Coverage and Care for Vulnerable Populations
Under Medicaid and CHIP
Chair: Sharon Long
Sunday, June 27 * 9:00 am–10:30 am
• Health Reform in Massachusetts: Impacts on
Coverage for Children
Genevieve Kenney, Ph.D.; Adela Luque, Ph.D.
Presented by: Genevieve Kenney, Ph.D., Senior
Fellow, Health Policy Center, Urban Institute, 2100 M
Street NW, Washington, DC 20037; Phone: (202) 2615568; Email: jkenney@urban.org
Research Objective: In 2006, Massachusetts enacted
health care reform legislation that included an expansion
of MassHealth (the state’s Medicaid program), new
subsidies for health insurance coverage, the creation of
a health insurance exchange, and coverage mandates
on adults and employers. This study assesses the
impacts of those policy changes on the health insurance
coverage of children in Massachusetts.
Study Design: The study uses Current Population
Survey data and multivariate difference-in-differences
estimation with propensity-score reweighting to estimate
the impact of Massachusetts health reform on all
children as well as lower (<=300% FPL) versus higherincome (>300% FPL) children. The period under
examination is 2004 to 2008 covering two years prior
and two years following the 2006 reform. A series of
sensitivity analyses are performed to assess the
robustness of the results.
Population Studied: Massachusetts children less than
19 years old.
Principal Findings: The reforms decreased the rate of
uninsurance among children by 2.5 percentage points in
the first two years after its implementation. The decline
in uninsurance for children was concentrated among the
low-income group, for whom the uninsurance rate
decreased by 4.8 percentage points and public and
other insurance coverage increased by 7.0 percentage
points (the reduction in employer sponsored insurance
was not statistically significant for this group). Children in
the higher-income group experienced a 3.6 percentage
point increase in employer-sponsored insurance
following the implementation of health reform in
Massachusetts. By 2008, the uninsured rate among
children in Massachusetts was 1.8% overall and just
3.0% among children with family incomes below 300%
FPL.
Conclusions: The net effect of health reform in
Massachusetts was to cut the uninsurance rate in half
for children, with an even larger percentage reduction
found among low-income children, narrowing the
difference in uninsured rates between lower and higher
income children to under one percentage point. The
reform increased rates of public coverage among lowincome children and increased rates of ESI coverage
among higher-income children.
Implications for Policy, Delivery or Practice: The
progress in Massachusetts was achieved primarily
because of increased participation among children who
were already eligible for coverage under MassHealth as
well as increased coverage among the children between
200-300% FPL who were made newly eligible for
MassHealth. While it is not known how the other reform
elements contributed to the coverage gains for children,
it is likely that the attention to outreach and enrollment
along with the expansion of subsidized coverage for
parents, the mandate that applied to parents, the joint
application and eligibility process for MassHealth and
CommCare and the development of mechanisms to
facilitate coordination across all programs were
important. Nationwide, the majority of uninsured children
are eligible for Medicaid/CHIP but not enrolled.
Therefore, in order to achieve substantial coverage
gains for children, it will be critical that federal health
care reform efforts address enrollment and retention
barriers and provide states with incentives and
resources to cover all uninsured children who are eligible
for public coverage.
Funding Source(s): RWJF
• Medicaid Adoption of Clinical Practice Guidelines
to Treat Tobacco Dependence
Sara McMenamin, Ph.D., M.P.H.; Matthew Ingram, B.A.;
Helen Ann Halpin, Ph.D., M.P.H.
Presented by: Sara McMenamin, Ph.D., M.P.H.,
Director of Research, Center for Health and Public
Policy Studies, University of California, Berkeley, 50
University Hall, #7360, Berkeley, CA 94720-7360;
Phone: (510) 643-8524; Email: saram@berkeley.edu
Research Objective: In May of 2008, the Public Health
Service published an updated clinical practice guideline
on Treating Tobacco Use and Dependence. The
guideline recommends insurers, including Medicaid
programs, provide coverage for all FDA approved
pharmacotherapy such as nicotine gum, nicotine patch,
nicotine inhaler, nicotine nasal spray, nicotine lozenge,
bupropion SR, and varenicline, as well as tobacco
cessation counseling. In addition, the 2008 version of the
guideline provides evidence that certain combinations of
pharmacotherapy are effective in treating tobacco
dependence. The guideline also recommends covering
these treatments without placing limitations and barriers
on their use. This study assessed the degree to which
coverage policies are in accordance with the
recommendations made in the 2008 PHS guideline.
Study Design: The UC Berkeley Center for Health and
Public Policy Studies conducted a survey of Medicaid
programs (N=51; response rate = 100%) in the spring of
2009. The 43-item questionnaire was administered online.
Population Studied: 51 Medicaid programs (50 state
programs plus the District of Columbia).
Principal Findings: Forty-five Medicaid programs
reported covering at least one tobacco-dependence
treatment (TDT) in their fee-for-service Medicaid
population, while 25 covered all seven FDA
recommended TDTs, and 17 covered all 4 combinations
of therapies identified as effective in the 2008 PHS
guideline. Ten programs covered both individual and
group cessation counseling, while another 10 covered
one or the other. Among programs offering coverage for
TDTs, 42 place limits on their access, with 33 requiring
copayments, 30 limiting duration of treatment, 25
requiring prior authorization approvals, 6 having stepped
care coverage policies, and 15 requiring enrollment in
behavioral modification to gain coverage for
pharmacotherapy. Only three states did not report
having any limitations on TDT coverage.
Conclusions: While significant progress has been made
with regards to coverage for pharmacotherapy
treatment, Medicaid programs still fall short of 2008 PHS
recommendations in terms of coverage for counseling
and limitations placed on use of tobacco dependence
treatments.
Implications for Policy, Delivery or Practice: While
states rely on the evidence-base in the clinical practice
guideline to decide which TDTs to cover, they may have
undermined the future impact of these policies as a
result of a basic misunderstanding of how preventive
care is best delivered to a population. Policy research
suggests that 1) requiring copayments for TDTs reduces
their use and quit rates, particularly in low-income
populations; 2) there is no evidence that limiting
treatment duration prevents over-utilization -- TDTs are
underutilized, 3) requiring prior authorization from
insurance administrators provides no added value and
only delays treatment, and 4) requiring enrollment in
counseling to obtain pharmacotherapy coverage adds no
value in terms of successful quitting at twice the cost. As
a result, the policies imposed on Medicaid TDT coverage
mean that states and the population at risk are less likely
to realize potential health improvements or cost savings.
It is not only critical that research on efficacy and
effectiveness of treatment influence coverage decisions,
but also that research on financing and delivery system
impacts influence the administrative policy decisions
under which these treatments will be made available and
utilized.
Funding Source(s): CDC
• An Imputational Model for Medicaid UnderReporting in the National Health Interview Survey
Jacob Klerman, M.A.; Michael Plotzke, Ph.D.; Michael
Davern, Ph.D.
Presented by: Michael Plotzke, Ph.D., Associate,
Health Policy, Abt Associates, Inc., 773 Concord Avenue
Unit 304, Cambridge, MA 02138; Phone: (314) 3878988; Email: Michael_Plotzke@abtassoc.com
Research Objective: Our research examines the quality
of responses on Medicaid coverage in the National
Health Interview Survey (NHIS). Like most surveys, the
NHIS substantially undercounts the number of people
enrolled in Medicaid relative to administrative data.
Evidence from other surveys and administrative data
suggests that many NHIS respondents who do not report
having Medicaid actually have Medicaid coverage at the
time of the interview. If individuals enrolled in Medicaid
report they are uninsured on the NHIS, the reporting
error will bias estimates of health insurance coverage in
the U.S. when using the NHIS. Our work adjusts the
NHIS to account for reporting errors in Medicaid
enrollment to achieve better estimates of both Medicaid
enrollment and the level of uninsurance.
Study Design: We link administrative data on Medicaid
enrollment from the Medicaid Statistical Information
System (MSIS) to the 2001 and 2002 NHIS. We then
use the linked data to build a probabilistic imputation
model that allows us to partially correct the 2006 and
2007 NHIS files for systematic Medicaid under-reporting.
We use the model estimates from the linked data to
estimate the probability that each NHIS respondent in
the 2006 and 2007 data had Medicaid coverage at the
time of the interview, conditional on whether each
respondent reported having Medicaid as well as other
respondent characteristics. We use the imputed data to
generate adjusted estimates of Medicaid enrollment and
uninsurance for 2006 and 2007.
Population Studied: A sample of the civilian
noninstitutionalized U.S. population as found in the
NHIS.
Principal Findings: Like similar models for the Current
Population Survey (CPS), the NHIS imputation model
substantially increases the estimate of the average
number of reported Medicaid enrollees for 2006 and
2007 from 31.3 million to 39.1 million. This adjustment
produces an estimate of Medicaid enrollment that is
much closer to the 42.5 million monthly Medicaid
enrollees (averaged over June 2006 and June 2007)
found in the administrative data during that time.
However, unlike with the CPS, the imputation’s impact
on estimates of the uninsured is trivial.
Conclusions: We believe our data-based correction of
Medicaid reporting in the 2006 and 2007 NHIS yields
tabulations that are more useful than the raw NHIS data
for evaluating enrollment in the Medicaid program and
the level of uninsurance. The MSIS and NHIS should
continue to be linked and the imputation models should
be updated as new data becomes available to achieve
accurate estimates of Medicaid enrollment and
uninsurance using the NHIS.
Implications for Policy, Delivery or Practice: Our
results suggest that using unadjusted survey data from
the NHIS (or CPS) to inform issues regarding health
insurance coverage lead to inaccurate estimates of
insurance coverage. We find the NHIS may provide
more accurate estimates of uninsurance than the CPS.
As a result, we feel that the estimates from the NHIS
should receive more attention in health policy analysis,
particularly analysis that requires estimates of the
number of uninsured, as has occurred in the recent
health care reform debate.
Funding Source(s): RWJF
• Cervical Cancer Screening among Medicaid
Managed Care Members: The Roles of Substance
Use Disorders, Mental Illness and Disability Status
Sharada Weir, D.Phil.; Heather Posner, M.S.P.H.;
Jianying Zhang, M.P.H.; Georgianna Willis, Ph.D.;
Jeffrey Baxter, M.D.; Robin Clark, Ph.D.
Presented by: Sharada Weir, D.Phil., Assistant
Professor, Center for Health Policy and Research,
University of Massachusetts Medical School, 333 South
Street, Shrewsbury, MA 01545; Phone: (508) 856-7852;
Email: sharada.weir@umassmed.edu
Research Objective: Examine evidence of disparities in
cervical cancer screening for an insured, but vulnerable,
population of women covered by Medicaid.
Study Design: Individual-level data were obtained for
women who met the National Committee for Quality
Assurance’s 2007 Healthcare Effectiveness Data and
Information Set (HEDIS) criteria for the cervical cancer
screening measure (i.e., female, ages 21-64 at the end
of 2006, and Medicaid-insured with a coverage gap of no
more than 45 days for each of the calendar years 2004,
2005 and 2006). Compliance with screening guidelines
was assessed for each individual using HEDIS criteria
(i.e., at least one Papanicolaou (Pap) smear test in the
past three years, 2004-2006, as determined from a
combination of insurance claims and medical record
data). Disability status was based on Medicaid eligibility
criteria. Substance abuse/dependence (alcohol and/or
drug) and mental health conditions were evaluated from
diagnosis codes in the Medicaid claims. We modeled
Pap screening as a binomial logistic function with
member characteristics, comorbidities, health services
utilization, primary care provider type, and health plan as
explanatory variables. Adjusted odds ratios were
computed from the logistic regression results.
Population Studied: Massachusetts Medicaid Managed
Care members meeting HEDIS criteria for cervical
cancer screening in the 2004-2006 measurement period
(n=1,868).
Principal Findings: Among women eligible for routine
cervical cancer screening, 12% had a drug or alcohol
use disorder, 25% were diagnosed with severe mental
illness (SMI; most commonly major depression or bipolar
disorder), and 26% qualified for Medicaid because of a
work-limiting disability. Among women with disabilities,
50% had an SMI and 21% had a substance use
disorder. A majority of women with a substance use
disorder had at least one co-occurring SMI diagnosis.
Disability status (OR=0.51; p<0.01) and having a
substance use disorder (OR=0.57; p<0.01) each had a
significant negative association with Pap screening.
Women with both a disability and a substance use
disorder were even less likely to be screened. However,
there was no significant relationship between serious
mental illness (defined either as a single category or
disaggregated by specific diagnosis) and cervical cancer
screening. Independent of co-morbidities, younger
women were more likely to be screened than older
women, and having more ambulatory care visits was
highly significant, suggesting the importance of regular
physician contacts for screening.
Conclusions: Our findings suggest disparities in routine
Pap screening for women with disabilities or substance
use disorders, but not mental illness, and provide
evidence of other factors that may impact cervical
cancer screening for this vulnerable population.
Implications for Policy, Delivery or Practice: The
prevalence of substance use disorders and disability in
the Medicaid population may help account for the gap in
Pap screening rates between Medicaid insurers (65% in
2008) and the national average across insurers (77% in
2005). More attention to these vulnerable groups is
called for in efforts to advance routine cervical cancer
screening. Health care providers may play a significant
role in encouraging screening among Medicaid
members. This role may become even more important
as the new American College of Obstetricians and
Gynecologists’ guidelines (recommending less frequent
screening under certain conditions) are interpreted by
women and their doctors.
Funding Source(s): MassHealth (Massachusetts
Medicaid Agency)
Sick and Broke: The Burden of High Cost Illness
Chair: Peter Cunningham
Sunday, June 27 * 9:00 am–10:30 am
• Trends in Preventable Hospitalization Patterns
Among the Adults: A Small Area Analysis of U.S.
States
Jayasree Basu, M.A., M.B.A., Ph.D.; Vennela Thumula,
B.S.
Presented by: Jayasree Basu, M.A., M.B.A., Ph.D.,
Senior Economist, Center for Primary Care, Prevention,
and Clinical Partnerships, AHRQ, 540 Gaither Road,
Rockville, MD 20850; Phone: (301) 427-1579; Email:
jayasree.basu@ahrq.hhs.gov
Research Objective: The study examines how patient
level and contextual factors explained variation and
trends in preventable hospitalization (PH) rates across
small areas over a 10 year time interval (1995-2005) in
eight US states. The two time periods mark the
beginning and end of several legislative and policy
initiatives that may have caused significant changes in
the health care market. The study focuses on the adult
subgroups (aged 18-64) of population. Previous
research found barriers to access to be the highest
among the young adult and middle aged populations.
Our primary interest is to assess the independent effects
of managed care insurance, supply of primary care, as
well as socio-demographic factors on PH rates over
time.
Study Design: The study uses hospital discharge data
from the Healthcare Cost and Utilization Project (HCUP)
State Inpatient Databases (SID) of the Agency for
Healthcare Research and quality for the states, AZ,
CA,OR,WA, MA, MD, NJ, and NY for the years 1995 and
2005, and merges them with contextual and provider
data from Health Resources and Services
Administration. The unit of analysis is the Primary Care
Service Area (PCSA), validated as a natural market for
primary care. The study includes a multivariate cross
sectional design, using both compositional factors
describing the hospitalized populations and the
contextual factors describing socioeconomic conditions
of the area, all aggregated at the PCSA level. The
dependent variable is adult PH rates per 1000 total
discharges for all hospitalizations. The study estimated
Ordinary Least Squares method (OLS) models by
specific regions and state, after conducting appropriate
tests for the model fitness and correcting for
heteroscedasticity.
Population Studied: Hospitalized adults in the 18-64
age group in eight US states.
Principal Findings: Adult PH rates remained steady
over time as a whole in eight states, although individual
state results varied. A small decline in PH rates occurred
in most states in the eastern region (except NJ).
However, the PH rates increased in OR and WA
substantially between 1995 and 2005 leading to an
overall increase in PH rates among the western states.
The multivariate analysis shows that private HMO
shares as well as contributions to PH rates remained
stable over the years, while Medicaid HMO enrollment
had weak associations with PH admissions in both
years. Although proportions of uninsured adults
declined, their contribution to increased PH rates
became stronger over the 10-year interval. Minority adult
subgroups also increased in proportions contributing to
increased PH admissions. The primary care physician
density was found to be associated with significant
reduction in PH rates for adults in 2005.
Conclusions: The study shows that, overall,
preventable hospitalization rates among the adults did
not exhibit appreciable decline between 1995 and 2005.
A stronger influence of minority and uninsured status, a
relatively stable contribution of managed care enrollment
in the commercial market, and a persistently weak
association of Medicaid managed care with preventable
hospitalizations may have contributed to a slower
reduction in adult rates than expected.
Implications for Policy, Delivery or Practice: Using
small area analysis, the study indicates that despite the
policies adopted toward increased physician supply, and
improved care coordination through managed care, the
growth of preventable hospitalizations among adults did
not slow down in the last decade.
Funding Source(s): AHRQ
• Out-of-Pocket (OOP) Spending Burden for
Medicare Beneficiaries with Cancer
Xuehua Ke, M.A.; Franklin Hendrick, B.S.; Thomas
Shaffer, M.A.; Naimish Pandya, M.D.; Amy Davidoff,
Ph.D.
Presented by: Xuehua Ke, M.A., Graduate Student,
Pharmaceutical Health Services Research, University of
Maryland School of Pharmacy, 220 Arch Street, 12th
Floor, Baltimore, MD 21201; Phone: (410)935-5176;
Email: xke001@umaryland.edu
Research Objective: Several studies have examined
total treatment costs, but little is known about the out-ofpocket (OOP) financial burden on Medicare beneficiaries
with cancer. Medicare has substantial cost sharing;
hence, even with supplemental coverage, may not
provide adequate financial protection. This may be
particularly true for traditionally vulnerable groups,
defined by race, income, and health status. The study
examines the OOP burden of medical care and
prescriptions for Medicare beneficiaries with cancer.
Study Design: We used data from 2005-2006 Medicare
Current Beneficiary Survey (MCBS), a nationally
representative survey of the Medicare population that
reports beneficiary demographics, health status, and
supplemental insurance coverage. Medical spending
was based on self-report augmented by Medicare
claims. We selected beneficiaries who reported that they
ever had a cancer diagnosis (N=2,007 in 2006). HMO
enrollees were excluded from spending analyses due to
concerns about underreporting. We report sample
means and selected comparisons of spending across
patient characteristic and years.
Population Studied: Elderly and disabled fee-forservice Medicare beneficiaries with cancer in 2005-2006.
Principal Findings: 7.5 million or 17% of the 2006
Medicare population reported ever receiving a cancer
diagnosis, with 3% reporting incident cancer. 89% were
age >=65, 8% black, 5% Hispanic, 45% low income,
33% in fair/poor health, 90% with supplemental medical
coverage, 89% with prescription coverage; 50% were
enrolled in Medicare Part D plans. In 2005 76% had drug
coverage. In 2006, (mean) total spending was $16,854
(95%CI: $15,539- $18,169), and OOP was $2,753
(95%CI: $2,408-$3,098) for prevalent cases; total
spending was $26,345 (95%CI: $22,439-$30,251) and
OOP was $4,062 (95%CI: $3,015-$5,109) for incident
cases. OOP spending for prevalent cases in 2006 was
lower for black patients vs white, excellent vs fair/poor
health, Medicaid vs no supplemental coverage (all at
p<.01). There was no significant change in total or OOP
spending for prevalent or incident cases between 2005
and 2006. The median value for financial burden of OOP
spending (including premiums) relative to income was
14% (18%) for the prevalent (incident) cancer cohorts in
2006, which was slightly higher than the 12% among the
full sample of fee-for-service Medicare enrollees. Total
spending on prescription drugs in 2006 for prevalent
(incident) cases was $2,874 ($3,278) with $809 ($866)
OOP, representing 42% (38%) of total OOP for these
patients.
Conclusions: Given the prevalence of major chronic
illness in the Medicare population, our prevalent cancer
cohort experienced a large, but not disproportionate
financial burden. However patients with new cancer
diagnoses, and those disadvantaged by socioeconomic
and poor health status were particularly vulnerable.
Implications for Policy, Delivery or Practice: OOP
spending and financial burden result from the complex
interaction of treatment
choices, supplemental insurance coverage, and financial
resources. Additional research is ongoing to better
understand how these factors influence access to care
and financial well-being among Medicare beneficiaries
with cancer.
• Risk Factors Associated with have High Financial
Burdens in Persons with Diabetes
Rui Li
Presented by: Rui Li, Division of Diabetes Translation,
CDC, 4770 Buford Highway, NE, MS K-10, Atlanta, GA
30341; Phone: (770) 488-1070; Email: Rli2@cdc.gov
Research Objective: Diabetes is a serious, high
prevalent and costly disease in the United States. A
majority (89%) of persons with diabetes had insurance
coverage in 2005. However, many insured diabetic
patients did not have adequate financial protection from
high out-of-pocket payment. Previous studies described
the financial burdens among adults with diabetes using a
single year data. The purpose of the study is to identify
the independent association of the characteristics of
people who are more likely to be uninsured using a
larger sample.
Study Design: We defined underinsurance as in the
literature based on the proportion of a patient’s annual
total annual family income spent on out-of-pocket health
care expenditure: if the proportion was more than 10%,
or more than 5% for low income families (less than 200
percent of federal poverty line). Multivariate logistic
regression model was used to predict the likelihood of
being underinsured as a function of patient's social
economic and demographic characteristics, private or
public insured, diabetic treatment type, diabetes
complications, comorbidities, and self-reported physical
and mental health status at the beginning of the survey.
We run separate analyses for different age and income
group.
Population Studied: 8091 persons who were
diagnosed as having diabetes and had public or private
insurance coverage from 2000-2005 Medical
Expenditure Panel Survey (MEPS) were included in the
analysis.
Principal Findings: In people with diabetes and
covered by insurance, one fourth of people at working
age (56% for low income, 12% for middle income, and
2.3% for high income) and almost half of people aged 65
years and older (73% for low income, 31% for middle
income and 11% for high income) were underinsured.
Among patients under 65 years, in low and middle
income group, being white, age between 45 and 64
years, treated with insulin, having cardiovascular
disease, reporting worse perceived physical and mental
health are significantly positively associated with being
underinsured; covered by Medicaid and having less than
high school education were significantly negatively
associated with being underinsured. In patients with high
income level, only having worse perceived physical
health was significantly positively associated with the
likelihood of being underinsured. Among all persons 65
years old and older, in low and middle income group, the
characteristics associated with being underinsured were
similar with these under 65 years. In patients with high
income level, only having cardiovascular disease was
significantly positively associated with being
underinsured.
Conclusions: a large proportion of insured people with
diabetes were underinsured, and they were clustered in
people with low income group and those age 65 years
and older. People with more progressive diabetes,
comobidities and complications, worse health status
were more likely to be underinsured. Having Medicaid
coverage was protecting low and middle income group
from being underinsured.
Implications for Policy, Delivery or Practice: Future
health policies on diabetes care need to take into
account reducing financial burdens of the diabetic
patients who are insured but not adequately protected,
especially in low and middle income population.
• Modeling the Effects of a Medicare Buy-in Program
Timothy Waidmann, Ph.D.; Jack Hadley, Ph.D.
Presented by: Timothy Waidmann, Ph.D., Senior
Fellow, Health Policy Center, The Urban Institute, 2100
M Street NW, Washington, DC 20037; Phone: (202)
261-5718; Email: twaidmann@urban.org
Research Objective: The idea of allowing individuals to
buy Medicare coverage when they are not otherwise
eligible has been proposed several times since the late
1990s, most recently during health care reform
negotiations. This paper simulates and compares the
effects of several options for structuring a Medicare BuyIn insurance option for people between aged 50-64 and
their dependents, a population at elevated risk for poor
health and ineligibility for affordable private coverage.
Study Design: We used data from the 2002-2004
Medicare Expenditure Panel Survey to calculate
actuarially fair age-based premiums for the 50-64 year
old population. We assume these premiums would be
subsidized according to household income. We estimate
a multivariate model of medical spending to estimate
private insurance premiums for eligible health insurance
units. Under the assumption of an individual mandate,
the uninsured are automatically assigned to the buy-in.
For those with private coverage, if the subsidized buy-in
premiums are lower than private premiums, individuals
may choose to switch to the buy-in. We then estimate
net changes in health care spending, government
subsidies, and uncompensated care under several sets
of assumed rules for buy-in participation.
Population Studied: Individuals in households with at
least one member between the ages of 50 and 64.
Principal Findings: In addition to providing an
affordable source of coverage for 10.5 million uninsured
individuals, up to 27 million privately insured persons
might be induced to switch coverage depending on the
structure of the program and the tax treatment of private
premiums. The buy-in program would be most attractive
to low income households that would receive the largest
subsidies. Under the most expansive program,
approximately 90% of the cost of the buy-in program
would be financed by premiums paid by participants,
increased tax revenues, and reductions in
uncompensated care. If employees of large firms are
excluded, government subsidy costs would be reduced.
Finally, because the buy-in would attract a sicker than
average population, the remaining risk pool for private
insurance policies would be healthier, potentially
reducing private premiums.
Conclusions: Establishing a public sector insurance
plan for the near-elderly (or a similarly structured private
insurance pool that prohibits risk selection based on
factors other than age) financed by participant premiums
and low-income subsidy payments could provide health
insurance coverage to a substantial portion of the
uninsured who are at significant risk for adverse health
events. Such a plan could be attractive to some who are
privately insured as well, especially those in relatively
poor health.
Implications for Policy, Delivery or Practice: Basing
premiums on age reduces incentives for adverse risk
selection. Subsidizing health insurance based on
individual income rather than (as currently) on
employers’ ESI contributions is inherently more fair. A
public sector plan whose members retain coverage
through changes in employment may have added
incentive to invest in prevention. Excluding employees of
large firms from public plans is important if maintaining a
private insurance system is desired.
Funding Source(s): CWF
Quality and Efficiency: Methods and Measures
Chair: Peter Hussey
Sunday, June 27 * 9:00 am–10:30 am
• Interpreting Hospital Performance on the CMS Core
Measures: Implications of Inclusion and
Discretionary Exclusion Rates
Elizabeth Drye, M.D., M.S.; Jeph Herrin, Ph.D.; Jersey
Chen, M.D.; Dima Turkmani, M.B.A., M.P.H.; Harlan
Krumholz, M.D., S.M.
Presented by: Elizabeth Drye, M.D., M.S., Associate
Research Scientist; Director, Quality Measurement
Programs, YNHHSC/CORE, Yale School of Medicine,
YNHHSC/Center for Outcomes Research and
Evaluation, 1 Church Street, Suite 200, New Haven, CT
06510-3330; Phone: (203) 764-5689; Email:
elizabeth.drye@yale.edu
Research Objective: Since 2004 the Centers for
Medicare and Medicaid Services (CMS) has reported
hospital performance on a set of 14 “core” process
measures for acute myocardial infarction (AMI) heart
failure (HF), and pneumonia (PN). Many patients
assessed, however, are excluded by pre-defined criteria
and, for 6 measures, physicians can exclude additional
patients at their discretion for any reason. These
measure attributes have implications for interpreting
measure results, since high performance can be
achieved by treating many patients in one hospital and
few in another. Further, the discretionary exclusion
provisions may encourage hospitals to improve
performance by changes in documentation rather than
improvements in care. Accordingly, we sought to: (1)
describe the percent of reported patients actually
included in the measures; (2) assess hospital variation in
discretionary exclusion rates; and (3) examine the
relationship between discretionary exclusions and
performance.
Study Design: For each measure we calculated 12month inclusion rates (patients included among those
submitted for each condition), performance rates (those
treated among those included), and, where applicable,
discretionary exclusion rates (patients excluded for
discretionary reasons among those not excluded for prespecified reasons). We used weighted linear regression
to examine the associations between hospital
performance rate (dependent variable) and discretionary
exclusion rate and between change in hospital
performance rate (dependent variable) and hospital
discretionary exclusion rates from year one to year four.
Population Studied: Our hospital-level sample
consisted of all hospitals that submitted 60 or more
cases for any condition to CMS for each 12-month
period between 1 July, 2004 and 30 June, 2008 for
potential inclusion in the AMI, HF, and PN core
measures; our patient-level sample consisted of all
patients submitted by these hospitals.
Principal Findings: In the most recent 12-month period
(7/07-6/08), overall inclusion rates for the 14 measures
ranged from 9.3% (PN-3a, blood culture within 24 hours)
to 88.6% (HF-2, evaluation of LVS function). In the same
period, discretionary exclusion rates for the 6 measures
varied widely across hospitals. For example, for AMI-2
(aspirin at discharge), the 25th, 50th, and 75th percentile
discretionary exclusion rates across hospitals were
45.1%, 70.3%, and 79.8%, respectively. Performance
and discretionary exclusion rates showed a weak but
statistically significant relationship for 5/6 measures,
though the directions were mixed. Change in
discretionary exclusion rate was positively but
moderately associated with change in performance rates
for 3/6 measures; HF-3 (ACEi or ARB for LVSD) showed
the strongest relationship (R2 =11.3%; p<0.0001).
Conclusions: Inclusion rates for these 14 core
measures average about 50%, limiting the extent to
which they reflect quality of care for AMI, HF and PN
patients. Discretionary exclusion rates vary across
hospitals and, for three measures, change in their use is
positively associated with change in performance. While
discretionary exclusions provide maximum clinical
flexibility, variation in their use may contribute to
reported performance differences that are unrelated to
quality.
Implications for Policy, Delivery or Practice: CMS
should make hospital-specific inclusion rates for each
measure available to assist with measure interpretation.
Further research should evaluate the extent to which
differences in discretionary exclusions reflect true
difference in case mix, treatment variation, or variation in
coding strategies.
Funding Source(s): CMS
• Medicare Physician Profiling
Robert Houchens, Ph.D.; Scott McCracken, M.B.A.;
William Marder, Ph.D.; Robert Kelley, M.S.
Presented by: Robert Houchens, Ph.D., Senior
Director, Healthcare & Science, Thomson Reuters, 5425
Hollister Avenue, Suite 140, Santa Barbara, CA 93111;
Phone: (805) 681-5867; Email:
Bob.Houchens@Thomson.Reuters.com
Research Objective: To identify physicians who were
outliers on Medicare utilization using an episode
grouper.
Study Design: An episode grouper was applied to over
150 million Medicare claims spanning 2002-2003 for
patients residing in six MSAs, generating over 8 million
treatment episodes per year. Episodes were attributed to
about 37,000 physicians per year, of which about 25,000
per year were attributed at least 20 episodes and were
included in the analysis. Payments were standardized
and totaled for each episode. Physicians were
considered outliers if their observed mean standardized
payment per episode exceeded 25 percent of their
expected mean payment at the .0001 significance level
based on two statistical methods. For both methods,
separate models were fit for each MSA and each
physician specialty so that each physician was
compared with other physicians of the same specialty
within their MSA. Both methods adjusted for disease
severity and patient complexity. For the first method we
employed multilevel (hierarchical) regression models,
which accounted for the correlation of episodes within
physicians and for the heterogeneity of episode
payments. For the second method we employed
randomization tests, which compared each physician's
observed mean payment with the mean from a large
number of random samples of similar episodes attributed
to other physicians of the same specialty within the
physician's MSA. To measure the stability of the
physicians' estimated deviations from their expected
means we calculated the correlation between the 2002
deviations and the 2003 deviations. We also compared
the consistency of the estimated outlier status between
the two years.
Population Studied: The populations studied were
treatment episodes for 2002 and 2003 Medicare patients
attributed to physicians in six MSAs: Boston, MA;
Greenville, SC; Miami, FL; Minneapolis, MN; Orange
County, CA; and Phoenix, AZ.
Principal Findings: Both methods yielded stable
estimates of physician-level deviations from their
expected mean episode payments. The year-to-year
correlation was 89 percent for the multilevel model and
87 percent for the randomization test. The multilevel
method identified a somewhat higher percentage of
outlier physicians compared with the randomization tests
(4.4% vs. 2.9% in 2002 and 4.7% vs. 3.4% in 2003).
About 90 percent of the outlier physicians identified in
one year also had large deviations in the other year.
Conclusions: This study establishes the feasibility of
episode groupers for Medicare physician profiling.
Implications for Policy, Delivery or Practice: These
methods can be used either for payment incentives or
for delivering feedback to physicians on their resource
utilization relative their peers.
Funding Source(s): MedPAC
• Fundamental Problems with a Class of Quality and
Safety Measures: The Perils of Exposure-Time
Michael Howell, M.D., M.P.H.; Long Ngo, Ph.D.; Meghan
Dierks, M.D.
Presented by: Michael Howell, M.D., M.P.H., Director,
Critical Care Quality, Silverman Institute for Healthcare
Quality and Safety, Beth Israel Deaconess Medical
Center, 330 Brookline Avenue, Boston, MA 02215;
Phone: (617) 632-7687; Email:
mhowell@bidmc.harvard.edu
Research Objective: A nationally prevalent class of
quality and safety metrics includes patients' exposuretime in the denominator. Examples include falls per
1,000 patient-days, infections per 1,000 catheter-days,
and pneumonias per 1,000 ventilator days. These
metrics implicitly assert that risk is constant over the
duration of the exposure. If this is not the case then
these metrics may mislead researchers, practitioners
and policymakers. We focused on one example of these
measures, falls per 1,000 patient-days. We sought to
understand the prevalence with which bias introduced by
the measure's construction would lead quality
improvement teams, researchers, and policymakers to
draw incorrect conclusions when comparing hospitals or
when evaluating one hospital over time.
Study Design: (1) We measured the daily risk of
inpatient falls in a single-hospital cohort that included
583,786 patient days.
(2) Drawing from the National Inpatient Sample 2001
and 2006, we conducted a stochastic simulation in which
we imposed an IDENTICAL time-varying fall risk (from
step 1) on each hospital in the simulation. We assessed
variation among hospitals in one year (2006) and within
hospitals over time (2001 vs 2006).
Population Studied: The fall risk profile was drawn from
a large urban hospital. The National Inpatient Sample is
the largest all-payor database of discharges in the US.
Principal Findings: 1) Fall risk was not constant over
the hospital stay, increasing at a roughly logarithmic rate
(r2 for log-fit curve = 0.80 for first 14 days). 2) In a
simulation in which the true time-varying fall risk was
identical in all hospitals, the metric induced substantial
artifactual variation in reported fall risk using the
conventional metric (falls/1,000 patient-days). We found
that – under conditions when the true fall risk did not
vary – 59% of hospitals differed from the nation’s median
“falls per 1,000 patient days” by 10% or more. Thirty
percent of hospitals varied from the median by 20% or
more, and 16% of hospitals by 30% or more. 3)Of the
244 hospitals present in both NIS2001 and 2006, 29% of
hospitals would have concluded that their fall
performance (measured in the ubiquitous falls/1,000
patient days) improved or worsened by 10% or more.
10% would have concluded that their performance
changed by at least 20%, and 5% of hospitals would
have seen at least a 30% variation in their fall safety
rating. Some of this variation is stochastic, but a
substantial amount is induced by the mathematical
properties of the metric.
Conclusions: The mathematical properties of the
current metric of "falls per 1,000 patient days" would
lead policymakers, researchers, and quality
improvement teams to draw incorrect conclusions about
individual hospitals' safety performance in a substantial
fraction of cases.
Implications for Policy, Delivery or Practice: Further
work should focus on disentangling the amount of
stochastic variation from that induced by the measure's
construction, and on mathematical adjustment
techniques to reduce this bias. In the interim, payment
schemes based on exposure-time metrics may create
incorrect incentives for hospitals, since the metric
frequently does not reflect underlying performance.
Funding Source(s): RWJF
• The Challenge of Modeling Acute Inpatient
Readmissions
Eugene Kroch, Ph.D.; Michael Duan, M.S.; John Martin,
M.P.H.
Presented by: Eugene Kroch, Ph.D., Senior Fellow,
Leonard Davis Institute of Health Economics, University
of Pennsylvania, Philadelphia, PA 19104; Phone: (215)
689-2240; Email: ekroch@wharton.upenn.edu
Research Objective: Health care reform builds off of
the notion that excess (preventable) readmissions can
be identified well enough to adjust payments to
hospitals. Yet the discriminatory power of the model
currently used by CMS is quite poor (c-statistic=0.60).
This study examines alternative ways to measure
readmissions and risk adjust them so as to distinguish
the provider effects from patient and environmental
factors.
Study Design: We start with a conventional logit model,
stratified into 142 disease groups according to principal
diagnoses, to predict the likelihood of readmission based
on standard clinical, demographic, and environmental
factors. The dependent variable is defined as the index
admission, followed by another hospitalization in the
same hospital within 30 days. We examined five
alternatives with respect to the relationship between the
index diagnosis and that of the readmission: (1) all
causes of re-hospitalization, (2) within the same broad
product line, (3) within the same narrow product line, (4)
in a related broad product line, and (5) in a related
narrow product line. An expert panel of clinicians
constructed the product lines and developed the
relationship matrix. Separate models were specified and
tested for each of the 5 definitions across all disease
strata.
Population Studied: This modeling effort examines all
major diagnoses using patient-level data from over 600
acute-care facilities over a two year period (2006q32008q2). It contains over 17 million discharges, which
represent 20% of all acute-care discharges in the U.S.
Principal Findings: Most of the discriminatory power of
the model comes from accounting for principal diagnosis
of the index admission, as would be expected from the
well known variation of readmissions across disease and
treatment areas. Even though the individual segments
show poor discriminatory power (c-stat ~ 0.60), the
hospital-wide model shows much better predictive power
(c-stat = 0.77). Alterative specifications across disease
strata revealed that a few non-conventional risk factors
were valuable controls. For example risk-adjusted
length-of-stay, showed a slightly positive influence on
readmissions in all major strata that were tested. In
addition taking account of prior readmissions improved
the model fit, but at the risk of confounding patient
factors with provider effects. Limiting readmissions to
those with a diagnosis related to the index admission
paradoxically tended to reduced predictive power.
Conclusions: Patient-level modeling to control for
readmission risk is poor at the diagnosis level, but
moderate at the hospital level. Hospital discrimination
rests mostly on the distribution of principal diagnoses.
Patient-level modeling of targeted diagnoses (HF, AMI,
PNE) has very little discriminatory power. Using our best
models to control for patient readmission risk is unlikely
to leave the remaining variation in readmission rates
attributable to hospital performance – the ultimate goal.
Implications for Policy, Delivery or Practice: Although
readmission-related policies may prove to be a
transformational force in health care reform, the
imprecision of our best models highlights the danger of
penalizing providers based on environmental factors
beyond their control, such as low socio-economic status.
Policy options may possibly mitigate this potential, but
the science may not be adequate to support that goal.
• New Measures of Risk-Adjusted Rates of
Complications of Elective Surgical Procedures
Reveal Substantial Variation in Hospital
Performance
Michael Pine, M.D., M.B.A.; Donald Fry, M.D.; Barbara
Jones, M.A.; Roger Meimban, Ph.D.
Presented by: Michael Pine, M.D., M.B.A., President,
Michael Pine and Associates, 5020 S Lake Shore Drive
Ste 304N, Chicago, IL 60615; Phone: (847) 492-0162;
Email: michaelorjoan@yahoo.com
Research Objective: The utility of patient safety
indicators based on single specified surgical
complications (e.g., respiratory failure) in heterogeneous
sets of elective surgical procedures is often
compromised by inconsistent coding, low incidence
rates, and marked differences in pre-operative risks by
type of procedure and underlying condition. To
overcome these problems, three composite measures of
risk-adjusted adverse surgical outcomes were developed
and applied using hospital claims data enhanced with
present-on-admission modifiers.
Study Design: Elective surgical cases were assigned to
one of 24 operative categories based on combinations of
types of procedure and principal diagnoses. Very severe
complications were defined as death or a surgical
complication associated with a mortality rate greater
than 4%, severe complications as death or a surgical
complication with a mortality rate greater than 2%, and
moderately severe complications as death or any
hospital-acquired surgical complication. Risk-adjustment
equations were derived using age, sex, medical
conditions present on admission, types of procedure,
and principal diagnosis by type of procedure as potential
risk factors. Risk-adjusted complication rates were
computed for hospitals with at least five predicted or
eight observed complications. Hospitals with significantly
(P<0.05) higher-than-predicted and lower-than-predicted
complication rates were identified.
Population Studied: Outcome indicators and riskadjustment equations were developed using three years
of data from 108 New York State hospitals that scored
better than 80/100 on a set of 12 data quality screens for
accuracy and completeness of present-on-admission
coding. Models were validated using data from 247
California hospitals that passed these data quality
screens. Cases were eligible for inclusion in the study
when qualifying procedures were performed during the
first two days of elective admissions of patients older
than 17 years with principal diagnoses consistent with
scheduled admissions for the type of operation
performed.
Principal Findings: Of 1,636,806 qualifying cases,
0.32% died, 3.39% had very severe complications;
7.61% had severe complications, and 9.74% had
moderately severe complications. C-statistics for
predictive models were 0.845 for very severe
complications, 0.738 for severe complications in cases
without very severe complications, and 0.755 for
moderately severe complications in cases without
severe complications. Of 332 hospitals, 23 had higherthan-predicted and 13 had lower-than-predicted riskadjusted rates of very severe complications. Of 347
hospitals, 32 had higher-than-predicted and 18 had
lower-than-predicted risk-adjusted rates of severe
complications. Of 353 hospitals, 40 had higher-thanpredicted and 22 had lower-than-predicted risk-adjusted
rates of moderately severe complications. At least one of
the three measures was significantly higher-thanaverage in 57 hospitals and at least one of the three was
significantly lower-than-average in 37 hospitals.
Conclusions: Newly-developed claims-based riskadjusted composite measures of surgical complication
rates at hospitals that demonstrate satisfactory coding of
present-on-admission modifiers are inexpensive,
powerful tools for initial comparisons of the quality of
elective surgical care.
Implications for Policy, Delivery or Practice: Patients
safety indicators based on clinically discrete
complications are theoretically attractive and have been
used in some public reports, but there is considerable
concern about their validity and their analytic power. This
research demonstrates the practicality and advantages
of an alternative approach to monitoring patient safety.
Funding Source(s): AHRQ
New Evidence on Health and Wellness Topics
Chair: Michael O'Grady
Sunday, June 27 * 9:00 am–10:30 am
• Does Johnson & Johnson’s Health and Wellness
Program Continue to Improve Employee Health
Almost Thirty Years after Implementation?
Rachel Mosher Henke, Ph.D.; Ron Goetzel, Ph.D.;
Maryam Tabrizi, M.S.; Janice McHugh, D.B.A,. R.N.,
C.O.H.N.; Fikry Isaac, M.D.; Jennifer Bruno, B.S.
Presented by: Rachel Mosher Henke, Ph.D., Research
Leader, Thomson Reuters, 150 CambridgePark Drive,
Cambridge, MA 02140; Phone: (617) 492-9328;
Email: rachel.henke@thomsonreuters.com
Research Objective: Comprehensive, multicomponent,
worksite health promotion programs were introduced in
the United States in the late 1970s and early 1980s, with
the goals of improving employee health and reducing
healthcare expenditures. Johnson & Johnson, a pioneer
in the field, first offered its worksite health promotion
program in 1979, with the expressed aim of making
“Johnson & Johnson employees the healthiest in the
world”. The goal of this study is to examine whether
Johnson & Johnson’s well-established worksite health
promotion program has continued to improve employee
health and generate a positive return-on-investment
(ROI). Findings inform the business case for continued
investment in employee health promotion programs.
Study Design: We collected Johnson & Johnson
employee health risk, demographic, and program cost
data from 2002-2008. We calculated the average annual
change in percentage of employees at high risk for each
of nine modifiable health risks: overweight/obese,
physical inactivity, poor nutrition, tobacco use, high
cholesterol, high blood pressure, high stress,
depression, and heavy alcohol use. We identified the
average annual program cost per eligible employee and
average annual labor costs. We compared Johnson &
Johnson health risk and cost data to data from
comparison employers to estimate health care and
productivity savings, adjusting for potential confounding
variables. We calculated program ROI by comparing
estimated health and productivity savings to program
costs. We tested the sensitivity of results to model
assumptions by estimating program ROI under several
scenarios.
Population Studied: Johnson & Johnson active, fulltime employees between the ages of 18 and 64.
Principal Findings: From 2002-2008, Johnson &
Johnson experienced an average annual decline in the
prevalence of 5 of the 9 health risks examined: physical
inactivity, poor nutrition, tobacco use, high cholesterol,
and high blood pressure. There was no change in
prevalence of depression or overweight/obesity and
there was a slight increase in the prevalence of stress
and alcohol risk. Comparing expected savings from
these health risk trends to program costs generated an
estimated ROI of between $1.54 to $4.07 savings per
$1.00 spent on the program. The majority of the savings
stemmed from improvements in employee productivity.
Conclusions: Johnson & Johnson’s worksite health
promotion programs continues to improve employee
health and produce health care and productivity savings
many years following initial implementation.
Implications for Policy, Delivery or Practice:
Employers should consider continual investment in
worksite health promotion programs as savings can
continue to accrue many years after program
implementation.
Funding Source(s): Johnson & Johnson
• An Integrative Group Wellness Program
Concurrently Reduces Pain and Stress, and
Improves Stress-Related Chronic Illnesses
Alba Rodriguez, Ph.D., C.Ht.; Ramon Nunez, D.Ac.;
Ronald M. Ball, B.S.; Jeffrey Nowicki, B.S.; Robert
Levine, Ph.D., C.Ht.
Presented by: Alba Rodriguez, Ph.D., C.Ht., Associate
Director, Center for Integrative Wellness, Henry Ford
Health System, 22777 W. Eleven Mile Road, Southfield,
MI 48033; Phone: (813) 786-6641; Email:
arodrig1@hfhs.org
Research Objective: The dramatic increase in chronic
pain and stress-related ill-health conditions has helped
fuel the dramatic rise in healthcare costs in the U.S. This
research study examined the effectiveness of a handsoff group intervention to reduce and eliminate chronic
pain of all types while simultaneously alleviating stress in
the same group of participants. Until detailed
assessments of potential cost savings are analyzed over
the long-term, it is assumed that improving wellness by
reducing and eliminating chronic pain and stress with a
cost-effective group approach will ultimately drive down
healthcare costs.
Study Design: In this controlled clinical trial, employees
received either no intervention (controls) or 18-24
contact hours (1.5-2 hours/week every other week) of an
integrative group wellness program that included Guided
Relaxation and Somatic Movement Education. Group
sizes ranged from 50 to 85 participants. These mindbody connection techniques may produce stress
alleviation and release muscles in reflex hypercontraction that contribute to pain. Wellness activities
performed outside of sessions included listening to
Guided Relaxation CDs and engaging in Somatic
Movement Education routines. Outcome measures
monitored at pre-, mid-, and post-program included peak
and average pain and stress (Numeric Rating Scale),
disability (Oswestry), depression symptoms (PHQ-9),
perceived stress (Perceived Stress Scale), and sleep
quality (Pittsburgh Sleep Quality Index).
Population Studied: 421 Chrysler and HEnry Ford
Health System (HFHS) employees attended group
sessions. These employees reported a total of 1063
chronic pain conditions (pain duration > 3 months) at the
start of the program. Back, shoulder, neck, knee, and hip
were the highest reported pain areas. 65% of
participants completed health outcomes surveys at the
end of the program.
Principal Findings: All outcome measures reported
below demonstrated statistical significance at the level of
p<.001. 45% of all reported chronic pain conditions were
eliminated (defined as average of “0” on a 0-10 scale) by
the end of the study. 14% of participants reported
eliminating stress by the end of the program. Disability,
depression symptoms, and perceived stress were all
reduced, while sleep quality improved. Of 645 stressrelated chronic illnesses reported by participants (e.g.
high blood pressure, diabetes, depression, anxiety,
sleep disturbance, etc.), 49% were improved and 9%
resolved (i.e., completely under control with no need for
medication) at the end of the program. 92% of
participants expressed satisfaction with the program and
an interest in taking another workplace group wellness
program of this type.
Conclusions: We have demonstrated that a costeffective group intervention using integrative wellness
approaches can simultaneously reduce chronic pain
conditions and stress all in the same group, while also
improving stress-related chronic illnesses. This group
approach is less expensive than conventional care and
has the potential to help much larger numbers of people.
Implications for Policy, Delivery or Practice: Chronic
pain and stress are intricately related, and the
importance of stress as a causal and/or aggravating
factor in most chronic illnesses cannot be
underestimated. This cost-effective group approach has
the potential to revolutionize how chronic pain and stress
are treated in the US because of the high degree of
effectiveness in helping people eliminate chronic pain
and stress.
Funding Source(s): Henry Ford Health System
• The Impact of Taking a Periodic Health Assessment
on Utilization and Costs of Health Services and
Employee Health Risks
Cynthia Sieck, Ph.D.; Allard Dembe, Sc.D.
Presented by: Cynthia Sieck, Ph.D., Research
Specialist, The Ohio State University College of Public
Health, Center for HOPES, 5036 Smith Lab, 174 West
18th Avenue, Columbus, OH 43210; Phone: (614) 2929479; Email: csieck@cph.osu.edu
Research Objective: This study examined the impact of
taking a periodic health assessment (PHA) on the
utilization and costs of health services and on employee
health risks over an 18 month period. The PHA was
offered as part of a larger employee wellness program
including chronic disease management programs,
lifestyle management programs and behavior change
programs such as weight management and smoking
cessation.
Study Design: A retrospective analysis of cost and
utilization of health care services overall and within the
categories of chronic care, primary care, preventive care
and pharmacy services was conducted. Service
utilization and cost were compared for member who took
a PHA and members who did not take a PHA at 6, 12
and 18 months after PHA completion. In addition,
changes in member health risks for those who took a
PHA were examined.
Population Studied: The study utilized a random
sample of 500 members who took a PHA during a
defined period as well as an age- and gender-matched
sample of 500 members who had never taken a PHA.
The total sample included 1000 members. The sample
was approximately 25% male with an average age of 44
years.
Principal Findings: T-tests and multivariate analyses of
claims and utilization showed that costs were similar in
both groups during the study period. However, PHAusers had 1.46 more visits for overall medical services
and were significantly more likely to have sought primary
care and prevention services in the first 6 months after
taking the PHA than were non-PHA-users. A trend of
lower pharmacy costs for PHA-users was also noted but
was not statistically significant. Changes in health risks
showed statistically significant improvements blood
pressure, total, HDL and LDL cholesterol, and blood
glucose for members taking the PHA who were initially
identified as being “at-risk” for these health conditions.
Conclusions: Overall, this study demonstrates that
efforts to improve employee health can have a
measurable impact on health risks within the first 18
months of assessment while showing no increase in
health care costs.
Implications for Policy, Delivery or Practice: The
results of this study are encouraging for improving
employee health, particularly in the areas related to
cardiovascular health, diabetes and obesity. Additional
research examining cost, utilization and health risks
beyond 18 months is needed to better understand the
impact of employee health improvement efforts.
Funding Source(s): The Ohio State University Health
Plan
• The Increasing Cost of Obesity: Changes in the
Impact of Physical Activity and Obesity on Medical
Expenditures from 1998 to 2006
Jeroen van Meijgaard, M.A.
Presented by: Jeroen van Meijgaard, M.A., Health
Services, UCLA School of Public Health, CHS 61-253,
Box 951772, Los Angeles, CA 90095-1772; Phone:
(310) 206-6236; Email: jeroenvm@ucla.edu
Research Objective: Physical activity and obesity are
both strong predictors of morbidity and mortality. We
hypothesize that physical activity is an independent
predictor of medical expenditures and confounds the
relation between overweight/obesity and medical
expenditures. The objective of this study is to evaluate
the independent impacts of both physical activity and
obesity on expenditures and how the relative impacts
have changed from 1998 to 2006.
Study Design: To estimate the independent impacts of
physical activity and obesity on expenditures, two-part
models were estimated for the under-65 and over-65
populations. The first part is a logit specification, which
provides relative risks for having any medical
expenditures, relative to the reference categories:
sufficient physical activity, expressed in METhrs/wk, and
normal BMI (18.5-25.0 kg/m2). The second part is a
GLM specification with a log link and Gaussian
distribution family. The study controls for age, gender,
race/ethnicity, income, insurance status, education,
health behaviors and health status variables that may
confound the relations between physical activity and
obesity, and medical expenditures. The predicted
marginal mean expenditures are calculated based on
physical activity behavior and level of BMI. Confidence
intervals of the means and of the differences across
categories are calculated using simulation methods.
Population Studied: The data used in this study is a
representative sample of adults in the United States from
the Medical Expenditure Panel Survey (MEPS), years
1998-2006, linked to the National Health Interview
Survey (NHIS), years 1997-2005. The analysis is
stratified by gender and age: (1) 18-64 years old and (2)
65 years and over.
Principal Findings: We find that overweight and obesity
significantly increase medical expenditures, by as much
as 50%. However, decreased levels of physical activity
do not increase medical expenditures; in both age
groups, medical expenditures of sedentary individuals
are not significantly different from those of physically
active individuals. Furthermore, for women 65 years and
over expenditures attributable to obesity rose more
rapidly from 1998-2002 to 2003-2006 as compared to
expenditures not attributable to obesity, by as much as
29%.
Conclusions: The results confirm previous work that
higher levels of overweight and obesity significantly
increase medical expenditures. The impact is substantial
and increasing over time. Currently as much as 6% of
total medical expenditures may be attributed to
increased BMI. No support was found for the impact of
physical activity on the level of expenditures. Thus,
although physical activity may lead to lower BMI, and
indirectly lower medical expenditures, there is no direct
impact of physical activity on medical expenditures. This
also suggests that physical activity is not a strong
confounder in the analysis of obesity and medical
expenditures.
Implications for Policy, Delivery or Practice:
Programs that aim to increase physical activity and/or
reduce obesity should take into account the different
impact these health determinants have on health
outcomes and medical expenditures. Further, these
impacts should be expressly evaluated to properly
compare and prioritize programs.
Medicare Spending Growth
Chair: Jeffrey Stensland
Sunday, June 27 * 9:00 am–10:30 am
• Medicare and Medicaid Spending on Dual Eligible
Beneficiaries: Exploring Policy Options
James Verdier, J.D.; Arkadipta Ghosh, Ph.D.; Ellen
Singer, M.A.; Mark Flick, B.A.
