characteristics likely affect the
ability of its providers to adopt new practices. Indeed,
researchers have identified a number of relevant
characteristics. We assessed the role organizational
context plays in fostering or hindering clinics’ adoption of
new practices.
Study Design: We conducted five qualitative case
studies to explore the unique mix of organizational
circumstances that may have affected the relative
penetration of a new practice. We collected both
qualitative (i.e., semi-structured interviews and
observation) and quantitative (i.e., surveys) data. We
conducted a content analysis of all data.
Population Studied: Five VA clinics involved in a
primary care quality improvement (QI) initiative, their
staff members (n=49) and patients (n=34), affiliated
medical center (n=12) and regional managers (n=7), and
QI program initiative staff (n=4) participated in the study.
Principal Findings: Four organizational factors that are
specific to a particular new practice are likely necessary
to achieve high penetration; these are the extent to
which the practice addresses an identified need,
absence of competing problems, sufficient resources to
adopt the practice, and the extent to which the practice
is not professionally threatening to affected services. In
addition, two practice-specific factors facilitate but may
not be necessary to adoption, active leadership support
and local championship. On the other hand, in
hierarchical organizations, leadership sanction, although
perhaps not active promotion, is likely essential. Further
two general characteristics of organizations, their ability
to resolve conflict constructively and their openness to
innovation, also facilitate but are not necessary to
adoption. Finally, there is substantial prior evidence that
local participation in the design and implementation of a
new practice facilitates its adoption. Interestingly, we
found that in the absence of such participation, a
generally participatory decision-making climate may
empower providers to reject a practice that they do not
believe represents an improvement over the status quo.
Thus, local participation in implementation efforts is likely
critical to new practice penetration.
Conclusions: We identified a number of intriguing
relationships between organizational factors and new
clinical practice penetration. Further, we clarified the
relative influence of these factors.
Implications for Policy, Delivery or Practice:
Perceived need for change, absence of competing
problems, resources, and the extent to which the
practice is not professionally threatening to affected
services will affect new practice adoption. Further, local
participation in implementation efforts is likely critical.
Funding Source(s): VA
♦ Involvement of Primary Care Physicians in
Inpatient Care & Risk of Hospital Readmission
Hoangmai Pham, M.D., M.P.H.; Ashish Jha, M.D.,
M.P.H.; Arnold Epstein, M.D.
Presented by: Hoangmai Pham, M.D., M.P.H., Senior
Health Researcher, Center for Studying Health System
Change, 600 Maryland Avenue, SW, Suite 550,
Washington, DC 20024, Phone: (202) 554-7571, Email:
mpham@hschange.org
Research Objective: Growth in the use of hospitalists,
revenue pressures, and other market trends have
resulted in primary care physicians (PCP) having
diminishing contact with inpatient care. Observers worry
that this “divorce” between inpatient and ambulatory
providers may make coordination during care transitions
more difficult. We assessed the association between the
degree of exposure that a PCP has to inpatient care and
the likelihood of readmission for their hospitalized
Medicare patients.
Study Design: We analyzed Medicare claims for 16,841
beneficiaries 65 years or older treated by one of 1,781
primary care physicians between 2004 and 2006. We
characterized each PCP’s exposure to inpatient care as
the percentage of their hospitalized patients in the prior
year for whom they billed an encounter during the
hospital admission. Alternatively, we considered whether
the PCP billed for an encounter with a patient during the
index hospitalization. We focused on beneficiaries
hospitalized with any of 60 most common medical
diagnosis related groups (DRGs) and calculated the
number of unique physicians, non-physician providers,
and practice organizations that billed for encounters with
each beneficiary during the hospitalization. We used
logistic regression models to examine the association
between a PCP’s exposure to inpatient care and the
likelihood of readmission within 30 days and, separately,
within 31-90 days, adjusting for patient characteristics
and comorbidities, the number of encounters with the
PCP in the prior year, and hospital, physician, practice,
and market characteristics.
Population Studied: Elderly beneficiaries treated a
primary care physician who responded to the nationally
representative 2004-2005 Community Tracking Study
Physician Survey
Principal Findings: Hospitalized patients were cared for
by providers from a mean of 4 different practice
organizations including a mean of 4 different physicians.
In 2004, PCPs billed for an inpatient encounter with an
average of 57% of their hospitalized patients, although
this rate varied widely across health care markets. 9.7%
of patients were readmitted within 30 days and an
additional 11.2% between 31-90 days. In adjusted
analyses, a PCP’s exposure to inpatient care in the prior
year was not associated with risk of readmission either
within 30 days or between 31-90 days. Results were
similar when we focused on whether the PCP cared for a
patient during the index hospitalization.
Conclusions: Despite the contribution of many
providers to the care of hospitalized Medicare patients,
the lack of involvement by the patient’s primary care
physician and the level of that physician’s exposure to
inpatient care did not increase risk of hospital
readmission.
Implications for Policy, Delivery or Practice:
Policymakers and health care organizations can be
reassured that market trends segregating inpatient and
ambulatory care providers do not appear to have
worsened readmission risk as one indicator of the quality
of care transitions. Further analysis may reveal if
individual providers and communities have developed
strategies to mitigate the potential adverse effects, such
as through greater use of care managers or improved
communication between inpatient and ambulatory
providers.
Funding Source(s): RWJF
♦ Patient-Centered Medical Home Functionality
among Michigan Providers
Christopher Wise, Ph.D., M.H.A.; Jeffrey Alexander,
Ph.D.; David Share, M.D.; Margaret Mason; Lingling
Zhang; Jean Malouin, M.D.
Presented by: Christopher Wise, Ph.D., M.H.A.,
Director, Program Development & Outreach, Faculty
Group Practice, Universtiy of Michigan Health System,
2500 Green Road, Suite 700, Ann Arbor, MI 481051500, Phone: (734) 936-0770, Email:
cwise@umich.edu
Research Objective: Assess current level of PatientCentered Medical Home (PCMH) functionality physician
practices in Michigan. The PCMH has been endorsed
by leading medical associations and healthcare experts
as critical infrastructure to address deficiencies in
healthcare cost and quality. However, little is known
about current levels of PCMH functionality among
healthcare providers.
Study Design: In 2008, nearly 2,300 physician practices
in Michigan completed a self-assessment questionnaire
reflecting the extent to which they have the infrastructure
and processes in place to function as a PCMH. The
assessment tool includes seven PCMH domains of
functions: 1) clinic implements patient-provider
agreement or other documented patient communication
process; 2) all-payer patient chronic disease registry
containing patient demographics and key clinical
parameters is in place; 3) key indicators established for
major chronic conditions; 4) individual care management
provided through multi-disciplinary provider teams, with
systematic approach to deliver comprehensive care, 5)
patients have 24-hour access to clinical decision-maker
by phone, and clinical decision-maker has feedback loop
to clinic, 6) policy in place requiring tracking and followup for test results, with identified timeframes for notifying
patients of results, and 7) uses electronic prescribing
system with link to electronic medical record or
pharmacy management hub.
Population Studied: Primary care physician practices
participating in Blue Cross / Blue Shield of Michigan’s
‘Physician Group Incentive Program’ (PGIP). PGIP is a
statewide initiative providing $50M annually to help
physician offices implement the infrastructure and
processes necessary to provide care in manner
consistent with the PCMH. As of May 2008, PGIP
included 35 physician organizations throughout
Michigan, representing 6,415 physicians. These
participating physicians represent approximately 64
percent of active primary care physicians and 15 percent
of specialty physicians in the PPO network, providing
care for 1.7 million members.
Principal Findings: The findings provide a topography
of PCMH functionality among PGIP participants for each
domain of function, correlated with additional
organization descriptors including physician size, degree
of specialization, ownership type and geographic
location. A methodology for scoring PCMH functionality
has been developed and applied to the self-assessment
data. Results demonstrate large variation in PCMH
functionality among provider sites and organizations,
with many practices not yet achieving basic PCMH
functionality. For example, 1% of practices have a
patient/provider agreement; 6% utilize a registry; 5%
report evidence-based indicators; 5% use individual care
management; 8% offer extended access; 2% have
policies for test tracking, and approximately 5% make
some use of electronic prescribing.
Conclusions: More work is required for Michigan
providers to reliably provide care to patients in a manner
consistent with the concepts inherent in the PCMH
model.
Implications for Policy, Delivery or Practice:
Information derived from the robust self-assessment
data will help identify the current level of PCMH
functionality among provider sites. This will lead to a
better understanding of gaps that need to be addressed,
aid in aligning implementation efforts, and help establish
realistic goals and expectations for policies and
programs, including pay for performance programs,
designed to encourage or support PCMH-based
practice.
Funding Source(s): Center for Healthcare Research &
Transformation, a University of Michigan / BCBSM joint
venture to test ideas for improving healthcare delivery,
financing, population health, and access. (see:
http://www.chrt.org/ )
Health Care Management & Performance Incentives
Chair: Sara Singer
Tuesday, June 30 * 8:00 a.m.-9:30 a.m.
♦ How Much Does Management Matter? Explaining
Variance in the Financial Health of America's Safety
Net Hospitals
Jonathan Clark, M.S.; Sara Singer, Ph.D.; Nancy Kane,
D.B.A.
Presented by: Jonathan Clark, M.S., Ph.D. Candidate,
Harvard University, Soldiers Field Road, Boston, MA
02163, Phone: (617) 402-0688, Email: jclark@hbs.edu
Research Objective: What is the relative impact of
external versus internal factors on the financial
performance of America’s safety net hospitals? For
decades the strategic management and industrial
economics literatures have debated a similar question
with respect to corporate performance. Empirical
evidence suggests that while industry and macroeconomic (external) factors matter, business specific
(internal) factors dominate. Hospitals are subject to
many non-market external forces, such as heavy
government regulation, administered pricing, and limited
obligations to serve the community regardless of ability
to pay. The financial performance of safety net
hospitals, by virtue of their more open-ended obligations
to serve vulnerable populations, may be particularly
driven by these external factors. Accordingly, one might
ask if the corporate strategy literature’s empirical
findings in favor of internal, organizational factors are
applicable to these organizations. In this paper we aim to
describe the relative importance of macro-economic,
state, market and organization level factors in explaining
the variance in hospital financial performance.
Study Design: Our analysis was conducted in two
phases. First we defined a set of safety net hospitals
using longitudinal methods and incorporating multiple
measures of a hospital’s safety net burden (including
Medicaid and charity care) relative to market averages.
Second, we followed the methodology of McGahan &
Porter (2002), and employed simultaneous ANOVA
methods to quantify the incremental explanatory power
of various hierarchical factors on measures of hospital
financial performance including operating performance,
liquidity, capital structure and a composite measure of
financial health. We examined our model, which includes
macro-economic (year), state, market and hospital fixed
effects, using panel data from two sources covering the
years 2002 through 2007: (1) audited financial data from
states that collect it and (2) the AHA annual survey of
hospitals.
Population Studied: 610 U.S., non-rural, general acute
care, safety net hospitals.
Principal Findings: Initial results suggested that
hospital fixed effects explained more of the variance in
hospital financial performance than factors that are
external to the organization, such as year, state, or
market fixed effects. Though true for all measures of
financial performance, including operating performance,
these results were particularly strong with respect to
liquidity, capital structure, and a composite measure of
financial health.
Conclusions: These findings extend the results
reported in the strategic management literature to safety
net hospitals. They suggest that though macro-economic
and market level factors are important, organization level
factors, which may include hospital characteristics,
structures and processes, matter more to their
performance.
Implications for Policy, Delivery or Practice: These
results suggest that strengthening the hospital safety net
is as much—if not more so—about organization and
management as it is about policy and market change.
Though the regulatory and market environments play an
important role, any claims that these external factors
prevent safety net hospitals from achieving financial
success may overstate empirical evidence. For the
leaders of safety net hospitals, these results suggest that
managerial levers are available to assist them as they
aim to improve the financial strength and performance of
their facilities.
Funding Source(s): CWF
♦ Quality-Based Payment for Medical Groups &
Individual Physicians
James Robinson, Ph.D.; Sara Fernandes-Taylor, B.A.;
Stephen Shortell, Ph.D.; Diane Rittenhouse, M.D.; Sara
Fernandes-Taylor, B.A.; Robin Gillies, Ph.D.; Lawrence
Casalino, M.D., Ph.D.
Presented by: Sara Fernandes-Taylor, B.A., Doctoral
Candidate, Health Policy & Management, University of
California Berkeley, 247C University Hall, University of
California, Berkeley, CA 94720-7360, Phone: (310) 9636258, Email: sft@berkeley.edu
Research Objective: The purpose of the study is to
measure the extent to which medical groups face
external pay-for-performance incentives based on quality
and patient satisfaction and the extent to which these
groups pay their primary care and specialist physicians
using similar criteria.
Study Design: Principal outcome variables include the
prevalence of pay-for-performance bonuses (quality and
patient satisfaction) received by medical groups and the
extent to which medical groups pay their individual
primary care and specialist physicians based on similar
criteria. Multivariate statistical methods were used to
examine the association between medical group and
individual physician payment methods, adjusting for
medical group size, ownership, and other characteristics.
Population Studied: The data are from a national
survey of medical groups in the United States with 20 or
more physicians, conducted between March 2006 and
March 2007 with adjusted response rate 58.7%.
Principal Findings: Over half (52%) of large medical
groups received bonus payments from health insurance
plans in 2006-07 based on measures of quality and
patient satisfaction. Medical groups facing external payfor-performance incentives are more likely to pay their
primary care physicians (OR 4.5, p<.001) and specialists
(OR 2.5, p=.07) based on quality and satisfaction.
Groups facing capitation payment incentives to control
costs are more likely to pay member physicians on
salary and less likely to pay based on productivity
(p<.001 for primary care; p<.05 for specialists) than
groups paid by insurers on a fee-for-service basis.
Groups with more Medicaid patients are more likely to
pay member physicians on salary and less likely to pay
based on productivity (p<.001), but not more likely to pay
based on quality or satisfaction than groups with more
Medicare and commercially insured patients.
Conclusions: Medical groups are increasingly paid
partly based on quality and patient satisfaction, and they
seek to align incentives with their member physicians by
paying them in a similar fashion.
Implications for Policy, Delivery or Practice: The
findings reported support the adoption of pay-forperformance programs by public insurers because
physicians develop analogous programs for themselves
when the medical group itself, rather than merely the
health insurer, allocates compensation across
productivity, quality, and other dimensions of physician
activity.
Funding Source(s): RWJF, The California Healthcare
Foundation; The Commonwealth Fund
♦ High-Performance Work Practices in Healthcare
Management: An Evidence-Based Review &
Synthesis
Andrew Garman, P.D., M.S.; Ann Scheck McAlearney,
Sc.D., M.S.; Paula Song, Ph.D.; Michael Iharrison,
Ph.D.; Megan McHugh, Ph.D.; Dina Moss, Ph.D.
Presented by: Ann Scheck McAlearney, Sc.D., M.S.,
Associate Professor, Health Services Management &
Policy, Ohio State University, 1841 Neil Avenue, Cunz
Hall 476, Columbus, OH 43210, Phone: (614) 292-0662,
Email: mcalearney.1@osu.edu
Research Objective: To review relevant research from
peer-reviewed and other industry-relevant sources to
develop an evidence-informed model of highperformance work practice (HPWP) use in healthcare
settings, including contexts likely to affect HPWP
adoption and impact, mechanisms by which HPWPs
have their effects, and potential HPWP impact on
quality, safety, and efficiency.
Study Design: We conducted a comprehensive
literature scan late in 2008. Following the scan and
synthesis, we developed a logic model. We
subsequently vetted this model with an advisory panel of
industry and academic experts. Panelists were asked to
react to the identified practices and bundles in terms of
their practicality for healthcare settings and to prioritize
the bundles’ potential for affecting quality, safety, and/or
efficiency.
Population Studied: We searched online databases,
and then searched the online archives of industry trade
groups in either healthcare management or human
resource (HR) management. Outreach to researchers
in these fields produced additional unpublished works.
We initially identified 114 relevant articles, white papers,
and manuscripts.
Principal Findings: We identified six exogenous factors
relevant to healthcare that may influence the adoption of
HPWPs: senior leadership support, HR involvement with
strategic planning, capabilities of the implementers,
network affiliations, organizational financial condition,
and union density. We found three major exogenous
factors that apparently influence HPWP impact and
sustainability: continued leadership support, financial
condition, and quality of local labor market. We then
characterized four HPWP subsystems (HPWS) of direct
relevance to healthcare: 1) organizational engagement
(including information sharing, performance-contingent
compensation, conveying mission and vision, and
employee involvement in decision-making); 2) staff
acquisition/development (including rigorous recruiting,
selective hiring, extensive training, and career
development); 3) frontline control/freedom to challenge
(including employment security, reduced status
distinctions, and use of teams/ decentralized decisionmaking); and 4) leadership alignment/development
(including management training linked to organizational
needs, succession planning, and performancecontingent leadership compensation practices). We
found evidence supporting the prospect of links between
HPWSs and both employee outcomes (e.g., turnover,
higher satisfaction/ engagement, lower burnout, and
higher general well-being) and care system and
organization-level outcomes (e.g., fewer “never events”,
lower malpractice costs, innovation adoption, lower
agency costs, and lower turnover costs).
Conclusions: Through our review process, we identified
a substantial number of studies whose contextual
features appeared relevant to healthcare settings, as
well several mechanisms through which HPWPs may
improve healthcare operations. Health services
researchers studying these practices should strive to
understand how additional practices support, enhance,
or detract from the practice that may be their focal
interest in a given study.
Implications for Policy, Delivery or Practice: Use of
HPWPs and their development within healthcare settings
should be pursued as a source of additional
performance improvement.
Funding Source(s): AHRQ
♦ Organizational Responses to Pay for Performance
in Primary Care in England & California: A
Comparative Study
Ruth McDonald, Ph.D.
Presented by: Ruth McDonald, Ph.D., Senior Research
Fellow, National Primary Care R&D Centre, University of
Manchester, NPCRDC, Williamson Building, Oxford
Road, Manchester, M13 9PL, UK, Phone: +44 161 275
3535, Email: ruth.mcdonald@manchester.ac.uk
Research Objective: To compare organizational
responses and their consequences, to large scale Pay
for Performance (P4P) schemes in England and
California.
Study Design: Mixed (qualitative and quantitative)
methods comparing organizational responses and
performance.
Population Studied: Physician organizations physician offices and the medical groups to which they
are affiliated in California and ‘practices’, organizations
of typically 1 to 6 doctors and their staff in England.
Principal Findings: Although the English P4P initiative
had a far greater number of targets there was much less
variability in target performance within this group and
physicians were much more aware of the content of
targets, compared with California. Higher levels of
performance in England were associated with the
introduction of information technology at the physician
office level, which enabled the maintenance of disease
registers for call and recall of patients and heightened
awareness of target measures by displaying
computerized prompts during office visits. In England,
performance measurement was based on the physician
office organization (or practice) and performance was
measured using data extracted directly from the
electronic records of these organizations. This appeared
to contribute to data ownership and buy-in from
participating doctors and their staff. In California,
affiliation to medical groups reduced the data collection
burden on physician offices. Assessment largely relied
on data collected by bodies outside of the practice (e.g.
lab results, pharmacy data) with data submitted by the
health plan or medical group as opposed to the
individual practice/physician office. This may contribute
to feelings of resentment and lack of ownership reported
by some Californian doctors, who in many cases,
reported being unaware of the content of targets or the
relationship between their activities and performance
bonuses. These doctors reported disputing data
submitted by their medical group on their behalf.
Whereas scores for each performance indicator for
every physician organization or ‘practice’ in England are
publicly available on the web, in California physicians
were wary of public reporting of performance data due to
concerns about data reliability. English physicians
reported concerns that computerized prompts and the
high data collection requirements during office visits,
which led to organizational effectiveness with regard to
performance measures, reduced eye contact between
doctors and patients and threatened to crowd out the
patient’s agenda.
Conclusions: In primary care settings, much of the
focus of P4P research has been on individual behaviour.
However, it is important to go beyond examination of
individual responses to assess the extent to which and
the ways in which the organizational setting provides the
capacity to respond to incentives, promotes ownership of
data and leads to unintended and undesirable
consequences.
Implications for Policy, Delivery or Practice: In
formulating responses to incentive schemes in primary
medical care organisational settings, attention needs to
be paid to factors likely to produce both desirable
outcomes and unintended consequences such as a
crowding out of the patient agenda during office visits
and an adverse impact on physician motivation.
However, consideration also needs to be given to the
diverse aims of P4P programs and the balance to be
struck between these different aims.
Funding Source(s): CWF
♦ The Reliability of Profiling Medical Group
Performance on Clinical Quality Measures
Hector Rodriguez, Ph.D., M.P.H.; Douglas Conrad,
Ph.D.; Lisa Perry, B.S; Charles Maynard, Ph.D.; Diane
Martin, Ph.D.; David Grembowski, Ph.D.
Presented by: Hector Rodriguez, Ph.D., M.P.H.,
Assistant Professor, Department of Health Services,
University of Washington, School of Public Health, Box
357660, 1959 Northeast Pacific Street, Seattle, WA
98102, Phone: (206) 685-4460, Email:
hrod@u.washington.edu
Research Objective: Medical groups are increasingly
being asked by payers to make clinical quality
information available to the public and to adopt financial
incentives for improving quality performance. Previous
research underscores that reliable individual physician
performance measurement on clinical quality measures
requires patient sample sizes that often exceed those
available in a physician’s panel. Consequently, medical
groups are considered the most appropriate targets for
inducing clinical quality improvements. Little research,
however, has assessed the group-level reliability of
widely-used ambulatory care quality measures. In order
to inform reliable measurement of groups’ clinical
performance, this study examines the sample sizes
required to achieve sufficiently precise estimates of
group performance.
Study Design: The ten clinical quality measures were
analyzed for this study, nine of which are HEDIS
measures. The measures included evidence-based
treatment of asthma, coronary artery disease (CAD),
diabetes, bronchitis, otitis media, and screening for
breast cancer and cervical cancer, and recommended
well child visits. The percentage of variability attributable
to group effects was examined using the intraclass
correlation coefficient (ICC). The Spearman-Brown
Prophecy formula was used to calculate the sample
sizes required to achieve group-level reliability of 0.70
and 0.80- common standards for reliability. We
examined the consistency of sample size projections
when using Bayesian hierarchical modeling (HM) to
quantify variations in the performance indicators across
groups that were attributable to the groups.
Population Studied: This study employs 7 years (20012007) of clinical quality performance data from all
patients qualifying for each measure for 20 medical
groups in Washington State, totaling 197,905 personyears. The average annual number of patients per
medical group was 2726 (SD=1602).
Principal Findings: Small patient sample sizes (<200
per medical group) were required to obtain reliable
estimates of annual medical group performance for the
bronchitis, otitis media, breast cancer screening, diabetic
hypercholesterolemia screening, and well child care
measures. Moderate patient samples (200-600 per
medical group) were required for reliable annual medical
group-level measurement of diabetic HbA1c screening,
angiotensin coverting enzyme inhibitors (ACE inhibitors)
or angiotensin receptor blockers (ARB) for hypertensive
diabetics, and cervical cancer screening. The asthma
medication use and CAD hypercholesterolemia
screening measures, however, required more than 600
patients per medical group, exceeding the annual
eligible patient samples for most groups. Large sample
size requirements for the asthma and CAD measures
stemmed from low proportions of performance variation
attributable to medical groups (ICC<0.004).
Conclusions: Most clinical quality measures studied
achieve adequate medical group-level reliability with
small to moderate patient samples. Results indicate that
patient sample size requirements for most of the clinical
quality measures are small enough to permit reliable
performance measurement and medical group profiling
by individual insurers with sufficient market share. In
contrast, this may not hold true for the asthma and CAD
measures.
Implications for Policy, Delivery or Practice: Because
medical groups account for a substantial proportion of
performance variation for widely-used clinical quality
measures, groups are appropriate targets for
performance measurement and improvement. It will be
important, however, to assess the allocation of
explainable variance across a range of organizational
units, i.e., physicians, practice sites, and medical groups,
to most effectively target quality improvement
interventions.
Funding Source(s): RWJF
Implementing QI in Hospitals: The Role of Safety
Climate & Culture
Chair: Rachel Werner
Tuesday, June 30 * 9:45 a.m.-11:15 a.m.
♦ Relationship of Hospital Organizational Culture to
Patient Safety Climate in the VA
Christine Hartmann, Ph.D.; Mark Meterko, Ph.D.; Amy
Rosen, Ph.D.; Shibei Zhao, M.P.H.; Sara Singer, Ph.D.;
David Gaba, M.D.
Presented by: Christine Hartmann, Ph.D., Research
Health Scientist, Center for Health Quality Outcomes &
Economic Research, Bedford, Massachusetts VA
Medical Center, 200 Springs Road, Bedford, MA 01730,
Phone: (781) 687-2738, Email: cwhrtmnn@bu.edu
Research Objective: The overarching organizational
culture of a healthcare facility may influence safety and
outcomes. Unlike other hospital characteristics (e.g.,
location or size) organizational culture is potentially
mutable and can change over time, thereby offering
opportunities for intervention. We assessed whether
safety climate at the hospital level is affected by
characteristics of hospitals’ organizational culture. The
VA is an important context in which to study this
relationship as results found in this study may be
potentially generalizable to other large, integrated
healthcare systems.
Study Design: Anonymous data were collected using
the Patient Safety Climate in Healthcare Organizations
(PSCHO) and the Zammuto and Krakower (Z&K)
surveys to measure safety climate and organizational
culture, respectively. The Z&K survey measures four
domains of organizational culture (group,
entrepreneurial, hierarchical, and rational) based on a
competing values framework. Combined weights
accounting for sample size, hospital size, and nonresponse were used in all analyses. The primary
outcome variable was computed by calculating the mean
percent problematic response across all PSCHO survey
items for each individual. We used two-level hierarchical
linear model (HLM) analyses to account for the effect of
clustering of respondents by hospital on variation in
perceptions of safety climate.
Population Studied: Data were collected in a stratified
random sample of 30 acute-care VA hospitals over a sixmonth period (response rate = 50%; n=4,625). At each
hospital we sampled 100% of senior managers and
physicians and a random 10% of other employees.
Principal Findings: Higher levels of group culture
(p<.001) and entrepreneurial culture (p<.001) were both
associated with higher levels of safety climate.
Hierarchical culture, however, had an inverse effect on
safety climate (p < 0.001).
Conclusions: We found a number of strong and
consistent associations between organizational culture
and safety climate. Group culture was positively
associated with safety climate, possibly because a
strong group culture may foster the psychological safety
necessary to bring safety problems into the open.
Likewise, higher levels of entrepreneurial culture were
also associated with higher levels of safety climate; a
strong entrepreneurial culture may empower local
initiative and promote the group learning and problem
solving needed to take effective, system-focused action
to understand and correct the causes of problems. By
contrast, higher levels of hierarchical culture were
associated with lower levels of safety climate, possibly
because a strong emphasis on adherence to standard
operating procedures, combined with a deference to
rank, may create an environment in which workers are
reluctant to raise safety issues.
Implications for Policy, Delivery or Practice:
Hospitals whose dominant organizational culture is
strongly hierarchical and bureaucratic may wish to
devote greater attention to modifying their organizational
culture in directions more likely to promote and sustain a
higher level of safety climate, including the promotion of
teamwork and empowering front-line groups to take the
initiative in solving problems. These changes may help
inform the design and implementation of future efforts to
mitigate patient safety hazards both in the VA and in
other large integrated hospital networks.
Funding Source(s): VA
♦ Transformational Change in Health Care:
Validation of a Model
Barbara Lerner, M.S.; Alexis Maule, M.P.H.; Carol
VanDeusen Lukas, Ed.D.; Michael Shwartz, Ph.D.; Irene
Cramer, Ph.D., M.S.S.A.; Martin Charns, D.B.A.
Presented by: Barbara Lerner, M.S., Project Manager,
Health Policy & Management, Boston University School
of Public Health, 9 Minola Road, Lexington, MA 02421,
Phone: (781) 771-8892, Email: lerner@bu.edu
Research Objective: Hospitals often struggle with the
process of patient care quality improvement (PCQI),
making investments in time and infrastructure that often
fall short of expectations. The purpose of this study was
to validate a model for moving organizations from shortterm, isolated performance improvements to sustained,
reliable, organization-wide, and evidence-based PCQI.
The transformational change model, previously
described by VanDeusen Lukas et al in Health Care
Management Review (2007), highlights five key drivers
and four system components critical to organizations
working to attain transformational change in the quality
of patient care. Our hypothesis was that high performing
hospitals embody the elements of the model more
deeply than lower performing hospitals.
Study Design: We performed a qualitative study in ten
US hospitals selected to represent differences in quality
based on 2003 CMS measures. Performance was
determined by calculating the observed/expected ratio
for AMI, CHF and pneumonia in all CMS sites. Sites
were sorted by hospital size (medium: 100-399 beds,
large: >399 beds) and performance quintiles. We
conducted telephone interviews with staff at each site
about specific behaviors, attitudes, and activities in
relation to PCQI. The questions addressed each model
element so that adherence to the elements could be
assessed. Two analysts independently coded each
interview for the model elements and then rated each
site using the evidence obtained. Ratings were
consistent between the analysts, within one point in all
but a few cases. Final analysis incorporated the sites’
2007 Hospital Compare data to align the sites’
performances to the point in time in which the interviews
were conducted. This accounted for changes in the sites’
quality since 2003.
Population Studied: Ten sites (six high performers from
the 1st quartile and four medium performers from the 3rd
quartile) were randomly selected. Ten to fifteen
employees were interviewed at each site. A total of 118
interviews were conducted with three - four senior
leaders, including the CEO/President and CQO, three
middle managers, two frontline providers and two - three
individuals directly involved in improvement initiatives.
Principal Findings: High performers have been actively
involved in PCQI longer than medium performers and
overall showed greater adherence to the model. The six
high CMS performers also had the high mean scores on
adherence to the model (range of 22.0-16.5 out of a
possible 30) while three of the four medium performers
scored lowest in adherence to the model (15.7-15.4 out
of 30). Only one of the ten sites did not conform to our
hypothesis; a medium performer scored 18.4.
Conclusions: The concordance between the sites’
embodiment of the model elements and their CMS
quality measures provides evidence for the validity of the
transformational change model.
Implications for Policy, Delivery or Practice: This
model can be helpful by providing both hospital
leadership and providers an understanding and roadmap
of the organizational elements necessary for PCQI. In
addition, this model serves as a theoretical framework
for future research into the transformational change
process in healthcare.
Funding Source(s): RWJF
♦ Experiences of Interdisciplinary Quality
Improvement Teams in Hospitals with Lower Doorto-Balloon Times for Patients with ST Elevation
Myocardial Infarction
Calie Santana, M.D., M.H.S.; Ingrid Nembhard, Ph.D.;
David Berg, Ph.D.; Leslie Curry, M.P.H., Ph.D.;
Elizabeth Bradley, Ph.D.
Presented by: Calie Santana, M.D., M.H.S., Associate
Director of Quality, Medicine, Montefiore Medical Center,
111 East 210th, Bronx, NY 10467, Phone: (718) 9443861, Email: csantanamd@yahoo.com
Research Objective: Interdisciplinary teams or teambased approaches have been identified as key
components of successful quality improvement (QI)
efforts. Many hospitals are currently employing
interdisciplinary teams to reduce the door-to-balloon
(D2B) times for patients with ST elevation myocardial
infarctions (STEMI) to 90 minutes or less, as
recommended by evidence-based guidelines. Little is
known about the strategies, behaviors and social norms
of QI teams in hospitals with the greatest improvements
in D2B times. The experiences of these teams will help
QI leaders develop effective team-based approaches to
implement evidence-based QI efforts in their settings.
Study Design: We conducted a qualitative study using
in-depth interviews with 122 participants in 11 hospitals.
Participants were asked what their hospital had done to
reduce D2B times. Transcripts were analyzed using the
constant comparative method. The research team
identified similarities and differences in the data and
prepared code structures of salient concepts. Atlas.ti
software was used to facilitate the analysis. We report
here on the concepts that describe D2B QI teams.
Population Studied: Study hospitals had median D2B
times of 90 minutes or less and showed the most
improvement in D2B times from 2001-2003 among all
hospitals in a national STEMI database. Interview
participants included administrators, physicians, nurses,
staff, and QI team members, with first-hand knowledge
of D2B QI efforts.
Principal Findings: QI teams demonstrated distinct
strategies and behaviors for achieving both their
fundamental goal of lowering D2B times and their
instrumental goals (the operational processes or
protocols used to achieve the larger D2B goal, e.g. cath
lab activation). Key fundamental goal strategies and
behaviors included: (1) expecting participation from all
providers and staff, (2) expecting 100% success, (3)
selecting interdisciplinary team members and not
allowing disagreements within the team to derail the
fundamental goal, (4) highlighting outside models of
success, (5) emphasizing departmental rather than
individual gains, and (6) including non-early adopters in
their meetings. Key strategies/behaviors utilized for
instrumental D2B goals included: (1) allowing
departments to redesign their own processes, (2)
discouraging individual adaptations of the D2B protocol,
(3) highlighting the benefits of collaboration between
clinical departments (patient benefit, a more efficient
process, no additional management responsibilities for
departments), and (4) avoiding adjudicating blame for
D2B delays. Social norms of these QI teams included:
(1) allowing participants to express their opinions about
other clinical disciplines as sources of D2B delays during
the initial stages of the process, (2) protecting the
integrity of the instrumental goals by judging any
proposed change against the ultimate criteria of 90
minutes, (3) recognizing the front-line staff for their part
in the D2B success.
Conclusions: We found that successful teams
emphasized strategies both for the fundamental goal of
achieving D2B times below 90 minutes but also
employed strategies for the operational or instrumental
smaller goals that allowed hospitals to lower D2B times.
Effective teams concentrated on encouraging
widespread participation and interdisciplinary
collaboration while simultaneously defending the
integrity of the D2B protocol.
Implications for Policy, Delivery or Practice: The
strategies, behaviors and social norms of successful
teams can teach other hospitals how to organize
effective team-based QI efforts to bring evidence-based
interventions to their environment.
Funding Source(s): RWJF
♦ Safety Climate in Naval Aviation & Hospitals:
Implications for Patient Safety Reform
Sara Singer, M.B.A., Ph.D.; Amy Rosen, Ph.D.; Shibei
Zhao, M.P.H.; Anthony Ciavarelli, Ph.D.; David Gaba,
M.D.
Presented by: Sara Singer, M.B.A., Ph.D., Assistant
Professor, Health Policy & Management, Harvard School
of Public Health, 677 Huntington Avenue, Boston, MA
02458, Phone: (617) 432-7139, Email:
ssinger@hsph.harvard.edu
Research Objective: Evidence of variation in safety
climate suggests the need for improvement among some
hospitals. However, comparisons only among hospitals
may underestimate the degree of improvement required.
Critical examination of hospitals in comparison to
analogous industries may provide a broader perspective
on the status of safety climate in our nation’s hospitals.
Safety experts regard organizations that operate reliably
despite intrinsically hazardous conditions as worthy of
comparison. Naval aviation is acknowledged to be one
such high reliability organization (HRO). This paper
compares safety-climate survey results among hospital
personnel with those of naval aviation personnel. We
hypothesized that despite efforts within healthcare in the
last decade to improve safety culture, measures of
safety climate would be worse among healthcare
workers than among naval aviators. However, we
expected that perceptions of hospital personnel working
in more intrinsically hazardous areas would be more
similar to those of aviators than other hospital workers.
Study Design: In a large-scale, nationwide,
observational study, we surveyed healthcare workers in
67 US hospitals and 30 VA hospitals using questions
designed to be highly similar to those posed at
approximately the same time (c. 2007) to 35 squadrons
of US naval aviators. Safety climate measures for
hospital personnel were derived from the Patient Safety
Climate in Healthcare Organizations survey and for
naval aviation from the Command Safety Assessment.
Survey results provide a measure of each respondent’s
perception of the level of safety climate at their institution
overall and for 16 individual items. Differences in
perceptions are examined using t-tests.
Population Studied: In US and VA hospitals, we
sampled 100% of senior managers, 100% of physicians,
and a random 10% sample of all other workers, with
selected over-sampling. In naval aviation, we conducted
a 100% sample of non-deployed personnel. We
received 13,841 completed surveys (41% response) in
US hospitals, 5,511 (50% response) in VA hospitals, and
14854 (82% response) among naval aviators.
Principal Findings: On average safety climate was
three times better among naval aviators than hospital
personnel. Naval aviators perceived a significantly safer
climate (up to seven times safer) than both US and VA
hospital personnel with respect to each of the 16 survey
items. However, aviation managers more often than
hospital managers felt resources were not adequate.
When compared to hospital personnel working in
comparably hazardous areas, safety-climate
discrepancies increased rather than decreased. While
no individual hospital performed as well as navy aviators
on average, with respect to all but three survey items,
safety climate among hospital personnel was equal to or
better than the naval aviation benchmark in at least one
hospital.
Conclusions: Despite concerns about resources, naval
aviation is able to achieve uniform safety climate.
Results confirm our hypothesis that hospitals have not
sufficiently created a uniform priority of safety. However,
if each hospital performed as well as the top-performing
hospital in each area, hospitals could become HROs.
Implications for Policy, Delivery or Practice:
Interventions to bolster the safety climate in hospitals are
needed to achieve a safety climate equivalent to that of
a recognized HRO.
Funding Source(s): AHRQ, VA HSR&D
♦ From Research to Practice: Facilitators & Barriers
in Implementing Two Patient Safety Innovations at
Six Healthcare Delivery Systems
Asta Sorensen, M.A.; H. L. Kane, Ph.D.; A.E. Roussel,
Ph.D.; Halpern, M.T., M.D., Ph.D.; S.L. Bernard, R.N.,
Ph.D.; M.I. Harrison, Ph.D.
Presented by: Asta Sorensen, M.A., Health Research
Analyst, Division for Health Services & Social Policy
Research, RTI International, 3040 Cornwallis Road,
Research Triangle Park, NC 27709, Phone: (919) 5411238, Email: asorensen@rti.org
Research Objective: Using Greenhalgh’s (2004)
framework on diffusion of innovations in service
organizations, this study examines the implementation
process of two patient safety innovations. These used
Targeted Injury Detected Systems (TIDS) to
prospectively or concurrently identify risk for adverse
drug events and pressure ulcers among hospitalized
patients and facilitate risk amelioration. TIDS use
clinical algorithms or “triggers” to flag medical records of
patients who are at high risk for iatrogenic adverse
events and provide guidelines for investigating,
confirming and responding to such events.
Study Design: TIDS development and implementation
involved two phases. During the alpha phase, the
research team developed, tested, and refined the clinical
effectiveness of TIDS. During the beta phase, the team
tested the refined system and assessed the feasibility of
implementing TIDS in hospitals. Implementation
evaluation used qualitative data collection and analysis,
including self-administered questionnaires, interviews,
and observations.
Population Studied: Twelve hospitals in six health care
systems.
Principal Findings: Although system-level
administrators and research champions decided on
participation in TIDS implementation, implementation
success depended mainly on hospital-level factors.
These included ability to identify and engage
implementation champions; organizational needs and
capacities for improvement; time lags between decisionmaking and actual implementation; TIDS complexity and
alignment of the proposed TIDS with hospital information
systems and workflows. Engaging champions and
obtaining user input and early buy-in enabled multiple
individuals to share responsibility for implementation. In
contrast, when administrators delegated implementation
responsibilities to would-be “champions,” support for
implementation was limited. Implementation was also
facilitated when TIDS was well aligned with existing
organizational structures, information systems, and
processes. Assessing organizational needs, available
resources, staffing levels, and implementation timing
was equally important. Long lags between commitment
to implement and actual implementation resulted in loss
of momentum, especially for implementation champions
and staff. In the interim, organizational priorities and IT
infrastructures changed, making TIDS less important or
less appropriate to the organization. TIDS complexity
influenced implementation process, associated costs,
and requisite user expertise and comfort. A complex
TIDS involved steep learning curves, additional training,
less user comfort, greater user time burden, and more
substantial programming requirements. Simpler TIDS
built on existing organizational processes, roles, and skill
sets, required little programming, and could be
implemented manually or using existing IT.
Conclusions: Consistent with implementation of other
patient safety innovations, organizational factors shaped
initiation of the TIDS. Translation of research-based
patient safety innovations to practice requires careful
assessment of organizational goals, innovation needs,
and fit between innovation characteristics and
organizational features and capacities. Implementation
also requires identifying and engaging local champions
and stakeholders. Commitment to implement should
occur close to actual implementation. In addition,
soliciting user feedback during process change provides
opportunities for adapting innovations to local needs,
thus improving chances of successful implementation.
Implications for Policy, Delivery or Practice:
Understanding factors facilitating implementation of
research-based patient safety innovations to practice is
important for successful diffusion of patient safety and
quality improvement interventions and best practices.
Determining fit between an innovation and organizational
needs, goals, and capacities is a critical first step in
innovation implementation.
Funding Source(s): AHRQ
Regulation, Allocation & Efficiency in Public Health:
Estimating Policy Implementation & Impact
Chair: Timothy Van Wave
Monday, June 29 * 9:45 a.m.-11:15 a.m.
♦ Understanding Resource Allocation Decisions of
Public Health Officials in the U.S.
Nancy Baum, M.H.S.; Susan Goold, M.D., M.H.S.A.,
M.A.
Presented by: Nancy Baum, M.H.S., Doctoral
Candidate, Health Management & Policy, University of
Michigan School of Public Health, M3025 SPHII 109
Oberservatory, Ann Arbor, MI 48109, Phone: (734) 6455018, Email: nmbaum@umich.edu
Research Objective: Resource allocation decisions lie
at the core of public health system operations and
significantly affect the health of communities. Little
empirical research has characterized resource allocation
decisions confronted by local public health department
officials (LHOs). This study aimed to: 1) describe the
nature and scope of resource allocation decisions LHOs
confront; 2) identify the processes LHOs use when they
allocate resources; 3) assess the degree of discretion
officials report in allocating resources and the factors
that influence that discretion; and, 4) explore whether
discretion affects officials’ abilities to assure that their
communities’ public health needs are met.
Study Design: We surveyed LHOs from 100% of large
health departments (based on the size of the population
served) (n=121) and from randomly selected medium
(n=577) and small (n=629) departments. Survey items
asked: the extent to which LHOs make certain allocation
decisions (e.g., increase/decrease funding to particular
activities); the processes used to make such decisions
(e.g., frequency of use of decision tools); reported levels
of discretion in allocation (e.g., proportion of funds they
could reallocate); and whether community needs for
certain public health services are met (e.g., lead
screening).
Population Studied: Local public health officials in the
US.
Principal Findings: Analyses of responses collected to
date (current RR=24%) show that LHOs report they
allocate personnel time to a greater extent than they shift
funds among population groups or change funding levels
to various activities. Factors moderately or very
influential in allocation decisions include previous
allocations (94%), input from staff (94%), the
effectiveness of activities (93%) and whether the
department is the sole provider of an activity in a
community (87%). Results from decision tools, direct
public input and input from county councils were
reported as moderately/very influential by fewer than half
of respondents. Sixty-five percent of LHOs report “a
great deal” or “complete” discretion overall in allocation
decisions. They report the ability to reallocate, on
average, 31% of funds from all sources, and 48% of
personnel time and effort. LHOs who report that their
communities’ needs for certain services are met also
report having greater discretion over allocation of funds
and personnel time, than those who report that their
communities needs are not met. For example, those
reporting that the need for oral health care in their
communities is met have discretion over 40% of funds,
compared to 29% for those with unmet need (students ttest, p<.01).
Conclusions: LHOs have more flexibility to allocate
personnel time and effort than to shift funds among
populations/activities. Standards for effectiveness and
assuring access to services are important considerations
in allocation decisions. Administrative discretion to
make allocation decisions may play an important role in
LHOs’ abilities to meet public health needs in their
communities.
Implications for Policy, Delivery or Practice: LHOs’
ability to apply public health funds effectively to meet
community public health needs may be improved if
funders allow greater discretion over the allocation of
such funds. Encouraging public health personnel to
build mixed skill sets may also create new opportunities
for LHOs to effectuate the delivery of necessary public
health services.
Funding Source(s): RWJF
♦ Examining Local Board of Health Practices in
Financial Issues of Local Public Health Agencies
Marie Fallon, M.H.S.A.; Charles Moon, Ph.D.
Presented by: Peggy Honoré, US Department of Health
and Human Services
Research Objective: To quantify the level of authority,
oversight and engagement that local boards of health
have over the fiscal issues of local public health
agencies.
Study Design: A cross-sectional survey of a national
sample of chairs of local boards of health was done in
2008.
Population Studied: The population consisted of 870
chairs of local boards of health.
Principal Findings: The 2008 survey results revealed
that approximately 64% of local boards of health did not
have authority to request a tax levy for public health,
85% do not impose taxes, however, 73% do impose
fees. Nearly 59% of local boards did not have a separate
budget from the local public health agency. Sixty-eight
percent of the boards actually approve the local agency
budget while 71% recommend approval of the agency
budget. Thirty-four percent of the respondents indicated
that they had a need for training in fiscal responsibility.
Sixty-nine percent of respondents indicated that board
capacity to develop and implement policy remained the
same over the last 3 years.
Conclusions: While a majority of boards perceive a role
in agency budget oversight, a majority of local boards do
not have authority to levy taxes and do not impose taxes
to finance public health services.
Implications for Policy, Delivery or Practice: Boards
should use this information to examine and monitor the
sufficiency of their roles and practices for ensuring
financial sustainability of local public health agencies.
Funding Source(s): RWJ
♦ Assessing & Forecasting Population Health
Jeroen van Meijgaard, M.A.; Jonathan Fielding, M.D.
M.B.A. M.P.H.; Gerald Kominski, Ph.D.
Presented by: Jeroen van Meijgaard, M.A., Student,
Health Services, University of California, Los Angeles
School of Public Health, CHS 61-253 - Box 951772, Los
Angeles, CA 90095-1772, Phone: (310) 206-6236,
Email: jeroenvm@ucla.edu
Research Objective: This study aims to promote the
development and dissemination of a comprehensive
population health forecasting model with the potential to
interject new and valuable information about the future
health status of the population, based on current
conditions, socioeconomic and demographic trends, and
potential changes in policies and programs.
Study Design: We use a continuous time
microsimulation framework to simulate individuals’
lifetime histories, using events, including disease
incidence, to mark a change in the state of the individual.
The framework can accommodate long induction periods
common to chronic diseases, complex sets of factors
that are known to influence health outcomes, and
detailed information on the distributional effects within
subpopulations.
Population Studied: The California Health Forecasting
Model combines and parses a large amount of
information from disparate sources into a
microsimulation framework to reflect the population in
California up to several decades into the future, including
subpopulations representing gender and race/ethnic
strata.
Principal Findings: The California model includes
physical activity, obesity, coronary heart disease, allcause mortality and medical expenditures. All rates are
gender, age and race/ethnic specific. The model
generates a reference forecast of future health in
California, the case where no targeted action is taken.
The reference case is used to compare the future impact
of policies and programs. We are using this model to
answer specific research questions, support debate on
important policy issue in public health, support
community advocacy and provide analysis on the long
term impact of proposed analyses.
Conclusions: The development of this model is only the
first step in a larger effort to bridge the gap between
research and practice. An intuitive interface and a broad
communication, dissemination and training program on
the applicability of the results are necessary to support
full utilization of this forecasting model by public health
agencies, community organizations, and other
stakeholders. The model in its current form can be most
easily used by entities for which specific data is
available, usually states, counties, and large cities. For
smaller units such as communities and neighborhoods, a
web-based tool was developed that interpolates results
to those levels based on its key socio-demographic
characteristics, utilizing small area estimation. This tool
also allows users to view and graph the model results
and translate forecasts to local communities by inserting
local data further supporting broad utilization.
Implications for Policy, Delivery or Practice: Our
forecasting model supplies policy makers with
information that emphasizes a multi-generational
approach as a counterweight to short-term thinking to
support specific interventions, policies and programs that
can improve the health of the populations they
represent.
Funding Source(s): The California Endowment
♦ Immunization Requirements for School Entry in the
United States: Are School Policies in Compliance
with State Laws?
Tara Vogt, Ph.D., M.P.H.; Shannon Stokley, M.P.H.;
Nancy Brener, Ph.D.
Presented by: Tara Vogt, Ph.D., M.P.H.,
Epidemiologist, Immunization Services Division, Centers
for Disease Control & Prevention, 1600 Clifton Road
Northeast, MS E52, Atlanta, GA 30333, Phone: (404)
718-8568, Email: tcv3@cdc.gov
Research Objective: Many states require proof that
students have received certain vaccinations as a
condition for school entry. However, it is unknown to
what extent schools adopt policies that comply with
these laws. Our objectives were to estimate the
proportion of US elementary and middle schools with
policies that comply with state immunization
requirements for school entry and to identify
characteristics of schools that are in compliance.
Study Design: The CDC conducts the School Health
Policies and Programs Study (SHPPS) every six years,
most recently in 2006. This study provides a
comprehensive assessment of school health programs
and policies in the United States. Questionnaires are
administered to education agency officials from all 50
states and the District of Columbia, as well as nationally
representative samples of school districts and public and
private elementary, middle, and high schools.
Population Studied: We analyzed 2006 SHPPS data
from elementary and middle schools that completed the
survey module that included immunization–related
questions. Information was available on a subset of
vaccines recommended by the Advisory Committee on
Immunization Practices for school-aged children,
including vaccines against tetanus/diphtheria, hepatitis
B, measles/mumps/rubella, varicella, and, for elementary
schools only, polio. Weighted logistic regression
analyses examined associations between compliance,
which was defined as having a school policy consistent
with state law for a specific vaccine, and several school
characteristics, including urban/rural/suburban location,
percent of students qualifying for free lunches, percent of
racial/ethnic minority students, public versus private
school status, school size, and school nurse availability.
Principal Findings: The analysis included 355
elementary and 319 middle schools. Overall, 84.7% of
schools complied with all state-specific school entry
requirements for vaccines addressed in SHPPS (87.4%
and 79.7% of elementary and middle schools,
respectively). Among states with school entry
requirements, compliance was lowest for varicella
(90.0% and 86.1% in elementary and middle schools,
respectively) and highest (100%) for measles, polio, and
tetanus/diphtheria in elementary schools. In elementary
schools with state requirements, increased compliance
was associated with having >=50% versus 0% of
students qualified for free lunches [odds ratio (OR=2.6,
95% confidence interval (CI): 1.2-5.6], having >=25%
versus 0% of students being racial/ethnic minorities
(OR=2.9, 95% CI: 1.1-7.8), being a public versus private
school (OR=2.6, 95% CI: 1.3-4.9), and having a school
nurse available (OR=2.8, 95% CI: 1.1-7.5). Among
middle schools with state requirements, no statistically
significant associations were observed.
Conclusions: Although a majority of US elementary and
middle schools report policies in compliance with state
laws requiring immunization as a condition for school
entry, compliance varied by vaccine. For elementary
schools, being a public school, having access to a
school nurse, and having higher proportions of
economically disadvantaged students and students who
are racial/ethnic minorities, were associated with
increased compliance.
Implications for Policy, Delivery or Practice: State
legislation requiring immunization as a condition for
school entry has contributed to a drastic reduction in
morbidity and mortality from vaccine-preventable
illnesses. State immunization programs should work
with school districts to ensure that all schools are aware
of state immunization requirements and have
appropriate policies in place.
Funding Source(s): CDC
♦ Cost Effectiveness of Universal Predischarge
Serum Bilirubin Screening in the Birthing Hospital to
Reduce Kernicterus & Jaundice Related
Readmission
Bin Xie, Ph.D.; Greg Zaric, Ph.D; Orlando da Silva, M.D.
Presented by: Bin Xie, Ph.D., Assistant Professor,
Obstetrics & Gynecology, University of Western Ontario,
454 Platt's Lane, London, CA, Phone: (519) 661-2111 x
55174, Email: bin.xie.1@gmail.com
Research Objective: Increasing incidences of
kernicterus has raised concerns worldwide, and
universal predischarge serum bilirubin screening is
recommended as a strategy to prevent kernicterus by a
number of agencies in Canada and other countries.
Such a strategy could also reduce jaundice related
hospital readmission, as earlier intervention for
hyperbilirubinemia has been shown to reduce
readmission rate. A cost effectiveness evaluation is
needed to establish the cost effectiveness ratios of such
a strategy. The objective of this study is to establish the
cost effectiveness ratios for universal predischarge
serum bilirubin screening, compared to current practice
of selected bilirubin testing based on visual inspection of
jaundice.
Study Design: A decision tree model is developed to
simulate a cohort of 1000 term or late preterm infants
(gestational age >= 35 weeks) who are otherwise
healthy. The time horizen is two weeks. In the universal
screenig strategy, every newborn would be screened,
and intervention such as phototherapy and/or exchange
transfusion would be carried out at the birth hospital if
necessary. Those whose bilirubin levels are high enough
to warrant diligent follow up but not high enough to
warrant immediate treatment would be subject to diligent
follow up. In the current practice strategy, only those
who appear jaundice upon visual inspection would have
their serum bilirubin level tested and would be treated if
necessary at the birth hospital. Infants in both strategies
would then follow the routine follow up schedule (have a
home visit and/or an appointment with family doctor in
the first week). Data for probabilites are obtained from
the literature, whereas cost data are obtained from the
case costing center at Victoria Hospital at the London
Health Science Centre in London, Ontario, Canada and
from the literature. The payer's perspective is used.
Given the significant variability of some of the data items
from the literature, a variety of sensitivity analyses will be
performed to assess their impact on the results.
Population Studied: Term or late preterm infants
(gestational age >= 35 weeks) who are otherwise
healthy
Principal Findings: Preliminary results show that the
universal screening strategy has a discounted (discounte
rate for both cost and health at 3%) cost/QALY of $4,350
(In 2008 Canadian dollars) when both kernicterus and
hospital readmission are included. While the cost to
prevent one case of kernicterus is high ($3,467,508),
universal screening can reduce readmission rates and
therefore the overall cost/QALY is very reasonable.
Preliminary sensitivity analyses show that cost/QALY
range from $358 to $8905, whereas cost to prevent one
case of kernicterus range from $1,789,032 to
$9,783,500.
Conclusions: Based on our preliminary results, the
universal screening strategy offers reduction in
kernicterus and jaundice related readmission at a
reasonable cost. Given the devastating consequences of
kernicterus and the fact that a majority of hospital
readmission for infants in their first two weeks of life are
jaundice related, such a universal screening strategy
appears to be a good investment for our limited
resources.
Implications for Policy, Delivery or Practice:
Universal predischarge serum bilirubin screening for
term or late preterm infants (gestational age >= 35
weeks) should be encouraged.
Structure & Performance in Public Health Delivery
Systems
Chair: Glen Mays
Tuesday, June 30 * 9:45 a.m.-11:15 a.m.
♦ The Relationship Between County Composition &
Public Health Performance for Regional Public
Health Systems: A Nebraska Study
Li-Wu Chen, Ph.D.; Liyan Xu, M.S.; Sara Roberts,
M.P.H.; Michelle Mason, M.A.; David Palm, Ph.D.
Presented by: Li-Wu Chen, Ph.D., Associate Professor,
Health Services Research & Administration, University of
Nebraska Medical Center, 984350 Nebraska Medical
Center, Omaha, NE 68198-4350, Phone: (402) 5595260, Email: liwuchen@unmc.edu
Research Objective: To examine the relationship
between county composition and the performance of
public health core functions for regional local health
departments (LHDs) in Nebraska.
Study Design: A 20-question tool developed by Turnock
et al. (1998) was used to measure the public health core
function performance of Nebraska’s regional LHDs using
data from a mail survey of LHD directors conducted in
May 2008. Using data from the Nebraska County Profile
and the US Census Bureau, county composition (for
each region) was defined as the variation among
member counties in geographic factors (e.g., land size,
population density), demographic characteristics (e.g.,
age, race, foreign-born), economic conditions (e.g., per
capita income, poverty, unemployment), social
conditions (e.g., crime rate, adolescent birth),
educational attainment (e.g., college graduate, high
school drop-out), maternal and child health, morbidity
(e.g., disease incidence rates), mortality rates, and
health care provider supply. For each region, the
variation among member counties in one category (e.g.,
economic conditions) was measured by an index that
aggregated the variation scores (based on standard
deviation estimate) of all factors in the category (per
capita income, poverty, unemployment, etc.). Correlation
analyses were conducted between performance and
county composition measures for regional LHDs.
Correlation coefficients are reported in principal findings
below.
Population Studied: 16 regional LHDs and their
member counties in Nebraska.
Principal Findings: Total performance was negatively
associated with county variation in morbidity (-0.67;
p<0.01), health care provider supply (-0.53; p<0.05),
geographic factors (-0.5; p<0.1), maternal and child
health (-0.47; p<0.05), and educational attainment (0.45; p<0.1). Performance in policy development was
negatively associated with county variation in social
conditions (-0.61; p<0.05), economic conditions (-0.56;
p<0.05), educational attainment (-0.54; p<0.05),
morbidity (-0.48; p<0.1), and mortality (-0.43; p<0.1).
Performance in assessment was negatively associated
with county variation in morbidity (-0.6; p<0.05),
maternal and child health (-0.48; p<0.1), health care
provider supply (-0.47; p<0.1), and mortality (-0.43;
p<0.1). Performance in assurance was negatively
associated with county variation in geographic
characteristics (-0.47; p<0.1).
Conclusions: Greater heterogeneity in geographic
factors, population educational attainment, health care
provider supply, and population health status (general
morbidity and maternal/child health) among counties in a
regional LHD’s jurisdiction is associated with lower
performance of general public health core functions for
regional LHDs. Specifically, the correlation between
performance and an LHD’s county composition varies by
core function. Lower performance of policy development
is most associated with greater county heterogeneity in
socio-economic and education factors. Lower
performance of assurance is most associated with
greater county heterogeneity in geographic factors.
Lower performance of assessment is most associated
with greater county heterogeneity in population health
and health care provider supply.
Implications for Policy, Delivery or Practice:
Administrators and practitioners of regional LHDs can
use these findings to design interventions based on the
type and degree of heterogeneity among counties within
their jurisdiction to improve the performance of specific
public health core functions. Whenever possible, the
formation of regional LHDs should follow geographic
boundaries within which the heterogeneity of county
composition is minimized.
Funding Source(s): RWJF
♦ Organizational Connectivity & Public Health
Preparedness in Alberta
Justin Hall, B.Sc.H., B.P.H.E.; Spencer Moore, Ph.D.,
M.P.H.; Alan Shiell, Ph.D.
Presented by: Justin Hall, B.Sc.H., B.P.H.E., Master's
Student, Kinesiology & Health Studies, Queen's
University, 69 Union Street, PEC 223, Kingston, K7L
3N6, Jamaica, Phone: (613) 533-2666, Email:
2jnh@queensu.ca
Research Objective: Outbreak response occurs initially
at the local level and thus the potential impact that a
threat will have on the overall Canadian population can
differ significantly depending on the capacity of the
public health system to respond. The effective
coordination of all agencies at local, regional, provincial,
and federal levels is essential to the management of
public health threats. However, limited knowledge exists
on the correlates of organizational- and system-level
public health preparedness. The current work examines
the association of perceived organizational connectivity
and perceived human and material resource capacity
with whether organizations are more or less likely to
have exercised their written emergency response plan.
Study Design: Between November 2007 and April
2008, using a stratified random sampling technique, a
geographically representative sample of organizations
across four jurisdictional levels (provincial, regional, city,
and local) was selected to complete a web-based
questionnaire assessing public health preparedness for
agencies across Alberta. Organizational representatives
from public health preparedness and emergency
management agencies were asked to describe their
organizational attributes, perceived connectivity, and
preparedness. For this study, the sample was restricted
to organizations that provided information in these three
areas (n=70). Multiple logistic regression was used to
test whether perceived organizational connectivity
moderates the association of perceived human and
material resource preparedness on whether an
organization exercised their preparedness plan either in
practice or in a real situation during 2006.
Population Studied: Organizations working in the area
of public health preparedness and emergency
management throughout Alberta, Canada.
Principal Findings: Findings suggest that perceived
organizational connectivity moderates the association of
perceived organizational human and material resource
capacity with having exercised a preparedness plan
(OR=1.29, 95%CI=1.06–1.57, p=0.01). Among
organizations with high perceived resource capacity,
increases in perceived connectivity led to higher odds of
having exercised a plan. Among organizations with low
perceived capacity, higher perceived connectivity led to
lower odds. This finding was constant across different
jurisdictional levels.
Conclusions: Organizations with higher perceived
human and material resource capacity are able to use
perceived organizational connectivity to their advantage,
whereas perceived connectivity appears to burden
organizations with lower perceived resource capacity.
Even if a system has ample resources in terms of
equipment, training, and funding, these components will
not function optimally if the system does not reach a
threshold level of connectivity. This connectivity
develops as a result of relationships with other agencies
and knowledgeable professionals, effective
communication, and mutual respect amongst connecting
parties.
Implications for Policy, Delivery or Practice:
Organizations with low perceived resource capacity
and/or connectivity levels should be targeted for
interventions to increase organizational preparedness.
Strategic efforts to improve connectivity and resource
capacity will benefit the entire preparedness system at
all jurisdictional levels by ensuring organizations are able
to quickly mobilize and mount an effective and
coordinated response to future infectious disease
outbreaks, terrorist events, natural disasters or other
public health emergencies.
Funding Source(s): Health Research Fund, Alberta
Heritage Foundation for Medical Research
♦ Investigating the Effects of Partnerships on Local
Health Departments Preparedness
Sergey Sotnikov, Ph.D.
Presented by: Sergey Sotnikov, Ph.D., Economist,
Centers for Disease Control & Prevention, 1600 Clifton
Road M/S: E-73, Atlanta, GA 30333, Phone: (404) 4981116, Email: ann0@cdc.gov
Research Objective: The purpose of this study was to
provide quantitative evaluation of the effects of
partnerships on the preparedness of local health
departments (LHDs).
Study Design: There are expectations that local health
departments that have developed a network of partners
will be better prepared to respond to public health
emergencies. However, uncovering effects of these
partnerships on preparedness pose some
methodological difficulties. The gold standard for study
designs quantifying the effects of interventions is a
randomized control trial (RCT). However, a RCT is not
viable in the case of partnerships since partnering is a
matter of choice, and, thus, random assignment of LHDs
into partner and non-partner groups is not feasible.
Partnership effects estimated without accounting for
non-random selection will be biased. We used
propensity-scores-matching methodology to conduct
quasi-experimental assignment of LHDs into comparable
pairs of cases and controls. The PSCORE routine in
STATA9 was used to estimate a Probit model of
partners’ choice as a function of observable
characteristics (LHD expenditures, number of customers
in jurisdiction, number of employees, etc). Predicted
probabilities of having a partner were used to match
LHDs with and without particular partner by nearestneighbor-matching method. The effects of LHD
partnerships were estimated by calculating the
difference in outcome variables for each pair. The
outcomes were dichotomous variables indicating if the
LHD was engaged in implementation of five emergency
preparedness activities.
Population Studied: Information on LHD
characteristics, partnerships, and types emergency
preparedness activities was obtained from the 2005
NACCHO survey of 440 LHD. The five preparedness
activities included in the survey were to: 1) develop or
update a written emergency plan, 2) review relevant
legal authorities 3) participate in drills or exercises, 4)
assess emergency preparedness competencies of staff,
and 5) provide emergency preparedness training to staff.
Principal Findings: LHDs were more likely to develop
or update a written emergency plan if they partnered
with emergency responders (30% point difference,
t=3.30), community organizations (20%, t=2.68), doctors
(15%, t=2.98), businesses (14%, t=2.97) and schools
(16%, t=1.79). Partnerships with businesses seemed to
induce LHDs to review legal authorities (20% point
difference, t=2.70). LHD participation in drills was more
likely if they partnered with emergency responders (25%
point difference, t=2.60), community organizations (19%,
t=2.51), or physicians (9%, t=1.84). LHDs more
frequently assessed emergency competencies of staff if
they partner with hospitals (31% difference, t=2.97),
emergency responders (30%, t=2.61, physicians (23%,
t=3.21), or businesses (15, t=2.11). LHDs tended to
provide more training if they partnered with hospitals
(21%, t=2.27), emergency responders (19%, t=2.01), or
community organizations (17%, t=1.95). No statistically
significant effects of partnerships with community heath
centers, insurers, economic development agencies, faith
based organizations and universities on LHD
preparedness activities were observed.
Conclusions: This study suggests that LHD
partnerships with emergency responders, doctors,
community organizations, hospitals and businesses may
have beneficial effects on preparedness activities.
Implications for Policy, Delivery or Practice: While
promoting LHD partnerships may have positive effects
on preparedness - some partnerships may improve
preparedness more than others.
Funding Source(s): CDC
♦ Public Health Systems: Community Networks for
Risky Youth Behavior, Elderly Care & Emergency
Preparedness
Douglas Wholey, M.B.A., Ph.D.; Walt Gregg, M.A.; Ira
Moscovice, Ph.D.
Presented by: Douglas Wholey, M.B.A., Ph.D.,
Professor, School of Public Health, University of
Minnesota, MMC 729 420 Delaware Street, Southeast,
Minneapolis, MN 55110, Phone: (612) 626-4682, Email:
whole001@umn.edu
Research Objective: To describe the association
between a public health system’s domain, local health
department governance, community size and public
health system organization, focusing on the local health
department centrality in public health systems
Study Design: The design is a case comparative
operational design examining the structure of public
health system network structure and organizational
participation in public health systems in the domains of
risky youth behavior, elder care, and emergency
preparedness. Social network graphical tools and
multivariate models were used for data analysis. Site
visit interviews with key informants from organizations
likely to participate in the public health system in each
domain were conducted followed by a web-based survey
of the site visit participants and key individuals identified
during the site visits to each community about
participation in the local public health system.