Presented by: Arkadipta Ghosh, Ph.D., Researcher,
Health Research Division, Mathematica Policy
Research, Inc., 600 Alexander Park, Princeton, NJ
08540; Phone: (609) 750-2008; Email:
aghosh@mathematica-mpr.com
Research Objective: Care for the 9 million beneficiaries
dually eligible for Medicaid and Medicare is highly
fragmented, complex, and uncoordinated. Health care
reform legislation and the proposed new CMS office for
dual eligibles have underscored the need to rethink the
current distribution of responsibilities for the financing
and provision of care for dual eligibles, and to consider
new ways of coordinating and integrating that care.
Based on results from a new, linked Medicare and
Medicaid dataset, we describe service use and
expenditures for dual eligible beneficiaries under both
Medicare and Medicaid, and explore policy options for
integration and better co-ordination of care for these
beneficiaries.
Study Design: Our analysis of 2005 and 2006 data
focuses on “all-year full duals” (described below). We
look at annual service use and expenditures for these
beneficiaries—both on a state-by-state basis and
nationally—for individual service categories, including
inpatient hospital, emergency room, physician, home
health, home and community based waiver services
(HCBS), short-term and long-term nursing facility
services, and prescription drugs. We also discuss
important sub-groups of dual eligibles, including those
above versus below age 65, those in the top decile of
total expenditures, and those who are nursing facility
users. Finally, we look at the prevalence of various
chronic conditions among duals in the top decile of
Medicare and Medicaid expenditures.
Population Studied: Full dual eligibles (those eligible
for full Medicaid benefits) who were enrolled in both
Medicare and Medicaid for all twelve months of the year,
or from January through their date of death in the case
of those who died during the year, during 2005 and
2006. These “all-year full duals” represent about 70
percent of all duals nationally.
Principal Findings: Medicaid expenditures on dual
eligibles substantially exceed Medicare expenditures.
Although Medicare accounts for over 90 percent of perenrollee expenditures for hospital and physician
services, Medicaid pays for over 80 percent of nursing
facility services, and for many costly services not
covered by Medicare, such as HCBS. Also, there is
substantially greater state-by-state variation in annual
Medicaid expenditures per enrollee than in annual
Medicare expenditures, with especially wide variation in
Medicaid expenditures on nursing facility services.
Conclusions: Medicare accounts for most acute care
services and Medicaid for the largest portion of longterm-care services for dual eligible beneficiaries, but with
substantial overlaps that are likely to be difficult for
beneficiaries to understand, and incentives for payers
and providers that are often misaligned.
Implications for Policy, Delivery or Practice:
Substantial opportunities exist to better align incentives
and improve co-ordination of care for dual eligible
beneficiaries. We will discuss alternative ways of
coordinating care for duals, including shifts from
Medicaid to Medicare for some or all services, taking into
consideration the impacts of possible changes in
reimbursement or benefit design, as well as potential
behavioral responses to such changes. Findings from
this analysis can provide guidance to policymakers on
the likely impacts of various proposed changes in
financing of care for dual eligibles.
Funding Source(s): MedPAC
• Understanding the Variation in Medicare Spending
for Multiple Chronic Conditions
Gretchen Jacobson, Ph.D.; Tricia Neuman, Sc.D.;
Anthony Damico, M.H.S.; Gerard Anderson, Ph.D.
Presented by: Gretchen Jacobson, Ph.D., Principal
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: Almost 75 percent of Medicare
beneficiaries have two or more chronic conditions and
98 percent of all Medicare expenditures were for people
with multiple chronic conditions in 2007. However, little is
known about the relative costs of specific combinations
of chronic conditions. Our objective was to estimate the
mean Medicare expenditures for all combinations of the
most common chronic conditions.
Study Design: This analysis used longitudinal data from
the Medicare Standard Analytic File to examine
Medicare expenditures for the 15 most prevalent chronic
conditions in the Medicare population: ischemic heart
disease, diabetes, cataracts, rheumatoid arthritis, heart
failure, Alzheimer’s disease or dementia, depression,
osteoporosis, chronic kidney disease, chronic
obstructive pulmonary disease (COPD), glaucoma, atrial
fibrillation, prostate cancer, stroke, and breast cancer.
Data were linked for survey years 2005 and 2006 to
identify 1) beneficiaries with no chronic conditions and 2)
beneficiaries with one of the 15 chronic conditions. Total
and mean medical care expenditures were calculated for
every possible combination of the diseases, using claims
data from 2007, which included expenditures from Part
D drug plans.
Population Studied: Medicare beneficiaries in the
Standard Analytic File for 2005 to 2007, including the
institutionalized population, who were enrolled in a Part
D drug plan in 2007. Beneficiaries with end-stage renal
disease (ESRD) were excluded from the analyses.
Principal Findings: Mean Medicare expenditures varied
by both the number and types of chronic conditions. For
example, average costs for beneficiaries with three of
the chronic conditions were almost $11,000, but ranged
from $5,000 (such as osteoporosis, glaucoma, and atrial
fibrillation) to $21,000 (heart failure, chronic kidney
disease, and COPD). For beneficiaries with four of the
conditions, average expenditures were $14,000, ranging
from $6,000 to $28,000. Medicare expenditures for
beneficiaries with five chronic conditions averaged
$18,500, ranging five-fold from $9,000 (ischemic heart
disease, cataracts, rheumatoid arthritis, osteoporosis,
and stroke) to $32,000 (ischemic heart disease, heart
failure, depression, chronic kidney disease, and COPD).
Disease combinations vary with respect to the
distribution of expenditures for different types of
services; some have high prescription drug expenditures
relative to total Medicare spending, while others have
high inpatient hospital expenditures.
Conclusions: Medicare expenditures for people with
chronic conditions range widely. Expenditures vary more
by the combinations of chronic conditions than by the
number of conditions. Likewise, the services accounting
for the largest share of Medicare expenditures also
varies widely across chronic conditions and varies more
by the combination of conditions than by the number of
conditions.
Implications for Policy, Delivery or Practice:
Interventions that focus on managing care and costs for
Medicare beneficiaries with chronic diseases, including
medical homes and care coordination programs, should
focus on beneficiaries with combinations of diseases that
have relatively high per capita expenditures. Efforts that
target individuals based on a specific disease, without
attention to combinations of conditions, may be less
successful in achieving cost and care outcomes. With
strong policy interest in efforts to improve the
management of high-cost Medicare beneficiaries,
greater attention should be paid to specific combinations
of chronic conditions, rather than the number of
conditions.
Funding Source(s): Kaiser Family Foundation
• Impact of a Disease Management-Health Promotion
Intervention on Total Health Care Expenditures
Hongdao Meng, Ph.D.; Dianne Liebel, R.N., Ph.D.;
Brenda Wamsley, Ph.D.
Presented by: Hongdao Meng, Ph.D., Assistant
Professor, Preventive Medicine, Stony Brook Unversity,
HSC, Level 3, Room 071, Stony Brook, NY 11794-8338;
Phone: (631) 444-7281; Email:
hongdao.meng@stonybrook.edu
Research Objective: To examine the impact of a
disease management-health promotion intervention on
total health care expenditures among communitydwelling Medicare beneficiaries with disabilities.
Study Design: The Medicare Primary and Consumer
Directed Care (PCDC) demonstration was a communitybased randomized controlled trial with a factorial design.
For the purpose of this study, we limited the analysis to
the disease management-health promotion intervention
group and the control group. Participants in the control
group received only the regular Medicare benefits.
Participants in the intervention group received the
regular Medicare benefits, plus a multi-component home
and community-based benefit involving patient
education, individualized health promotion coaching,
medication management, and primary care coordination.
Individual characteristics were obtained via face-to-face
interviews by trained interviewers at baseline and at 22
months post-enrollment. Data on healthcare services
use were collected via weekly diaries completed by all
participants. Total health care expenditures included all
major categories of health care services use (physician
office visits, hospital, emergency room, and nursing
home admissions, and home health care use), with the
exception of prescription drug use. We estimated
generalized linear models to predict total health care
expenditures during the study period while controlling for
treatment assignment, individual socio-demographic
variables, health and functional status variables, and
prior use of health services.
Population Studied: We studied 766 fee-for-service
Medicare beneficiaries with disabilities from the
intervention group (n=382) and the control group
(n=384) of the PCDC demonstration conducted in 19
counties in Western New York, West Virginia, and Ohio.
Principal Findings: A total number of 452 individuals
completed the 22-month follow-up. The mean age of the
study sample was 75.8 years and more than two-thirds
were female. Ten percent of the participants were
enrolled in Medicaid and 60% reported annual
household income of $20,000 or less. The average
participant scored 31 on the SF-36 Physical Component
Summary and 48 on the Mental Component Summary.
The average participant had 2 ADL limitations, 3 IADL
limitations, and 4 chronic conditions. Adjusting for
covariates, the average monthly total health care
expenditures were 15% ($161) lower in the intervention
group compared to the control group ($886 versus
$1,047, p=0.03). Significant predictors of higher total
health care expenditures included the following: female,
minority, living alone, higher levels of ADL and IADL
limitations, prior skilled home health use, reside in New
York State, and having higher Medicare expenditures
prior to study entry.
Conclusions: The disease management-health
promotion intervention is associated with lower total
health care expenditures among Medicare beneficiaries
with disabilities who completed the study. Based on the
study findings, the intervention should be promoted
among Medicare beneficiaries with disabilities who are
likely to complete the tasks associated with the
intervention.
Implications for Policy, Delivery or Practice: Previous
studies have shown that the intervention was associated
with better disability outcome. This study provided
additional evidence that the intervention may be costeffective among certain high risk Medicare beneficiaries.
Future research is needed to replicate these findings in
other settings/regions. Potential strategies for improving
the targeting, enhancing the intervention effectiveness,
and/or reducing the cost of intervention delivery should
be tested.
Funding Source(s): CMS
• Is Higher Continuity Associated with Lower Risk of
Preventable Hospitalization?
David Nyweide, Ph.D.
Presented by: David Nyweide, Ph.D., Social Science
Research Analyst, Office of Research, Development,
and Information, Centers for Medicare and Medicaid
Services, 7500 Security Boulevard, Mailstop C3-21-28,
Baltimore, MD 21244; Phone: (410) 786-0699; Email:
david.nyweide@cms.hhs.gov
Research Objective: To determine whether higher
continuity is associated with lower risk of preventable
hospitalization among chronically ill older adults.
Study Design: For each chronically ill patient with at
least 4 ambulatory evaluation and management visits, a
Continuity of Care (COC) score was calculated based on
the concentration of visits across physicians over the
course of a year. Restricting to at least 4 visits avoided
ascribing high COC scores to beneficiaries with few
visits. The COC score was divided into terciles according
to the data distribution for each chronic illness. Logistic
regression models were used to measure the risk of
occurrence of at least one preventable hospitalization,
adjusting for patient age, sex, race, Charlson
comorbidity score, and ZIP Code mean monthly retiree
Social Security income as well as local acute care
hospital bed supply and regional managed care
penetration.
Population Studied: Fee-for-service Medicare
beneficiaries from the 2005 Part B 20 percent sample
older than 65 years of age with a prior diagnosis of
congestive heart failure (CHF) (n = 264,434), chronic
obstructive pulmonary disease (COPD) (n = 427,424),
diabetes (n = 667,691), or hypertension (n = 999,029).
Principal Findings: With respect to patients in the low
tercile of the COC score, patients with CHF or diabetes
in the high tercile were less likely to have a preventable
hospitalization (CHF OR 0.90, 95% CI 0.87—0.92;
diabetes OR 0.70, 95% CI 0.66—0.75). After controlling
for patient- and area-level characteristics, patients with
hypertension in the high tercile were additionally less
likely to have a preventable hospitalization (CHF OR
0.90, 95% CI 0.88—0.93; diabetes OR 0.80, 95% CI
0.79—0.82; hypertension OR 0.86, 95% CI 0.84—0.87).
Patients with COPD with higher continuity were more
likely to have a preventable hospitalization before
(medium tercile OR 1.12, 95% CI 1.07—1.17; high
tercile OR 1.19, 95% CI 1.14—1.24) and after
adjustment (medium tercile OR 1.12, 95% CI 1.09—
1.14; high tercile OR 1.23, 95% CI 1.20—1.26).
Preventable hospitalization was strongly correlated with
patient illness burden, followed by local acute care
hospital bed supply.
Conclusions: Most chronically ill older adults are less
likely to have a preventable hospitalization when their
ambulatory care patterns exhibit higher continuity.
Implications for Policy, Delivery or Practice: It
appears that the care that most chronically ill patients in
the fee-for-service Medicare program receive outside the
hospital can affect their chances of being admitted to the
hospital. Although the mechanisms for this relationship
are unclear, policies that discourage fragmented
ambulatory care patterns may be beneficial for
chronically ill patients. However, any protective effects of
continuity do not seem to affect patients with the
greatest illness burden, who are probably hospitalized
regardless of the robustness of their ambulatory care.
Funding Source(s): NIA
Improving Child Health Care Quality at Multiple
Levels: Relevance for Practice and Policy?
Chair: Claire Brindis
Sunday, June 27 * 11:00 am–12:30 pm
• Adolescent Females and the Human Papillomavirus
Vaccine: Factors Associated with Vaccination and
Its Recommendation in the U.S.
Mau Lau, M.D., M.P.H.; Hua Lin, Ph.D.; Glenn Flores,
M.D.
Presented by: Hua Lin, Ph.D., Biostatistical Consultant
III, Department of Pediatrics, University of Texas
Southwestern Medical Center, 5323 Harry Hines
Boulevard, Dallas, TX 75390; Phone: (214) 648-5034;
Email: hua.lin@utsouthwestern.edu
Research Objective: Human papillomavirus (HPV)
vaccine has been recommended for adolescent females
11-12 years old and above since 2007. The objective of
this study was to identify factors associated with HPV
vaccination and healthcare provider (HCP)
recommendation of HPV vaccine in adolescent females.
Study Design: The National Survey of Children's
Health, sponsored by the Maternal and Child Health
Bureau and conducted by the National Center for Health
Statistics using the State and Local Area Integrated
Telephone Survey mechanism, was a random-digit-dial
telephone survey in 2007 of a nationally representative
sample of households with children 0-17 years old.
Bivariate and multivariable analyses were used to
examine associations of sociodemographic and
healthcare factors with HPV vaccination and HCP
recommendation of HPV vaccine for all adolescent
females 12-17 years old.
Population Studied: A nationally representative sample
from the 2007 NSCH of US households with adolescent
females 12-17 years old at the time of the interview.
Principal Findings: Analyses of data on 16,139
adolescent females 12-17 years old revealed that
significantly higher proportions of HPV-immunized vs.
HPV-unimmunized adolescent females received the
tetanus/TD/Tdap (94% vs. 81%) and meningitis (65% vs.
31%) vaccines, were insured (94% vs. 91%), had a
usual source of care (96% vs. 93%), had a preventive
medical visit in the past year (94% vs. 91%), and had
their HCP recommend the HPV vaccine (84% vs. 20%).
In multivariable analyses adjusting for 8 covariates,
adolescent females who were Native American,
multiracial, or had received the meningitis vaccine had
about triple the adjusted odds of HPV vaccine receipt;
those who received the tetanus/TD/Tdap vaccine or
were poor had about double the adjusted odds of HPV
vaccine receipt; and HCP recommendation of the HPV
vaccine was associated with about 18 times the adjusted
odds of HPV vaccine receipt. In separate multivariable
analyses adjusting for 11 covariates, adolescent females
who were African-American, had parents who were not
high-school graduates, were uninsured, had no
preventive visit in the past year, and lived in the
Midwest, South, or West had lower adjusted odds of an
HCP recommendation for HPV vaccination. Adolescent
females who received the tetanus/TD/Tdap or meningitis
vaccines and who have a personal doctor or nurse had
about double the adjusted odds of receiving an HCP
recommendation for HPV vaccination.
Conclusions: HCP recommendation has a significant
impact on receipt of HPV vaccine in adolescent females.
African-American race, lower educational attainment,
uninsurance, no preventive visits in the past year, and
certain US regions are associated with lower odds of
HCP recommendation for HPV vaccine. HCP
recommendation of HPV vaccination may substantially
improve HPV vaccination rates in adolescent females.
Implications for Policy, Delivery or Practice: The
study findings suggest that HCPs should recommend
HPV vaccination to all adolescent females 12-17 years
old, and especially for particular high-risk groups,
including adolescent females who are African-American,
uninsured, made no preventive visits in the past year,
and have parents with lower educational attainment.
• Estimating the Comparative Efficiency of Inpatient
Care Settings for Pre-term Births
Glen Mays, Ph.D., M.P.H.; Heath Gauss, M.S.
Presented by: Glen Mays, Ph.D., M.P.H., Professor
and Chairman, Department of Health Policy &
Managementq, University of Arkansas for Medical
Sciences, 4301 W. Markham Street, #820, Little Rock,
AR 72205; Phone: (501) 526-6633; Email:
gpmays@uams.edu
Research Objective: Continued growth in the
prevalence of cost of pre-term births underscores the
need for improved management of cases across
available care settings. Acutely premature and very low
birthweight (VLBW) infants experience improved health
outcomes when delivered in inpatient settings equipped
with neonatal intensive care units (NICUs) and
neonatologist coverage. The relative costs of pre-term
delivery at NICU vs. non-NICU hospitals, however is less
clear due to differences in case mix and survival rates
across facilities. A better understanding of the economic
impact of preterm delivery in NICU-equipped hospitals is
needed to inform policies for increasing the quality and
efficiency of care for preterm infants. To this end, this
study uses a novel methodology for estimating
differences in hospital lengths of stay and costs for
preterm infants delivered in NICU vs. non-NICU
hospitals, accounting for both adverse selection in case
mix as well as censoring due to in-hospital mortality.
Study Design: We assembled birth records for all preterm infants born in Arkansas during calendar years
2001 through 2004, and linked them with hospital
records from Arkansas’ hospital discharge data system.
Multivariate negative binomial and logarithmic models
were used estimate differences in combined maternalinfant LOS and costs between hospital settings while
adjusting for observable covariates including birth
weight, gestational age, congenital anomalies, maternal
demographics, and maternal risks. Because complex
and high-risk cases are more likely to be referred to
NICU-equipped hospitals, we use instrumental variables
(IV) methods with geographic instruments to account for
the nonrandom selection of cases across hospital
settings. Furthermore, we use discrete factor
approximation methods to control for censoring of LOS
and cost measures due to in-hospital neonatal mortality,
allowing this censoring process to be endogenously
influenced by the hospital setting and unobservables.
Population Studied: A total of 12,258 preterm births
were included in the analysis, of which 15.3% were
VLBW and another 81.6 were LBW. Our analysis
distinguishes between three types of hospital settings:
(1) regional academic perinatal centers with NICUs; (2)
community hospitals with NICUs; and (3) community
hospitals without NICUs. Overall 52.6% of these births
were delivered in NICU-equipped hospitals.
Principal Findings: Estimates from single-equation
multivariate models without adjustment for endogenous
selection and censoring suggest that LOS was 25.2%
higher for deliveries in academic NICU settings and
32.1% higher in community NICU settings compared
with non-NICU hospitals (p<0.01). When the IV selection
and censoring adjustments were used, LOS was 9%
lower in academic NICU hospitals and 17% higher in
community NICU settings compared with non-NICU
settings (p<0.05).
Conclusions: The adjusted LOS differences imply that
inpatient delivery costs could be reduced by 12-15% for
each VLBW delivery shifted from non-NICU to academic
NICU settings, and by 28-33% for each delivery shifted
from community NICU to academic NICU settings.
Community NICU hospitals appear to be the costliest
settings for VLBW pre-term deliveries, due to a
combination of lower adjusted in-hospital mortality and
higher adjusted LOS.
Implications for Policy, Delivery or Practice: Policy
strategies to increase the proportion of VLBW deliveries
occurring in NICU-equipped hospitals may realize
efficiencies by prioritizing academic regional perinatal
centers, particularly for the most acutely pre-term
deliveries.
Funding Source(s): NIH National Center for Research
Resources
• Comparison of Dental Plans, Demographics and
Geographic Regions for Dental Services Provided to
SCHIP in California’s (Healthy Families Program)
Muhammad Nawaz, Ph.D; Shelley Rouillard, B.A.; Mary
Watanabe, B.A.
Presented by: Muhammad Nawaz, Ph.D, Research
Manager II, Managed Risk Medical Insurance Board,
Health and Human Services, 1000 G Street,
Sacramento, CA 95814; Phone: (916) 324-7444; Email:
mnawaz@mrmib.ca.gov
Research Objective: Comparative evaluation of
preventive and treatment services provided to Healthy
Families Program (HFP) children by “open network” and
“capitated” dental plans and the differences between
ethnicity, language and geographic regions for 8 dental
measures.
Study Design: The California Managed Risk Medical
Insurance Board (MRMIB) analyzed 2008 data for one
HEDIS measure and seven new measures developed by
dental advisory group for HFP. In SAS, General Linear
Model and the Student Neuman Kule tests were used for
analyses and ranking purposes.
Population Studied: The administrative data from
“open network” plans (Delta Dental and Premier Access)
and the “capitated” plans (Access Dental, Health Net
Dental, SafeGuard Dental and Western Dental) were
used for these analyses. Each network serves
approximately 50% of HFP members. Over 600,000
HFP children under 19 years of age were included in this
study. HFP is California’s State Children’s Health
Insurance Program (SCHIP) and is the largest SCHIP in
the country.
Principal Findings: Children enrolled in the “open
network” plans consistently received dental treatment
and preventive services at significantly higher rates
(16% to 53%) compared to children enrolled in
“capitated” plans. In some cases, children of the same
ethnicity or in the same geographic region in the “open
network” plans received services at four times the rate of
those in the “capitated” plans. Annual Dental Visit for
“open network” plans was 70% compared to 38% for
capitated” plans. However, the percentage rates for
Annual Dental Visits decreased from 61% to 55% from
2005 to 2008. Similarly, less than 40% of children
enrolled in “capitated” plans received a preventive
service in 2008 compared to over 60% of children
enrolled in “open network” plans. Overall, half of HFP
children received an oral health evaluation in 2008. Six
out of ten children enrolled in the “open network” plans
had received oral examinations compared to just two out
of ten children enrolled in the two lowest performing
“capitated” plans, Health Net Dental and Western
Dental. Less than half (45%) of HFP children overall
received treatment for caries or a caries-preventive
procedure. However, less than 20% of the children
enrolled in the two lowest performing plans, Health Net
Dental and Western Dental, received a caries related
dental service. Demographic analysis revealed that
Vietnamese speaking children received dental services
at the highest rate followed by Chinese, Spanish, “Other”
languages, English and Korean speaking children.
Korean children received the less dental services (9% to
24%) than Vietnamese children. Among the Asian
groups, it is not clear why Vietnamese and Chinese
children rank the highest, while Korean children rank the
lowest in receiving dental services. In ethnic
comparisons, African American, White and children of
“Other” ethnicities received dental treatment and
preventive services at the lowest rates across most
measures. The rates for Asians and Latinos were
significantly higher across most measures in both the
“open network” and “capitated” plans. Continuous
enrollment in the same dental plan and having a “dental
home” appears to increase the likelihood that a child will
go to the dentist for annual visits. Nearly seven out of ten
children who were continuously enrolled in the same
plan and had a cleaning or oral evaluation in 2007 also
received a cleaning and oral evaluation in 2008. For
children enrolled in Delta Dental, the percentage was
over 80%, whereas only one-third of children in Health
Net Dental received services in both years. Children in
the Northern, Valley and and Bay Area regions had
significantly higher (7 to 27%) rates for eight measures
compared to children from Los Angeles, South Coast
and south regions. Children enrolled in the “open”
network” plans had 2 to 3 time’s higher rates across all
regions for all dental measures compared to Children in
“capitated” plans.
Conclusions: Children enrolled in the “open network”
plans consistently received dental treatment and
preventive services at much higher rates compared to
children enrolled in “capitated” plans. Among
demographic comparisons, African American children
and Korean speakers were the lowest in the dental
services utilization.
Implications for Policy, Delivery or Practice: To
improve the quality of care, plans must do a better job of
providing dental care to children in HFP. MRMIB needs
to identify mechanisms to hold “capitated” plans
accountable for quality of dental care and may consider
terminating contracts with low performing plans.
Furthermore, there is a need to identify and remove
barriers to dental services for ethnic groups having low
access rates, including African American and Korean
speaking members.
• High Quality Primary Care Reduces
Hospitalizations among Children with Special Health
Care Needs
Jean Raphael, M.D., M.P.H.; Minghua Mei, Ph.D.; David
Brousseau, M.D., M.S.; Thomas Giordano, M.D., M.P.H.
Presented by: Jean Raphael, M.D., M.P.H., Assistant
Professor, Health Services Research, Pediatrics, Baylor
College of Medicine, Suite 1540.00, 6621 Fannin Street,
Houston, TX 77030; Phone: (832) 822-1791; Email:
raphael@bcm.edu
Research Objective: Improving the quality of primary
care has been advocated as a strategy to reduce
unnecessary health care utilization among children with
special health care needs (CSHCN). For this population,
utilization of high-acuity services, the emergency
department (ER) and inpatient wards, often represents
exacerbation of chronic disease and potentially
inadequate primary care. Our objective was to determine
whether parent-reported quality of primary care
significantly influenced high-acuity health care utilization
among CSHCN.
Study Design: We conducted a secondary analysis of
prospectively collected data on CSHCN for whom data
regarding the experience of quality primary care were
available (n=1591) from the 2004-2005 and 2005-2006
panels of the Medical Expenditure Panel Survey
(MEPS). The primary outcome variables were ER visits
and hospitalizations. The main independent variables
were composite measures for family-centeredness,
timeliness, and realized access derived from the
Consumer Assessment of Healthcare Providers and
Systems (CAHPS) questions within MEPS. Composite
scores were dichotomized as high quality versus low
quality. Only encounters occurring after completion of
the CAHPS survey were included in the analysis.
Weighted multivariate Poisson regression analyses were
performed, yielding Incident Rate Ratios (IRRs) to
assess associations between quality of primary care and
subsequent health care utilization, adjusting for sociodemographic variables and health status. Stratified
results are presented wherever significant interactions
were identified.
Population Studied: Children, ages 0-17, identified as
CSHCN according to the CSHCN screener instrument in
MEPS.
Principal Findings: Sixty-eight percent of parents rated
the family-centeredness of their child’s primary care as
high quality; 51.5% reported timeliness as high quality,
and 80.4% reported realized access as high quality.
Less than 30% of parents reported that their children
received high quality care in all three quality-of-care
domains. Children who received low quality familycentered care had higher rates (IRR 2.18, 95% CI 1.074.46) of hospitalizations than children who received high
quality family-centeredness. Stratification by insurance
status showed that for privately insured children, low
quality family centeredness was associated with higher
rates (IRR 3.79, 95% CI 1.22-11.72) of hospitalizations
and low quality realized access was associated with
similarly higher rates (IRR 3.63, 95% CI 1.39-9.46) of
hospitalizations. For publicly insured children, no
significant associations were found. There were no
associations between quality-of-care domains and ER
utilization.
Conclusions: Higher rates of hospitalization among
CSHCN were associated with low quality family-centered
primary care and low quality realized access, although
not uniformly across insurance types. High quality
primary care may not be able to impact ER visits since
many of the encounters for CSHCN may be urgent.
However, it may have potential to prevent illness from
becoming severe enough to require hospitalization.
Implications for Policy, Delivery or Practice:
Improving the delivery of primary care may offer an
effective strategy to appropriately reduce
hospitalizations, and potentially medical expenditures,
attributable to CSHCN. Although quality-of-care domains
were associated with hospitalizations among privately
insured children, it remains unclear what potential quality
domains may impact hospitalizations among publicly
insured children. More research needs to be done to
understand these discrepancies and to develop policy
solutions that may ameliorate their effects.
Improving Hospital Safety and Quality
Chair: Anne-Marie Audet
Sunday, June 27 * 11:00 am–12:30 pm
• Improving Outcomes Through the Use of Inpatient
Order Sets: A Systematic Review
John Chang, M.D., Ph.D., M.P.H.; Alison Dietrich, M.D.;
Michael Langberg, M.D.; Paul Silka, M.D.
Presented by: John Chang, M.D., Ph.D., M.P.H., Zynx
Health, 10880 Wilshire Boulevard, Suite 300, Los
Angeles, CA 90024; Phone: (310) 954-5683; Email:
jchang@zynx.com
Research Objective: The American Recovery and
Reinvestment Act of 2009 authorizes the Centers for
Medicare & Medicaid Services (CMS) to provide
incentives to eligible hospitals and professionals who
become “meaningful users” of electronic health record
technology. One of the early objectives identified by the
Health IT Policy Committee, a Federal advisory
committee, is to have both eligible providers and
hospitals use evidence-based order sets. The objective
of this systematic review was to identify and summarize
studies evaluating the use of order sets by physicians in
inpatient settings.
Study Design: MEDLINE and the reference lists from
identified articles published between June 1999 and
June 2009 were used to identify studies for this
systematic review. Studies were included if they
evaluated the development and/or use of order sets.
Studies were grouped into three categories, those that
focused on outcomes related to the use of order sets,
e.g. improved quality, those that focused on health
information technology (HIT) implementation using order
sets, and those that focused on technical development.
Population Studied: Medical centers or groups
evaluating the development and/or use of order sets
published in the peer-reviewed literature from 1999 to
2009.
Principal Findings: Twenty-three studies were
identified. Of these, sixteen studies examined outcomes
related to order set usage, nine studies examined
experiences with implementation, and nine studies
examined experiences that assist with the technical
development of order sets. Of the sixteen studies
examining outcomes, the majority (56%) focused on the
adult inpatient setting, but some evaluations occurred in
the pediatric inpatient (25%) and emergency department
settings (19%). A heterogeneous group of conditions
were studied, including acute myocardial infarction,
pneumonia, sepsis, venous thromboembolism (VTE)
prophylaxis, diabetes, and immunizations. A
heterogeneous group of outcomes were studied,
including mortality, length of stay, appropriate
medication use, medication errors, glucose control, and
increased adherence to recommended care. Fourteen of
the sixteen studies demonstrated improved clinical
outcomes, including reduced mortality, reduced length of
stay, improved appropriate medication use, improved
VTE prophylaxis, improved glucose control, and
improved inpatient pneumococcal and influenza
vaccination rates. One study found no change in
guideline adherence in the emergency department
setting. One study cautioned about medication errors in
the pediatric setting with the use of computerized
physician order entry, not due to safety issues with the
order set orders themselves, but in how physicians
decided to use them. Of the studies examining technical
development and implementation, development of an
information warehouse of order entry data was identified
as an important strategic initiative to provide data to
inform improvements in provider education, resource
utilization, order configuration, and patient care.
Conclusions: Use of inpatient order sets is an effective
strategy for improving clinical outcomes for several
important clinical conditions. Developing both an
information warehouse of computerized physician order
entry data and analysis capacity will be essential for
future evaluations and continuous improvements in both
order sets and patient care.
Implications for Policy, Delivery or Practice: This
systematic review provides current evidence for the use
of order sets for improving clinical outcomes and that the
use of evidence-based order sets remains an important
objective for the “meaningful use” of electronic health
record technology.
Funding Source(s): Cedars-Sinai Medical Center
• Perceptions of Safety Climate and Hospital
Readmission
Luke Hansen, M.D., M.H.S.; Sara Singer, M.B.A., Ph.D.
Presented by: Luke Hansen, M.D., M.H.S., Instructor,
Department of Medicine, Northwestern University
Feinberg School of Medicine, 750 N. Lake Shore Drive,
Suite 11-191, Chicago, IL 60611; Phone: (312) 5032826; Email: luke.hansen1@gmail.com
Research Objective: Preventable hospital readmission
is a prominent consideration in policy discussions aimed
at reducing morbidity and cost in the United States
healthcare system. Hospital patient safety culture—
defined as a hospital’s organizational culture as related
to patient safety—is believed to be one determinant of
hospital patient safety performance and may be
associated with readmission resulting from failure to
ensure safe transitions in care. This project examines
the association between measures of hospital safety
culture—its safety climate—and hospital readmission
rates.
Study Design: The Patient Safety Climate in Healthcare
Organizations survey was administered to employees in
participating hospitals between July 2006 and May 2007.
For each hospital, to identify the level of low safety
climate a percent problematic response (PPR) was
calculated for each survey item, for 12 component
dimensions of safety climate, and for safety climate as a
whole. For each hospital, we also obtained readmission
outcomes information for three publicly reported disease
states (heart failure [HF], acute myocardial infarction
[AMI], and pneumonia). Robust multiple regression
models were estimated in which 30 day riskstandardized readmission rates were the dependent
variables in separate disease-specific models and
measures of safety climate were the key independent
variables. We estimated separate models for all hospital
staff, physicians, nurses, hospital senior managers, and
frontline staff.
Population Studied: We surveyed a random sample of
36,375 hospital employees from 75 hospitals nationwide.
Principal Findings: There was a significant association
between lower safety climate (higher PPR) and higher
readmission rates for AMI and CHF (p=0.05 for both
models) but not for pneumonia. When stratified by
management level, frontline staff perceptions of safety
climate were associated with readmission rates for AMI
and HF (p=0.01), but senior management perceptions
were not. Hospitals with a lower safety climate among
physicians were more likely to experience higher
readmission rates after AMI (p=0.01), while hospitals
with a lower safety climate among nurses were more
likely to experience higher readmission rates following
HF exacerbation (p=0.05). The association between
lower safety climate and higher rates of readmission was
present across multiple component dimensions reflecting
interpersonal, unit, and hospital level contributions to
safety climate.
Conclusions: Our findings indicate that hospital patient
safety climate is associated with readmission outcomes
for AMI and CHF. This work supports previously
identified differences in senior management and frontline
staff perceptions of safety climate and their impact on
patient outcomes. Our finding that associations between
safety climate and readmission were disease- and
discipline-specific may be due to different intensity of
services required at the time of discharge including
patient education and home safety evaluation.
Implications for Policy, Delivery or Practice: While
currently accepted tools for hospitals to reduce
avoidable readmission emphasize process changes
such as inpatient assessment of readmission risk prior to
discharge, our results indicate that lower safety culture
may also interfere with safe discharge. Efforts to
implement practices to reduce readmission in the
absence of supportive safety culture may fail to promote
optimal care around discharge.
• Determinants of Inpatient Smoking Cessation
Quality
Douglas Levy, Ph.D.; Raymond Kang, M.A.; Christine
Vogeli, Ph.D.; Nancy Rigotti, M.D.
Presented by: Douglas Levy, Ph.D., Assistant
Professor of Medicine, Mongan Institute for Health
Policy, Massachesetts General Hospital/Harvard Medical
School, 50 Staniford Street; 9th Floor, Boston, MA
02461; Phone: (617) 643-3595; Email:
dlevy3@partners.org
Research Objective: Among the Joint Commission’s
National Hospital Quality Measures (NHQM) are
measures of whether smokers admitted to the hospital
with acute myocardial infarction (AMI), heart failure (HF),
or pneumonia (PN) receive smoking cessation advice
and/or counseling. We present the first national study
examining simultaneously how hospital and patient
characteristics influence compliance with the NHQM
smoking cessation measures.
Study Design: We assessed changes in the relative
importance of patient and hospital characteristics on
rates of compliance with the Joint Commission smoking
cessation measure from 2005 to 2008 and then
conducted multivariate analysis to identify factors most
closely associated with compliance on the smoking
cessation measure using the most current year of data.
Patient-level data on NHQM measure performance and
demographic characteristics (age, gender, race,
ethnicity, insurance, co-morbidities, length of stay, and
discharge status) were acquired from CMS. Hospital
characteristics (patient demographics, number of beds,
teaching status, and ownership) came from aggregated
patient data and the 2007 American Hospital Association
annual survey. We used hierarchical linear models with
hospital and hospital referral region (HRR) random
effects.
Population Studied: Smokers admitted to U.S.
hospitals with a diagnosis of AMI, HF, or PN from 2005
to 2008.
Principal Findings: Nationally, smoking cessation
advice/counseling rates were high in 2005 (AMI 84%, HF
77%, PN 74%) and rose steadily through 2008 (AMI
96%, HF 92%, PN 90%). Intraclass correlation
coefficients indicate that variability in the smoking
cessation measure due to hospital/patient characteristics
in 2005 vs. 2008 was 36%/63% vs 64%/36% among AMI
patients, 25%/72% vs. 50%/46% among HF patients,
and 22%/75% vs. 36%/58% among PN patients. The
small amount of remaining variation was associated with
HRR-level factors. Based on multivariate analysis of
2008 data, older age, discharge to an institution, and comorbidities (chronic lung disease, metastatic cancer,
paralysis) were associated with lower smoking cessation
measure performance for all conditions. In certain cases,
minority patients were less likely to get smoking
cessation advice/counseling than whites: Hispanics less
likely for HF and PN, blacks less likely for PN, and
Asians less likely for AMI and PN. Number of hospital
beds and minor teaching status were positively
associated with smoking cessation measure
performance. Public hospital ownership and percent of
patients who were Medicaid beneficiaries were
negatively associated with performance.
Conclusions: Compliance with the smoking cessation
measure is approaching perfection. As the NHQM have
achieved prominence, hospitals have increasingly
exerted their influence to ensure compliance with the
smoking cessation measure. The sickest patients were
least likely to receive smoking cessation advice.
Hospitals serving larger proportions of indigent patients
were the most likely to under-perform.
Implications for Policy, Delivery or Practice: Despite
high hospital compliance with smoking cessation
counseling, important subgroups of hospitalized patients
do not receive routine counseling because of their
prognoses and the characteristics of hospitals where
they receive care. Efforts should be directed towards
improving care, even for the sickest patients, as they too
benefit from cessation. Improving smoking cessation
advice rates in institutions serving high proportions of
indigent patients will have to take account of the
challenges these institutions face.
Funding Source(s): RWJF
• A Multicenter, Phased Cluster-Randomized
Controlled Trial to Reduce Central Line-Associated
Blood Stream Infections in Intensive Care Units
Jill Marsteller, Ph.D., M.P.P.; J. Bryan Sexton, Ph.D.,
M.A.; Yea-Jen Hsu, A.B.D., M.H.A.; Chun-Ju Hsiao,
Ph.D., M.H.S.; Peter Pronovost, Ph.D., M.D.; David
Thompson, D.N.Sc., M.S., R.N.
Presented by: Jill Marsteller, Ph.D., M.P.P., Assistant
Professor, Health Policy and Management, Johns
Hopkins School of Public Health, 624 N. Broadway,
Room 433, Baltimore, MD 21205; Phone: (410) 6142602; Email: jmarstel@jhsph.edu
Research Objective: Central-line associated
bloodstream infections (CLABSI) in intensive care units
(ICUs) are common and costly, though largely
preventable. Using an observational design, a previous
study showed that an evidence-based intervention
significantly reduced CLABSI and improved unit safety
culture. The present study used a randomized design to
test the effectiveness of this intervention and to
determine the generalizability of the intervention effects.
Study Design: A phased, clustered randomized
controlled trial assigned hospitals from two health care
systems to either the intervention or control group. The
intervention group began implementation of the
intervention, which consisted of five evidence-based
infection prevention practices (included in a checklist)
and the six-step Comprehensive Unit-based Safety
Program (CUSP) to improve safety, teamwork and
communication, in March 2007. Seven months later, in
October 2007, the control group began the intervention.
Baseline data are from the year 2006 and postintervention data are from October-December 2007, the
first quarter of the control group’s implementation phase.
The analysis used a simple population average
analytical framework with the ICU as the unit of analysis
to assess the effect of the intervention on the primary
outcome variable, number of CLABSIs (with an offset for
catheter days), adjusted for baseline CLABSI and
hospital system. We used a zero-inflated Poisson model
with robust clustering to account for shared variance
among ICUs in the same hospital. In addition, we
calculated the monthly and quarterly CLABSI rates,
incidence rate ratios and percent changes for both
groups for all reported periods from baseline through the
end of the intervention.
Population Studied: Thirty-five hospitals from two
affiliated, faith-based regional health care systems were
randomized, with 23 ICUs assigned to the intervention
group and 22 to the control group.
Principal Findings: Before the intervention, the average
number of CLABSI per 1000 central-line days was 4.48
and 2.71 for the intervention and control groups,
respectively (statistically equivalent, p=0.28). Postintervention, the average infection rate declined to 1.33
for the intervention group (a 70% reduction), while the
control group had an average rate of 2.16 (a 21%
reduction). Both groups achieved a median rate of zero
infections by the post-intervention period, however, the
intervention group had significantly lower infection rates
post-intervention than the control group (IRR=0.16,
p=0.03, 95% CI=0.03 to 0.84). The first intervention
group sustained its rates at 18 months, for an overall
reduction of 81%. The second intervention group also
realized reductions at one year post-intervention (69%).
Conclusions: The evidence-based practices for
CLABSI prevention and the CUSP safety program
effectively reduce CLABSI. The control group was also
able to reduce CLABSI rates after starting the
intervention, and both groups were able to sustain
substantial reductions over time. This study
demonstrates a causal relationship between use of the
multifaceted intervention and reduced CLABSI. It also
shows that reductions in CLABSI in the successful
previous project can be replicated.
Implications for Policy, Delivery or Practice: Using
multifaceted interventions that help to ensure adherence
to evidence-based infection control guidelines, it is
possible to nearly eliminate CLABSI in hospital intensive
care units across the nation.
Funding Source(s): RWJF
Medicaid and CHIP Costs and Cost Containment
Strategies
Chair: Chris Peterson
Sunday, June 27 * 11:00 am–12:30 pm
• Who Pays for Health Care Spending: The Incidence
of Public Payments by Family Income
E. Kathleen Adams, Ph.D.
Presented by: E. Kathleen Adams, Ph.D., Professor,
Health Policy and Management, Emory University,
Rollins School of Public Health, 1518 Clifton Road NE
Room 654, Atlanta, GA 30322; Phone: (404) 727-9370;
Email: eadam01@sph.emory.edu
Research Objective: The financing of over $2 trillion of
health care spending comes from a combination of
private and public revenues ultimately paid by
individuals/families through out- of -pocket payments,
direct purchase of insurance or forgone wages and tax
payments to federal, state or local governments. Our
objective is to apply conventional theory to estimated
health care spending by tax type to identify the incidence
of these payments by family income in 2004.
Study Design: We used data from the 2004 and 2005
Current Population Survey (family characteristics/
income), the 2004 Census of Government (federal, state
and local tax composition) and data on government
funded health care (National Health Accounts, National
Association of State Budget Officers) to estimate publicly
funded health care spending supported by each type of
tax. We distributed spending by tax type back to families
based on their ‘shares’ of the total tax base. For
example, health care spending supported by general
sales taxes was distributed based on the family’s share
of total taxed consumption. Adjustments were made for
tax exporting internationally and domestically. The
TAXSIM model was used to estimate total federal and
state income taxes paid and health care spending
supported by these taxes distributed to families based
on their ‘share’ of total income taxes paid.
Population Studied: All 174,031 families (weighted n =
129 million) in the pooled 2004 and 2005 CPS data.
Principal Findings: Taxes to support publicly funded
health care absorbs 13 percent of family income.
Federal financing imposes the heaviest burden at almost
10 percent while state/local tax revenues equal around 3
percent. The incidence of federal financing is
progressive throughout, rising from 4.3 percent in the
lowest quintile to almost 14 percent in the highest. In
contrast, the pattern for state funding is mildly
regressive, moving from 3.9 percent to 3 percent across
these income groups. Medicare accounts for around 3.9
percent of family income, increasing from 1.8 percent for
families in the lowest quintile to almost 5 percent in the
highest. In contrast to a regressive pattern for total state
supported health care, the Medicaid program, by using a
combination of federal and state tax revenues, follows a
progressive incidence.
Conclusions: Only tax sources used at the federal level
introduce a progressive element into public health care
financing. The lack of a cap on the payroll tax base used
for Medicare plays a role in this pattern. The influx of
federal tax dollars to help finance Medicaid, and at a
higher rate in poorer states, plays an important role in
not only moderating the other regressive pattern of state
taxes, but actually reversing it.
Implications for Policy, Delivery or Practice: To the
extent vertical equity is a goal for the financing of the
public sector, maintaining or increasing the share paid
by federal taxes is important in meeting this goal. It will
be important to consider the level and structure of
federal matching rates should Medicaid expansion be
used as the cornerstone of expanding health insurance.
Funding Source(s): RWJF
• Using Consumer Incentives To Increase Well-Child
Visits
Jessica Greene, Ph.D.
Presented by: Jessica Greene, Ph.D., Associate
Professor, Planning, Public Policy & Management,
University of Oregon, 1209 University of Oregon,
Eugene, OR 97403; Phone: (541) 346-0138; Email:
jessicag@uoregon.edu
Research Objective: Medicaid and State Children’s
Health Insurance Programs (CHIP) in several states,
including California, Florida, Idaho, Michigan, and
Wisconsin, have begun piloting consumer incentive
programs to improve recipients’ health behaviors and
use of preventive care. This study examines the impact
of Idaho’s wellness incentive program, which rewards
CHIP enrollees who are up-to-date with well-child visits
with $30 in credits quarterly for use towards their CHIP
premiums.
Study Design: This quasi-experimental study examined
whether children with CHIP increased well-child visit
rates relative to children with Medicaid, who were not
eligible for the incentive. We examined well-child visit
rates in three years: baseline, the first year of
implementation (when the reward was either premium
payment or a voucher for health-related products), and
the second year of implementation (when the reward
was exclusively for premiums). Claims data was used to
compute whether children, based upon their age, were
up-to-date with well-child visits according to the
American Academy of Pediatrics guidelines.
Population Studied: We examined well-child visit rates
for all children with Medicaid and CHIP in Idaho who had
coverage for at least 11 of 12 months in a study year.
Children with CHIP were divided into two groups
because premiums differed based on family income.
Those with incomes 133%-150% FPL paid $10 premium
per month, which the incentive could completely cover.
Those with incomes 150%-185% FPL paid a $15
monthly premium, which was more than the incentive
could cover.
Principal Findings: At baseline, rates of being up-todate with well-child visit recommendations were similar
among those with Medicaid and the two CHIP groups
(133%-150% FPL and 150%-185% FPL). Among 3-6
year olds, rates were 40%, 39%, and 38% respectively.
In the first year of the incentive program, well child visit
rates increased for the two CHIP groups by 19% and
37% respectively, while the rate for children with
Medicaid decreased by 3%. Well-child visit rates
continued to increase in the second year of the program.
Relative to baseline, the CHIP groups increased by 47%
and 58% respectively, while children with Medicaid
increased by 7%. Similar patterns of increases were
observed for the other age groups (1-2, 7-11, and 1218), though improvements were smaller in magnitude for
adolescents and very young children. Among children
with CHIP, the increase in well-child visit rates was 34%
higher among Latino children than whites.
Conclusions: Idaho’s experience using consumer
incentives resulted in substantially higher rates of wellchild visits among children with CHIP, compared with
children with Medicaid who were not eligible for the
incentive.
Implications for Policy, Delivery or Practice: This
study provides early evidence that policymakers can
successfully improve use of preventive care for low
income children through consumer incentives. The
incentive made a similar impact for those who had to pay
no CHIP premium as a result of the reward, as well as
those who had to pay a reduced premium. The impact,
however, was smaller for young children, who require
repeated visits to be up-to-date with well-child visits, and
for adolescents.
• The Effects of Medicaid Policy Changes on Adults’
Receipt of Medical and Dental Care and Service Use
Patterns in Kentucky and Idaho
Genevieve Kenney, Ph.D.; James Marton, Ph.D.;
Jennifer Pelletier, B.A.; Ariel Klein, B.A.; Jeffery Talbert,
Ph.D.
Presented by: Genevieve Kenney, Ph.D., Senior
Fellow, Health Policy Center, Urban Institute, 2100 M St
NW, Washington, DC 20037; Phone: (202) 261-5569;
Email: jkenney@urban.org
Research Objective: This study examines receipt of
medical and dental care among non-elderly adults in
Medicaid in two states that adopted policy changes
aimed at increasing receipt of primary and preventive
care. It also examines the impact of cost containment
measures adopted by the Kentucky Medicaid program,
including new cost-sharing and prior authorization
requirements for services and prescriptions.
Study Design: Descriptive and impact analyses,
including linear probability and hazard models, are used
to examine the effect of policy changes with
administrative enrollment and claims data spanning the
period the policy changes were made (2004-2008).
Models control for age, gender, race/ethnicity, and
eligibility category (TANF or SSI).
Population Studied: Adult Medicaid enrollees ages 19
to 64 in Idaho and Kentucky eligible under TANF or SSI
and enrolled during the study period.
Principal Findings: In Kentucky, preliminary descriptive
statistics indicate that following the increase in
reimbursement rates for office visits, the shares of adults
in Medicaid who had any physician’s visit and any dental
visit in the prior year increased by less than 1
percentage point (to 87% and 31%, respectively, in the
post period), while the shares who had any preventive
physician’s visit and any preventive dental visit
decreased by less than 1 percentage point (to 12% and
11%, respectively, in the post period). Additional
analyses will examine effects of new cost sharing
arrangements, prior authorization requirements, and
service limits, which are hypothesized to reduce service
use. Preliminary descriptive analysis in Idaho indicates
that an estimated 10% of adults in Medicaid had
received a preventive physician’s visit following its
addition to the adult benefit package, while the share of
adults who received any physician’s visit remained
constant at 78%. After outsourcing dental care for TANF
enrollees to a managed care organization, which
increased reimbursement rates to dental providers, the
share of adults enrolled in the TANF eligibility category
who had any dental visit in the past year increased from
46% to 51%. In contrast, for SSI adults who remained in
fee-for-service dental care, there was no change in the
share having any dental visits. Similarly, the share of
TANF adults who received a preventive dental visit
increased from 24% to 29%, while the share of SSI
adults who had a preventive dental visit remained
constant.
Conclusions: While the majority of adults in Medicaid in
both states received primary medical care in the past
year, rates of preventive care and of dental care use are
very low. Preliminary analysis from Idaho suggests that
the addition of an adult wellness exam to the benefit
package had modest effects on service use and that the
adoption of managed care for dental provision for adults
in TANF appears to have increased use of preventive
dental care and dental care overall among that
population.
Implications for Policy, Delivery or Practice: Policy
changes such as fee increases, benefit package
changes, and delivery system changes can lead to
increases in primary care use among adults. However,
additional policy changes would be required to address
the persistent shortfalls in preventive and dental care
receipt.
Funding Source(s): RWJF
• Associations Between Prior Authorization for
Psychiatric Medications and Health Services Use
among Medicaid Patients with Bipolar Disorder
Christine Lu, Ph.D.; Alyce Adams, Ph.D.; Dennis RossDegnan, Sc.D.; Fang Zhang, Ph.D.; Yuting Zhang,
Ph.D.; Stephen Soumerai, Sc.D.
Presented by: Christine Lu, Ph.D., Research Fellow,
Department of Population Medicine, Harvard Medical
School and Harvard Pilgrim Health Care Institute, GPO
Box 2471, Adelaide, Australia, 5001; Phone:
+61883021335; Email: christine.lu@unisa.edu.au
Research Objective: Prior authorization (PA) policies
are commonly used by state Medicaid programs and
Medicare Part D plans to control psychotropic drug
expenditures. This study examined the association of a
PA policy for atypical antipsychotic and anticonvulsant
agents with medication discontinuation and use of nondrug health services among patients with bipolar
disorder.
Study Design: We used a pre-post-with-historicalcomparison-group study design to analyze Maine
Medicaid and Medicare claims data (2001-2004). We
estimated changes in rates of medication
discontinuation, and physician, psychiatric, emergency
room (ER) visits before and after bipolar drug initiation.
Population Studied: Newly treated patients during the
policy period (Jul 2003-Feb 2004; n=946) and a
comparison group from an equivalent period one year
earlier (Jul 2002-Feb 2003; n=1014). We stratified
patients according to their pre-initiation use of services in
community mental health centers (CMHCs) that target
those with more severe mental illness: CMHC attenders
(at least 2 visits) and non-attenders (fewer than 2 visits).
Principal Findings: CMHC attenders had substantially
higher rates of comorbidity and use of medications and
health services than non-attenders. Among nonattenders, the policy cohort was more likely than the prepolicy cohort to discontinue medications during the first
30 days of drug treatment (hazard ratio: 1.29; 95% CI
[confidence interval], 1.04 to 1.60). Among CMHC
attenders, the hazard of medication discontinuation was
similar for the policy and pre-policy cohorts during the
first month of drug treatment. However, the risk of
discontinuation increased among the policy group for the
remainder of follow-up (hazard ratio: 1.72; 95% CI, 1.03
to 2.86). The policy was associated with reductions in
psychiatric visits after discontinuing medication among
CMHC attenders (-64 per month per 100 patients; 95%
CI, -126 to -3), possibly because patients had less
reason to visit clinicians after discontinuing psychiatric
medications. Among non-attenders, the policy was
associated with increases in ER visits after discontinuing
medication (16 per month per 100 patients; 95% CI, 5 to
26), possibly indicating either increased incidence of
symptoms while off-treatment or attempts to manage
medication issues in ERs. During the 8-month follow-up,
the policy had no detectable impact on rates of
hospitalization.
Conclusions: The Maine PA policy was associated with
increased rates of medication discontinuation among
patients initiating new episodes of bipolar drug
treatment, and following these discontinuations,
reductions in psychiatric visits among the sickest
patients treated in CMHCs and increases in ER visits in
other patients. These small but meaningful unintended
policy effects raise quality of care concerns for a group
of very vulnerable patients. Long-term consequences of
PA policies on patient outcomes warrant further
investigation.
Implications for Policy, Delivery or Practice: Our
findings suggest that the PA policy had a differential
impact on discontinuation of medications and non-drug
health services among newly treated patients with
bipolar disorder by level of disease severity (i.e., as
measured by attendance at CMHC). To the extent that
procedural barriers contribute to increased medication
discontinuation and subsequent changes in use of nondrug health services, such barriers should be avoided in
patients with chronic mental illnesses.
Funding Source(s): RWJF
• The Effects of Emergency Department Copayments
on Medicaid Enrollees’ Use of Physician and
Hospital Services
Karoline Mortensen, Ph.D., M.A., B.S.; Paula Song,
Ph.D., M.H.S.A., B.A.; Hanns Kuttner, M.A., A.B.
Presented by: Karoline Mortensen, Ph.D., M.A., B.S.,
Assistant Professor, Health Services Administration,
University of Maryland, 3310 SPH Building #255,
College Park, MD 20782; Phone: (301) 405-6565;
Email: karoline@umd.edu
Research Objective: Cost sharing has been widely
adopted in state Medicaid programs to discourage
demand for unnecessary services. Although many states
have charged nominal copayments for physician
services for years, there has been momentum recently in
charging cost sharing for nonemergent use of the
emergency department (ED). This study analyzes the
effect of ED copayment changes on Medicaid enrollees’
office-based physician visits and inpatient hospital
utilization.
Study Design: This study uses a quasi-experimental
methodology to examine physician visits and
hospitalizations before and after ED copayment
changes. State identifiers are matched to the Medical
Expenditure Panel Survey (MEPS) public use files to link
state data on Medicaid copayments for nonemergent ED
visits to individuals in the 29 most populous states.
Difference-in-difference analysis is applied to explore
exogenous variation in copayments arising from the 9
states that increased their copayment rates between
2001 and 2006.
Population Studied: The study population includes
respondents to the 2001 to 2006 MEPS aged 19 to 64
years old. The subpopulation of individuals enrolled in
Medicaid for 12 months or longer includes 7,457
enrollees, representing 89,484 person-months.
Principal Findings: ED copayments for nonemergent
visits range from $0 in 6 states to the patient bearing the
full cost of a nonurgent ED visit in 1 state in the study
sample. Seventy-three percent of enrollees had one or
more office-based physician visits, 27% had at least one
ED visit, and 14% had one or more hospitalizations.
Difference-in-difference results suggest that ED
copayments are associated with statistically significant
increases in the likelihood of a physician visit after states
increased copayments, relative to enrollees in states that
did not alter their ED cost sharing. Hospitalizations are
also found to increase after copayment increases.
Conclusions: Implementing or increasing copayments
for Medicaid ED services has been found to be
associated with statistically significant decreases in ED
visits. Results from this study show that ED copayments
also result in increases in physician visits by Medicaid
enrollees. ED copayments are associated with an
increase in inpatient hospitalizations, an unintended
consequence of the policy.
Implications for Policy, Delivery or Practice: The
results from this analysis provide a national perspective
on the direct and indirect effects of charging ED
copayments to the low-income, vulnerable Medicaid
population. State policymakers implement copayments
with the intention of creating the correct incentives for
enrollees to access appropriate care. It is important to
determine whether they are effective, or if they are
having unintended effects on utilization. The Deficit
Reduction Act of 2005 simplified the process of
implementing cost sharing in Medicaid, so the policy
implications are timely as states determine whether to
adopt (or increase) ED cost sharing.
Recent Evidence on Chronic Care Treatment from
the VA
Chair: Michael Davern
Sunday, June 27 * 11:00 am–12:30 pm
• Effectiveness, Intervention Cost, and Health Care
Utilization Associated with Group Medical Visits for
Diabetes and Hypertension: A Randomized
Controlled Trial
Santanu Datta, Ph.D.; Cynthia Coffman, Ph.D.; Amy
Jeffreys, M.S.; Morris Weinberger, Ph.D.; David
Edelman, M.D.
Presented by: Santanu Datta, Ph.D., Health Research
Scientist / Assistant Research Professor, Center for
Health Services Research in Primary Care / General
Internal Medicine, Durham VA Medical Center / Duke
University, HSR&D (152), 508 Fulton Street, Durham,
NC 27705; Phone: (919) 286-6936; Email:
santanu.datta@duke.edu
Research Objective: Group medical visits (GMVs) are
being widely implemented for diabetes management. We
evaluated the effectiveness of GMVs as well as its cost
and impact on health services utilization.
Study Design: Groups with the same 7-8 patients met
with the same pharmacist and general internist each
visit; there were different physicians and pharmacists
across groups. Each session included group education
and structured group interactions moderated by a
registered nurse or certified diabetes educator.
Additionally, individual medication adjustments were
made by the pharmacist and physician to manage A1c
and BP. Each group had an initial visit and then met
every two months for a year. We estimated the cost of
GMVs by summing labor costs (salary and fringe
benefits) associated with the group sessions
themselves, follow-up calls with patients, and 2 hours of
nurse training. All patient-care related phone calls were
logged throughout the study. We estimated base-case
as well as minimum and maximum costs (provided in
parentheses) using appropriate ranges of personnel
salaries and call times. To assess intervention impact on
health services utilization, we used VA-specific codes in
administrative data to calculate primary care (exclusive
of GMVs) and emergency department usage rates and
hospitalizations that occurred between 1-13 months after
enrollment.
Population Studied: 239 patients receiving primary
care at the Durham, NC or Richmond, VA Veterans
Affairs Medical Center (VAMC) with poorly controlled
diabetes (A1c > 7.5%) and blood pressure (BP) (systolic
BP > 140 or diastolic BP > 90) were randomized within
VAMC to receive either GMVs or usual care.
Principal Findings: For patients in the GMV arm, BP
improved from 153 mmHg at baseline to 139 mmHg at
12 months; for patients in usual care, BP was 153
mmHg at baseline and 147 mmHg at 12 months (p=
0.01). GMVs did not have a differential effect on A1c
compared to usual care. GMVs averaged 1.5 hours of
physician time and 2 hours each of pharmacist and
nurse time. Clinicians also placed 175 follow-up calls to
the 133 intervention patients. We estimated that the cost
of each GMV was $504 ($445-$578); assuming 8
patients per group, the per-patient cost was $63 ($56$72). If patients attended all 7 GMV sessions, the annual
per-patient cost would be $441 ($389-$506); follow-up
calls cost an additional $19 ($4-48), bringing the annual
intervention cost per patient to $460 ($393-$554).
Patients in the intervention group had 0.9 fewer primary
care visits (5.3 vs. 6.2 per patient-year, 95% CI -1.5,-0.2,
p=0.01) and 0.44 fewer emergency care visits (0.9 vs.
1.3 visits per patient-year, 95% CI -0.70,-0.20,
p=0.0004). For inpatient stays, 23 GMV patients (17%)
had a total of 32 hospitalizations; 23 usual care patients
(22%) had a total of 39 hospitalizations (OR 0.8, 95% CI
0.4, 1.4).
Conclusions: GMVs reduced primary care and
emergency department visits and have the potential to
reduce hospitalizations. These reductions at least
partially offset the annual per patient cost of GMVs and
could be cost-saving.
Implications for Policy, Delivery or Practice: Given
their beneficial effect on BP, GMVs may be a costeffective means for caring for patients with poorly
controlled diabetes and hypertension.
Funding Source(s): VA
• The Effect of Health Coaching Services on
Changes in Health Care Utilization and Expenditures
for Medicaid Members with Chronic Diseases
Wen-Chieh Lin, Ph.D.; Georgianna Willis, Ph.D.; HungLun Chien, M.P.H.; Timothy Ferris, M.D.; Kate Staunton,
M.P.A.; Heather Bottella, M.P.A.
Presented by: Wen-Chieh Lin, Ph.D., Assistant
Professor, Center for Health Policy and Research,
University of Massachusetts Medical School, 333 South
Street, Shrewsbury, MA 01545; Phone: (508) 856-6162;
Email: wen.lin@umassmed.edu
Research Objective: To examine the effect of the
Connection Program, a telephonic health coaching
service, on health care utilization and expenditures for
Medicaid members aged 18 to 64 with an acute
hospitalization or emergency department (ED) visit and
one of ten selected chronic diseases.
Study Design: We used a quasi-experimental design to
examine changes in four outcomes among Connection
members (N=865) for one year before and after their
Connection enrollment compared with a comparison
group (N=865). Massachusetts Medicaid claims and
Connection Program data from November 1, 2003 to
December 31, 2007 were merged for analysis. The study
included all members eligible for the Connection
Program regardless of their participation or engagement
status. We identified the comparison group by exact
matching on major characteristics followed by matching
on propensity scores. The four outcomes were number
of acute hospitalizations, number of ED visits, number of
ambulatory care visits, and Medicaid expenditures. We
used difference-in-differences framework for the analysis
and examined different time segments, including annual,
semi-annual, and quarters. We applied the generalized
estimating equations to account for within-subject
correlations, used negative binomial regression to
examine utilization, and modeled the log-transformed
expenditures based on the normal distribution.
Population Studied: After matching, the two study
groups were similar on demographics, disease burden,
and health care utilization before enrollment. The
average age was 46, about two-thirds were female, and
the average number of chronic diseases was 3.3.
Principal Findings: Regardless of various time
segments examined, the Connection Program did not
demonstrate statistically significant effects. Using the
semi-annual example, differences in changes on ED
visits and ambulatory care visits between study groups
were minimal, only 2 to 3 %. Although the reduction of
acute hospitalizations (19%, p=0.15) and Medicaid
expenditures (10%, p=0.22) appears to be large
proportionally, the reduction was approximately 0.06
acute hospitalizations and $405 in Medicaid
expenditures per person during the last 6 months of the
one-year follow-up period.
Conclusions: We did not observe statistically significant
changes in health care utilization and expenditures. The
potential effect of behavioral changes might not yet fully
reflect on changes in the above outcomes during the first
year of enrollment. Although changes in acute
hospitalizations and Medicaid expenditures were in the
desired direction, further analysis is required to evaluate
the sustainability of the possible reduction in subsequent
years.
Implications for Policy, Delivery or Practice: Health
coaching strategies used by the Connection Program
are essential components for disease management
programs. Disease management continues to be a
popular approach to reduce cost and improve outcomes,
but more evidence based on scientifically rigorous
studies is needed to document its effectiveness.
Findings from this quasi-experimental design and
matched-pairs analysis add to our understanding of the
effectiveness of disease management programs. Instead
of expecting short-term savings, it may be more realistic
for public or private purchasers of these programs to
expect a relative small effect during the initial
implementation and to plan for a medium to long term
investment.
Funding Source(s): University of Massachusetts
Medical School
• Post-Surgical Health Care Expenditures and Weight
Change
Matthew Maciejewski, Ph.D.; Valerie Smith, M.S.; Maren
Olsen, Ph.D.; Edward Livingston, M.D.; Leila Kahwati,
M.D.; David Arterburn, M.D., M.P.H.
Presented by: Matthew Maciejewski, Ph.D., Core
Investigator, Center for Health Services Research in
Primary Care, Durham VA, 508 Fulton Street, Durham,
NC 27705; Phone: (919) 286-0411 ext. 5198; Email:
mlm34@duke.edu
Research Objective: The prevalence of severe obesity
(body mass index [BMI]>40 kg/m2) increased 50% in
2000-2005 and super obesity (BMI>50 kg/m2) increased
75%, resulting in an estimated $11 billion in direct U.S.
health care expenditures in 2000 and 82,066 deaths.
Bariatric surgery induces significant reductions in weight,
comorbidity and mortality, and has the potential to
reduce health care utilization. It is unknown whether
health care utilization and expenditures are reduced for
veterans after bariatric surgery. The purpose of this
study was to examine health care utilization and
expenditures of severely obese individuals before and
after bariatric surgery within the Veterans Health
Administration, and to examine whether post-surgical
expenditures vary by weight loss.
Study Design: A retrospective, longitudinal cohort
design.
Population Studied: The sample included 853 veterans
who received bariatric surgery at one of 12 VA bariatric
surgical centers in 2000-2006, based on National
Surgical Quality Improvement Program (NSQIP) data.
The VA outpatient, inpatient and total expenditure
outcomes were derived from VA Avenuerage Cost Data,
percentage of baseline weight lost (PBWL) at one year
was derived from the VA Corporate Data Warehouse,
and patient covariates were derived from NSQIP and VA
administrative claims data. Annual expenditures in the
three years before and after surgery were estimated
using generalized linear models, and adjusted for PBWL,
age, gender, race, marital status, copayment status,
baseline BMI, and Diagnostic Cost Group (DCG) risk
adjuster.
Principal Findings: The average age was 52, 74%
were male, 79% were Caucasian, and 55% were
married. The average DCG score was 0.64, 13% were
smokers, the mean initial BMI was 49.3, 40% were
taking medications for diabetes, and 42% were taking
lipid-lowering medications. Veterans in the upper tertile
of weight loss had a 40% decrease in baseline weight at
one year (on average), veterans in the lowest tertile had
a 21% decrease in baseline weight at one year, and the
middle tertile of veterans had a 31% decrease at one
year. In adjusted analyses, we found that outpatient
health care utilization and expenditures generally
decreased in the years after surgery, but the number
and cost of inpatient hospitalizations were significantly
increased. As a result, the total (inpatient plus
outpatient) expenditures trends did not decrease
significantly among veterans during the three years after
bariatric surgery compared to the three years before
surgery. Veterans with the greatest weight loss had
higher total expenditures (p=0.03) in the first year after
surgery due to higher admission rates compared to
veterans with the least weight loss, but lower total
expenditures in the second post-surgical year. Higher
one-year costs appear to be driven by post-surgical
complications associated with inpatient admission.
Conclusions: Older, male bariatric surgery patients do
not achieve a reduction in total expenditures three years
after bariatric surgery compared to the three years
before surgery. Variation in post-surgical expenditures
appears to be influenced by the proportion of baseline
weight that patients lose and subsequent complications
in the year after surgery.
Implications for Policy, Delivery or Practice: Variation
in post-surgical expenditures appears to be influenced
by the proportion of baseline weight that patients lose
and subsequent complications in the year after surgery.
Future studies should seek to clarify the relationship
between weight loss, complications, and health care
costs.
Funding Source(s): VA
• Changes in Chronic Condition Prevalence in the VA
Health Care System 2000-2008
Jean Yoon, Ph.D.; Jennifer Yang, M.S.; Todd Wagner,
Ph.D.; Ciaran Phibbs, Ph.D.
Presented by: Jean Yoon, Ph.D., Health Economist,
Health Economics Resource Center, Palo Alto VA, 795
Willow Road, Menlo Park, CA 94025; Phone: (650) 4935000; Email: jean.yoon@va.gov
Research Objective: Aging Vietnam-era veterans and
younger veterans seeking care for conflict-related
disabilities placed greater demand for care on the VA
health care system in recent years. To understand how
the needs of VA patients have changed over time, we
look at how the prevalence of chronic conditions
changed in the VA between 2000 and 2008.
Study Design: All VA inpatient, outpatient, and
pharmacy records were obtained for patients receiving
care from a VA provider in 2000 and 2008. VA files were
supplemented with records for patients who received
care from a contracted, non-VA provider in Fee Basis
files. Demographic information including age, gender,
and race/ethnicity, marital status, means test indicator,
and insurance status were obtained from outpatient
records. Major chronic conditions were identified by at
least two ICD-9 diagnosis codes for a chronic condition
in either inpatient or outpatient encounter records in
fiscal years 2000 and 2008. A 20% random sample for
each year was drawn for a total of 1,768,330 patients.
The prevalence rate for each condition was calculated
out of the total number of unique patients receiving any
care in the VA in each year. Age and sex-adjusted rates
were calculated based on a standardized population
using a combined, weighted sample of the original 2000
and 2008 samples to account for differences in age and
sex distribution in the two time periods. Separate,
multivariable models predicted the likelihood of having
each condition adjusting for patient demographics and
year in logisitic models.
Population Studied: Patients receiving care from a VA
provider in 2000 and 2008.
Principal Findings: While the number of patients within
all age categories increased between 2000 and 2008,
the most rapid growth in VA patients occurred among
those 76 years and older. A higher proportion of patients
had a 50% or higher service-connected disability in
2008, mostly due to recent veterans. Most chronic
conditions increased in prevalence, indicating a more
comorbid population of VA patients over time. The most
rapid growth in chronic conditions occurred for renal
failure from about 2% of all patients in 2000 to 5% of
patients in 2008 which represented a 177% increase in
rate. Tobacco/nicotine dependence (+139%), hepatitis C
(+124%), and PTSD (+92%) also increased much faster
than other conditions. These conditions as well as
depression, alcoholism, and drug abuse were
significantly related to younger age and greater service
connection. Older age and a positive time trend were
associated with higher likelihood of having conditions
such as diabetes, hypertension, renal failure, and
prostate cancer over time.
Conclusions: Between 2000 and 2008, the number of
older, Medicare-eligible veterans and younger veterans
with a high service-connected disability in the VA health
care system grew dramatically. Overall, patients were
more comorbid over time, due to both aging of older
veterans and a time trend in greater disease prevalence.
The growth of patients treated for mental health and
substance abuse problems was concentrated among
younger, service-connected veterans.
Implications for Policy, Delivery or Practice: The VA
must continue to adapt to the changing health care
needs of veterans such as demand for mental health
and substance abuse treatment for newer veterans and
chronic disease management for dual-eligible veterans.
Funding Source(s): VA
The Importance of Gender in Cost, Quality, and
Access
Chair: Chloe Bird
Sunday, June 27 * 11:00 am–12:30 pm
• Gender Differences in Inpatient Experience:
National Results from the HCAHPS Survey
Laura Giordano, R.N., M.B.A.; Marc Elliott, Ph.D.;
Elizabeth Goldstein, Ph.D.; William Lehrman, Ph.D.;
Katrin Hambarsoomian, M.S.
Presented by: Laura Giordano, R.N., M.B.A., Vice
President, Surveys, Research & Analysis, Health
Services Advisory Group, 1600 E. Northern Avenue,
Suite #100, Phoenix, AZ 85020; Phone: (602) 665-6158;
Email: LGiordano@hsag.com
Research Objective: To compare the experiences of
male and female inpatients as reported through the
HCAHPS Survey.
Study Design: Multivariate models compare six multiitem composites (communication with nurses,
communication with doctors, responsiveness of hospital
staff, pain management, communication about
medicines, and discharge information) and two standalone report items (cleanliness and quietness of the
hospital environment) by gender, controlling for patientmix (including service line) and survey mode. Additional
models were limited to surgical and medical service
lines, respectively. Outcomes were linearly rescaled to a
0-100 range.
Population Studied: The analysis includes 2,684 acute
and critical access hospitals (~ 55% of all eligible
hospitals), of which ~ 30% are located in rural areas;
86% have fewer than 400 beds, with 31% having fewer
than 100 beds; 68% are nonprofit, 15% government
controlled, and the remaining for-profit. The 942,705
patients included are 18 or older, with an inpatient stay
of one night or longer October 2006 through June 2007
in a medical (61%) or surgical (39%) service line.
Principal Findings: In contrast to generally inconsistent
patterns found in meta-analyses of gender differences in
satisfaction with medical care, we find consistently less
positive experiences for women than for men (p<0.001) ,
with female experiences significantly less positive than
male experiences for 7 of 8 measure (all but
communication with doctors). The largest differences
were for cleanliness (83.4 vs. 87.1), communication
about medicines (70.6 vs. 74.2), and discharge
information (76.7 vs. 80.0); differences for pain
management and quietness were very small (<0.5
points). Intermediate differences were seen for staff
responsiveness and communication with nurses. Gender
differences were comparable in magnitude to
racial/ethnic differences in HCAHPS scores. Similar
patterns were found within the medical and surgical
service lines.
Conclusions: Female inpatients reported consistently
less positive inpatient experiences with medical and
surgical care then men, especially with respect to
information needed for self-care after discharge
(communication about new medicines and discharge
information), which are among the HCAHPS measures
with the lowest overall scores.
Implications for Policy, Delivery or Practice: This
research suggests that targeting improvements in the
experiences of female patients has the potential to both
reduce disparities and improve overall hospital scores,
given that 62% of HCAHPS respondents (including the
maternity service line) are women. Efforts to improve
communication about new medicines and
communication of discharge information to female
patients are especially indicated and may improve posthospital outcomes and recovery.
Funding Source(s): CMS
• Gender Equity in Access to Community Care Using
Ambulatory Care Sensitive Conditions (ACSC) as a
Proxy
Carey Levinton, M.Sc.; Brenda Tipper, M.H.Sc.;
Adalsteinn Brown, Ph.D.; Sandie Orlando
Presented by: Carey Levinton, M.Sc., Health Policy,
Management and Evaluation, University of Toronto, 155
College Street, Toronto, M5T 3M6, CA; Phone: (416)
779-1510; Email: carey.levinton@utoronto.ca
Research Objective: Ambulatory Care Sensitive
Conditions (ACSC), comprising chronic conditions such
as angina, congestive heart failure, asthma, diabetes,
chronic obstructive pulmonary disease, and depression,
are considered a valid marker for access to timely and
appropriate primary/outpatient/community care. Men
typically have higher rates of hospital discharges for
ACSCs than women. Disparities in health outcomes and
access to services are commonly analyzed through
stratifying results of measures and analyzing the
differences across sub-groups. Our goal was to
determine differences in the degree of inequity between
men and women in access to community care using
ACSC rates as a proxy
Study Design: Retrospective analysis of Canadians
who participated in the Canadian Community Health
Survey (CCHS) between 2002 and 2005, linked to the
national Health Person Oriented Information database
(HPOI), a database capturing all admissions to acute
care hospitals. All results were population weighted. A
conceptual model of relationships between selected SES
and demographic characteristics and binary response to
hospitalization for an ACSC condition was developed.
Classification and regression tree (CART) analysis was
used to determine which of the characteristics were most
significant in segmenting the population group into
relatively homogeneous sub-groups based on the ACSC
rates. The results were used to plot a Lorenz curve of
cumulative percent of total population versus cumulative
percent of the population with an ACSC hospitalization.
Gini coefficients, ranging from 0 (perfect equity) to 1
(perfect inequity), of cumulative ACSC rates were
calculated comparing males and females for both
Eastern and Western Canada.
Population Studied: An eligible cohort of 2,818,537
men and women over the age of 15, who had previously
been admitted to a Canadian hospital between 2002 and
2005, with the target population being an individual
diagnosed with any of the ACSC conditions described
above.
Principal Findings: The percentage of males
hospitalized varied from 23.9% in Eastern Canada to
25.41% in Western Canada compared with 17.75% and
18.17% for women. The equity coefficient for males in
Eastern Canada was 0.375 (0.335, 0.419), nearly
identical to that in the West 0.375 (0.315, 0.417). Results
for females demonstrated no regional differences but
showed much greater inequity than results for males
with 0.525 (0.491,0.560) in Eastern Canada and 0.522
(0.490, 0.563) in the West. The difference in the equity
coefficient of approximately 0.15 between men and
women was significant at the 0.05 level. Factors such as
income, ethnicity, education, and community and social
integration are key contributors to this difference.
Conclusions: A coefficient of equity as a summary
measure of disparities in access to health services or
outcomes across population sub-groups has been
demonstrated to be a useful tool for understanding the
extent of inequity in community care for ACSC
conditions.
Implications for Policy, Delivery or Practice: A
summary measure along with the clinical and socioeconomic factors influencing the equity coefficient can
inform the development of policies and targets for health
system equity. The impact of strategies and policies can
be tracked from the perspective of equity to assess
whether improvement in equity through levers afforded
to policy-makers coincides with improvement on
measures of access or outcomes.
Funding Source(s): Canadian Institutes of Health
Research
• Prospective Association of Intimate Partner
Violence (IPV) with Receipt of Clinical Preventive
Services in Women of Reproductive Age
Jennifer McCall-Hosenfeld, M.D., M.Sc.; Cynthia
Chuang, M.D., M.Sc.; Carol Weisman, Ph.D.
Presented by: Jennifer McCall-Hosenfeld, M.D.,
M.Sc., Assistant Professor of Medicine and Public
Health Sciences, Medicine and Public Health Sciences,
Penn State Milton S. Hershey College of Medicine, 600
Centerview Drive, Mailcode: A210, Hershey, PA 17033;
Phone: (717) 531-8161; Email: jsm31@psu.edu
Research Objective: In its National Consensus
Guidelines on Identifying and Responding to Domestic
Violence Victimization in Health Care Settings (2004),
the Family Violence Prevention Fund recommends
safety planning for victims of IPV. In addition, IPV is
associated with increased risk for sexually transmitted
infections (STIs), unintended pregnancy, and substance
abuse. Thus, the need for preventive services is high
among survivors of IPV. However, IPV often goes
undetected in outpatient healthcare settings, and little is
known about whether IPV survivors receive appropriate
clinical preventive services including counseling and
screening. This study investigates whether exposure to
IPV predicts receipt of clinical preventive services
among women of reproductive age.
Study Design: The Central Pennsylvania Women's
Health Study is a longitudinal survey of a populationbased sample of women of reproductive age. Women
were interviewed in 2004-2005, and again two years
later. IPV was defined at baseline by an affirmative
response to any of eight items assessing physical and
sexual violence exposure in the past 12 months. We
defined eight clinical preventive services that women of
reproductive age might reasonably be expected to have
received in the two year interval between interviews,
including additional services appropriate for IPV
survivors. Services examined were counseling for safety
and violence concerns, tests for STIs including HIV,
counseling for STIs, counseling for smoking or tobacco
use, birth control counseling, counseling for alcohol or
drug use, pap testing, and blood pressure testing. We
assessed bivariate relationships between IPV exposure
and receipt of services, then developed multivariable
models to investigate the independent contribution of
IPV to receipt of each of the services. All multivariable
analyses employed logistic regression, controlling for
age, educational status, poverty, and continuous health
insurance coverage in the past 12 months.
Population Studied: We studied women ages 18-45
residing in a 28-county region of Central Pennsylvania (n
= 1,420). The baseline sample was representative of the
target population with regard to key demographics.
Principal Findings: The prevalence of IPV in the
baseline survey was 6%. In unadjusted models of the
preventive services examined, women with IPV were
more likely to have received and safety and violence
counseling (20% versus 10%, p=0.01), STI testing (51%
versus 23%, p<0.01), STI counseling (17% versus 10%,
p=0.05), smoking and tobacco counseling (49% versus
35%, p=0.02), with no differences noted in the remaining
services. In multivariable models, IPV retained
independent assocations with receipt of safety and
violence counseling (AOR 2.43, 95% CI 1.27, 4.65), and
STI testing (AOR=2.43, 95% CI 1.42, 4.17). Notably,
lack of continous health insurance was associated with
reduced odds of receiving several preventive services
including safety counseling (AOR 0.55, 95% CI 0.31,
0.97), receiving a pap smear (AOR 0.36, 95% CI 0.25,
0.52) and receiving a blood pressure check (AOR 0.41,
95% CI 0.24, 0.68).
Conclusions: In multivariable analysis, IPV at baseline
was associated with increased receipt of counseling for
violence and safety, which is consistent with an
appropriate healthcare response to IPV, as well as
increased STI testing, which is appropropriate based on
increased rates of STIs in this population. However, the
overall rates of provision of clinical preventive services is
alarmingly low among women exposed to IPV. Lack of
continous health insurance further reduces the odds of
receiving appropriate safety counseling and other
services.
Implications for Policy, Delivery or Practice: These
findings reinforce calls for better evidence and improved
guidelines for identification of and response to IPV in
outpatient healthcare settings. Further, they highlight the
importance of continuous health insurance coverage for
the provision of appropriate healthcare for this
vulnerable population.
Funding Source(s): This project is funded, in part,
under grant number 4100020717 with the Pennsylvania
Deparment of Health. The Department specifically
disclaims responsibility for any analyses, interpretations
or conclusions.
• Utilization of Healthcare Services among
Heterosexual and Lesbian Women Enrolled in The
ESTHER Project: Does Disclosure of Sexual
Orientation to Healthcare Providers Impact
Healthcare Utilization Among Lesbian Women?
Helen Smith, Ph.D., M.P.H., M.A.; Michael Marshal,
Ph.D.; Kevin Kraemer, M.D.; Nina Markovic, Ph.D.;
Michelle Danielson, Ph.D.
Presented by: Helen Smith, Ph.D., M.P.H., MA, Postdoctoral Fellow, Center for Research on Health Care,
Division of General Internal Medicine, University of
Pittsburgh, 230 McKee Place, Pittsburgh, PA 15213;
Phone: (412) 692-2650; Email: smithha@upmc.edu
Research Objective: Lesbian women have higher rates
of smoking and obesity that put them at greater risk for
developing health problems than heterosexual women;
however, lesbians have more barriers to healthcare
access. Our objective is to assess differences in
healthcare service utilization between heterosexual and
lesbian women. We aim to determine if disclosure of a
lesbian sexual orientation (being “out”) to healthcare
providers effects healthcare service utilization among
women. Study aims are to: (1) Determine the prevalence
of lesbians “out” to healthcare providers, (2) Assess
differences in healthcare service utilization among
heterosexual women, lesbian women who are “out” to all
of their providers, and lesbian women who are “out” to
some or none of their providers, and (3) Determine if
being out to healthcare providers is predictive of
healthcare service utilization after adjusting for
demographic (age, race, education, income) factors,
self-reported health status, and health insurance
coverage.
Study Design: Secondary data analysis was performed
on information collected through the ESTHER
(Epidemiologic Study of Health Risk in Women) Project.
Main outcome measures included: having a usual
healthcare provider, time since last routine checkup, use
of a mental health provider in the past 12 months, time
since last pap smear, and time since last clinical breast
exam. The main predictors were sexual orientation
(heterosexual vs. lesbian) and, among lesbians,
disclosure of sexual orientation to healthcare providers
(“out” to all vs. “out” to none or some). Multivariate
logistic regression analyses were performed to
determine the relationship between disclosure of sexual
orientation and healthcare service utilization.
Population Studied: Cross-sectional sample of lesbian
(N=479) and heterosexual (N=400) women ages 35 to
64 who participated in the ESTHER Project (Pittsburgh,
PA, 2003-2006).
Principal Findings: When compared to heterosexuals,
lesbians were more likely to have seen a mental
healthcare provider in the past 12 months (Adjusted
Odds Ratio [AOR 2.2], 95%CI [1.6, 2.9]), but were less
likely to have had a pap smear within the past two years
(AOR 0.50, 95%CI [0.34, 0.76]). When stratified by
sexual orientation and disclosure of sexual orientation,
“out” lesbians were more likely to report having a usual
healthcare provider than heterosexuals (AOR 2.1,
95%CI [1.3, 3.4]). Approximately 56.2% (N=262) of
lesbians reported they were “out” to all of their
healthcare providers. Among lesbians only, those who
were “out” to all of their healthcare providers were more
likely to have a usual healthcare provider (AOR 2.4,
95%CI [1.4, 4.1]) than those who were “out” to some or
none of their healthcare providers. Sexual orientation
and being “out” to a healthcare provider were not
significantly associated with time since last routine
checkup and clinical breast exam.
Conclusions: Lesbian disparities in healthcare
utilization exist, and may differ by disclosure of sexual
orientation to healthcare professionals.
Implications for Policy, Delivery or Practice: Results
suggest that service providers and patients would benefit
from intervention programs designed to increase
awareness of disclosing sexual orientation to healthcare
providers, and how being “out” impacts healthcare
utilization and practice. Results also suggest a need for
outreach programs focused on mental health concerns
and the importance of yearly gynecological screening
within lesbian populations.
Funding Source(s): The ESTHER Project was funded
by the National Heart Lung & Blood Institute (NLHBI):
CVD Risk Factors and Sexual Identity in Women
(5R01HL067052 I).
• Gender Differences in the Burden of Out-of-Pocket
Health Care Expenditures
Amy Taylor, Ph.D.; Lan Liang, Ph.D.
Presented by: Amy Taylor, Ph.D., Senior Economist,
CFACT, AHRQ, 540 Gaither Road, Rockville, MD
20850; Phone: (301) 427-1660; Email:
ataylor@ahrq.gov
Research Objective: It has been well documented that
women use more health care and have higher medical
expenditures than men throughout much of the life cycle.
Women are also more likely to spend more than 10% of
their income out of pocket for medical care than men in
all age groups. This difference is particularly pronounced
for those older than age 65. This analysis will examine
the factors that influence out-of-pocket spending for
women and men, and that account for the high burden of
medical care for women.
Study Design: We use the most recent Medical
Expenditure Panel Survey to document the relative
burden of health care borne by men and women,
including proportions of those who spend more than
10% their income out of pocket for health care for
various age groups. Multivariate analyses will then be
conducted to examine what factors predict whether an
individual has a high burden of health care relative to
income. Based on the parameter estimates and
distribution of individual characteristics, we will perform
decomposition techniques to analyze the relative
contributions of factors such as education, marital status,
race and ethnicity, income, health insurance, health
status, risky behaviors and obesity, to the gender
differences in the burden of out-of-pocket health care
expenditures.
Population Studied: A nationally representative sample
of non-institutionalized women and men, age 18 and
over, in the MEPS-Household survey, 2007. Men and
women in 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.
Principal Findings: Data show that more than 17% of
women age 65 or older spent 10 percent of more of their
income out-of-pocket for medical care in 2006,
compared to only 8% by similar age men. While high
burden men and women had comparable levels of total
out-of-pocket spending, a larger fraction of that was
spent on inpatient hospital care for men than for women.
A very high percent of women with high burdens were
widows, while the largest percent of high burden men
were married. High burden women are more likely to
have three or more chronic conditions than men with
high burdens.
Conclusions: The burden of out-of-pocket spending
falls more heavily on women than men. This is
particularly true for the older age groups. This, in part,
was due to the fact that women had lower incomes than
men. However, even controlling for income differences,
women were still more likely than men to spend more
than 10 percent of their incomes out-of-pocket.
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
The Interdisciplinary Health Workforce: Needs, Work
Environments, and Supply
Chair: Robyn Cheung
Sunday, June 27 * 4:15 pm–5:45 pm
• Medical Assistants in Community Clinics: An
Evolving Role
Susan Chapman, Ph.D., R.N.
Presented by: Susan Chapman, Ph.D., R.N.,
Associate Professor, School of Nursing, Department of
Social & Behavioral Sciences, UCSF, 3333 California
Street, Suite 455, San Francisco, CA 94118; Phone:
(415) 502-4419; Email: schapman@thecenter.ucsf.edu
Research Objective: This project aimed to investigate
the emerging role of Medical Assistants (MAs) in
community clinics from the perspective of clinic
managers, medical directors, and representative MAs.
MAs have become the most frequent non-physician
worker in community clinics while RN and LVN use has
decreased. Our goal was to describe MA roles that clinic
staff identified as innovative and discuss commonalities
or differences across clinics as well as differences in the
perspectives of clinic staff and providers. Policy options
that may enhance the education and utilization of
medical office assistants in community clinics were
explored.
Study Design: Community clinics in California were
identified by consultants, foundation representatives, a
statewide community clinic association, and by selfnomination, as having developed “innovative” roles for
medical assistants in their organization. Project staff
selected 10 clinics from the list with an attempt to
represent various geographic regions and rural and
urban settings in the state. Thirty (30) key informants
were contacted; 27 agreed to participate. Semistructured, 45 minute, telephone interviews were
conducted by 2-3 project staff. Interview notes were
compiled, summarized and categorized by project staff
to identify key themes.
Population Studied: Clinic managers, medical
directors, and MAs from 10 representative community
clinics in California.
Principal Findings: Medical assistants represent a
large component of the healthcare workforce in
community clinics. OSHPD data indicate nearly 80% of
clinics use MAs; 50% report using RNs. Managers and
medical directors agreed that MAs are essential to clinic
operations, “they make or break the provider’s day.”
Most noted a lack of adequate MA skills and training for
new roles with most clinics needing to provide up to a
month of additional training/orientation after hire. The
main role of MAs in clinics is to facilitate the patient visit
and assist providers. Expanded roles varied across
clinic; examples included immunization coordinator,
health educator, chronic disease manager using
standard protocols, diabetes manager, referral
coordinator, and women’s health specialist. MA wages
ranged from $9-$12/hour up to $16-$20/hour for
expanded roles. MA career options include supervision
of MAs, lead MA, or preparing for other health
professions such as nursing or medicine. MAs stated
they were generally satisfied with expanded roles but
agreed that additional preparation and training are
needed. Workflow redesign is required to allow MAs to
take on these added responsibilities.
Conclusions: MAs are a critical component of the team
model of care in clinics yet underprepared for their role
in disease management and patient education. While
continuing to practice under a limited scope of practice,
MA functions have expanded to include a variety of roles
in patient education and disease management. MAs are
important member of the clinic care team care yet often
receive inadequate preparation in training programs and
are often poorly compensated and recognized for their
contribution.
Implications for Policy, Delivery or Practice: Potential
need to increase legal scope of practice for MAs and
standardize training certification requirements. Further
research of changing models of care in community
clinics.
• The Effect of the Supply of Dentists and Dental
Hygienists Per Capita on Oral Health Preventive
Care Utilization and Outcomes
Tracey Continelli, A.B.D.
Presented by: Tracey Continelli, A.B.D., Research
Associate, Public Health, Center for Health Workforce
Studies, 1 University Place, Room 220, Rensselaer, NY
12144; Phone: (518) 402-0250; Email:
tac02@health.state.ny.us
Research Objective: A comprehensive review of the
literature indicates that most oral health research studies
have analyzed data from large national surveys, such as
Medical Expenditure Panel Survey (MEPS), National
Health and Nutrition Examination Survey (NHAMES), the
National Health Interview Survey (NHIS), Consumer
Expenditure Survey (CES), or the Survey of Income and
Program Participation (SIPP). These studies have either
analyzed national trends for select dental variables over
time, or else have investigated individual-level sociodemographic predictors of oral health outcomes in the
overall population. However, none of these data files
contains geographical identifiers below the regional level
(North, South, Midwest, West). Furthermore, the lack of
available oral health workforce data has impeded the
inclusion of such variables in previous research studies.
As a result, hardly any studies have examined oral
health outcomes at more local levels of analysis, and
very few studies have incorporated oral health workforce
variables within their analyses of oral health outcomes in
the population. This research seeks to go beyond
previous studies by examining the effect of the oral
health workforce supply on oral health outcomes among
smaller geographical units of analysis across the U.S.
Study Design: The current study utilizes two separate
Centers for Disease Control datasets entitled Selected
Metropolitan/Micropolitan Area Risk Trends (SMART),
one MMSA-level and one county-level, from the 2006
Behavioral Risk Factor Surveillance System (BRFSS).
These SMART datasets are both documented and
verified subsets of the 2006 BRFSS with a sufficiently
large number of cases that have also been weighted to
produce valid, representative local area estimates. A
total of 120 MMSAs and 223 counties were used for two
separate local area analyses. The number of active
dentists by county of practice was purchased from the
American Dental Association. In addition, geographical
data on currently licensed dental hygienists (at the zip
code level) was gathered from individual state license
files that were complied, culled for duplications and
outdated licenses and then matched to their respective
county or MMSA. Linear regression and path analyses
were conducted utilizing, as independent variables, both
the standard socio-demographic variables as well as the
supply of dentists and dental hygienists per capita in
order to predict two separate oral health outcomes; the
percent of adults who recently (within the past 12
months) had their teeth cleaned, and the percent who
haven’t had any teeth removed due to decay or disease.
Population Studied: Telephone survey data of a
stratified random sample of adults 18 years or older
across the U.S. was analyzed.
Principal Findings: Controlling for all other factors, the
results indicate the significant positive effect of the
dentist rate on the percent who had no teeth removed
due to decay/disease, and the significant positive effect
of the dental hygienist rate on both recent teeth cleaning
and having no teeth removed due to decay/disease.
Conclusions: These findings underscore the
importance of incorporating oral health workforce
indicators in future oral health research.
Implications for Policy, Delivery or Practice: The
results provide a basis for calculating the number of
dentists and dental hygienists necessary to achieve
favorable oral health preventive service utilization rates
and oral health outcomes.
• Estimating the Need for States' Primary Care
Workforce: Challenging Pre-Reform Assumptions
Pamela Hanes, Ph.D., M.S.W.; Christine DemontHeinrich, M.S.P.H.
Presented by: Pamela Hanes, Ph.D., M.S.W.,
President and CEO, Colorado Health Institute, 303 E.
17th Avenue, Suite 930, Denver, CO 80203; Phone:
(303) 831-4200; Email:
hanesp@coloradohealthinstitute.org
Research Objective: The Colorado Health Professions
Workforce Policy Collaborative, a statewide
multidisciplinary body funded by The Colorado Trust to
inform and educate policymakers about Colorado's
primary care shortages, asked the Colorado Health
Institute (CHI) to conduct a primary care workforce
supply/demand study to forecast primary care workforce
needs in the wake of national health insurance reform.
Study Design: Using 2005 health professions licensure
data as baseline and HRSA-developed supply-demand
modeling methods, CHI forecasted Colorado's primary
care workforce (physicians, advance practice nurses and
physician assistants) needs through 2020. Status quo
assumptions embedded in the HRSA model were found
to be significantly limiting when projecting primary care
needs for a population with expanded insurance
coverage or assuming alternative models of primary care
involving interdisciplinary teams. Therefore, CHI
employed a number of alternative scenarios including a
fully covered population and expanded utilization of
alternative primary care providers to adjust its
projections.
Population Studied: Using health professions licensure
data from the Colorado Department of Regulatory
Agencies and the AMA Master File, CHI built primary
care models to include all active physicians (N=12,923),
advance practice nurses (N=1,162) and physician
assistants (N=632) licensed to practice in Colorado in
2005.
Principal Findings: The supply-demand curves for
primary care providers were influenced by changing the
assumptions built into the models. Primary care
physician shortages projected for 2020 were reduced by
nearly 500 by increasing the utilization of advance
practice nurses and PAs as primary care providers.
Further, because of the aging of Colorado's physician
workforce, the physician shortage could be reduced by a
similar amount if physicians delayed their retirement by 5
years. We also found that shortages were sensitive to
geography, with some areas of the state experiencing
significantly greater projected shortages than others.
Conclusions: Estimates of supply and demand that are
sensitive to population demographics and a changing
health policy environment confirmed that straight line
estimates were not sufficiently sensitive to be useful for
state workforce planning. In an era when states and the
federal government are making substantial investments
in expanding health care coverage, old models that
assume primary care needs are filled largely by
physicians may be antiquated and limiting. Collaborative
models of care which optimize the competencies of team
members where professionals working together can
address the physical, mental, behavioral and oral health
care needs of individuals and families produce superior
outcomes to traditional models of care. With ACOs being
looked to as a policy solution to bend the cost curve and
produce more appropriate health care delivery,
collaborative models of care hold much policy appeal.
Implications for Policy, Delivery or Practice: The
findings were both provocative and timely as states and
the federal government reform how health care is
financed and delivered. As the time honored policy goals
of access, quality and cost continue to be jointly pursued
with new technological tools and new assumptions,
sensitivity to the complex needs that present in primary
care settings is needed. This study has demonstrated
that challenging status quo assumptions in supplydemand modeling is needed if workforce planning is to
be relevant in an era of health reform.
Funding Source(s): Colorado Foundation
• Children’s Mental Health Workforce In
Massachusetts: Defining Workforce Capacity in a
Complex Healthcare System
Karen Linkins, Ph.D.; Wendy Holt, M.P.P.; Jessica
Boehm, M.P.P.; Richard Dougherty, Ph.D.; Alison
Oelschlaeger, B.A.
Presented by: Wendy Holt, M.P.P., Principal, DMA
Health Strategies, 9 Meriam Street, Suite 4, Lexington,
MA 02420; Phone: (781) 863-8003; Email:
wendyh@dmahealth.com
Research Objective: In comparison to most other
states, Massachusetts has high rates of mental health
professionals per thousand population and high
outpatient mental health utilization rates in Medicaid and
private HMOs. However, there is a widespread
perception of significant shortages in the Massachusetts
children’s mental health workforce. The court-ordered
implementation of a statewide system of care for
children on Medicaid (Rosie D. v. Romney) has created
additional demand. In this context, the Blue Cross Blue
Shield of Massachusetts Foundation commissioned the
Lewin Group and DMA Health Strategies to survey
licensed mental health practitioners in the state to
describe current children’s mental health workforce
capacity and analyze how well it matches the mental
health needs of children and families. Prior mental health
workforce studies have not addressed capacity to serve
children.
Study Design: The study included estimation of need
across the state based on prevalence and utilization
rates, and a mail and web survey of licensed mental
health professionals. A survey tailored for prescribing
providers (Psychiatrists and Clinical Nurse Specialists)
was sent to the entire universe. A survey tailored to nonprescribers (Psychologists, Mental Health Counselors,
Marriage and Family Therapists, and Social Workers)
was sent to a random sample, adjusted by provider
presence in six regions. Key stakeholder interviews
informed the project.
Population Studied: The survey universe was drawn
from licensing board records, which do not identify child
providers. Child serving providers were defined as those
who reported serving a case load of at least 10%
children and adolescents (ages 0-21). Of the 1,982
survey respondents, 735 (37%) met this threshold.
Principal Findings: In contrast to perceptions of limited
access, many child providers reported one or more
openings in their practices most of the time. However,
the survey found that 37% to 51% of professionals do
not participate on any public insurance panels, and 10%
to 17% of prescribers do not participate on any panels.
Administrative burden, lack of compensation for
necessary collateral work, and low rates of payment
were identified as disincentives for participating on
insurance panels. Most significantly, more than half
(54%) of children’s mental health providers reported that
they plan to leave the state or leave direct care in the
next five years and the predicted entry of new licensees
fall far short of the anticipated loss.
Conclusions: Defining workforce capacity in a complex
system is challenging. It is difficult to develop
geographically specific need estimates that appropriately
account for poverty, race and ethnicity. Ability to access
providers usually depends on their participation in a wide
variety of different health plans, and many do not
participate in public health plans where higher need
children are clustered.
Implications for Policy, Delivery or Practice: Creating
a mental health workforce for children and families that
can adequately meet the need for accessible, high
quality services requires addressing reimbursement and
administrative issues by public and commercial health
plans, collecting additional data during the licensing
process, developing consistent and valid approaches to
tracking mental health access, strengthening the training
and internship system, and making real-time information
on provider availability available to families and referral
sources.
Funding Source(s): Blue Cross Blue Shield of
Massachusetts Foundation
• Employee Gender, Generation, and Experience:
Relationship to Workplace Climate Perceptions
Katerine Osatuke, Ph.D.; Scott Moore, Ph.D.; Jonathan
Fishman, M.A.; Jill Draime, Psy.D.; Sue Dyrenforth,
Ph.D.
Presented by: Katerine Osatuke, Ph.D., Health
Scientist, NCOD, Veterans Health Administration, 11500
Northlake Drive, Suite 230, Cincinnati, OH 45249;
Phone: (513) 247-2255; Email:
Katerine.Osatuke@va.gov
Research Objective: As Veterans Health Administration
(VHA) strives to account for changing workforce
demographics in workforce development planning,
employee generational and gender differences became
a focus of attention. We used qualitative interview data
and quantitative survey data to explore relative
importance of differences in birth generations and
organizational tenure groups, while accounting for
gender.
Study Design: Studying generational differences
involves two strategies. One is age-based, and
examines the implications of birth generation on
workplace perceptions; another is stage-based, and
examines how length of experience on the job shapes
workplace perceptions. This study contrasted both
strategies. Qualitative workplace assessments from 90
workgroups at 57 VHA facilities include interviewees’
descriptions of strengths, weaknesses, and desired
changes in their organizations. These data were
analyzed using grounded theory methods; themes of
generations and experience were summarized.
Quantitative data from the VHA annual voluntary All
Employee Survey include workplace climate ratings.
Three dimensions identified by previous research are of
particular interest to this study: Civility, Leadership, and
Customer Focus. Using univariate ANOVAs, we
examined differences in these dimensions among
respondents whose birth year defined them of baby
boomers, X generation, and Millennials, while
distinguishing between respondents who worked more
than, or less than 2 years at their current workplace. The
groups were randomly selected from the subsets of all
respondents with demographics of interest. Analyses
were conducted separately for two genders
Population Studied: Veterans Healthcare
Administration employees
Principal Findings: Qualitative data suggested that
employees’ experience at the specific workplace was
salient, and generational differences were not salient for
respondents. In quantitative data, both for men and
women samples, main effects of generation and
experience at the current workplace were significant on
all the three examined dimensions. Main effects of
experience were stronger than main effects of
generation. All main effects were stronger (F values
twice as large) for men than they were for women. For
the subsample with less than two years of experience at
the current workplace, both generation and gender had
significant main effects only for Civility; the main effect of
gender was stronger than the main effect of generation.
No main effects were significant for Leadership and for
Customer Focus. For the subsample with more than two
years of experience at the current workplace, both
generation and gender had significant main effects of
comparable strength on all three dimensions
Conclusions: Employees’ organizational age (being a
new versus old employee in a particular workplace) had
stronger effects on climate perceptions than employee
birth age. Both of these factors had stronger impact for
male versus female employees, in regards to their
perceptions of civility, leadeership, and customer focus
at their workplace. Further studies are needed to
systematically assess the effects of such differences on
employees’ workplace needs (e.g. supervisory support)
and related outcomes (e.g. job satisfaction, work quality,
productivity).
Implications for Policy, Delivery or Practice: The
findings redefine the importance and possibly the
meaning of generational differences at the workplace,
suggesting a greater emphasis on employees’
experience within organization rather than on their
generational differences. This focus would directly
impact decisions about workforce development and
succession planning within Veterans Healthcare
Funding Source(s): VA
The Role of Information Exchanges and
Interoperability in the Diffusion of Health Information
Technology
Chair: Lucy Savitz
Sunday, June 27 * 4:15 pm–5:45 pm
• Regional Health Information Organizations: A
Progress Update
Julia Adler-Milstein; Ashish Jha, M.D., M.P.H.
Presented by: Julia Adler-Milstein, Doctoral
Candidate, Health Policy, Harvard University, 176
Upland Road #3, Cambridge, MA 02140; Email:
jadlermilstein@hbs.edu
Research Objective: The American Recovery and
Reinvestment Act delineates health information
exchange (HIE) as a critical component of health IT
adoption. Policymakers’ primary approach is through
support of Regional Health Information Organizations
(RHIOs). Given that there are no nationally
representative data on RHIO activity or sustainability
since the passage of ARRA, we conducted our third
survey of all existing RHIO efforts to inform policymakers
on the most successful approach to nationwide health
information exchange.
Study Design: We relied on multiple sources to create a
comprehensive list of 231 entities that potentially
engaged in HIE. We implemented a web-based survey
between December 2009 and January 2010 that asked
RHIOs to report on development stage, organization
demographics, types of data exchanged, funding
sources, and barriers to development.
Population Studied: All entities engaged in facilitating
clinical data exchange between independent entities
during the time period of 6/1/08 and 12/1/09. We defined
facilitation as providing a technical infrastructure to
support clinical data exchange.
Principal Findings: Twenty-four respondents did not
meet our definition of a RHIO. Among the remaining 107
respondents, 59 (55%) were operational (actively
exchanging clinical data), 43 (40%) were in the planning
stage, and 5 had pursued clinical data exchange in the
past but were no longer pursuing it. Among operational
RHIOs, test results were the most commonly exchanged
type of data (85% of RHIOs), followed by outpatient and
inpatient demographics (71% and 64% respectively). Six
percent of planning RHIOs and 36% of operational
RHIOs reported that they were able to cover operating
costs with revenue from entities participating in data
exchange (our definition of financial sustainability).
Among those not yet financially sustainable, operational
RHIOs expressed greater pessimism: while 36% of
planning RHIOs reported that they were unlikely to
eventually cover operating costs with revenue from
participating entities, 46% of operational RHIOs did not
expect to ever do so. Both planning and operational
RHIOs reported government grants as their most
substantial form of support. Both groups were also most
likely to cite lack of funding as substantial barrier to
development (53% and 34% respectively). Most
planning RHIOs (84%) felt that ARRA would improve
their financial position while a much smaller subset of
operational RHIOs (38%) thought so.
Conclusions: We found almost 60 currently operational
RHIOs and have early evidence of declining failure rates
compared to our prior work. However, major challenges
persist: Most operational RHIOs remain focused on
exchanging only a subset of clinical data (i.e., laboratory
results); relatively few RHIOs have financially
sustainable models; and therefore, many RHIOs remain
heavily dependent on grant funding.
Implications for Policy, Delivery or Practice: The
current approach to spur growth in the number of RHIOs
appears to be working, bolstered by grant funding and
other federal efforts. However, the small number of
financially sustainable RHIOs suggests that government
involvement may be necessary for an extended period of
time. Without data that RHIOs are having an impact on
costs and quality of care in their community, greater
participation and funding by other stakeholders, such as
payers, is unlikely.
Funding Source(s): Office of the National Coordinator
for HIT
• Trends in Utilization of Preventive Services in
Medically Under-Served Communities among Small
Urban Practices that have Recently Adopted Health
IT
Samantha De Leon, Ph.D.; Sarah Shih, M.P.H.
Presented by: Samantha De Leon, Ph.D., City
Research Scientist, 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: Assess whether implementation of
a fully integrated Electronic Health Record (EHR) can
increase the delivery of recommended preventive
services. Identify if practice management data acts as a
proxy for tracking increases in preventive services.
Study Design: Aggregated patient de-identified
ambulatory services data were used to tabulate
preventive health service utilization categories based on
selected Healthcare Effectiveness Data and Information
Set (HEDIS) measures. Monthly patient service
utilization data was modeled for individual practices as a
growth curve, with adjustments for autocorrelation
between observations. Among practices adopting the
city-subsidized EHR, the data are automatically
aggregated and transmitted by the EHR.
Population Studied: Small practices that have adopted
an EHR and have successfully transmitted aggregated
practice data to New York City for at least 9 months. For
this abstract, 60 practices met the inclusion criteria of
having a minimum of 9 months of data. An additional
101 practices will become eligible for the analyses by the
second quarter of 2010. Of the 60 eligible practices, 63%
have a single provider and 20% have 2 providers; 62%
are staffed with 1 Full Time Equivalent provider (FTE)
and 28% have 1-2 FTE. From self-reported data, 72% of
practices identify themselves as providing services in
Primary Care; 88% of the providers identify their
specialties as Family Medicine, Internal Medicine or
Pediatrics, and average number of encounters per year
is about 6,000.
Principal Findings: The frequency of preventive
procedure codes was low for many of the practices, with
many of the selected measures (ranging from 0-5
procedures per month). Increases per month were
observed for preventive service utilization categories
with greater than 20 counts per month. Longitudinal
trends were higher but not statistically significant for
childhood immunizations, with a 2.33% increase per
month (p-value=0.06). A 1.66% increase per month was
observed for Chlamydia screening (p-value = 0.59);
Influenza vaccinations (0.47% [p-value= 0.83]); and
Pneumoccocal vaccinations (1.72% [p-value= 0.21]).
Only flu season months were considered for influenza
vaccinations.