Population Studied: Public health system activities and
organization in eight rural communities Four
communities were located in a state where local health
departments are part of state government (centralized
governance) and four are located in a state where local
health departments are part of county government
(decentralized governance). The communities were
stratified according to degree of urbanization with two
micropolitan communities and two non-core communities
in each state.
Principal Findings: Organizational participation in
public health systems varies substantially across public
health domains. Collaboration is assessment,
assurance, and advocacy activities is more likely than
co-funding collaboration. While local health departments
are central in each public health domain, other types of
organizations are likely to be the most central actors
depending on the context of the issues being addressed.
Conclusions: The role and centrality of local health
departments in public health systems vary across
problems domains, with the most central actor in each
problem domain being an organization other than the
local health department.
Implications for Policy, Delivery or Practice:
Understanding the effect of public health systems on
health outcomes will require understanding of the role
local health departments play in public health systems.
This understanding should be incorporated into current
public health accreditation efforts and efforts to develop
effective public health systems.
Funding Source(s): RWJF
♦ Structural Capacities, Processes & Performance
Small Local Public Health Systems
Susan Zahner, Dr.P.H., M.P.H., R.N.
Presented by: Susan Zahner, Dr.P.H., M.P.H., R.N.,
Associate Professor, Nursing, University of WisconsinMadison, 600 Highland Avenue, Madison, WI 537922455, Phone: (608) 263-5282, Email:
sjzahner@wisc.edu
Research Objective: The aim of this study was to
explore relationships between structural capacity,
community health assessment and planning processes,
and outcomes of local public health systems (LPHS)
serving small population jurisdictions.
Study Design: The study utilized the conceptual
framework of public health system performance by
Handler, Issel, and Turnock (2001). A cross-sectional
web-administered survey was conducted and secondary
data sources were used. LPHS were defined as
including the local health department (LHD), county
extension service, law enforcement, aging agency, K-12
school, county social services, primary health care, and
hospitals in each county. Structural capacities were
examined in five areas. Processes studied included
community health assessment, planning, and
partnerships. Outcomes assessed included
organizational actions, perceptions of LPHS
effectiveness, and county health rankings.
Population Studied: Key informants from LPHS
organizations in 21 counties with less than 25,000
population in Wisconsin were identified by LHD directors
and invited to participate in the study (n=287). The
overall response rate was 62% (179 of 287 invited).
Most of the respondents were female (71%), in
management positions (66%), had an average tenure of
14 years with their organization and 25 years living in the
county.
Principal Findings: Information technology and
physical facility capacities were reported as adequate for
most or all organizational work. Physical co-location with
at least one other organization was reported by 73%.
Organizational capacities examined included
engagement, effectiveness and visibility of the local
board of health and the county board on public health
issues; 22% of respondents were unaware of the
existence of the local board of health. Fiscal capacity
was reported as adequate by 56% of respondents and
human resource capacity was reported as adequate by
66%. Community health assessment and written reports
of the results were reported by 87% of LHD informants
although 37% of all informants were unaware of the
community assessment process. Assessment and
planning processes were most likely to be lead by LHDs.
Informants reported their organizations engaged in
multiple ways including participation in community
partnerships for assessment (58%) and improvement
(61%). Actions taken in response to assessment and
planning were most frequently reported by LHDs and
hospitals. Actions by policy-making bodies were
infrequent. Respondents rated their systems as
modestly effective in working together (Mean = 4.9 on a
7 point scale). Systems with LHDs that were certified at
a lower level ranked lower on one performance measure
(county health rankings).
Conclusions: LPHS capacity is strongest in information
technology and physical facilities but is challenged with
regard to fiscal and human resources. LPHS are
actively engaged in community health assessment,
planning, and use partnerships. LHD continue to provide
leadership in these essential service processes. Actions
are taken by LPHS partners in response to these
processes, most commonly by the LHD, but infrequently
by the county board. Measuring the impact of capacity
and process on performance outcomes remains
challenging.
Implications for Policy, Delivery or Practice: Future
research on LPHS performance should utilize the public
health system conceptual framework and include data
from system partners as well as the LHD.
Funding Source(s): RWJF, Changes in Healthcare
Financing and Organization Program
Quality & Efficiency: Measurement #1
Chair: Patrick Romano
Sunday, June 28 * 2:30 p.m.- 4:00 p.m.
♦ Effects of Statistical Uncertainty on the
Classification of Physicians Based on their Cost
Profiles
John Adams, Ph.D.; Elizabeth McGlynn, Ph.D.; J.
William Thomas, Ph.D.; Ateev Mehrotra, M.D.
Presented by: John Adams, Ph.D., Senior Statistician,
RAND Health, RAND Corporation, 4570 Fifth Avenue,
Suite 600, Pittsburgh, PA 15213, Phone: (412) 6832300, Email: adams@rand.org
Research Objective: It is increasingly common for
health plans to create physician cost profiles which
reflect the costs of care provided by a physician
compared to his or her peers. Health plans use such
profiles, among other things, to partition provider
networks into tiers (e.g. low cost, average cost, high
cost). To date, such partitioning ise typically defined
using simple percentile cut-offs and does not account for
the statistical uncertainty of physician performance
measures used. Similarly confidence intervals are not
shown around estimates. In this paper we introduce a
method for accurately estimating standard errors of
physician cost performance measures that reflect the
measures’ complex structure. We then assess the level
of agreement between two methods for partitioning
physicians into tiers, percentile cut-offs vs. a statistical
test.
Study Design: We created an aggregated dataset using
2004-2005 claims data from four health plans in
Massachusetts. Consistent with the methods used by
health plans, we employed commercial software to
create episodes of care and assigned responsibility for
each episode to the physician having the highest
proportion of professional costs in the episode. A
physicians’ cost profile was the ratio of the sum of
observed costs divided by the sum of average costs
across all assigned episodes. We then partitioned
physicians in to low, average, and high cost categories,
first using percentile cut-offs and then using t-tests.
Population Studied: There were 8585 Massachusetts
physicians in 27 specialties who were assigned 30 or
more episodes.
Principal Findings: Across the physician sample,
38.6% of physicians were assigned a different cost
category when comparing percentile cut-off method and
the t-test. This varied greatly across specialties with
14.9% disagreement for obstetrics/gynecology and
68.5% for nephrology.
Conclusions: We introduce a method for incorporating
statistical uncertainty when categorizing physicians
based on their cost-profiles. If statistical uncertainty is
addressed, a substantial of physicians are assigned to a
different cost tiers.
Implications for Policy, Delivery or Practice: Our
method of incorporating statistical uncertainty should be
utilized in future physician cost profiling efforts.
♦ Assessing Physician Performance: Findings from
the California Better Quality Information Pilot Project
Cheryl Damberg, Ph.D.; Robert Houchens, Ph.D.; Ted
von Glahn; David Hopkins, Ph.D.
Presented by: Cheryl Damberg, Ph.D., Director of
Research, Pacific Business Group on Health, 221 Main
Street, San Francisco, CA 94107, Phone: (310) 3967036, Email: cdamberg@pbgh.org
Research Objective: There is increasing interest
among purchasers, private health plans, and Medicare in
assessing the performance of individual physicians as a
means of driving down variation in care practices and
improving quality of care. CMS funded six pilot projects
to pool data across multiple payers to assess the
performance of individual physicians and to examine
methods issues, including attribution and reliability (to
minimize misclassification error). This study highlights
key findings from this methods work in the California
Better Quality Information project.
Study Design: Using aggregated claims data from three
large California PPOs and Medicare, we computed
performance scores at the individual physician level for
18 clinical measures. Three different approaches to
attributing patient events to physicians based on E&M
visits were tested and we validated the attribution
approaches with 50 physicians who were attributed
2,500 patient events. We computed reliability scores for
each performance measure and examined the fraction of
physicians who met or exceeded a threshold reliability of
0.70. HEDIS specifications were applied against
measurement year 2005, 2006, and 2007 data that were
aggregated across the 4 payers.
Population Studied: The analysis is based on claims
for 64,000 physicians in California who contract with the
PPOs and/or Medicare.
Principal Findings: Non-relevant-specialists claimed
zero percent responsibility (even if they were the only
physician the patient saw during the measurement
period), while relevant-specialty physicians claimed
responsibility between 68-85% of the time when they
constituted the plurality of visits, and only 22-43% of the
time when they did not represent the plurality of visits.
The number of physicians achieving the 0.70 reliability
threshold ranged from a low of zero physicians (for the
heart attack measures) to a high of 14,696 physicians for
the colorectal cancer screening measure. Minimum
patient denominator sizes varied across measures, from
19 to 267. Average measure rates ranged between
25%-75%, well below national 90th percentile
benchmarks.
Conclusions: The lack of ownership expressed by
many physicians highlights challenges related to
accountability for quality, particularly when multiple
physicians touch a patient only once during a
measurement period or the only physician seen is notrelevant to the performance measure. Reliability scores
are a function of physician sample size and the
physician HEDIS/measure rate; the “n” required to
achieve a specified level of reliability varies physician to
physician and reliabilities are measure dependent.
Achieving reliable denominator sizes at the physicianlevel remains a challenge. Possible methods to increase
reliability include forming composite measures, pooling
data over multiple years, incorporating data from more
health plans, and summarizing results at a practice site
level.
Implications for Policy, Delivery or Practice:
Measuring physician performance and providing
information back to physicians is critical for quality
improvement and public accountability. The methods
work done in this project can help inform the efforts of
private payers and Medicare to generate reliable
measures of physician performance.
Funding Source(s): CMS, health plans and Pacific
Business Group on Health
♦ Cost Profiling in Health Care: Should Individual
Physicians or Physician Groups be Profiled?
Ateev Mehrotra, M.D.; John Lloyd Adams, Ph.D.; J.
William Thomas, Ph.D.; Elizabeth McGlynn, Ph.D.
Presented by: Ateev Mehrotra, M.D., Policy Analyst,
RAND Health, RAND Corporation, 4570 Fifth Avenue,
Suite 600, Pittsburgh, PA 15213, Phone: (412) 6832300, Email: mehrotra@rand.org
Research Objective: Health care purchasers are now
focusing on identifying which individual physicians
deliver care in the least costly manner (“efficiently”).
There is an ongoing debate on whether cost profiles
should be generated for individual physicians or for
physician groups. From a patient’s perspective,
measures for individual physicians are important, since
patients tend to choose doctors rather than groups. But
physicians argue that it is more effective to improve care
at the group level, that an individual physician’s effect on
spending is difficult to define, and that measurement of
individual performance may result in sample sizes that
are too small. To our knowledge, ours is the first study to
examine these issues empirically.
Study Design: We used an existing database in which
physicians in 27 specialties in Massachusetts have been
placed into groups and the groupings have been
validated by the physician leadership of the groups. We
created an aggregated dataset using 2004-2005 claims
data from four health plans in Massachusetts to create
the individual physician and physician group cost
profiles. Consistent with the methods used by health
plans, we used commercial software to create episodes
of care and assigned episodes to the physician with the
highest proportion of professional costs in the episode. A
physician’s episodes were then assigned to the group in
which they practice. A physician or group cost profile
was the ratio of the sum of observed costs divided by the
sum of average costs across all assigned episodes.
Population Studied: The study sample was comprised
of 12,610 Massachusetts physicians who submitted at
least one claim during the two year period. Of these
7,786 (61.7%) physicians practiced in one of 171
physician groups in the state.
Principal Findings: Physician groups were
heterogeneous in their composition and size. For
example, 30% of groups had =50 physicians while 32%
had =9 physicians. Of the explainable variation in costs,
58% was driven by individual physicians and 18% by an
independent physician group effect. The median
reliability was higher among physician group cost
profiles compared to individual physician cost profiles
(0.85 vs. 0.69), but among smaller groups (=9 MD) the
median reliability was lower (0.69). Among the 3681
physicians who practice in a low-cost physician group,
only 15% would be categorized as low-cost if they were
profiled individually.
Conclusions: There are a number of competing issues
that play a role in the debate on whether to profile
individual physicians or physician groups. Based on
variance explanation, profiling individual physicians
incorporates the most “signal” on what is driving the
variation in costs. Based on reliability results, physician
group profiles are superior in that there is higher
reliability or less statistical “noise”. But if a patient
chooses a low-cost group the patient is unlikely to
receive care from a low-cost doctor.
Implications for Policy, Delivery or Practice:
Recognizing that the results are limited to
Massachusetts which may decrease generalizability,
these results can help inform the continuing debate
among physicians and health plans on whether
individual physicians or physician groups should be
profiled on their relative costs.
♦ Do Intermediate Outcome Measures of Quality
Provide Incentives for Inefficient Care?
Justin Timbie, Ph.D.; Rodney Hayward, M.D.; Sandeep
Vijan, M.D.
Presented by: Justin Timbie, Ph.D., Postdoctoral
Fellow, Health Services Research & Development
Center for Clinical Management Research, VA Ann
Arbor Healthcare System, 2215 Fuller Road, Ann Arbor,
MI 48105, Phone: (734) 845-3600, Email:
justinti@med.umich.edu
Research Objective: To assess heterogeneity in the
expected health improvements from an intermediateoutcome based approach to quality measurement, and
to estimate the impact of incorporating treatment-related
disutility on the magnitude of the health benefit.
Study Design: We used Monte Carlo simulation to
estimate the expected benefit of a “treat-to-target”
strategy, that was designed to lower diabetes risk factors
(LDL-cholesterol, hemoglobin A1c, and blood pressure
(BP)) to common intermediate outcome targets (LDL:
100 mg/dl, A1c: 7%, BP: 130/80 mmHg). Treatment
regimens included 5 increasingly potent doses of statins,
4 steps of antihyperglycemic therapy, and 8 steps of
antihypertensive medications. We abstracted mean
treatment efficacy parameters, variance estimates, and
discontinuation rates from individual studies or metaanalyses of placebo-controlled trials where available.
We used a Markov model to estimate the gain in qualityadjusted life years (QALYs) associated with reductions
in each risk factor at the end of the treatment regimen.
We then accounted for disutilities from both the
inconvenience of treatment and adverse events using
published event rates from clinical trials. We stratified
analyses by a subject’s baseline risk of adverse
outcomes, defined as the expected loss in QALYs
attributable to a subject’s baseline risk factor level
relative to target levels.
Population Studied: Patients aged 18 years and older
with diabetes. Baseline risk factor data were from the
National Health and Nutrition Examination Survey-III.
Principal Findings: For patients having the highest
baseline risk of adverse outcomes, the benefit of treating
to LDL targets was a gain of 2.64 QALYs; the lowest risk
group had a gain of only 0.23 QALYs. Results for A1c
were +0.25 (highest risk), +0.009 (lowest risk); blood
pressure results were +3.17 (highest risk), +0.20 (lowest
risk). The percentage of the population represented by
high risk categories was 4.0% (LDL), 0.9% (A1c), and
1.4% (BP), and for the lowest risk categories was 75.2%
(LDL), 85.4% (A1c), and 72.8% (BP). When we
accounted for treatment related disutility, highest risk
groups maintained larger expected benefits (+2.46
QALYs (LDL), -0.11 (A1c), +2.98 (BP)); lowest risk
groups had QALY gains of +0.11 (LDL), -0.24 (A1c), and
+0.07 (BP). The disutility associated with A1c-lowering
medications outweighed the expected benefit for all risk
groups. In sensitivity analyses we found low risk
populations were harmed by aggressive blood pressure
treatment.
Conclusions: For patients with diabetes, the benefit of
attaining target levels of intermediate outcomes varies
widely across the population. Incorporating treatmentrelated disutility lowers the net benefit of a treat-to-target
approach, and a large fraction of the population might
potentially receive net harm.
Implications for Policy, Delivery or Practice: Quality
measures that fail to account for heterogeneity in the
benefit of treatment promote a uniformly aggressive, and
thus inefficient, treatment style. Process measures of
quality, such as indicators of whether treatment
intensification occurred in a timely manner for high risk
patients, have been proposed and their development
should be encouraged. Extensive data requirements
pose a challenge to implementing such measures in
many practice settings. Decision support is needed to
reconcile the benefits and risks of intensifying treatment
at the point of care.
Funding Source(s): VA
♦ Estimating Reliability & Decision Consistency of
Physician Practice Performance Assessment
Weifeng Weng, Ph.D; Gerald Arnold, Ph.D, M.P.H.;
Lorna Lynn, M.D.; Rebecca Lipner, Ph.D.
Presented by: Weifeng Weng, Ph.D, Health services
researcher, American Board of Internal Medicine, 510
Walnut Street Suite 1700, Philadelphia, PA 19106-3699,
Phone: (215) 606-4134, Email: wweng@abim.org
Research Objective: Physician-level pay for
performance or reward programs often require patient
samples of 25. However, little is known whether this
provides sufficient reliability and decision consistency
(i.e., reward granted or not). This study evaluates
reliabilities of individual performance measures and full
profiles, consistency of reward decisions, and
appropriateness of sample size requirement.
Study Design: Data for ten clinical and two patient
experience measures were obtained from medical
record audits and patient surveys completed as part of
the Diabetes Practice Improvement Module (PIM)
developed by American Board of Internal Medicine
(ABIM). First, we created physician performance profiles
equivalent to Bridges to Excellence’s Diabetes Care Link
program from the clinical measures, awarding physicians
points if their average per measure reached a
predetermined criterion (e.g., >=40% of patients). Points
for all measures were summed to determine the
recognition decision. Second, a bootstrap procedure for
estimation of reliability and decision consistency was
applied in this complex assessment (e.g., measure
specific criterion, skewed measure distributions,
interrelated measures with different importance weights).
Patient experience measures were then added to the
assessment to examine their impact on reliability and
decision consistency. Finally, the analyses were
replicated for a second chronic condition using data from
ABIM’s Hypertension PIM.
Population Studied: Between October 2005 and
October 2007, 957 physicians completed the Diabetes
PIM with at least 10 patients between the ages of 18-75,
providing 20, 131 chart audits and 18, 706 patient
surveys; 657 physicians who completed the
Hypertension PIM with at least 10 patients between the
ages of 18-75, providing 13, 073 chart audits and 14,897
patient surveys.
Principal Findings: Chart and survey data were
replicated using (1,000) bootstrap samples per
physician. Intermediate outcomes measures reliabilities
ranged from .51 to .58; process measures ranged from
.38 to .80 for the average audit sample of 21 patients per
physician. The full profile assessment reliability was .79,
which translates to a reliability of .82 for a sample of 25
patients. Decision consistency index refers to the
consistency of decisions over many measurements or
patients samples. Index values close to 1.0 indicate
fewer false classifications. Higher decision consistencies
were achieved for very low or high cut scores. Even for
the worst case, the decision consistency index was still
.84. Reliabilities for both patient experience measures
were .56. When added to the full profile, the two
experience measures increased the reliability to .81. The
findings for hypertension were similar, with full profile
reliability of .81.
Conclusions: Although individual measures do not yield
sufficient reliabilities themselves, a full profile of about
ten measures given a sample size of 25 patients per
physician provides satisfactory reliability and decision
consistency. Adding patient experience measures
increases the reliability slightly. A sample of 25 patients
achieves a reasonable reliability for both conditions
studied.
Implications for Policy, Delivery or Practice: The
findings help understand the reliability and decision
consistency of physician reward programs, performance
assessment and the appropriateness of sample size
requirement. Bootstrapping estimation is a practical
method for assessing reliability and decision
consistency.
Funding Source(s): ABIM
Quality & Efficiency: Measurement #2
Chair: Cheryl Damberg
Monday, June 29 * 11:30 a.m.-1:00 p.m.
♦ Comparison of Hospital Risk-Standardized
Mortality Rates Using Inpatient & 30-Day Models:
Implications for Hospital Profiling
Elizabeth Drye, M.D., S.M.; Sharon-Lise Normand,
Ph.D.; Yun Wang, Ph.D.; Geoffrey Schreiner, B.S.;
Harlan Krumholz, M.D., S.M.
Presented by: Elizabeth Drye, M.D., S.M., Director,
Quality Measurement Programs, Yale-New Haven
Health Services Corporation/Center for Outcomes
Research & Evaluation, Internal Medicine, Section of
Cardiovascular Medicine, Yale School of Medicine &
Yale-New Haven Health Services Corporation/Center for
Outcomes Research & Evaluation, 1 Church Street,
Suite 200, New Haven, CT 06510, Phone: (203) 7645689, Email: elizabeth.drye@yale.edu
Research Objective: Both inpatient and 30-day riskadjusted mortality measures are used to assess the
quality of hospital care for medical procedures and
conditions. Thirty-day mortality measures are more
desirable because they have a fixed outcome period not
affected by hospital differences in length of stay (LOS),
transfer policies, and the use of post-acute care settings.
Measuring 30-day mortality is more difficult and costly,
however, because it requires linking inpatient and
outpatient data. If the difference between inpatient and
30-day rates were constant across hospitals, then
inpatient and 30-day models would give comparable
results. We examine this difference and assess whether
inpatient mortality measures for acute myocardial
infarction (AMI), heart failure (HF), and pneumonia are
reasonable proxies for 30-day measures for profiling the
nation’s acute care hospitals.
Study Design: We estimated hospital 30-day and
inpatient risk-standardized mortality rates (RSMR) for
AMI, HF, and pneumonia for United States acute care
non-federal hospitals. We used the Centers for
Medicare and Medicaid Services’ publicly reported 30day claims-based hierarchical generalized linear models
(HGLMs) and fitted inpatient HGLMs with the same
covariates to the same data. We calculated the
difference between 30-day and inpatient RSMRs (DIFF),
and identified hospital characteristics associated with
this difference. We compared between-hospital
variations (BHVs) and RSMR quartile placement for the
two measures.
Population Studied: Our hospital sample included all
U.S. acute care non-federal hospitals with at least 30
discharges for Medicare fee-for-service patients age 65
and older with a qualifying discharge diagnosis between
January 1, 2004, and December 31, 2006. The number
of hospitals (admissions) was: AMI: 3,135(718,508); HF:
4,209(1,315,845); pneumonia: 4,498(1,415,237).
Principal Findings: For AMI, HF, and pneumonia, the
respective mean (SD) 30-day RSMRs were 16.1(1.8),
11.2(1.7), and 12.2(2.1). There were remarkable
differences in BHVs between the 30-day and inpatient
measures. The ratios of BHVs (in-hospital to 30-day)
were 1.6 (AMI), 1.8 (HF), and 2.1 (pneumonia). The
mean LOS (days) for hospitals ranged from: AMI: 2-13;
HF: 3-11; and pneumonia: 3-14. The DIFF varied widely
across hospitals for all 3 conditions with mean (SD) and
range of: AMI: 5.3% (1.3), 1.2-11.0%; HF: 6.0% (1.3),
1.4-11.2%; pneumonia: 5.7% (1.4), -0.4-12.1%. Hospital
rankings also disagreed. For AMI, 38% of 783 hospitals
in the best performing quartile using 30-day changed
categories when inpatient was used; 37% of 784
hospitals in the worst performing quartile also moved to
another category. The pattern was similar for the other
conditions.
Conclusions: Hospital quality rankings using inpatient
mortality measures for AMI, HF and pneumonia disagree
with those obtained with 30-day measures. The use of
in-hospital mortality imposes a potentially substantial
bias in favor of hospitals with a shorter LOS.
Implications for Policy, Delivery or Practice: The
National Quality Forum has approved and some states
are publicly reporting inpatient mortality measures.
Although inpatient measures may be appropriate for
comparing the performance of homogeneous groups of
hospitals or tracking the performance of individual
hospitals over time, our findings suggest 30-day
measures are more appropriate for publicly reporting
hospital quality among diverse hospitals.
Funding Source(s): CMS
♦ How Accurate is the Present on Admission
Indicator?
John Hughes, M.D.; Elizabeth McCullough, M.S.; John
Muldoon, M.H.A.; Mona Bao, M.S.
Presented by: John Hughes, M.D., Medicine, Yale
School of Medicine, 68 West Rock Avenue, New Haven,
CT 06515, Phone: (203) 623-8201, Email:
jshughes@mmm.com
Research Objective: The addition of a Present on
Admission (POA) indicator to the diagnosis codes
submitted for reimbursement has been advocated as a
way to identify possible in-hospital complications using
administrative data. In-hospital complications can be
identified from among secondary diagnoses (SDX) that
were not present on admission (NPOA). The accuracy of
hospital complication rates will therefore depend on the
accuracy of POA coding. The purpose of this study was
to examine the accuracy of POA coding in the state of
California, which has required POA coding on all hospital
discharges for over a decade.
Study Design: We calculated the percent of SDx coded
as POA for all hospitals (POA rate). We identified
probable “false negative” POA codes – hospital-acquired
conditions incorrectly coded as POA – among elective
surgery patients by counting how often conditions
unlikely to be present before surgery were coded POA.
These included post-operative complications (post-op
hemorrhage, post-op wound infection) and acute
medical problems (pneumonia, acute MI) that likely
arose after surgery. We also examined “false positives”
for all medical and surgical patients by identifying the
proportion of all SDx coded as NPOA that belonged to a
list of chronic conditions that should always be
considered POA (e.g. hypertension, diabetes).
Population Studied: We examined data from 345
California acute care hospitals for the years 2004-2005,
after eliminating hospitals with fewer than 1,000
admissions per year, a morality rate over 7%, or an
average length of stay over 8 days.
Principal Findings: The percent of SDx coded as POA
ranged widely among hospitals, from 80.6 to 100 percent
(median 94.1, inter-quartile range 92 to 96.2). Ten
percent of hospitals had a POA rate over 98% and 5%
had a POA rate over 99.1%. Hospitals with the highest
POA rates had much higher rates of probable false
negatives: those with overall POA rates over 99% coded
more than 60% of post-operative surgical complications
as POA, and over 70% of post-op medical complications
as POA. False-positive rates (SDX for chronic
preexisting conditions incorrectly coded as NPOA)
ranged from 0% to 73.3% (median 9.6%, inter-quartile
range 6.3-15.0%). Ten percent (35 hospitals) had a rate
over 26%, and 5 percent had a rate of 40% or more. The
number of hospitals that should be considered to have
performed inadequate POA coding varies depending on
the cut-off values for false positives and false negatives
considered acceptable. As an example, requiring a false
positive rate of less than 40%, and for false negatives for
elective surgery, requiring less than 60% of postoperative surgical complications and less than 70% of
probable post-op medical complications to be coded as
POA would eliminate 60 hospitals (17.4%).
Conclusions: There were wide variations in POA
coding among California hospitals, which could
substantially affect the determination of hospital
complication rates. Hospitals that tend to code postadmission complications as POA will appear to have
lower complication rates than they deserve, and gain an
unfair advantage in comparisons with other hospitals.
Implications for Policy, Delivery or Practice: The
methods used to monitor hospitals will need to be
scrutinized as closely as the hospitals themselves.
Funding Source(s): 3M Health Information Systems
♦ Preventing Readmissions: The Predictors &
Consequences of Discharge Planning in U.S.
Hospitals
Ashish Jha, M.D., M.P.H.; E. John Orav, Ph.D.; Arnold
Epstein, M.D., M.A.
Presented by: Ashish Jha, M.D., M.P.H., Assistant
Professor, Health Policy & Management, Harvard School
of Public Health, 677 Huntington Avenue, Boston, MA
02115, Phone: (617) 432-5551, Email:
ajha@hsph.harvard.edu
Research Objective: The Centers for Medicare and
Medicaid Services (CMS) and others have embarked on
a national program to encourage hospitals to participate
in public reporting of their discharge planning in select
conditions. We sought to examine rates of performance
on the two publicly-reported discharge metrics, to
identify characteristics associated with better
performance on these discharge measures, and to
determine whether higher performance on these metrics
is related to lower readmission rates.
Study Design: We used the September 2008 release of
the Hospital Compare database to examine hospital
performance in 2007 on two discharge planning metrics:
adequate documentation in the chart of discharge
planning for patients with congestive heart failure (CHF),
and adequacy of discharge planning as reported by
patients discharged after hospitalization for a medical or
surgical condition through the Healthcare Consumer
Assessment of Hospital Providers and Systems
(HCAHPS) program. We used data from the American
Hospital Association annual survey to examine whether
key hospital characteristics were associated with better
performance on these two discharge metrics and finally,
we examined whether higher performance on these
discharge metrics was associated with lower riskadjusted readmission rates for CHF and pneumonia, the
two most common causes of hospitalizations among
Medicare patients.
Population Studied: Acute care U.S. hospitals that
provide general medical care to Medicare patients.
Principal Findings: Among the 2194 hospitals that
reported performance on both discharge metrics, there
was essentially no relationship between how hospitals
fared on the chart-based metric and the patient-reported
metric (correlation 0.06). While larger hospitals
performed better on the chart-based metric, smaller
hospitals, those located in the Midwest, and those with
higher nurse staffing levels had better peformance on
the patient-reported discharge metric. There was no
relationship between the chart-based metric and
readmission rates for CHF patients (readmission rates
among hospitals performing in the top quartile versus
bottom quartile: 23.7% versus 23.5%, p=0.49).
However, hospitals with higher performance on the
patient-reported metric had lower readmission rates for
both CHF (readmission rates among top versus bottom
quartile performers: 22.6% verus 24.5%, p<0.001) and
pneumonia patients (18.1% versus 19.5%, p<0.001).
Conclusions: There is essentially no correlation
between how hospitals fare on chart documentation of
adequate discharge instructions and patient-reported
adequate discharge instructions. We found a modest
but consistent relationship between patients’
understanding of discharge information and the
hospital’s readmission rates for both CHF and
pneumonia.
Implications for Policy, Delivery or Practice: The lack
of a relationship between the chart-based metric and
readmission rates suggests that this measure may not
be a valid way to assess readmission prevention
practices. Efforts to improve patient-reported experience
of discharge planning may lead to reduced readmission
rates.
Funding Source(s): CWF
Population Studied: We analyzed data from 4,460 nonfederal hospitals that reported HQA data in the 2007
calendar year and participated in the 2006 AHA Annual
Survey.
Principal Findings: Although each approach produced
a similar total number of safety net hospitals (612 for
Medicaid caseload, 697 for uncompensated care, and
573 for facility characteristics), there was little overlap
among hospitals that were categorized as safety net
providers across the three approaches. Only 83
hospitals qualified as safety net providers under all
three. Under the Medicare caseload approach, safety
net hospitals had lower performance scores than non
safety net hospitals across all categories of performance
(AMI, HF, PN, and SCIP). Under the facility
characteristics approach, safety net hospitals
outperformed non safety net hospitals in all four
categories. And under the uncompensated care
approach, results were mixed.
Conclusions: It is too simplistic to conclude that safety
net hospitals perform better or worse than non safety net
hospitals; findings vary based on how safety net
hospitals are defined.
Implications for Policy, Delivery or Practice: How
researchers and policy makers define safety net
providers can affect research conclusions and policy
recommendations.
Funding Source(s): CWF
♦ Inpatient Quality of Care at Safety Net Hospitals
Megan McHugh, Ph.D.; Raymond Kang, M.A.; Romana
Hasnain-Wynia, Ph.D.
Quality & Efficiency: Measurement #3
Presented by: Megan McHugh, Ph.D., Director,
Research, Health Research & Educational Trust, One
North Franklin, Chicago, IL 60606, Phone: (312) 4222634, Email: mmchugh@aha.org
Monday, June 29 * 3:00 p.m.-4:30 p.m.
Research Objective: One challenge to investigating
quality of care at safety net hospitals is the absence of a
common definition of what constitutes a safety net
hospital. The purpose of this study was to identify
commonly used approaches for classifying hospitals as
safety net providers and investigate whether findings on
the quality of care varies based on the definition used.
Study Design: A systematic review of the literature
between 1996 and 2008 revealed three commonly used
approaches to defining safety net hospitals –
approaches based on Medicaid caseload,
uncompensated care volume, and facility characteristics
(i.e. public and teaching hospitals). Using the three
different approaches, we identified safety net and non
safety net hospitals using data from the American
Hospital Association’s Annual Survey. We used t-tests
to identify differences in Hospital Quality Alliance (HQA)
scores for acute myocardial infarction (AMI), heart failure
(HF), pneumonia (PN), and the prevention of surgical
infection (SCIP) between safety net and non safety net
hospitals under the three approaches.
Chair: Bruce Landon
♦ Higher Quality of Care for Hospitalized Older
Adults is Associated with Improved Survival One
Year After Discharge
Vineet Arora, M.D., M.A.; Melissa Fish, B.A.; Anirban
Basu, Ph.D.; Jared Olson, M.D.; Greg Sachs, M.D.;
David Meltzer, M.D., Ph.D.