Conclusions: All observed trends were in a positive
direction. With the exception of childhood immunizations,
no strong positive trends in preventive service utilization
were observed in the first 9 months after adoption of a
prevention-focused EHR. Additional analyses are being
conducted to determine if there are variations in
preventive service utilization by practice characteristics
such as practice type (solo provider versus multiprovider practice); specialty; FTE status; intermediate
quality of care measures (e.g. control of blood pressure
for patients with hypertension) and use of specific EHR
functions (e.g. clinical decision support).
Implications for Policy, Delivery or Practice:
Implementation of health information technology in small
practices has the potential to improve patient quality of
care as well as track the use and receipt of
recommended preventive services.
• Patient Consent and Preferences Related to Health
Information Exchange
Vaishali Patel, Ph.D., M.P.H.; Alison Edwards, M.S.;
Rina Dhopeshwarkar, M.P.H.; Ranjit Singh, M.D., M.A.,
M.B.A.; Lisa Kern, M.D., M.P.H.; Rainu Kaushal, M.D.,
M.P.H.
Presented by: Vaishali Patel, Ph.D. M.P.H., Assistant
Professor, Division of Quality and Medical Informatics,
Weill Cornell Medical College, 402 E. 67th Street, New
York, NY 08820; Phone: (646) 962-8069; Email:
vpatel@aya.yale.edu
Research Objective: In order to improve quality of care
and reduce costs, the federal government is making
unprecedented investments to develop infrastructure
and encourage the use of electronic health records
(EHRs) that can support health information exchange
(HIE), the electronic flow of information across
organizations. New York State has distributed
substantial funds to support community-wide HIE.
However, if consumers do not consent to have their
information widely shared and viewed via HIE, potential
benefits will not be realized. Understanding consumers’
attitudes towards HIE can help shape policies and
technology to reflect their preferences. We sought to
characterize consumers’ attitudes towards HIE in a
community participating in New York State’s initiative.
Study Design: We conducted a cross-sectional study
that consisted of a random digit-dial telephone survey in
February, 2009. The survey domains included:
demographic and health characteristics; Internet use;
attitudes towards HIE and consent; and preferences
regarding privacy and security of HIE.
Population Studied: The respondents were adult,
English-speaking residents in the greater Buffalo region
of New York.
Principal Findings: We obtained a 79% (n=200)
response rate. The age distribution varied, with about
32% under the age of 44 and over a quarter older than
65 years old. Half of respondents were female, 97%
were white, and 76% had some college education. Over
85% (n=169) would be willing to sign a patient consent
form to allow electronic sharing of their health data
between physicians. Most consumers expressed support
for physicians’ electronically viewing and sharing their
medical data, including viewing their records from other
physicians and institutions (86%) and electronically
sending medical records to other sites where they
receive care (87%). A large proportion believed that HIE
would greatly or slightly improve communication among
their doctors (88%) and the overall quality of medical
care (77%). Most consumers considered it important to
have safeguards to: limit unauthorized viewing (92%);
have the ability to see who has viewed their data (92%);
and select which healthcare providers can view their
data (89%). Multivariate analyses found that consumers’
willingness to consent to HIE was independently
associated with beliefs regarding HIE’s ability to improve
the quality of their care (O.R. 5.01; 95% CI 1.54 –16.27)
or communication with their doctor (OR 3.21; 95% CI
1.05 –9.84), and whether they thought their physician
had an EHR (OR 12.93; 95% CI 2.83 –59.05).
Conclusions: Consumers largely support their
physicians’ use of HIE and are largely willing to consent
to HIE although they also considered it important to have
safeguards in place to protect their health information.
Consumers whose providers have adopted EHRs or
those that believe that HIE will lead to improved quality
and coordination of care were more likely to consent to
HIE.
Implications for Policy, Delivery or Practice: These
findings suggest that regulations regarding HIE consent
should include safeguards that give consumers greater
control and transparency over the exchange and viewing
of their data. Although consumers reported high levels of
willingness to consent, consumer outreach campaigns
that explain the potential benefits of HIE may be
necessary to achieve close to universal patient
participation in HIE.
Funding Source(s): HEALTHeLINK RHIO
• Enabling a Successful State Electronic Health
Information Exchange Program: Lessons for State
Policymakers from the Health Information Security
and Privacy Collaboration
Stephanie Rizk, M.S.; Alison Banger, M.P.H.; Linda
Dimitropoulos, Ph.D.
Presented by: Stephanie Rizk, M.S., Health Services
Researcher, Survey Research Division, RTI
International, 230 W Monroe, Suite 2100, Chicago, IL
60615; Phone: (312) 456-5276; Email: srizk@rti.org
Research Objective: Here we review lessons learned
from the Health Information Security and Privacy
Collaboration (HISPC), a 4-year, 42-state project,
highlighting the areas that promised the most substantial
returns from coordinated, multi-state efforts to move
forward health information exchange (HIE) initiatives.
We will outline the potential of these activities as
indicated by the outcomes achieved under the project,
and provide suggestions for specific areas in which
continued support from state and local policymakers
may have the most impact for achieving the goal of
nationwide interoperable health information exchange.
Study Design: Between 2005 and 2009, the Office of
the National Coordinator* for Health IT funded the Health
Information Security and Privacy Collaboration. The
purpose of this project was to capture the variation in
business practices, policies, and laws currently
governing HIE in order to gain a better understanding of
the privacy and security challenges to interoperable
exchange. Between 2005 and 2007 the project was
jointly funded by the Agency for Healthcare Research
and Quality and was referred to as the Privacy and
Security Solutions for Interoperable Health Information
Exchange project.
Population Studied: The project undertook a largescale community-based participatory design in which
states collected information from local organizations
about the issues that prohibited exchange of health
information and worked with those same stakeholders to
develop solutions. This process sought to engage and
educate stakeholders within their states and build longterm coalitions committed to implementing consensusbased solutions. Through the synthesis and analysis of
information provided by the state teams, a number of
cross-cutting challenges were identified including:
consumer engagement, provider education, consent
policy and management, establishing interorganizational
agreements, harmonizing privacy law and developing
standard policies. During the final phase of the project, a
total of 42 states and territories joined together in multistate collaborative workgroups to develop common,
replicable solutions to these problems.
Principal Findings: Project participants collected
hundreds of policies, practices and state laws that
present challenges to interoperable HIE. In the process
of creating individual solutions to these problems, a
discourse developed across states and patterns
emerged that supported the potential benefits of creating
shared solutions.
Conclusions: At the conclusion of the project, perhaps
the most powerful outcome was the development
foundational set of processes and tools which could be
used for executing solutions at the state and local level
across the nation.
Implications for Policy, Delivery or Practice: Building
on the groundwork laid by the participants of this project,
we recommend specific solutions for policy makers that;
a) allocate resources to both education and engagement
of consumers and health care providers, b) improve the
transparency of the process behind health information
exchange, and c) solidify political support and
governance for ongoing decision making as the area
evolves and changes over time.
Funding Source(s): Office of the National Coordinator
and AHRQ
• Evaluating the Outcomes of the New York Home
Health Interoperability Program
Peri Rosenfeld, Ph.D.; Caroline Kim, M.P.H.; Robert
Rosati, Ph.D.
Presented by: Peri Rosenfeld, Ph.D., Senior
Evaluation Scientist, Center for Home Care Policy &
Research, Visiting Nurse Service of New York, 1250
Broadway - 20 Floor, New York, NY 10001; Phone:
(212) 609-5763; Email: peri.rosenfeld@vnsny.org
Research Objective: As part of HEAL-NY, one large
non-profit home care agency launched NYCHHIP (New
York Community Home Health Interoperability Program)
to increase and improve communication of clinical and
business data between home care nurses and referring
physician practices. Five specific components comprised
the program: electronic lab results, e-referrals, e-plan of
care, e-messaging and development of a patient portal.
Evaluation plans, including formative and summative
measures, were developed to assess whether the
proposed objectives were met.
Study Design: Using qualitative and quantitative
methods, this descriptive, longitudinal study monitored
the progress and outcomes of the specific components
from baseline to completion of the two year study period.
Data sources included surveys of physician comfort
levels and utilization of electronic communications;
monitoring administrative data on the number and quality
of electronic communications over of time; surveys of
provider satisfaction with electronic innovations;
utilization data on patient portal interface, and in-depth
interviews with key stakeholders.
Population Studied: Five physician practices in NYC,
representing over 150 MDs were identified for the
initiative. In 2007, 104 of these MDs made 89 home
health referrals to the agency. Home health nurses on
12 teams assisted in testing various components of the
evaluation. Over 300 patients were contacted to test the
Patient Portal. Semi-structured interviews were
conducted with a purposive sample of eight
stakeholders.
Principal Findings: Surveys to physicians (n=83; 55%
response rate) revealed that 75% reported “very little
knowledge” of the project and only 20% had any
personal experience processing referrals to home care,
suggesting minimal interest in the project. At the
completion of the study, only two components were
ready for testing: e-labs and patient portal. E- labs
eliminated all non-clinical reporting errors (which
occurred in 3% of cases at baseline) but increased the
average amount of time nurses spent resolving clinical
abnormalities (from 3.3 minutes to 4.8). The patient
portal was developed but not implemented due to low
interest among patients: only 22 of the 300 patients
invited to participate had computers at home; 9 agreed
to test the site and 6 “hits” were made to the site.
Content analysis of interviews revealed a range of
impediments to the completion of the proposed
components including inadequate support from the
software vendor; insufficient commitment from physician
practices and staff turnover.
Conclusions: Bridging the electronic chasm between
physician practices and the home health agency are
challenging due to the low number of referrals from
physician practices to home care; diffuse nature of home
care delivery system; and regulatory issues unique to
home care nursing. Also, agency patients, with a median
age of 73 are less likely to embrace patient portals and
other technological innovations.
Implications for Policy, Delivery or Practice: Current
interest in EHR, interoperability and HIE focus on
hospitals and physician practices. As with other settings,
adoption of these innovations in home care is impeded
by the expense of new technologies, necessary training
of physicians and other health care professionals, and
insufficient evidence of desired outcomes. However,
additional challenges unique to home health care must
be overcome to improve effective coordination of care
across multiple settings.
Funding Source(s): NYSDOH
Reforming Medicare Payment
Chair: Aaron McKethan
Sunday, June 27 * 4:15 pm–5:45 pm
• Medicare Advantage (MA) Benchmark Payment
Rates and Their Impacts
Deborah Healy, Ph.D.
Presented by: Deborah Healy, Ph.D., Research
Economist, Health Care Financing and Payment, RTI,
15301 Mastin Street, Overland Park, KS 66221; Phone:
(913) 400-2850; Email: dhealy@rti.org
Research Objective: To explore how MA county
benchmark payment rates and the ratio of MA payment
rates to FFS cost “overpayment” impact the availability
of MA plans and premiums.
Study Design: We analyzed 2008 plan availability and
premiums by MA county payment rates and ratio of the
benchmark rate to FFS costs. The county benchmark
rates were from the CMS website and the premium data
analyzed were from the CMS Health Plan Management
System. Plan availability and premiums were analyzed
separately for HMOs and private FFS (PFFS) plans.
Population Studied: MA Plans
Principal Findings: Preliminary findings show HMOs
and PFFS plans were impacted differently by the
absolute payment rate and the MA/FFS rate ratio. We
found HMO plan availability and premiums were
correlated with the benchmark rate while PFFS plan
availability and premiums were correlated with the
MA/FFS rate ratio. HMO plan availability increased from
less than 1 contract in counties with benchmark rates
below $750, to more than 11 contracts in counties with
rates higher than $900 while Part C monthly premiums
fell from $49.35 to $5.79 as the benchmark rate
increased from less than $750 to more than $900.
However, for PFFS plans, plan availability increased
from less than 5 contracts in counties with a rate ratio
less than 1.05 to approximately 10 contracts in counties
with a ratio greater than 1.15 while Part C premiums fell
from $31.38 to $6.64 as the rate ratio increased from 1
to more than 1.25.
Conclusions: Our preliminary conclusion is that the
type of private plan may interact with payment rates and
costs in affecting plan availability and generosity. One
reason for the difference may be that HMOs have a
different organizational structure. HMOs rely on
networks of physicians and hospitals from which
enrollees must obtain care. In high-cost urban areas,
HMOs may be able to bargain with providers for lower
reimbursements resulting in costs lower than traditional
Medicare FFS, while in low cost rural areas HMOs may
be unable to obtain provider discounts and incur costs
higher than FFS. Consequently, when the absolute level
of payment is high, as it is in high-cost urban areas,
HMOs are more likely to be offered with lower premiums.
PFFS plans however typically do not have provider
networks from which enrollees must obtain care and
their ability to bargain with providers is limited. In fact,
PFFS plans pay providers at least the Medicare FFS
rate. Hence, the relevant measure of MA payment
generosity for PFFS plans is the ratio of the MA payment
benchmark to local FFS costs. When this ratio is high,
PFFS plans are more likely to be offered with lower
premiums.
Implications for Policy, Delivery or Practice: One
proposal in health care reform is cutting payments to MA
plans, advocated because of plan payment rates
significantly higher than FFS costs in some areas. The
impact of these cuts may impact beneficiaries differently
depending on the county’s absolute payment rate and
rate to FFS ratio.
Funding Source(s): CMS
• Is There Potential For Expanding Bundling of
Services in Medicare Payments for Outpatient
Surgical Procedures?
Peter Hussey, Ph.D.; Barbara Wynn; Elizabeth Sloss,
Ph.D.; Lee Hilborne, M.D.
Presented by: Peter Hussey, Ph.D., Policy
Researcher, RAND, 1200 S Hayes Street w7w,
Arlington, VA 22202; Phone: (703) 413-1100 ext. 5460;
Email: hussey@rand.org
Research Objective: The Medicare Payment Advisory
Commission has recommended expanding the use of
bundled payment as a strategy for limiting outpatient
hospital spending growth, and CMS has announced
intentions to do so. Outpatient surgical procedures have
been identified as a relatively feasible area for bundled
payment since these services are more homogeneous
than medical encounters. The purpose of this study was
to identify the range of services related to selected
outpatient surgical procedures and explore the policy
implications of bundling them for Medicare payment.
Study Design: Medicare payments for potentially
bundled services were analyzed by type of service and
by provider. Medicare claims data and clinical expert
input were used to identify services related to the six
study procedures within specified time windows.
Analyses examined the potential for extending Medicare
bundled payment in several ways: (1) bundling related
hospital services performed on the same day, extending
changes made in 2008; (2) bundling physician
professional services with hospital facility services; (3)
bundling related services occurring over a span of
multiple days; and (4) bundling related services provided
by multiple hospitals and physicians.
Population Studied: Five percent national sample of
beneficiaries of Medicare Parts A and B receiving one of
six study procedures in 2006.
Principal Findings: Payments for related services
provided by the index hospital were a relatively large
share of total payments. Among related services
provided by the index hospital, service categorized as
“procedures” were the largest category, ranging from
one percent to 41 percent of total payments. Payments
for imaging, tests, and evaluation and management
(E&M) were relatively small, ranging between zero and
two percent of total payments. Payments to the index
physician were lower than those to the index hospital,
but still substantial. As with hospital services, payment to
the index physician for procedures were larger than
payments for imaging, tests, and E&M. Services by
providers other than the hospital and physician
performing the index study procedure were relatively
small, ranging from two percent to 15 percent of total
payments.
Conclusions: This study confirmed that it is possible to
identify a large number of bundling candidate services
that are likely to be clinically related to outpatient
surgical procedures. The majority of related services
were performed by the hospital and physician performing
the index procedure, and were performed on a single
day. Services classified as “procedures” accounted for a
larger share of payments than imaging and tests.
Implications for Policy, Delivery or Practice: The
greatest potential for expansion of Medicare bundling
policy is to include additional hospital procedures
provided during an encounter. Further extensions of
bundling to include multiple days of care and multiple
providers would include relatively few services and
would be complex to implement.
Funding Source(s): MedPAC
• Strengthening the Signal: Including Readmissions
in Medicare’s (non-payment for) Hospital Acquired
Conditions Policy
Peter McNair, M.P.H., M.H.S.; Harold Luft, Ph.D.
Presented by: Peter McNair, M.P.H., M.H.S., Clinical
Epidemiologist, Palo Alto Medical Foundation Research
Institute, 795 El Camino Real, Palo Alto, CA 94301;
Email: mcnairp@pamfri.org
Research Objective: This study defines and quantifies
acute inpatient readmissions that arise from, or complete
the Medicare definition of, Hospital Acquired Conditions
(HACs) in California between 1 July 2006 and 30 June
2007. The data is extrapolated to estimate the
nationwide impact.
Study Design: Prospective payment systems have, to
date, reimbursed hospitals on outputs rather than
outcomes. As a first step towards outcome based
funding, Medicare introduced a (non-payment for) HACs
policy in 2008. The policy excludes diagnosis codes for
ten ‘preventable’ complications of care from the payment
calculation process. We use a record linkage number to
search the dataset for (re)admissions (or transfers) that
are a consequence of, or themselves constitute HACs
(e.g. an admission with CABG and a subsequent
admission with mediastinitis). An estimated cost for each
episode of care is calculated from hospital charge data
and the hospital-specific cost-to-charge ratio. An
estimated Medicare payment is also calculated.
Population Studied: The study utilizes record-linked
data from the 2006 & 2007 OSHPD Patient Discharge
Datasets, which include all California non-federal
inpatient discharges.
Principal Findings: The California-wide estimated
annual number of readmissions or transfers to treat
HACs is 1,412 with estimated hospital costs of $62.9m
and Medicare equivalent payments of $25.9m. The
estimated nationwide impact of readmissions arising
from HACs on hospital payments is $232m ($103m for
Medicare) with $565m in costs ($203m for Medicare) for
hospitals. Patient readmissions arising from HACs
include: 1) 87 within six months for foreign object
retained after surgery; 2) Five within seven days for
iatrogenic air embolism; 3) One within seven days for
incompatible blood transfusion; 4) None within 90 days
for catheter-associated UTI; 5) Six within seven days for
vascular-catheter associated infection; 6) 32 on the
same day for poor (inpatient) glycemic control; 7) 47 for
mediastinitis within 60 days of a CABG procedure; 8)
119 within six months to treat a previous in-hospital fall
or trauma (82% transferred to another acute care
facility); 9) 1,073 for surgical site infection within six
months of an orthopedic procedure (175 involving an
infected prosthesis); 10) None for infection within six
months of bariatric surgery; 11) Six within thirty days of
orthopedic surgery for DVT or PE (excludes admissions
from SNF); and 12) 37 within six months of an admission
in which a pressure (decubitus) ulcer developed. Around
eighty percent of the impact ($21.4m/$25.8m;
$9.0m/$11.4m for Medicare) involves orthopedic
infection or mediastinitis. The study may underestimate
the total number of HAC-associated readmissions.
Specifically, diagnoses often captured in nursing notes
(e.g. catheter-associated UTI and pressure ulcer) may
not be consistently captured.
Conclusions: Non-payment for readmissions that are a
consequence of HACs will reduce annual Medicare
payments $103m; 50-100 times more than the projected
$1-2.4 million impact of the current HAC program.
Implications for Policy, Delivery or Practice: Although
a small fraction (0.10%) of Medicare’s acute inpatient
budget, non-payment for readmissions that arise from, or
complete the definition of, a HAC will provide a much
greater incentive to reduce HACs. If adopted, this
payment modification will provide a strong signal that
Medicare is serious about reducing ‘preventable’
complications of care.
Funding Source(s): CWF
• Financial Results from the Medicare Physician
Group Practice Demonstration
Gregory Pope, M.S.; Diana Trebino, B.A.; John Kautter,
Ph.D.; Jenya Kaganova, Ph.D.; Michael Trisolini, Ph.D.;
Diana Trebino, B.A.
Presented by: Diana Trebino, B.A., Research Analyst,
Health Care Finance and Payment, RTI International,
1440 Main Street, Waltham, MA 02451; Phone: (781)
434-1780; Email: dtrebino@rti.org
Research Objective: To measure financial performance
of physician groups participating in the Medicare
Physician Group Practice Demonstration.
Study Design: Ten large physician groups are given
financial incentives to improve the efficiency and quality
of their care through a "shared savings" financial model.
The groups share 80% of savings to the Medicare
program above a minimum savings threshold of 2%.
Savings are measured as the difference between target
and actual expenditures in each of five performance
years. Target expenditures are base year expenditures
of beneficiaries assigned to a group trended forward by
the expenditure growth of a local comparison group of
Medicare beneficiaries. Assigned and comparison
expenditure growth is risk adjusted. Half of shareable
savings are paid as a cost control bonus to the groups,
and half are prorated based on quality indicator
performance. Performance payments are capped at 5%
of target expenditures. Losses are accrued when actual
expenditures of beneficiaries assigned to a group are
more than 102% of the target.
Population Studied: Savings are calculated for
Medicare fee-for-service beneficiaries who received the
plurality of their primary care from a participating
physician group. Beneficiaries are retrospectively
reassigned each year to the physician groups.
Approximately 200,000 assigned beneficiaries per year
are involved in the Demonstration.
Principal Findings: Results from three performance
years of the Demonstration are currently available and
savings have increased each year. In the third
performance year, five participating physician groups
earned performance payments of $25.3 million total and
two groups accrued a loss of $3.9 million total. After
performance payments and accrued losses, savings to
the Medicare Trust Fund were $3.1 million. However,
only one group achieved savings on a non-risk adjusted
basis. Savings occurred in high-cost assigned
beneficiary subpopulations, and specifically among
chronic obstructive pulmonary disease and diabetes
patients. Larger savings were generated in inpatient than
outpatient expenditures in performance year three,
which was consistent with the groups’ focus on reducing
inpatient admissions. More rapid than market risk score
growth and continuation of pre-Demonstration lower than
market expenditure growth among participating
physician groups appear to have contributed to
measured Demonstration savings. In PY3, the PGP
Actual Expenditures aggregated across all 10 sites were
$137 or 1.3% lower than Target Expenditures and
savings were statistically significant (p<.01). In the
simulated pre-Demonstration period, the PGP
expenditures for the 10 sites were $105 or 1.0% lower
than Target Expenditures, but not statistically significant.
Thus, Demonstration savings adjusted for the preDemonstration trend were $32 or 0.4%, and not
statistically significant, which suggests that the preDemonstration trend contributed to the observed
Demonstration savings.
Conclusions: The first three years of the Demonstration
provide evidence of modest and increasing cost savings,
but the possibility that no true cost savings were
achieved cannot be ruled out.
Implications for Policy, Delivery or Practice: The
shared savings model gives provider groups financial
incentives to improve efficiency and quality while limiting
provider risk and maintaining beneficiary freedom of
provider choice. Generalizing the model will require
aggregating smaller physician practices into larger
entities for performance measurement and simplifying
the Demonstration expenditure target methodology.
Funding Source(s): CMS
Pediatric Quality and Performance Measurement:
Key Considerations
Chair: Astrid Guttmann
Sunday, June 27 * 4:15 pm–5:45 pm
• Inpatient Pediatric Quality Indicators: Limitations of
Small Numbers
Naomi Bardach, M.D.; Alyna Chien, M.D., M.S.; R.
Adams Dudley, M.D., M.B.A.
Presented by: Naomi Bardach, M.D., Research Fellow,
General Pediatrics, University of California San
Francisco, 3333 California Street, Suite 245, San
Fransisco, CA 94118; Phone: (415) 476-8273; Email:
nbardach@gmail.com
Research Objective: To determine the percentage of
hospitals with adequate sample size to meaningfully
assess their performance using the Agency for
Healthcare Research and Quality (AHRQ) pediatric
inpatient quality indicators (PDIs), which have been
nationally endorsed, are currently publicly reported in at
least two states, and which measure pediatric inpatient
adverse events such as decubitus ulcer rate and
infections due to medical care.
Study Design: We performed a cross-sectional analysis
from 2005-2007 for all patients <18 years old, using
California's publicly-available hospital discharge
database and AHRQ software. For nine hospital-level
PDIs, we excluded discharges with PDIs indicated as
present on admission, then determined for each PDI: the
statewide mean rate, the eligible pediatric volume at
each hospital, and the percent of hospitals with
adequate volume to identify an adverse event rate twice
the statewide mean.
Population Studied: California hospitals caring for
children 2005-2007.
Principal Findings: Unadjusted California-wide event
rates for PDIs during the study period (N=2,333,556
discharges) were 0.2-38/1000 discharges. Event rates
for specific measures were, for example, 0.2/1000
(iatrogenic pneumothorax in non-neonates), 19/1000
(post-operative sepsis) and 38/1000 (pediatric heart
surgery mortality), requiring patient volumes of 49,869,
419, and 201 to detect an event rate twice the statewide
average; 0%, 6.6%, and 25% of California hospitals had
this pediatric volume, respectively.
Conclusions: Using these AHRQ-developed, nationallyendorsed measures of the quality of inpatient pediatric
care, one would not be able to identify many hospitals
with performance two times worse than the statewide
average due to extremely low event rates and
inadequate pediatric hospital volume.
Implications for Policy, Delivery or Practice: PDIs are
adverse event measures that are easy to calculate and
are being used by some to compare hospitals caring for
children. Although monitoring PDIs is important to
regional quality improvement efforts, physicians, payors
and policymakers should recognize that PDIs cannot
differentiate high quality hospitals from low ones.
Inpatient pediatric quality measures that can be used for
comparative purposes need to be developed.
Funding Source(s): National Institute for Childhood
Health and Development
• Testing a Comprehensive Measure Set for Well
Child Care in Health Plans
Sepheen Byron, M.H.S.; Judy Ng, Ph.D.; Natalie Davis;
Sarah Hudson Scholle, M.P.H., Dr.PH.
Presented by: Sepheen Byron, M.H.S., Assistant
Director, Performance Measurement, Performance
Measurement, NCQA, 1100 13th St NW, Suite 1000,
Washington, DC 20005; Phone: (202) 955-3500; Email:
byron@ncqa.org
Research Objective: Many of the existing performance
measures for child health care assess whether children
visited their providers for a defined frequency. These
“visit-count” measures do not provide the information
required to evaluate the content of care received. To
address this gap, NCQA developed a comprehensive set
of measures that appreciates the role healthy
development in childhood plays in effecting healthy and
productive adults. The objective of this study was to test
the feasibility of implementing these measures that
evaluate the provision and quality of well-care for
children at the health-plan level.
Study Design: Participating health plans collected
specific information on a retrospective sample of eligible
patients, based on data available in administrative
claims and enrollment files and medical records. In
addition to data on their performance across specified
measures, plans submitted descriptive information on
continuous enrollment, age and gender. The measure
set was composed of five measures that assessed a
child’s receipt of services across four domains:
Protection of Health; Healthy Cognitive, SocialEmotional, Behavioral, and Physical Development;
Protection of Health Through a Safe Environment; and
Management and Follow-Up of Children with Chronic
Conditions. Measures signified milestone ages along a
child's development path: age six months and two, six,
13, and 18 years.
Population Studied: Two commercial and three
Medicaid managed care organizations submitted
aggregated data based on claims and medical record
data for a random sample of members age 18 years and
under who met continuous enrollment and outpatient
visit criteria. Members were enrolled in the plan for
calendar year 2008. Plans were from all regions of the
United States, and each plan submitted 250 records for
a total sample size of 1250.
Principal Findings: All five health plans were able to
report data for numerators and denominators for each
measure within the set. Performance varied according to
the type of measure and the stringency of the numerator
requirements. For example, the rate of screening for
developmental delays was 65%; however, when
screening with a standardized tool was required, the rate
fell to 8%. Results of screening tests were often
undocumented, and results deemed abnormal or
indeterminate did not have follow-up action documented
in the chart. For example, out of 260 newborns screened
for metabolic conditions, 63 had undocumented results.
Out of the 12 whose results were abnormal or
indeterminate, only eight had notation of proper followup. Rates for whether children with chronic conditions
received an individualized care plan ranged from 9 to
22% across the age groups.
Conclusions: Overall, results suggest that children are
not receiving recommended well-care services, and
children with chronic conditions are not receiving a care
plan. Moreover, follow-up of abnormal or indeterminate
results was lacking, and screening with a standardized
tool was virtually non-existent despite clinical guidelines.
Implications for Policy, Delivery or Practice: Across
all measures, there was much room for improvement.
Low rates may have been the result of services not
occurring or poor documentation. Efforts that focus on
building systems to communicate guidelines or prompt
physicians may have a major impact. Furthermore, the
move towards electronic medical records may bolster
such efforts. In general, our study showed that measures
that assess the content of well-child visits are feasible to
implement in health plans; these data have the potential
to contribute significantly to quality-improvement efforts.
Funding Source(s): CWF, Merck & Co, Bristol Myers
Squibb
• Accounting for Small NICUs in Hospital
Comparisons of Nosocomial Infections in VLBW
Infants
Henry Lee, M.D., M.S.; Alyna Chien, M.D., M.S.; Naomi
Bardach, M.D.; Jeffrey Gould, M.D., M.P.H.; R. Dudley
Adams, M.D., M.B.A.
Presented by: Henry Lee, M.D., M.S., Assistant Clinical
Professor, Pediatrics / Neonatology, University of
California San Francisco, 533 Parnassus Avenue Room
U503, San Francisco, CA 94143-0734; Phone: (650)
580-2963; Email: LeeHC@peds.ucsf.edu
Research Objective: Although hospital comparisons
are increasingly used to drive internal quality
improvement activities and underpin external public
reporting and pay-for-performance efforts, stakeholders
may under-recognize the extent to which existing
performance measurement conventions impact whether
hospitals are assessed for quality and the ratings they
may receive. Performance measurement conventions
are of particular interest in pediatrics where patient
volumes generally tend to be lower, and low-volume
providers may be proliferating. For example, very low
birth weight (VLBW) infants are increasingly cared for by
low-volume neonatal intensive care units (NICUs). The
purpose of this study is to examine the extent to which
three performance measurement conventions affect the
proportion of NICUs and VLBW infants that are included
in quality assessments and the distribution of their
quality ratings.
Study Design: Cross-sectional study of nosocomial
infection (NI) rates among VLBW infants (birthweight
<1500 grams) born at or transferred to NICUs
participating in the California Perinatal Quality Care
Collaborative (CPQCC) between 2007-2008. We
calculated risk-adjusted NI rates using positive bacterial
or fungal cultures and clinical factors (e.g., patient sex,
gestational age, Apgar score, need for surgery and
presence of congenital malformation, prenatal care,
multiple gestation). We compared three statistical
methods: 1. Excluding “low-volume” NICUs (i.e., those
caring for less than 30 VLBW infants in a year); 2.
Bayesian versus frequentist estimation methods, and 3.
Aggregating across two versus one year of data. Our
main outcomes of interest were: the proportion of NICUs
and patients that would be excluded in quality
comparisons, the proportion of NICUs that would be
considered “average”, and the proportion of low-volume
NICUs whose performance rating changed depending
on the statistical strategy.
Population Studied: CPQCC collects data on >90% of
California NICUs.
Principal Findings: Thirty-nine percent of NICUs would
be omitted from quality comparisons if the low-volume
exclusion conventions were used, whereas 1% of NICUs
would be if two-years of data and Bayesian methods
were used to measure performance. Similarly, care to
16% of VLBV infants would be excluded from quality
measurement if low-volume exclusion conventions were
applied, whereas <1% of patients would be excluded if
two-years of data and Bayesian methods were used to
calculate performance. However, 91% of NICUs would
be considered “average” using Bayesian methods and
one year of data, whereas 68-79% would be considered
“average” using the other techniques. Forty-one percent
of low-volume NICUs change ratings depending on the
method being used.
Conclusions: In care settings where low-volume
providers are common, the proportion of providers being
excluded from quality assessment and their quality
ratings can shift dramatically depending on the
performance measurement methodology being used.
Bayesian estimation methods in combination with data
aggregation may be the optimal strategy for including as
many providers as possible while maintaining the ability
to differentiate quality of care.
Implications for Policy, Delivery or Practice:
Physicians, payers, and policymakers should closely
examine the extent to which existing performance
measurement conventions impact whether hospitals are
assessed for quality and the ratings they may receive,
particularly when low-volume providers are
commonplace.
Funding Source(s): CTSI KL2 (NIH K12)
• The Importance of Unmeasured Casemix
Differences when Evaluating the Outcomes of
Premature Infants Delivered at High Volume
Neonatal Intensive Care Units (HV NICUs)
Scott Lorch, M.D., M.S.C.E.; Mike Baiocchi, B.A.;
Corinne Fager, M.A.; Dylan Small, Ph.D.
Presented by: Scott Lorch, M.D., M.S.C.E., Assistant
Professor of Pediatrics, Neonatology, The Children's
Hospital of Philadelphia, 3535 Market Street, Suite 1029,
Philadelphia, PA 19104; Phone: (215) 590-1714; Email:
lorch@email.chop.edu
Research Objective: One method of quantifying the
effect of a regionalized health care system is to measure
the change in outcomes when care is delivered at highvolume, specialty hospitals. Neonatal intensive care has
been marked by the proliferation of a de-regionalized
system of low volume, high-technology “specialty”
neonatal intensive care units (NICUs), because of
conflicting evidence on the role of volume versus
technology in improved mortality rates. One reason for
this conflict is that no study has controlled for
unmeasured differences in casemix between high and
low volume NICUs. The objective of this study is to
measure the change in mortality and complication rates
of premature infants delivering at HV NICUs using an
instrumental variables approach to control for
unmeasured casemix differences.
Study Design: We constructed a population cohort of
California (CA) and Pennsylvania (PA) infants born with
a gestational age (GA) of 23-36 weeks between 19952005 using birth certificates linked to death certificates
and maternal and infant hospital discharge records
(N=821,404). We calculated the difference in rates of
death and 16 complications between infants delivering at
HV NICUs (high-technology, level III NICUs delivering at
least 50 premature infants/year) or other NICUs (1)
without risk adjustment; (2) adjusting for measured
factors such as GA, birth weight, race, and pregnancy
complications; and (3) adjusting for measured and
unmeasured factors using the difference in distances
between the mother’s zip code and the nearest HV NICU
or non-HV NICU as an instrument to approximately
randomize women to delivery hospital.
Population Studied: Premature infants with a GA of 2336 weeks
Principal Findings: In unadjusted analyses, infants
delivering at HV NICUs had significantly higher rates of
mortality (PA difference 1.32%, relative risk (RR) 1.62,
p<0.001; CA difference 1.38%, RR 1.75, p<0.001) and
all complications including bronchopulmonary dysplasia
(RR 3.07 in PA, RR 2.59 in CA), bacterial infection (RR
1.66 in PA, RR 1.93 in CA), and perinatal asphyxia. After
controlling for measured factors, infants delivering at HV
NICUs had non-significantly higher mortality rates (0.3%0.6%) and significantly higher complication rates.
Stratification by the instrument resulted in similar rates of
all measured confounders while decreasing the
likelihood of delivering at a HV NICU from 80-85% in the
nearest quartile to 36-42% in the furthest quartile. Now,
infants delivered at HV NICUs had a 1.8% mortality
reduction in PA (RR 0.44, p<0.001) and a 0.9%
reduction (RR 0.83, p<0.001) in CA. Rates of several
complications, such as perinatal asphyxia, were
significantly lower for infants delivering at HV NICUs,
whereas other complications remained higher, especially
complications occurring later in the hospital course such
as bronchopulmonary dysplasia (RR 1.16) and bacterial
infection (RR 1.30).
Conclusions: After controlling for unmeasured
differences in casemix, infants delivered at HV NICUs
have lower rates of mortality and several early
complications of prematurity.
Implications for Policy, Delivery or Practice: Ignoring
unmeasured casemix differences between high and low
volume NICUs may support a deregionalized system of
perinatal care. An instrumental variables approach to
adjust for these differences suggests that delivery
volume and level of neonatal care are important to
optimize perinatal outcomes.
Funding Source(s): AHRQ
Methods/Measurement in Disparities Research
Chair: Paul Hebert
Sunday, June 27 * 4:15 pm–5:45 pm
• Heterogeneity of Medicare Advantage and
Prescription Drug Plan Experiences by Beneficiary
Race/Ethnicity: Considerations for Public Reporting
by Race/Ethnicity
Marc Elliott, Ph.D.; Amelia Haviland, Ph.D.; Katrin
Hambarsoomian, M.S.; David Kanouse, Ph.D.; Elizabeth
Goldstein, Ph.D.
Presented by: Marc Elliott, Ph.D., Senior Statistician,
Economics and Statistics, RAND Corporation, 1776
Main Street, Santa Monica, CA 90401; Phone: (310)
393-0411; Email: elliott@rand.org
Research Objective: To assess the extent to which the
relative CAHPS scores of Medicare Advantage (MA) and
Prescription Drug Plan (PDP) plans vary by patient
race/ethnicity in order to develop guidance for stratified
public reporting of plan scores by beneficiary
race/ethnicity.
Study Design: We predict each of 8 CAHPS measures
using mixed linear regression models that employ
beneficiary-level case-mix adjustors, self-reported
race/ethnicity (Hispanic, Black, non-Hispanic
White/NHW, or Asian & Pacific Islander/API), and year
(2008 or 2009) as fixed effects and contracts (“plans”) as
random effects. Additional models add random effects
for race/ethnicity by plan interactions, year by plan
interactions, and hospital referral regions (HRRs) as a
measure of geography/market. These models assess
the plan-level reliability of CAHPS reports of plan scores
stratified by race/ethnicity (Hispanic, Black, NHW, API),
nationally and within HRR. They also assess the extent
to which racial/ethnic-specific scores at smaller sample
sizes, versus overall scores at larger sample sizes,
provide more accurate estimates of the plan-specific
experiences of members of specific racial/ethnic groups.
We use two measures of immunization (flu, pneumonia),
four composite measures of Part C experience (getting
needed care, getting care quickly, doctor
communication, customer service), and two composite
measures of Part D experience (getting drugs, getting
information).
Population Studied: Hispanic, Black, NHW, and API
Medicare beneficiaries: ~800,000 MA and PDP enrollees
responding to the 2008-2009 Medicare CAHPS Survey
in any of 541 MA plans or 82 PDPs.
Principal Findings: 100 completes for a specific
racial/ethnic group over two years of pooled data provide
adequate reliability (generally >0.7) within racial/ethnic
groups for MA plans for all measures but doctor
communication; the same holds for 200 completes for
PDPs. These thresholds would permit reporting on a
minority of plans for Blacks/Hispanics (26-29%) and API
(5-11%), but these plans would contain the vast majority
of Black/Hispanic (85-93%) and API (66-67%)
beneficiaries. Statistically significant heterogeneity of
plan scores by race/ethnicity was evident in 29 of 30
instances involving Hispanics, Blacks, and API. Within
MA, median squared correlations of racial/ethnic-specific
plan scores with overall plan scores were only 0.52,
0.59, and 0.71 for API, Hispanics, and Blacks
respectively. Heterogeneity was especially evident for
Part D measures. Including HRR in the models resulted
in somewhat smaller and less consistent but generally
persistent evidence of heterogeneity, except for doctor
communication, where the heterogeneity was only
between HRRs.
Conclusions: Beneficiary experience can be reliably
measured by race/ethnicity (Hispanic, Black, NHW, API)
for MA plans and PDPs in which a majority of minority
beneficiaries are enrolled using two years of pooled
CAHPS data for 7 measures of beneficiary experience.
The best plan for one group is not necessarily the best
for others. With the exception of doctor communication,
stratified reporting by race/ethnicity could provide
valuable supplementary information, especially for
Hispanic and API beneficiaries, and especially for Part D
measures.
Implications for Policy, Delivery or Practice: Stratified
reporting by race/ethnicity has potential value for
monitoring and reducing disparities at the plan level.
Such reporting could spur improvement by plans and
guide beneficiaries to the plans that might most
effectively meet their linguistic, cultural, and formulary
needs.
Funding Source(s): CMS
• Can my Patient Read and Understand Written
Health Information? A Systematic Review and MetaAnalysis of Literacy Screening Instruments
Benjamin Powers, M.D., M.H.S.; Jane Trinh, M.D.;
Hayden Bosworth, Ph.D.
Presented by: Benjamin Powers, M.D., M.H.S.,
Assistant Professor, General Internal Medicine, Duke
University and Center for Health Services Research in
Primary Care, Durham VAMC, 2424 Erwin Road, Suite
1105, Durham, NC 27705; Phone: (919) 668-2360;
Email: power017@mc.duke.edu
Research Objective: An estimated ninety million adult
Americans lack the ability to adequately read written
health information and suffer worse health outcomes as
a result. Health care providers do not accurately identify
patients with limited literacy and current literacy
measurements used in research are impractical for
clinical use. We sought to systematically review the
accuracy of brief screening instruments for limited health
literacy.
Study Design: We performed a systematic review of
English-language literature through August 2009 using
Pubmed, Psychinfo, and bibliographies of selected
manuscripts for articles on health literacy, numeracy,
reading ability, and reading skill. Where appropriate, we
performed meta-analysis of the diagnostic test
characteristics for screening instruments.
Population Studied: We initially identified 2233 studies
for abstract review and 25 articles met criteria for full text
review. Studies were evaluated independently by 2
reviewers and each abstracted information on the study
sample, design, screening test characteristics and
overall quality rating for eligible studies. Disagreements
were adjudicated by a third reviewer. Nine studies using
6 different screening instruments met inclusion criteria.
Several studies evaluated different screening
instruments and utilized different cutoffs for both the
reference standard (inadequate versus inadequate or
marginal literacy) and the screening instrument.
Principal Findings: Several single item questions about
confidence with filling out medical forms, use of a
surrogate reader, and self-rated reading ability
performed moderately well in identifying patients with
inadequate or marginal health literacy. For identifying
patients with inadequate or marginal health literacy,
asking “How confident are you in filling out medical
forms by yourself?” is associated with a summary
likelihood ratio (LR) 5.0 (95% CI, 3.8-6.4) for an answer
of “a little confident” or “not at all confident”; a summary
LR of 2.2 (95% CI, 1.5-3.3) for an answer of “somewhat
confident” ; and a summary LR of 0.44 (95% CI, 0.240.82) for answers of “quite a bit” or “extremely confident”.
Asking patients “How often do you have someone help
you read hospital materials?” was associated with a
summary likelihood ratio (LR) 2.9 (95% CI, 2.3-3.7) for
an answer of “at least sometimes”; a summary LR of 1.0
(95% CI, 1.5-3.3) for an answer of “rarely”; and a
summary LR of 0.53 (95% CI, 0.38-0.73) for an answer
of “never”. Combinations of screening questions and
demographic information did not perform better than
single item screening instruments. The Newest Vital
Sign, based on reading a nutritional label, was effective
for ruling out inadequate or marginal health literacy, but
significantly less practical than the single item measures.
Conclusions: Asking patients about their confidence
with filling out medical forms, use of a surrogate reader
for health information, and their self-rated reading ability
were all effective questions for identifying patients with
limited health literacy.
Implications for Policy, Delivery or Practice:
Screening for inadequate health literacy is easy and can
be performed accurately with a single question. Patients
who screen positive with these questions may need
extra attention and providers should regularly assess
adequate recall and comprehension of information to
ensure high quality and safe delivery of healthcare.
Funding Source(s): NCRR
• Measuring Physician Cultural Competence: Results
from a National Survey
Somnath Saha, M.D., M.P.H.; Melissa Gatchell, M.P.H.;
Martha Gerrity, M.D., Ph.D., M.P.H.; Nancy Perrin, Ph.D.
Presented by: Somnath Saha, M.D., M.P.H., Associate
Professor of Medicine, Section of General Internal
Medicine, Portland VA Medical Center, 3710 SW U.S.
Veterans Hospital Road (P3HSRD), Portland, OR
97239; Phone: (503) 220-3474; Email:
sahas@ohsu.edu
Research Objective: Cultural competence (CC) training
for current and future physicians has been widely
endorsed as a means to reduce racial disparities in
health care. Evidence-based curriculum development
and evaluation, however, has been limited by the paucity
of well-designed, validated tools measuring physician
CC. We sought to develop and test the construct validity
of an instrument measuring physician CC.
Study Design: We first conducted a systematic review
of published articles describing physician CC and used
qualitative analytic methods to develop a conceptual
map of physician CC dimensions. For each dimension,
we created a set of items that covered the breadth of its
meaning as described in the literature. Eight national
experts reviewed the items for content validity and
suggested changes and additions. We revised our item
pool and evaluated items for conceptual precision in
cognitive interviews with 28 physicians from diverse
racial/ethnic groups and specialties. After further
revisions we included a final pool of 61 Likert-scale items
in a questionnaire that also included items about
demographics and prior formal training in CC and
communication skills.
Population Studied: We mailed the questionnaire to a
random sample of 1800 internists and family physicians
in zip codes with at least a 25% nonwhite population. We
oversampled African American and Latino physicians.
Respondents could complete the questionnaire online or
on paper. Using responses to the 61-item pool, we
conducted factor analysis to derive discrete scales and
labeled the scales based on item content. We then used
linear regression to test the hypotheses that minority
physicians and those who had completed prior CC
training would have higher CC scores as measured by
these scales, after adjusting for physician age, sex, and
prior communication skills training.
Principal Findings: Among 1516 potentially eligible
physicians, 795 (52%) responded. Respondents
included mostly white (55%) or Asian (21%) physicians,
with 12% being African American and 9% Latino. Most
were male (65%), and most reported having had past
training in CC (62%) and communication skills (78%).
Our analysis generated 7 factors: cultural awareness (8
items, alpha 0.87), cultural self-efficacy (5 items, alpha
0.79), awareness of racial disparities (5 items, alpha
0.81), valuing diverse perspectives (6 items, alpha 0.77),
support for “culturally and linguistically appropriate
services” (CLAS) standards (6 items, alpha 0.80),
biomedical orientation (negative scale, 2 items, alpha
0.67), and relationship-centered orientation (13 items,
alpha 0.88). In regression analyses, nonwhite physicians
had higher scores than whites (p < .005) on all
dimensions except biomedical orientation. Women had
higher scores than men for awareness of racial
disparities, valuing diverse perspectives, support for
CLAS standards, and relationship centered orientation (p
<= .001). Physicians reporting prior CC training had
higher scores in all dimensions (p <= .002) except
biomedical orientation and valuing diverse perspectives,
whereas prior communication skills training was not
associated with any CC dimension.
Conclusions: We developed a theoretically based,
novel instrument spanning multiple dimensions of
physician CC that appears to have reasonable construct
validity.
Implications for Policy, Delivery or Practice: If further
validated as a predictor of better and more equitable
patient care, dimensions in this instrument could inform
the content and objectives of future CC training, and
validated scales could be used as evidence-based
evaluation tools.
Funding Source(s): NHLBI
• Using Indirect Methodology to Estimate
Race/Ethnicity for Proactive Outreach with Culturally
Relevant Strategies
Zachary Vernon, B.A.; Grace Ting, M.H.A.; Terri Amano,
B.A.; Virginia Cullop, B.S., R.D.
Presented by: Zachary Vernon, B.A., Senior Health
Information Consultant, Programs in Clinical Excellence,
WellPoint, Inc., 602 S. Jefferson Street, Mail Stop
VAG104-A200, Roanoke, VA 24011; Phone: (540) 8533316; Email: zack.vernon@anthem.com
Research Objective: Historically, health plans did not
collect voluntary and self-reported race/ethnicity data on
its members due to lengthy implementation timelines
and expensive systemic and process changes required.
In the interim, many plans have been turning to indirect
methodologies to derive race and ethnicity information
for members as a relatively inexpensive, yet reliably
accurate strategy to bridge the data collection gap until
primary source data is available for all members. To
date, most applications of indirect race/ethnicity have
been limited to identifying aggregate or region health
disparities trends. In this study, WellPoint examined the
utilization of estimated race and ethnicity data for
proactive direct outreach to individual members with
culturally relevant strategies. Levels of member abrasion
were examined.
Study Design: The experimental design involved
employees of six separate employer groups in two states
representing a range of industries and socioeconomic
status. Each employer group granted consent after
receiving a careful explanation on the potential risk of
participant abrasion. Estimated race/ethnicity was
derived using indirect methodologies and, where
available, overruled by self-reported data. To minimize
member abrasion, member selection using the indirect
methodology was limited to members whose probability
of being Hispanic or African American was greater than
80%. Participants estimated to be African American or
Hispanic were randomly assigned either to the
experimental condition of proactively being offered a
suite of culturally relevant strategies for diabetes selfmanagement as adjuncts to traditional services or to the
control condition of continuing their usual services. The
introductory postcard and cover letter accompanying the
culturally relevant strategies included a toll-free number
for participants to contact WellPoint opt out of the
program. The metric of interest for this study assessed
member abrasion resulting from proactive outreach
based on estimated race/ethnicity. Outcomes were
evaluated using intent-to-treat analysis.
Population Studied: Study participants were
commercially insured African American and Hispanic
persons 18 years and older with diabetes. There were
1,172 individuals estimated to be African American in the
study group and 1,166 in the control group; there were
873 individuals estimated to be Hispanic in the study
group and 871 in the control group.
Principal Findings: Of the 2,045 individuals in our study
groups who received proactive culturally relevant
strategies based on estimations of their race/ethnicity
derived from indirect methodologies, only one individual
informed us of an incorrect estimation, and there were
no reports of participant abrasion from the estimation of
race/ethnicity (there was one complaint from an
individual about an image used in one booklet, but the
complaint did not address the metric of interest).
Conclusions: This randomized controlled trial
demonstrated that using estimated race/ethnicity data for
proactive health messaging outreach to Hispanics and
African Americans can pose little, if any, risk of abrasion
when appropriately sensitive outreach strategies are
employed.
Implications for Policy, Delivery or Practice: Study
results demonstrate that healthcare organizations may
move beyond traditional applications of indirectly derived
estimations of race/ethnicity data at only the aggregate
or population-based level. Such data may be applied
successfully for direct, individual-level health intervention
outreach to address disparities if the indirect
methodology is rigorous and the communication plan is
culturally and linguistically sensitive.
Funding Source(s): Self-Funded
Choices in a Changing Health Care Environment:
Influencing Consumer Behavior
Chair: Jill Yegian
Sunday, June 27 * 4:15 pm–5:45 pm
• Too Smart to Forgo: Cognitive Ability and
Enrollment in Medicare Part D
Helen Szrek, Ph.D.; Kate Bundorf, Ph.D., M.B.A., M.P.H.
Presented by: Kate Bundorf, Ph.D., M.B.A., M.P.H.,
Assistant Professor, Health Research and Policy,
Stanford University School of Medicine, HRP Redwood
Building, Stanford, CA 94305-5405; Phone: (650) 7250067; Email: bundorf@stanford.edu
Research Objective: To determine whether cognitive
ability affects the likelihood that Medicare beneficiaries
enroll in a prescription drug plan and whether the effect
of choice set size on enrollment varies by the cognitive
ability of the beneficiary.
Study Design: We conducted an experiment in which
we asked people 65 and older to make hypothetical
choices among Medicare Part D prescription drug plans,
varying the number of plans in the choice set (2, 5, 10 or
16) across participants. After making their choice, we
asked participants a question about the likelihood they
would enroll in the plan they chose. We also collected
three measures of cognitive ability: 1) numeracy; 2)
cognitive reflection; and 3) recall. We analyzed the
correlation between the respondent’s likelihood of
enrollment and the three measures of cognitive ability.
We also tested whether the effect of choice set size
varied by the respondent’s cognitive ability.
Population Studied: A randomly selected sample of
members of an Internet-enable panel aged 65 and over.
We limit our analysis to those taking one or more
prescription drugs based on prior research
demonstrating that enrollment in a prescription drug plan
is financially beneficial for this group.
Principal Findings: We find that high cognitive ability,
as measured by tests of numeracy, cognitive reflection,
and recall, is positively associated with likelihood of
enrollment. The effects of cognition are large in
magnitude. For example, beneficiaries with a high
cognitive reflection score are 24 percentage points more
likely than those with a low score to indicate they would
enroll in a plan. We also find that size of the choice set
affects likely enrollment only among respondents with
high cognition scores. Among this group, the likelihood
of enrollment first increases and then declines with
choice set size. Respondents with low cognition scores,
in contrast, were less likely to indicate they would enroll
independent of choice set size.
Conclusions: Older adults with low cognitive ability may
be making decisions about prescription drug plans that
are not in their best interest financially. Regardless of
choice set size, the enrollment task appears to be
difficult among this group. The number of plans available
to beneficiaries may present a greater challenge to
decision-making among older adults with greater
cognitive ability.
Implications for Policy, Delivery or Practice:
Informational interventions which assist beneficiaries in
making choices may be particularly helpful for older
adults with high cognitive ability choosing among plans.
Older adults with lower cognitive ability, in contrast, may
benefit from automatic enrollment.
Funding Source(s): NIA
• The Relative Influence of Calorie Labeling and
Behavioral Economic Nudges in Altering Fast Food
Choice
Brian Elbel, Ph.D., M.P.H.; Dan Ariely, Ph.D.; Jason Riis,
Ph.D.; Janet Schwartz, Ph.D.
Presented by: Brian Elbel, Ph.D., M.P.H., Assistant
Professor of Medicine and Health Policy, Division of
General Internal Medicine, New York University, 423
East 23rd Street, 15-120N, New York, NY 10010;
Phone: (212) 263-4283; Email: Brian.Elbel@nyumc.org
Research Objective: The obesity epidemic in the
United States lacks a clear solution. Most interventions
focus on providing information to encourage healthier
food choices. Research from the social sciences,
particularly behavioral economics, has shown that while
information-based interventions can change attitudes
and intentions, they often fail to change behavior.
Alternatively, relatively small and simple changes to the
environment can “nudge” people in the right direction
and often achieve far better results than information-
based campaigns. Here, we directly test the relative
influence of calorie labeling vs. behavioral nudging to
reduce calorie consumption in a fast food restaurant.
Study Design: Two field experiments were conducted at
an Asian-style fast food restaurant located on a
southeastern private university campus. We examined
the relative influence of labeling as compared to a
behavioral nudge in reducing the total calories
purchased. In both studies customers were nudged by
restaurant staff to “cut over 200 calories from your meal”
by taking a half-portion of the side dish for a nominal (25
cent) discount. In the second study calorie labeling was
introduced, allowing us to compare the relative influence
of labeling and the nudge. Individual meal receipts and
total daily sales were utilized as outcomes. Study 1 data
were collected for two days without the nudge, followed
by two days with the nudge. Study 2 data were collected
during consecutive three-week blocks before and after
labeling was introduced. The nudge was offered during
the middle week of each block.
Population Studied: Study 1 (pre-labeling, nudge-only)
participants were primarily university/hospital staff
(n=137). Study 2 (nudge vs. labeling) participants were
primarily college students (n=994).
Principal Findings: Thirty percent of university/hospital
staff accepted the smaller serving nudge, reducing the
total food calories purchased by 99 per meal averaged
across all subjects (p<.05). For college students, 17%
accepted the offer, reducing total food calories
purchased by 45 per meal (p < .05). The labeling
manipulation, in contrast, actually led to an increase of
total food calories purchased by 35 per meal in the
receipt data, although this increase was not apparent in
total sales data across the study period. The labeling by
nudge interaction for total calories purchased was
marginally significant (p<09) such that calorie savings
from the nudge were smaller in the presence of labeling.
Additionally, acceptance of the nudge was lower in the
presence of labeling (21% versus 13%, p<.05)
Conclusions: Calorie labeling alone did not reduce
calories purchased per meal. However, a simple nudge
to encourage smaller portions and fewer calories
significantly reduced calories purchased per meal.
Moreover, calorie labeling did not make the nudge more
effective, and in fact may have made it less effective.
Implications for Policy, Delivery or Practice: Many
policies and interventions targeting obesity assume that
consumers will rationally respond to information and
consequently make better choices. In reality, such
information may have limited ability to change behavior.
In contrast, we found that a simple behavioral nudge
was effective. Policymakers, retailers, and researchers
should increasingly consider these approaches as useful
tools to change food choice.
• Preventive Care in Consumer Directed Health
Plans: Do Consumers Avoid Deductible Exempt
Care?
Mary Reed, Dr.PH.; Vicki Fung, Ph.D.; John Hsu, M.D.,
M.B.A., M.S.C.E.
Presented by: Mary Reed, Dr.PH., Staff Scientist,
Division of Research, Kaiser Permanente, 2000
Broadway, Oakland, CA 94612; Phone: (510) 891-3808;
Email: Mary.E.Reed@kp.org
Research Objective: Consumer Directed Health Plans
(CDHPs) with Health Savings Accounts (HSAs) could
potentially engage consumers in their health care and
decrease unnecessary care-seeking; however, there is
limited information on whether consumers understand
plan exemptions of preventive care and concern that
these plans may cause reductions in preventive care,
even when it is exempted from the deductible. We
examined consumer knowledge of their CDHP benefits’
preventive exemptions, and cost-related changes in
preventive care-seeking behavior.
Study Design: We conducted telephone interviews with
patients to examine their knowledge of which office
visits, medical tests, and cancer screenings were subject
to their deductible, and whether they had changed their
care-seeking behavior for these services because of
cost in the previous year. We used multivariate logistic
regression to assess the association between patient
characteristics (including age, race, household income,
and education) and both plan knowledge and preventive
care-seeking behavior.
Population Studied: We interviewed a random sample
of adult members of an integrated delivery system (IDS)
with an HSA-eligible deductible plan in 2008 (488
participants, 78% response rate).
Principal Findings: Overall, 83.6% of participants knew
that their plan included a deductible; among whom
33.7% knew that their plan exempted a routine annual
primary care office visit from the deductible, and 28.9%
knew that preventive lab tests and cancer screenings
were exempt; altogether 17.5% knew all the preventive
services that were exempt from their deductible. Among
all participants, 8.6% reported delaying or avoiding an
annual routine physical because of concerns about
costs. Among participants meeting guideline
recommendations for obtaining one of the exempted
preventive tests or cancer screenings (according to age,
gender, etc.), 20.3% reported delaying or avoiding an
exempted test or screening because of costs (including
14.8% delaying or avoiding cholesterol tests, 11.0% for
diabetes tests, 13.2% for colon cancer screenings and
11.6% for mammograms). In multivariate analyses,
participants who did not know that routine preventive
physicals were exempt from their deductible were
significantly more likely to avoid them due to cost
concerns (OR=2.13, 95%CI=1.09-4.17), and those who
reported that non-preventive screenings were included in
the deductible (i.e., pay full price until reaching
deductible) were more likely to report avoiding
preventive tests/screenings (OR=1.95, 95%CI=1.03 3.69).
Conclusions: Even though their deductible plan
exempted preventive primary care visits, preventive
medical tests and cancer screenings, only one third of
consumers understood each of these exemptions and
less than one in five knew all the preventive care
exemptions. Those who did not understand the
exemptions were more likely to avoid preventive care
because of cost concerns.
Implications for Policy, Delivery or Practice: The
complexity of CDHP details may not be clearly
understood by patients, and this confusion could create
barriers to seeking preventive care, even when it is
exempt from the deductible. Reports of delaying or
avoiding preventive care raise concerns about the
clinical appropriateness of these care-seeking choices
and highlight the importance of education efforts to
increase awareness of insurance benefit design features
designed to promote preventive care, including in
CDHPs and emerging value-based designs.
Funding Source(s): Kaiser Foundation Research
Institute
• Prescription Drug Use Before and After Switching
to a High-Deductible Health Plan
Sheila Reiss, M.S., R.Ph.; Dennis Ross-Degnan, Sc.D.;
Stephen Soumerai, Sc.D.; James Frank Wharam, M.B.,
B.Ch., B.A.O., M.P.H.; Fang Zhang, Ph.D.; Alan
Zaslavsky, Ph.D.
Presented by: Sheila Reiss, M.S., R.Ph., Ph.D.
Candidate, Research Fellow, Department of Population
Medicine, Harvard Medical School & Harvard Pilgrim
Health Care Institute, 133 Brookline Avenue, 6th Floor,
Boston, MA 02215; Phone: (617) 509-9510; Email:
skreiss@fas.harvard.edu
Research Objective: Employers are increasingly
turning to high-deductible health plans (HDHPs) to
control rising health care costs. Although HDHPs
reduce expenditures and premiums, concerns exist that
members might underutilize necessary care due to
increased cost sharing. Research has demonstrated
that HDHPs that subject prescriptions to a deductible
alter use of essential chronic medications. However, no
studies have assessed whether HDHPs that selectively
exclude medications from full cost sharing preserve
utilization.
Study Design: Interrupted time series with comparison
group.
Population Studied: We examined 2001–2008
pharmacy claims data of 3,348 continuously enrolled
adults in a Massachusetts health plan for 9 months
before and 24 months after an employer-mandated
switch from a traditional HMO plan to a HDHP,
compared with 20,534 contemporaneous matched
controls who remained in traditional HMO plans by
employer choice. Both study groups faced modest
three-tiered drug copayments for the duration of the
study. We defined sub-cohorts with diabetes,
hypertension, hyperlipidemia, and chronic pulmonary
disease based on the presence of baseline ICD-9
diagnoses. We calculated the daily average number of
medications on hand over a month (“daily medications
available”, DMA) for all prescription drugs and four
chronic medication classes in the sub-cohorts above:
hypoglycemics, lipid-lowering agents, antihypertensives,
and COPD/asthma controllers. We used generalized
linear models and segmented time-series regression
analysis to examine differential changes in the level and
trend in medication use. Statistical models (GLM)
adjusted for key individual characteristics as well as
changes in drug cost sharing.
Principal Findings: After the index date the HDHP and
control groups had comparable changes in the level and
trend of overall mean DMA (all drugs combined), which
were not statistically different by study group after
controlling for individual covariates and drug costsharing changes. We detected similar patterns in
medications used to treat hypertension, hyperlipidemia,
and chronic pulmonary disease. Some evidence
suggests that diabetic patients in HDHPs may have
experienced a small relative decline in hypoglycemic use
compared to patients who remained in HMO plans.
Conclusions: Switching to an HDHP that included
modest, tiered copayments for medications did not
change overall prescription drug dispensing or reduce
the use of essential medications for three common
chronic illnesses. Future studies should examine the
impact of HDHPs on medication use for diabetes
patients and other vulnerable populations to be sure that
essential care is maintained for the sickest patients.
Implications for Policy, Delivery or Practice: HDHPs
with modest drug cost sharing may be a viable policy
option for preserving overall use of medications while
more broadly controlling costs. Such plans may also
preserve the use of several chronic medication classes
that are essential in managing diseases causing a high
degree of morbidity and mortality. However, there may
be illness-specific exceptions to this finding, such as
diseases that are severe and costly.
Funding Source(s): Harvard Pilgrim Health Care
Foundation
• Evidence on Consumer Health Plan Choice When
the Choice Set Includes a Dominated Plan
Anna Sinaiko, M.P.P.; Richard Hirth, 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 health plan choices
and switching rates when consumers face a set of health
plans that includes a dominated plan: a plan that is the
same or worse than another plan on all dimensions and
worse than that plan on at least one dimension for all
possible health states.
Study Design: We examine a private employer setting
where one of six plans offered to a subset of employees
was dominated. For single subscribers, one HMO option
(HMO A) was dominated by the POS plan because for
the same price (zero out-of-pocket premium), the POS
plan offered the same benefits as HMO A with access to
the same network of providers, plus self-referral to
specialists in-network, partial coverage for care out-ofnetwork, and a few additional benefits. We conducted
descriptive and multivariate analyses (logit and nested
logit models) to understand patterns of enrollment in the
dominated plan, the characteristics of employees who
select the dominated plan, and patterns and
characteristics associated with switching out of the
dominated plan in comparison to the other plans.
Population Studied: We analyze data on health plan
choices made by 10,758 unique employees who
selected individual coverage through the University of
Michigan. HMO A was dominated from 1991-2003, we
have data from the last two years of this period. The
data include employee age, gender, annual salary, jobtype (academic or not), campus, union status, residence
zip code, and number of years employed.
Principal Findings: Approximately one-third of workers
enrolled in the dominated plan (HMO A) in both 2002
(35.2%) and in 2003 (35.3%); workers who have been
employed for at least six years were more likely to be in
the dominated plan. Some of this enrollment may be
explained by inertia (individuals who selected the plan
before it became dominated in 1991 and then failed to
switch out of the plan over time). However, an equally
large portion of employees selected the suboptimal plan
when their initial choice set included the dominated plan.
Overall, rates of switching out of the dominated plan
were similar to that of all other plans (4.6% vs 5.1%,
p=0.30); conditional on switching between HMO A and
the POS, the relative switch rate into the POS is greater
than into HMO A. Men are more likely to be in the
dominated plan and less likely to switch out of it.
Sensitivity analyses using data on choices made by our
analysis sample in 2004 when we have data on total
pharmaceutical spending, a crude proxy for health
status, do not change these findings.
Conclusions: Enrollment in the dominated plan may be
due to inertia and poor decision-making. Higher rates of
decision-making errors are observed among workers
who chose the dominated plan when it was dominated
(post-1991), and because of low switching rates, remain
in this plan over time.
Implications for Policy, Delivery or Practice: In a
setting where the number of choices is modest, the
market on its own will not eliminate the choice of suboptimal health plans. Health reform that relies heavily on
consumer choice may result in unintended and inefficient
outcomes.
Funding Source(s): NIA
Chronic Care Complexity and Coordination
Chair: Susan Reinhard
Sunday, June 27 * 4:15 pm–5:45 pm
• Chronic Illness Pain Control Impact of a Pre-visit
Assessment of Patient Agendas
Betty Chewning, Ph.D.; Betsy Sleath, Ph.D.; Brenda
Devellis, Ph.D.; Carolyn Bell, Ph.D.; Kevin McKown,
Ph.D.; Morris Weinberger, Ph.D.
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: Midst growing time pressure,
there is a need to maintain and even enhance the quality
of physician-patient encounters, particularly for
vulnerable, older adults with chronic conditions.
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 the health
outcome of pain would improve if a rheumatology
patient’s priorities would be assessed immediately
preceding their rheumatology 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)
control: patients received a computerized lifestyle
assessment in the waiting room immediately before they
entered the exam room; or 2) experimental: 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 (AIMS 2). 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 to cue discussion. A 12 month longitudinal design
was used with a pre-intervention baseline, initiation of
the intervention at the 6 month visit, and follow-up
intervention at the 12 month visit when patient pain
measures were collected. Measures collected at
baseline (T1), 6-months (T2), and 12-months (T3)
included the patient’s visual analogue scale of pain in
the past 24 hours, the physician’s global assessment of
the patient’s health and the patient’s AIM2 subscale of
pain in the past month.
Population Studied: A total of 523 patients met the
study criteria of being at least age 45 and having a
formal diagnosis of rheumatoid arthritis, mental
competence, and the ability to read and speak English.
The final sample was 450 with a participation rate of
86%. Patients had a mean age of 62 and were enrolled
from 6 rheumatology clinics in two states (Wisconsin and
North Carolina). Eighteen rheumatologists participated,
but three were dropped from the following analyses
because they saw too few patients (3, 5, and 8). Eighty
four percent of the patients were retained for 1 year.
Principal Findings: Consistent with the apriori
hypotheses, a positive significant treatment effect for
patients’ pain at T3 (12-month visit) was found. We
explored the dynamics underlying this effect. The largest
impact occurred when physicians perceived the patient’s
health having declined at T2 (6-month visit) compared to
T1 (baseline visit).
Conclusions: The condition under which it is imperative
to address pain is where pain has gotten worse, and this
is precisely where the intervention had its greatest
impact.
Implications for Policy, Delivery or Practice: This
study suggests that a simple, pre-visit computerized
assessment and summary of patient health priorities can
contribute to an improved health outcome such as pain
for patients with a chronic condition such as rheumatoid
arthritis. Further, well organized computerized aids
(including EHR) are needed to help physicians track
patient symptoms longitudinally.
• The Implications of Therapeutic Complexity on
Medication Adherence
Niteesh Choudhry, M.D., Ph.D.; Michael Fischer, M.D.,
M.S.; Jerry Avorn, M.D.; Joshua Liberman, Ph.D.;
Sebastian Schneeweiss, M.D., Sc.D.; William Shrank,
M.D., M.S.H.S.
Presented by: Niteesh Choudhry, M.D., Ph.D.,
Assistant Professor, Division of Pharmacoepidemiology
and Pharmacoeconomics, Harvard Medical School,
Brigham and Women's Hospital, 1620 Tremont Street,
Suite 3030, Boston, MA 02120; Phone: (617) 278-0930;
Email: nchoudhry@partners.org
Research Objective: Medications are a cornerstone of
the prevention and management of chronic diseases and
their complications. Because a substantial number of
patients have multiple chronic conditions, treatment
regimens are often complex. This complexity may
undermine the goals of chronic disease management.
For example, patients who are prescribed medications
that must be taken multiple times per day are less likely
to adhere to their treatments than patients with simpler
dosing schedules. Structural aspects of the health care
system, including the number of prescribers, pharmacies
and visits patients must make to pick up their
prescriptions, may also increase therapeutic complexity
and influence adherence. These factors are potentially
subject to intervention but have not been evaluated.
Study Design: We assembled a cohort of patients who
were prescribed: (1) a statin cholesterol lowering
medication (n=1,827,474) or (2) an angiotensin
converting enzyme inhibitor (ACEI)/renin angiotensin
blocker (ARB) (n=1,480,948). During the 3-month period
after their first eligible prescription (the complexity
assessment period), we measured the number of unique
medications, prescribers, pharmacies, pharmacy visits
and pharmacy visit inefficiency (a measure of the
number of medications filled per visit with higher
numbers representing less synchronization of refills). For
the ACEI/ARB analysis we also measured the number of
daily medication doses. After this 3-month window we
assessed medication adherence during the subsequent
year by calculating the proportion of days covered (PDC)
for each medication class. We performed multivariable
linear regression to determine the relationship between
the various measures of therapeutic complexity and
adherence, after controlling for patient demographics,
comorbidity, and medication costs.
Population Studied: Individuals receiving prescription
drug coverage from CVS Caremark, a large pharmacy
benefits manager.
Principal Findings: During the 3-month complexity
assessment period, patients in the ACEI/ARB cohort
used a mean of 6.6 unique medications (90th percentile
12.0), had prescriptions written by a mean of 2.0
prescribers (90th percentile 4.0), filled prescriptions at a
mean of 1.1 pharmacy (90th percentile 2.0), made a
mean of 5 visits to the pharmacy (90th percentile 11.0),
consumed a mean of 1.1 ACEI/ARB doses per day (90th
percentile 2.0), and had a mean visit inefficiency of 0.5
(90th percentile 0.9). In multivariable models,
independent predictors of worse medication adherence
included a greater number of prescribers, visits to more
unique pharmacies and less synchronization of refills.
For example, each additional pharmacy visit during the 3
month complexity assessment window was associated
with a 2% reduction in medication adherence over the
subsequent year. Using more unique medications was
associated with greater adherence. Similar results were
seen in the statin and ACEI/ARB cohort. Additionally, in
the ACEI/ARB cohort, a greater number of daily doses
was associated with worse adherence.
Conclusions: In users of the two common medication
classes we studied, medication use was extremely
complex. Patients with more complex treatment
regimens and filling patterns are less likely to be
adherent.
Implications for Policy, Delivery or Practice: These
results suggest that novel efforts to improve chronic
disease management and medication use may include
strategies that increase care efficiency by reducing the
number of physicians and pharmacies from which
patients receive their medications and improving the
coordination of medication filling at pharmacy visits.
Funding Source(s): CVS Caremark
• Results from Radical Makeover of Care
Coordination Program Show How Program Design
Affects Success in Reducing Hospitalizations and
Costs: Evidence from a Randomized Controlled Trial
Before and After Key Changes in Program Design
Deborah Peikes, Ph.D., M.P.A.; Greg Peterson, M.P.A.;
Jennifer Schore, M.S.W., M.S.; John Lynch, M.D.; Sandy
Graff, R.N., B.A., C.C.M., C.P.U.R.; Randall Brown,
Ph.D.
Presented by: Deborah Peikes, Ph.D., M.P.A., Senior
Researcher, Health Research, Mathematica Policy
Research, 600 Alexander Park, Princeton, NJ 08540;
Phone: (609) 750-2005; Email: dpeikes@mathematicampr.com
Research Objective: Determine whether cost
effectiveness of Washington University (WU)’s care
coordination program, part of the Medicare Coordinated
Care Demonstration (MCCD), changed after switching
from a model where an out-of-state case management
firm (StatusOne) provided coordination services
telephonically for 80% of beneficiaries to a fully local
delivery model where WU nurses: met with patients and
physicians in person; developed care plans based on
more extensive, in-person assessments; provided
transitional care; and developed computerized systems
to support medication management and other activities.
Study Design: MCCD was a randomized controlled trial
of 15 different care coordination interventions across the
country. We analyzed Medicare claims to compare
impacts on hospitalizations and Medicare expenditures
before (8/2002–2/2006; N=2,144) and after WU’s switch
to a local model (3/2006–8/2008, N=2,166). Regressionadjustment controls for chance pre-enrollment treatmentcontrol differences in medical history, service use, and
demographics.
Population Studied: FFS Medicare beneficiaries with
one or more chronic conditions, at significant risk for
hospitalization. Common chronic conditions were
coronary artery disease (63%), congestive heart failure
(46%), diabetes (41%), cancer (not skin) (27%), chronic
obstructive pulmonary disease (25%), and depression
(24%). Participants averaged 1.8 hospitalizations and
$2,496 in monthly Medicare expenditures in the year
before enrollment. 20% were dually eligible for Medicaid.
Principal Findings: The primarily telephonic
intervention did not reduce hospitalizations or Medicare
expenditures, leading to increased total costs (with fees)
to Medicare (p=0.02). After switching to the local model,
the program reduced hospitalizations by 12% (0.159
hospitalizations/beneficiary/year, p=0.04), and Medicare
expenditures by 10% ($217 PBPM, p=0.05), enough to
cover program fees of $151 PBPM. Impacts were
concentrated among beneficiaries whose conditions and
utilization, at enrollment, placed them at higher risk of
subsequent hospitalizations. For example, for the 57
percent of enrollees who had CAD, CHF, or COPD and
1+ hospitalization in the prior year, WU reduced
hospitalizations by 17% (0.289 admissions/year, p=0.01)
and expenditures, without fees, by $413 PBPM
(p=0.01)—resulting in $261 PBPM estimated net savings
(including fees). Additional analyses showed the larger
impacts after 3/2006 were not due to enrollees’ longer
tenure in the program.
Conclusions: While complex case management
delivered to most patients telephonically did not reduce
expenditures for chronically ill Medicare beneficiaries,
switching to a local model that included the opportunity
for increased in-person contact with patients and
physicians and transitional care did. Furthermore, the
savings for a high-risk group defined by particular
conditions and a recent hospitalization more than offset
program costs, reducing total Medicare spending,
including fees, by 9.5%. If impacts could be replicated
for the 13.6% of Medicare FFS beneficiaries nationwide
who meet this high-risk definition, Medicare expenditures
could be reduced by roughly $11 billion per year (2009
dollars).
Implications for Policy, Delivery or Practice: This
intervention joins the few tested interventions that
generate savings for chronically ill Medicare
beneficiaries and is especially promising for other urban,
safety net settings. The findings reinforce the conclusion
reached by others that care coordination programs that
are more connected to patients and providers are more
successful for Medicare beneficiaries than telephonic
ones. Important next steps are to develop detailed
protocols and test replicability in other settings.
Funding Source(s): RWJF, (HCFO) and CMS
• Managing Heart Disease in Older Americans: CostEffectiveness of Cardiac Rehabilitation
Donald Shepard, Ph.D.; Jose Suaya, M.D., Ph.D.,
M.P.H.; William Stason, M.D., M.S.; Philip Ades, M.D.
Presented by: Donald Shepard, Ph.D., Professor,
Heller School, Brandeis University, Heller School, Room
275, MS 035, Waltham, MA 02454-9110; Phone: (781)
736-3975; Email: shepard@brandeis.edu
Research Objective: Each year, about 13 million
Americans suffer from coronary heart disease (CHD)
and about 480,000 die from the condition. Cardiac
rehabilitation (CR), which includes monitored aerobic
exercise, and instruction for diet, weight loss, and stress
modification, is professionally recommended for many
categories of patients with CHD and covered by
Medicare and most commercial insurers. This paper
conducts a cost-effectiveness analysis of CR in older
Americans.
Study Design: Using the framework recommended by
the US Public Health Service, we estimated the costeffectiveness ratio as net impact on lifetime health costs
divided by the net impact on lifetime on quality-adjusted
life years (QALYs). We developed an Excel model and
calibrated it with data from the literature (e.g. Medical
Expenditure Panel Survey, US life tables, and a
randomized trial by Yu et al., 2004) and our own analysis
of Medicare claims and denominator data. We estimated
impacts on outcomes and costs from two matched
groups of Medicare beneficiaries with CHD. The
treatment group received at least one CR session. The
comparison group (beneficiaries using no CR) was
matched using propensity-based matching based on
extensive medical and socio-demographic
characteristics. After calibrating the model, costs and
survival were projected for each beneficiary’s remaining
lifetime.
Population Studied: We studied 601,099 fee-forservice Medicare beneficiaries aged 65 and above
hospitalized in 1997 for CHD. We matched 70,056 pairs
of beneficiaries and followed each for 5 years,
generating 700,000 person-years of data.
Principal Findings: Only 12.2 % of beneficiaries
received one or more CR outpatient sessions. Older
patients, those with co-morbid conditions, residents of
low-income neighborhoods, and women were
particularly unlikely to use CR. Cumulative 5-year
mortality was 16.3% in CR-users vs. 24.6% in matched
non-users at five years, a 34% reduction (p<0.001).
Overall, each participant gained 0.32 QALYs over the
observation period and 0.69 QALYs over his lifetime, of
which 67% was achieved through longer survival.
Because CR users live longer than non-users, their
lifetime costs were $7414 higher. The incremental costeffectiveness of CR was $10,771 per QALY gained.
Conclusions: Standard guidelines from US government
and international agencies rate interventions with costeffectiveness ratios under $100,000 and $145,000,
respectively, as cost-effective. CR is highly costeffective, being only a tenth of either of these thresholds.
Like smoking cessation, CR is highly cost-effective but
underutilized. CR is also substantially more costeffective than increasingly used technological
approaches to heart disease, such as implantable
defibrillators.
Implications for Policy, Delivery or Practice: The
combination of very favorable effectiveness and costeffectiveness of CR coupled with low rates of use
suggests that policy makers develop and test strategies
to improve CR utilization. Promising options include
“automatic” referral of eligible patients, improved
communication about CR among physicians, patients,
hospitals, and CR facilities, public reporting of rates of
referral to CR and utilization of CR by hospital, and
incentives for attainment and improvement on rates of
CR referral and utilization.
Funding Source(s): CMS
Family Life and Child Health: Intergenerational
Inquiries
Chair: Alyna Chien
Monday, June 28 * 9:45 am–11:15 am
• Domestic Violence Impacting Children with Special
Health Care Needs
Anthony Goudie, Ph.D.; Gerry Fairbrother, Ph.D.; Lisa
Simpson, M.B., B.Ch., M.P.H., F.A.A.P.
Presented by: Anthony Goudie, Ph.D., Assistant
Professor, Child Policy Research Center, Cincinnati
Children's Hospital Medical Center, 3333 Burnet
Avenue, Cincinnati, OH 45229; Phone: (513) 803-2107;
Email: anthony.goudie@cchmc.org
Research Objective: This study examines the
association between physical violence against a parent
or guardian and whether the household is home to a
child with special health care needs (CSHCN). The
direct and indirect stressors of caring for a CSHCN may
be contributing factors in the increased risk of domestic
violence. Children exposed to violence in the household
may also experience higher levels of emotional,
developmental, or behavioral difficulties that require
special health care needs. This study will: i) identify if
there is a higher incidence of violence in families with
CSHCN, ii) determine if violence is associated
specifically with increased odds of children having
emotional, developmental, or behavioral difficulties, and
(iii) ascertain if children with emotional, developmental,
or behavioral difficulties have more emergency
department (ED) visits or delayed/forgone needed health
care.
Study Design: This study uses data collected during the
2008 Ohio Family Health Survey (OFHS). Physical
violence is measured as the number of incidents the
respondent identified that they were hit, slapped,
pushed, kicked or physically hurt in the previous 12
months. Determination of special health care needs is
obtained through a standard series of validated screener
questions. Odds ratio results from logistic regression
models are adjusted for parent/guardian’s education,
race, gender, poverty and marital status, and child’s age
and gender. Insurance status is included in resource
utilization models.
Population Studied: In Ohio, an estimated 106,856
adults, or 4.3% of the adult population caring for children
were the victim of at least one episode of physical
violence in the year preceding the survey. Of these,
37,841 (35.4%) were the parent or guardian of a child
with special health care needs (CSHCN).
Principal Findings: Compared to non-CSHCN, CSHCN
requiring both regular prescription medications and
elevated health-related services were 1.7 times (95% CI:
1.1, 2.9) more likely to reside in a household with a
parent or guardian who was a victim of physical
violence. For children with functional limitations this rate
is 3.1 times (95% CI: 2.0, 4.6) higher compared to nonCSHCN. Compared to households with no episodes of
physical violence, those with violence are 2.5 times
(95% CI: 1.8, 3.6) more likely to have a child with
emotional, developmental, or behavioral difficulties.
These children are 2.0 times (95% CI: 1.7, 2.5) more
likely to have had an ED visit and 2.3 times (95% CI: 1.7,
3.2) more likely to have delayed or forgone needed
health care compared to children without emotional,
developmental, or behavioral difficulties.
Conclusions: Higher levels in the complexity of special
health care needs are associated with higher levels of
domestic violence. Also, physical violence is associated
with higher odds of children with emotional,
developmental, or behavioral difficulties in the
household. These children use the ED and delay/forgo
health care at higher odds than children who do not have
these difficulties.
Implications for Policy, Delivery or Practice: This
study has demonstrated the utmost importance of having
parents and caregivers of CSHCN that are not victims of
physical violence. Interventions must be available to help
relieve stressors and develop coping mechanisms to
avoid circumstances that result in acts of violence.
• Modeling Family and Health System Correlates of
Caregiver Burden Among Families of Children with
Developmental Delays and Disabilities
Beth McManus, P.T., M.P.H., Sc.D.; Adam Carle, Ph.D.;
Dolores Acevedo-Garcia, Ph.D.; Michael Ganz, Ph.D.;
Penny Hauser-Cram, Ed.D.; Marie McCormick, M.D.,
Sc.D.
Presented by: Beth McManus, P.T., M.P.H., Sc.D.,
RWJ HSS Scholar, Population Health Sciences,
University of Wisconsin-Madison, 610 Walnut Street,
707 WARF, Madison, WI 53726; Phone: (617) 5298138; Email: mcmanus2@wisc.edu
Research Objective: Previous research suggests that
nearly 1 in 5 children will have a developmental disability
and that the vast majority of these children receive their
cared at home. Parents assume an informal caregiver
role and can experience tremendous financial and time
burden. In this study, we sought to describe sociodemographic and health service characteristics
associated with caregiver time and financial burden of
parents of children with special health care needs
(CSHCN).
Study Design: We used a structural equation model to
examine the relationship among 3 constructs: Caregiver
Burden, Ease of Accessing and Navigating the Health
Care System, and Unmet Health Care Needs. We
operationalized these constructs using theoretical and
empirical evidence from the International Classification
of Function, Disability, and Health; American Academy
of Pediatrics policy on medical homes; Maternal and
Child Health Bureau best practice guidelines for family
centered care and care coordination, and federal policy
governing Special Education.
Population Studied: We used a subset of data from the
2005-2006 National Survey of CSHCN and included
15,891 children with a parent reported developmental
disability or delay that affected the child’s ability to
function at least some of the time. Additionally,
compared to similarly aged peers, the children we
included also either needed physical, occupational, or
speech therapy or had functional limitations; or had
developmental or behavioral difficulties; or required
additional medical, educational, or developmental
services.
Principal Findings: Our model revealed a moderately
prevalent rate of caregiver burden among families of
CSHCN. Nearly 25% of families reported some aspect of
financial burden and 15% spent more than 6 hours per
week providing or coordinating their child’s health care.
Ease of Accessing and Navigating the Health Care
System was associated with less caregiver burden (ß = .985, SE(ß) = 0.019) and there was a positive
association between Unmet Health Care Needs and
Caregiver Burden (ß = .923, SE(ß) = 0.020). The largest
contributor to Caregiver Burden was time that families
spent providing care for their child. Not participating in
Special Education was the largest contributor to both
Ease of Accessing the Health Care System and Unmet
Health Care Needs. Poor and (p=0.0005) non-white
families (p=0.08) were more likely to experience
caregiver burden, unmet healthcare needs, and difficulty
accessing and navigating the healthcare system.
Conclusions: Families of CSHCN endure time and
financial burden and these experiences affect poor
families more dramatically.
Implications for Policy, Delivery or Practice: Policy
and programmatic initiatives that ensure that families of
CSHCN access and navigate the healthcare system and
receive all necessary health services will likely reduce
caregiver burden. In particular, participation in Special
Education will apparently buffer unmet healthcare needs.
Pediatricians and Special Education practitioners should
play an integral role in bolstering service delivery for
CSHCN in order to reduce caregiver burden.
Funding Source(s): CDC
• Psychotropic Medication Use in Dependent
Children of Active Duty Soldiers Following Parent’s
Deployment
Beth Mohr, M.S.; Mary Jo Larson, Ph.D., M.P.A.; Rachel
Sayko Adams, M.P.H.; Jennifer Perloff, Ph.D.; Michael
Keane, Dr.PH.; Thomas Williams, Ph.D.
Presented by: Beth Mohr, MS, Senior
Programmer/Biostatistician, The Heller School, Mailstop
035, Brandeis University, P.O. Box 549110, Waltham,
MA 02454-9110; Phone: (781) 736-3814; Email:
mohr@brandeis.edu
Research Objective: Deployment is a stressful time for
military families, and children especially experience
increased levels of depression, anxiety, and stress when
a parent deploys. Compounding these problems,
families may face logistical and other barriers to
accessing mental health treatments. We analyzed data
from TRICARE, the military’s healthcare program, to
determine whether psychotropic medication usage
increased among child dependents following the
deployment of their active duty parent (sponsor).
Study Design: Quasi-experimental design to compare
dependent children of sponsors who had a deployment
overlapping FY07 (deployed group) to children of
sponsors without a deployment for 24 months inclusive
of FY07 (comparison group). Deployment was defined
as 6 months or more on a contingency operation away
from the permanent station. Psychotropic medication
users in the year before and after deployment start date
(pseudo deployment date assigned for comparison
group) were compared using difference-in-differences
(DID) analysis, with adjustment (multivariate regression)
for age, gender, Sponsor’s rank and race/ethnicity,
residence region, proximity to military treatment facilities,
“risk” (HCC) score, and primary care manager (military,
civilian, or unenrolled in managed care). Psychotropic
medications were defined as antidepressants,
antipsychotics, anxiolytics, sedatives, hypnotics, and
stimulants.
Population Studied: Dependent children of Army Active
Duty sponsors with TRICARE eligibility in the
deployment month and 24 months abutting deployment
and no reported other health insurance. Three samples
were analyzed: full (N=337,122), younger (less than 12
yr pre-deployment; n=252,953) and older (greater than
12 yr; n=84,169).
Principal Findings: In the full sample, children of
deployed sponsors were younger (median age 7 yr) than
children in the comparison group (9 yr). During the
period before deployment, rates of psychotropic
medication usage in the deployed and comparison
groups were similar: full 7.2% and 7.6%, respectively.
Psychotropic medication usage in the full sample
increased from pre to post deployment in the deployed
and comparison groups, but by a larger amount in the
deployed group (adjusted DID statistic: 0.4 percentage
points; 95% confidence interval (CI): 0.2-0.6; p<0.0001).
Usage relative to the comparison group also increased
in both the younger (0.4; 0.2-0.6; p<0.0001) and older
samples, but the increase was only marginally significant
in the older sample (0.4; 0.01-0.8; p<0.0454).
Conclusions: Relative to the comparison sample and
adjusting for group differences, children of deployed
sponsors increased their overall psychotropic
medications usage by 6% and their antidepressant
usage by 17% in the year following their parent’s
deployment.
Implications for Policy, Delivery or Practice: This
study demonstrates that TRICARE could assist families
by creating programs to reduce adverse effects of
deployment. In particular, TRICARE could develop
continuous care plans for children with identified
behavioral health concerns to prevent problems from
escalating. Also, TRICARE should ensure psychotropic
medications are appropriately prescribed and managed
among all children, but especially in children who may
have adjustment problems associated with the recent
deployment of a parent.
Funding Source(s): Task Order contract, (HHS
Program Support Center), TRICARE Management
Activity, Department of Defense
• Similarities and Differences in Mental Health
Services Use for Children with and without
Homeless Episodes
Jung Min Park, Ph.D.
Presented by: Jung Min Park, Ph.D., Assistant
Professor, School of Social Work, University of Illinois at
Urbana-Champaign, 1010 W. Nevada Street, Urbana, IL
61801; Phone: (217) 244-5243; Email:
parkjm@illinois.edu
Research Objective: This study examined whether
children who become homeless differ from other lowincome children in their mental health service use before
and after their first homeless episode, and whether and
to what extent homelessness is associated with the
likelihood of and disparities in mental health service use.
This study addressed several limitations of previous
studies in this area by looking at a large cohort of
children who entered the homeless shelter system,
linking the cohort to Medicaid claims data to provide
objective measures of mental health service use,
comparing the experiences of homeless children over
time to those of other low-income children, and providing
better insight into the temporal relationship between
homelessness and health care use.
Study Design: This is a population-based longitudinal
study. The prevalence, intensity, and cost of inpatient
and outpatient mental health services over 7 years
between children with and without an episode of
homelessness were compared. Logistic regression
analysis was conducted to assess the association of
homelessness and other covariates with inpatient and
outpatient mental health services use.
Population Studied: This study followed 241,692
Medicaid-enrolled children in a large metropolitan area
with and without history of homelessness to observe
their mental health service use.
Principal Findings: Overall, 4.7% of the homeless
group received inpatient mental health services during
the observation period, compared with 3.0% of the nonhomeless group. Use of outpatient mental health
services was more common in both groups.
Approximately 24.9% of homeless children used
outpatient services, compared with 17.9% of nonhomeless children. On average, the number and cost of
outpatient visits were higher among homeless children.
Homeless children were similar to other low-income
children in mental health service use prior to their first
homeless episode. Differences in rates of service use
emerged during and following homelessness, and the
gap between the two groups widened thereafter. In
adjusted analyses, homelessness increased the
likelihood of using inpatient care by 61% (P<.001) and
outpatient care by 50% (P<.001). Being male, White,
Hispanic, older age, receiving SSI, and foster care
history were also associated with an increased likelihood
of mental health service use.
Conclusions: Our results suggest that not only
homelessness increases need for mental health services
due to its magnifying effect on familial dysfunctions and
difficulties with fitting into the shelter life, but also contact
with the homeless shelter system may trigger
professional recognition that services are needed and
act as a gateway to those services.
Implications for Policy, Delivery or Practice:
Comprehensive initial health screenings and inquiries
about previous and current health service use at the time
of intake interviews at the shelter system can contribute
to identifying service needs of homeless children and
facilitating adequate referrals of the children to health
professionals.
Funding Source(s): National Institute of Child Health
and Human Development
• The Impact of Childhood Activity Limitations on
Child and Family-Level Healthcare Related Financial
Burden in the U.S.
Whitney Witt, Ph.D., M.P.H.; Kristin Litzelman, B.A.;
Carmen Mandic, Sc.D; Lauren Wisk, B.S; John
Hampton, M.S; Carissa Gottlieb, M.S.
Presented by: Whitney Witt, Ph.D., M.P.H., Assistant
Professor, Department of Population Health Sciences,
University of Wisconsin, Madison, 610 North Walnut
Street, WARF Office 503, Madison, WI 53726; Phone:
(608) 265-6290; Email: wwitt@wisc.edu
Research Objective: Families of children with special
healthcare needs and activity limitations have higher
healthcare utilization, healthcare expenditures, and outof-pocket expenses than children without. Increased outof-pocket healthcare expenses for these families can
lead to substantial financial burden. Our objective was to
examine the relative and absolute burden attributable to
both child and family-level expenditures for families with
and without a child with an ongoing activity limitation. We
also examined whether, and to what extent,
socioeconomic disparities exist in financial burden.
Study Design: Ten full panels (1996-2006) of the
Medical Expenditure Panel Survey (MEPS) were used to
examine out-of-pocket healthcare related expenditures
for 17,857 families with children aged 0-17 years.
Logistic regression was performed to determine the
relationship between childhood activity limitation status
and absolute and relative financial burden at the child
and family level, stratifying by income and adjusting for
demographic factors. Absolute burden was defined as
excessive out-of-pocket healthcare expenditures.
Relative burden was the ratio of out-of-pocket
expenditures to income (adjusted for family size and
composition using the OECD-modified equivalence
scale).
Population Studied: This study uses a nationally
representative sample of the civilian non-institutionalized
population in the United States. Children were defined
as having activity limitations if they were limited in their
daily living activities reflective of their developmental
stage due to an impairment or a physical or mental
health problem.
Principal Findings: Families of children with activity
limitations were more likely to report relative and
absolute burden at both the child and family-level. This
effect on relative burden significantly varied by income,
such that families of children in the lowest income tertile
had the greatest odds of experiencing child and familylevel financial burden (>5% and >10%, respectively).
Families of children with activity limitations in the
medium and high income tertiles were significantly more
likely to experience absolute family-level financial burden
(>$1000 per year) than families of children without
limitations in the highest income tertile. All families of
children with activity limitations were more likely to
experience absolute child-level financial burden (>$500
per year).
Conclusions: Childhood activity limitations are not only
responsible for increased expenditures related to the
child’s healthcare, but also for increased healthcare
expenditures by the family as a whole. Families of
children with activity limitations experience both greater
absolute and relative financial burden compared to
families of children without activity limitations.
Furthermore, families in the lowest income tertile had the
greatest risk of experiencing excessive financial burden,
indicating a significant disparity.
Implications for Policy, Delivery or Practice: An
increase in family-level expenditures indicates the
rippling effect that an entire family can experience as a
result of childhood activity limitations. These findings
underscore the need for family focused care and for
understanding how addressing caregiver needs may
improve their mental health status and reduce financial
burden. More policies are needed to assist families in
obtaining affordable, comprehensive insurance coverage
that will reduce out-of-pocket expenses, including reevaluating SCHIP eligibility requirements and expanding
coverage to include the entire family.
Funding Source(s): National Institute of Child Health
and Human Development
The Effects of Benefit Design on Patients
Chair: Lisa Dubay
Monday, June 28 * 9:45 am–11:15 am
• An Evaluation of the Impact of Copayment
Reductions for Essential Cardiovascular
Medications on Health Spending and Clinical
Outcomes
Niteesh Choudhry, M.D., Ph.D.; Michael Fischer, M.D.,
M.S.; Jerry Avorn, M.D.; Sebastian Schneeweiss, M.D.,
Sc.D.; Daniel Solomon, M.D., M.P.H.; William Shrank,
M.D., M.S.H.S.
Presented by: Niteesh Choudhry, M.D., Ph.D.,
Assistant Professor, Division of Pharmacoepidemiology
and Pharmacoeconomics, Harvard Medical School,
Brigham and Women's Hospital, 1620 Tremont Street,
Suite 3030, Boston, MA 02120; Phone: (617) 278-0930;
Email: nchoudhry@partners.org
Research Objective: Patent cost-sharing is widely used
to contain health care spending by forcing patients to
consider the costs of therapies or health services before
deciding whether to purchase them. While these
strategies help address the “moral hazard” that may
result from insurance coverage, patients may also cut
back on services of high clinical value. An alternative
approach is to base cost-sharing on value and
specifically to reduce copayments for medications that
provide high benefits relative to their costs. Such valuebased insurance designs (VBID) have attracted much
attention and preliminary evidence supports their ability
to improve appropriate medication use. The impact of
VBID on health care outcomes and spending is
unknown.
Study Design: We measured monthly rates of insurer
spending on prescription drugs, insurer spending on
health care services (including physician visits,
procedures, emergency visits and hospitalizations), rates
of major resource utilization (hospitalizations and
emergency visits), and rates of major coronary events
before and after the introduction of the new copayment
policy for those eligible for reduced copayments
(n=3,513) and compared them to an external control
population (n=49,803). Analysis was performed using
linear segmented regression models. Generalized
estimating equations were used to control for correlated
error terms and potential confounders. In secondary
analyses, we re-ran our models for the subgroup of
patients recently initiated on the study medications, for
those who had a recent myocardial infarction, and after
matching intervention and control subjects in a 1:3 ratio
on their cohort entry date and their baseline health care
spending.
Population Studied: Beneficiaries of a large U.S.
corporation that eliminated copayments for statins
(among patients with diabetes or vascular disease) and
lowered them for clopidogrel (in all employees
prescribed this medication). Control patients were
commercially-insured beneficiaries of a large health
insurer that uses the same pharmacy benefit manager
and the intervention firm.
Principal Findings: Copayment reductions were
associated with small but significant increases in insurer
spending on prescription drugs (increased slope of $5.59
per month for statin users and $9.39 per month for
clopidogrel users, p<0.0001). Medical and overall
spending changed slightly, with levels and slopes going
in opposite directions, such that 12 months after the new
copayment was introduced there were no significant
differences in spending in either cohort. Similarly, there
were no changes in the rates of resource utilization or
major coronary events (non-significant p-values for level
and slope in all analyses). Results were similar in all
sensitivity analyses.
Conclusions: The reduction of copayments for statins
and clopidogrel were not associated with significant
changes in rates of medical spending, resource
utilization or clinical events.
Implications for Policy, Delivery or Practice: These
results do not demonstrate meaningful changes in health
outcomes or spending from VBID in the population and
time-frame evaluated. Studies of longer duration and/or
involving higher-risk patients who may be more likely to
derive greater clinical and economic benefit from
effective medication use, may help further clarify the
benefits of VBID.
Funding Source(s): CWF
• Value Based Benefit Design in Medicare
Beneficiaries with Diabetes
Amy Davidoff, Ph.D., M.S.; Bruce Stuart, Ph.D.; Ruth
Lopert, M.D.; Thomas Shaffer, M.A.; Jennifer Lloyd,
M.A.; J. Samantha Shoemaker, B.A.
Presented by: Amy Davidoff, Ph.D., M.S., Associate
Professor, Pharmaceutical Health Services Research,
University of Maryland School of Pharmacy, 220 Arch
Street, Baltimore, MD 21201; Phone: (410) 706-5397;
Email: adaivodf@rx.umaryland.edu
Research Objective: To examine potential cost savings
to the Medicare program associated with a “value based”
approach to prescription drug benefit design (VBBD).
Adherence to statin therapy has been demonstrated to
reduce medical costs for Medicare beneficiaries with
diabetes. Reductions in drug plan out of pocket (OOP)
prices may increase medication adherence, increasing
total and plan spending, but with cost offsets for the
Medicare program. In this study we use nationally
representative data to estimate cost responsiveness and
simulate total cost associated with benefit design
changes in a Medicare population.
Study Design: We used 4-year panels constructed from
the 1997-2005 Medicare Current Beneficiary Survey
(MCBS), a nationally representative survey of the
Medicare beneficiary population. We selected
beneficiaries with 1) self report or claims-based
diagnoses of diabetes in Year 1, and 2) use of statins in
Year 2. N= 1,134. Patient drug use and spending was
summed across years 2-4. We computed mean number
of 30 day adjusted statin prescription fills, OOP and third
party (plan) spending on drugs, and Medicare Part A and
B spending. We computed mean OOP payments for
each statin user. We estimated a multivariate OLS
model to predict number of statin fills as a function of
OOP price, and a GLM model with a logit link predicting
Medicare spending as a function of number of fills. Both
models controlled for baseline sociodemographic,
economic, and health status measures. We used the
estimated coefficients to simulate changes in fills
associated with copayments of $5 and $10, and
computed changes in third party payments and Medicare
cost offsets associated with incremental fills.
Population Studied: Medicare beneficiaries with
diabetes who filled statin prescriptions.
Principal Findings: User reported mean values were
fills (21.9 out of a maximum of 36), OOP price ($22) and
plan payments ($57). The estimated effect of OOP price
on statin fills was -0.085 (p<.001). Each incremental
statin fill was associated with a $234 reduction in
Medicare spending. Total plan spending was $1,254. A
simulated OOP price of $5 increased fills by 1.47,
increased plan spending by $486, and generated
Medicare Part A/B savings of $343. Results were
sensitive to the estimated price responsiveness, with a
breakeven reached when the price elasticity was set to 0.14.
Conclusions: Reducing the OOP price of statins for
Medicare beneficiaries with diabetes resulted in small
increases in use, and reductions in other medical
spending, but shifted substantial costs to the prescription
drug plan. This cohort of diabetics was selected because
of expected reductions in medical spending associated
with statin use, but price sensitivity is inadequate to
justify this type of VBBD strategy. In ongoing research
we are examining strategies for targeting OOP price
reductions to selected subgroups, as well as examining
potential use of VBBD to encourage initiation of statin
therapy.
Implications for Policy, Delivery or Practice: Benefit
designs adopted by prescription drug plans can affect
Medicare spending, creating an incentive for Medicare to
intervene in this process, at least for Part D plans. Our
analysis demonstrates that refinements to benefit
designs will need to be carefully crafted to balance
therapeutic and cost-containment goals.
Funding Source(s): RWJF
• The Effects of Health Care Benefits for New
Disability Insurance Beneficiaries: A Randomized
Control Trial
Charles Michalopoulos, Ph.D.; David Wittenburg, Ph.D.;
Anne Warren; Stephen Freedman
Presented by: Charles Michalopoulos, Ph.D., Senior
Fellow, MDRC, 475 14th Street, Suite 750, Oakland, CA
94612; Phone: (510) 844-2235; Email:
charles.michalopoulos@mdrc.org
Research Objective: Under current law, most Social
Security Disability Insurance (SSDI) beneficiaries are not
eligible for Medicare until 24 months after they are
eligible to receive cash benefits. Many therefore lack
health insurance during a period when this might
improve their medical condition. To assess the effects of
providing immediate access to health benefits to newly
entitled SSDI beneficiaries who have no health care
coverage, the Social Security Administration developed
and funded the Accelerated Benefits Demonstration
(AB). The study is especially timely given current
discussions about reforming the health care system to
expand health insurance coverage.
Study Design: New SSDI beneficiaries without health
insurance were recruited by telephone and randomly
assigned to three groups: (1) the AB group, which
received access to a generous health benefit plan, (2)
the AB Plus group, which received the same health
benefit plan as well as medical case management and
services to help them return to work, and (3) a control
group. Surveys were administered at study entry and 6
and 12 months after study entry. In addition, Social
Security administrative records provide information on
impairment type and disability benefits.
Population Studied: The study includes approximately
2,000 new SSDI beneficiaries without health insurance,
about equally divided between men and women. The
most common types of primary impairments were mental
health (22%), musculoskeletal (19.4%), diseases of the
nervous system (16.8%), diseases of the circulatory
system (11.6%), and neoplasms (8.2%). About 70% of
sample members indicated they had an unmet medical
need at the time they entered the study. Reflecting lower
insurance rates in the South, nearly half of the sample
came from the South.
Principal Findings: In the six months following study
entry, five in six program group members had used the
project’s health care benefits. Although some control
group members acquired health insurance after they
entered the study, three-fourths were still uninsured six
months later. Nonetheless, virtually all control group
members received some health care, with 85 percent
seeing a doctor in the six months after entering the study
and 72 percent indicating they had a regular source of
care. Despite the high rates of health care use among
control group members, program group members were
more likely than control group members to see a doctor
(p-value=.02) and to have a regular source of care
(p=0.01). Program group members also made more
health care visits than control group members. Despite
the increased access to regular care, program group
members were also more likely to use the Emergency
Department (36.6% vs. 27.8%, p=0.04) and had more
hospital admissions (23.3% vs. 15.8%, p=0.04). Finally,
program group members were substantially less likely to
indicate they had unmet medical needs six months after
study entry (45% vs. 63.8%, p<.0001).
Conclusions: Providing health care benefits increases
the use of health care and reduces unmet needs,
although most individuals without insurance received
some amount of care.
Implications for Policy, Delivery or Practice: Ending
the Medicare waiting period for new SSDI beneficiaries
would lead to increased access to health care for the 12
percent of new beneficiaries who are currently
uninsured. In addition, the results provide especially
rigorous evidence that lack of health insurance results in
substantial unmet medical needs.
Funding Source(s): Social Security Administration
• Two-Year Colorectal Cancer Screening Rates and
Socioeconomic Disparities after Switching to a HighDeductible Health Plan
James Wharam, M.D., M.P.H.; Bruce Landon, M.D.,
M.B.A.; Amy Graves, B.A.; Fang Zhang, Ph.D.; Stephen
Soumerai, Sc.D.; Dennis Ross-Degnan, Sc.D.
Presented by: James Wharam, M.D., M.P.H.,
Instructor, Population Medicine, Harvard Medical School
and Harvard Pilgrim Health Care Institute, 133 Brookline
Avenue, Boston, MA 02215; Phone: (617) 509-9948;
Email: jwharam1@yahoo.com
Research Objective: Consensus guidelines
recommend colonoscopy as the first-line screening
modality for detecting colorectal cancer. The increasing
number of health plans that subject colonoscopy to high
deductibles could reduce screening, especially among
vulnerable populations. We previously found that in the
first year after transition to a high-deductible health plan
(HDHP), members substituted a fully covered test (fecal
occult blood testing, FOBT) for colonoscopy. No
published studies have examined longer-term utilization
or effects on disparities.
Study Design: Pre-post with comparison group and a
difference-in-differences analytic framework.
Population Studied: We studied administrative claims
for one year before and two years after an employermandated switch from traditional HMO plans to a HDHP
for 1535 Massachusetts health plan members insured
between 2001 and 2008 who were eligible for colorectal
cancer screening. We compared screening rates among
7863 contemporaneous controls whose employers
remained in HMO plans. To minimize selection bias, we
included only continuously enrolled members not offered
a health plan choice during follow-up years. Both groups
had full coverage of FOBT whereas the HDHP subjected
colonoscopy, flexible sigmoidoscopy, and doublecontrast barium enema to $500-$2000 annual
deductibles. We defined low socioeconomic status
(SES) as residence in a census block with >10% of
households below poverty or 25% of adults with less
than a high school education (21.5% of HDHP and
16.4% of control members). We used logistic regression
to adjust for member characteristics including age,
gender, and morbidity. We stratified analyses by SES.
Principal Findings: After adjustment, overall colorectal
cancer screening rates in the the HDHP relative to the
control group were unchanged from baseline to the first
and second follow-up years (ratios of change, 0.98, 95%
C.I., [0.87 to 1.12] and 0.89, 95% C.I., [0.78 to 1.01],
respectively). Low SES HDHP members demonstrated
similar patterns (1.01, [0.77 to 1.33] and 0.94, [0.72 to
1.22], respectively). However, by the second follow-up
year, HDHP members experienced relative reductions in
colonoscopy, flexible sigmoidoscopy, and doublecontrast barium enema (0.80, [0.69 to 0.94]), a pattern
more pronounced among low SES members (0.69, [0.48
to 0.99]). We detected no changes in FOBT in the two
follow-up years (1.05, [0.91 to 1.21] and 1.03, [0.89 to
1.20], respectively) although the ratios among low SES
HDHP members were higher (1.27, [0.93 to 1.72] and
1.29, [0.95 to 1.74], respectively). The ratio of
colonoscopy screening in low versus high SES HDHP
members remained unchanged from the baseline to the
second follow-up year (unadjusted disparity rate ratios of
0.82 and 0.80, respectively). In contrast, disparity rate
ratios improved from 0.85 to 0.96 among controls.
Conclusions: Switching from a traditional plan to a
HDHP that fully covered FOBT but not other colorectal
cancer screening modalities was not associated with
overall changes in screening rates, although the
proportion of members receiving colonoscopy, flexible
sigmoidoscopy, and double-contrast barium enema
declined after 2 years. This impact was more
pronounced among low SES members, who
experienced no improvement in pre-existing
socioeconomic disparities.
Implications for Policy, Delivery or Practice: Policy
makers should consider exempting colonoscopy from
health insurance deductibles or targeting interventions to
members at risk of foregoing screening.
Funding Source(s): Harvard Pilgrim Health Care
Foundation
Strategies to Manage Utilization: Impact on Cost,
Access, and Outcomes
Chair: Chien-Wen Tseng
Monday, June 28 * 9:45 am–11:15 am
• Physician Acquisition of MRI: Effects on Utilization
and Spending
Laurence Baker, Ph.D.