Presented by: Vineet Arora, M.D., M.A., Assistant
Professor, Medicine, University of Chicago, 5841 South
Maryland Avenue MC 2007, AMB W216, Chicago, IL
60637, Phone: (773) 834-9788, Email:
varora@medicine.bsd.uchicago.edu
Research Objective: Ideally, adherence to quality
measures is associated with improvements in patient
outcomes. The relationship between adherence to
quality measures for hospitalized older adults and
patient outcomes is unknown. This study aims to assess
the relationship between quality of care, measured by
ACOVE (Assessing Care of Vulnerable Elders) quality
indicators (QIs), and survival one year after discharge for
hospitalized frail older patients.
Study Design: Medical charts were reviewed for
adherence to 16 QIs (mobility and discharge planning,
assessment of cognition, physical function, nutrition,
pain, and diagnosis and treatment of delirium and
pressure ulcers). A composite score reflecting percent
adherence to all QIs was calculated. Post-discharge
death date was obtained from the Social Security Death
Index. Multivariate logistic regression controlling for
demographic characteristics (age, sex, race, marital
status) and possible confounders (VES-13 score,
number of baseline ADL limitations, DNR/DNI status,
length of stay, Charlson comorbidity index, and number
of QIs triggered) was used to ascertain the relationship
between quality of care and post-discharge mortality.
Cox proportional hazards models was used to determine
differences n 1 year survival rates for patients receiving
above and below the median quality score. The
relationship between adherence to individual QIs and
survival after discharge was also examined.
Population Studied: Patients age 65 and older who
were hospitalized at a single academic medical center
between May 2004 and June 2007 and identified as
"vulnerable" using the VES-13 (Vulnerable Elder
Survey). Patients who died in the hospital, were
discharged to hospice, or were transferred from an ICU
were excluded from this analysis.
Principal Findings: Of the 5099 older patients were
admitted during the study period, 68% (3454) consented
to participate. 53% (1861) were deemed as "vulnerable
elders." The mean age of 80 (SD 8.3). Patients
triggered a mean of 8.3 (SD 2.0) QIs. Mean quality of
care score was 59.3% (SD 19.2). 495 patients (26.7%)
died within one year of discharge. Multivariate logistic
regression demonstrated that for every 10% increase in
quality score, the odds of death within one year postdischarge decreased by 7% [OR 0.93 (95% CI = 0.871.00), p = 0.045]. Using Cox proportional hazards
regression, patients receiving higher quality of care
(above median score) were 18% less likely to die within
1 year of discharge [HR 0.82 (95% CI = 0.68-1.00), p =
0.05]. This relationship was particularly significant for
assessment of nutritional status which was associated
with a 39% reduction in mortality 1 year after discharge
[HR 0.61 (95% CI = 0.40-0.93), p = 0.022].
Conclusions: Higher quality of care for hospitalized
vulnerable elders, as measured by ACOVE quality
indicators, is associated with improved survival one year
after discharge. This relationship is particularly
significant for those older patients who receive inpatient
nutritional assessments.
Implications for Policy, Delivery or Practice: Future
research should aim to understand the mechanism for
these findings. Possible mechanisms include: (1) Better
quality of care improves post-discharge survival; (2)
Inpatients that will live longer receive higher quality of
care; or (3) Adherence to certain process of care
measures is a proxy for an unmeasured variable
influencing survival.
Funding Source(s): Hartford Foundation, National
Institutes on Aging
♦ Dartmouth Aggressive Care & Surgical Outcomes
Jeffrey Silber, M.D., Ph.D.; Robert Kaestner, Ph.D.
Presented by: Jeffrey Silber, M.D., Ph.D., Professor,
Children's Hospital of Philadelphia Center for Outcomes
Research, University of Pennsylvania, 3535 Market
Street, Suite 1029, Philadelphia, PA 19104, Phone:
(215) 590-5635, Email: silberj@wharton.upenn.edu
Research Objective: The work of the Dartmouth group,
now widely disseminated in the national media, asserts
that more aggressive medical care, (where “aggressive”
is defined in part by increased Medicare expenditures in
the last 2 years of life or increased hospital days or
increased ICU days), may be undesirable both because
aggressive care may not optimize patient satisfaction
and because it is wasteful, as no significant benefits in
survival are purported to accrue from such care. We ask
a simple question: Is more aggressive care associated
with lower death rates after surgical complications i.e.,
better failure-to-rescue (FTR)? If more aggressive care
is associated with better (lower) FTR, then more
aggressive care may be beneficial, and the Dartmouth
premise that aggressive care does not produce better
outcomes may be incorrect.
Study Design: We focus on FTR (the probability of
death within 30 days of admission following a
complication) because it has superior risk adjustment
properties compared to other outcome measures and
because it provides a good measure of a hospital’s
ability to manage complicated patients - an important
aspect of hospital quality of care. Logistic regression
was used to examine 30-day FTR for patients in more
versus less aggressive hospitals, as defined by the
Dartmouth Atlas (a hospital level end of life Medicare
expenditure measure). The regression models included
30 comorbidities with a 180-day “lookback”, adjustments
for year, age and sex, 180 DRG/Principal Procedure
groups, 34 interaction terms, and 5 hospital variables
reflecting size, technology, teaching intensity, nurse
staffing ratio and nurse mix. We also develop separate
models for 30-day mortality and in-hospital
complications. Finally, we also examined other
measures of end of life Dartmouth aggressiveness
defined by total hospital days or total ICU days instead
of the Medicare expenditure variable.
Population Studied: We studied a national sample of
Medicare inpatient hospital claims on general,
orthopedic and vascular surgery admissions in the U.S.
for 2000 - 2005 (N = 4,658,954 patients). Our measures
of aggressiveness were obtained directly from the
Dartmouth Atlas data set by hospital.
Principal Findings: We found significant improvements
(reductions) in failure-to-rescue with increased
aggressiveness. For every $10,000 increase in
Dartmouth end of life expenditure, we find a 7%
reduction in the odds of failure-to-rescue, (95% CI 5%,
9%); a 6% (5%, 10%) reduction in the odds of mortality;
and a statistically insignificant 1% (0%, 2%) increase in
the odds of post-operative complications. Results for
Dartmouth hospital days and ICU days were very similar
to total expenditures, with more aggressiveness
associated with large and significant reductions in FTR
and mortality and no association with complications.
Conclusions: Survival after complications is higher at
more aggressive hospitals, even after adjusting for other
hospital characteristics generally associated with better
outcomes.
Implications for Policy, Delivery or Practice: Our
results should serve to remind policy makers and the
public that on average, more aggressive care as defined
by the Dartmouth group is associated with a higher odds
of surviving surgical complications and lower 30-day
mortality, with little or no increase in complications.
Funding Source(s): NHLBI
♦ A Refined Approach to Evaluating Hospital
Readmission Rates: Accounting for Multiple Visits to
the ED for Potentially Preventable Conditions
Claudia Steiner, M.D., M.P.H.; Marguerite Barrett, M.S.;
Bernard Friedman, Ph.D.; Joanna Jiang, Ph.D.; Chaya
Merrill, Dr.P.H.
Presented by: Claudia Steiner, M.D., M.P.H., Research
Medical Officer, Agency for Healthcare Research &
Quality, Email: claudia.steiner@ahrq.hhs.gov
Research Objective: High hospital readmission rates
for potentially preventable conditions may suggest
substandard quality of hospital care or poor outpatient
follow-up care. Previous research has primarily focused
on inpatient (IP) readmissions without accounting for
patient re-visits to the emergency department (ED). The
primary objective of this study is to evaluate the
additional utilization and cost impact of including re-visits
to the ED for selected potentially preventable conditions.
Study Design: This study is a two-year retrospective,
observational cohort study using all-payer hospital IP
and ED data from the 2005 – 2006 Healthcare Cost and
Utilization Project (HCUP) State Inpatient Databases
(SID) and State Emergency Department Databases
(SEDD) for four states: AZ, NE, NY, and TN.
Population Studied: Study population included patients
admitted to the hospital or treated & released from the
ED for five potentially preventable conditions as defined
by the AHRQ Prevention Quality Indicators (PQIs):
asthma, diabetes, congestive heart failure (CHF),
bacterial pneumonia, and pediatric gastroenteritis. Using
encrypted patient identifiers and discharge dates, visits
were aggregated by unique patients and the index visit
was flagged. The main outcome measure was re-visits
to the hospital and/or ED during the two-year period for
the same condition. Results were analyzed by patient
age, gender, expected payer, community-level income
and urban-rural location.
Principal Findings: Accounting for ED visits more than
doubled the number of encounters for the selected PQI
conditions from 580,000 IP events to about 1.2 million
total events and increased hospital charges by $630M to
nearly $12B. About 84% of these visits were among
patients seen once in the study period; 16% of patients
experienced a re-visit for the same condition. Patients
treated in the ED had more re-visits for the same
condition than patients seen in the IP setting: the
additional ED visit data increased the overall re-visit
percentage by 23%.
The impact of ED data varied by PQI condition. Pediatric
gastroenteritis and asthma encounters occurred 84%
and 78% of the time in the ED, respectively. In contrast,
ED visits added relatively less for CHF, with ED data
representing about 11% of all CHF visits. Visit rates
differed substantially by patient populations, payer
groups, and States. For example, the elderly were half
as likely to use the ED for asthma visits compared to
adults and children. From a payer / State perspective,
uninsured children in NY seen for gastroenteritis had
higher re-visit rates within one-month of their index visit
compared to those who were always insured; whereas,
the opposite was true for uninsured children in TN.
These payer findings were largely influenced by the
addition of ED data.
Conclusions: This innovative study demonstrates the
impact patient re-visits to the ED have on overall hospital
utilization and costs for selected potentially preventable
admissions. Because a substantial portion of re-visits
manifest as ED encounters, these findings caution
against the sole use of inpatient admission and
readmission rates as an indicator of hospital cost, quality
and access, without accounting for patient visits to the
ED. In fact, ED "treat and release" visits can substitute in
some cases for an IP readmission. Overall, they
increase the total cost of revisits, but in some programs
or geographic areas they may be substituting for more
costly IP readmissions.
Implications for Policy, Delivery or Practice: Findings
can provide important insights to policy-makers when
designing strategies to reduce multiple visits for
potentially preventable conditions. A more
comprehensive analysis of potentially preventable
hospital visits by including visits to the ED is likely to
alter inferences and interventions aimed at reducing readmission rates for potentially preventable medical
conditions.
Funding Source(s): AHRQ
♦ Measuring the Process-Outcome Link with
Composite Indices in Trauma Services
Cameron Willis, B.P.; Johannes Stoelwinder, M.B.B.S.,
M.D.; Fiona Lecky, M.B.B.S., Ph.D.; Maralyn Woodford,
M.B.B.S., M.D.; Omar Bouamra, Ph.D.; Peter Cameron,
M.B.B.S., M.D.
Presented by: Cameron Willis, B.P., Ph.D. Scholar,
Epidemiology & Preventive Medicine, Centre for
Research Excellence in Patient Safety, The Alfred
Hospital, Monash University, Melbourne, 3004, AU,
Phone: +0061399030623, Email:
cameron.willis@med.monash.edu.au
Research Objective: Measuring and reporting hospital
performance requires tools that are appropriate for the
complexity of healthcare. This investigation, using
trauma care as an example, aimed to determine if
composite indices that aggregate process measures into
a single index demonstrate greater association with inhospital mortality measured at the unit of the hospital.
Study Design: This investigation used data from the
Victorian State Trauma Registry (VSTR) in Australia and
the Trauma Audit and Research Network (TARN) in the
UK. VSTR is a state-wide registry of all trauma
admissions in the Australian state of Victoria. TARN
contains information on trauma patients treated in the
UK, and is currently the largest source of trauma data in
Europe. In total, 9 trauma process indicators of the suite
developed by the American College of Surgeons
Committee on Trauma (ACSCOT) were available for
analysis in both TARN and VSTR. Three composite
methods were applied to these indicators: two
denominator based weight approaches employed by the
Centers for Medicare and Medicaid Services (CMS) and
the Agency for Healthcare Research and Quality
(AHRQ) as well an additional method based on Factor
Analysis as used by the OECD. Patient level data was
aggregated into hospital/year panel data. Composite
measures were calculated for each hospital/year
observation. Each composite was entered as an
independent variable in separate Poisson regression
models with the count of in-hospital mortality per year as
the dependent variable. The number of expected deaths
per observation was calculated using the Trauma score
(revised) and Injury Severity Score methodology
(TRISS). The change in-hospital mortality across the
central 50% of each composite scale was ascertained.
Population Studied: Blunt trauma patients aged > 15
years, who received treatment between January 2001
and December 2007 were included for analysis.
Penetrating injuries were excluded. The final dataset
included 9218 patients, treated within 14 hospitals over 6
years. The final hospital year dataset therefore included
84 hospital/year observations.
Principal Findings: A statistically significant association
between composite measures and in-hospital mortality
was present for each composite index. While hospital
rankings varied by method, each composite was
inversely associated with mortality, whereby higher
composite performance was linked with lower mortality.
For the denominator based weight approaches, the
decrease in mortality across the central 50% of the
composite scale was 12.06% and 13.58%, while the
factor analysis composite was associated with a 16.13%
decrease in mortality (p<0.05).
Conclusions: Hospital rankings and the strength of
association between composite performance and patient
outcomes varied depending on composite method.
While these results do not support the superiority of a
particular composite method, they suggest each has the
capacity to be a useful tool for measuring quality in
complex systems such as healthcare.
Implications for Policy, Delivery or Practice: The link
between composite process measures and patient
outcomes identified in this study is essential for
establishing the construct validity of quality indicators in
trauma. Therefore, the composite indices in this study
could serve as useful measures for future public
reporting and pay for performance programs in trauma
care.
Funding Source(s): National Health and Medical
Research Council of Australia
Quality & Efficiency: Measurement #4
Chair: Gareth Parry
Tuesday, June 30 * 8:00 a.m.-9:30 a.m.
♦ An Automated Model that Predicts Risk of
Readmission for Heart Failure: Importance of Social
Factors & Implications for Pay-for-Performance
Ruben Amarasingham, M.D., M.B.A.; Ying Tabak, Ph.D.;
Tim Swanson, B.A.; Christopher Clark, M.P.A.; W. Gary
Reed, M.D.; Billy Moore, Ph.D.
Presented by: Ruben Amarasingham, M.D., M.B.A.,
Associate Chief of Medicine, Center for Innovation &
Knowledge Translation, Parkland Health & Hospital
System, 5201 Harry Hines Boulevard, Dallas, TX 75235,
Phone: (214) 590-6724, Email:
ramara@parknet.pmh.org
Research Objective: Readmission to the hospital within
30 days of an admission for heart failure (HF) has
gained widespread attention as a potential pay-forperformance measure. However, existing models that
could be used to risk adjust for HF readmission,
including a proposed government model, demonstrate
poor to moderate predictive capability (area under
receiver operating characteristic curves [AUC] do not
exceed 0.6) and are not designed to identify high risk
patients in real-time. Though social and environmental
factors may be associated with higher readmission risk,
few models comprehensively incorporate these
variables. We sought to improve on previous HF models
using automated clinical and social data available early
in a hospital admission.
Study Design: A model for 30 day readmission was
derived retrospectively from 1,425 HF admissions to an
urban safety net hospital using automated data obtained
within 24 hours of admission. We assessed severity of
illness using a modified version of the Tabak mortality
score for HF, a validated model that uses age, laboratory
and vital sign data to assign clinical risk. Race, sex,
payer, no.of emergency contacts, history of positive
urine cocaine, history of mental illness, patient´s census
tract of origin, medication refill adherence rate, no. of
home address changes, no. of emergency department
(ED) visits, and no. of hospital admissions in the prior
year were also assessed through multivariable logistic
regression. We internally validated model coefficients by
applying bootstrap sampling to candidate variables;
variable selection was performed using step-wise
regression and the Bayes Information Criterion. We
assessed model fit through calibration, discrimination,
and re-classification and assessed overall model
improvement using the AUC, the Hosmer-Lemeshow
test, and the integrated discrimination improvement
index. The final model was externally validated using
495 separate HF admissions from the same period.
Population Studied: 1,217 adult patients (representing
1,920 hospital encounters) admitted to an academic
urban safety net hospital between January 2007 and
October 2008 for HF; 75% were randomized into the
derivation group and 25% into the validation group.
Principal Findings: Crude readmission rate was 19%.
Significant predictors (p<.05) after multi-variable
adjustment included clinical score (OR 1.45), Medicare
status (1.74), emergency contacts >2 (1.33), prior
positive urine cocaine (1.19), history of mental illness
(1.17), low vs. high risk census tract (0.71), refill
adherence rate > 10% (0.43), >2 prior ED visits (1.41) or
>4 hospitalizations (5.35). The AUC for the clinical
model was .61 (95% CI: 0.57, 0.65). The AUC improved
to 0.76 (95% CI: 0.72, 0.80) when social factors were
included, and remained high in the validation model (OR
0.79; 95% CI: 0.73, 0.84).
Conclusions: At a large safety net hospital, an
electronic model can predict risk for HF readmission
using clinical and social data obtained within 24 hours of
admission. This model exceeds the predictive capability
of prior models, including a proposed CMS model.
Implications for Policy, Delivery or Practice:
Incorporating social and environmental data greatly
increases the model's accuracy, suggesting that these
factors be considered in the design of a federal pay-forperformance program evaluating readmission rates for
HF. Electronically derived risk scores may enable finely
targeted interventions to reduce readmission for HF.
♦ Patients with Multiple Chronic Conditions Perceive
Problems with Coordination of Care: Analysis of
International Patient Experience Data
Jako Burgers, M.D., Ph.D.; Eric Schneider, M.D., M.S.
Presented by: Jako Burgers, M.D., Ph.D., Harkness
Fellow 2008/2009, Health Policy & Management,
Harvard School of Public Health, 677 Huntington
Avenue, Kresge 429, Boston, MA 02115, Phone: (617)
432-6448, Email: jburgers@hsph.harvard.edu
Research Objective: Chronic diseases are by far the
leading cause of death in the world and their impact is
growing. An international survey in 2007 showed that
30% of adults reported two or more conditions.
Clinicians may find it challenging to provide optimal care
for patients with multiple conditions, but prior studies
suggest that performance on process of care measures
is not lower for such patients. Patient experience reports
are another important source of information about the
quality of care. Our study assessed whether the patientreported experience of care differs based on the
number, type, and specific combinations of chronic
conditions.
Study Design: The Commonwealth Fund International
Health Policy Survey 2008 screened an initial sample of
26,269 adults by telephone identifying a study sample of
9,944 chronically ill adults, meeting one or more of four
criteria: 1) rated their health as fair or poor; 2) reported
that in the past two years they had a serious illness,
injury, or disability requiring intensive medical care; 3)
had major surgery; 4) had been hospitalized.
Respondents completed a longer telephone interview
including questions about the presence of seven chronic
conditions (hypertension, heart disease, diabetes,
arthritis, chronic lung problems, cancer, and mental
health problems), and 12 questions about their
experience with (1) a personal doctor (2) specialists, (3)
coordination of care, and (4) quality of care overall. We
stratified respondents based on the number, type and
specific combinations of conditions, comparing patientreported experiences across these strata using ANOVA
or Chi-square tests as appropriate. Results will be
adjusted for potential confounders (e.g., perceived
health status, country) using multivariable regression.
Population Studied: Patients with multiple chronic
conditions among population of “sicker” adults.
Principal Findings: Seventy-five percent of the study
cohort reported one or more chronic conditions with 23%
reporting two conditions, 14% reporting three conditions,
and 8% reporting four or more conditions. The most
prevalent reported conditions were hypertension (38%),
arthritis (30%), and depression (24%). Patients with two
or more chronic conditions reported higher ratings of
their personal doctor and specialists than patients with
one or none. However, reported coordination of care
and overall quality of care was lower among patients
with more than two chronic conditions compared with
others. Patients with diabetes or cancer reported higher
ratings of care than patients with chronic lung problems
and mental health problems. Patients with concordant
conditions (combinations of hypertension, heart disease,
diabetes) reported higher quality than patients with other
combinations of conditions. Adjusted results of the
analysis will be presented at the meeting.
Conclusions: Patients with multiple chronic conditions
had favorable views of their physicians, but were more
likely than those with fewer chronic conditions to report
problems with coordination of care. Patients with
diabetes and cancer were more likely than patients with
other chronic conditions to report positive care
experiences.
Implications for Policy, Delivery or Practice: Chronic
conditions are associated with higher ratings of
providers, but lower scores on coordination of care.
Quality improvement efforts should focus on improving
coordination of care in patients with multiple conditions,
in particular those with chronic lung or mental health
problems
Funding Source(s): CWF, Harvard School of Public
Health
♦ Use of Patient-Level Composite Index to Track
Quality of Care for Acute Myocardial Infarction: The
Singapore Experience
Matthew Niti, M.B.B.S., M.P.H., Ph.D.; Eng Kok Lim,
M.B.B.S., M.S.; Khuan Yew Chow, M.B.B.S., M.S.; Jian
Ming Kung, M.B.B.S.; Deurenberg-Yap Mabel, M.B.B.S.,
M.S., Ph.D.
Presented by: Matthew Niti, M.B.B.S., M.P.H., Ph.D.,
Medical Epidemiologist, Health Services Research &
Evaluation Division, Ministry of Health, Ministry of Health
Singapore, College of Medicine Building, 16 College
Road, 169854, Singapore, Phone: +65 63257474 (DID),
Email: niti_matthew@moh.gov.sg
Research Objective: Our research objective was to
develop a composite quality index to track quality of care
for acute myocardial infarction (AMI) in public hospitals
in Singapore.
A combination of both process and outcome indicators
was used to provide a holistic assessment of care
provided. The relationship between the provision of
recommended processes of care and outcomes
achieved was also evaluated.
Study Design: Patient-level achievement for AMI
process indicators was determined using the Centers for
Medicare & Medicaid Services/Joint Commission on
Accreditation of Healthcare Organization (CMS/JCAHO)
aligned measure specifications.
Risk-adjusted hospital standardized mortality ratio
(HSMR) for 30-day mortality were determined using the
methodology developed by Sir Brian Jarman of the Dr
Foster Unit at Imperial College London. Patient-level
composite process scores were computed using the ‘Allor-none’ (proportion of patients receiving all applicable
processes of care) and the ‘average patient rate’
(proportion of applicable processes of care received by
patients) methods.
The relationship between the provision of recommended
processes of care and outcomes achieved was
assessed. Tests of independent associations between
hospital-specific attainments for the two composite
process scores and risk-standarised 30-day mortality
were then performed using multivariate logistic
modeling.
Population Studied: The study covered AMI cases
admitted to public hospitals and registered with the
Singapore Myocardial Infarction Registry in 2006.
Principal Findings: Using all AMI process indicators,
inter-hospital variations as indicated by coefficient of
variation were 0.10 and 0.04 respectively.
While the ‘All-or-none’ process scores were not
significantly associated with 30-day mortality (p=0.61); a
significant association was observed for the ‘Average
patient rate’ after adjusting for age, gender, ethnic group,
past history (of hypertension, diabetes mellitus,
dyslipidemia, AMI, PTCA, CABG), smoking, heart failure
at admission, left ventricular systolic disfunction,
creatinine, STEMI/ NON-STEMI, primary PTCA,
subsequent PTCA, and admitting hospital (p<0.001). For
‘average patient rate’, patients who received 70% or
more of the applicable care processes (‘70% standard’
method) were 50% less likely to die within 30-days after
AMI (OR=0.51, 95% CI=0.41-0.64).
Conclusions: The study highlighted significant
differences between hospitals indicating likely variation
in quality of care. Both the ‘All-or none’ and ‘Average
patient rate’ methodologies for composite scoring can be
used to identify inter-hospital variations. However, while
the ‘All-or-none’ methodology was more sensitive, it was
not significantly associated with the measured outcomes
of care.
Implications for Policy, Delivery or Practice: The
combination of AMI process measures as defined by the
CMS/JCAHO aligned measure specifications and 30-day
HSMR for AMI appear to be a valid measure for
inclusion as a performance measure for quality
improvement framework in public hospitals.
♦ Examining Diabetes Cost of Care Health Plan
Measurement Stability Over Time
Sally Turbyville, M.A, M.S.; David Knutson, M.S.; L.
Gregory Pawlson, M.D., M.P.H.
Presented by: Sally Turbyville, M.A, M.S., Research
Scientist, Performance Measurement, National
Committee for Quality Assurance, 1100 13th Street, NW,
Suite 1000, Washington, DC 20005, Phone: (202) 9551756, Email: turbyville@ncqa.org
Research Objective: In 2007, the National Committee
for Quality Assurance (NCQA) introduced standardized
measures of health plan costs of care. This study
examines whether health plan performance remains
consistent from year to year.
Study Design: Health plans submit data on costs of
care for diabetics in four service categories: inpatient
facility, evaluation and management, procedure and
surgery and ambulatory pharmacy services. Plans apply
standardized prices to utilization to estimate cost. Data
are risk adjusted to account for variation in health plan
case and risk-mix of members. NCQA calculates an
observed-to-expected (O/E) ratio for each plan
comparing the actual costs to expected costs (given the
case-mix/risk of their members). For each year, NCQA
ranked health plans by their O/E results and placed
plans into four quartiles. We calculated the number of
plans moving between quartiles from 2006 to 2007.
Extreme movement was defined as plan movement form
either the highest to lowest quartile or lowest to highest
quartile.
Population Studied: 186 commercial HMOs submitted
the RRU for diabetes measure in both years for at least
one service category. The eligible population included
diabetics who were enrolled in the plan for at least 11
months during the measurement year. Plans
represented all regions of the U.S.
Principal Findings: Of the 183 that reported evaluation
and management costs, 57% percent stayed in the
same quartile, 31% moved to an adjacent quartile and
12% experienced extreme movement. Of the 12% (or 21
plans), 5 reported small sample size (<400) and 8 noted
calculation errors in 2006. Both the pharmacy and the
procedure and surgery categories had similar patterns.
Of the 185 plans that reported inpatient facility costs,
45% stayed in the same quartile, 51% moved to an
adjacent quartile, and 3% experienced extreme
movement. Both the pharmacy and the evaluation and
management categories had similar patterns. Of the185
plans that reported inpatient facility costs, 45% stayed in
the same quartile, 51% moved to an adjacent quartile,
and 3% experienced extreme movement.
Conclusions: Health plan results on costs of care
performance were generally consistent across two years
of reporting. Inpatient facility costs had the least
amount of extreme plan movement. Large changes in
health plan ranking were related to smaller eligible
patient populations and difficulty in following measure
specifications.
Implications for Policy, Delivery or Practice: As the
costs of health care continue to increase, purchasers
and policy makers are demanding comparative data on
costs. Measurement approaches that are a reflection of
true health plan utilization are feasible. Consistent
rankings of health plans over time suggest that these
results can be useful for making comparisons across
plans. NCQA has improved guidance for health plans
on how to calculate costs of care measures and will
consider the size of the eligible population in future plans
for public reporting. Using RRU measure findings, plans,
consumers, and policymakers may glean extensive
knowledge about resource use for particularly costly
conditions and can compare plan to each other and over
time.
♦ Relationship Between Process Quality Measures &
Acute Care Utilization for People with Asthma
Enrolled in Medicaid
Pierre Yong, M.D., M.P.H.; Rachel Werner, M.D., Ph.D.
Presented by: Pierre Yong, M.D., M.P.H., Clinical
Scholar, Robert Wood Johnson Clinical Scholars
Program, University of Pennsylvania, 1303A Blockley
Hall, 423 Guardian Drive, Philadelphia, PA 19104,
Phone: (215) 573-2573, Email:
pyong@mail.med.upenn.edu
Research Objective: As controller medications for
asthma prevent exacerbations, whether or not patients
appropriately receive these medications is currently used
as a HEDIS quality measure. However, prior studies of
this measure suggest that receipt of controller
medications is associated with higher rates of asthma
exacerbations, possibly due to unmeasured disease
severity. While alternative measures have been
proposed to try to account for differences in disease
severity, little is known whether these alternative
measures are predictive of clinical outcomes. The
objective of this study was to compare the association
between quality measures and asthma exacerbations
among Medicaid beneficiaries for three quality
measures: the current HEDIS asthma metric of receipt
of at least 1 controller medication in a calendar year and
2 recently proposed asthma quality metrics.
Study Design: We performed a retrospective cohort
study of Medicaid beneficiaries with persistent asthma,
as defined by HEDIS criteria using outpatient, inpatient
and pharmacy service use for asthma in 2001 – 2002 in
California and New York. We assessed 3 asthma quality
metrics for each beneficiary in 2002: 1) the current
HEDIS measure of filling at least 1 controller medication
prescription; 2) filling at least 4 controller medication
prescriptions; and 3) a controller-to-total asthma
medication ratio of at least 0.5. The first comparison
metric assesses whether those with asthma receive at
least 4 controller medication dispensings in a calendar
year. The second comparison metric is a controller-tototal (controller plus short-term reliever) asthma
medication ratio of at least 0.5, which may better reflect
control of asthma symptoms as those with wellcontrolled disease will need less short-term reliever
medication and thus will have a higher ratio. We
calculated the odds of having an asthma exacerbation
(defined as an emergency department [ED] use or
hospitalization for asthma) in 2003 as a function of
performance on each of the quality metrics, adjusting for
race, sex, age and prior use of acute care services for
asthma.
Population Studied: 50,505 persistent asthmatics in CA
(52.3%) and NY (47.2%).
Principal Findings: Those who obtained at least 1 or at
least 4 controller medications had increased likelihood of
poor outcomes (adjusted ORs 1.46 [95% CI 1.34 – 1.59]
and 1.19 [95% CI 1.12 – 1.26], respectively). In contrast,
beneficiaries meeting the controller-to-total asthma
medication ratio measure were 19.1% less likely to
utilize acute care services (adjusted OR 0.81 [95% CI
0.76 - 0.86]).
Conclusions: A higher controller-to-total asthma
medication ratio was predictive of lower likelihood of
subsequent ED visits and hospitalizations for asthma,
whereas assessing number of prescription dispensings
for controller medications predicted higher odds of acute
care utilization regardless of the number filled.
Implications for Policy, Delivery or Practice: While
appropriate treatment of asthma using controller
medications is an important component of high quality
care, quality metrics based on this process of care vary
in their association with clinical outcomes. Adequate
assessment of quality of care for asthma should include
process measures that are predictive of good clinical
outcomes.
Funding Source(s): Leonard Davis Institute for Health
Economics
Quality & Efficiency: Measurement #5
Chair: G. Caleb Alexander
Tuesday, June 30 * 11:30 a.m.-1:00 p.m.
♦ Enhancing Measurement of Pediatric Patient
Safety Indicators Through Data Linkage: The
Canadian Experience
Astrid Guttmann, M.D.C.M., M.Sc.; Anne Matlow, M.D.;
Geta Cernat, M.D.; Christopher Parshuram, M.D., Ph.D.;
Jennifer Bennie, M.Ed.; Geoffrey Anderson, M.D., Ph.D.
Presented by: Astrid Guttmann, M.D.C.M., M.Sc.,
Scientist, Institute for Clinical Evaluative Sciences, 2075
Bayview Avenue, G106, Toronto, ON M4N4M5, CA,
Phone: (416) 480-4055 x 3783, Email:
astrid.guttmann@ices.on.ca
Research Objective: To determine the impact on rates
of pediatric safety indicators of 1) increasing the
denominator of eligible cases by including same day
surgery (SDS) as well as inpatient surgery cases and 2)
broadening the search for adverse events (i.e.,
numerator) through linkage to post-discharge rehospitalization and emergency department (ED) visits .
Study Design: We used a Canadian expert panel to
develop a set of safety indicators based on AHRQ
pediatric safety indicators that could be applied to
inpatient and SDS cases. We identified ICD-10 codes
for each of these indicators. We applied these codes to
a comprehensive set of inpatient and SDS data for the
province of Ontario to identify eligible index cases and to
determine the number of safety events recorded in these
cases. We used unique identifiers to link the index cases
to subsequent inpatient hospitalizations and ED visits to
widen the window to detect safety events.
Population Studied: All pediatric inpatients and SDS
patients in Ontario, Canada for 2003-2007.
Principal Findings: Overall, 2/3 of all operations on
children in Ontario are performed in the SDS setting.
There were more than double the number of cases of
post-operative hemorrhage in SDS patients compared
with inpatients (401 vs. 170), and these events occurred
in 63/133 of all community hospitals in Ontario.
Postoperative pneumonia and sepsis were the next most
common adverse events in SDS patients, and although
the rates were relatively low (0.6 and 0.14 per 1,000)
there were 173 cases of pneumonia detected in SDS vs.