Presented by: Laurence Baker, Ph.D., Professor of
Health Research and Policy, Health Research and
Policy, Stanford University School of Medicine, HRP
Redwood Building, 259 Campus Drive, Room 110,
Stanford, CA 94305; Phone: (650) 723-4098; Email:
laurence.baker@stanford.edu
Research Objective: The costs associated with MRI are
growing rapidly. One area of concern is the increasing
prevalence of MRI equipment in the practices of nonradiologist physicians. Some argue that this can improve
access to valuable services, but others argue that the
financial incentives that accompany physician acquisition
of equipment can promote inefficient use. Some older
cross-sectional studies suggest very large impacts of
acquisition on use. This study tracks physicians over
time in recent data, examining practice patterns before
and after MRI acquisition, to investigate the impacts of
acquisition on utilization patterns and total patient
spending.
Study Design: Panel-data analysis of MRI use in the
practices of orthopedists and neurologists who billed
Medicare for the treatment of elderly fee-for-service
Medicare beneficiaries between 1999 and 2005. A
sample of patient care episodes associated with these
physicians was drawn from Medicare claims data.
Patient receipt of MRI on the same day as the initial visit,
and within 7, 30, and 90 days of the initial visit were
tracked for each episode. Whether, and if so when,
physicians acquired MRI equipment was determined
based on billing patterns. Regression analyses were
used to identify changes in MRI use before and after
acquisition of MRI equipment, controlling for patient
characteristics. Regressions also control for time trends
and include physician fixed effects. Total health care
spending in the 90 and 365 days following the initial visit
is also tracked, and regression analyses relate total
spending to use of MRI and provider acquisition of MRI
equipment.
Population Studied: Analyses examine the practice
patterns of 23,729 orthopedists and 12,459 neurologists,
using a sample of patient care episodes (N=~3.3 million
for orthopedists; N=~1.3 million for neurologists).
Principal Findings: In all, orthopedists had a 30-day
MRI rate of about 89 procedures per 1000 episodes.
Neurologists had a rate of about 262. After using
regression analysis to adjust for patient characteristics,
general time trends, and physician fixed effects,
acquiring MRI was associated with an increase in the
30-day MRI rate of about 30% for orthopedists and
about 20% for neurologists (p<.001). Increases in use of
MRI after acquisition are observed across wide ranges
of patients, including patients with diagnoses where MRI
is common and patients where MRI is not. MRI
acquisition is associated with an increase in total
spending for both orthopedist and neurologist patients,
including increases in both spending for MRI and
spending for other imaging and other tests and
procedures.
Conclusions: Provider acquisition of MRI is associated
with increased utilization. Effects are relatively large
(though considerably smaller than implied by some
previous cross-sectional analyses). More use of MRI
appears to drive up total spending.
Implications for Policy, Delivery or Practice: Efforts to
encourage efficient utilization of MRI by acquiring
physicians may be warranted.
• Medicare Coverage with Evidence Development
Policy and Access to New Technology
Peter Groeneveld, M.D., M.S.; Andrew Epstein, Ph.D.,
M.P.P.; Lin Yang, M.S.; Feifei Yang, M.S.; Daniel
Polsky, Ph.D.
Presented by: Peter Groeneveld, M.D., M.S., Assistant
Professor of Medicine, Department of Medicine,
Philadelphia VAMC / University of Pennsylvania, 1229
Blockley Hall, 423 Guardian Drive, Philadelphia, PA
19104; Phone: (215) 898-2569; Email:
peter.groeneveld@va.gov
Research Objective: In 2005, as part of its Coverage
with Evidence Development (CED) initiative, Medicare
implemented a novel coverage policy for carotid arterial
stent systems with cerebral protection (CAS), a new
intravascular device. Under this policy, hospitals were
required to be certified as meeting several quality
benchmarks for CAS provision in order to be eligible to
receive reimbursements. This was a marked departure
from previous Medicare coverage decisions, which did
not require institutional certification for specific
procedures. We hypothesized that this policy may have
limited access to CAS among specific patient groups,
particularly those residing in localities with fewer tertiarycare hospitals.
Study Design: To identify U.S. hospitals with the
technical ability to offer CAS, we used Medicare claims
from 2004-2006 to identify all hospitals that provided
percutaneous coronary intervention (PCI) or other
vascular interventional procedures in 2004-2006. We
then used Medicare claims combined with Medicare’s
online registry of CAS-certified hospitals to identify
hospitals that provided CAS in 2005-2006 after
Medicare’s coverage policy was implemented. Each
hospital was geo-coded to one of 306 U.S. hospital
referral regions (HRRs) as defined by the Dartmouth
Atlas. Demographic and healthcare system information
was obtained for each HRR from the Dartmouth Atlas,
Medicare claims, and the U.S. Census. Hospitals located
in HRRs in which more than 5 hospitals offered vascular
interventional procedures were excluded. For hospitals
in the remaining HRRs, we estimated weighted
multivariable regression models predicting use of CAS in
2005-2006, controlling for HRR-level demographic
factors (% black population, per capita income, urban
status), health system factors (physicians per capita,
hospital beds per capita) as well as hospital factors
(academic status, hospital ownership, volume of care).
Population Studied: We identified 228 HRRs with = 5
hospitals equipped to provide vascular interventional
procedures, comprising 41% of the U.S. population. In
total, there were 592 hospitals in these localities that
provided vascular interventional procedures.
Principal Findings: Among these 592 hospitals, 330
(56%) offered CAS after Medicare implemented its 2005
CAS coverage policy. By comparison, 79% of these
hospitals provided coronary bypass surgery, 92% of
these hospitals provided PCI, and 99% provided carotid
endarterectomy during the same time period (p<0.001
for differences with CAS %). Hospitals in localities with
larger (>12%) black populations were significantly less
likely to adopt CAS in 2005-06 (odds ratio [OR] 0.56,
95% confidence interval[CI] 0.36 to 0.88, p=0.01) than
hospitals in predominantly white localities. This
difference persisted (OR 0.53, 95% CI 0.29 to 0.95,
p=0.03) after adjustment for other HRR demographic
factors, health system factors, and hospital factors.
Conclusions: During the years immediately following
Medicare’s coverage decision for CAS, in localities that
had = 5 hospitals equipped to provide interventional
vascular services, substantially fewer hospitals offered
CAS compared to the number of hospitals offering other
interventional cardiovascular procedures, and hospitals
in areas with larger black populations were less likely to
adopt CAS.
Implications for Policy, Delivery or Practice:
Medicare’s coverage policy for CAS had the unintended
consequence of limiting access to this new treatment,
particularly among blacks living outside of the nation’s
largest urban areas. Future coverage policies might be
designed to incentivize adoption of technology among
these hospitals, in order to equalize opportunity to
receive new treatments.
Funding Source(s): NHLBI
• Turning the Tide? Medication Adherence after
Copayment Reductions
Matthew Maciejewski, Ph.D.; Joel Farley, Ph.D.; Daryl
Wansink, Ph.D.
Presented by: Matthew Maciejewski, Ph.D., Core
Investigator, Center for Health Services Research in
Primary Care, Durham VA, 508 Fulton Street, Durham,
NC 27705; Phone: (919) 286-0411 ext. 5198; Email:
mlm34@duke.edu
Research Objective: Increasing medication
copayments have burdened patients with a greater
share of total medication expenditures and have
adversely impacted medication adherence, particularly
for patients with chronic conditions. Cost-related nonadherence has prompted employers to re-evaluate their
cost-sharing policies and a large southeastern
commercial insurer eliminated copayments for generic
medications and lowered copayments (from Tier 3 to
Tier 2) for brand-name medications to treat diabetes,
hypertension, hyperlipidemia and congestive heart
failure in January 2008. The purpose of this study is to
evaluate whether medication adherence changed after
the implementation of this VBID program on a population
basis, and whether adherence changes varied by
medication type.
Study Design: A retrospective pre-post quasiexperimental design with a non-equivalent control group
made more equivalent via propensity score matching.
Population Studied: Adherence was compared
between treatment and control groups in the 12 months
(January—December 2007) prior to program
implementation and in the 24 months after
implementation (January 2008—December 2009). The
insurer’s enrollees were included if they were taking at
least one of eight classes of drugs (statins, oral
hypoglycemic, diuretics, beta-blockers, ACE inhibitors,
ARBs, calcium channel blockers, cholesterol absorption
inhibitors) that were included in the analysis and were
enrolled with the insurer for the entire duration of the
study period. The treatment group of program
participants included 32,032 employers (representing
638,796 enrollees) who were fully underwritten by the
insurer and 51 self-funded employers (representing
108,504 enrollees). The control group of program nonparticipants consisted of 176 self-funded employers
(representing 638,091 enrollees) who chose not to
implement the program who were propensity matched to
program participants to reduce the non-equivalence of
the control group. The medication possession ratio
(MPR) was used to assess adherence via generalized
linear models that controlled for age, gender,
comorbidity burden, baseline generic fill rate, and total
medication burden.
Principal Findings: Copayments for generic
medications were dropped on average from $10.74$11.38 to $0, while brand-name copayments dropped on
average from $33.79-$34.39 to $30.50-$30.74. In
adjusted analyses, program participation was associated
with a statistically significant improvement for six of the
eight classes of drugs (statins, thiazides (diuretics), betablockers, ACE inhibitors, calcium channel blockers, and
biguanides), suggesting that the copayment reductions
mitigated non-adherence observed in the non-participant
cohorts. Adherence to ARBs was similar between
program participants and non-participants, which was
expected since brand-name copays were reduce for
both cohorts.
Conclusions: This is the largest VBID study to date and
found that elimination of generic copayments and
reduction in copayments for brand-name medications
improved adherence in nearly all therapeutic classes.
The insurer experienced significantly higher medication
costs given the number of people participating in the
program, so the long-term viability of this innovative
policy change depends critically on whether cost offsets
arise in the medium- to long-term.
Implications for Policy, Delivery or Practice: If these
promising results are validated in other settings, the
trend of increasing copayments may be appropriately
reversed by decreasing or eliminating copayments to the
betterment of patients and payers.
Funding Source(s): Blue Cross Blue Shield of North
Carolina
• Associations Between Physician Characteristics
and Relative Cost Profiles
Ateev Mehrotra, M.D., M.P.H.; Rachel Orler, B.S.; John
Adams, Ph.D.; Mark Friedberg, M.D.; Elizabeth
McGlynn, Ph.D.; Peter Hussey, Ph.D.
Presented by: Ateev Mehrotra, M.D., M.P.H., Assistant
Professor, Health, RAND, 1207 Malvern Avenue,
Pittsburgh, PA 15217; Email: mehrotra@rand.org
Research Objective: The continued rise in health care
costs has led to great interest in how to “bend the cost
curve” and reward efficient care. One increasingly
popular strategy to achieve this objective is the cost
profiling of individual physicians. Physician cost profiles
are used for a variety of policy interventions including
public reporting and selection of which physicians are
included in a health plan’s network. The characteristics
of low-cost or high-cost physicians remain unknown.
Previous research has examined the relationship
between physician characteristics and discretionary
testing or decision making when faced with uncertain
clinical scenarios, but little work has looked at overall
costs. In this study we examined the association
between cost profile scores and physician characteristics
including experience, gender, board certification status,
and history of malpractice claims.
Study Design: Consistent with the approach taken by
health plans and Medicare, we created individual cost
profiles for each physician. We first used commercial
software to construct episodes of care which were
assigned to the physician with the highest proportion of
professional costs in the episode. We created a
summary cost profile for each physician by summing the
costs of assigned episodes and dividing by the sum of
average costs of case-mix matched episodes for
physicians in the same specialty. We then linked the
cost profiles to the publicly available physician
characteristics available from the Massachusetts Board
of Medicine.
Population Studied: All Massachussetts physicians
(n=12,181) who cared for one of the 1.1 million adults
enrolled in 4 commercial health plans in Massachusetts.
Principal Findings: We found a strong and linear
association between a physician’s years of experience
and costs. Compared to those physicians in the highest
quintile of experience (>33 years), physicians in the
lowest quintile (<12 years) had 15% higher overall costs
(p<0.001). We found a more modest association
between costs and volume of care (as measured by
episodes). Physicians in the lowest volume quintile had
5% higher costs (p<0.001) than those in the highest
quintile. International medical school graduates had 2%
higher costs (p=0.006) than domestic graduates. Other
physician characteristics including history of malpractice
claims, gender, or board certification had no significant
association with cost.
Conclusions: Physician experience is strongly
associated with the cost of the care they provide. Lessexperienced physicians provide higher-cost care. It is
possible that younger physicians are more comfortable
with newer testing modalities and drugs or acculturated
in a more aggressive form of care. It is also possible that
familiarity with clinical problems leads more experienced
physicians order less unnecessary testing. An important
caveat is that previous work has found that older
physicians have on average lower quality care and so
the lower costs observed among more experienced
physicians might represent omissions of necessary care.
Implications for Policy, Delivery or Practice: This is a
provocative finding that need to be confirmed in other
studies, but it is possible that one driver of rising health
care costs is that newly trained physicians have a more
costly practice style.
• The Impact of Hospital Profitability on Mortality
Outcomes
Kevin Volpp, M.D., Ph.D.; R. Tamara Konetzka, Ph.D.;
Jingsan Zhu, M.B.A; Wei Chen, M.S.; Rich Lindrooth,
Ph.D.
Presented by: Kevin Volpp, M.D., Ph.D., Director,
Center for Health Incentives, Leonard Davis Institute,
Medicine and Health Care Management, University of
Pennsylvania School of Medicine and the Wharton
School, 1232 Blockley Hall, 423 Guardian Drive,
Philadelphia, PA 19104-6021; Phone: (215) 573-0270;
Email: volpp70@exchange.upenn.edu
Research Objective: The relationship between
generosity of payment and patient outcomes has
important implications for health reform and pay for
performance programs which impact provider payment
levels. The objective of this paper is to measure the
effect of changes in service-line payment generosity on
30-day mortality of patients in 21 major hospital service
lines.
Study Design: This is an observational study using
MEDPAR claims data for 1997-2005, with a dependent
variable of risk-adjusted 30-day mortality. Predicted
mortality was calculated by creating patient risk scores
using out-of-sample data (MEDPAR 1999 and 2003) to
develop betas for each comorbidity and patient-level risk
factor. These coefficients were then applied to the
patients within each study year (1997, 2001 and 2005) to
predict mortality. Service-line payment generosity is
measured as the percent of reimbursement over costs
(hereafter “markup”) calculated using cost-to-charge
ratios from CMS Hospital Cost Reports, Medicare
charges, and actual Medicare reimbursement. Riskadjusted 30-day mortality was regressed on the serviceline markup; service-line markup interacted with the
hospital's Medicare share; hospital*service-line and year
fixed effects; service-line volume; and service-line
specific time trends. The results are identified using
variation in markups across service lines and over time.
Service-lines with larger decreases in markups are
hypothesized to have larger increases in risk-adjusted
mortality, with effects hypothesized to be increasing with
a hospital's Medicare share and to be larger in not-forprofit (NFP) hospitals.
Population Studied: We selected index admissions to
short-term, acute-care hospitals of Medicare patients
aged 65-90 excluding patients admitted from Long-term
Care, transferred in from other hospitals, and with organ
acquisition costs outside of PPS. The final study data
included 19,613,992 discharges for FY 1997, 2001 and
2005.
Principal Findings: Markups decreased from an
average across all service lines of 21% in 1997 to -3% in
2005. While the markup main effect was not significantly
different than zero (for hospitals with no Medicare
share), the interaction between markup*Medicare share
had a coefficient of -0.008 (p= 0.008). This translates
into a 0.0032 percentage point increase in mortality for
each one percentage point decrease in Medicare cost
markups for a hospital with the national average
Medicare market share of 40%. For hospitals with 40%
Medicare share, the estimated increase in deaths
nationally due to declines in the average markup relative
to the case if markups remained at the 1997 level was
13,721 between 1997 and 2001 and 36,940 between
1997 and 2005. The magnitude of the coefficient was
larger for NFP hospitals ( =-0.18 for NFP hospitals, =
0.04 among for profit hospitals; p-value for difference
0.019).
Conclusions: Decreases in Medicare payment
generosity from 1997-2005 led to significant increases in
mortality, with bigger increases in mortality in service
lines with bigger reductions in profitability. The increases
were greater at NFP hospitals consistent with the notion
that NFP hospitals provide discretionary levels of quality
that decline as payments are reduced.
Implications for Policy, Delivery or Practice: Policies
regarding Medicare reimbursement need to consider the
effect of reimbursement levels on quality, particularly in
the context of health reform.
Funding Source(s): RWJF, Health Care Financing and
Organization (HCFO)
Public Health: Measurement and Quality
Improvement
Chair: Michael Stoto
Monday, June 28 * 9:45 am–11:15 am
• County Health Rankings: Mobilizing Action Toward
Community Health
Bridget Booske, Ph.D., M.H.S.A.; Julie Willems Van Dijk,
Ph.D., R.N.; Brenda Henry, Ph.D.; David Kindig, M.D.,
Ph.D.; Patrick Remington, M.D., M.P.H.
Presented by: Bridget Booske, Ph.D., M.H.S.A.,
Senior Scientist, Population Health Institute, University
of Wisconsin School of Medicine and Public Health, 610
Walnut Street, Room 507, Madison, WI 53726; Phone:
(608) 263-1947; Email: bbooske@wisc.edu
Research Objective: In collaboration with the Robert
Wood Johnson Foundation, the University of Wisconsin
Population Health Institute will publish the first annual
County Health Rankings in the 50 states in February
2010. The Rankings are part of a broader project,
"Mobilizing Action Toward Community Health (MATCH)"
that is designed to a) Emphasize the many factors—
clinical care access and quality of care, health
behaviors, social and economic factors, and the physical
environment—that, if improved, can help people lead
healthier lives and make communities health places to
live, work, learn and play, b) Foster engagement among
public and private decision makers to improve
community health, and c) Develop incentives to
encourage coordination across sectors for community
health improvement.
Study Design: The County Health Rankings Website
will provide access to the 50 state reports, ranking each
county within the 50 states according to its health
outcomes and the multiple health factors that determine
it’s health. Each county will receive a summary rank for
its health outcomes and health factors and also for the
four different types of health factors: health behaviors,
clinical care, social and economic factors, and the
physical environment. Each county will also be able to
drill down to see specific county-level data (as well as
state benchmarks) for the measures upon which the
rankings are based. These measures are obtained from
a number of data sources such as: CDC, HRSA, Census
Bureau, FBI, and the Dartmouth Atlas for Health Care.
Population Studied: Over 90% of US counties will be
ranked within their respective states.
Principal Findings: We will report on results from the
release of the County Health Rankings, including results
from the data as well as the successes and failures of
the associated communication strategies and our efforts
to translate research into practice and engage public
health and other community leaders across the country
in population health improvement.
Implications for Policy, Delivery or Practice: This
project is an example of dissemination research,
translating complex data into summary measures and
delivering key communication messages about
population health. We will discuss opportunities and
challenges in trying to stimulate discussions about
community health and action toward community health
improvement.
Funding Source(s): RWJF
• Measuring Hospital Preparedness for Pandemic
and Mass Casualty Events: What is Most Important?
Sheryl Davies, M.A.; Tamara Chapman, M.A.; Kathryn
McDonald, M.M.; Christian Sandrock, M.D.; Patrick
Romano, M.D., M.P.H.; Jeffrey Geppert, J.D.
Presented by: Sheryl Davies, M.A., Research
Manager, Department of Medicine, Stanford University,
117 Encina Commons, Stanford, CA 94305; Phone:
(650) 723-0820; Email: smdavies@stanford.edu
Research Objective: Recent events such as the H1N1
influenza pandemic and Hurricane Katrina, as well as
the ongoing threat of terrorism, have highlighted the
need for hospital preparedness for mass casualty
events. Efforts to aid such preparation have focused on
the implementation of guidelines and preparedness
standards, including The Joint Commission standards
and checklists developed by federal agencies and the
American Hospital Association. The Pandemic and AllHazards Preparedness Act requires tracking and
congressional reporting of preparedness. Thus,
preparedness has become a part of hospital quality and
public health efforts, yet there is a lack of consensus as
to the appropriate way to measure it. Applying
techniques used to develop clinical hospital quality
indicators, we evaluated the consensual validity of
potential indicator topics for reporting state-level hospital
preparedness.
Study Design: We identified potential indicator topics
based on currently existing standards and guidelines,
such as “Hospital has a plan for evacuation.” Through a
modified Delphi approach, we utilized three panels of
clinicians and other professionals involved in hospital
emergency preparedness or response to assess the
importance of including each proposed topic in a state
level report. The 43 panelists were nominated by
seventeen national organizations, and included
generalist and specialist physicians, disaster planners,
administrators, nurses, and public health officials with
broad experience in actual natural disasters, pandemics,
terrorist attacks, and other disasters. Panelists rated
each topic on a 5 point scale (1=Not at all important;
5=Extremely important/Essential) then participated in
conference calls to discuss the highest rated topics, and
finally re-rated the topics. After re-rating, each panelist
created an ideal set of topics from all candidate items.
Support for a topic was evaluated using median ratings,
a measure of agreement based on the RAND/UCLA
Appropriateness Method, and whether the majority of
panelists included the topic in an ideal set.
Principal Findings: Of the 179 indicator topics initially
rated, seven received a median of 4 or greater with
agreement and were included in more than 50% of
panelists’ ideal sets. An additional fifteen topics received
median ratings of 4 or greater with indeterminate
agreement and were included in more than 50% of
panelists’ ideal sets. Indicator topics included in these
top two priority levels spanned communications;
community integration; continuity of operations;
countermeasures, supplies and personal protective
equipment; decontamination; emergency management
procedures and planning; evacuation and shelter in
place; patient management and care; safety and
security; staff training; and surge capacity. Of note was
the omission of topics related to behavioral health,
disease reporting and surveillance, and fatality
management. Panelists favored comprehensive
indicators over those that are more focused on specific
standards. The mean number of indicators included in
ideal indicator sets was 20.7 (SD = 7.2).
Conclusions: Although comprehensive guidelines and
standards include hundreds of items, our study
establishes support for measurement based on a smaller
number of topics.
Implications for Policy, Delivery or Practice:
Assessing the importance of topics included in reporting
to Congress and other stakeholders ensures
comprehensive coverage that would more accurately
depict actual hospital preparedness without excessive
measurement burden. Further research should focus on
developing specific indicators within these topics and
validating their relationship with performance during
mass casualty events.
Funding Source(s): AHRQ
• Strengthening Public Health Departments Through
Process Improvement: Findings from the Common
Ground Evaluation
Alycia Infante, M.P.A.; Prashila Dullabh, M.D.; Rachel
Singer, Ph.D., M.P.H., M.P.A.; Michael Meit, M.A.,
M.P.H.; Jonathan Moore, B.A.
Presented by: Alycia Infante, M.P.A., Principal
Research Analyst, Public Health Research, National
Opinion Research Center (NORC), 4350 East-West
Highway, Suite 800, Bethesda, MD 20814; Phone: (301)
634-9371; Email: infante-alycia@norc.org
Research Objective: The objective is to evaluate the
Robert Wood Johnson Foundation’s (RWJF) three-year,
$15 million Common Ground program, which funded
thirty-one state and local health departments to
transform the delivery of public health services through a
methodology of process improvement and requirements
gathering for information systems. Key research
questions include: 1) how and to what extent the goals of
Common Ground were met; 2) success factors for
analyzing and redesigning agency business processes
to improve public health outcomes; and 3) the potential
for Common Ground to be used as a vehicle for practice
transformation in other health departments.
Study Design: NORC is conducting a four-year, multimethod process evaluation. This is the third year of the
evaluation. Data collection methods include grantee
telephone interviews, focus groups, surveys, and site
visits. NORC also conducted a data analysis comparing
the characteristics of Common Ground health
departments to non-grantee health departments. NORC
will deliver a final evaluation report to RWJF in 2011.
Population Studied: The population is thirty-one state
and local health departments funded by Common
Ground: 15 Informatics Capacity (IC) grantees that were
funded in 2006 for 15 months to analyze and redesign
their business processes to support essential public
health services, and 16 Requirements Development
(RD) grantees that were funded for three years to
analyze and redesign their business processes and
develop requirements for information systems.
Principal Findings: Grantees implemented projects that
focus on business processes in various areas of public
health practice, including emergency preparedness,
chronic disease management, and information
exchange. The RD grantees collaborated through
national work groups to document common public health
processes and develop information system requirements
that can be applied across diverse health departments.
A post-initiative survey of the IC grantees found that
analyzing and redesigning business processes can
foster new relationships within health departments,
enhancing cross-divisional and cross-organizational
communication. Site visits with the RD grantees
demonstrated the value of Common Ground as a
performance improvement tool. Some of the RD
grantees conducted regional training sessions for other
health departments in business process analysis and
redesign. Several grantees defined requirements for
information systems, though few purchased or
developed new systems. Grantees reported challenges
associated with translating business process principles
to public health practice as well as lessons learned.
Conclusions: Findings show that Common Ground
offers tools for facilitating quality improvement in public
health departments and that most grantees will require
additional funding to adopt new information systems.
Implications for Policy, Delivery or Practice: Health
departments face growing demands to effectively share
information within and across agencies to promote public
health, deliver quality care, and efficiently respond to
public health threats. Common Ground is a tool that can
help health departments to improve the way they do their
work – establishing the conditions by which they are
better able to serve their populations, and respond to
emerging health issues. Further, given its focus on
quality improvement, Common Ground may have
implications for health departments as they prepare for
agency accreditation.
Funding Source(s): RWJF
• Quality Improvement in Local Health Departments:
The Development of a Classification System
Brenda Joly, Ph.D., M.P.H.; Prashant Mittal, M.S.C.,
M.S.
Presented by: Brenda Joly, Ph.D., M.P.H., Public
Health and Health Policy, Muskie School of Public
Service, PO Box 9300, Portland, ME 04104; Phone:
(207) 288-8456; Email: bjoly@usm.maine.edu
Research Objective: To define and score the maturity
of a local health department's maturity with respect to its
quality improvement culture, capacity and competency,
and alignment and spread.
Study Design: As part of its evaluation of a 16-state
evaluation, the authors developed a survey based on
known factors shown in the literature to promote or
influence the adoption and spread of quality
improvement within an organization. The survey was
administered to 1178 local health departments following
review by an expert panel, cognitive testing and piloting.
Respondents were matched based on department
name, state, city and zip code information, with a
database provided by National Connection for Local
Public Health (NACCHO). Factor analysis was
conducted on survey data from respondent local health
departments to identify sub-domains related to each of
the three primary domains: culture, capacity and
competency, and alignment and spread. With these
observations and results from hierarchical clustering, an
optimum cluster solution was found to explain
differences among local health departments with respect
to domains and sub-domains. A scoring algorithym was
devised to measure self-reported QI maturity by domain
and across domains.
Population Studied: The analysis was conducted on a
matched set of 640 local health departments which
completed both the evaluation survey and the 2008
NACCHO (National Association for Local Public
Health)survey.
Principal Findings: Major findings include: 1) A five
cluster solution most ideally explains the differences
among local health departments with respect to the three
domains and nine sub-domains, 2) These have been
found to be completely discreet clusters, and 3) Clusters
can be used as a scoring algorithm and to place a local
health department within a continuum based on survey
responses.
Conclusions: Our working assumption at the start of
this research was that local health departments vary
significantly in their practice and use of quality
improvement tools and techniques. A primary purpose of
this research was to distinguish among local health
departments on factors or characteristics that account
for the adoption and use of quality improvement. Our
research concludes that the maturity of a local health
department can be defined and scored based on selfreported assessments of culture, capacity and
competency, and alignment and spread.
Implications for Policy, Delivery or Practice: Given
the advent of national voluntary accreditation and the
program’s anticipated launch date of 2011, exploring the
readiness of agencies to embrace quality improvement
is timely and directly relevant to the public health
practice community. Based on a recently updated
statement of policy from the National Association of
County and City Health Officials (NACCHO), it is clear
that the country’s national organization representing
approximately 3,000 local health departments (LHDs) is
encouraging each governmental entity responsible for
public health to engage in quality improvement and
prepare for accreditation through QI processes and
activities. In addition to NACCHO support, several other
national entities representing the practice community
have been vocal about their the need for public health
agencies to enhance QI capacity, including the
Association of State and Territorial Health Officials8 and
the Centers for Disease Control and Prevention. The
proposed objectives for Healthy People 2020 also
include new areas related to quality improvement. This
level of attention and support suggests that public health
practitioners, organizations and associations are aware
of the movement, momentum and potential surrounding
quality improvement. The National Public Health
Systems Research Agenda, published in 2006, identified
the need to explore agency performance and outcomes
as one of three top priorities. Research assessing quality
improvement maturity will likely accelerate knowledge
and interest in building capacity and core competencies.
Funding Source(s): RWJF
Organizational Factors and Care Delivery
Chair: Christopher Friese
Monday, June 28 * 9:45 am–11:15 am
• Economies of Scale and Scope: The Case of
Specialty Hospitals
Kathleen Carey, Ph.D.; James Burgess Jr., Ph.D.; Gary
Young, Ph.D.
Presented by: Kathleen Carey, Ph.D., Associate
Professor, Health Policy and Management, Boston
University School of Public Health, 715 Albany Street,
Boston, MA 02118; Phone: (781) 687-2140; Email:
kcarey@bu.edu
Research Objective: The recent growth of physicianowned hospitals specializing in cardiac, orthopedic, and
surgical specialty services (specialty hospitals) in the
U.S. has generated considerable controversy, yet there
is little understanding of the economic logic of organizing
hospital services around these single specialties.
Because specialty hospitals are small relative to the
general hospitals with which they compete, an important
economic question that arises is: Do specialty hospitals
have sufficient size to achieve economies of scale and
economies of scope? This paper takes a multiple output
hospital cost function approach to empirical investigation
of this issue.
Study Design: We estimated two hospital random
effects models that regressed total annual operating
costs on discharges, outpatient visits, average length of
stay, indices for inpatient and outpatient case-mix, input
prices, and teaching and ownership status. In order to
analyze economies of scale and scope separately for
distinct types of specialty hospitals, the first model
included cardiac specialty hospitals and the second
model included orthopedic and surgical specialty
hospitals. Binary variables indicating whether a particular
hospital was a specialty hospital were entered as main
effects and interacted with output variables. Using
regression results, we calculated measures of ray scale
economies for the two key outputs of discharges and
outpatient visits. We also estimated economies of scope
by simulating the cost of producing outputs separately in
general hospitals and specialty hospitals compared to
producing the same level of outputs jointly in general
hospitals. The primary data source was the Medicare
Cost Reports. Identification of specialty hospitals was
made with the assistance of the Centers for Medicare
and Medicaid Services supplemented by web searches.
Additional data came from the American Hospital
Association Annual Survey Database.
Population Studied: The models were estimated on all
specialty hospitals operating during the period 19982007 in the 10 key states in which 90 percent of
specialty hospitals were located, as well as all acute
care general hospitals serving the same market areas,
defined as Dartmouth Hospital Referral Regions.
Principal Findings: The empirical results suggest that
general hospitals realize significantly greater economies
of scale than either cardiac or orthopedic/surgical
specialty hospitals. Specialization of either cardiac or
orthopedic/surgical services in separate facilities does
not lower total cost compared to joint service in general
hospitals.
Conclusions: Previous research has found specialty
hosptials to be less cost efficient than general hospitals.
This paper suggests that part of the explanation may be
that specialty hospitals do not produce enough output to
achieve economies of scale and of scope.
Implications for Policy, Delivery or Practice:
Following the recent lift of a three-year moratorium on
new physician-owned cardiac, orthopedic, and surgical
specialty hospitals, a number of bills have been
introduced in the U.S. Congress that would ban the
referral of Medicare and Medicaid patients to specialty
hospitals by physician-owners. The results generated in
this paper inform this heated policy debate over the
future organization of hospital services.
Funding Source(s): RWJF
• Is More Better? Examining the Relationship
Between Provider Supply and Ambulatory Care
Sensitive Hospitalizations.
Larry Hearld, Ph.D.; Jeffrey Alexander, Ph.D.; Jane
Banaszak-Holl, Ph.D.; Richard Hirth, Ph.D.; Richard
Price, Ph.D.
Presented by: Larry Hearld, Ph.D., Assistant
Professor, Health Services Administration, University of
Alabama at Birmingham, 1530 3rd Avenue S,
Birmingham, AL 35294; Phone: (205) 934-0976; Email:
lhearld@uab.edu
Research Objective: Access to appropriate health
services remains a fundamental challenge for the U.S.
health care system. Ambulatory care sensitive
hospitalizations (ACSH), defined as hospitalizations for
health conditions that potentially could have been
avoided with timely and effective outpatient care, are
increasingly used as indicators of appropriate access in
health services research. Emerging models of primary
care emphasize the importance of multiple provider
types in improving access to appropriate care, yet
empirical research on ACSH has tended to overlook the
role of organizations. Furthermore, ACSH research that
does include providers often focuses narrowly on
physician supply and conceptualizes supply in terms of
capacity (i.e., number of providers relative to
patients/market residents), which underemphasizes
questions about the mixture of providers in a market and
whether these are the right kinds of providers. This study
built upon these gaps by examining whether the supply
of six types of provider organizations (i.e., community
health centers, staff/group model HMOs, home health
agencies, hospitals, nursing homes, physician
organizations), conceptualized as provider capacity (i.e.,
number of providers per capita) and provider
composition (i.e., number of providers relative to
hospitals), was differentially associated with market-level
acute care, chronic care, and aggregate ACSH rates.
Study Design: Longitudinal, pooled cross-sectional
analysis of secondary data for the years 1998-2005.
Patient discharges associated with 14 clinical conditions
identified by AHRQ as potentially avoidable were
aggregated to the market-level (i.e., county) and then
merged with other market-level data from the Area
Resource File and the California Office of Statewide
Health Planning and Development (OSHPD).
Generalized linear mixed models tested whether
provider supply was associated with market-level ACSH
rates after controlling for population characteristics (e.g.,
race, gender, SES, health status) and health service
utilization (outpatient services per 1,000 residents).
Population Studied: 58 California markets (N=450
market-years). We restricted discharges to short-term,
acute care hospitals to facilitate comparisons across
markets.
Principal Findings: The most robust findings pertained
to provider composition, where the ratios of home health
agencies, nursing homes, and physician organizations to
hospitals were in the direction predicted - significantly
and negatively associated with ACSH rates. Although
provider capacity generally failed to demonstrate
significant relationships with ACSH rates, supplementary
analysis performed on a condition-specific basis
suggested that the effects of provider capacity may be
limited to specific clinical conditions.
Conclusions: Different results for provider capacity and
provider composition indicate the effects of provider
supply may depend on how supply is conceptualized.
Results also suggest that the relationship between
structural characteristics of a market such as provider
supply and ACSH rates depend on the medical condition
and the type(s) of organizations under study. These
findings raise questions about the appropriateness of
combining clinical conditions into aggregated
hospitalization rates.
Implications for Policy, Delivery or Practice:
Research and policy focused on provider supply should
continue to take a broad view that considers provider
composition as well as provider capacity. Results
showing that the relationship between provider supply
and ACSH rates vary by clinical condition suggest that
customized policies and organizational strategies may
be required to effectively lower ACSH rates.
Funding Source(s): AHRQ
• The Role of Slack Resources and Influenza
Vaccinations for Primary Care Practices
David Mohr, Ph.D.; Justin Benzer, Ph.D.; Gary Young,
J.D., Ph.D.; Mark Meterko, Ph.D.; Marjorie Nealon
Seibert, M.B.A;. Bert White, M.B.A., D.Min.
Presented by: David Mohr, Ph.D., Center for
Organization, Leadership and Management Research,
VA Boston Healthcare System, 150 South Huntington
Avenue (152M), Boston, MA 02130; Phone: (857) 3645679; Email: david.mohr2@va.gov
Research Objective: The administration of an annual
influenza (flu) vaccination has been advocated as a best
practice in outpatient care for older adults and its use is
associated with lower lower risks of pneumonia,
hospitalization and death for patients. Despite the
benefits, not all eligible patients receive vaccinations.
Changes in organizational structure (e.g., job redesign,
procedures, infrastructure) has noted as an effective way
to improve influenza vaccination rates. Because
vaccinations occur during a few months during the year,
higher resource demand is placed on practices during
this time. This study investigates the effect of
organizational slack resources, the extra pool or
“cushion” of resources, on the likelihood of a patient
receiving a vaccination.
Study Design: The study is a multi-level analysis using
patient-level and practice-level data. The dependent
variable for the study is a dichotomous variable to
indicate whether an eligible patient received an influenza
vaccine. Slack resources variables consisted of the ratio
of observed panel size to capacity of the panel size for
the primary care practice (where 100% indicates balance
and higher values indicate greater demand on practice).
Botha linear and a curvilinear term were used. A
dichotomous variable was created based on whether the
number of support staff per provider ratio exceeded 2.5.
The model controlled for a number of geographical
characteristics (square mile coverage, urbanization, and
census region), patient demand (appointments per
month, and ratio of new to established patients), and
practice size characteristics (teaching hospital affiliation,
hospital or community-based practice, and number of
providers).
Population Studied: Over 14,000 patients were
included over a five-month time period in 2007. A total of
614 primary care practices were included. The context
was the Veterans Health Administration in the United
States.
Principal Findings: The model provided support for the
role of slack resources. We found a positive effect for the
linear panel size ratio variable and a negative effect for
the curvilinear panel size ratio variable. We found
additional support staff was associated with a greater
likelihood of vaccination. We found other factors
positively associated with likelihood of vaccination to
include patient age, northeast geographic region, and
teaching affiliation.
Conclusions: Findings indicate that having a panel size
ratio that is too high can decrease the likelihood of
vaccinations being performed. Having additional support
staff may be another way to organize the practice during
busy times to cope with the demand for the service.
Findings highlight the importance of monitoring and
aligning panel size and support staff along with patient
demand to find a balance.
Implications for Policy, Delivery or Practice: In terms
of managing the workforce supply, results indicate that
for vaccination rates, the panel size ratio should be
closely monitored. Hiring additional support staff may
help to alleviate the workload for growing practices or
practices that have lost provider staff recently. The extra
support staff can cost more and require additional space,
but they may be able to improve quality adherence tasks
and activities.
Funding Source(s): VA
• Does Quantity of Emergency Department Sepsis
Experience Impact Inpatient Sepsis Mortality?
Emilie Powell, M.D., M.B.A.; Rahul Khare, M.D.; D. Mark
Courtney, M.D.; Joe Feinglass, Ph.D.
Presented by: Emilie Powell, M.D., M.B.A.,
Postdoctoral Fellow, Institute for Healthcare Studies,
Northwestern University, 750 N. Lakeshore, 10th Floor,
Chicago, IL 60611; Phone: (773) 317-3877; Email:
emilie.powell@gmail.com
Research Objective: Sepsis, an overwhelming systemic
infection, is an increasing problem with significant
mortality. Early aggressive resuscitation of sepsis
patients in the emergency department (ED) has been
shown to decrease mortality. Sepsis is a complex
disease state that may be difficult to diagnosis and
resuscitation can be resource and time intensive. Care
and outcomes may be variable and related to ED sepsis
case volume and experience, but this relationship has
not been demonstrated on a nation-wide level. We
hypothesized that ED sepsis admissions to hospitals
with a high ED sepsis case volume have a lower
inpatient mortality rate when compared to low ED sepsis
volume hospitals.
Study Design: This was a cross-sectional analysis
using discharge data from the Healthcare Cost and
Utilization Project 2007 Nationwide Inpatient Sample.
Admissions identified for inclusion were >18, had a
principal diagnosis of sepsis, and were admitted through
an ED with >25 sepsis admissions/year. Hospitals were
categorized into quartiles based on 2007 ED sepsis case
volume (quartile 1-4: 25-143, 144-247, 248-371, >371
cases/year). The chi-square test was used to test the
significance of univariate association of sepsis volume
with inpatient mortality. A random effects logistic
regression model of inpatient mortality was employed to
account for nesting within hospitals and simultaneous
effects of age, sex, co-morbidities, payer-status,
weekend admission, hospital size, hospital teaching
status, location, and ED sepsis volume.
Population Studied: Discharge records from 90,144 ED
sepsis admissions in 551 hospitals from 40 states.
Principal Findings: Overall inpatient sepsis mortality
was 17.4%. The quartile with the highest ED sepsis
volume had an unadjusted mortality rate of 16.0%,
18.3% in quartile 3, 18.1% in quartile 2, and 17.3% in
quartile 1 (p<0.001). The risk adjusted odds ratio (OR) of
mortality was 0.74 (95% CI 0.65-0.85, p<0.001) in
quartile 4 or a 26% lower odds of inpatient mortality
among patients admitted to hospitals in the highest ED
sepsis volume quartile as compared to the lowest ED
sepsis volume quartile. The OR for quartile 3 was 0.86
(95% CI 0.77-0.96, p=0.008) and quartile 2 was 0.90
(95% CI 0.82-0.99, p=0.037) when compared to quartile
1.
Conclusions: After adjustment for other patient and
hospital factors there was a significant association
between ED sepsis case volume and individual inpatient
mortality in patients admitted to the hospital via the ED
with sepsis. Patients admitted to hospitals with higher
annual ED sepsis volume had a 26% lower odds of
sepsis mortality in this large heterogeneous sample.
Implications for Policy, Delivery or Practice: The
significant association between ED sepsis case volume
and mortality suggests that ED resuscitation and
quantity of ED experience play significant roles in acute
sepsis detection and care. There is the potential for
sepsis mortality reduction with ED quality improvement
efforts that focus on lower sepsis volume EDs with less
experience in sepsis resuscitation. Future research
should focus on novel education efforts and techniques,
and improvements in operational efficiencies of care
delivery across all experience levels, targeting lower
volume institutions, to improve national sepsis mortality
rates.
Funding Source(s): AHRQ
Hospital-Based Systems Redesign
Chair: Robin Newhouse
Monday, June 28 * 9:45 am–11:15 am
• Team Training and Operating Room Performance
James Bramble, Ph.D. M.P.H.; Armour Forse, M.D.;
Kevin Fuji, Pharm.D.
Presented by: James Bramble, Ph.D. M.P.H.,
Associate Professor, Center for Health Services
Research and Patient Safety, Creighton University, 2500
California Plaza, Boyne, 140, Omaha, NE 68116;
Phone: (402) 280-4129; Email:
jbramble@creighton.edu
Research Objective: Efforts to train team members in
communication, attitude, and coordination have resulted
in improved performance in high-profile industries.
TeamSTEPPS is an evidence-based teamwork training
program designed to improve teamwork skills, such as
communication with the goal of helping organizations
provide higher quality and safer patient care by
increasing team performance. The objective of this study
is to determine if team training using a federallysponsored team training program improves operating
room performance and culture.
Study Design: A prospective exploratory one group
pretest-posttest design with multiple measurements was
conducted. TeamSTEPPS training was conducted over
a two month period for all members of the operating
room team in February 2007. Data from both primary
and secondary data sources examined the effectiveness
of the TeamSTEPPS training. Data collected measured
patient satisfaction, employee satisfaction, and clinical
outcomes. Tests of significance were conducted were
conducted between pre- and post-intervention.
Population Studied: The participants for this study
came from the perioperative department of a major
academic medical center. Study participants included all
perioperative caregivers (surgeons, anesthesiologists,
CRNAs, nurses, and technicians).
Principal Findings: After nine months there was a
significant improvement in operating room teamwork
(score 53.2 to 62.7, p < 0.05), OR communications
(score 47.5 to 62.7, p < 0.05) and operating room first
case starts (69% to 81%). Surgical care improvement
project (SQIP) scores also improved; including, antibiotic
administration (78% to 97%, p < 0.05); VTE
administration (74% to 91%, p < 0.05) and beta blocker
administration (19.7% to 100%, p < 0.05). Patients
reported a greater satisfaction and a willingness to
recommend (77% to 89.3%, p < 0.05). National surgical
quality improvement program (NSQIP) measures of
overall surgical morbidity and mortality were significantly
improved (mortality 2.7% to 1%, p < 0.05; morbidity
16.2% to 7.7%, p < 0.05). A year later, the improvement
in some areas receded; including first case on time
starts (81% to 69%, p < 0.05), willingness to recommend
(89.3% to 80.8%, p< 0.05), mortality rate (1% to 1.8%, p
< 0.05) and morbidity (7.7% to 11%, p < 0.05).
Conclusions: These data confirm that team training
improves operating room performance but continued
team training is required to provide sustained operating
room cultural change. Following TeamSTEPPS training
a team of key change agents made up of physicians,
nurses, technicians and other respected leaders in their
area implemented, coached, and monitored the use of
TeamSTEPPS concepts. Turnover of these key change
agents resulted in a less intense implementation of
TeamSTEPPS and the resulting decline in performance
as indicated by the data above.
Implications for Policy, Delivery or Practice: The
findings from this study suggest that policy makers,
hospital administrators, and other stakeholders must
devote the necessary resources for continual
implementation of safety improvement efforts such as
TeamSTEPPS. If left to a few key individuals, programs
such as TeamSTEPPS will likely not experience
sustained success.
• Hospital Characteristics Associated with Failure to
Rescue in High Risk Surgery
Amir Ghaferi, M.D.; Nicholas Osborne, M.D., M.S.; John
Birkmeyer, M.D.; Justin Dimick, M.D., M.P.H.
Presented by: Amir Ghaferi, M.D., Health Services
Research Fellow, Surgery, University of Michigan, 1562
Abigail Way, Ann Arbor, MI 48103; Email:
aghaferi@umich.edu
Research Objective: Variations in surgical mortality
have recently been shown to be associated with
differences in the early recognition and management of
postoperative complications once they occur (i.e., higher
failure to rescue rates in high mortality hospitals). In this
study, we sought to better understand the hospital
characteristics that may explain failure to rescue.
Study Design: We performed a retrospective cohort
study using data from the 2000-2006 Nationwide
Inpatient Sample (NIS) to identify 8,862 patients who
underwent pancreatic resections in 672 hospitals in the
United States. First, we divided hospitals into 5 equal
groups (quintiles) based on reliability-adjusted mortality
rates. We then compared major complication and failure
to rescue (i.e., death following the development of a
major complication) rates across these hospitals. Finally,
we linked our data with the American Hospital
Association survey to evaluate the effects of five hospital
level characteristics that could affect failure to rescue
rates—teaching status, hospital size, average daily
census, nurse to patient ratios, and hospital technology.
Using multivariate logistic regression models, we
determined the relative contribution of each of these
factors to the failure to rescue rates at the lowest and
highest mortality hospitals.
Population Studied: All patients undergoing pancreatic
resections in the Nationwide Inpatient Sample from
2000-2006.
Principal Findings: Failure to rescue rates varied
nearly 6 fold across hospitals (6.4% in very low mortality
hospitals vs. 40.0% in very high mortality hospitals,
Odds Ratio 9.79, 95% CI 5.71-16.8). Teaching status
(OR 0.66, 95% CI 0.53-0.82), hospital size > 200 beds
(OR 0.65, 95% CI 0.48-0.87), average daily census
>50% capacity (OR 0.56, 95% CI 0.32-0.98), increased
nurse to patient ratios (OR 0.94, 95% CI 0.89-0.99), and
high hospital technology (OR 0.65, 95% CI 0.52-0.81)
were all statistically significant predictors of lower failure
to rescue rates. The difference in failure to rescue
between very low and very high mortality hospitals is
accounted for to varying degrees by each hospital
characteristic—teaching status (23%), hospital size
(11%), average daily census (3%), nurse to patient ratios
(17%), and low hospital technology (24%). Including all
variables into a multivariate model results in a 36%
reduction in the odds of failure to rescue between very
high and very low mortality hospitals (Adjusted OR 6.63,
95% CI 3.69-11.9).
Conclusions: Teaching status, hospital size, average
daily census, nurse to patient ratios, and hospital
technology all contribute to differences in failure to
rescue rates with high risk surgery.
Implications for Policy, Delivery or Practice: While
current efforts continue to focus on the reduction of
postoperative complications, we have demonstrated the
importance of preventing mortality following a major
complication (i.e., failure to rescue). More importantly,
we have identified several hospital characteristics
associated with lower failure to rescue rates. This
information could provide two potential avenues for
quality improvement. First, selective referral policies
could direct patients undergoing high-risk surgery to low
failure to rescue hospitals. Similar policies have been
advocated based on previous volume-outcome research.
However, some have shown that selective referral may
further exacerbate disparities in quality of care. Second,
these hospital attributes may be proxy measures for
effective processes of care. Identification of such
processes could improve care at high failure to rescue
hospitals. Ultimately, this study identifies hospital
attributes with a close association to failure to rescue
rates, however, it does not establish a causal pathway
between these characteristics and lower failure to rescue
rates. Rather, future work should attempt to elucidate the
intricacies of care delivered at these large, busy,
academic hospitals.
Funding Source(s): NCI
• Intensive Care Unit Staffing and Failure to Rescue
with Major Surgery
Amir Ghaferi, M.D.; John Birkmeyer, M.D.; Justin Dimick,
M.D., M.P.H.
Presented by: Amir Ghaferi, M.D., Health Services
Research Fellow, Surgery, University of Michigan, 1562
Abigail Way, Ann Arbor, MI 48103; Email:
aghaferi@umich.edu
Research Objective: Every year thousands of patients
undergoing major surgery experience adverse outcomes
resulting in admission to an intensive care unit (ICU).
Optimal management of these patients in the ICU
through evidence based guidelines and processes of
care may improve morbidity and mortality. However, the
added value of certified intensivists in guiding this care
remains debatable. We sought to determine whether the
presence of certified intensivist had an impact on the
ability to rescue a patient from a postoperative
complication.
Study Design: We performed a retrospective cohort
study using 2006 Medicare data, we identified patients
undergoing colectomy (n=49,327), pancreatectomy
(n=2,748), and esophagectomy (n=2,242) at hospitals
participating in the Leapfrog Group Hospital Quality and
Safety Survey. A total of 1,044, 634, and 704
participating hospitals performed colectomy,
pancreatectomy, and esophagectomy, respectively. We
compared rates of major complications (pulmonary
failure, pneumonia, myocardial infarction, deep venous
thrombosis/pulmonary embolism, acute renal failure,
hemorrhage, surgical site infection, and gastrointestinal
bleeding), failure to rescue (death following a major
complication), and 30-day in-hospital mortality between
hospitals reporting adherence to the Leapfrog ICU
physician staffing model and those who did not.
Population Studied: All Medicare beneficiaries
undergoing colectomy, pancreatectomy, and
esophagectomy in 2006.
Principal Findings: For colectomy, pancreatectomy,
and esophagectomy, there were 51.9%, 35.6%, and
40.9%, who underwent surgery in a hospital with
certified intensivists, respectively. Hospitals with the
presence of a full-time intensivist had lower mortality
rates for all three operations. Failure to rescue rates
were lower in hospitals where an intensivist managed or
co-managed all ICU patients who underwent
pancreatectomy (15.7% vs. 26.5%; OR 2.11, 95% CI
1.43-3.12), and colectomy (24.4% vs. 26.1%; OR 1.10,
95% CI 1.01-1.19). For esophagectomy, there was a
trend toward lower failure to rescue rates in hospitals
with dedicated intensivists (19.7% vs. 21.3%; OR 1.04,
95% CI 0.73-1.50).
Conclusions: Hospitals with the presence of full-time
intensivists who manage or co-manage all ICU patients
are associated with lower mortality and failure to rescue
rates after high risk surgery.
Implications for Policy, Delivery or Practice: Efforts to
implement an ICU staffing standard across the United
States should continue to emphasize the potential
improvements in patient safety.
Funding Source(s): NCI
• Measuring the Effects of Nurse Staffing on Patient
Outcomes: The MilNOD Project
Lori Loan, Ph.D., R.N.C.; Mary McCarthy, Ph.D., R.N.;
Patricia Patrician, Ph.D., R.N., F.A.A.N.
Presented by: Mary McCarthy, Madigan Army Medical
Center, 9040 Fitzsimmons Drive, Tacoma, WA 984311100; Phone: (253) 968-2289
Research Objective: The Military Nursing Outcomes
Database (MilNOD) was created in response to the
national mandate to examine nurse staffing
effectiveness and to inform decisions regarding safe
levels of nurse staffing in military hospitals. The study’s
specific aim was to examine the relationship of nurse
staffing to patient outcomes.
Study Design: Contrary to popular studies at the time
which relied on annually collated existing administrative
data for both staffing and patient outcomes, the MilNOD
used prospective, shift-based data collection. A
descriptive, observational design was employed. The
American Nurses Association's nursing sensitive quality
indicators were used. Data included inpatient nurse
staffing numbers and mix, patient days, patient falls,
medication administration errors, needlestick injuries,
pressure ulcer and restraint prevalence, nursing
personnel education, experience and job satisfaction,
and patients' perceptions of satisfaction with care.
Patient turnover, unit level patient acuity and the nursing
work environment were also measured. Instruments
used were valid and reliable and comprehensive
protocols for ensuring and measuring data quality were
employed. Bayesian hierarchical logistic regression and
RM-ANOVA were used to analyze the data.
Population Studied: A voluntary, convenience sample
of 57 medical, surgical, stepdown and critical care units
from 13 Army, Navy and Air Force large and small
hospitals participated.
Principal Findings: The analysis included 115,062
eight hour shifts. The overall adverse event rate was
2.47%. Shifts with higher RN skill mix (OR 1.07, 95% CI
1.00-1.16), more total nursing care hours per patient
(OR 1.08, 95% CI 1.03-1.14), and higher percentage of
civilian nurses (OR 1.42, 95% CI 1.10-1.79) were
associated with the likelihood of fewer adverse events.
Participating units significantly lowered their fall rates
(69%, p = 0.028) and medication administration error
rates (50%, p = 0.019) over the study period. Hospital
acquired pressure ulcer prevalence also decreased
significantly (62%, p = 0.036).
Conclusions: The level of detail in MilNOD data
collection methods elucidated relationships that have not
been shown to exist in annualized administrative data.
This model for collecting and disseminating reliable,
valid and usable inpatient data across military hospitals
has been tested and proven to be effective as a patient
safety initiative.
Implications for Policy, Delivery or Practice:
Participating hospitals received quarterly reports
allowing them to compare their own performance against
other participating hospitals as well as similar civilian
hospitals. These data were used to develop evidencebased policy, for ongoing evaluations of inpatient care
quality and to monitor the effects of nurse staffing on
clinical and service outcomes.
Funding Source(s): TriService Nursing Research
Program
Building Health Systems and Supporting Patients:
Dispatches from the Old World
Chair: Timothy Doran
Monday, June 28 * 11:30 am–1:00 pm
• International Comparability of Patient Safety
Indicators in 13 OECD Member Countries: A
Methodological Approach of Adjustment by
Secondary Diagnoses
Saskia Droesler, M.D.; Patrick Romano, M.D., M.P.H.;
Daniel Tancredi, Ph.D.; Ian Brownwood; Niek Klazinga,
M.D., Ph.D.
Presented by: Saskia Droesler, M.D., Professor,
Faculty of Health Care, Niederrhein University of Applied
Sciences, Reinarzstrasse 49, Krefeld, 47805, Germany;
Phone: +0114921518226643; Email:
saskia.droesler@hsnr.de
Research Objective: As part of the Health Care Quality
Indicators project of the Organization for Economic CoOperation and Development (OECD), we explored
methods to improve the international comparability of
patient safety measurement by evaluating Patient Safety
Indicators (PSIs) originally published by the US Agency
for Healthcare Research and Quality (AHRQ). Two
previous pilots with up to 16 participating countries
showed the feasibility of the method. The objective of the
2009 analysis was to identify potential explanations for
variation in PSI rates across countries. As previous
analyses demonstrated a marked correlation between
non-obstetric PSI rates and the mean number of coded
secondary diagnoses, a quantitative model to adjust for
coding differences was investigated.
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, Germany, Italy, Ireland, New
Zealand, Norway, Singapore, Spain, Switzerland, the
United Kingdom, and the United States of America (US)
in 2006 or 2007 (except that Danish cases were from
2008). Each country provided data representing a
probability sample (US, Germany) or a complete sample
of eligible discharges, although two countries excluded
nonpublic hospitals.
Principal Findings: Age and sex-standardized rates
varied across countries. An ordinary least squares
unweighted regression model was estimated for each
PSI using the mean number of secondary diagnoses
among denominator cases (separately reported for each
indicator) as the predictor variable (R2=23% to 74%).
Estimated country-specific residuals were linearly
transformed into adjusted PSI rates with the same mean
value as the unadjusted but standardized rates.
Variation among PSI rates decreased substantially after
this adjustment. Coefficients of variation dropped as
expected from 92.4 to 72.9 for “catheter related
bloodstream infections”, from 89.8 to 45.9 for
“postoperative sepsis,” from 67 to 56.8 for “accidental
puncture or laceration”, from 63.7 to 43.7 for
“postoperative deep vein thrombosis and pulmonary
embolism”, and from 47.3 to 42.4 for “foreign body left
after procedure”. Ranking of countries was altered such
that six countries moved more than two ranks for the
indicator “catheter related bloodstream infections”, and
five countries moved more than two ranks for the
indicator “postoperative deep vein thrombosis and
pulmonary embolism”.
Conclusions: Between-country variation in the mean
number of secondary diagnoses reported is associated
with differences in measures of health system
performance that are based on administrative data and
can confound unadjusted international comparisons.
Performance measures that have been statistically
adjusted for under- or over-reporting of secondary
diagnoses are less variable than unadjusted measures
and illustrate the effect that adjustment can have on
country rankings. International comparisons of health
system performance based on unadjusted patient safety
indicators are problematic due to suspected coding or
ascertainment bias.
Implications for Policy, Delivery or Practice: Our
model could be used as an interim approach to provide
comparable information on hospital quality and safety
across different countries. Over the long term,
policymakers should create incentives to improve
accurate and complete documentation of hospital
diagnoses (including complications of care).
Funding Source(s): OECD
• Strategies for Safeguarding and Improving Access
to Primary Care Services
Dionne Kringos, M.Sc., B.Sc.; Wienke Boerma, Ph.D.
Presented by: Dionne Kringos, M.Sc., B.Sc.,
International Health Services Researcher, NIVEL
(Netherlands Institute for Health Services Research),
Otterstraat 118-124, Utrecht, 3513 Netherlands; Phone:
+0031302729843; Email: d.kringos@nivel.nl
Research Objective: Rising health care costs, ageing
populations, more complex health needs, lack of
accountability and inefficiency in health care delivery are
critical developments that health care systems globally
are faced with. These challenges and demands,
combined with a general dissatisfaction about the
progress made towards improved health outcomes (e.g.
based on Millennium Development Goals) have resulted
in an increasingly recognised need by health care
stakeholders to strengthen health care systems through
primary care (PC). This notion was recently reaffirmed
by the World Health Report 2008 which made the case
that PC is more relevant today than ever before.
Achieving appropriate access for patients to PC services
is therefore a critical success factor in strengthening
health care systems. The objective of this study is to
measure the accessibility of PC services in 31 European
countries to identify strategies conducive to improving
access to PC. The study is part of the PHAMEU
(Primary Health Care Activity Monitor for Europe) project
which measures the development of PC systems across
Europe.
Study Design: On the basis of a systematic literature
review on PC, and consultations with experts across
Europe, a comprehensive set of PC indicators has been
developed. The indicator-set allows to assess stages of
development of PC systems and identify possible
elements to be improved. Access to PC services is one
of the key focus points of the instrument. The instrument
measures the structure (e.g. governance, workforce),
process (e.g. access, continuity and coordination of
care) and outcomes (e.g. quality) of PC systems. Access
is conceptualised as key dimension of the PC process.
In 2009, a consortium involving organizations from 10
member states started implementing the developed
Monitoring system by collecting PC data in 31 European
countries by reviewing (inter)national literature and
statistical databases, and consulting panels of national
experts.
Population Studied: PC experts in 31 European
countries, including representatives of various PC
stakeholders, policymakers, PC researchers and
academics.
Principal Findings: It will be shown how the complexity
of European PC can be captured with the European
Primary Health Care Activity Monitor. Particular attention
will be paid to explaining the function of access within
primary care systems. International comparative results
will show the current variation in accessibility of PC in
Europe. This will be illustrated by using indicators such
as national and geographic availability of PC services,
organizational access arrangements, affordability and
acceptability of PC services. Furthermore, the efforts of
European countries to improve access by appropriately
structuring their PC system through policies and
regulation, financial measures and workforce
development will be presented.
Conclusions: This study has developed and
implemented a PC monitoring instrument producing
comparable information on the structure, process and
outcomes of PC systems in Europe. It includes up to
date information on the degree in which countries offer
an accessible PC system. This resulted in know-how of
policy strategies conducive to improving access to PC
services.
Implications for Policy, Delivery or Practice: Results
are meant to be used by national decision makers,
patient- and consumer organizations and international
and local partners of the participating countries, to better
inform the policy making process for strengthening
health systems through primary care.
Funding Source(s): European Commission
• Burying the Dead but Saving the Sick: Supporting
People Living with HIV through Traditional Burial
Groups in Ethiopia
Francis Okello, M.A.; Francesca Stuer, M.Sc., R.N.;
Altaye Kidane, M.D.; Medhanit Wube, M.P.H., R.N.
Presented by: Francis Okello, MA, Senior Technical
Officer, Surveillance, Project Monitoring and Evaluation,
Family Health International, 4401 Wilson Boulevard,
Arlington, VA 22203; Phone: (703) 647-4598; Email:
fokello@fhi.org
Research Objective: Access to healthcare in Ethiopia is
limited, a predicament only exacerbated by the HIV
pandemic. HIV prevalence estimate is 7.7% in urban
areas and 0.9% in rural. On average, Ethiopians who
seek healthcare travel 34km to the nearest hospital, and
7km to the nearest health center/post. FHI aimed to
contribute to improve access of people living with HIV
(PLHIV) to information and care, and to promote positive
attitudes and behaviors. Beginning in 2003, FHI
collaborated with the Government of Ethiopia, partnering
with NGOs and idirs (traditional burial societies) in 14
Ethiopian cities to deliver home/community-based care
to PLHIV and their families. Idirs are formed by
community members to provide support when death
occurs. FHI contracted and provided technical support to
local NGOs, who engaged, built capacity of, and
supervised idir volunteers to deliver care and behavior
change strategies. In 2009, the project outcomes were
evaluated among PLHIV and their households, and
among idirs.
Study Design: Qualitative and quantitative methods
were used. The qualitative approach used participatory
rapid appraisal techniques (intervention and results tree
and pair-wise ranking conducted in group discussions),
in-depth interviews and case studies. Quantitative
methods used secondary analysis of service delivery
statistics collected by implementing partners. Outcomes
investigated included: extent of local capacity building,
care delivery capability, beneficiary health status,
adherence to ART, stigma and discrimination reduction,
and livelihood improvement.
Population Studied: Study participants included PLHIV,
ministry of health staff working in HIV programs in the
intervention regions, idir home-based care committee
members, program managers of implementing partners,
nurse supervisors working with implementing partners,
and volunteer caregivers.
Principal Findings: Over 200 idirs improved
management practices and developed skills to deliver
care and support to PLHIV. Over 21,000 PLHIV received
project services, including: nursing, referral and followup clinical services, psychosocial support, nutritional
support and economic strengthening. Cumulatively,
11,409 PLHIV were put on antiretroviral therapy (ART).
Adherence to ART was greater than 99% among project
clients. Mortality declined from 10% of current clients in
2005 to 0.5% in 2009. Qualitative findings indicate
considerable reduction in stigma and discrimination,
household economic improvement, and better care and
support for orphans and vulnerable children (food,
shelter and care, protection, access to healthcare,
education and vocational training support, psychosocial
support, livelihood development and small scale
savings).
Conclusions: When adequately capacitated,
community-based organizations (CBOs) can sustainably
deliver lasting improvement in the health, social life, and
livelihoods of PLHIV, and can effectively transform their
communities.
Implications for Policy, Delivery or Practice: Dialogue
among donors and governments about local ownership
and capacity building of CBOs has been rife, but mixed
results have been achieved in different settings.
Strengthening CBOs capacity enhances the
effectiveness of donor and government investment to
provide quality care and treatment for PLHIV, particularly
in resource–constrained settings. With proper training
and supervision, individuals with basic or even no
schooling can support efforts to care for PLHIV. Because
good indigenous organizations represent the moral and
social fiber of communities, they can be effective
development partners. Based on these findings, their
ability to improve attitudes and lessen discrimination
toward PLHIV is unequaled.
Funding Source(s): PEPFAR; Royal Netherlands
Embassy
• Strengthening Laboratory Systems in ResourceLimited Settings
Stuart Olmsted, Ph.D.; Melinda Moore, M.D., M.P.H.;
Robin Meili, M.B.A.; Herbert C. Duber, M.D.; Jeffrey
Wasserman, Ph.D.; Preethi Sama, Ben Mundel, Lee
Hilborne, M.D., M.P.H.
Presented by: Stuart Olmsted, Ph.D., Natural
Scientist, RAND Corporation, 4570 Fifth Avenue, Suite
600, Pittsburgh, PA 15213; Phone: (412) 683-2300;
Email: olmsted@rand.org
Research Objective: Public health laboratories are a
critical component of global communicable disease
detection, prevention and control. Improving laboratory
services in resource-limited settings has been the focus
of many governmental and non-governmental funding
programs in recent years, driven in part by the HIV/AIDS
crisis. We assessed how countries and these funding
sources have worked to improve laboratory services and
describe opportunities to enhance public health
laboratory systems in resource-limited settings.
Study Design: We reviewed published reports,
interviewed major donor organizations, and conducted
case studies of laboratory systems in Kenya, Ethiopia
and Thailand, focusing on laboratory systems and
infrastructure development, coordination of external
funding, and the adoption of standards, quality systems,
and accreditation.
Principal Findings: Considerable resources, especially
from the Global Fund to Fight AIDS, TB and Malaria and
the U.S. President’s Emergency Plan for AIDS Relief,
have been invested in recent years to improve laboratory
systems in resource-limited settings. While infrastructure
and the provision of services have seen improvement,
important opportunities remain for further advancement.
Countries are building multi-tiered laboratory systems
with modern central laboratories and developing
strategic national plans, as recommended by
international organizations. However, implementation of
strategic plans is inconsistent, human resources remain
limited, and quality laboratory services rarely extend to
lower tier laboratories (e.g., health clinics, district
hospitals). Coordination within host governments,
between governments and donor organizations, and
among the various donor organizations is also frequently
problematic. Finally, laboratory standardization and
quality control are improving but remain very
challenging, making accreditation a difficult goal.
Conclusions: During the past decade, efforts have
expanded to improve public health laboratory capacity in
resource-limited countries. While we identified some
challenges associated with laboratory development, we
identified even greater opportunities for host
governments and their external partners to improve
laboratory systems, coordinate better across funding
sources, and adopt quality laboratory systems.
Appropriate leadership on the part of all stakeholders is
critical. While we studied three countries in depth, our
literature review and interviews with donor organizations
suggest that our findings and recommendations are
likely to be more broadly applicable to other resourcelimited countries.
Implications for Policy, Delivery or Practice: Based
on our findings, we offer four policy recommendations for
host countries and external funding partners: 1) Support
planned, integrated laboratory capacity development
within the context of tiered systems compatible with the
Maputo Report. External funding agencies should
consider ways they can work with ministries of health
and other organizations to develop sustainable
laboratory capacity across diseases and centered
around a national strategic plans that are grounded in
strong technical guidelines, 2) Support an “owner-driven
agenda” based on countries’ own national plans and
organizations. Donors should work to respect and fit
their own programming into host country national plans,
3) Support career and leadership development for
laboratory professionals. Host country governments and
funding agencies should commit to building leadership
and management skills in the laboratory cadres and take
steps to ensure there are high-level positions within
government for these leaders, and 4) Support laboratory
quality improvement. External funders and host
countries should incorporate laboratory standards,
comprehensive quality systems, and goals for
accreditation into their plans.
Funding Source(s): Department of Health and Human
Services
• Health Workforce Migration and the European
Union
Matthias Wismar, Ph.D., M.Sc.; Irene Glinos, M.Sc.;
Claudia Maier, M.Sc.
Presented by: Matthias Wismar, Ph.D., M.Sc., Senior
Health Policy Analyst, European Observatory on Health
Systems and Policies, rue de l'Autonomie 4, Brussels,
1070, Belgium; Phone: +003225250938; Email:
mwi@obs.euro.who.int
Research Objective: PROMeTHEUS research project,
2009-2011, co-funded by the European Commission
FP7 grant agreement no.223383, is exploring the
changing migratory patterns to understand the scale,
directions and importance of health workforce migration
in and beyond Europe.
Study Design: Collection of secondary qualitative data
in 17 European countries carried out by local teams.
Country material described and analysed according to
common template. Cross-country analysis carried out on
the basis of country findings. Collection of secondary
quantitative data in EU27 and selected OECD countries.
Assessment of indicators, analysis of data collection
instruments, and triangulation of data sets from different
sources.
Population Studied: Stocks, inflows and outflows of
medical doctors, nurses and dentists in countries studied
in the context of health workforce migratory movements.
Principal Findings: What were relatively predictable
migratory flows are changing. European geo-politics of
the 21st century has affected migration possibilities and
directions as old regimes disappeared and the European
Union expanded in 2004/2007. Societal and
demographic developments imply that countries have to
deal with health workforce shortages, the ageing of
users as well as providers of health services, new
disease patterns, new technology and challenges related
to forecasting needs and workforce supply. These
provide the context in which health workforce migration
has to be understood. In Europe, health professionals
move between neighbouring countries and from ‘new’ to
‘old’ Member States, while the US continues to attract
European health workforce to alleviate its domestic
underproduction. With few exceptions, European
countries recruit health workforce from within Europe,
and while the absolute numbers of intra-European
movements appear increasing in recent years, relative
volumes of flows appear diminishing as the stock of
national health workforces grow. Impacts of migration
can be at system level but effects of in/outmigration are
often more pronounced for particular medical specialties,
in underserved geographical areas, and among certain
population groups. Relative magnitude of flows differs
widely between countries and between health
professional categories.
Conclusions: While health workforce migration seldom
constitutes a critical challenge for European countries, it
is typically a symptom of deeper running problems in the
relevant health systems and often exacerbates other
pre-existing difficulties related to general health
workforce shortages, demographic ageing,
maldistribution of health workforce in geographical terms
or in terms of medical specialisations and cadres, or
attrition of health professionals to other sectors of the
economy.
Implications for Policy, Delivery or Practice: The
notion of national self-sufficiency in terms of health
workforce is increasingly ambiguous as markets become
global, countries interdependent and as movements
fluctuate. In the face of demographic changes and
workforce ageing, migration and international
recruitment are likely to have larger roles in the future if
countries do not scale up domestic production of health
workforce. Policy makers and managers need to
respond but robust data on health workforce migration is
scarce and domestic approaches to health workforce
migration appear insufficient or outdated. A panEuropean study as PROMeTHEUS is able to overcome
national biases and to address the information gaps.
Funding Source(s): Co-funded by European
Commission
Using Microsimulation Models to Examine Public
Health Investments
Chair: Glen Mays
Monday, June 28 * 11:30 am–1:00 pm
• Expanded HIV Screening: What Will It Cost, and
Who Will Pay? A Budget Impact Analysis
Erika Martin, Ph.D., M.P.H.; A. David Paltiel, Ph.D.;
Rochelle Walensky, M.D., M.P.H.; Bruce Schackman,
Ph.D.
Presented by: Erika Martin, Ph.D., M.P.H., Assistant
Professor, Department of Public Administration and
Policy, Rockefeller College of Public Affairs and Policy,
University at Albany, SUNY, Milne 300E, 1400
Washington Avenue, Albany, NY 12222; Phone: (518)
442-5243; Email: emartin@albany.edu
Research Objective: In 2006, the Centers for Disease
Control and Prevention (CDC) revised their HIV
screening guidelines to increase detection rates and
facilitate early entry into care. Prior analyses have
examined the cost-effectiveness of this policy; however,
affordability concerns remain an obstacle to widespread
implementation. If government HIV testing and care
programs are under-funded, expanded HIV screening
may result in large numbers of newly-identified cases
who are unable to access treatment. Expanded
screening may have different budget impacts on each of
the various government programs that currently finance
HIV care. We forecasted the budget impact of expanded
HIV screening to: discretionary government programs
with fixed annual budgets (uncompensated care pools
and the Ryan White HIV/AIDS Program, which oversees
AIDS Drug Assistance Programs); entitlement programs
(Medicaid and Medicare); and government-funded
testing programs.
Study Design: We used a Monte Carlo simulation
model of HIV screening, disease, and treatment to
determine the five-year budget impact of expanded HIV
screening to government programs. We estimated the
incremental testing and treatment costs of increasing
average test frequencies from every 10 years (current
practice) to every 5 years. We used CDC estimates of
HIV prevalence (1.1 million) and annual incidence
(56,000), and considered variations in screening
frequency (no screening to annual screening), test return
rates (50%-100%), linkage to care (50%-100%), test
characteristics, and eligibility for government screening
and treatment programs.
Population Studied: We focused on HIV-infected
patients without private insurance or access to care
through the Veterans Administration.
Principal Findings: Under current practice, 177,000
new HIV cases will be identified over five years.
Expanded screening will identify an additional 46,000
cases at an incremental five-year cost of $2.7 billion,
representing approximately $59,000 per newly-identified
case. The financial burden will fall disproportionately on
discretionary programs that fund care for newly-identified
patients. Testing will represent a small proportion (18%)
of the total budget. Pharmaceutical costs will be the
main driver of budget increases. Expanded screening
will increase the pharmaceutical costs of discretionary
programs by $1.9 billion over five years, which is
equivalent to 25% of the current AIDS Drug Assistance
Program budget. These findings are sensitive to the
frequency of screening and the proportion linked to care.
Conclusions: Expanded screening can identify new HIV
cases, but treating these individuals will increase budget
requirements for government programs. The burden will
fall disproportionately on discretionary programs,
because persons identified with HIV early will be less
likely to be immediately eligible for entitlement programs.
Implications for Policy, Delivery or Practice:
Expanded HIV testing may result in significant numbers
of newly-identified cases who are unable to access care
unless policy-makers increase budgets for discretionary
programs such as Ryan White. Expanding Medicaid
services to low-income individuals who have not yet
progressed to AIDS may alleviate some of the increased
budgetary demand on the Ryan White program.
Funding Source(s): NIDA, Agency for Healthcare
Research and Quality; National Institute of Mental
Health; Doris Duke Charitable Foundation
• Assessing and Forecasting the Impact of Air
Quality on Health Outcomes for a Local County
Health Department
Jeroen van Meijgaard, M.A.; Jonathan Fielding, M.D.,
M.B.A., M.P.H.; Riti Shimkhada, Ph.D.
Presented by: Jeroen van Meijgaard, M.A., Health
Services, UCLA School of Public Health, CHS 61-253,
Box 951772, Los Angeles, CA 90095-1772; Phone:
(310) 206-6236; Email: jeroenvm@ucla.edu
Research Objective: The objective of this study was to
apply an existing microsimulation framework to model
the health effects of changes in two air quality indicators,
fine particulate matter (PM2.5) and ozone, for Placer
County, an area in California that routinely experiences
poor air quality. This study also demonstrates how these
results are being used by the local county health
department for community outreach, advocacy and
mobilization.
Study Design: We adapted the California health
forecasting model to estimate the impact of daily levels
of ozone and PM2.5 on health outcomes in Placer
County. The model was used to estimate the impact of
alternative future scenarios on health outcomes through
2030. Three scenarios were identified by the Placer
County Department of Health as areas of interest: (1) a
targeted reduction of PM2.5 and ozone of 20% over a
20-year time frame, (2) climate change, and (3)
increased frequency of wildfires. These scenarios were
compared with a baseline (i.e. no change) forecast. The
model is based on a microsimulation framework in which
individuals’ lifetime histories are simulated, including
disease incidence and mortality. Data on exposure were
obtained from the California Air Resources Board and
relative risk functions for the associations between
PM2.5 and ozone on health outcomes were obtained
from the literature, including the Environmental Benefits
Mapping and Analysis Program (BenMap) developed by
the Environmental Protection Agency (EPA).
Population Studied: The Placer County population,
stratified by gender, race/ethnicity and age, was included
in the study. Results of the simulation were summarized
at the County and board of supervisor districts district
level.
Principal Findings: In the Sacramento Valley air basin,
where about 85% of the population of Placer County
resides, a 20% reduction in ozone and PM2.5 levels
results in a 67% reduction in the number of days
exceeding the EPA standard for PM2.5 (35 ug/m3) in
2030 compared to the level we expect without targeted
changes. The reduction in days exceeding the ozone
standard (75 ppb) is about 92%. Whereas changes in
health outcomes resulting from worsening air quality due
to climate change or increasing wildfires are minimal,
with a 20% reduction in air pollutants we expect a 10%
reduction in acute bronchitis hospital admissions and
asthma emergency room visits by 2030, as well as a
large reduction in school absences (73,500 days) and
work days lost (9,000 days).
Conclusions: Achievable declines in air contaminants
can have significant impact on outcomes, namely a
decline in the number of school absences due to
respiratory illness. The full results are made available
through a web-based tool, which allows users to graph
results and translate forecasts to communities by
inserting local data. County health departments can use
these results to communicate the importance of air
quality on health of their populations, particularly
children, and support advocacy around policies designed
to curb air pollution.
Implications for Policy, Delivery or Practice: This
study shows how evidence-based research can support
advocacy and policy-making at the local level. The web
interface further allows stakeholders to directly access
information, thus broadening the support for advocacy
and community engagement.
Funding Source(s): Placer County Department of
Health Services
• Who Pays the Costs? Who Realizes the Benefits?
Using a Microsimulation Approach to Inform the
Business Case for Smoking Cessation
Wenya Yang, M.P.A.; Timothy Dall, M.S.; Yiduo Zhang,
Ph.D.; Shiping Zhang, M.S.; Erica Moen, B.S.; David
Arday, M.D., M.P.H.; Patricia Dorn, R.N., M.S.N.
Presented by: Wenya Yang, M.A., M.P.A., Consultant,
The Lewin Group, 3130 Fairview Park Drive, Suite 800,
Falls Church, VA 22042; Phone: (703) 269-5694; Email:
grace.yang@lewin.com
Research Objective: We model the potential reduction
in beneficiaries’ lifetime medical costs associated with
successful smoking cessation for current smokers in the
Military Health System’s Prime (managed care) plan.
Study Design: A Markov Chain Monte Carlo simulation
model, the Health Promotion Microsimulation Model,
was designed to quantify current and future disease
cases and lifetime benefit of smoking cessation with and
without weight gain that often accompanies cessation.
Model parameters are based on published findings for
clinical trials and other studies, as well as multivariate
regression analysis with medical claims (FY2007-2008)
and biometric data from 2.1 million beneficiaries under
age 65. Disease transition probabilities for 16 smoking
comorbidities (e.g. chronic airways obstruction, lung
cancer) were estimated using Logistic regressions to
predict annual disease risk (in FY2008) as a function of
observed characteristics from the previous year (FY2007
data). Predictors included demographics (age and sex),
clinical measures (e.g., body mass index, systolic blood
pressure), and health-related behaviors (e.g., smoking,
body mass index). Regression coefficients were used to
simulate changes in disease risk over one’s lifetime as a
function of patient characteristics updated for each year.
At the end of simulation, person-years with a specific
condition were calculated and a 3% discount rate was
applied to the calculation. We also estimated total
annual medical cost per beneficiary with a condition from
OLS regression models where annual medical
expenditures were regressed on the existence of each
comorbidity and other characteristics. Study end
points—including disease cumulative incidence, person-
years with condition and associated cost—were then
aggregated to calculate the difference between the
status quo and the intervention scenarios.
Population Studied: The simulation analysis was run
using data for 612,332 current smokers with electronic
health records and at least 10 consecutive months of
enrollment in Prime in both FY2007 and FY2008. This
includes 390,873 active duty service members, 113,517
family members, and 107,942 retirees and their
dependents.
Principal Findings: Cessation increases average life
expectancy by 3.7 years. Average lifetime societal
reductions in medical expenditures from improved health
($5,600) are offset by additional expenditures from
prolonged life ($7,300). Without accompanying weight
gain, savings increase from improved health increase
($7,000) as do additional expenditures from prolonged
life ($8,000). If smoking were completely eliminated the
present value of future Prime medical expenditures
would decline by $1.15 billion (with $1.9 billion achieved
if cessation were coupled with weight management).
Savings to Other payers is $350 million ($539 million
without weight gain). Due to increased longevity, lifetime
Medicare expenditures rise by $3.1 billion ($3.5 billion
without weight gain).
Conclusions: Smoking cessation reduces lifetime risk
for numerous chronic diseases and increases longevity.
Cessation has little impact on lifetime medical
expenditures, with savings from improved health offset
by expenditures from prolonged life. Numerous studies
have shown, however, that improved health and
increased longevity have significant quality of life and
productivity implications.
Implications for Policy, Delivery or Practice:
Microsimulation models can be used to quantify the
potential long-term health and economic implications of
health promotion initiatives. Such findings help inform
the potential health and financial implications of specific
prevention strategies targeted to specific populations.
Funding Source(s): TRICARE Management Activity
(Department of Defense)
• Projected Lifetime Cost of Excess Weight among
TRICARE Prime Plan Beneficiaries: the Business
Case for Weight Loss Interventions
Yiduo Zhang, Ph.D.; Timothy Dall, M.S.; Navita Sahai,
B.S.; Shiping Zhang, M.A.; David Arday, M.D.
Presented by: Yiduo Zhang, Ph.D., The Lewin Group,
3130 Fairview Park Drive, Suite 800, Falls Church, VA
22042; Phone: (703) 269-5603; Email:
yiduo.zhang@lewin.com
Research Objective: This study quantifies expected
lifetime medical savings associated with intentional
weight loss among overweight and obese TRICARE
Prime (managed care) plan beneficiaries. Applying
findings from a Department of Defense weight loss
demonstration, we simulated the implications for DoD
and for society if the program were extended
successfully to the entire beneficiary population. Such
information helps inform the business case for weight
loss interventions.
Study Design: Using a Markov Chain Monte Carlo
simulation approach, we modeled individuals’ clinical
outcomes, disease progression, and death over his or
her lifespan. The model starts with observed
characteristics (demographics, biometrics, health
behavior, disease presence) and projects future onset of
chronic diseases linked to excess weight. Medical
claims, clinical and wellness measures, and
demographic information from administrative files were
linked for 857,200 overweight and 521,800 obese
beneficiaries age 18 to 64 in 2008. Disease transition
probabilities for 40 morbidities linked to excess weight
were modeled using FY2007 and 2008 data. Logistic
regression is used to estimate FY2008 disease risk as a
function of previous year (FY2007) observed
characteristics (e.g., age and sex), clinical measures
(e.g., body mass index, systolic blood pressure,
presence of chronic conditions), and health-related
behavior (e.g., smoking). Coefficients from the logistic
regressions are used to simulate changes in disease risk
over one’s lifetime as a function of demographics and
changes in risk factors such as body weight and blood
pressure (which also change over time as a function of
age and other risk factors). Person years with chronic
conditions are calculated to capture the timing and
duration of disease prognosis under status quo and
alternative sustained weight loss scenarios. Age-specific
estimates of the annual, marginal medical costs
associated with presence of each chronic condition were
calculated using beneficiary medical claims. Combining
simulated person-years of disease and annual cost per
disease, we calculated differences in present value of
lifetime medical costs under alternative weight loss
scenarios. Model validation activities included
comparison of simulated findings against published
findings—e.g., from studies such as the Diabetes
Prevention Project and the Framingham Heart Study.
Population Studied: The simulation starts with
observed characteristics from all 4.2 million plan
beneficiaries under age 65 in March 2008.
Principle Findings: Among overweight and obese
beneficiaries, lifetime medical expenditures decline by
$440 (3% discount rate) for each 1% reduction in body
weight. This includes $590 in savings from improved
health, offset by $150 in additional expenditures from
prolonged life. Approximately 52% of net savings benefit
TRICARE, 3% benefit Medicare, and 45% benefit other
insurers. Change in lifetime expenditures per 1% weight
loss ranges from $660 reduction for grossly obese adults
under age 45, to $40 gain from grossly obese adults age
55-64 (for whom increased expenditures from longevity
exceeding savings from improved health).
Conclusions: Long-term societal savings from weight
loss interventions significantly outweigh short-term
savings that will accrue to the current payer/insurer.
Implications for Policy: Long-term societal savings
from weight loss interventions significantly outweigh
short-term savings that will accrue to the current
payer/insurer. Our findings inform the business case for
weight loss interventions, but also highlight the
contribution of weight loss to improving health and
reducing premature mortality.
Funding Source(s): Department of Defense
The Effect of Health Information Technology on
Clinical Quality
Chair: Jeffrey McCullough
Monday, June 28 * 11:30 am–1:00 pm
• Impact of Telehomecare on Readmission in Heart
Failure
Kathryn Bowles, Ph.D., M.S.N., B.S.N.; Barbara Riegel,
Ph.D., M.S.N., B.S.N.; Mark Weiner, M.D.; Henry Glick,
Ph.D.; Lee Goldberg, M.D.; Mary Naylor, Ph.D., M.S.N.,
B.S.N.
Presented by: Kathryn Bowles, Ph.D., M.S.N., B.S.N.,
Associate Professor, School of Nursing, University of
Pennsylvania, 418 Curie Boulevard, Philadelphia, PA
19034; Phone: (215) 898-0323; Email:
bowles@nursing.upenn.edu
Research Objective: Examine the effect of a
telehomecare intervention on 60 day readmission rates
and time to readmission for older adults with heart failure
compared to usual care. Video and medical equipment
was placed in the patients’ homes and connected via
telephone to nurses’ videophones and computers in the
home care agencies. Home health nurses monitored
patients’ health status and taught patients via the
technology how to self monitor and act upon the
information.
Study Design: Randomized, controlled trial with a
control group who received standard in-person home
care. The intervention group received a combination of
in-person and telehomecare visits. The type and number
of visits were guided by a standardized protocol that
defined expectations of telehealth encounters and home
visits during an episode of home care. Wilcoxon Rank
Sums Test compared 60 day readmissions rates and
survival analysis of time to readmission was conducted
up to six months from start of care.
Population Studied: Eligible patients were discharged
from the hospital to home care after an exacerbation of
HF, English speaking; mentally competent, weighed less
than 450 pounds (scale maximum); had a telephone;
Medicare insurance; were able to see, hear, place a cuff
on their arm, and stand on a scale to weigh themselves.
Principal Findings: Results are based on 116
completed patients among 218 enrolled to date.
Avenuerage age is 70.5, 65% female, 70% black,
average time with heart failure 5.4 years. The data
demonstrate a trend toward improved outcomes with
telehomecare. The 60 day readmission rate was 3.4 for
usual care patients and 1.8 for telehomecare patients,
p=0. 53. Time to first readmission showed no statistically
significant difference between the two groups (log-rank
test p = 0.58, although median time to first readmission
was 60 days for telehealth compared to 47 for control.
Conclusions: Despite the varied efforts of individual
home health agencies, the present national average rate
of acute care hospitalization during home care is 29%.
Agencies are searching for innovative health services
such as telehomecare to assist them in lowering these
rates. These findings show the promise of telehealth as
a strategy to prevent hospital readmission.
Implications for Policy, Delivery or Practice: The
study indicates a trend toward demonstrating the value
of telehomecare interventions to target HF as the most
common chronic illness in home care and the most
costly for Medicare. The technology is ideal for HF
patients because they require frequent,close monitoring
and a great deal of teaching to recognize the early and
subtle signs and symptoms of exacerbation. The
efficiency gained with telehomecare may enable
increased contact between providers and patients that is
so important in the management of HF. Even though
they require frequent provider contact, compared to
other types of patients, home care agencies receive
moderate reimbursement for HF care making them
expensive to manage by in-person visits alone. If shown
to be effective, telehealth technology may assist
agencies in providing the close monitoring and teaching
that is needed, while maintaining or decreasing numbers
of in-person encounters.
Funding Source(s): National Institute of Nursing
Research
• Changes in Safety and Efficiency of Outpatient
Prescribing with Use of E-Prescribing Systems
Catherine DesRoches, Dr.PH.; Corey Angst, Ph.D.; Rita
Agarwal, Ph.D.; Michael Fischer, M.D.
Presented by: Catherine DesRoches, Dr.PH.,
Assistant Professor, Department of Medicine (Health
Policy), Harvard Medical School, 50 Staniford Street,
Boston, MA 02114; Phone: (617) 724-6958; Email:
cdesroches@partners.org
Research Objective: To understand physician
perceptions of the utility of e-prescribing systems, the
effect of these systems on clinical practice and
prescribing processes and how perceptions differ
between physicians using a “stand alone” system and
those using one integrated with an electronic health
record (EHR).
Study Design: We conducted a mailed survey of 1,947
practicing physicians. The survey was fielded between
April and September 2009. Physicians were provided a
$20 cash incentive to encourage participation. Multiple
follow-up contacts were made to non-responders. The
survey had an overall response rate of 52%.
Population Studied: The sample was drawn from a
comprehensive list of physicians enrolled in eprescribing systems maintained by SureScripts.
Physicians enrolled with the 15 largest e-prescribing
vendors in the US as of April 2009 were eligible for
inclusion. To ensure that our sample included a sufficient
number of physicians who were enrolled with an eprescribing vendor but were not using the system at the
expected rate, our sample included a “low user” strata.
Principal Findings: We received completed surveys
from 1,019 physicians. Fifty-five percent of physicians
had an e-prescribing system that was integrated into
their EHR, while 45% reported using a “stand alone”
system (e.g., a system that was not linked to the
patient’s clinical record). Physicians with an integrated
system were more likely than those with a stand alone
system to report fewer years in practice and practicing in
larger groups, hospitals or academic medical centers.
Physicians with an integrated system reported higher
levels satisfaction overall (45.9% very satisfied among
users of an integrated system vs. 33.8% very satisfied
among stand alone user), and specifically with the
reliability (43.1% vs. 38.0%) and flexibility (27.6% vs.
22.1%) of their systems. They were also significantly
more likely than their counterparts with stand alone
systems to report that the use of e-prescribing made
many of the tasks associated with prescribing, such as
refill requests and medication reconciliation easier.
Finally, physicians with an integrated system were
significantly more likely than those with a stand alone
system to report avoiding a drug allergy (44.8% vs.
23.1%) or a potentially dangerous medication interaction
(38.6% vs. 26.1%) in the past 6 months due to a prompt
from their EHR.
Conclusions: Findings suggest that physicians using eprescribing systems that are integrated into an EHR are
more satisfied with e-prescribing and perceive greater
benefits related to administrative tasks and patient safety
resulting from the use of their system than physicians
using stand alone systems.
Implications for Policy, Delivery or Practice: The
effective use of e-prescribing has the potential to
improve patient safety and reduce administrative hassles
associated with prescribing. However, our findings
suggest that stand alone e-prescribing systems, while
offering advantages over integrated systems in terms of
the cost of implementing a system, offer fewer benefits
for physicians than systems that are integrated with an
electronic health record. This is particularly relevant in
the area of patient safety. Current health information
technology priorities for the Obama administration, with
its focus on the “meaningful use” of electronic health
records suggest that, despite their lower cost, stand
alone e-prescribing systems may soon become
obsolete.
Funding Source(s): AHRQ
• Prescribing in Compliance with Patient Formularies
Increases Primary Adherence in Patients Receiving
Electronic Prescriptions
Michael Fischer, M.D., M.S.; Niteesh Choudhry, M.D.,
Ph.D.; Jerry Avorn, M.D.; Sebastian Schneeweiss, M.D.,
Sc.D.; William Shrank, M.D., M.S.H.S.
Presented by: Michael Fischer, MD, MS, Assistant
Professor of Medicine, Division of
Pharmacoepidemiology and Pharmacoeconomics,
Brigham & Women's Hospital, Harvard Medical School,
1620 Tremont Street, Suite 3030, Boston, MA 02120;
Phone: (617) 278-0930; Email: mfischer@partners.org
Research Objective: Patient non-adherence to
prescribed medication is common and limits the
effectiveness of treatment for a variety of conditions.
Most studies of adherence are conditional on filling a first
prescription, and evaluate subsequent filling behavior.
With the advent of electronic prescribing (e-prescribing)
systems, recent studies have begun to measure the rate
of “primary non-adherence,” identifying prescriptions
given to patients but never filled at the pharmacy. The
availability of these new data provides an opportunity to
identify important predictors of primary non-adherence.
Study Design: We obtained data on e-prescriptions
issued with the iScribe e-prescribing system during
calendar 2008 for a population of patients covered by
the pharmacy benefits manager (PBM) Caremark. We
also obtained PBM data containing all filled claims for
these patients in 2008 and the first 6 months of 2009.
We matched e-prescriptions issued to patients with the
filled claims by using data on the drug name, date of eprescription, and date of filled claims, allowing up to 180
days for patients to fill e-prescriptions. We evaluated the
rate of primary adherence across multiple characteristics
of patients, prescribers, e-prescribing processes, and the
medications provided.
Population Studied: Our sample included 1.04 million
e-prescriptions and over 33 million filled claims. There
were 3,634 prescribers and 309,500 patients.
Principal Findings: The primary non-adherence rate
was 22.8%. By patient age, adults from 45-64 were more
likely to fill e-prescriptions (78.6%) than children and
young adults (75.0%). Men and women adhered at
similar rates. Patients living in zip codes with higher
incomes were more likely to fill e-prescriptions than
patients from lower income areas (80.3% in highest
quintile vs. 74.9% in lowest quintile). Adherence rates
were similar by prescriber age, gender, and volume of eprescribing use. Medications that were non-formulary
were filled 72.6% of the time while medications that were
on-formulary were filled 77.1% of the time and preferred
medications were filled 78.7% of the time. Prescriptions
that were transmitted electronically were more likely to
be filled (80.0%) than prescriptions that were written in
the e-prescribing system but then printed and given to
the patient (73.5%).
Conclusions: Over 20% of e-prescriptions are not filled.
Patients living in higher-income regions are more likely
to fill their e-prescriptions. The formulary status of the
medication chosen is strongly associated with whether
the e-prescription is eventually filled. This is consistent
with prior research in other settings demonstrating that
cost to patients can be a barrier to medication
adherence. When e-prescriptions were transmitted
directly to the pharmacy the adherence rates were
higher, likely by eliminating the effort and time required
for patients to bring paper prescriptions to the pharmacy.
Implications for Policy, Delivery or Practice: Our
results identify areas that physicians can target to
improve medication adherence. In addition, the ability to
identify non-adherence through e-prescribing systems
may offer potential for future interventions directed to
either patients or prescribers.
Funding Source(s): CVS/Caremark
• Hospital Electronic Health Record Adoption and
Nurse-Assessed Patient Safety Outcomes
Ann Kutney-Lee, Ph.D., R.N.
Presented by: Ann Kutney-Lee, Ph.D., R.N., Assistant
Professor, Center for Health Outcomes and Policy
Research, University of Pennsylvania School of Nursing,
418 Curie Boulevard, Claire M. Fagin Hall, Room 375,
Philadelphia, PA 19104; Phone: (215) 898-9669; Email:
akutney@nursing.upenn.edu
Research Objective: Few large-scale studies have
assessed the adoption of EHR systems on quality of
care. The objective of this study was to examine the
effect of having a basic electronic health record (EHR)
system on nurse-assessed patient safety outcomes.
Study Design: The study is a cross-sectional analysis of
linked survey data from registered nurses working in
hospitals in four large states (California, Pennsylvania,
New Jersey and Florida) in 2006-2007, the recently
released 2007 American Hospital Association (AHA)
EHR Adoption Supplement, and AHA Annual Survey
data. The final sample included 17,271 nurses working
in 330 hospitals. Hospitals in the sample were divided
into two groups for the analysis: with and without a basic
EHR system. Generalized linear models that accounted
for the clustering of nurses within hospitals were used to
evaluate the relationship between adoption of a basic
EHR system and a variety of nurse-assessed patient
safety outcomes.
Population Studied: This study examined nurses’
assessments of patient safety in hospitals that
implemented a basic EHR system in all patient care
units. A basic EHR system was defined as electronic
clinical documentation of patient demographics,
problems, medications and discharge summaries, as
well as electronic laboratory, radiologic and diagnostictest results, and computerized physician order entry for
medications. Nurse-assessed patient safety outcomes
were related to the exchange of patient information
during shift changes and transfers, medication errors,
and overall assessments of hospital safety.
Principal Findings: Only 22 (7%) of the 330 hospitals in
the sample had a basic EHR system. Nurses working in
hospitals that had implemented a basic EHR system in
all patient care units, as compared to nurses working in
hospitals without EHR were 11% less likely to report that
important patient information was lost during shift
changes, 16% less likely to report that things “fall
between the cracks” during transfers, 24% less likely to
report frequent medication errors (borderline statistically
significant), and 22% less likely to give a poor grade to
their unit for patient safety. Nurses working in these
hospitals were also 37% more likely to report that their
hospital management makes safety a priority.
Conclusions: This is some of the first evidence using
such a large sample of hospitals to show that
implementation of a basic EHR system may improve
continuity of patient care and patient safety as assessed
by nurses – the frontline providers of care. Hospitals that
adopt EHR technology may be more likely to have a
broader focus on patient safety.
Implications for Policy, Delivery or Practice: At the
time of the AHA EHR Adoption Survey, a large majority
of hospitals in the United States did not have a basic
EHR system. Hospitals’ investment in EHR technology
may not only result in improved nursing care, but also
better care coordination and safety for patients.
Funding Source(s): National Institute of Nursing
Research
• The Influence of Integrated Electronic Medical
Records and Computerized Nursing Notes on
Nurses’ Time Spent in Documentation
Tracy Yee, M.P.H.; Jack Needleman, Ph.D.; Marjorie
Pearson, Ph.D., M.S.H.S.; Patricia Parkerton, Ph.D.,
M.P.H.; Melissa Parkerton, M.A.; Joelle Wolstein, M.A.
Presented by: Tracy Yee, M.P.H., Graduate Student,
Department of Health Services, UCLA School of Public
Health, 1320 N Veitch Street, Apartment 322, Arlington,
VA 22201; Phone: (310) 968-3289; Email:
tracyyee@ucla.edu
Research Objective: Recent focus on integrated
electronic medical records (EMRs) has brought attention
to the effects of EMRs on the quality of care, cost
effectiveness, and overall efficiency in documenting
patient care. The purpose of this study was to examine
nurses’ time spent in documentation as it relates to the
use of integrated electronic medical records and
computerized nursing notes.
Study Design: Cross-sectional analyses on time motion
study data collected during a nursing process and quality
improvement initiative was completed. Nurses were
randomly selected within the units to carry PDAs
(personal digital assistants) to track their location and
activities. Descriptives and cross tabulations were used
to obtain an overall understanding of the data and
findings. A Wald test was done to examine possible
effects due to seasonality. Ordinary least squares
regression with a cluster adjustment for unit pairings by
hospital was completed to examine characteristics
associated with nurses’ time spent in documentation.
Population Studied: Time study data on 105 units in 55
hospitals was captured from September 2007 through
March 2009. Frontline staff nurses on all shifts from units
participating in the Transforming Care at the Bedside
(TCAB) initiative intervention and control units units were
studied.
Principal Findings: Over half of the hospitals (53%)
were using integrated EMRs and 61% were using
computerized nursing notes in their documentation.
These electronic charting methods were already in place
before the start of the intervention; TCAB did not directly
address any changes associated with documentation.
Control and intervention units were nearly identical in
how they spent their time; subsequent analyses were
combined to illustrate the findings as a whole. A Wald
test found no significant changes over time by month.
Review of the percentages revealed very little difference
in time spent in documentation with or without the use of
EMRs or computerized nursing notes. Nurses were
found to spend 19% of time in documentation,
regardless of electronic charting usage.
Conclusions: Integrated EMRs and computerized
nursing notes had essentially no effect on nurses’
percentage of time spent in documentation when
compared to all other categories of care. No significant
differences between intervention and control units were
found in the way nurses’ spent their time. During the
course of the initiative, time spent in documentation (and
other categories of care) remained largely unchanged for
both the control and intervention units.
Implications for Policy, Delivery or Practice: While
these findings may suggest that integrated EMRs and
computerized nursing notes do not improve the
efficiency of work for nurses by reducing time spent in
documentation, it also does not show that EMRs and
computerized nursing notes make more work for nurses.
Studies examining time spent in documentation by other
clinicians are necessary to fully understand the impacts
on staff time. It is important to explore whether or not
EMRs are associated with more complete charting and
higher quality of documentation, as well as improved
coordination and delivery of care. Future studies on the
impact of EMRs are required to explore measurements
in quality, in addition to issues of cost and efficiency.
Funding Source(s): RWJF
Quality and Efficiency in Specific Conditions:
Cardiovascular Disease, Diabetes, Asthma and
ESRD
Chair: Peter Hussey
Monday, June 28 * 11:30 am–1:00 pm
• Race and Ethnicity Data for End-Stage Renal
Disease (ESRD) Patients
Claudia Dahlerus, Ph.D., M.A.; Jeffrey Pearson, M.S.;
Robert Wolfe, Ph.D.; Shannon Hunter, M.S.; Valarie
Ashby, M.A..; Tempie Shearon, M.S. Jyothi Thumma
M.P.H.; Brett Lantz M.A.; Joseph Messana M.D.; Bruce
Robinson M.D.; Jack Kalbfleisch Ph.D.; Rajiv Saran
M.D.
Presented by: Claudia Dahlerus, Ph.D., M.A., Project
Manager, Health Policy and Practice Projects, Arbor
Research Collaborative for Health, 315 W Huron Street,
Suite 360, Ann Arbor, MI 48103; Phone: (734) 6654108; Email: claudia.dahlerus@arborresearch.org
Research Objective: Accurate race and ethnicity data
are necessary to inform policy on health care disparities.
Previous studies demonstrate these data in the
Medicare Enrollment Database (EDB) do not conform to
Office of Management and Budget (OMB) standard
categories and are subject to validity and reliability
problems, with implications for investigating health care
disparities. This study evaluates race and ethnicity data
collected on ESRD Medical Evidence Form (CMS-2728)
to inform adaptation of this instrument to improve data
accuracy.
Study Design: The CMS-2728 collects providerreported data on ESRD patients. The EDB uses data
collected at birth by the Social Security Administration
using non-OMB race/ethnicity categories. The Scientific
Registry of Transplant Recipients (SRTR) database
contains provider-reported race identifiers, also using
non-OMB race/ethnicity categories. We compared CMS2728 race data with the EDB and SRTR and with the
ESRD Clinical Performance Measures (CPM) data that
report Hispanic/Latino ethnicity separately from race.
Finally, we evaluated differences between self-reported
and provider-reported race/ethnicity data from the U.S.
Dialysis Outcomes and Practice Patterns Study
(DOPPS). Kappa statistics (k) were calculated to
measure agreement among sources.
Population Studied: We examined 331,176 ESRD
patients with both EDB and CMS-2728 data; 63,666
patients with both CMS-2728 data and SRTR listings;
approximately 10,000 patients from three annual CPM
samples (2006-2008); and 4,467 patients with both self
and provider-reported race/ethnicity in the DOPPS.
Principal Findings: Comparison of the CMS-2728 to
the EDB showed nearly perfect agreement of White
(96.3%, k=0.808) and Black (97.0%, k=0.956) race
categories, and less agreement for American
Indian/Alaska Native race (81.3%, k=0.788),
Asian/Pacific Islander race (61.9%, k=0.711),
Hispanic/Latino ethnicity (35.4%, k=0.479), and
Other/Multi-Racial (11.5%, k=0.015) categories. Data
reported on the CMS-2728 compared to SRTR data
showed overall almost perfect agreement (k= 0.726 to
0.952) except with Other Race/Multi-Racial (k=0.093)
and Pacific Islander (k=0.352). Comparisons of
Hispanic/Latino ethnicity between the CMS-2728 with
CPM data showed nearly perfect agreement (all
k>=0.966). In the DOPPS, comparison between facility
and patient-reported race showed nearly perfect
agreement for White (k=0.917) and Black (k=0.948)
categories, and somewhat lower agreement for
Hispanic/Latino ethnicity (k=0.869). Patients were more
likely than providers to identify as American
Indian/Alaska Native, Asian, or other race.
Conclusions: Comparison between the CMS-2728 and
EDB suggests that White and Black races are
consistently reported. There is substantial
underreporting in the EDB of Native American, Asian,
and Other/Multi-Racial. Using Hispanic/Latino ethnicity
as a race classification also leads to substantial
underreporting. Comparisons of race and ethnicity
reported by different providers showed good inter-rater
agreement; however, DOPPS results suggest that
provider-reported data underreport racial categories
other than White and Black when compared to selfreported data.
Implications for Policy, Delivery or Practice: The
CMS-2728 is an accurate data source for race/ethnicity
and an appropriate collection platform because it
captures information about every ESRD patient starting
renal replacement therapy. Incorporation of self-reported
race/ethnicity could potentially increase the accuracy of
the CMS-2728, especially Hispanic/Latino ethnicity and
races other than White and Black to inform
understanding of health care disparities. As payers
consider adjustments for prospective reimbursement, it
is important to consider adjustments for racial categories
would create incentives that may influence reporting.
Funding Source(s): CMS
• Impact of Volume on Quality, Outcomes, and Costs
of Care for Heart Failure
Karen Joynt, M.D.; Ashish Jha, M.D., M.P.H.; E. John
Orav, Ph.D.
Presented by: Karen Joynt, M.D., Fellow, Health Policy
and Management, Harvard School of Public Health, 677
Huntington Avenue, Boston, MA 02115; Phone: (617)
432-5551; Email: kjoynt@partners.org
Research Objective: Heart failure (HF) is the most
common and costly cause of hospitalization among
Medicare patients, and despite recent pharmacologic
and technical advances, outcomes remain suboptimal. A
large body of literature suggests that hospitals
performing a higher volume of surgeries have better
outcomes for those procedures, and often do so at a
lower cost. However, whether greater volume leads to
better, more efficient care for non-procedure-based
hospitalizations for chronic conditions such as HF is not
well known. Therefore, we sought to evaluate the
relationship between hospital HF volume and HF
processes of care, outcomes of care, and costs of care
among U.S. hospitals.
Study Design: Using Medicare claims data from 20062007, we created risk-adjusted linear regression models
between a hospital’s case volume for HF and its
performance on the Hospital Quality Alliance (HQA) HF
process measures, 30-day mortality rates, 30-day
readmission rates, and inpatient costs of care.
Population Studied: All Medicare patients in the Feefor-Service system admitted to a U.S. hospital in 20062007 with a primary discharge diagnosis of HF.
Principal Findings: Among the 4,009 U.S. hospitals
that met our inclusion criteria, higher-volume hospitals
took care of a patient population that was older, with a
higher burden of medical comorbidities. Despite these
differences in the population, we found that high volume
hospitals had higher performance on the HQA scores,
lower 30-day mortality rates, and lower 30-day
readmission rates. Examining these relationships by
quartiles of case volume, hospitals in the highest-volume
quartile had higher quality performance on HQA process
measures than those in the low-volume quartile (88.9
versus 75.8, p<0.001 for linear trend across groups),
lower 30-day mortality rates (9.5% versus 10.5%,
p<0.001 for trend), and lower 30-day readmission rates
(22.2% versus 26.7%, p<0.001 for trend) than the lowvolume quartile. Higher-volume hospitals had higher
costs than lower-volume centers: those in the highestvolume quartile had, for a typical patient, approximately
10% higher costs than hospitals in the lowest quartile
(observed to predicted cost ratio of 1.05 versus 0.94,
p<0.001 for trend).
Conclusions: We found that hospitals with a high
volume of HF patients provide substantially better care
to a sicker patient population, and have better outcomes,
but do so at somewhat higher costs.
Implications for Policy, Delivery or Practice: Given
the large and growing burden of chronic conditions such
as HF on the health care system, finding ways to
improve efficiency and outcomes is critical. Our findings
suggest that the volume-outcome relationship extends
beyond surgical procedures and offers new approaches
for improving the care and outcomes of complex,
chronically ill patients: understanding which of the
practices employed by high volume institutions account
for these advantages could help improve the quality of
care and clinical outcomes for all HF patients.