204 in the inpatient sample. Rates per 1,000 of the
inpatient indicators using the original AHRQ definitions
were lower in Ontario than reported in the US for postoperative sepsis (9.33 vs 27.39), decubitus ulcer (1.43
vs 3.6), selected infections (1.91 vs. 3.25) and foreign
body (0.001 vs. 0.03). Ontario had higher rates per
1,000 of post-operative hemorrhage (3.78 vs 1.76) and
pneumothorax (0.4 vs 0.37 in neonates, and 0.33 vs
0.21 in non-neonates). Linking to subsequent
hospitalizations and/or ED visits (for decubitus ulcer
only) up to 21 days post-discharge for some indicators
increased the number of cases detected over the 3
years –from 204 to 431, 229 to 522, and 331 to 764 for
post-operative pneumonia, sepsis and selected
infections respectively. This also increased the number
of hospitals with events in all cases.
Conclusions: Although the rates of adverse events are
low in SDS cases, the large volume of these cases
means that including SDS substantially increases the
number of patient safety incidents detected. Using data
linkage to detect adverse events that result in ED visits
or return hospitalizations can substantially increase the
number of patient safety incidents detected. Further
work needs to be done to assess the validity of using
these measures.
Implications for Policy, Delivery or Practice:
Expanding the scope of pediatric patient safety
indicators to include SDS and to include events
subsequent to discharge from the index hospitalization
could provide a more complete view of pediatric patient
safety issues. Policy makers and administrators should
consider these issues when developing accountability or
payment tools based on adverse event measurement.
Funding Source(s): Canadian Institute for Health
Research
♦ Enhanced Risk Adjustment from Adding
Laboratory Test Measures to Administrative Data in
the Veterans Health Administration (VA)
Amresh Hanchate, Ph.D.; Ann Borzecki, M.D.; Michael
Shwartz, Ph.D.; Arlene Ash, Ph.D.; Amy Rosen, Ph.D.
Presented by: Amresh Hanchate, Ph.D., Research
Assistant Professor, General Internal Medicine, Boston
University School of Medicine, 801, Massachusetts
Avenue, #2077, Boston, MA 02118, Phone: (617) 6388889, Email: hanchate@bu.edu
Research Objective: Accurate risk adjustment is critical
for quality assessment, provider comparisons, and
benchmarking across healthcare systems. Chart-based
clinical data, although theoretically ideal for risk
adjustment, are not readily available. Thus, risk
adjustment continues to be based on administrative
data, such as for Medicare’s 2008 Hospital Compare
ratings, despite its known limitations. Increasingly
healthcare systems such as the VA have automated
laboratory test and vital signs data. In this study, we
compared the ability of a STANDARD (administrativedata-based) model to one ENHANCED with laboratory
data to predict: 1) outcomes from selected acute medical
conditions, 2) patients at high and low risk of the
specified outcomes, and 3) hospital-level risk-adjusted
outcomes.
Study Design: We conducted a retrospective
observational study using 2004-2007 VA inpatient
administrative and laboratory data to predict in-hospital
death (Y/N) and length of stay (LOS; days). Predictors
included age, gender, race, comorbidities from those
listed on the inpatient administrative record, and
laboratory values. Starting with a STANDARD model, we
evaluated improvements in predicting in-hospital death
and LOS from adding risk factors based on six
laboratory tests (albumin, bilirubin, serum sodium,
creatinine, blood urea nitrogen and white blood cell
count). Model development and hypothesis testing used
hierarchical multivariate logistic and linear regression
models.
Population Studied: We included all 2004-2007 acutecare admissions (N=368,000) from 160 VA facilities with
a principal diagnosis of acute myocardial infarction,
congestive heart failure (CHF), cirrhosis and alcoholic
hepatitis, chronic obstructive pulmonary disease,
gastrointestinal hemorrhage, hip fracture, pneumonia,
acute renal failure and acute stroke.
Principal Findings: Hip fracture was the smallest cohort
(N=8,688) and CHF the largest (N=87,698). Virtually all
laboratory test measures were significant predictors in all
cohort regressions. ENHANCED models had better
discrimination (C-statistics) for most cohorts and both
outcomes; the largest improvement was for death from
cirrhosis & alcoholic hepatitis (from 0.66 to 0.78). Model
discrimination, as measured by comparing actual
outcomes in the bottom and top risk deciles from each
model, also improved significantly across most cohorts.
For example, in AMI, observed mortality in the lowest
and highest deciles under the STANDARD model was
1.0% and 19.8%; under the ENHANCED model, the
analogous figures were 0.8% and 25.0%. The models
identified different facilities as having the most extreme
levels of risk. For example, across the 9 cohorts,
between 1 and 5 of the 10 facilities with the lowest riskadjusted mortality were common to both models;
between 3 and 7 of the 10 facilities with the highest riskadjusted mortality overlapped.
Conclusions: Adding laboratory test measures to
administrative data-based risk-adjustment models i)
improved our ability to identify patients at higher risk for
inpatient death or longer hospitalization, and ii) changed
our view of relative hospital performance.
Implications for Policy, Delivery or Practice: Adding
laboratory data to administrative data enables better risk
adjustment for monitoring inpatient care in the VA. The
more accurate models can also help target veterans at
higher risk of adverse outcomes for protective
interventions.
Funding Source(s): VA
♦ Linking Practice Guidelines & Abstraction of
Electronic Medical Record Data to Measure the
Quality of Cancer Care
George Jackson, Ph.D., M.H.A.; L. Douglas Melton,
M.P.H.; David Abbott, M.P.H., M.S.; Leah Zullig, M.P.H.;
Diana Ordin, M.D., M.P.H.; Dawn Provenzale, M.D.,
M.S.
Presented by: George Jackson, Ph.D., M.H.A.,
Research Health Scientist, Health Services Research &
Development Service, Durham Veterans Affairs Medical
Center, 508 Fulton Street, Durham, NC 27705, Phone:
(919) 286-0411 x 7091, Email:
george.l.jackson@duke.edu
Research Objective: As part of a Veterans Affairs (VA)
healthcare operations-Health Services Research &
Development quality improvement partnership, our goal
was to link clinical practice guidelines to data abstracted
from the VA electronic medical record to measure the
quality of colorectal cancer (CRC) care provided by the
VA.
Study Design: We developed six stage-specific quality
indicators based on 2003 National Comprehensive
Cancer Network (NCCN) colon and rectal cancer
practice guidelines and three timeliness-of-care
measures to serve as a metric for evaluating quality
care. Through a special study of the External Peer
Review Program, VA’s official system for measuring
quality of healthcare, data were abstracted remotely
(without facility review) from the VA Computerized
Patient Record System (CPRS) on a sample of CRC
patients diagnosed between October 1, 2003-March 31,
2006. Patients who potentially had CRC diagnosed
within the time period were identified using the VA
Decision Support System via an algorithm utilizing
diagnosis (ICD-9), procedure (CPT), and provider type
codes to define patterns of diagnosis and VA healthcare
utilization within +/- 3 months of the target study period.
Criteria for inclusion in the final analytic dataset were: 1)
incident CRC; 2) diagnosis October 1, 2003-March 31,
2006; 3) curative intent surgery in the VA; and 4) cancerstage documentation in CPRS.
Population Studied: Of 9,599 patients initially identified
by the algorithm, 5.9% did not have CRC and 48.3%
were diagnosed outside the study time period. Of the
remaining 4,388 cases 1,280 did not have surgery in the
VA and 212 did not have a documented cancer stage,
leaving a final analytic data set of 2,898 VA-treated CRC
patients.
Principal Findings: More than 80% of patients had
preoperative carcinoembryonic antigen (CEA)
determination (82.8%) [stage II-III patients, n=1729] and
documented clear surgical margins (81.1%) [stage II-III,
n=1,729]. Between 72% and 80% of patients had a
preoperative computerized tomography
(CT) scan of the abdomen and pelvis (72.1%) [stage IIIII, n=1,729], appropriate medical oncology referral
(77.5%) [stage II-III, n=1,729], and adjuvant 5-FU-based
chemotherapy (73.5%) [stage III, n=808]. Less than half
of stage I-III CRC patients without obstructing lesions
surviving >= one year had a surveillance colonoscopy 718 months after surgery (43.5%) [n=1,259]. The mean
number of days between major treatment events
included: 26.6 days (SD=38.2) [stage II-III, n=1,729]
between diagnosis and initiation of treatment; 64.9 days
[SD=54.9] [stage II-III, n=767] between definitive surgery
and start of adjuvant chemotherapy; and 444.1 days
(SD=182.1) [stage I-III, n=644] between definitive
surgery and follow-up colonoscopy.
Conclusions: Quality of care for diagnostic evaluation
and treatment was good. However, there is significant
opportunity for improvement in colonoscopic
surveillance. While national guidelines for surveillance
colonoscopy varied from 1-3 years during the study
period, sensitivity analysis found less than optimal
surveillance rates regardless of the standard used.
Implications for Policy, Delivery or Practice:
Improving surveillance warrants special focus. This will
involve multiple medical specialties as the VA conducts
ongoing cancer quality improvement collaboratives.
Although no directly comparable data for the quality of
CRC care outside the VA are available, limited similar
data indicates the VA provides diagnostic evaluation and
treatment that is comparable to the private sector.
Funding Source(s): VA
♦ The North Carolina Harm Study: Validating the IHI
Global Trigger Tool (GTT) as a Potential National
Harm Measure
Christopher Landrigan, M.D., M.P.H.; Paul Sharek, M.D.,
M.P.H.; Gareth Parry, Ph.D.; Andy Hackbarth; Kate
Bones, M.S.W.; Donald Goldmann, M.D.
Presented by: Christopher Landrigan, M.D., M.P.H.,
Research Director, Inpatient Pediatrics Service,
Children's Hospital Boston, 300 Longwood Avenue,
Boston, MA 02118, Phone: (617) 355-2568, Email:
clandrigan@partners.org
Research Objective: To assess the suitability of the IHI
GTT for use as a measure of patient harm at individual
hospital and national levels and to inform the
methodology required for a national harm measurement
system.
Study Design: A retrospective review of 10 patient
charts per quarter from 10 randomly selected acute care
hospitals over a 6 year period. Charts were reviewed by
teams internal and external to the hospital. Further, 10%
of the charts were reviewed by a ‘gold standard’ team of
experienced IHI GTT reviewers. Each team applied the
GTT methodology, and harms identified were compared
within and between team (using Kappa statistics). A
secondary analysis explored harm over time (using a
random effects poison regression model).
Population Studied: The study population comprised
patients admitted to 10 randomly chosen acute care
hospitals in North Carolina between 2002 and 2007.
Principal Findings: Internal, external and ‘gold
standard’ teams found harm rates of 22.9 (95% CI 21.4,
24.9) per 100 patients (537 harms, 2344 charts), 17.2
(95% CI 15.6, 19.0) per 100 patients (403 harms, 2337
charts) and 36.6 (95% CI 28.8, 46.0) per 100 patients
(74 harms, 202 charts). Internal teams displayed an
almost perfect level of intra-rater agreement, where their
associated Kappa statistics were higher than external
teams for indicating any harm (internal Kappa=0.87 vs
external Kappa=0.57), number of harms (0.93 vs 0.72)
and severity of harm (0.87 vs 0.59). Internal teams also
displayed more (inter-rater) agreement with the ‘gold
standard’ reviewers than external teams for indicating
any harm (0.49 vs 0.32), number of harms (0.37 vs 0.30)
and severity of harm (0.53 vs 0.26).
No significant change in harm over time was detected
from internal reviews, 0.99 relative reduction per year,
(95% CI 0.94, 1.04 p=0.613) and external reviews 0.97
per year (95% CI, 0.92, 1.02 p=0.268). There was a
significant reduction in preventable harm found by
external reviews 0.91 per year (95% CI 0.84, 0.99
p=0.023), but not internal 0.99 per year (95% CI 0.93,
1.05 p=0.770).
Conclusions: The relatively high levels of agreement
within and between the review teams in this study of a
random sample of hospitals in one US State suggests
the IHI GTT may be a suitable measure of harm both for
individual hospitals and nationally.
Although the study was not powered to detect subtle
changes in harm rates over time, there was no
suggestion of an improvement trend over this over this 6
year period. However, there has been a
contemporaneous change in case mix and severity of
illness in US hospitals, and the results are unadjusted for
these factors. The results may indicate that current
strategies for improving specific aspects of patient safety
are not yet resulting in measureable overall
improvement.
Implications for Policy, Delivery or Practice: In order
to more clearly understand and assess the impact of
policies, recommendations and associated initiatives
aimed at improving patient safety, a nationally applicable
measure of patient harm is required. The time may now
be right for establishing such a measurement system
and performing robust studies to assess changes in
harm rates over time.
Funding Source(s): Rx Foundation and Institute for
Healthcare Improvement
♦ Measuring Quality of Care from the Patients’
Perspective: Results from the Consumer Quality
Index
Jany Rademakers; Dolf de Boer; Diana Delnoij; Niek
Klazinga
Presented by: Jany Rademakers, Head of Research
Department, Netherlands Institute for Health Services
Research, P.O. Box 1568, Utrecht, 3500 BN, NL,
Phone: +31 30 2729847, Email: j.rademakers@nivel.nl
Research Objective: The Consumer Quality Index
(CQI) is a CAHPS-inspired methodology for measuring
patient experiences and patient priorities, developed and
used in the Netherlands. Since patient groups may differ
in their care process, needs and priorities, separate CQI
surveys are developed for each patient group. At
present, seven CQI surveys are available for
benchmarking and another 15-20 are being developed.
The CQI is the national standard, and several large and
sometimes nationwide surveys have been undertaken.
In the CQI, questions about experiences are combined
with questions about the patient’s priorities. This
combination enables priority setting with respect to
quality improvement by providers. In this paper we will
present (a) differences between patient groups with
respect to their priorities and (b) demonstrate that
combining priorities and experiences provides additional
value to the quality information typically used for quality
improvement purposes.
Study Design: Data collected for the development of
four disease/procedure specific CQI surveys were used
for secondary analysis.
Population Studied: The four surveys covered breast
cancer patients (N=356), patients who underwent total
hip- or knee surgery (N=1686), patients who underwent
cataract surgery (N=4640) and patients with rheumatoid
arthritis (N=409).
Principal Findings: Broadly, there are several recurrent
themes that capture patient priorities, such as
‘information and communication’, ‘being treated with
respect’, ‘standard of care’ and ‘accessibility of care’. On
a more detailed level however, there are also striking
differences in priorities between patient groups. For
example, rapid accessibility of diagnostics and care were
of the utmost importance to breast cancer patients, while
for patients who underwent surgery, information and
standard of care were most important. We combined
patients’ priorities and experiences to generate a
measure of potential for improvement. These
‘improvement scores’ provide valuable management
information beyond needs / priorities or experiences
alone. Judging from priorities for example, information
about side effects of radiotherapy would seem a prime
candidate for quality improvement in breast cancer: the
priority rate is 3.7 on a 4-point scale. However, since not
many patients report negative experiences in this
respect (4.2%), the improvement score is low (0,15)
suggesting no need for immediate action. Similarly, while
one in five breast cancer patients report negative
experiences with email correspondence with the
hospital, the improvement score is rather low (0,48)
because these patients do not give email
correspondence with the hospital an extremely high
priority (2.4). On the other hand, when both priorities and
the percentage negative experiences are (relatively) high
the improvement score is too. For patients with
rheumatoid arthritis, this is the case with information
about treatment costs and refunds (3.3 and 51%
respectively).
Conclusions: Although there are some recurrent
themes, priorities vary between patient groups, which
stresses the need for surveys tailored to patient groups.
Combining priorities and experiences provides a
valuable contribution to information for quality
improvement, beyond needs assessments or experience
scores only.
Implications for Policy, Delivery or Practice: To better
tailor quality of care to the needs and wishes of patients
it is important to include questions about patients’
priorities in measurement instruments.
Funding Source(s): ZonMW / Dutch Ministry of Health
Impact of Public Reporting on Quality of Care
Chair: Hoangmai Pham
Monday, June 29 * 9:45 a.m.-11:15 a.m.
♦ Benchmarking Outpatient Rehabilitation Clinics
Pedro Gozalo, Ph.D.; Dennis Hart, Ph.D.; Linda Resnik,
Ph.D.
Presented by: Pedro Gozalo, Ph.D., Assistant
Professor (Research), Community Health, Brown
University, Box G-S121-6, Providence, RI 02912,
Phone: (401) 863-7795, Email:
Pedro_Gozalo@brown.edu
Research Objective: Assessment of quality of physical
therapy care is a new, but important area of research.
Payers are currently moving towards value purchasing
for outpatient therapy, and the Centers for Medicare &
Medicaid Services is actively exploring alternatives to
the therapy caps. Provider profiling has gained
popularity as a strategy to evaluate provider
performance which can in turn be used to guide pay for
performance policies and facilitate quality improvement
initiatives. The objective of this study is to estimate the
percent of variations in patient rehabilitation outcomes
attributable to physical therapists and to clinics, and the
ranking of clinics by performance.
Study Design: This was a prospective, longitudinal,
cohort study. The primary outcome was patient
functional status (FS) at discharge. FS was measured
using the FOTO tools on a scale of 0-100, with 100
indicating higher functioning. Hierarchical 3-level models
(patients nested within therapists, and therapists nested
within clinics) adjusting for patient case-mix are used to
predict estimates of the clinic and therapist specific
effects. Patient case-mix covariates included sex, age,
functional status at intake, number of days since onset of
condition, type of condition (10 categories including
lumbar, shoulder, knee, cervical, foot/ankle, hip,
wrist/hand, elbow, ribs, and craniofacial), number of
surgeries, a functional comorbidities index, and payer
type. Censoring of the outcome measure is accounted
for using inverse probability of censoring weights.
Population Studied: The population was drawn from
the Focus On Therapeutic Outcomes, Inc. (FOTO)
database. Individuals with an intake date between July
1, 2006 and June 30, 2008 were included (N=90,392
patients served by 2040 therapists in 532 clinics with a
minimum of 30 patients per clinic).
Principal Findings: Clinic effects were larger than
therapist effects. After adjusting for patient-level case
mix, the clinic effect explained 9% of the total variation,
while the therapist explained 2.4%. We used of therapist
and clinic effect estimates to rank clinics by performance
and the results show clear and statistically significant
differences between clinics. Estimated Discharge FS
attributable to clinics range from 0.4 to 24 units (in the 0-
100 scale) and differences between clinic performance
for clinics ranked in the lowest and highest performance
quartiles was statistically significant at 99% significance
level. Censoring of the discharge outcome was 36% but
correcting for censoring had small effects in the rankings
of most clinics (although a few clinics had relatively
larger changes).
Conclusions: Our findings suggest that profiling models
like ours offer an adequate method to benchmark
outpatient rehabilitation clinics.
Implications for Policy, Delivery or Practice: Clinic
benchmarking can be used as a tool to control costs and
evaluate quality. The performance information provided
can be used to help identify good and bad practice
processes that can be used to improve service quality
and efficiency.
Principal Findings: Of 22,683 hospital discharges,
20,108 had a discharge status of alive. Age, presence of
any of the six complications and the interaction of
complications with a gap in staffing were most predictive
of FTR (0<.01). However different staffing measures
exhibited different levels of significance within and
across complication types.
Conclusions: We have reported on a fully powered
study on the effect of unit/shift level staffing on FTR.
The specific measure of staffing affected the significance
of the staffing variable in predicting FTR.
Implications for Policy, Delivery or Practice: The
impact of nurse staffing on FTR differed across the six
FTR complication types. These findings have
implications for studies of nursing sensitive outcomes.
Funding Source(s): AHRQ
♦ Nurse Staffing & Failure to Rescue
Jack Needleman, Ph.D.; Harris, Marcelline, Ph.D.; Peter
Buerhaus, Ph.D.; Cynthia Leibson, Ph.D.; V. Shane
Pancratz, Ph.D.; Catherine Vanderboom, Ph.D.
♦ Misleading Advice about AMI Mortality from
Medicare
Jeffrey Silber, M.D., Ph.D.; Paul Rosenbaum, Ph.D.;
Tanguy Brachet, Ph.D.; Richard Ross, M.S.; Scott Lorch,
M.D., M.S.C.E.; Kevin Volpp, M.D., Ph.D.
Presented by: Jack Needleman, Ph.D., Associate
Professor, School of Public Health, University of
California, Los Angeles, 650 Charles Young Drive South,
Room 31-236B CHS, Los Angeles, CA 90095-1772,
Phone: (310) 267-2706, Email: needlema@ucle.edu
Research Objective: The association of nurse staffing
with quality outcomes remains a topic of high interest.
Failure to Rescue (FTR) is a National Quality Forum
(NQF) nursing-sensitive performance measure and
proposed 2010 CMS quality measure. FTR uses
inpatient billing data to identify hospital acquired
complications that end in death. Six FTR complication
types are defined; for each, a denominator is
constructed by applying inclusion and exclusion rules to
ICD-9-CM discharge diagnoses and the numerator is
number of deaths. Among the challenges in analyzing
nurse staffing and FTR rates is the way nurse staffing is
measured. Moreover, the impact of nursing shortages is
at the shift and unit level, however the majority of studies
are based on hospital level data and are cross-sectional
thus one cannot associate staffing with unique patient
outcomes. This study links nurse staffing to specific
patients, examines two measures of nurse staffing
obtained at the unit and shift level, and their association
with failure to rescue.
Study Design: An observational design was used to
examine over 250,000 Mayo Clinic hospital discharges
from 2003-2006. The failure to rescue measure was
constructed using the methods published by the Agency
for Healthcare Research and Quality. Staffing measures
were based a method for acuity adjusting unit census to
recommend staffing needs on a shift-to-shift basis.
Staffing measures included actual hours and the gap
between recommended and actual hours. Logistic
regression was used to analyze the impact of nurse
staffing on FTR.
Presented by: Jeffrey Silber, M.D., Ph.D., Professor,
Center for Outcomes Research, The University of
Pennsylvania & The Children's Hospital of Philadelphia,
3535 Market Street, Suite 1029, Philadelphia, PA 19104,
Phone: (215) 590-5635, Email:
silberj@wharton.upenn.edu
Research Objective: We ask whether Medicare’s
Hospital Compare (HC) random effects model correctly
assesses AMI hospital mortality rates when there is a
volume-outcome relationship.
Study Design: We fit a logit model with the same
patient variables as in Medicare’s HC mortality model
but included hospital AMI Medicare volume. Consistent
with the literature, this model demonstrates that AMI
mortality is higher at hospitals with low Medicare volume.
Using this model, we created a Medicare population with
simulated deaths to insure a “true” volume-outcomes
relationship. We then fit the HC random effects model to
the simulated data set and asked if it correctly ranked
hospitals in this simulated population.
Population Studied: Medicare claims on 208,157 AMI
patients admitted from July, 2004 – June, 2005 in 3,629
acute care hospitals throughout the U.S.
Principal Findings: Using simulated deaths, where
risks are known by construction, HC greatly
underestimates risk at low-volume hospitals. Of 734
hospitals in the quintile with the highest “true” risk of
death (based on volume), HC classified only 30 hospitals
(4.1%) as being in that highest risk quintile. We repeated
the simulations 500 times and obtained very stable
results, with the range in correct assignment by
Medicare for this worst quintile being from 10 of 734
hospitals (1.36 %) to 45 of 734 hospitals (6.13 %).
Furthermore, the overall agreement between “true” risk
and Medicare HC predicted risk for all 3,629 hospitals
was no better than chance: the Kappa statistic relating
"true" rankings to Medicare HC rankings was near 0,
Kappa = -0.0068 (95% CI = -0.0229 to 0.0093) indicating
no association. In short, when you construct an artificial
data set which has a “true” volume-outcomes
relationship, the CMS HC random effects model
removes that relationship. Using real data, we observed
the same pattern.
Conclusions: The HC random effects model is biased
because it significantly underestimates the typically
poorer performance of low-volume hospitals.
Implications for Policy, Delivery or Practice: Our
simulation results confirm what intuition suggests: if
there is a volume-outcome relationship, but the
estimated risk at a small hospital is moved towards the
national average because the sample size is small at
that hospital, then this will mask or even eradicate the
volume-outcome relationship. We therefore conclude
that consumers (patients or health care providers or
researchers) should avoid using the Medicare Hospital
Compare model in its present form because
comparisons between large and small hospitals are
biased.
Funding Source(s): NHLBI
♦ Do Bad Report Cards Have Consequences? How
Publicly Reported Provider Quality Information
Impacts the CABG Market in Pennsylvania
Justin Tsung-Yi Wang, Ph.D.; Jason Hockenberry,
Ph.D.; Shin-Yi Chou, Ph.D.
Presented by: Justin Tsung-Yi Wang, Ph.D. Economics,
Lehigh University, 1949 Willings Lane, Hellertown, PA
18055, Email: tyw204@lehigh.edu
Research Objective: This paper investigates the impact
of CABG report cards in Pennsylvania.
Study Design: We first examine the impact of CABG
report cards on a provider's aggregate volume and
aggregate volume by patient severity. Then we employ a
nested logit model to investigate the matching between
patients and providers. Finally, we use predicted
demand from the nested logit model to construct a
report-card induced market concentration measure and
to analyze the impact of market concentration on
patients' health outcomes and resources used.
Population Studied: Pennsylvania residents (aged 30
and above) who were undergoing an isolated CABG
procedure in PA hospitals and who were admitted
between the third quarter of 1998 and the first quarter of
2006 (N=127,285).
Principal Findings: The evidence in this paper
suggests that the report card lowers poor performing and
unrated surgeons' volume, but does not have an impact
on hospital-level volume. We do not find the report card
publication improves the matching between patients and
providers. In addition, we find that report-card-induced
market concentration does not have an impact on
patients' in-hospital mortality, but reduces the amount of
resources used for low severity patients.
Conclusions: Our results indicate that surgical volume
is negatively associated with a surgeon's poor or no
rating at the aggregate level, regardless of patient
severity. We do not find hospital-level report cards have
an impact in hospital-level surgical volume. In addition,
the results from our patient-level choice model suggest
the demand side is aware of the report cards publication
and uses information to select high-quality surgeons. As
a result, the CABG market in Pennsylvania has become
more concentrated over time. Finally, we construct the
HHI using the predicted market share from the nested
logit model and we find the report card induced market
concentration leads to lower mortality and low resources
used for healthier patient, though the impacts on
mortality are not precisely estimated.
Implications for Policy, Delivery or Practice: The
findings in this paper suggest CABG market in PA
response to the newly released report cards and the
report cards improve the welfare of low severity patients,
but the welfare implication for high severity patients is
ambiguous.
Effects of Pay for Performance on Quality & Safety
Chair: Amy Rosen
Monday, June 29 * 3:00 p.m.-4:30 p.m.
♦ Effect of Physician-Specific Pay-for-Performance
Incentives to Improve Quality of Care in a Large
Primary Care Group Practice
Sukyung Chung, Ph.D.; Latha Palaniappan, M.D., M.S.;
Laurel Trujillo, M.D.; Haya Rubin, M.D., Ph.D.; Hal Luft,
Ph.D.
Presented by: Sukyung Chung, Ph.D., Health Policy
Research, Palo Alto Medical Foundation Research
Institute, 795 El Camino Real, Palo Alto, CA 94301,
Phone: (650) 853-4763, Email: chungs@pamfri.org
Research Objective: To assess the improvement in
quality of care measures with a physician-specific pay
for performance (P4P) program implemented in a large
primary care group practice.
Study Design: In 2007, the Palo Alto Division of the
Palo Alto Medical Foundation (PAMF/PAD), a multispecialty physician group practice in Northern California,
changed from a group-focused to physician-specific P4P
program. Primary care physicians received bonus
payment (maximum of $5000/year per physician) based
on their own performance on incentivized measures.
The PAMF/PAD has been assessing and periodically
reporting individual physicians’ performance on
established quality measures since 2004, using
electronic health records. In the physician-specific P4P
program, the amount of the incentives was linked to
each individual physician’s performance on a subset of
these quality measures. We analyzed nine incentivized
measures, including diabetes outcomes (HgbA1C, LDL,
and blood pressure control), asthma controller
prescription, preventive screening (colon cancer, cervical
cancer, Chlamydia), tobacco history documentation, and
measurement of weight and height. Other various
measures (such as blood pressure control for
hypertensive patients and alcohol history
documentation) reported to the physicians without
incentives were also analyzed for comparison purposes.
In the multivariate regressions, the main dependent
variable was percent score ((patients meeting the
target/eligible patients)*100) of each physician for each
measure. Difference in scores between 2006 and 2007,
was compared with the difference between 2005 and
2006. We also compared the performance of the Palo
Alto Division with that of two other divisions (Camino and
Santa Cruz) not implementing physician-specific
incentives.
Population Studied: All the PAMF/PAD primary care
physicians practicing in three departments – family
medicine, general internal medicine, and pediatrics – in
five clinics were included (n=167). All the active patients
meeting the measure-specific criteria, regardless of
insurance type, of each physician were included in the
quality assessment.
Principal Findings: Eight of nine measures included in
the physician-specific P4P program showed a significant
improvement in 2007 as compared to 2006 (p<0.05); the
improvement was the largest for colon cancer screening
(7%; p<0.01). The improvement between 2006 and
2007 was significantly better than previous years’ (20052006) improvement in three measures: blood pressure
control for diabetes patients, colon cancer screening,
and tobacco history documentation (all p<0.01).
However, a similar trend was observed in two of four
measures not included in the program: blood pressure
control for hypertensive patients and alcohol history
documentation (both p<0.01). Furthermore, the
improving trend in the quality of care measures in the
Palo Alto Division during 2005-2007 was not different
from the trend in other two divisions.
Conclusions: We did not find strong evidence of
enhanced quality improvement due to the physicianspecific P4P program. Although there was a modest
improvement, this could not be definitively linked to the
financial incentive program.
Implications for Policy, Delivery or Practice: In the
context of other organizational-level quality improvement
efforts, the relatively small financial incentives to
individual physicians implemented by the medical group
had limited incremental effects on established quality
measures. The effects of alternative types of incentives
for quality improvement (e.g. increasing coverage of staff
hours dedicated to quality improvement) need to be
explored.
Funding Source(s): AHRQ
♦ Transforming Acute Care in U.S. Hospitals: The
Financial Impact of Improving Safety & Eliminating
Redundant Tests
Ashish Jha, M.D., M.P.H.; David Chan, M.D., M.S.;
Abigail Ridgway, B.A.; Calvin Franz, Ph.D.; David Bates,
M.D., M.S.
Presented by: Ashish Jha, M.D., M.P.H., Assistant
Professor, Department of Health Policy & Management,
Harvard School of Public Health, 677 Huntington
Avenue, Boston, MA 02115, Phone: (617) 432-5551,
Email: ajha@hsph.harvard.edu
Research Objective: Adverse events, or injuries due to
medical care, are common, expensive, and often
preventable. Given the rising costs of healthcare and
the urgent need to improve patient safety, understanding
the financial impact of improving safety may motivate
providers, payers, and policy makers to redouble their
efforts to improve care.
Study Design: Using a combination of literature review
and expert consensus, we identified ten adverse events
(AE) that are common, expensive, and preventable:
venous thromboembolism (VTE), surgical site infections,
catheter-related blood stream infections, catheter-related
urinary tract infections, nosocomial pneumonia, adverse
drug events, in-hospital falls, pressure ulcers, postoperative hemorrhage, and iatrogenic pneumothorax.
Through literature review, we determined, for each AE,
the incidence rate, preventability, the frequency with
which prevention efforts are used, and the cost of each
adverse event. We then used the 2004 National
Inpatient Sample along with incidence and preventability
rates from our literature review to create national
estimates of how often each of these adverse events
occur in aggregate, how many are preventable, and the
costs associated with these preventable events. We
also considered an “ideal savings” scenario where we
estimated the potential savings of completely eliminating
each of the ten adverse events identified (i.e. assuming
preventability rate of 100%). In both cases, we
performed a stochastic sensitivity analysis with Monte
Carlo simulation to estimate a range of likely savings
given the ranges of parameters obtained from literature
reviews.
Population Studied: Patients admitted to U.S. hospitals
in 2004.
Principal Findings: In 2004, there were approximately
5.7 million adverse events in U.S. hospitals, of which
approximately 53% were preventable. These included
approximately 828,000 episodes of VTE (62% were
preventable associated with $3.1 billion in potential
savings). Similarly, there were 1.7 million cases of
hospital-acquired infections, of which 82% were
preventable and these preventable events were
associated with nearly $5.8 billion in annual savings.
Other adverse events included an estimated 2.1 million
adverse drug events (26% were preventable with $ 3.8
billion in potential savings), 720,000 falls (33%
preventable with $2.7 billion in savings) and
approximately 220,000 cases of pressure ulcers (81%
preventable with $748 million in savings). Overall, we
estimated approximately $16.6 billion in annual savings
(5.5% of total hospital costs) from reducing adverse
events in hospitals. When we assumed that all ten AEs
could be completely eliminated, overall savings rose to
$32.3 billion annually or 13.5% of hospital costs.
Conclusions: Adverse events are often preventable and
consume substantial resources in our healthcare
system.
Implications for Policy, Delivery or Practice: These
figures can be used by policymakers and organizations
to help justify investing in prevention efforts that would
also reduce harm.
Funding Source(s): RX Foundation (Cambridge, MA)
♦ Why are Financial Incentives not Effective at
Influencing some Smokers to Quit? Results from a
Process Evaluation
Annice Kim, Ph.D., M.P.H.; Kian Kamyab, B.A.; Jingsan
Zhu, M.B.A.; Kevin Volpp, M.D., Ph.D.
Presented by: Annice Kim, Ph.D., M.P.H., Behavioral
Scientist, Public Health Policy Research Program, RTI
International, 3040 East Cornwallis Road, Research
Triangle Park, NC 27707, Phone: (919) 316-3972,
Email: akim@rti.org
Research Objective: Concerns about poor health
outcomes and consistently high rates of increase in
health care costs have led to great interest in incentivebased interventions to improve health behaviors among
employers and insurers. In a randomized controlled trial
of 878 smokers employed at General Electric, we
demonstrated that a $750 incentive effectively tripled
smoking cessation rates in the incentive group
compared to controls (14.7% vs 5.0%, p<0.0001). To
better understand why incentives were not effective at
influencing some smokers to quit, we conducted a
process evaluation to explore participants’ awareness
about the program; their perceptions about the value and
structure of the incentives; and analysis of
sociodemographic, smoking, and environmental
characteristics that may have mitigated the impact of
incentives.
Study Design: Closed-ended process evaluation
measures were developed and added to the 6 and 12
month follow-up surveys and administered to all
participants in the incentive group of the main trial. A
subset of these participants was asked more in-depth
open-ended questions at the end of their survey.
Qualitative responses were coded for emergent themes
and analyzed with the quantitative responses to
triangulate findings. Responses are compared for
quitters vs. non-quitters in the incentive group.
Population Studied: 878 adult smokers employed at
General Electric nationwide who participated in a
randomized controlled trial assessing the efficacy of
financial incentives for smoking cessation. Eligibility
criteria for study participation and characteristics of the
study sample are described elsewhere (Volpp et al,
NEJM, 2009).
Principal Findings: There was high confirmed
awareness about the incentive among quitters and nonquitters alike. The majority of non-quitters (68%) said a
larger incentive would not have motivated them to quit;
nearly 40% report that even double the incentive amount
($1500) would not have influenced them to quit. Nonquitters felt that they should quit on their own and not be
motivated by money to do something that they know is
beneficial to their health. In contrast, nearly 88% of
quitters said they would have quit for less money, with
48% responding that they would have quit even if no
incentives were offered. In general, non-quitters were
more addicted to nicotine than quitters and fewer at
baseline were seriously thinking about quitting. Nonquitters were also historically less successful at quitting,
with fewer past quit attempts and a shorter duration of
previous successful abstinence. Additionally, nonquitters had lower incomes and were more likely to live
in homes where smoking is allowed, which may have
mitigated the impact of incentives.
Conclusions: Incentives may have lower efficacy
among smokers who have had less previous personal
success in quitting, who are not seriously motivated to
quit, and who live in homes where smoking is allowed.
Implications for Policy, Delivery or Practice: Financial
incentives are increasingly utilized by employers and
insurers as a cost-effective strategy to improve
consumer health. Results from this process evaluation
suggests that considering factors such as prior success
of behavior change, perceptions about utility of
incentives, and sociodemographic and environmental
characteristics in designing interventions could make the
interventions more effective.
Funding Source(s): CDC
♦ Are Hospital-Acquired Catheter-Associated Urinary
Tract Infections Coded Accurately to Trigger NonPayment by the CMS Hospital-Acquired Conditions
Initiative?
Jennifer Meddings, M.D.; Sanjay Saint, M.D., M.P.H.;
Laurence McMahon, Jr., M.D., M.P.H.
Presented by: Jennifer Meddings, M.D., Clinical
Lecturer, Research Fellow, Internal Medicine, Division of
General Medicine, University of Michigan Health
System, 300 North Ingalls Building, Room 7D-10, Ann
Arbor, MI 48109, Phone: (734) 936-9118, Email:
meddings@umich.edu
Research Objective: Effective 1 October 2008, the
Centers for Medicare and Medicaid Services (CMS) no
longer pays hospitals more to treat specific “reasonably
preventable” hospital-acquired complications. The goals
are simple: improve patient safety by motivating
hospitals to pursue strategies to prevent complications,
and save healthcare dollars by not paying for
preventable complications. Yet, the policy’s rules are
complex to detect and then deny payment for
complications. Importantly, if hospitals do not assign
accurate diagnosis codes to describe hospital-acquired
complications, hospitals will receive payment for the
diagnoses by default. Our objective was to evaluate
whether hospital-acquired catheter-associated urinary
tract infections (CAUTIs) were being accurately identified
by hospital-coder assigned diagnosis codes to trigger
non-payment for the complication per CMS policy.
Study Design: We conducted a retrospective medical
record review of a random sample of 80 hospitalized
adults discharged between May 2006 and September
2007 from an academic medical center with a coded
secondary diagnosis of urinary tract infection (UTI). One
physician abstractor trained in UTI and CAUTI clinical
criteria reviewed each record to determine if UTIs were
catheter-associated and/or hospital-acquired. Physician
abstractor categorization of UTIs as catheter-associated
and/or hospital-acquired (considered the ‘gold standard’)
was compared with diagnosis codes assigned by
hospital coders.
Population Studied: The 80 UTI patients in our sample
had the following characteristics: 56 (70%) were
women; mean age was 57.8 years; median length-ofstay was 6 days; and 50 (62%) had a urinary catheter
during the hospitalization.
Principal Findings: Of the 80 patients for which hospital
coders had assigned a UTI code, physician abstraction
confirmed that 77 records were consistent with a clinical
diagnosis of UTI. Of the 80 UTI cases identified by
hospital coders, 21 (26%) were coded as present-onadmission in error since physician abstraction revealed
the UTIs to be hospital-acquired. While hospital coders
did not identify any CAUTI cases in the 80 records (as
catheter-association code 996.64 was not used),
physician abstraction identified 36 CAUTI cases (45%),
of which 28 were hospital-acquired and 8 were presenton-admission. Urinary catheter use was often evident
only from nursing notes which – unlike physician notes –
are not routinely reviewed by hospital coders.
Conclusions: Our single site study found that hospital
coders frequently did not include the catheter-specific
code 996.64 to correctly identify CAUTI for patients
discharged with a secondary diagnosis of UTI. Also,
hospital coders often coded UTIs as present-onadmission when the medical record indicated the UTIs
were hospital-acquired.
Implications for Policy, Delivery or Practice: Since
accurate coding of hospital-acquired CAUTI is
complicated and fraught with error, non-payment per
CMS policy for this complication may not reliably occur.
Accordingly, the effective implementation of this policy
will require an enhanced auditing process by CMS,
which could mitigate financial gains anticipated from
non-payment for the complication.
♦ Impact of the Quality & Outcomes Framework Payfor-Performance Scheme on Quality of English
Primary Care: Interrupted Time Series Analysis
Stephen Campbell, B.A., M.A., Ph.D.; Evan
Kontopantelis, Ph.D.; David Reeves, Ph.D.; Martin
Roland, M.D.; Bonnie Sibbald, Ph.D.
Presented by: David Reeves, Ph.D., University of
Manchester
Research Objective: A major pay-for-performance
scheme based on meeting clinical quality targets was
introduced to English family practice in 2004. It included
136 indicators covering chronic disease management,
practice organisation and patient experience. The
scheme is voluntary but 99.6% participate. Payments
make up approximately 25% of family practitioners’
income. This study explored the effect of the scheme on
quality of care.
Study Design: Interrupted time series analysis of quality
of care with data collected before (1998 and 2003) and
after (2005 and 2007) the introduction of the scheme.
Data for asthma, diabetes and coronary heart disease
were extracted from medical records, and data on
access, continuity of care and inter-personal aspects of
care were collected from patient questionnaires, at each
time point).
Population Studied: Patients with 42 practices
representative of all English family practices. 1). Clinical
audit data were abstracted for serial cross sectional
samples of random samples of patients (20 in 1998; 12
in 2003, 2005 and 2007) with heart disease, asthma and
diabetes. Data collection in 2007 was consistent with
previous data collection periods in 1998/9, 2003 and
2005 1. 2). For patient evaluation, a version of the
General Practice Assessment Questionnaire (GPAQ)
(www.gpaq.info/ ) was mailed, with one reminder, to
random samples of 200 registered adult patients (aged
=18) in each practice in 2003, 2005 and 2007.
Principal Findings: The rate at which quality was
improving increased for asthma and diabetes (p<0.001)
following the introduction of the scheme (2003 to 2005)
but not for coronary heart disease. Compared to the preincentives period (1998 to 2003), the rate of
improvement after the scheme (2005 to 2007) did not
change for asthma or diabetes, but reduced for coronary
heart disease (p=0.018). Quality of care for nonincentivized aspects of asthma and coronary heart
disease care declined after 2005. No significant changes
were seen in patients’ reports of access to care, or interpersonal aspects of care. Previously constant levels of
continuity of care showed a step reduction following the
introduction of pay-for-performance (p<0.001) and then
continued at the new lower level.
Conclusions: For these three major chronic diseases
there were significant improvements in measurable
aspects of clinical performance between 1998 and 2007.
Against a background of already improving quality, the
pay-for-performance scheme accelerated improvements
in quality for asthma and diabetes in the short term
between 2003 and 2005. However, there were no further
improvements in quality once targets had been reached.
There may have been some unintended consequences,
including reductions in continuity of care.
Implications for Policy, Delivery or Practice: The
UK’s pay-for-performance scheme has achieved the aim
of incentivizing providers to attain targets. However, if
the aim of pay-for-performance is to incentivize
continued improvement, payments should relate to
improvement rather than the achievement of targets.
Funding Source(s): UK DH
Policies to Improve the Quality of Care
Chair: Mark Friedberg
Monday, June 29 * 4:45 p.m.-6:15 p.m.
♦ Physician Knowledge of the FDA-Approved
Indications of Commonly Prescribed Drugs: Results
of a National Survey
Rachael Moloney, B.A.; G. Caleb Alexander, M.D., M.S.;
Donna Chen, M.D., M.P.H.; Matthew Wynia, M.D.,
M.P.H., F.A.C.P.
Presented by: G. Caleb Alexander, M.D., M.S.,
Assistant Professor, Medicine, University of Chicago,
5841 South Maryland Avenue (MC 2007), Chicago, IL
60637, Phone: (773) 834-9177, Email:
galexand@uchicago.edu
Research Objective: The FDA regulates prescription
drug marketing, not prescribing, and medication use for
non-FDA approved indications (“off-label use”) is
common. However, some off-label uses occur with little
or no supporting evidence and may expose patients to
unwarranted risk. It is unknown how often physicians
are aware that they are prescribing off-label. We sought
to determine physicians’ knowledge of the FDAapproved indications of several commonly prescribed
drugs, and to assess whether physicians’ belief that an
indication is FDA-approved increases with level of
evidence supporting such use.
Study Design: We conducted national mail survey, from
November 2007 through August 2008, of 599 primary
care physicians and 600 psychiatrists randomly selected
from the American Medical Association Masterfile of all
U.S. physicians. The survey presented 14 drugindication pairs (e.g., gabapentin [Neurontin®] for
diabetic neuropathy) that varied in FDA-approval status
and levels of supporting evidence. Physicians were
asked whether they had prescribed each drug in the
prior 12 months, whether they had prescribed the drug
for the specified indication, and to identify whether the
specified drug-indication pair was FDA-approved. We
used the Drugdex® compendium to categorize labeling
status and level of evidence regarding efficacy. Our
primary outcome was physicians’ knowledge of whether
each drug was FDA-approved for the indication in
question. We used Spearman’s rho, a non-parametric
correlation coefficient, to examine bivariate associations
between ranked categories of levels of evidence and the
percent of physicians believing each drug-indication pair
was FDA approved.
Principal Findings: The adjusted response rate was
47%, and the mean (median) number of drugs examined
that the physician had prescribed during the previous 12
months was 11 (12). The average respondent correctly
identified the FDA-approval status of just over half of the
drug-indication pairs queried (mean 55%; median 57%).
The proportion increased modestly (mean 59%, median
61%) when limited to drugs the respondent reported
having prescribed during the previous 12 months. There
was a strong association between physicians’ belief that
an indication was FDA-approved and greater evidence
supporting that use (Spearman’s rho 0.74, p<0.001).
However, 41% of physicians believed at least one drugindication pair with uncertain or no supporting evidence
(e.g., quetiapine [Seroquel®] for dementia with agitation)
was FDA approved.
Conclusions: Our report highlights for the first time
physicians’ beliefs about the FDA label status of drugs
they prescribe, and suggests that physicians may
conflate the level of evidence supporting a drug’s use
and the drug’s FDA approval status. A significant
minority of physicians also appear to prescribe some
drugs for off-label indications while believing that such
uses are approved, despite uncertain or no supporting
evidence.
Implications for Policy, Delivery or Practice: Although
the FDA regulates drug approval, not drug prescribing,
there is increasing appreciation for the scope and
potential public health impact of off-label use of
pharmacotherapies in settings of insufficient scientific
support. Our findings highlight an important need for
more effective methods to inform physicians about the
evidence base, or lack thereof, for drugs they prescribe
off label.
Funding Source(s): AHRQ, RWJF
♦ Impact & Lack of Impact of the 2004 Clinical
Academies’ Guidelines on the Medical Management
of Otitis Media in the U.S.
Lawrence Kleinman, M.D., M.P.H.; Leonardo Trasande,
M.D., M.P.P.; Salomeh Keyhani, M.D., M.P.H.
Presented by: Lawrence Kleinman, M.D., M.P.H., Vice
Chair for Research & Education, Health Policy, Moutn
Sinai School of Medicine, One Gustav Levy Place, Box
1077, New York, NY 10029-6574, Phone: (212) 6599556, Email: lawrence.kleinman@mssm.edu
Research Objective: To measure the impact of two
guidelines released May, 2004 – American Academies
of Pediatrics’ (AAP) and Family Physicians’ (AAFP) joint
guideline on the diagnosis and management of acute
otitis media (AOM) and the AAP, AAFP, and American
Academy of Otolaryngology-Head and Neck Surgery’s
joint guideline on the management of otitis media with
effusion (OME)– on the management of otitis media in
the United States. Guideline recommendations would
reduce the proportion of all otitis media diagnosed with
AOM compared to OME (because of strict diagnostic
criteria for AOM), eliminate use of antibiotics for OME
(OME guideline), and reduce use of antibiotics for AOM
(AOM guideline).
Study Design: Segmented regression analysis
(interrupted time series) of nationally representative data
on ambulatory care for otitis media in children through
16 years, from 2002 – 2006 National Ambulatory
Medical Care and National Hospital Medical Care
Surveys. Outcomes included the proportion of cases
treated with antibiotics, and the proportion of otitis media
visits diagnosed as OME rather than AOM. As
appropriate, analyses were done for all ages and
stratified by age group, for all otitis media, and stratified
by AOM or OME.
Population Studied: Representative sample of all visits
(other than to otolaryngologists) of children through 16
years old to non-federal facilities – physicians offices,
hospital clinics, and emergency rooms – from 2002
through 2006.
Principal Findings: More than 80% of otitis media visits
are for AOM. Unadjusted proportion of cases with
antibiotic use from 2002 to 2006: All otitis media 78% to
76%; AOM 84% to 80%, OME 27% to 44%. The
segmented regression analysis found that for AOM, the
guideline was associated with the end of a significant
trend (-2.6 % per year) towards decreasing antibiotic use
and an 8.5% absolute increase in the use of antibiotics.
For OME, the guideline was associated with the reversal
of a large (13.8% per year) and significant trend towards
increasing antibiotic use and a 34.7% absolute decrease
in the use of antibiotics. The guidelines did not have the
intended effect of decreasing the proportion of cases
with AOM. Comparing current estimates with
counterfactual estimates (as if the guideline effect were
missing and trends remained constant), the impact of the
guidelines has been a 10% absolute increase in
proportion of otitis media cases for which antibiotics are
used, despite a 48% absolute reduction the proportion of
OME cases receiving antibiotics.
Conclusions: The guideline neither reduced the use of
antibiotics for AOM, nor decreased the proportion of
otitis media cases diagnosed with AOM. Although
antibiotic use for OME remains stable, prior trends
towards increased use have abated, suggesting a
guideline effect.
Implications for Policy, Delivery or Practice: These
clinical practice guidelines prioritized societal risk of
bacterial resistance over the modest clinical benefit to
the individual child when they advocated watchful
waiting over antibiotics for many children with AOM and
all children with OME. Physicians in the US have not
changed fundamentally their use of antibiotics for otitis
media. This study suggests that pediatricians and family
physicians may not be ready to follow the lead of their
clinical societies in prioritizing population risks over
individual patient benefit.
♦ Adjuvant Chemotherapy in Colon Cancer:
Differences by System of Care & Stage
Elizabeth Tarlov, R.N., Ph.D.; Todd Lee, Pharm.D.,
Ph.D.; Ramon Durazo-Arvizu, Ph.D.; Qiuying Zhang,
M.S.; Charles Bennett, M.D., Ph.D.; Denise Hynes, R.N.,
Ph.D.
Presented by: Elizabeth Tarlov, R.N., Ph.D., Research
Health Scientist, VA Information Resource Center,
Department of Veterans Affairs, Hines VA Hospital, 5000
South 5th Avenue (151V), Hines, IL 60141, Phone:
(708) 202-2413, Email: Elizabeth.Tarlov@va.gov
Research Objective: Practice guidelines for stage III
colon cancer care include the routine use of
chemotherapy following colectomy. Since clinical
studies have failed to establish a definitive survival
benefit of adjuvant chemotherapy in stage II, guidelines
for that group have recommended that adjuvant
chemotherapy be reserved for clinical trials or, more
recently, be determined on a case-by-case basis in
discussion between physician and patient. In the
presence of uncertainty regarding most efficacious
therapy, non-clinical factors such as practice
environment or physician reimbursement incentives may
emerge as influential determinants of treatment choice.
In this study, we examined adjuvant chemotherapy use
in stage II compared to stage III colon cancer in the
Medicare fee-for-service system and in a prepaid and
integrated healthcare system to ascertain the extent to
which probability of receiving chemotherapy among
patients with stage II cancer is influenced by system of
care.
Study Design: We conducted a retrospective cohort
study of elderly veterans diagnosed with stage II or III
colon cancer between 1999 and 2001 who had
healthcare coverage through both the Department of
Veterans Affairs (VA) and Medicare. Using linked
cancer registry, VA, and Medicare data and Cox
proportional hazards regression modeling, we examined
the relationship between stage at diagnosis, system of
care, and chemotherapy initiation.
Population Studied: Veterans with colon cancer age 65
years and older who were dually eligible for VA and
Medicare-funded healthcare.
Principal Findings: We identified 1,005 veterans with
stage II (59%) or III (41%) colon cancer who had
undergone colectomy. Twenty percent were diagnosed
in the VA and the remainder at non-VA facilities, 94%
were male and mean age was 76 years. Twenty-eight
percent of stage II and 62% of stage III patients received
at least one chemotherapy treatment. The initial
regression model controlled for stage and age at
diagnosis, race, marital status, residential census tract
income, comorbidities, year, and geographic region and
revealed that compared to VA patients, non-VA patients
were more likely to receive chemotherapy (IRR: 1.59,
CI95%: 1.01 - 2.50). The addition of a stage-by-system
interaction term to the model revealed that stage II
patients outside the VA were over twice as likely as their
VA counterparts to receive chemotherapy (IRR: 2.64,
CI95%: 1.06 - 6.61) while patients with stage III cancer
were equally likely to receive chemotherapy, irrespective
of system of care (IRR comparing non-VA to VA
patients: 1.23, CI95%: 0.88 - 1.70).
Conclusions: The association between stage at
diagnosis and receipt of chemotherapy depends on
system of care; patients with stage II cancer who were
diagnosed at non-VA facilities and whose care was
covered by Medicare were much more likely to have
adjuvant chemotherapy than patients treated in the VA.
Among stage III patients, system of care had no impact
on likelihood of adjuvant chemotherapy.
Implications for Policy, Delivery or Practice: Further
study is needed to uncover the drivers of these marked
differences in use of a cancer treatment whose benefit
has not been established. In view of high price tags on
recently developed chemotherapy regimens, implications
for costs of cancer care may be substantial.
Funding Source(s): VA
♦ Does Tort Law Improve the Health of Newborns, or
Miscarry? A Longitudinal Analysis of the Effect of
Liability Pressure on Birth Outcomes
Y. Tony Yang, L.L.M., Sc.D., M.P.H.; Michelle Mello,
J.D., Ph.D.; David Studdert, L.L.B., Sc.D., M.P.H.; S.V.
Subramanian, Ph.D.
Presented by: Y. Tony Yang, L.L.M., Sc.D., M.P.H.,
Assistant Professor of Health Policy & Law, Health
Administration & Policy, George Mason University, 4400
University Drive, Mail Stop 1J3, Fairfax, VA 22030,
Phone: (703) 993-9733, Email: ytyang@gmu.edu
Research Objective: Previous research provided
evidence that higher malpractice pressure resulted in
decreased use of vaginal births after cesareans and
increased use of cesarean sections. A question arises
as to whether these changes in obstetrical practice
resulting from greater malpractice risk are associated
with better birth outcomes, reflecting a socially desirable
deterrent effect, which is the primary justification for the
current negligence-based medical malpractice system.
Study Design: We used a longitudinal research design
to exam secondary data. We employed a hierarchical
mixed-effects model and investigated the impact of
malpractice risk, as measured by malpractice premiums
and various tort reforms, on six adverse birth outcomes:
birth injury, low 5-minute Apgar score, low birthweight,
preterm birth, infant mortality, and maternal mortality.
Population Studied: Population drew from fifty-one
jurisdictions over twelve (1991-2002) years. There were
around 48 million births.
Principal Findings: Our results suggest that the
frequency of adverse birth outcomes is not associated
with malpractice premium level and adopting a tort
reform. The effects are neither statistically significant
nor large in absolute terms. Our findings show that the
main drivers of poor birth outcomes are medical risk
factors.
Conclusions: The results of this study suggest that the
changes in procedure rates shown in previous research
were not justified, in the sense that there were no
significant differences in birth outcomes. These liability
pressures may produce a level of precaution-taking in
obstetrics that is higher than socially optimal.
Implications for Policy, Delivery or Practice: The
foundation of the current fault-based malpractice system
is its effect in deterring medical negligence. The system
is said to prevent accidents by creating incentives to
engage in optimal levels of precaution-taking. However,
such effects were not evident in our analysis. In
addition, we found that tort reforms which mitigate the
liability pressure did not result in worse birth outcomes.
Adopting liability-limiting reforms, at least in the area of
obstetrics, is unlikely to adversely affect the quality of
medical care, as some tort-reform opponents fear.
Funding Source(s): Chiang Ching-Kuo Foundation
♦ The Effect of Patient Knowledge & Involvement on
Outpatient Cost & Service- Evidence from an
Experiment in China
Wei Zhang, M.D., Ph.D.; Wanchuan Lin, Ph.D.
Presented by: Wei Zhang, M.D., Ph.D., Assistant
Professor of Management, Management, China Europe
International Business School, 699 Hongfeng Road,
Pudong, Shanghai, 201206, CN, Phone: +86-2128905661, Email: wzhang@ceibs.edu
Research Objective: To assess the impact of patient
use of drug knowledge on physician’s prescription
behavior and physician-patient interaction in teaching
hospitals in China
Study Design: The study involves repeating a simple
experiment. We trained 8 actors of equivalent age,
education level and gender with standardized script to
be simulated patients with flu-like symptoms and sent
them to 12 teaching hospitals for outpatient consultation
in Dec. 2008. .Each actor was trained to plan 2 roles: A,
a regular, passive patient; and B, a well-informed and
aggressive patient who explicitly told the physician “I
learned from internet that simple flu patients should not
take antibiotics” after explaining their standardized
symptoms and history during the outpatient visit. In each
studied hospital, we randomly assigned 8 actors into 4
pairs (one A and one B), each pair seeing one physician,
and we collected the prescriptions and audio recording
for analysis. We called the 2 groups A and B,
respectively. Because unobserved difference between
group A and B, as well as between hospitals/physicians,
are minimized b sending these actors back to back to
the same physician, this study provides a potential
powerful means of estimating the effect of drug literacy
and active use of such knowledge on prescription of
antibiotics and the extend of health care cost saving
Population Studied: Attending physicians (internal
medicine) at outpatient department of 12 teaching
hospitals in a large city in China
Principal Findings: 57.8% of actors received antibiotics
prescription, demonstrating severe antibiotic abuse in
China. We observed a significant reduction of antibiotic
abuse in group B than in group A (51.3% vs. 63.6%,
p<0.01), and a 17% decrease in average outpatient
expenditure in group B. Moreover, when facing wellinformed patients in group B, physicians were less likely
to offer information on the physician examination, drug
use .and diagnosis, less likely to make detailed inquiries
about patient’s status, and thus leading to lower
satisfaction rating from our feedback surveys.
Conclusions: Patient's drug literacy and the
subsequent active involvement in medical service could
reduce the probability of antibiotics abuse, reduce the
total amount of prescription, and increase the probability
of physician selecting lower-cost therapies. However,
physicians tended to be less friendly and thorough in
their outpatient service when encountering a wellinformed and active patient.
Implications for Policy, Delivery or Practice: Patient
drug literacy, combined with active involvement in
clinical decision making, can help assure the quality of
care such as rational use of antibiotics and may lead to
subsequent reduction in medical expenditure. While
health policy makers should take note of such
consumerism, physicians should adapt to the emerging
patient health literacy and involvement in a more
collaborative way.
Funding Source(s): CEIBS Research Fund
Improving Quality: Handoffs, Hospital Boards, Work
Environment, the Market in Guidelines
Chair: Eric Holmboe
Monday, June 29 * 9:45 a.m.-11:15 a.m.
♦ Boards & Governance in U.S. Hospitals & the
Relationship to Quality of Care
Ashish Jha, M.D., M.P.H.; Arnold Epstein, M.D., M.A.
Presented by: Ashish Jha, M.D., M.P.H., Assistant
Professor, Health Policy & Management, Harvard School
of Public Health, 677 Huntington Avenue, Boston, MA
02115, Phone: (617) 432-5551, Email:
ajha@hsph.harvard.edu
Research Objective: Hospital boards may play a role in
the quality of care delivered but whether and how they
are engaged in these issues is largely unknown. We
conducted a national survey of board chairpersons of
non-profit hospitals to determine boards’ engagement
and activities in quality. In addition to creating a national
portrait, we sought to determine whether boards of highperforming hospitals differed in their priorities, expertise
and function from boards of hospitals that perform poorly
on standard quality metrics.
Study Design: Hospital boards may play a role in the
quality of care delivered but whether and how they are
engaged in these issues is largely unknown. We
conducted a national survey of board chairpersons of
non-profit hospitals to determine boards’ engagement
and activities in quality. In addition to creating a national
portrait, we sought to determine whether boards of highperforming hospitals differed in their priorities, expertise
and function from boards of hospitals that perform poorly
on standard quality metrics.
Population Studied: Nationally representative sample
of chairpersons of boards of directors of non-profit U.S.
hospitals. We weighted all responses to account for our
sampling scheme to create national averages.
Principal Findings: We received responses from 78.3%
of board chairpersons surveyed. Overall, board chairs
from 32% of hospitals reported that their board received
any formal training that covered clinical quality.
Respondents from 52% of hospitals identified quality as
a top priority for board oversight and 43% identified
quality as one of the top two factors in evaluating their
CEO’s performance. Quality was consistently on the
board’s agenda in 63% of hospitals and 72% of hospital
boards examine a quality dashboard. Finally, just 1% of
board chairs reported that quality in their hospital was
worse than the typical U.S. hospital while 66% reported
that quality was better than in the typical hospital.
Compared to boards from low-performing hospitals,
those from high-performing institutions more often
underwent training in quality (47% versus 21%,
p<0.001), identified quality as a top priority for oversight
(69% versus 42%, p<0.001) and CEO evaluation (59%
versus 31%, p<0.001), and regularly included quality on
the board’s agenda (74% versus 57%, p=0.003).
Among board chairs of poor-performing hospitals (those
in the bottom decile), none reported that the care in their
hospital was worse than in the typical hospital, while
58% said it was better than in the typical U.S. hospital.
Conclusions: Quality is often not a high priority among
hospital boards and only a minority of boards receives
training in quality. A large proportion of board chairs are
not aware of their own hospital’s quality performance.
There were large differences between high- and lowperforming hospitals in each of the areas of board’s
activities and priorities.
Implications for Policy, Delivery or Practice: Given
the critical need to find levers to improve quality, our
findings of a nationally-representative sample of board
chairs suggest that the board may play an important
role. Whether changing the board’s priorities and
practices translates into better care for patients is not
clear but given the large differences in governance
between the best and worst hospitals, this represents a
tempting target for intervention.
Funding Source(s): Other Foundation, The Hauser
Center for Non-Profit Governance (Harvard Law School)
and the RX Foundation (Cambridge, MA)
♦ The Free Market Place of US Guidelines
Salomeh Keyhani, M.D., M.P.H.; Azalea Kim, B.S.;
Deborah Korenstein, M.D.
Presented by: Salomeh Keyhani, M.D., M.P.H.,
Assistant Professor, Health Policy, James J. Peters VA
Medical Center/Mount Sinai School of Medicine, 1
Gustave L. Levy Place, New York, NY 10029, Phone:
(212) 659-9563, Email:
salomeh.keyhani@mountsinai.org
Research Objective: Physicians in the US have access
to a range of clinical guidelines for each condition. We
examined the quality and content of current guidelines
for cancer and cardiovascular risk factor screening
issued by US organizations.
Study Design: We systematically collected guidelines
using the national guideline clearing house, organization
websites and medline. We coded guideline sources as
1) government 2) medical society 3) disease
organization or 4) other, and used a published guideline
evaluation tool to rate the quality of each guideline. We
grouped the tool´s 32 items into 4 domains: 1-general
criteria (e.g panel member expertise, 8 items), 2evidence gathering and synthesis methods (e.g. conduct
of a systematic review, 11 items), 3-specificity/content
(e.g. screening start and stop dates with detail on high
risk populations, 11 items) and 4) impacts on costs (2
items). Two investigators assessed each guideline;
disagreements were discussed until consensus was
reached. We rated both the quality and the impact of
each guideline. For each guideline, we calculated the
percent of items met in each domain and compared an
overall score for each guideline across issuing entities
using chi square statistics. We then calculated the
number of life time screens recommended for a healthy
low risk population and compared average associated
lifetime screens for each condition by issuing entity.
Population Studied: Screening guidelines for cancer
(breast, cervical, colorectal, prostate and ovarian) and
cardiovascular risk factors (diabetes mellitus,
hypertension and lipid disorders).
Principal Findings: We identified 47 unique guidelines
for 8 conditions. Overall guideline quality varied across
issuing entity and conditions (p <0.05). Government
guidelines met general criteria 100% of the time, medical
societies 72.8%, disease organizations 93.7% and other
entities 90.6% of the time. Government guidelines
(72.7%) met the evidence criteria more often than
medical societies (33.2%), disease organizations
(43.1%) or the other entities (68.1%). Less than 60% of
all guidelines employed a systematic review in the
evidence extraction process. Similarly, government
guidelines (81%) met the specificity and content criteria
more often than medical societies (59.7%), disease
organizations (74.7%) or the other entities (57.1%)
examined. Less than 10% of guidelines met cost criteria.
Life time screens varied across issuing entity. For
example, breast cancer recommendations ranged from
13 (Institute for Clinical Systems Improvement) to 36
(American Cancer Society) life time screens for a
healthy low risk woman. Screening for diabetes mellitus
with fasting blood glucose ranged from uncertain
evidence to 10 life time screens. Screening
recommendations issued by non government entities on
average exceeded government entities for breast cancer
(25 v 29), cervical cancer (15 vs. 24) and prostate
cancer (uncertain evidence vs. 15).
Conclusions: The quality of guidelines and screening
recommendations varies across issuing entities.
Implications for Policy, Delivery or Practice: Many
policymakers have called for evidence based practice to
decrease unnecessary care. It is doubtful that such a
plethora of guidance with varying quality and
inconsistent recommendations is serving the best
interests of patients, physicians or the tax paying public.
National standards set by one organization may improve
the quality and content of recommendations issued.
Funding Source(s): Dr. Keyhani is Funded by a VA
HSRD Career Award
♦ Impact of Work Environment & Processes on Risk
of Pressure Ulcers in NYS Nursing Homes
Helena Temkin-Greener, Ph.D.; Shubing Cai; Nan
Zheng; Honwei Zhao, Sc.D.; Dana Mukamel, Ph.D.
Presented by: Helena Temkin-Greener, Ph.D.,
Associate Professor, Community & Preventive Medicine,
University of Rochester, Box 644, 601 Elmwood Avenue,
Rochester, NY, 14642, Phone: (585) 275-8713, Email:
Helena_Temkin-Greener@urmc.rochester.edu
Research Objective: The occurrence of pressure ulcers
(PUs) in nursing homes (NHs) is a marker for poor
quality of care. Studies suggest that work environment
and processes (e.g. work effectiveness, teamwork,
primary assignment) influence quality of care, but few
tested these relationships empirically in NHs. We
examine the relationship between NH work environment
and processes and risk-adjusted PUs.
Study Design: Primary data include survey responses
from 7,418 direct care workers in 162 NYS NHs,
collected in 2006-2007. Secondary data for the same
period come from the Minimum Data Set (MDS) and the
On-Line Survey Certification and Reporting System
(OSCAR). For each facility, primary and secondary data
are linked. Using the MDS, long-term care (LTC)
residents with high risk for PUs are identified. For
residents with multiple quarterly/annual assessments
one assessment is randomly selected for analysis.
Population Studied: The analytical sample includes
20,929 LTC residents at high risk for PUs, in 162
NHs.The analysis is based on individual-level data. The
dependent variable is dichotomous, indicating PU
presence/absence. Independent variables of primary
interest include facility-level measures of: work
effectiveness (a 5-point, 7-items Likert scale score);
prevalence of daily care teams; and percent of staff with
primary assignment. These variables are constructed
from survey responses. The measure of work
effectiveness has been demonstrated, in a prior
published study, to be psychometrically reliable and
valid. Other control variables include individual PU risk
factors and facility characteristics. The analytical sample
is randomly split into two halves to allow cross validation
of the estimated risk adjustment models. We fit a risk
adjustment model in the training sample and keep risk
adjustors with p<=0.2. The reduced model is tested on
the validation sample using Hosmer-Lemeshow and C
statistics. We then estimate a GEE model with robust
standard errors. Probability weights are used to correct
for the higher than expected proportion of non-profit
facilities in our sample.
Principal Findings: Overall, 13.7% of high-risk
residents have PUs. The work effectiveness scores
range from 3.16-4.79 with mean=4.22 (SD=0.22). Higher
scores denote greater work effectiveness. Penetration of
care teams ranges from 0-50% with mean=7.64%
(SD=6.47). After controlling for individual risk factors
and facility characteristics, higher work effectiveness is
associated with lower PU risk. A high-risk resident in a
facility with work effectiveness score of 4.5 is 46% less
likely to have PUs compared to a similar resident in a
facility with the score of 3.5 (OR=0.54, P<0.001). We
detect a nonlinear relationship between team penetration
and PUs. In facilities with lower than 14% team
penetration, the impact of self-managed team
prevalence on PU risk is negative, but at higher levels of
team penetration, the marginal effect is positive.
Conclusions: Our findings support the hypothesis that
NH work environment attributes and processes impact
quality of care. High risk residents living in NHs where
staff report higher perceived work effectiveness and
greater presence of self-managed teams show a
significantly lower PU risk.
Implications for Policy, Delivery or Practice: These
findings provide important insights into NH work
processes that administrators and regulators should
consider for improving quality of care for residents.
Funding Source(s): NIA
♦ A Handoff Training & Improvement Initiative
Significantly Improved the Effectiveness of Actual
Clinical Handoffs
Matthew Weinger, M.S., M.D.; Jason Slagle, Ph.D.;
Audrey Kuntz, Ed.D.; Dan France, M.P.H., Ph.D.;
Jonathan Schildcrout, Ph.D.; Ted Speroff, Ph.D.
Presented by: Matthew Weinger, M.S., M.D., Professor
& Vice Chair, Anesthesiology, Vanderbilt University,
1211 21st Avenue South, MAB 732, Nashville, TN
37212, Phone: (615) 936-6598, Email:
matt.weinger@vanderbilt.edu
Research Objective: Failures of communication have
been associated with poor quality care. We developed a
simulation-based training intervention to improve patient
care transitions, initially focusing on handoffs between
anesthesia providers (AP) and Post-Anesthesia Care
Unit (PACU) nurses (RN). We hypothesized that
simulation-based training and performance improvement
would increase handoff quality, enhance culture of
communication, and improve quality of care.
Study Design: Using a multiple baseline prospective
cohort design with repeated measures, the intervention
was introduced into an adult (VUH) and a pediatric
(VCH) PACU. The curriculum and supporting tools were
designed based on observations of PACU handoffs and
targeted interviews of AP and RN. The focus was on
obstacles to effective handoffs including clarity of roles &
responsibilities, lack of standardization, and interruptions
& distractions. The core elements of handoff quality were
engagement, organization & completeness,
coordination, situational awareness, comprehension,
communication, and conflict management. The
intervention included a didactic webinar, a new handoff
report tool, and a 2-hour simulation-based training
session that used standardized patients and clinicians,
manikin simulators, and facilitated video debriefing. An
assessment tool was iteratively developed and validated.
Trained RN observers, who were unaware of the general
training schedule or each subject’s training status,
scored 958 actual handoffs over 12 months with monthly
feedback to PACUs on their performance and
opportunities for improvement. VUH personnel were
trained in Months 3-4 and then received a “refresher” (1hr simulation course) in Month 9. VCH personnel were
trained in Month 6. Aggregated handoff performance
was scored pre- vs. post-training with VCH as a parallel
control group.
Population Studied: AP and PACU RN.
Principal Findings: Based on a global effectiveness
scale of 1 (not at all) to 5 (extremely), baseline (pretraining) data were stable in both PACUs with the quality
of the vast majority of handoffs rated as “somewhat
effective” (i.e., 2) or worse (VUH: 93% =3; 2.07±0.51
(95% CI), VCH: 76% =3; 2.23±1.03). The simulationbased course received excellent trainee evaluations with
overall ratings of 7.8±1.3 and 8.1±0.8 (mean±SD on
scale of 1 to 9 (best)) from VUH and VCH trainees,
respectively. After training, handoff quality improved
significantly with most handoffs observed being rated as
“moderately effective” or better (=3) in both PACUs
(VUH: 70% =3; 2.86±1.27 (post-refresher), VCH: 71%
=3; 2.84±1.27, both P<0.001 vs. pre-training by KruskalWallis).
Conclusions: Creating and delivering simulation-based
clinical handoff training, with associated real-world
assessment, is inherently complex, challenging, and
resource intensive. This study cannot assess the relative
impact of the training component vs. the new handoff
tool or performance feedback to clinicians. Pre- vs. posttraining data on simulated videotaped handoffs and
patient outcomes remain to be analyzed. We found a
significant improvement in actual PACU handoff
effectiveness following a simulation-based training and
performance improvement intervention.
Implications for Policy, Delivery or Practice:
Improvements in patient care handoffs can be attained
with significant effort. The impact on outcomes remains
to be demonstrated. Because “communication failure” is
a major contributor to adverse events, if such
interventions are successful, care quality will be
improved.
Funding Source(s): AHRQ
Quality Improvement in Medical Practices: Medical
Homes, Care Management Processes, Testing
Processes, Encounter Intervals
Chair: Anne-Marie Audet
Monday, June 29 * 4:45 p.m.-6:15 p.m.
♦ Improving Chronic Illness Care: A Longitudinal
National Cohort Analysis of Large Physician
Organizations
Stephen Shortell, Ph.D., M.B.A., M.P.H.; Lawrence
Casalino, M.D., Ph.D.; Robin Gillies, Ph.D.; Juned
Siddique, Dr.P.H.; Diane Rittenhouse, M.D., M.P.H.;
James Robinson, Ph.D.; Rodney McCurdy, M.H.A.
Presented by: Lawrence Casalino, M.D., Ph.D., Chief,
Division of Outcomes & Effectiveness Research,
Department of Public Health, Weill Cornell Medical
College, 402 East 67th Street, New York, NY, 10065,
Phone: (646) 962-8044, Email:
lac2021@med.cornell.edu
Research Objective: To answer two questions: (1) has
the use of commonly recommended care management
processes for chronic illness increased in large medical
groups and independent practice associations (IPAs)
between 2000 and 2006? (2) what factors were
associated with change in the use of these processes?
Study Design: Cohort analysis of data from a national
telephone survey of leaders of medical groups
conducted in 2000 and again in 2006. Participants
provided information on their organizations’ ownership,
size, use of defined care management processes,
external and internal financial incentives, participation in
externally initiated quality improvement (QI) initiatives,
and use of electronic medical records (EMR). Data were
analyzed using a multivariate “difference in differences”
approach.
Population Studied: Medical groups and IPAs of 20
physicians or more (N=369) that treated patients with
asthma, congestive heart failure, depression and
diabetes and that responded to the survey in both 2000
and 2006. The 2000 survey sought responses from a
national database we created that was intended to
include all such physician organizations in the U.S.
When the organizations that responded to the survey in
2000 and 2006 were compared to the organizations that
responded only in 2000, the cohort organizations used
(in 2000) more care management processes and more
EMR elements.
Principal Findings: Sixty percent of eligible
organizations responded to the survey. Use of care
management processes increased from 6.25 to 7.67 (out
of a possible total of 17; p = .001) – small in absolute
terms, but a relative increase of 23%, between 2000 and
2006. Most of the increase was in use of registries and
in patient self-management support services.
Participation in QI programs increased from 45-54%.
The mean number of EMR elements used increased
from 1.55 to 2.36 (of six possible). The percentage of
organizations that received additional income from
health plans for their quality performance increased from
48-54%. Increases in the use of care management
processes were greatest for organizations that received
financial rewards for quality in both years or in 2006 but
not in 2000, and for organizations and that participated
in QI activities in both years or in 2006 but not in 2000.
Increase in the number of EMR elements used was not
associated with an increase in the use of care
management processes. The cohort design of the study
and use of a “difference in differences” approach
increases the likelihood that these factors actually
“caused” the increased use of care management
processes, rather than simply being associated with the
increase.
Conclusions: The use of organized care management
processes to improve chronic illness care is increasing in
large medical groups and IPAs, but there remains
significant opportunity for improving chronic illness care,
even in these relatively large physician organizations.
Implications for Policy, Delivery or Practice: Public
and private (health insurance plans and large
employers) policies that include financial rewards for
improving quality and that encourage quality
improvement initiatives are likely to be associated with
improved use of care management processes designed
to improve chronic illness care.
Funding Source(s): RWJF, Commonwealth Fund,
California Healthcare Foundation
♦ A Multi-Methods Risk Assessment of Testing
Processes in Urban Community Health Centers
Milton Eder, Ph.D.; John Hickner, M.D., M.S.; Sandy
Smith, Ph.D.; Nancy Elder, M.D., M.S.P.H.; Eric Chen,
M.S.P.H.
Presented by: Milton Eder, Ph.D., Director of Research
Programs, External Affairs - Research, Access
Community Health Network, 1501 South California
NR6-106, Chicago, IL 60608, Phone: (773) 257-6087,
Email: edem@accesscommunityhealth.net
Research Objective: This study examines the testing
process at offices within a centrally administered
network of community health centers to assess error
rates and patient safety risks and to identify and
implement changes that would improve the reliability and
safety of the testing process.
Study Design: Because the testing process is complex,
this study of how primary care offices manage lab and
imaging tests utilized a broad, systems assessment.
Complementary data-gathering methods included: an
on-site office systems engineering assessment to
document and examine health center testing processes,
procedures, and policies; an audit of patient medical
records to obtain empiric evidence of rates of failures in
the steps of the testing process; a chart audit of
management of critical abnormal test results for PSA
tests, pap smears, mammograms and anticoagulation
monitoring (INR); a phone survey of patients to obtain a
patient perspective on the testing process; event reports
to raise staff awareness of safety issues in the testing
processes and identify specific instances of testing
process failures; a medical office safety culture survey to
assess the degree to which safety principles are known
by employees and practiced in the health centers.
Population Studied: The study population consisted of
health center staff (primarily clinicians, medical
assistants, and receptionists) within a network of
Federally Qualified Health Centers that have paperbased medical records in the Chicago metropolitan area.
At the time of the study, the entire network had a staff of
more than 800, a patient base > 200,000 and
approximately 600,000 patient encounters/year. We
studied a purposeful sample of ten health centers
selected to provide variation in size and location.
Principal Findings: 1) The management of tests and
results is time intensive. Few sites dedicated sufficient
staff time to accomplish high reliability test tracking.
2) The management of the testing process demonstrated
tremendous variation both within and between health
centers. 3) While documentation failures were common
throughout the testing process, including providers’
failures to document test results review and to document
patient notification, high failure rates in documenting
communication of critical abnormal test results to
patients and in monitoring patients through follow-up
poses serious patient safety risks. 4) There was
tremendous variation in physician and staff perceptions
of office safety culture from health center to health
center. Physicians and staff agreed that staff were much
more likely to be disciplined for mistakes compared to
physicians.
Conclusions: This multi-methods risk assessment of
testing processes in community health centers
discovered many errors and high risk situations and
great variation in perception of safety culture among
health centers. Errors occur within every step in the
testing process and point to opportunities for minimizing
the risks to patients through performance improvement.
Minimizing variation in the management of tests,
particularly within a single health center, presents an
opportunity for significant improvements in patient
safety. In addition, error rates in the management of
critical abnormal results point to serious patient safety
problems in managing abnormal test results in this
underserved inner-city population.
Implications for Policy, Delivery or Practice: This
research informs practice based quality and
performance improvement of the testing process.
Funding Source(s): AHRQ
♦ Patient Assessment of Quality & the Patient
Centered Home
Bradley Gray, Ph.D., M.S.; Weifeng Weng, Ph.D.
Presented by: Bradley Gray, Ph.D., M.S., Health
Services Researcher, American Board of Internal
Medicine, 510 Walnut Street, Suite 1700, Philadelphia,
PA 19106, Phone: (202) 213-6646, Email:
bgray@abim.org
Research Objective: The policy question we address is
the relationship between a system infrastructure
measure (Physician Practice Connections (PPC®) of the
“Patient Centered Medical Home (PCMH)” and the
patient’s experience with care. Background:The PCMH
model of care encourages groups of physicians to
operate in an environment supporting: systematic care
management enabled by use of health informatics tools,
coordination of care among different providers, and
fostering a partnership between patients and physicians
to produce the best health outcomes. The PCMH model
of care has garnered enthusiasm among policy makers
and private payers as a promising new approach to
improving care coordination and revitalizing primary
care. Numerous efforts are underway to demonstrate
the effectiveness of PCMH to enhance quality of care
and control costs. Notably, NCQA’s PCMH recognition
is based on measures of infrastructure related to patientcentered care (PCC) rather than measures of the quality
of patient experiences with their provider. For example,
in the newest incarnation of NCQA’s PPC-PCMH index,
patient experience with care are scored by whether
practices collect data on “Access to Care”, “Quality of
Physician Communication”…, rather than the patient’s
own assessment.
Study Design: We use data from a unique source, the
American Board of Internal Medicine’s comprehensive
care project. This project used the comprehensive care
practice improvement module (CCPIMSM), to assess
the clinical performance of 236 general internists across
a variety of conditions typically presented in an internist’s
office. CCPIM integrates chart-audits, patient-surveys
(similar to the CAHPS-Clinical Group patient survey),
and practice infrastructure (characteristics of systems
that physicians practice within). Applying these data, we
construct a system-level measure of PCC-MH that
closely mirrors an instrument commonly used to
evaluate PCC-MH programs (NCQA’s PPC® index).
The PPC-index is a predecessor to the NCQA medical
home certification survey. We also construct measures
of patient perception of physician quality drawn from the
CCPIMSM patient survey [overall assessment of
physician quality (score 1-10)] as well as measures of
PCC (i.e. communication, access to care, care
coordination, and quality of staff interaction). Lastly, we
predict patient assessment of quality as a function of the
PPC-index and it subscales (controlling for patient and
physician demographics).
Population Studied: General Internists and their
patients
Principal Findings: Overall, the PPC-index is not a
policy-significant predicator of the patient perception of
quality of care. For example, although statistically
significant (P < .05), our analysis indicates that
increasing the PPC-index index by 50% results in just a
6 percent increase in the likelihood of receiving a 10 on
the patients’ overall assessment of physician quality
(PCC-index sub-scales were neither policy nor
statistically significant). Since the PPC-PCMH is in part
designed to identify practices that are more patientcentered, it is surprising that these relationships became
weaker when we applied patient survey measures
specifically related to patient-centered care.
Conclusions: Our findings suggest that certification of
PCMH should include both system level and patient level
measures. Another implication of our study is that
existence of a system infrastructure that supports PCC
may not be viewed as patient-centered by the patients
themselves.
Implications for Policy, Delivery or Practice: Our
findings suggest that certification of PCMH should
include both system level and patient level measures.
Another implication of our study is that existence of a
system infrastructure that supports PCC may not be
viewed as patient-centered by the patients themselves.
♦ Shorter Encounter Intervals are Associated with
Improved Blood Pressure Control in Hypertensive
Patients with Diabetes
Alexander Turchin, M.D., M.S.; Saveli Goldberg, Ph.D.;
Maria Shubina, Sc.D.; Jonathan Einbinder, M.D., M.P.H.;
Paul Conlin, M.D.
Presented by: Alexander Turchin, M.D., M.S., Assistant
Professor of Medicine, Division of Endocrinology,
Brigham & Women's Hospital, 221 Longwood Avenue,
Boston, MA 02115, Phone: (617) 732-5661, Email:
aturchin@partners.org
Research Objective: The relationship between
encounter intervals and patient outcomes is largely
unexplored. We have conducted a study to determine
whether shorter physician-patient encounter intervals are
associated with faster achievement of blood pressure
control.
Study Design: This retrospective cohort study
evaluated the association of the average encounter
intervals with a) time to blood pressure (BP)
normalization and b) rate of BP decrease. Each distinct
“hypertensive period” served as the unit of analysis. A
hypertensive period started at the first encounter with
elevated BP (= 130/85 mm Hg) and ended at the first
encounter with BP < 130/85 mm Hg. Study data were
obtained from the electronic medical record system at
Partners HealthCare. The log-rank test was used to
compare time to BP normalization between different
lengths of encounter interval. A Cox proportionalhazards model was employed to estimate the hazard
rate for BP normalization. A hierarchical multivariable
mixed linear regression model was used to analyze the
relationship between encounter interval and the rate of
BP change.
Population Studied: Adult hypertensive patients with
diabetes followed at primary care practices at Partners
HealthCare for at least two years between 01/01/2000
and 08/31/2005.
Principal Findings: The average encounter interval was
3.7 months for 5,042 patients with 10,447 hypertensive
periods included in the study. BP of the patients with the
average encounter interval = one month normalized after
a median of 1.5 months compared to 12.2 months for the
encounter interval greater than one month (p < 0.0001).
Similarly, systolic blood pressure decreased at the rate
of 28.7 mm Hg/month vs. 2.6 mm Hg / month for patients
with encounter intervals = one month vs. > one month,
respectively (p < 0.0001). Median time to BP
normalization was 0.7 vs. 1.9 months for the average
encounter interval = 2 weeks vs. between 2 weeks and 1
month, respectively (p < 0.0001). In proportional hazards
analysis adjusted for patient demographics, initial BP
and treatment intensification rate, a one month increase
in the average encounter interval was associated with a
hazard ratio of 0.764 for time to BP normalization (p <
0.0001). Multivariable analysis adjusted for patient
demographics and treatment intensification rate showed
that systolic BP rose by 0.7 mm Hg / month for every
extra month between encounters (p < 0.0001). This
relationship was particularly pronounced for average
encounter intervals < 1 month where systolic BP rose by
additional 22 mm Hg / month for every extra week
between encounters (p < 0.0001).
Conclusions: In patients with diabetes and
hypertension, shorter physician-patient encounter
intervals are associated with more rapid decreases in
blood pressure and faster blood pressure normalization.
Greatest benefits were observed at encounter intervals =
2 weeks.
Implications for Policy, Delivery or Practice:
Reducing encounter intervals may improve blood
pressure control in patients with hypertension. Further
studies are needed to determine whether this could be
similarly accomplished by increased frequency of faceto-face physician visits as well as by visits with allied
health professionals and remote encounters (telephone /
email).
Funding Source(s): AHRQ
Health Workforce Distribution, Diversity & Access
Chair: Sharon Arnold
Sunday, June 28 * 11:00 a.m.- 12:30 p.m.
♦ Race, Ethnicity & the Experience of Practicing
Medicine
Michael Dill
Presented by: Michael Dill, Senior Data Analyst, Center
for Workforce Studies, Association of American Medical
Colleges, 2450 N Street, NW, Washington, DC 20037,
Phone: (202) 828-0673, Email: mdill@aamc.org
Research Objective: This study examines differences
and similarities across race and ethnicity groups in
physicians’ experience of practicing medicine.
Study Design: Using two nationally representative
sample surveys of physicians in the U.S., one of doctors
under 50 years of age and one of those over 50,
collected during 2006 in a joint AAMC-AMA venture
(over 50 n=12,167; under 50 n=4,188), the current study
examines the practice characteristics, behaviors and
attitudes of physicians with multivariate analyses of
relationships among race and ethnicity groups in
principal work setting, satisfaction, retirement plans,
financial status and specialty. In particular, differences
in these observed relationships between the two
surveyed age groups are analyzed for indications of
change.
Population Studied: Physicians in the U.S.
Principal Findings: Preliminary findings are
predominantly bivariate. No significant difference in
average hours worked exists across race and ethnicity
groups for physicians under 50; but for those over 50,
both Blacks and Hispanics reported working significantly
more hours than Whites or Asians. The relationship
between race and practice setting is significant for both
age groups, but the pattern of distribution across settings
appears to be converging for younger doctors. The
relationship between race-ethnicity and physicians’
satisfaction with their careers in medicine, specialty and
current position, is statistically significant for physicians
over 50, but not for those under 50. Across all race and
ethnicity groups, physicians under 50 plan on retiring
approximately five years earlier than their older
colleagues. Younger physicians are more likely to report
that part-time work is not available. The least likely to
report the availability of part-time work among physicians
under 50 are Hispanics; and for doctors over 50,
Hispanics and Others (includes Native American and
Other). The relationship between physician raceethnicity and willingness to leave medicine if they could
afford to do so is not significant among those under 50,
but it is among those who are over 50 and not already
retired. Across all race and ethnicity groups, younger
doctors are more likely to be female, but the greatest
increases in female representation have occurred
among Blacks and Hispanics. Indeed, a majority of
Black physicians under 50 are women. Whether or not a
physician is practicing in primary care is significantly
related to race and ethnicity among older doctors, but
not those under 50. Moreover, the percentage reporting
primary care practice is higher for physicians under 50
than those over 50 for all the race and ethnicity groups
except Blacks, and their percentage is almost identical
between the two age groups.
Conclusions: Race and ethnicity are related to the work
experience of physicians in important, and complex,
ways, including where they work, how much they work,
and how they feel about their work. While variations by
race and ethnicity seem to have diminished among
younger doctors, disparities remain.
Implications for Policy, Delivery or Practice: As
minority physicians are more likely to provide care for
poor and underserved communities, the racial and ethnic
diversity of the physician workforce bears directly on
addressing disparities in access to care. Furthermore,
assuring an adequate supply of physicians will
increasingly rely on a diverse physician workforce.
Funding Source(s): AAMC/AMA
♦ The Aging of the Dentist Workforce: Are Rural
Locations at Higher Risk?
Mark Doescher, M.D, M.S.P.H.; Gina Keppel, M.P.H.
Presented by: Mark Doescher, M.D, M.S.P.H., Director,
Washington, Wyoming, Alaska, Montana, & Idaho Rural
Health Research Center, Family Medicine, University of
Washington, 4311 Eleventh Avenue, Northeast, Suite
210, Seattle, WA 98105, Phone: (206) 616-9207, Email:
mdoesche@u.washington.edu
Research Objective: This study quantifies the extent to
which rural dentist shortages may be exacerbated by
impending retirement. Dentists are an essential
component of rural health care, but rural communities
may struggle to recruit and retain sufficient numbers of
dentists to meet their oral health care needs. As more
dentists select specialty practice concentrated in urban
locations, the retirement of older dentists with broad
clinical skills may place additional strain on the supply of
rural dentists.
Study Design: Cross-sectional assessment of dentist
supply employing data from the American Dental
Association 2008 Masterfile.
Population Studied: The US population of “generalist”
rural dentists encompassing those in general practice,
pediatric dentistry and dental public health was
identified. This study focused on those nearing
retirement, defined as being aged 56 years or older and
clinically active in full- or part-time practice (n=4,924).
Federally-employed dentists and those in residency
training were excluded from analyses. Proportions and
generalist dentist/population ratios were determined at
the national- and county-level for metropolitan (“urban”)
and nonmetropolitan (“rural”) locations. Counties in the
upper quartile of the overall generalist dentist age
distribution were termed “aging generalist dentist”
locations. Counties lacking generalist dentists were
termed “no generalist dentist” locations.
Principal Findings: The US rural generalist
dentist/population ratio (dentists/100,000 persons) of
20.3 was significantly lower than the corresponding
figure in urban areas of 24.1 (p<0.001). Accounting for
part-time dentists (by weighting anyone who listed their
practice as being part-time as 0.5 dentist) decreased the
mean generalist dentist/population ratio to 18.2 in rural
locations as opposed to 21.7 in urban locations (p<.001).
Nationally, rural areas had a higher percentage of
generalists aged 56 or older than did urban locations
(43.8% vs. 39.0%; p<.0001). This percentage increased
to 45.3% in remote rural locations. Of 2,051 rural
counties in the US, 519 fell into the upper quartile of the
age distribution, so were termed “aging generalist
dentist” locations. The mean age of generalist dentists in
these counties was 60.0 years. Also, 326 (15.9%) of the
US rural counties were “no generalist dentist” locations.
In contrast, only 48 (4.4%) of the 1,090 US urban
counties were “no generalist dentist” locations (p<0.001).
Conclusions: Rural generalist dentist shortages will be
exacerbated in the coming years by impending
retirement. Furthermore, retirement-related attrition will
have the largest impact on locations in which the burden
of oral disease is likely to be high, such as remote rural
locations.
Implications for Policy, Delivery or Practice: To
reduce the impact of retirement-related attrition, public
and private investment to bolster the dentist workforce
supply could be directed preferentially to rural locations
currently without generalist dentists and locations with
high proportions of generalist dentists who are
approaching retirement.
♦ The Shortage of On-Call Coverage: Understanding
the Issue
Mitesh Rao, M.D.; Catherine Lerro, M.S.; Cary Gross,
M.D.
Presented by: Mitesh Rao, M.D., Clinical Scholar,
Robert Wood Johnson Clinical Scholars Program, Yale
School of Medicine, IE-61 SHM P.O. Box 208088, New
Haven, CT 06520-8088, Phone: (203) 785-6499, Email:
mitesh.rao@yale.edu
Research Objective: The Institute of Medicine report
from 2006 entitled Hospital Based Emergency Care: at
the Breaking Point reported that physician specialists are
often unavailable to provide emergency and trauma
care. The ability to consult a specialist is critical to the
quality of care provided by emergency and trauma
physicians. The primary objective of this study is to
report the experiences of a national sample of
Emergency Department Directors regarding: the degree
of difficulty in providing on-call specialist coverage, the
impact of coverage shortages on patient care, and the
barriers to improving on-call coverage.
Study Design: 14 multi-level quantitative questions
directed at each of our primary and sub-domains
constituted the bulk of our instrument. The instrument
was designed and piloted with the help of the
Department of Emergency Medicine at Yale University.
To improve response rate, we employed a five-wave
method of administration: pre-notice contact, two
individualized mailing with cover letter, a thank you
letter, and follow-up phone calls. Data will be analyzed
using SAS 9.1 Statistical Software, with responses
compared by hospital (trauma level, ownership, size)
and geographic variables (region, MSA).
Population Studied: We conducted a cross-sectional
self-administered survey of a national random sample of
ED Directors distributed proportionally across all 50
states. Power calculations assured that we would be
powered to detect a 10% change in response between
our sample (n=750) and the respondents of the only
previous national study (n=1427).
Principal Findings: We are currently at a 50%
response rate after completing the mailing phase and
beginning the phone call follow-up phase. We plan to
obtain at least a 60% response rate by the end of
January 2009. Overall, 75% of respondents report that
their hospital has a problem with on-call coverage. That
percentage increases to as much as 80% of hospitals in
certain less-populated areas of the country, such as the
Southwest. 20% of respondents report that shortages of
on-call coverage have resulted in either a downgrade or
suspension of their trauma level. 65% report having lost
the ability to provide coverage for a specialty in the past
four year. 55% report increases in their volume of
outgoing transfers over the past year. In regards to the
perceived barriers to improving on-call coverage, 76%
cite financial costs of providing on-call care, 66% cite
medical liability, and 64% cite high numbers of under
and un-insured.
Conclusions: Early results indicate that on-call specialty
care shortages are a problem for three-quarters of
Emergency Departments across the country.
Furthermore, a considerable number of Departments
have recently experienced losses of specialty coverage
and ramifications to their trauma capabilities. Volumes of
outgoing transfers have increased for more than half of
EDs across the country. A majority of ED Directors cite
financial costs, medical liability, and increased numbers
under/un-insured patients as the biggest barriers to
improving on-call specialty coverage.
Implications for Policy, Delivery or Practice: On-call
specialty care shortages are an evolving issue with
implications to both health care access and cost. Armed
with a better understanding of the effect of the problem
as well as the perceived roadblocks to change, we can
increase awareness of the issue and move forward with
designing solutions to maintain and improve specialty
coverage capabilities.
Funding Source(s): RWJF, ACEP
♦ Unionization & the Wage Structure of Nursing
Joanne Spetz, Ph.D.; Michael Ash, Ph.D.; Jean Ann
Seago, Ph.D., R.N.
Presented by: Joanne Spetz, Ph.D., Associate
Professor, Community Health Systems, University of
California, San Francisco, 3333 California Street, Suite
410, San Francisco, CA 94118, Phone: (415) 502-4443,
Email: jojo@thecenter.ucsf.edu
Research Objective: Of 2.4 million registered nurses
employed in the United States in 2003, unions
represented about 472,000, or nearly 21 percent. This
rate is over five percentage points higher than for all
workers in the United States. Recent research has
confirmed that nursing unions confer a wage premium to
their members. Freeman and Medoff argue that unions
also compress the wage structure as an expression of
solidarity and worker preferences. There may be reason
to think that the taste for compression is less applicable
in the case of nurses than for other workers. Career
ladders and skill-based pay scales often figure
prominently among the policy goals espoused by nurse
advocates. These would tend to decompress the wage
structure for nurses, which some advocates have
complained emerges from traditional feminization of the
profession and contributes to turnover and exit. This
paper examines the impact of nursing unions on the
wage structure of registered nurses.
Study Design: We use the Current Population Survey
(2000-2006) and the National Sample Survey of
Registered Nurses (2004) to examine the effect of
unionization on the wage distribution of registered
nurses. We examine the compression hypothesis in two
ways. First, we examine how unionization status affects
pay differences that are widely observed: gender,
racial/ethnic, educational, and seniority. Second, we
examine wage variation and residual wage variation by
union status.
Population Studied: Registered nurses employed in the
United States, 2000-2006.
Principal Findings: Preliminary regression equations
using the Current Population Survey provide mixed
evidence for the compression hypothesis. The gender
gap is actually larger in the union than in the nonunion
sector. Education wage gaps are mildly compressed,
with unions reducing the wage penalty for diploma
nurses from 11 to 3 percent while the other educational
gaps are relatively stable. The black penalty falls by
more than half, from 11 percent to 5 percent. The
Hispanic penalty falls from a statistically significant 9
percent to an insignificant 7 percent, but the difference is
itself not statistically significant. The age-earnings profile
in the union sector is somewhat flatter than in the nonunion sector, which suggests that unions do compress
earnings of older and younger nurses, which runs
contrary to the hypothesis that career ladders are a
union goal. We examine the overall distribution of wages
in the union and non-union sectors. The standard
deviation of the logarithm of wage is a standard measure
of dispersion. The non-union and union sectors have
very similar standard deviations of log wage and residual
log wage, which suggests that wage compression is not
a strong force in the union sector.
Conclusions: We find little evidence to support the
hypothesis that unions compress the wage structure,
with the exception that unions reduce the wage gap for
immigrants and for minorities, especially for blacks and
Hispanics.
Implications for Policy, Delivery or Practice: Unions
may play a role in reducing earnings disparities between
minorities and whites. As the nursing workforce
becomes more diverse, the effect of unions on the wage
structure may become more important.
Funding Source(s): AHRQ
♦ How the Inter-State Migration of Registered Nurses
Affects the Nursing Workforce
Renae Waneka, M.P.H.; Joanne Spetz, Ph.D.
Presented by: Renae Waneka, M.P.H., Research
Analyst, Center for the Health Professions, University of
California, San Francisco, 3333 California Street, Suite
410, San Francisco, CA 94118, Email:
rwaneka@thecenter.ucsf.edu
Research Objective: To examine the inter-state
migration of registered nurses (RNs) and to identify what
intentions RNs have to cross state borders to work.
Study Design: Data from the 2004 National Sample
Survey of Registered Nurses are used to examine the
demographics of nurses who moved to another state
between 2003 and 2004. Nursing licensure and
endorsement data from the California Board of
Registered Nursing are used to measure and
characterize movements of RNs with California licenses.
A random sample survey of 2,400 RNs who requested
endorsements of their nursing licenses into or out of
California was conducted in 2007 and 2008. These data
are used to describe the residence and employment
plans of nurses. Descriptive statistics are used to
describe all data.
Population Studied: The population studied includes a
national sample of RNs from 2004 and a sample of RNs
who requested endorsement of their RN license into or
out of California.
Principal Findings: Overall, nurses who migrate across
state borders to work are young, single, less
experienced in nursing than the average RN, educated
through a BSN program, and likely to practice travel
nursing. Nationally, nurses who moved to another state
to work reported changing jobs for family reasons. In
California, RNs who requested an endorsement of their
RN license out of the state reported that high cost of
living, moving closer to family and friends, and wanting
to live elsewhere, were their primary motivations for
requesting an endorsement. Many of the RNs who
requested an endorsement of their RN license into or out
of California plan to work as travel nurses. A large share
of internationally-educated RNs may be using California
as a “pass-through” state, by receiving initial RN
licensure in California and then endorsing to another
state. California is, overall, gaining more RNs by
endorsement than it is losing.
Conclusions: Although personal factors were the most
commonly reported reasons for RNs who endorsed their
licenses from California to other states, policies that
encourage nurses to continue practicing in their current
state of licensure may help the state recruit and retain
more of its nurses. Since the majority of these RNs are
young and many of them work as travel RNs, providing
incentives to these groups may encourage them to
continue practicing in their home state.
Implications for Policy, Delivery or Practice: As the
nursing shortage continues, the inter-state migration of
RNs is an important factor for states to consider when
determining recruitment and retention strategies for their
nursing workforce.
Funding Source(s): California Board of Registered
Nursing
Recruitment, Retention & Productivity of the Health
Workforce
Chair: Jean Moore
Sunday, June 28 * 2:30 p.m.- 4:00 p.m.
♦ Assessment of the Frontline Health & Healthcare
Workforce & the Business Case for Employer
Investment in Systems Change
Emmeline Chuang, A.B.; Jennifer Craft Morgan, Ph.D.;
Brandy Farrar, M.S.; Janette Dill, M.A.; Thomas Konrad,
Ph.D.
Presented by: Emmeline Chuang, A.B., Doctoral
Candidate, Health Policy & Management, University of
North Carolina-Chapel Hill, Campus Box 7411,
McGavran-Greenberg Hall, Chapel Hill, NC 27510,
Phone: (858) 774-6586, Email:
emchuang@email.unc.edu
Research Objective: Characterize the frontline health
and healthcare workforce (FLWs), identify common
challenges to the skill and career development of these
workers, and discuss the business case for healthcare
employers to address these challenges through systems
change and the testing of innovative educational models.
Differences in organizational context between employer
types are also examined.
Study Design: Data used for this study include 229
interviews, 26 frontline worker focus groups, and 22
frontline supervisor focus groups conducted as part of
the evaluation of seventeen workforce development
projects jointly funded by the Robert Wood Johnson
Foundation, the Hitachi Foundation, and the Department
of Labor for the Jobs to Careers: Promoting Work-Based
Learning for Quality Care national program. This
program supports partnerships of healthcare employers,
educational institutions, and other organizations to
expand and redesign systems to create lasting
improvements in the training and advancement of FLWs,
and test new models of education and training that
incorporate work-based learning.
Population Studied: Upper-level administrators,
supervisors, and FLWs in seventeen workforce
development partnerships between educational
institutions (primarily community colleges) and a wide
range of health and healthcare employers, including 9
hospitals and/or health care systems, 5 behavioral
health centers, 5 community health centers, and 8 longterm care facilities.
Principal Findings: Frontline positions currently
account for half of the total health and healthcare
workforce. Although demand for these positions is rising,
they are characterized by low pay, few benefits, heavy
workloads, and undereducated workers. Pervasive
problems in retention are reported, and exacerbated by
frequently antagonistic relationships between FLWs and
supervisors, and FLW perception that they are not
valued or respected by their organizations. Key barriers
to FLW advancement include lack of educational
readiness, high rates of poverty, and competing
demands associated with family responsibilities and
second jobs. From an employer perspective, need for
skill development of FLWs is extremely high, particularly
with regards to developing FLW understanding of
professional boundaries and establishing standardized
clinical competencies. Improving service quality,
reducing retention, and “growing your own” were
described as critical motivators for employer investment
in systems change and the development of innovative
educational models such as work-based learning. Workbased learning models that allow for on-the-job skill
development and/or academic credentialing appear to
be successful at reducing barriers to FLW advancement,
though the long-term impact on desired employer
outcomes remains to be seen.
Conclusions: While some differences in organizational
needs between sectors exist, evidence suggests that
FLWs constitute a single workforce facing common
barriers to skill and career development. Work-based
learning models may have the potential to reduce many
of these barriers, but require substantial investment in
systems change from both educational and employer
partners. In the healthcare sector, the combination of
mid-level worker shortages, high turnover, and
anticipated occupational growth due to population aging
has created incentives for employers to make these
changes. Whether other partners are ready to make this
level of investment, and whether these models will be
sustainable in the long-term remains to be seen.
Implications for Policy, Delivery or Practice: The
need for improved skill and career development for
FLWs is an important issue that needs to be addressed.
Funding Source(s): RWJF
♦ Factors Affecting the Career Choices of Medical
Students and Residents
Martey Dodoo, Ph.D.; Robert Phillips, M.D., M.S.P.H.;
Andrew Bazemore, M.D., M.P.H.; Bridget Teevan, M.S.;
Imam Xierali, Ph.D.; Stephen Petterson, Ph.D.
Presented by: Martey Dodoo, Ph.D., Chief Economist,
Robert Graham Center, 1350 Connecticut Avenue, NW,
Suite 201, Washington, DC 20036, Email:
mdodoo@aafp.org
Research Objective: To identify factors associated with
physicians’ choice of careers in primary care, practice in
rural and underserved populations. We tested for factors
including student characteristics, debt, medical school
and residency training.
Study Design: Based on a theoretical framework, our
analyses included bivariate procedures to identify
associations and estimate relative risk and odd ratios,
and stepwise multivariate analysis to explain outcomes
while selecting and controlling for other variables and
interaction terms. We also calculated hours-adjusted net
present value (NPV) as a measure of the financial return
to education (discount rate=5%) comparing primary care
careers to other physician career options.
Data used included full-year 2001-2005 Medicare
outpatient institutional claims from health centers (FQHC
and RHC), 2000-2006 AMA Physician Master file
database, 1979-2004 AAMC GQ survey data, 19782004 NHSC participant database, 1978-2004 HRSA Title
VII exposure database, primary care medical residency
training history database, MGMA specialty-specific
income data, AAMC and JAMA historical data on
medical school tuition and resident stipends, and various
supplementary data on medical student training costs
and data from the US Department of Labor. All financial
data were adjusted for inflation using the CPI. Data
Limitations: Response rates to annual GQ surveys
varied greatly. We were unable to include data for
osteopathic physicians. Pediatricians are
underrepresented in health center analyses due to
reliance on Medicare claims. We were unable to obtain
medical school matriculation survey data.
Population Studied: US. Medical students, medical
residents, and physicians from 1978 to 2004
Principal Findings: Students with any debt were more
likely to participate in the NHSC compared to no debt
(OR= 1.66-2.88; Pr<0.0001). Lower debt was associated
with scholarships and loan repayment. Separate
analyses for public and private medical schools revealed
different pictures for the odds of choosing primary care
for physicians with debt when compared to no debt.
Higher levels of debt were more likely to be associated
with choosing primary care (OR=1.11-1.18; Pr<0.0001)
or working in a community health center (OR=1.01-1.25;
Pr<0.0001). Scholarships were associated with primary
care practice, rural practice, service in health centers
and in underserved areas. Higher levels of debt were
associated with greater likelihood of rural practice.
Attending public medical school increased the likelihood
of family medicine practice (OR=2.02; Pr<0.0001), and
attending one in rural area increased the likelihood of
future rural practice (OR=2.41; Pr<0.0001).
Conclusions: We identified various levels of debt and
type of school funding and location of school, as factors
associated with physicians’ choice of careers in primary
care, and practice in rural and underserved populations.
Implications for Policy, Delivery or Practice: Within
the last decade, US medical student choice fell well
below the thresholds necessary to maintain the
physician workforce in primary care and underserved
settings.
Funding Source(s): Josiah Macy, Jr. Foundation
♦ Cutting Time? How Hours Spent in Clinical Care
Vary for General Surgeons in Different Birth Cohorts
Erin Fraher, Ph.D., M.P.P.; Anthony Charles, M.D.,
M.P.H.; Lindsee McPhail, M.D.
Presented by: Erin Fraher, Ph.D., M.P.P., Director,
North Carolina Health Professions Data System, CB #
7590, University of North Carolina, Chapel Hill, Sheps
Center for Health Services Research, 725 Airport Road,
Chapel Hill, NC 27599-7590, Phone: (919) 966-5012,
Email: erin_fraher@unc.edu
Research Objective: Despite extensive discussion
about the effects of gender and worklife choices on the
hours worked by general surgeons, little empirical
evidence exists about differences in workforce
participation rates of male and female surgeons at the
same age in different birth cohorts. This study
investigated the influence of historical period, gender,
age, and birth cohort on the number of hours worked in
patient care by North Carolina general surgeons
between 1980 and 2006.
Study Design: A retrospective cohort analysis was
conducted of licensed general surgeons in North
Carolina from 1980-2006. Descriptive and bi-variate
analyses were used to examine the effect of age and
gender on hours worked for seven birth cohorts of
general surgeons in different time periods. The main
outcome variable analyzed was hours in patient care per
week, excluding on-call hours.
Population Studied: Annual North Carolina licensure
files were merged from 1980-2006 and included all
active, in-state, non-federal, non-resident-in-training
physicians reporting a primary specialty of general
surgery. The sample included 16,042 observations on
1,818 general surgeons.
Principal Findings: Hours per week have declined in
recent years. The general trend is toward fewer hours
worked by successive birth cohorts at the same age.
General surgeons between 30-39 years of age in the
WWII cohort worked an average of 60.6 hours per week
compared to Generation Xers of the same age who
worked 56.8 hours, p<.01. The differential was even
greater between ages 40-49 when the WWII cohort
worked an average 6.4 more hours, p<.01, the Boomer 1
cohort worked an average 5.1 more hours, p<.05, and
the Boomer 2 cohort worked an average 4.4 more hours,
p<.05, than Gen X general surgeons who averaged 50.1
hours per week. The average age of the surgical
workforce in North Carolina did not increase over the
period. The average age for both male and female
surgeons was fairly constant in all years at about 50 and
40 years respectively. Female surgeons worked fewer
hours in all age categories but particularly between ages
30-39 when they worked nearly 5 fewer hours per week,
p<.01, and between ages 40-49 when they worked 3.3
fewer hours per week than their male colleagues, p<.01.
Female general surgeons increased from 0.8% of the
workforce in 1980 to 8.2% in 2006 but their small
numbers suggest that gender effects on workforce
participation rates will not be a significant factor in the
near future.
Conclusions: The number of hours worked by general
surgeons in North Carolina has declined and this
decrease appears to be driven by period and cohort
effects, not age and gender effects.
Implications for Policy, Delivery or Practice: Existing
projections of general surgeon supply do not account for
gender, age, and cohort effects. Most models are based
on cross-sectional data that tend to produce substantial
errors if gender-age-cohort patterns change over time.
Given the rapidly changing demographics of the general
surgeon workforce, future models of supply need to
incorporate age-gender-cohort effects into supply
estimates.
Funding Source(s): American College of Surgeons
Health Policy Research Institute
♦ Innovations in Modeling Registered Nurse
Turnover
Cheryl Jones, Ph.D.; Barbara Mark, Ph.D.; Catherine
Zimmer, Ph.D.; YunKyung Chang, Ph.D.; Linda Hughes,
Ph.D.; Michael Gates, Ph.D.
Presented by: Cheryl Jones, Ph.D., Associate
Professor, School of Nursing, University of North
Carolina at Chapel Hill, CB # 7460, Chapel Hill, NC
27599-7460, Phone: (919) 966-5684, Email:
cabjones@email.unc.edu
Research Objective: Registered nurse (RN) turnover
has been studied extensively, yet we still know very little
about the mechanisms that drive RN turnover. This may
be due in part to the models that have been used to
explain nurse turnover -- conceptualized largely as a
function of traditional individual and organization factors,
and accounting for only a small portion of the variance in
turnover. With a few exceptions, we also know very little
about the effects of nurse turnover on patient and
organizational outcomes, yet both positive and negative
effects have been postulated. Lacking consistent
evidence, policy-makers are unsure about if and how to
address RN turnover. Social capital theory values
assets embedded in the social relations of work groups,
and has shown promise in explaining the turnoverorganizational performance relationship. That is, a work
group’s extant social capital may influence turnover
among group members and may, in turn, affect patient
and organizational outcomes. Examining nurse turnover
by accounting for social relationships may better explain
the underlying mechanisms of turnover, and may help us
better understand whether these relationships affect unit
turnover, patient outcomes and organizational
performance.
Study Design: Unit-level RN turnover was examined
using a random intercepts model to estimate
associations between variables, while accounting for
clustering of nursing units within hospitals. Unit-level RN
turnover was measured monthly for six months to derive
a mean turnover rate for the period. We then modeled
RN turnover as a function of contextual variables
(external, hospital and unit environment) and social
capital variables (i.e., structural, cognitive, and relational
dimensions), and as a predictor of quality of care and
organizational financial performance variables.
Population Studied: We used data from the Outcomes
Research for Nursing Administration project, a large,
longitudinal, multi-site organizational study examining
relationships between hospital context, structures, and
outcomes. Our sample included 286 patient care units
in 146 hospitals.
Principal Findings: The contextual variable, work
complexity, and the social capital variable, percent
agency staff, were positively related to RN turnover; the
social capital variables, group cohesion and unit staff
stability, were negatively related to RN turnover. RN
turnover was also negatively related to certain quality of
care variables, namely patient satisfaction and symptom
management, but was not associated with patient falls or
medication errors. There were no relationships found
between RN turnover and unit-level costs or average
patient length of stay.
Conclusions: We found some evidence supporting
relationships between turnover and certain structural and
relational dimensions of social capital. We also
identified important relationships between RN turnover
and patient outcomes.
Implications for Policy, Delivery or Practice: Our
study contributes knowledge to the field of turnover
research, and also provides healthcare leaders and
clinicians insights into RN turnover, which can serve as a
basis for developing more relevant approaches to
addressing nurse turnover and developing organizational
policy. Our study suggests that investing in certain
aspects of social capital on patient care units and
mitigating RN turnover may improve aspects of quality in
organizations that make such investments.
Funding Source(s): NIH/NINR
♦ What Drives Primary Care Physician Productivity
Carol Simon, Ph.D., M.S.; William White, Ph.D.
Presented by: Carol Simon, Ph.D., M.S., Vice
President, The Lewin Group, 3130 Fairview Park Drive,
Suite 800, Falls Church, VA 22042, Phone: (703) 6249615, Email: carol.simon@lewin.com
Research Objective: There is tremendous variation in
primary care physician productivity, measured in terms
of patient visits, RVUs or financial measures such as
revenues generated. This paper looks at organizational,
staffing, training and environmental factors that are
associated with variation in productivity including: the
availability of HIT; the use of non-physician mid-level
providers in the practice; practice size and organization;
and the presence of financial incentives that target
utilization.
Study Design: This study uses data from a 2006-7
multi-mode survey of physicians in PC and pediatric
practices. Data domains include physician demographic
characteristics, income, practice revenues and structure
(e.g., resources, payer type, and use of HIT, including
electronic medical records (EMRs) and decision support
systems), and administrative controls. Multivariate
weighted regressions are used to model physician
practice productivity, analyzing the effects of: (1)
technology; (2) practice organization; (3) physician
characteristics; (4) use of mid-level non-physician
providers; (5) performance incentives on a number of
measures of physician productivity. Data are weighted to
account for sampling design and known sources of nonresponse.
Population Studied: A random sample of 1967 primary
care (PC) and pediatric physicians in 5 states (California,
Illinois, Georgia, Pennsylvania and Texas). The sample
was derived from the American Medical Association
Physician Masterfile. Pediatric and minority physicians
were over sampled. Survey response rate was 69.7%
Principal Findings: Practice size, organization,
availability of HIT, use of Nurse practitioners & Physician
Assistants; and certain types of incentive mechanisms
significantly affect physician productivity. Notably,
comprehensive HIT capabilities tend to increase
measured productivity by 5-20%; NPs and PAs augment
physician productivity by 18-25%, per provider; mid-size
practices (10-15 mds) have highest measured
productivity; and the presence of financial incentives
have, on average, a modest effect (5-10%) on measured
productivity – tho it varies considerably across different
practice settings and can have negative implications in
some specifications
Conclusions: Preliminary findings suggest that there
are systematic differences in physician productivity that
should be accounted for in workforce modeling. HIT and
use of mid-level physician providers enhances
productivity. Practices exhibit limited scale economies.
Implications for Policy, Delivery or Practice:
Productivity may be enhanced through policy measures
that enable greater use of HIT, non-physician providers;
and certain types of incentive mechanisms.
Funding Source(s): AHRQ
The Right Mix: Linking the Workforce to Patient &
Health Outcomes
Chair: Susan Skillman
Sunday, June 28 * 4:30 p.m.- 6:00 p.m.
♦ The Impact of Within-Nursing Unit Variation in
Patient Care Hours on Post-Discharge Utilization &
Costs
Kathleen Bobay, Ph.D., R.N.; Olga Yakusheva, Ph.D.;
Marianne Weiss, D.N.Sc., R.N.; Jane Nosbusch, M.S.N.,
R.N.
Presented by: Kathleen Bobay, Ph.D., R.N., Assistant
Professor, Nursing, Marquette University, P.O. Box
1881, Milwaukee, WI 53201-1881, Phone: (414) 2883851, Email: kathleen.bobay@mu.edu
Research Objective: To describe the relationship of
nursing unit-level staffing characteristics (RN hours per
patient day [RNPPD], RN overtime hours [RNOT], and
non-RN hours per patient day [nRNHPPD]) to patient
readmissions and Emergency Department (ED)
utilization within the first 30 days after hospital
discharge.
Study Design: The study used a hierarchical panel
logistic regression model to determine predictive/causal
relationships among study variables. Monthly nurse
staffing characteristics from 16 nursing units at 4
hospitals of a Midwestern multi-hospital health care
system were obtained from electronic health information
systems during the period of January through June
2007. Patient-level outcome data included in-patient
readmission and ED utilization within 30 days postdischarge for hospitalization-related (primary diagnosis
and co-morbidities) and all-cause reasons. Patient-level
control variables included age, sex, type of insurance
and major diagnostic category.
Population Studied: 1660 hospitalized patients, age 18
or older, who were discharged home without hospice
care. Equal numbers of patients were randomly selected
from each of the 16 NDNQI-designated medical,
surgical, or medical-surgical units.
Principal Findings: Increasing non-overtime RNHPPD
by 1 hour reduced the probability of readmission by
2.2% (p=.01, two-tailed) for related and 3.5% (p=.04) for
all-cause occurrences; ED utilization by 0.2% (p=.00)
for related and 1.4% (p=.03) for all-cause occurrences;
and the probability of either readmission or ED visit by
2.5% (p=.01) for related and 4.9% (p=.01) for all-cause
occurrences. Increasing nRNHPPD by 1 hour reduced
the probability of readmission by 2.1% (p=.02) for a
related condition and 3.0% (p= .12) for all-cause
occurrences, ED utilization by 0.2% (p=.00) for related
and 1.4% (p=.02) for all-cause occurrences; and the
probability of either readmission or ED visit by 2.3%
(p=.01) for related and 4.4% (p=.05) for all-cause
occurrences. RNOT was not associated with the
probability of readmission. Increasing RNOT by 1 hour
increased the probability of ED utilization by 1.1%
(p=.02) for related conditions and 7.3% (p=.08) for allcause ED occurrences. The average net cost saving of
an additional non-overtime RNHPPD was $249.86 for
each admitted patient. The average net cost saving of an
additional nRNHPPD was $277.28 for each admitted
patient.
Conclusions: Using hierarchical panel analysis
permitted estimation of the impact of within-nursing unit
staffing changes over time on post-discharge utilization.
Within nursing units, patients discharged when the
staffing levels (RNHPPD and nRNHPPD) were lowest
within the 6 month study period, had highest risk of
readmissions and ER visits. The association between
RNOT and ED utilization warrants further investigation to
determine if higher RNOT contributes adversely to posthospitalization utilization.
Implications for Policy, Delivery or Practice: The
results emphasize the contribution of the RN and nonRN staffing complement on individual nursing units to
patient outcomes beyond hospital discharge. Within the
range of staffing hours observed on each study unit,
targeting higher non-overtime RNHPPD and nRNHPPD
levels could result in reductions in occurrences and
costs related to compensatory post-discharge care.
Investment in optimal staffing, along with monitoring and
remediation of changes in staffing complement to avoid
HPPD reductions should be considered outcome
improvement and cost-containment strategies.
Funding Source(s): RWJF
♦ The Effect of Shift Structure on Performance: The
Role of Fatigue for Paramedics
Tanguy Brachet, Ph.D.; Guy David, Ph.D.; Reena
Duseja, M.D.
Presented by: Tanguy Brachet, Ph.D., Assistant
Professor, University of Pennsylvania School of
Medicine, Center for Outcomes Research, 3535 Market
Street, Suite 1029, Philadelphia, PA 19104, Phone:
(215) 590-5758, Email: brachet@mail.med.upenn.edu
Research Objective: The effect of shift structure on
health care worker performance has been an issue of
increasing interest among health care facilities and
regulatory bodies, motivated by the belief that fatigue is
a critical mediator. This study aims to measure the
extent to which the performance of paramedics towards
the end of their shift is impacted by its length.
Study Design: An observational study of all paramedics
(N=2,400) in the state of Mississippi between 2001 and
2005, partitioned into 24 hour and 12 hour (and below)
shifts. We estimate linear regressions, adjusting for
patient characteristics, locations and time of incidents,
types of trauma and injury characteristics (for trauma
runs) and indicators of symptoms (for medical runs).
Multiple time series research design is employed to
benchmark changes in performance throughout the
duration of shifts.
Population Studied: We study the universe of trauma
incidents which involve at least one indication of injury
and result in emergency transport to a hospital
(N=155,392), and all medical incidents involving
emergency transport to a hospital (N=587,617).
Principal Findings: Paramedics working longer shifts
performed poorly towards the end of their shift (typically
midnight to 6AM), as measured by total out-of-hospital
time, compared to paramedics working shorter shifts. In
addition, the number of pre-hospital interventions fell,
while minutes-per-procedure were significantly longer for
paramedics towards the end of longer shifts.
Conclusions: Paramedics working longer shifts
experienced deteriorations in performance towards the
end of their shifts, likely due to fatigue.
Implications for Policy, Delivery or Practice: This
finding has implication for the organization of the health
care workforce and supports current regulations
designed to limit extended work hours.
♦ Benefits of Family Members Serving as PCAs
James Maxwell, Ph.D.; Karen Schneider, Ph.D.; Jaya
Mathur, B.A.; Tom Mangione, Ph.D.; Jack Boesen, Esq.;
Christine Bishop, Ph.D.
Presented by: James Maxwell, Ph.D., Director of Health
Policy & Management Research, Health Care Policy &
Management Research, JSI Research & Training
Institute, Inc., 44 Farnsworth Street, Boston, MA 02210,
Phone: (617) 482-9485, Email: jmaxwell@jsi.com
Research Objective: The Massachusetts PCA program
funds home-based care for elderly and disabled
consumers. As a consumer-directed program,
consumers are responsible for hiring and training
workers. They are allowed to hire anyone, including
family members, to work as paid caregivers. The
purpose of this project is to evaluate the extent to which
family members as paid PCAs improves consumers’
hiring and retention of workers, and their satisfaction
with the way their needs are met, compared to
consumers who hire strangers or acquaintances as
PCAs.
Study Design: Questions were taken from evaluations
of other state PCA programs and prior research on
home-based care. A random sample of consumers was
drawn from the PCA program consumer population. For
consumers less than 18 years of age or those incapable
of completing the survey on their own, a proxy
respondent completed the interview. Survey data were
analyzed in SAS. Chi-square tests for categorical
variables and t-tests for continuous variables were used
to test for significant differences, p less than 0.05.
Population Studied: Data for 147 consumers with
family member PCAs and 211 consumers with
strangers/acquaintances as PCAs participating in the
PCA program.
Principal Findings: Compared to consumers
stranger/acquaintance PCAs, consumers with family
PCAs were more likely to have been in the program for
LTE 5 years, 76 percent vs. 50 percent, and more likely
to have only one PCA, 64 percent vs. 43 percent. Sixtythree percent of consumers with family PCAs received
unpaid help from family/friends, compared to 53 percent
of consumers with stranger/acquaintance PCAs.
Consumers who hired family members had lower
turnover rates than consumers with
stranger/acquaintance PCAs, 12 percent vs. 20 percent.
Thirty-seven percent of consumers with family PCAs
responded that it took LT one week to find a new PCA
and 81 percent reported that it was not at all difficult to
find a PCA, compared to 57 percent and 64 percent of
consumers who hired strangers/acquaintances,
respectively. Ninety-five percent of consumers with
family PCAs reported never being mistreated in the past
year by their PCA, compared to 77 percent of
consumers with stranger/acquaintance PCAs. Even
though there was no difference in ADL/IADL needs,
consumers who hired family had less unmet need for
ADLS than consumers with stranger/acquaintance
PCAs. Additionally, 93 percent of consumers who hired
family reported being very satisfied with the way their
ADLs were met, compared to 84 percent of consumers
who hired strangers/acquaintances.
Conclusions: Hiring family members as PCAs shows
benefits across the board. It improves PCA retention
rates, while decreasing the effort required of consumers
to find and hire PCAs. Further, it improved consumer
satisfaction and allows family members to be
compensated for some of the unpaid care they are
already providing to consumers.
Implications for Policy, Delivery or Practice: Family
members provide an important source of caregiving for
PCA consumers and create a more stable workforce
than if consumers hire strangers or acquaintances.
Other state PCA programs should consider adopting
policies that allow family members to serve as PCAs for
elderly and disabled consumers. These findings have
implications for the organization of other home-based
long-term care services.
Funding Source(s): PCA Quality Home Care Workforce
Council
♦ A Longitudinal Analysis (1996-2002) of Rural
Hospital Financial Margins, Nurse Staffing & Patient
Outcomes
Robin Newhouse, Ph.D.; Laura Morlock, Ph.D.; Peter
Pronovost, M.D., Ph.D.; Elizabeth Colantuoni, Ph.D.;
Mary Johantgen, Ph.D.
Presented by: Robin Newhouse, Ph.D., Assistant Dean,
Doctor of Nursing Practice Studies & Associate
Professor, School of Nursing, University of Maryland,
655 West Lombard Street, Suite 516B, Baltimore, MD
21201, Phone: (410) 706-7654, Email:
newhouse@son.umaryland.edu
Research Objective: To examine the association
between a) changes in financial margins and nurse
staffing per hospital bed [Registered Nurse (RN),
Licensed Practical Nurse (LPN) and total nursing Full
Time Equivalent (FTE)], b) nurse staffing per hospital
bed and patient outcomes [(Health Care Utilization
Project(HCUP) Quality Indicators (QI) and Patient Safety
Indicators (PSIs)] and c) changes in financial margins on
patient outcomes among rural hospitals during 1996 2002.
Study Design: A time-series design was used.
Population Studied: Secondary data for 186 rural
hospitals of all types with over 25 beds from 19 states
were abstracted for 1996-2002 from three sources:
American Hospital Association Annual Survey (hospital
and nurse staffing), State Inpatient Databases [HCUP
QIs heart failure (HF), stroke and acute myocardial
infarction (AMI) and PSI failure to rescue (FTR)], and
Medicare Cost Reports (hospital financial margins).
Principal Findings: In pooled estimates across years,
each additional one RN FTE per bed results in lower risk
adjusted mortality for HF (14%) and stroke (9%). When
measuring the change in RN FTE/bed the following year,
adding one RN FTE per bed results in 15% lower HF
mortality, 13% lower stroke mortality and 17% lower
FTR. In pooled estimates across years, each additional
one Nursing FTE (RN and LPN) per bed results in lower
risk adjusted mortality for HF (11%) and stroke (7%).
Nurse staffing in rural hospitals of all sizes was not
significantly affected by financial margins or changes in
margins during the study time period. Changes in
financial margins over time did not affect patient
outcomes. Nurse FTE (RN, LPN and total) per bed was
not significantly affected by financial margins or changes
in margins during the study time period.
Conclusions: Rural hospitals of all types with bed sizes
above 25 that have more RNFTEs per bed also have
lower risk adjusted mortality for HF and stroke. Adding
one RN FTE per bed the following year results in lower
HF mortality, lower stroke mortality and lower rates of
failure to rescue. Rural hospitals have not reduced
nursing staff (RNs or LPNs) or experienced lower quality
outcomes despite negative financial margins. The
number of RNs per bed has a significant effect on
patient outcomes.
Implications for Policy, Delivery or Practice: Although
similar trends linking RN staffing and outcomes have
been found in other studies, this study is specific for the
rural hospital setting. Policies to promote adequate
numbers of RNs in the rural setting are needed to
achieve optimal patient outcomes. Despite negative
trends in rural hospital financial margins after the
implementation of the Balanced Budget Act, between
1996 and 2002, nurse staffing and patient outcomes
have not been affected.
Funding Source(s): AHRQ
♦ Do Stable Nursing Home Staff Improve Resident
Outcomes?
Sally Stearns, Ph.D.; Laura D'Arcy, M.P.A.
Presented by: Sally Stearns, Ph.D., Associate
Professor, Health Policy & Management, The University
of North Carolina at Chapel Hill, CB #7411, Chapel Hill,
NC 27599-7411, Phone: (919) 843-2590, Email:
sstearns@email.unc.edu
Research Objective: Many nursing homes experience
high turnover rates among staff providing direct resident
care. While low levels of turnover may facilitate
selection of quality staff, high staff turnover may have
deleterious effects on resident outcomes. This study
estimates the effects of two measures of staff stability
[turnover among certified nursing assistants (CNAs) in
the past three months and the percent of CNAs on staff
for more than one year] on five resident outcomes:
hospital or emergency room use, pressure sores, falls
within 30 days, falls within 180 days, and presence of
pain.
Study Design: Previous estimations of the relationship
between turnover and resident outcomes suffer from
limitations including small samples, facility rather than
resident-level data, and failure to control for the
endogeneity of turnover. The potential for endogeneity
bias arises because unobserved factors that affect
turnover may also affect outcomes, and staff may be
more likely to leave facilities with poor quality care. This
study improves on previous estimates by using a
nationally representative resident-level survey and by
adjusting for endogeneity with facility fixed effects (FE)
and instrumental variables (IV). We first model turnover
and staff retention separately using facility-level
observations. We model these staff stability measures
as functions of observed facility characteristics and area
characteristics (e.g., county unemployment rate, wage
rates, and housing values). We then model outcomes
using resident-level observations, controlling for resident
characteristics and facility fixed effects to represent
observed and unobserved facility characteristics.
Finally, we use the estimated facility fixed effects to
determine the proportion of between-facility variation in
outcomes that is associated with predicted values of the
turnover and retention measures, which provides
unbiased estimates of the effects of staff stability on
outcomes.
Population Studied: We use the resident and facility
components of the National Nursing Home Survey
(NNHS). The 2004 NNHS selected 1,500 of the 16,628
nursing homes in the United States. The facility
response rate was 81% (1,174 nursing homes of 1,500
randomly sampled in the US). A total of 14,017 residents
were sampled from these homes; the resident response
rate was 96%. Exclusions for missing data result in an
analysis sample of approximately 10,100 residents at
909 facilities, with up to 12 resident observations per
facility.
Principal Findings: Although the combined IV/FE
process results in slightly larger and in some cases
statistically significant effects of staff stability on resident
outcomes, the effects are quite modest. Instead, much
of the between-facility variation in outcomes not
attributable to measured differences in resident case mix
severity appears to be associated with unobserved
facility characteristics.
Conclusions: While reducing turnover and promoting
staff retention remain desirable goals for nursing homes,
this analysis shows that broader measures of facility
quality are likely critical in explaining variation in resident
outcomes.
Implications for Policy, Delivery or Practice: The lack
of strong evidence of the effectiveness of programs such
as “Better Jobs, Better Care” may be attributable to the
fact that comprehensive reforms may be needed to
improve outcomes for nursing home residents.
Reducing turnover and increasing retention may be a
smaller part of the challenge than previously imagined.
Funding Source(s): NIA