Funding Source(s): NIH training grant
• Is Patient Activation Associated with Future
Utilization Outcomes for Adults with Diabetes?
David Mosen, Ph.D., M.P.H.; Carol Remmers, Ph.D.,
M.P.H.; Judith Hibbard, Ph.D.
Presented by: David Mosen, Ph.D., M.P.H., Senior
Program Evaluation Consultant/Affiliate Investigator,
Center for Health Research, Kaiser Permanente
Northwest, 3800 North Interstate Avenue, Portland, OR
97227-1110; Phone: (503) 335-6637; Email:
David.M.Mosen@kpchr.org
Research Objective: Patient activation refers to an
individual’s skills and abilities to manage their own
health and their ability to engage health providers in
shared decision making practices. Such skills are
important for the ongoing management of such chronic
conditions as diabetes. However, little research has
examined the relationship of patient activation with
prospective utilization outcomes for adults with diabetes.
We examined the relationship of patient activation with
the following prospective outcomes: 1) all-cause
inpatient admissions, 2) diabetes-specific inpatient
admissions and 3) acute myocardial infarction (AMI)specific inpatient admissions.
Study Design: We examined survey and administrative
data for 1,126 diabetics enrolled in a staff model HMO.
Diabetics were identified during calendar year 2003
using HEDIS inclusion criteria. In fall 2004, the same
patients were surveyed (via mail/telephone) regarding
their level of patient activation using a valid and reliable
instrument developed by Hibbard and colleagues. A 0100 composite score was constructed, with zero
representing the lowest patient activation and 100
representing the highest. The measure was
dichotomized into low activation (0-54) and high
activation (55-100). Utilization measures were measured
via an electronic medical record during calendar year
2006 and 2007. Logistic Regression was used to
examine the independent association of patient
activation with: 1) all-cause inpatient admissions (>= 1
admissions vs. none), 2) diabetes-specific inpatient
admissions (>= 1 admissions vs. none) and 3) AMIspecific inpatient admission (>= 1 admissions vs. none)
after adjusting for age, gender, race/ethnicity, functional
health status, and geographic location.
Population Studied: Adults with Diabetes in a GroupModel Health Maintenance Organization (HMO).
Principal Findings: After adjusting for demographic
factors, functional status, and geographic location, we
found that higher patient activation was associated with
lower inpatient utilization (OR = 0.71, 95% CI = 0.52,
0.97) in 2006 and lower AMI-specific inpatient utilization
(OR = 0.34, 95% CI = 0.12, 0.94) in 2007.
Conclusions: We found that higher levels of patient
activation were independently associated with lower
prospective all-cause inpatient utilization and AMIspecific utilization.
Implications for Policy, Delivery or Practice: Further
research is needed to better understand the association
of patient activation with disease-specific diabetes
measures and whether incremental improvements in
patient activation results in improved health outcomes
for adults with diabetes.
Funding Source(s): Kaiser Permanente
• Comparison of Health Plan Quality and Emergency
Department Discharges for Medicaid Members with
Asthma
Sally Turbyville, M.A.; M.S.
Presented by: Sally Turbyville, M.A.; M.S., Research
Scientist, Performance Measurement, NCQA, 1100 13th
Street, NW Suite 1000, washington, DC 20005; Phone:
(202) 955-1756; Email: turbyville@ncqa.org
Research Objective: In 2009, the National Committee
for Quality Assurance (NCQA) collected standardized
HEDIS® measures of quality of care (appropriate
medication for people with asthma) and emergency
department (ED) visits for members with asthma. There
is an interest in reducing ED use; this study draws from
Medicaid HMO plans across the U.S. This study
examines whether there is a relationship between health
plan quality of care and emergency department visits for
Medicaid members with asthma.
Study Design: Medicaid HMOs submit summarized
plan-level data based on claims data for members
between the ages of 5 and 56 years of age with
persistent asthma. For this population, health plans
submit the number of members who were appropriately
dispensed at least one preferred prescription therapy
and the number of ED visits in 2008. For ED use, NCQA
calculates an observed-to-expected (O/E) ratio for each
plan comparing the observed use to expected use.
Observed use is the plan submitted use; expected use is
the national Medicaid average use adjusted for each
plan’s case- and risk-mix of members with asthma.
NCQA established the range of O/E results and the
mean risk adjusted use for the eligible population
(per/1,000 MM for those with asthma) for HMO Medicaid
plans. Univariate analysis was conducted.
Population Studied: 148 Medicaid HMO plans
submitted both the appropriate use of medication and
the ED utilization data based on claims data for
members with asthma. Members with asthma were
enrolled in the same plan for at least 22 months during
the measurement year (2008). This study included plans
from all regions of the U.S.
Principal Findings: Among Medicaid members with
asthma, variation in ED use was substantial, with a
range of 162% points (or 77% lower to 86% higher than
expected). There was less variation in quality of care,
with a range of 33% points (or 64% to 97%). Medicaid
HMO plans with higher quality results for their members
with asthma were associated with lower ED use among
these members (-0.257, p=0.0016). Similar findings
were present among commercial plans.
Conclusions: While variation in quality of care varied
moderately, there was substantial variation in ED use.
There was a statistically significant negative relationship
between quality of care and ED use among Medicaid
plans.
Implications for Policy, Delivery or Practice:
Understanding and containment of health care costs is a
rapidly emerging policy issue in the United States.
Examining and understanding differences in emergency
department utilization along with relevant quality results
is critical to developing practical and effective policies
related to the delivery and use of health services.
Processes for Care and Disease Management
Chair: David Dorr
Monday, June 28 * 11:30 am–1:00 pm
• Care Coordination by Means of Community-Based
Nurse Care Management
Kenneth Coburn, M.D., M.P.H.; Sherry Marcantonio,
M.S.W.; Nancy Davis, M.S.N., A.N.P.; Maryellen Keller,
B.S.N., R.N.
Presented by: Kenneth Coburn, M.D., M.P.H., CEO
and Medical Director, Health Quality Partners, 28
Honeyman Road, Basking Ridge, 07920; Phone: (908)
432-1102; Email: coburn@hqp.org
Research Objective: To design an effective, practical
and sustainable model of community-based nurse care
management tin order to deliver enhanced care
coordination and preventive services to older adults.
Study Design: The study was a long term, prospective
randomized, controlled, trial undertaken within the
Medicare Coordinated Care demonstration. Primary
outcome is all cause mortality. Secondary outcomes
include changes in clinical measures of cardiovascular
risk and satisfaction measures among the intervention
group. Analyses of other measures related to the
frequency of hospitalization and Part A & B Medicare
expenditures which were undertaken by CMS as part of
the demonstration project will also be reviewed.
Population Studied: Chronically ill older adults with fee
for service Part A & B Medicare coverage and one or
more of the following chronic conditions; diabetes,
coronary artery disease, heart failure, asthma,
hypertension, or high cholesterol. The program was
implemented over a 4 county area in eastern
Pennsylvania in collaboration with over 90 primary care
physician practices.
Principal Findings: The risk of death in the intervention
group was 25% lower overall (p=0.05), 34% lower
among participants scoring high on pre-randomization
geriatric risk assessment (p=0.03), and 48% lower
among participants with coronary artery disease prior to
enrollment (p=0.02). There was a significant
improvement in several clinical cardiovascular risk
factors among the intervention group between
enrollment and last follow-up. Satisfaction of participants
with the program across a number of dimensions was
high. Per the analysis conducted by Mathematica Policy
Research, Inc. for CMS, a number of readily identifiable
higher-risk subgroups demonstrated a significant
intervention-control effect toward reduced
hospitalizations and net Part A & B Medicare
expenditures.
Conclusions: Community-based nurse care
management, if carefully designed with attributes of a
high reliability learning organization, can improve
longevity and reduce cardiovascular risk factors among
chronically ill older adults.
Implications for Policy, Delivery or Practice:
Redesign of the health care delivery system has not yet
been addressed as a means to improve the
effectiveness and lower the cost of health care in the
United States. The 8 year experience of this model
provides strong evidence that it could be one means for
doing so.
Funding Source(s): CMS
• Improving Chronic Disease Management and
Preventive Care through Patient-Centered
Navigation
Elizabeth Whitley, R.N., Ph.D.; Rachel Everhart, M.S.;
Viola Rendon; Ana Barrett
Presented by: Rachel Everhart, M.S., Data Team
Administrator, Community Health Services, Denver
Health, 777 Bannock Street MC 3240, Denver, CO
80204; Phone: (303) 436-5393; Email:
rachel.everhart@dhha.org
Research Objective: To determine the impact of a
patient-centered navigation intervention on diabetes and
hypertension chronic disease management and cancer
screening preventive care.
Study Design: Using a nonrandomized prospective
cohort design, three primary care clinics involved in the
patient-centered navigation intervention were compared
to the remaining six clinics in our integrated safety net
health system receiving usual care. Each of the three
intervention clinics had a fulltime patient navigator
integrated into their clinical setting. Patients with
diabetes and hypertension who were behind in their
cervical, breast or colorectal cancer screening were
navigated to needed lab tests (such as HGBA1C and
cholesterol), cancer screening, blood pressure
monitoring and primary care appointments. The patient
navigators provided intervention services designed to
identify and reduce barriers to care, improve adherence
to plan of care and ultimately improve the health
outcomes of medically underserved patients. Patients
were identified as eligible for the intervention through the
use of electronic clinical registries.
Population Studied: Clinical registries identified 5500
patients eligible for navigation at the 3 intervention sites.
Of these patients, 45% were uninsured, 22% Medicaid,
24% Medicare and less than 4% has private insurance.
Patient navigators were able to enroll 1825 (33%) during
the 18-month study period from July 2008 through
December 2009. Of the enrolled patients, 55% were
Hispanic, 19% were Black, and 22% were White. The
participants were predominantly female (63%); 21%
were 35-49 years of age, 49% were 50-64 years, and
26% were 65 years or more.
Principal Findings: The most common barriers
addressed by the patient navigators were problems with
scheduling care, financial, transportation, language and
lack of understanding. Medical visit co-payments, bus
tokens and grocery coupons were used to decrease
barriers. Unadjusted analyses demonstrate improved
compliance with clinical standards and clinical outcomes
for patients at the intervention sites. Compared to usual
care clinics, intervention clinics were more likely than
usual care sites to achieve HGBA1C, LDL and blood
pressure control by 13% (OR 95% CI 1.01-1.27), 48%
(OR 95% CI 1.32-1.67), and 20% (OR 95% CI 1.051.36) respectively. Among hypertensive patients, blood
pressure control was also 10% (OR 95% CI 1.02-1.18)
more likely in intervention sites as compared to usual
care clinics. The patients at navigated clinics were also
more likely to be current with cancer screening
recommendations: 46% (OR 95% CI 1.32-1.62) for
breast, 19% (OR 95% CI 1.10-1.30) for colorectal, and
12% (OR 95% CI 1.02-1.23) for cervical.
Conclusions: This innovative patient-centered
navigation project improves health equity by improving
health outcomes for patients with chronic conditions and
associated risk factors. To date, the results of this
project demonstrate that patient navigation increases
access to diagnostic, surveillance and treatment
services, and that patients in clinics with patient
navigators have improved diabetic and hypertensive
control and compliance with cancer screening
recommendations.
Implications for Policy, Delivery or Practice: This
project supports patient-centered navigation as an
effective way to improve quality outcomes and provide
efficient care to patients by avoiding multiple diseasespecific outreach efforts to patients. These findings are
relevant given the current attention to Medical Home
initiatives and should be considered when planning care
coordination and management programs.
Funding Source(s): Colorado Department of Public
Health and Environment Office of Health Disparities
• Improved Processes of Care for End-Stage Renal
Disease Patients in a Centers for Medicare &
Medicaid Services Disease Management
Demonstration
Sylvia Ramirez, M.D., M.P.H., M.B.A.; Jeffrey Pearson,
M.S.; Claudia Dahlerus, Ph.D.,M.A.; Christine Cheu,
M.P.P.; Diane Frankenfield, Dr.PH.; Bruce Robinson,
M.D.,M.S.; Brett Lantz, M.A.; Tania Chowdhury, M.S.;
Sabrina Gomes, B.S.
Presented by: Jeffrey Pearson, M.S., Manager of
Analytic Support, Health Policy and Practice Projects,
Arbor Research Collaborative for Health, 315 W Huron
Street, Suite 360, Ann Arbor, MI 48103; Phone: (734)
665-4108 ext. 268; Email:
jeffrey.pearson@arborresearch.org
Research Objective: CMS implemented the ESRD
Disease Management Demonstration to test the
effectiveness of disease management provided to ESRD
patients enrolled in Medicare Advantage plans
collaborating with three disease management
organizations (DMOs) in nineteen geographic areas. The
DMOs designed unique disease management models
for the ESRD population, provided dialysis at
participating facilities and coordinated other medical
services for beneficiaries. The Demonstration evaluated
the impact of disease management on clinical, patientcentered, and financial outcomes in the ESRD
population; here we evaluate the impact of select DMOspecific interventions.
Study Design: Data from Medicare ESRD patients who
voluntarily enrolled in the three DMOs during 2006-2008
were compared to published results from the United
States Renal Data System (USRDS) when possible.
Processes of care measures for each DMO include:
immunization and diabetes monitoring measures
(Organization A); the adoption of advanced care plans
(Organization B); and the effects of oral nutritional
supplements (ONS) on serum albumin (a nutritional
biomarker), hospitalization, and mortality (Organization
C).
Population Studied: 2378 Medicare ESRD patients
enrolled in the Demonstration (727 in Organization A,
271 in Organization B, and 1380 in Organization C).
Principal Findings: In Organization A, by the end of
2008, 90% of patients received an influenza
immunization within one year, exceeding the 57%
reported by the USRDS (2006). Over 60% of patients
received a pneumococcal vaccination, exceeding 20%
as reported by the USRDS (2005 and 2006). The
percentage of patients with diabetes receiving annual
retinal exams improved from 30% in 2006 to 53% in
2008 (p<0.01). The percentage with four or more HbA1c
tests annually improved from 23% in 2006 to 36% in
2008 (p<0.01). For Organization B, the percentage of
patients with an advanced care plan increased from 8%
to 19%. In Organization C, ONS use was associated
with increased serum albumin in patients with diabetes
(OR=1.07; 95% confidence interval [CI] 1.00, 1.14;
p=0.05) and without diabetes (OR=1.16; 95% CI 1.01,
1.33; p=0.01). After adjusting for demographics and
baseline serum albumin, every one month increase in
ONS use was associated with a reduction in
hospitalization (adjHR=0.87; 95% CI 0.85, 0.89; p<0.01)
and mortality (adjHR=0.92; 95% CI 0.90, 0.95; p<0.01).
These findings are preliminary and final results will be
presented at the conference.
Conclusions: Our findings suggest disease
management programs may result in observed
improvement in processes of care in the ESRD
population. Furthermore, certain interventions as part of
care coordination may improve patient morbidity and
mortality.
Implications for Policy, Delivery or Practice: The
ESRD patient population is well suited for disease
management intervention because of frequent existence
of multiple comorbidities, high rates of hospitalization
and mortality, and a disproportionately high cost of care.
Improvements in processes of care were associated with
improved clinical outcomes. Preliminary findings from
this demonstration suggest the potential benefit of
improved care coordination in this high utilization and
high cost population.
Funding Source(s): CMS
• Pre-Post Evaluation of a VA Collaborative to
Improve the Timeliness of Follow-Up after a Positive
Colorectal Cancer Screening Test
Adam Powell, Ph.D.; Sean Nugent, B.A.; Diana rdin,
M.D., M.P.H.; Siamak Noorbaloochi, Ph.D., M.Sc.;
Melissa R Partin, Ph.D.
Presented by: Adam Powell, Ph.D., Assistant
Professor, Center for Chronic Disease Outcomes
Research (CCDOR), Department of Veterans Affairs,
One Veterans Drive (111-0), Minneapolis, MN 55417;
Phone: (612) 467-4364; Email: Adam.Powell@va.gov
Research Objective: Previous research indicates that
many patients fail to receive timely diagnostic follow-up
of positive colorectal cancer (CRC) screening tests. To
address this issue, the VA initiated a CRC diagnosis
quality improvement collaborative that took place
between September 2005 and August 2006.
Participating facilities formed local quality improvement
teams, mapped processes of care, and set improvement
goals. Based on these goals, site-specific process
change strategies were identified and implemented.
Learning was shared across teams on an ongoing basis.
This analysis evaluates pre-post change in the
timeliness of colonoscopy procedures following a
positive fecal occult blood test (FOBT) at facilities
participating in the collaborative.
Study Design: Dates of FOBT lab results and
colonoscopy procedures were extracted from VA
electronic medical records of patients receiving a
positive FOBT lab result at each participating medical
center. Improvement was measured by calculating preintervention/post-intervention change in the percent of
patients receiving a VA colonoscopy within 60 days of a
positive FOBT lab result. (Sixty-day follow-up of positive
FOBTs reflects a national VA objective instituted in
2006.) The average number of days from positive FOBT
to colonoscopy was also calculated among patients
receiving a colonoscopy within one year of positive
FOBT date. Measures are reported both in total and by
facility. Colonoscopies received outside the VA were not
observed.
Population Studied: Patients receiving a positive FOBT
lab result between September 2004 and August 2005
(pre-intervention) and between September 2006 and
August 2007 (post-intervention) at 21 medical centers
participating in the VA CRC diagnosis learning
collaborative (one medical center from each of the VA’s
21 national regions).
Principal Findings: Across all facilities, the percent of
positive FOBT patients receiving a VA colonoscopy
within 60 days increased from 11% prior to the
intervention to 18% post-intervention (p<.001). Among
patients receiving a VA colonoscopy within one year of a
positive FOBT lab result, average time to VA
colonoscopy decreased from 117 days prior to the
intervention to 98 days post intervention (p<.001).
Improvement in the 60-day colonoscopy completion rate
and the measure of average days to colonoscopy was
significant at 9 of 21 facilities. The facility range of prepost change was +31% to -4% on the 60-day
colonoscopy completion rate and 116 to -33 days on the
average time to colonoscopy measure.
Conclusions: The VA’s CRC diagnosis quality
improvement collaborative appears to have had an
overall positive effect on the timeliness of colonoscopy
following a positive FOBT result.
Implications for Policy, Delivery or Practice: Multi-site
collaboratives have the potential to improve the
timeliness of follow-up after a positive CRC screening
test; however, benefits may not be evenly distributed
among facilities.
Funding Source(s): VA
Nursing Process of Care and Job Experiences
Chair: Ying Xue
Monday, June 28 * 11:30 am–1:00 pm
• Nurse Reports of Relational Coordination: An
Emerging Theory to Improve Communication Across
the HealthCare Team
Donna Havens, Ph.D.; Joseph Vasey, Ph.D.; Jody
Hoffer Gittell, Ph.D.; Wei-Ting Lin, M.S.N., M.B.A.
Presented by: Donna Havens, Ph.D., Professor, The
School of Nursing, The University of North Carolina at
Chapel Hill, Carrington Hall, Campus Box 7460, Chapel
Hill, NC 27599; Phone: (919) 843-1244; Email:
dhavens@email.unc.edu
Research Objective: Relational coordination (RC) coordination of work through shared goals, shared
knowledge and mutual respect in the provision of care to
patients (Gittell, 2009) - has potential for improving the
quality and safety of care. This presentation (1) identifies
RN reported levels of RC between nurses and other
providers and associated outcomes and (2) informs
management and clinical practice to improve the quality
of relationships and communication across healthcare
providers.
Study Design: A non-experimental research design was
used. The relationship of nurses' perceptions of RC with
patient and nurse outcomes was studied through a
series of correlational and regression analyses. A selfadministered questionnaire was completed by staff RNs
(n=747) from 5 acute care community hospitals located
in rural counties in Pennsylvania. A modified Dillman’s
Tailored Design Method (Dillman, 2000) was used to
enhance survey response rates which was 64%. Multiple
measures were used: the Relational Coordination
Survey for Patient Care; four single-item nurse-report
measures of the quality of care; a one item global
measure of nurse job satisfaction; and the Maslach
Burnout Inventory – General Survey (MBI-GS) (Shaufeli,
Leiter, Maslach, & Jackson, 1996) was used to measure
emotional exhaustion and professional efficacy.
Population Studied: All direct care RNs who had been
full time or part time in 5 acute care community hospitals
in rural counties in Pennsylvania were invited to
participate. The 5 hospitals were private, non profit, non
religious, and the bed sizes ranged from 75 to 179
licensed and staffed beds. The respondents were similar
in age to nurses across the US, similar in terms of full
time status and slightly more reported their highest level
of education at the Associate Degree level.
Principal Findings: RC between RNs on the same
nursing unit was higher than RC between RNs on other
units and their colleagues in other functions (physicians,
and therapists). The weakest ties were between nurses
and therapists. Nurse reports of positive relational
coordination was significantly related (positive) to reports
of quality of care, satisfaction with job and career and
perceptions of professional efficacy and negatively
related to emotional exhaustion.
Conclusions: The findings provide insights regarding
opportunities to identify relational and communication
strengths among providers and while also identifying
areas for improvement. This article reports the findings
from the first study to assess relational coordination as
reported by RNs working in non-academic acute care
rural community hospitals – which represent a large
population of US hospitals (41% cite).
Implications for Policy, Delivery or Practice: This
presentation is timely as key organizations promoting
healthcare quality have called for better communication
among providers to improve the quality of care and the
quality of the practice environment a key component in
the retention of the healthcare workforce. The emerging
theory of relational coordination has significant potential
as a framework to healthcare provider relationships and
communication. This is highly relevant with application
for health services management, research and practice.
• Do Nurses' Job Perceptions Provide a Barometer
for the Patient Experience?
Matthew McHugh, Ph.D., J.D., M.P.H., R.N.; Ann
Kutney-Lee, Ph.D., R.N.; Douglas Sloane, Ph.D.;
Jeannie Cimiotti, D.N.S., R.N.; Linda Aiken, Ph.D.,
F.A.A.N., R.N.
Presented by: Matthew McHugh, Ph.D., J.D., M.P.H.,
R.N., Assistant Professor of Nursing, School of Nursing,
University of Pennsylvania, 418 Curie Boulevard,
Philadelphia, PA 19104; Phone: (215) 746-0205; Email:
mchughm@nursing.upenn.edu
Research Objective: We seek to determine whether
there is an association between how nurses are faring in
their jobs at the bedside and patients’ satisfaction with
their hospital care.
Study Design: We conducted a cross-sectional analysis
of linked survey data on nurses and patients using the
Penn Multi-State Nursing Care & Patient Safety Survey
and Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAHPS) survey data from
2006. The first part of the analysis was descriptive and
was conducted at the individual-nurse level to assess
the job satisfaction and burnout levels of nurses working
in different roles and settings. The second part of the
analysis was conducted at the hospital-level and used
data from all acute care hospitals in California, Florida,
New Jersey and Pennsylvania that reported HCAHPS
data and were represented in the nurse survey. We
employed ordinary least squares regression to evaluate
the relationship between nurse burnout, job satisfaction
and patient satisfaction.
Population Studied: The first set of analyses examined
the burnout and job satisfaction levels of almost 70,000
nurses in four states working in all settings. The second
part of the study included nurses and patients in 428
hospitals in these states.
Principal Findings: Nurses in hospitals and nursing
homes, particularly those caring for patients, are more
dissatisfied and burned out than nurses not working with
patients, in other settings, or not in nursing. We found
that 24% of hospital nurses and 27% of nursing home
nurses providing direct patient care reported being
dissatisfied with their jobs. Only 9% of nurses not
working in hospitals and not working as nurses reported
job dissatisfaction. Similar differences were evident with
respect to burnout. About half of nursing home and
hospital nurses providing patient care were dissatisfied
with their healthcare and retirement benefits. We found
that satisfaction differed by quality of the nursing work
environment. Nurses were half as likely to be dissatisfied
if they practiced in hospitals with good work
environments as compared to poor work environments.
Differences for burnout were similarly large and
significant. Hospital nurse burnout and job satisfaction
had a highly significant impact on patient satisfaction.
The percentage of patients giving the hospital a high
rating decreased by 2% in hospitals for every 10% of
nurses reporting high burnout.
Conclusions: Our findings suggest that the most
important nurses, those with direct clinical responsibility
for patients, are faring much worse in their jobs than
nurses not caring for patients. Employment benefits are
significantly worse for nurses at the bedside and jobrelated burnout is high. The further nurses move away
from hospital employment and clinical care the more
satisfied they are, suggesting a reward structure that is
significantly at odds with communicating that patient
care is important. Additionally, nurse burnout and job
satisfaction appear to be barometers for patient
satisfaction.
Implications for Policy, Delivery or Practice: How well
nurses are faring in their jobs is significantly associated
with patients’ satisfaction with care, suggesting the
possibility that improving nurse work environments could
improve nurse retention in clinical care and quality of
care.
Funding Source(s): National Institute for Nursing
Research
• Changes in Nurse Satisfaction from 2004 to 2008
Joanne Spetz, Ph.D.; Carolina Herrera, M.A.
Presented by: Joanne Spetz, Ph.D., 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: Nurse satisfaction is an important
metric, because it has been shown to predict staff
turnover and is associated with the quality of patient
care. In recent years, many hospitals have made efforts
to improve workplace characteristics, in order to improve
nurse retention and quality of care. Some states have
implemented legislation to improve working conditions.
This paper examines whether satisfaction increased
among nurses who worked in hospitals in California
between 2004 and 2008; during this time period
California also implemented minimum nurse staffing and
mandatory overtime legislation. While we cannot directly
associate California’s laws with changes in satisfaction,
we can assess whether composite efforts to improve the
nursing workplace have affected the perceptions of RNs.
Study Design: We use data from RN surveys
conducted by the California Board of Registered Nursing
(BRN) from 2004, 2006, and 2008. We focus on
hospital-employed RNs. Satisfaction variables are
obtained from 30 questions for which respondents were
asked to rate their satisfaction on a five-point Likert
Scale. First, t-tests were conducted to determine
whether changes in average satisfaction scores were
statistically important. Second, logistic regression
equations were estimated, to control for nurse and job
characteristics that might be different over time, and that
might affect nurse satisfaction.
Population Studied: California nurses in 2004, 2006,
and 2008.
Principal Findings: Avenuerage nurse satisfaction
improved with most survey items, including overall job
satisfaction. Between 2004 and 2008, average
satisfaction scores increased the largest number of
points for the adequacy of staff, benefits, adequacy of
clerical support, job overall, time for patient education,
salary, nursing profession overall, and skills of RNs. In
general, satisfaction increased more between 2004 and
2006 than it did between 2006 and 2008. Controlling for
family, job, and demographic characteristics, the odds of
a nurse being satisfied or very satisfied were 24 percent
higher in 2006 than in 2004, and 25 percent higher in
2008 than in 2004. There was no statistically significant
change in the odds of being satisfied with the nursing
profession overall. The largest improvements in
satisfaction between 2004 and 2006 were with adequacy
of RN staff, adequacy of clerical support, amount of
paperwork, and relationship with agency/registry nurses.
These improvements were generally stable between
2006 and 2008. There was deterioration in satisfaction
with some items over time, including non-nursing tasks
required, opportunities to use skills, and opportunities for
employer-supported education.
Conclusions: There were improvements in nurse
satisfaction between 2004 and 2008, which cannot be
attributed solely to changes in nurse demographic, job,
and family characteristics.
Implications for Policy, Delivery or Practice: Between
2004 and 2008, nurses in California became more
satisfied with the adequacy of staffing where they work,
and with a number of other job-specific factors. Their
overall job satisfaction also increased. However, some
areas for improvement continue to be evident. Nurse
leaders should institutionalize changes enacted that
have led to improvements in satisfaction, and focus
efforts on addressing areas where improvements have
yet to be seen.
Funding Source(s): Government Agency
• What Predicts Perceptions of Job Difficulties
among Newly Licensed RNs?
Lynn Unruh, Ph.D., R.N.; Jennifer Nooney, Ph.D.
Presented by: Lynn Unruh, Ph.D., R.N., Associate
Professor, Health Management and Informatics,
University of Central Florida, 4000 Central Florida
Boulevard, Orlando, FL 32804; Phone: (407) 823-4237;
Email: lunruh@mail.ucf.edu
Research Objective: To ascertain predictors of newly
licensed RN perceptions of job difficulty and job
pressure.
Study Design: Newly licensed RNs in Florida were
surveyed using an instrument that was validated and
pilot tested by Kovner and Brewer in prior studies. The
survey was mailed to a random sample of 40%
(n=3,027) of RNs newly licensed in Florida, with followup to non-responders. Due to a response rate of 18%, a
bias analysis was done. The sample was
demographically and geographically representative of
the population. For this analysis we used a subsample of
414 respondents who were currently working in
hospitals. Explanatory variables were age, gender,
ethnicity, race, health, educational level, marital status,
presence of children, prior work experience, hospital
type, adequacy of orientation, length of employment,
shift length and time, number of hours worked per week,
and the number of patients on most recent shift.
Response variables were 9 indicators of job difficulty, 4
indicators of job pressure, a scaled job difficulty variable,
and a scaled job pressure variable. For the analysis of
individual aspects of job difficulty and job pressure we
used multinomial logistic regressions. Analysis of scales
of job difficulty and job pressure utilized multiple
regression analysis.
Population Studied: RNs who were newly licensed in
Florida within the last 1-2 years from the date of the
survey.
Principal Findings: Younger age was significantly
related to perceiving that the job required working very
fast and that it was difficult due to organizational rules
and workload. Poorer health was related to perceptions
of lack of time to get things done properly, and difficulties
with conflicting demands, insufficient help, incorrect
instructions, interruptions, and lack of information and
supervisor support. Those with higher degrees found
difficulty with rules and workload. Those with no children
had more difficulty with interruptions. Nurses working in
academic medical centers had less difficulty with
equipment. Those who perceived that their orientation
was inadequate found the job difficult for all 9 reasons
and felt 2 indicators of job pressure. Greater number of
hours worked and patients were significantly related to
nearly all job difficulty and job pressure variables. Day
shift, hours worked, and number of patients were
significantly related to the job pressure scale. Health,
orientation, day shift, hours, and number of patients
were related to the job difficulty scale.
Conclusions: These results indicate that the adequacy
of orientation, the number of patients, and the hours of
work are the most consistent predictors of perceptions of
job difficulty and job pressure. However, age, health,
education and family were predictors of specific job
difficulties and pressures.
Implications for Policy, Delivery or Practice: Patient
load, hours of work and adequate orientation are top
items needing improvement in order to make the work of
newly licensed RNs less difficult and pressured. It is
important to also deal with job demands in relation to
new RNs' health, age, education and family life.
Funding Source(s): Florida Center for Nursing
• Impact of Unit-Level Nurse Staffing on Readiness
for Hospital Discharge and Post-Discharge
Utilization
Marianne Weiss, D.N.Sc., R.N.; Olga Yakusheva, Ph.D.;
Kathleen Bobay, Ph.D., R.N.
Presented by: Olga Yakusheva, Ph.D., Assistant
Professor, Business, Marquette University, PO Box
1881, Milwaukee, WI 53201-1881; Phone: (414) 2883409; Email: olga.yakusheva@marquette.edu
Research Objective: The purposes of this study were:
(1) to determine the direct and indirect effects of unitlevel nurse staffing on patient perceptions of discharge
teaching, readiness for discharge, and subsequent
utilization in the first 30 days post-hospital discharge;
and (2) to estimate the net economic benefit of reduced
post-discharge utilization after accounting for increased
costs of nurse staffing during the index hospitalization.
Study Design: A nested multi-level panel data approach
was used to test the structural relationships from unitlevel nurse staffing variables to: a) patient perception of
quality of discharge teaching process, b) patient
perception of readiness for hospital discharge, and c)
post-discharge use of emergency department (ED) and
readmission. Analysis included patient-level control
variables and hospital and unit-level fixed effects. Nurse
staffing cost data were derived from 2008 average
hourly cost of compensation (including salary and
benefits) from the U.S. Bureau of Labor Statistics. Postdischarge utilization costs were derived from study site
cost accounting databases.
Population Studied: Using within-unit random
selection, the sample consisted of 1892 adult medicalsurgical patients who were discharged home following
hospitalization on 16 medical surgical nursing units of 4
Midwest hospitals between January and July 2008.
Principal Findings: Higher RN hours per patient day
(RNHPPD) were directly associated with fewer
unplanned readmissions for conditions related to the
index hospitalization (OR=.59, P=.04) and more RN
overtime was associated with greater likelihood of ED
visits (OR=1.87, P=.02). RNHPPD were also associated
with higher quality discharge teaching (B=.27, P=.04)
and the quality of discharge teaching was positively
associated with patient perception of discharge
readiness (B=.35, P=<.01), which was in turn associated
with unplanned readmissions (OR=.84, P=.04) and ED
visits (OR=.72, P=.01) and unplanned/related ED visits
(OR= .72, P=.04). Cost analysis indicated that an
increase of .75 RNHPPD would result in a loss of
$185.50 for the hospital (due to higher nurse staffing
costs and lower patient revenue) while reducing the
payors’ costs by $552.83, for net cost savings of
$367.33 per hospitalized patient, or $10.0 million
annually for the units included in the study sample.
Conclusions: The results suggest that, within a nursing
unit, when RNHPPD were higher, patients perceived that
quality of discharge teaching was better, they felt more
ready for discharge, and they were less likely to be
readmitted or use ED. Investment in additional nursing
care hours in the index hospitalization could potentially
reduce adverse post-discharge occurrences that result in
unplanned and costly utilization.
Implications for Policy, Delivery or Practice:
Reducing readmissions and emergency department
visits are core strategies in reducing health care costs.
Recommendations emerging from this unit level study
include: (1) increasing nursing unit hours per patient day
to improve patient readiness for hospital discharge and
reduce subsequent readmissions and ED use; (2)
formalizing discharge readiness assessment as a
component of the discharge preparation process; (3)
aligning incentives to support optimal nursing unit
staffing to achieve desired post-discharge outcomes and
cost savings.
Funding Source(s): RWJF
Hospital/Facility-Level Variations: Implications for
Disparities
Chair: Ninez Ponce
Monday, June 28 * 11:30 am–1:00 pm
• Accuracy of Diagnostic Mammography at Facilities
Serving Vulnerable Women
Elizabeth Goldman, M.D., M.C.R.; Rod Walker, M.S.;
Diana Miglioretti, Ph.D.; Rebecca Smith-Bindman, M.D.;
Karla Kerlikowske, M.D.
Presented by: L. Elizabeth Goldman, M.D., M.C.R.,
Assistant Professor of Medicine, Medicine, University of
California, San Francisco, 533 Parnassus Avenue. Box
0131, San Francisco, CA 94143; Phone: (415) 5142095; Email: goldmanl@medicine.ucsf.edu
Research Objective: Lack of identification of breast
cancer on diagnostic mammography can contribute to
diagnostic delays, while high false-positive rates may
lead to some women undergoing unnecessary invasive
procedures. Whether accuracy of diagnostic
mammography at facilities serving vulnerable women
differs from other facilities is unknown. Our objective is
to compare diagnostic mammography accuracy between
facilities serving vulnerable women and those serving
non-vulnerable women.
Study Design: We included 168,251 diagnostic
mammography examinations performed at Breast
Cancer Surveillance Consortium (BCSC) facilities from
1999-2005. We used logistic-normal mixed effects
models to compare the sensitivity, false positive rates,
and cancer detection rates of facilities treating
predominantly vulnerable vs. non-vulnerable
populations. Facilities were classified as serving a
vulnerable population based on the proportion of
mammograms performed on women with lower
educational attainment, racial/ethnic minority status,
limited household income, or rural/urban residence.
Population Studied: Women ages 40-80 undergoing
diagnostic mammography to evaluate an abnormal
screening mammography result or a clinical sign or
symptom.
Principal Findings: Sensitivity did not significantly vary
across vulnerability indices. Diagnostic mammography
performed to evaluate a symptomatic breast problem at
facilities serving predominantly vulnerable women had
higher false-positive rates for each definition of
vulnerability, including high proportion of racial/ethnic
minorities (OR 1.32; 95% CI 0.98, 1.76); rural residence
(OR 1.55; 95% CI 1.27, 1.88); limited income (OR 1.34;
95% CI 1.08, 1.66); and educational attainment (OR
1.39; 95% CI 1.08, 1.79). Unadjusted cancer detection
rates (CDR) were higher at facilities serving vulnerable
women in 3 of the 4 definitions of vulnerability: high
proportion of racial/ethnic minorities (CDR per 1000
exams 37.6 vs. 36.9); rural residence (CDR per 1000
exams 43.5 vs. 34.9); limited income (CDR per 1000
exams 39.7 vs. 36.2); and lower education (CDR per
1000 exams 36.9 vs. 37.0).
Conclusions: Women undergoing diagnostic
mammography to evaluate a breast problem at facilities
serving vulnerable populations have higher false positive
rates than facilities serving non-vulnerable populations.
A higher false-positive rate may reflect concern for a
high cancer prevalence and whether women will
complete diagnostic work-ups.
Implications for Policy, Delivery or Practice:
Investigators need to consider whether there are
intervenable approaches to decrease differences in false
positive rates or whether these findings result from
incomplete capture of cancer outcomes due to loss to
follow-up.
Funding Source(s): California Breast Cancer Research
Program
• The Characteristics of the Best and Worst U.S.
Hospitals: Implications for Disparities
Ashish Jha, M.D., M.P.H.; Arnold Epstein, M.D., M.A.;
John Orav, Ph.D.
Presented by: Ashish Jha, M.D., M.P.H., Associate
Professor, Health Policy and Management, Harvard
School of Public Health, 677 Huntington Avenue,
Boston, MA 02115; Phone: (617) 432-5551; Email:
ajha@hsph.harvard.edu
Research Objective: Ensuring high quality and low
costs is a top priority for policymakers. Although prior
work has demonstrated a weak relationship between the
costs and quality in the hospital setting, there is strong
national policy interest in rewarding (or penalizing)
hospitals based on these two metrics. Understanding
what types of hospitals are able to provide high quality
care at low costs and which hospitals struggle on both
metrics would be helpful. Further, given ongoing concern
about the potential impact of such policies on disparities
in care, understanding how often minority-serving
hospitals are high performers on these metrics (and
therefore, likely to be rewarded) or low performers (and
therefore, likely to be penalized) would help
policymakers understand the impact of these programs.
Study Design: We used Medicare inpatient data as well
as those from the Hospital Quality Alliance (HQA)
program to identify hospitals’ performance on quality
measures as well as their risk-adjusted costs. We
classified hospitals that were simultaneously in the top
quartile of quality and bottom quartile of risk-adjusted
cost as the “best hospitals", those in the bottom quartile
of quality and top quartile of costs as the “worst
hospitals”. We used the American Hospital Association
survey data to examine hospital characteristics.
Population Studied: All non-federal acute care
hospitals that submitted data to Medicare.
Principal Findings: We found moderate to substantial
differences in the types of hospitals that were classified
as the “best” (high quality, low cost) and the “worst” (low
quality, high cost). The best hospitals were somewhat
more likely to be large, far more likely to be located in
the Northeast or Midwest compared to the worst
hospitals (55% versus 22%, p<0.001), far less likely to
be in the South (14% versus 32%, p<0.001) and far less
likely to be public hospitals (4% versus 25%, p<0.001).
The best hospitals were also far less likely to be in the
top quartile of proportion of black patients (13% versus
38%, p<0.001) or Hispanic patient s (19% versus 43%,
p<0.001) compared to the worst hospitals.
Conclusions: Our findings suggest the subset of
hospitals that are high performers on both cost and
quality is very different than the subset of hospitals that
are poor performers on both. The poor performing
hospitals are far more likely to be public hospitals,
located in the south, and with a high proportion of black
and Hispanic patients.
Implications for Policy, Delivery or Practice: In
designing delivery reform efforts, as we reward hospitals
that perform well on both cost and quality metrics, it is
important to understand the kinds of hospitals that will be
the winners and losers. Our findings suggest that
minority-serving institutions as well as public hospitals
are far more likely to come out on the losing end of these
two metrics and efforts are needed to ensure that they
can improve care and be more efficient.
Funding Source(s): CWF
• How Do Minority-Serving Hospitals Perform on
Patient Safety Indicators?
Dan Ly, B.A.; Lenny Lopez, M.D., M.Div., M.P.H.;
Thomas Isaac, M.D., M.B.A.; Ashish Jha, M.D., M.P.H.
Presented by: Dan Ly, B.A., Harvard Kennedy School,
10 Akron Street, Unit. 101, Cambridge, MA 02138;
Phone: (615) 478-2666; Email:
dan_ly@hks11.harvard.edu
Research Objective: Previous studies have shown that
hospitals that disproportionately care for black and
Hispanic patients may perform somewhat worse on
process-based quality measures such as those reported
in the Hospital Quality Alliance (HQA) program. We
know little about whether these hospitals also have
worse outcomes, especially in the area of patient safety.
Therefore, we sought to determine how hospitals that
have a high proportion of black or Hispanic patients
perform on Patient Safety Indicators (PSIs). PSIs are
automated tools developed by the federal government
and are being included in several national pay-forperformance programs and for publicly profiling
hospitals.
Study Design: We used the 2007 MedPAR dataset to
calculate the performance of hospitals on twelve medical
and surgical PSIs. We then segmented hospitals into
those serving a high, medium, and low proportion of
blacks (top 5% of hospitals, 6-25%, and 26-100%,
respectively) and separately segmented hospitals into
those serving a high, medium, and low proportion of
Hispanics. We ran bivariate and multivariate analyses
(adjusting for hospital characteristics) to examine the
relationship between proportion of blacks and of
Hispanics served and PSI rates in those hospitals. We
also examined the small subset of hospitals that had a
high proportion of both black and Hispanic patients.
Population Studied: Medicare enrollees discharged
from 4,554 acute-care hospitals.
Principal Findings: Those hospitals serving a high
proportion of black patients performed worse than those
serving a low proportion on 7 of 12 PSIs and better on
only one. Hospitals serving a high proportion of
Hispanics performed worse than those serving a low
proportion on 6 of 12 PSIs and performed better on
none. For example, hospitals with a high proportion of
black patients had higher rates of pressure ulcers (68
per 1,000 versus 28 per 1,000, p<0.001) compared to
hospitals with a low proportion of black patients.
Adjusting for hospital characteristics had only modest
effects: hospitals with a high proportion of black or
Hispanic patients continue to have higher rates of
adverse events across multiple PSIs. The subset of
hospitals that cared for a high proportion of both black
and Hispanic patients performed worse on 8 of the 12
PSIs and better on none.
Conclusions: Hospitals that disproportionately care for
blacks or Hispanic patients have higher rates of adverse
events than other hospitals.
Implications for Policy, Delivery or Practice: Given
that minorities are disproportionately cared for by
institutions that are less safe as measured by PSIs, our
findings suggest that if the current efforts to penalize
hospitals that have high PSI rates continue, such efforts
will disproportionately impact hospitals that care for
minorities. Whether this motivates those hospitals to
improve care or will cause them to fall further behind is
unclear. However, additional efforts are needed to help
these institutions improve quality and reduce the harm
that results from the care they provide to all their
patients.
• Mortality and Readmission Rates at Safety Net and
non-Safety Net Hospitals
Joseph Ross, M.D., M.H.S.; Susannah Bernheim, M.D.,
M.H.S.; Zhenqiu Lin, Ph.D.; Elizabeth Drye, M.D.;
Sharon-Lise Normand, Ph.D.; Harlan Krumholz, M.D.,
S.M.
Presented by: Joseph Ross, M.D., M.H.S., Assistant
Professor, Department of Geriatrics and Palliative
Medicine, Mount Sinai School of Medicine, One Gustave
L. Levy Place, Box 1070, New York, NY 10029; Phone:
(212) 241-9370; Email: joseph.ross@mssm.edu
Research Objective: To compare hospital-specific riskstandardized mortality and readmission rates among
Medicare beneficiaries hospitalized for acute myocardial
infarction (AMI), heart failure (HF), and pneumonia
between urban safety net hospitals and non-safety net
hospitals located within the same metropolitan statistical
area.
Study Design: We used 2006-2008 Medicare
administrative claims data for all fee-for-service
beneficiaries aged 65 years or older admitted to urban
hospitals located within metropolitan statistical areas
(MSAs) that contained at least 1 safety net and nonsafety net hospital. Hospitalizations for AMI, HF, or
pneumonia were identified using ICD-9-CM codes. Our
main outcome measures were hospital-specific riskstandardized all-cause 30-day mortality rates (RSMR)
and readmission rates (RSRR), calculated using twolevel hierarchical linear models that accounted for age,
sex, and multiple co-morbidities. Both models have been
approved by the National Quality Forum for hospital
comparisons. Safety net hospitals were defined as public
hospitals or private hospitals with a Medicaid caseload
greater than one standard deviation above the states´
mean private hospital caseload. We used t-tests to
examine the association between safety net status and
mean hospital-specific RSMRs and RSRRs.
Population Studied: There were 318,251 distinct
hospitalizations for AMI in 1263 hospitals; 66,781 in 310
safety net hospitals and 251,470in 953 non-safety net
hospitals. There were 718,320 distinct hospitalizations
for HF in 1433 hospitals; 149,863 in 376 safety net
hospitals and 568,457 in 1057 non-safety net hospitals.
There were 564,988 distinct hospitalizations for
pneumonia in 1447 hospitals; 114,212 in 384 safety net
hospitals and 450,776 in 1063 non-safety net hospitals.
Principal Findings: Safety net hospitals were more
likely to be teaching institutions and had higher average
condition-specific volumes when compared with nonsafety net hospitals (p values < 0.001). For all three
conditions, safety-net hospitals had modestly higher
RSMRs and RSRRs when compared with non-safety net
hospitals. AMI RSMRs: 16.6% versus 16.1% (p<0.001);
0.6% average within-MSA difference (standard error
[SE]=0.11%). AMI RSRRs: 20.3% versus 20.0%
(p=0.02); 0.2% average within-MSA difference
(SE=0.09%). HF RSMRs: 10.8% versus 10.6% (p=0.11);
0.1% average within-MSA difference (SE=0.09%). HF
RSRRs: 25.2% versus 24.6% (p<0.001); 0.6% average
within-MSA difference (SE=0.13%). Pneumonia RSMRs:
11.5% versus 11.1% (p<0.001); 0.4% average withinMSA difference (SE=0.11%). Pneumonia RSRRs: 18.7%
versus 18.4% (p=0.003); 0.2% average within-MSA
difference (SE=0.11%). In addition, there was
substantial heterogeneity in both RSMRs and RSRRs
among safety-net and non-safety net hospitals for all
three conditions with extensive overlap in performance.
Conclusions: Urban safety net and non-safety net
hospitals have similar risk-standardized rates of HF
mortality and statistically significant, but only modestly
higher risk-standardized rates of HF readmission, rates
of AMI mortality and readmission, and rates of
pneumonia mortality and readmission.
Implications for Policy, Delivery or Practice: Urban
safety net hospitals’ performance approximates that of
non-safety net hospitals located within the same MSAs,
despite caring for more vulnerable and financially
disadvantaged populations.
Funding Source(s): CMS
• Hospital Characteristics Associated with Racial
and Ethnic Disparities in Waiting Times at U.S.
Emergency Departments
Nancy Sonnenfeld, Ph.D.; Stephen Pitts, M.D., M.P.H.;
Susan Schappert, M.A.
Presented by: Nancy Sonnenfeld, Ph.D., Associate
Div. Director for Science, Division of Health Care
Statistics, CDC/National Center for Health Statistics,
3311 Toledo Road, Hyattsville, MD 20782; Phone: (301)
458-4156; Email: nls2@cdc.gov
Research Objective: Emergency department (ED)
crowding threatens quality, including patient safety.
Racial and ethnic disparities in U.S. ED waiting times
have previously been reported. We sought to better
understand disparities in waiting time by including two
key variables, ED volume and boarding, which have
been omitted from previous national analyses.
Study Design: We linked data from the 2005-2006
National Hospital Ambulatory Medical Care Surveys with
the SDI Hospital Marketing Profile Solution databases
for 2006-2007. We compared waiting times among visits
by non-Hispanic black and Hispanic patients with those
of non-Hispanic white patients in fixed effects regression
models. Racial and ethnic differences were estimated
within and across EDs simultaneously through hybrid
fixed effects specification. We defined waiting time as
time from arrival until the patient saw a physician.
Waiting time data were log-transformed because they
were skewed; consequently, geometric means and
percent differences are reported. ED volume was
measured annually. We defined a proxy for boarding as
a visit which met two criteria: (1) the patient was
admitted or transferred, and (2) time from treatment start
to ED discharge was 6 hours or more. We adjusted for
triage status, time of visit, patient age, sex, and expected
payment source. Using a best subsets approach, we
evaluated other potential hospital covariates, including
size of metropolitan statistical area; ownership, teaching
hospital status; trauma level; percentages of visits with
diagnostic imaging; percentages of uninsured, Medicaid,
or S-CHIP visits; inpatient hospital bed size and annual
average inpatient bed occupancy.
Population Studied: Data are from a nationally
representative sample of 63,744 visits to 457 U.S.
hospital EDs.
Principal Findings: In unadjusted models, visits by nonHispanic white patients had a geometric mean waiting
time of 26 minutes. Waiting times for visits by nonHispanic black and Hispanic patients were 34% and
40% longer, respectively (p < .001 for both). Adjusting
for visit characteristics only, non-Hispanic black and
Hispanic visits had 28% and 33% longer waiting times (p
< .001 for both). Adjusting for ED volume, bed size,
teaching hospital status, and percent boarded reduced
relative increases in waiting times to 18% and 21% for
visits by non-Hispanic blacks and Hispanics (p < .001 for
both). Within-hospital differences were reduced to 3% (p
= .07) for non-Hispanic black and 9% (p < .001) for
Hispanic visits. Across hospitals, waiting times were
5.7% and 6.1% longer for every 10 percentage point
increase in visits by black and Hispanic patients (p <
.001 for both). Overall, waiting time increased by 16% for
every 10,000 visit increase in ED volume up to 50,000
visits (p < .001). Among EDs with volume greater than
50,000, waiting time did not vary. At EDs which boarded
more than 5% of patients, waiting time was 23% longer
(p = .009).
Conclusions: Non-Hispanic black and Hispanic patients
wait longer for ED treatment than non-Hispanic whites.
Adjusting for ED volume and percent boarded reduced
these disparities considerably.
Implications for Policy, Delivery or Practice: Recent
policy reports have emphasized the problem of ED
boarding. To reduce racial and ethnic disparities in
waiting times, greater focus on ED volume may also be
needed.
Funding Source(s): CDC
Impact of Organizational Practices on Financial and
Quality Outcomes
Chair: Andrew Garman
Monday, June 28 * 11:30 am–1:00 pm
• Organizational Complements to Electronic Health
Record Use
Julia Adler-Milstein
Presented by: Julia Adler-Milstein, Doctoral
Candidate, Health Policy, Harvard University, 176
Upland Road, Cambridge, MA 02140; Email:
jadlermilstein@hbs.edu
Research Objective: The American Reinvestment and
Recovery Act allocates billions of dollars to increase the
adoption and use of electronic health record systems
(EHRs). Research on the impact of IT adoption in other
industries points to substantial variation across
organizations, with organizations that realize the
greatest gains from IT restructuring to take advantage of
the new capabilities IT affords. In health care, there is
little research on whether such findings apply and if so,
which organizational changes are required. We
assessed whether a set of changes in work structure
resulted in productivity gains in primary care practices
using EHRs.
Study Design: We measured productivity as the
number of work relative value units billed per practice
per month. Our key independent variables were derived
from data on which type of staff member (provider,
clinical, or administrative) conducted a range of in-visit
tasks (e.g., collecting patient history) and between-visit
tasks (e.g., responding to request for prescription refill).
Each task was first assigned to the type(s) of staff who
most commonly performed it. Role-based fit was then
calculated as the percent of tasks per practice per month
in which the primary staff type assigned to the task
completed it. Delegation was calculated as the percent
of tasks per practice per month in which staff with less
training conducted the task, among tasks assigned to
two or more roles. We estimated the effects of fit and
delegation on productivity using a conditional fixed
effects regression.
Population Studied: Forty-two US-based primary care
practices using a fully hosted EHR (i.e., the technology
was identical across all practices). Practices had used
the EHR for an average of 16 months, with a minimum of
6 months. Practices ranged in size from 1 to 14 with an
average of 4 full-time providers.
Principal Findings: Practices in which clinical staff
members focused on their core tasks during the patient
visit had a substantial increase in productivity
(coefficient: 180.04; p<0.05). In contrast, practices in
which providers focused on their core activities during
the patient visit had a substantial decrease in
productivity (coefficient: -207.23; p<0.05). For tasks
shared by providers and clinical staff during the visit,
practices in which clinical staff performed the task more
often were more productive (coefficient: 239.64; p<0.05).
We found no evidence that the degree of role-based fit
and delegation of tasks performed outside the patient
visit impacted productivity.
Conclusions: Practices that reorganized their work
realized greater productivity gains from the EHR. The
most important changes centered around clinical staff
activities during the patient visit. Allowing clinical staff to
focus on their key tasks, particularly those that are
shared with providers, resulted in substantial productivity
gains. In contrast, practices benefited from allowing
providers to spend time on a variety of activities,
including those not in their primary area.
Implications for Policy, Delivery or Practice: The
widespread adoption of EHRs without a set of
complementary organizational changes is unlikely to
yield substantial benefits. One set of changes revolves
around restructuring work to take advantage of the new
capabilities. Current definitions of meaningful use of
health IT required for providers to receive ARRA
incentive payments do not address such changes and
will likely fall short of eliciting the full potential value from
IT adoption.
• Informing a Business Case to Prevent Infections
Acquired in Acute Care Hospitals
Juliette (Yaozhu) Chen, M.P.A.; Timothy Dall, M.S.;
Erica Moen, B.Sc.
Presented by: Juliette (Yaozhu) Chen, M.P.A., Senior
Associate, The Lewin Group, 3130 Fairview Park Drive,
Suite 800, Falls Church, VA 22042; Phone: (703) 2695709; Email: juliette.chen@lewin.com
Research Objective: This study illustrates the potential
benefits for hospitals to reduce hospital-acquired
infections (HAI) in terms of reduced medical costs,
length of stay (LOS), and in-hospital mortality.
Study Design: The 2007 Nationwide Inpatient Sample
(NIS) was linked to the American Hospital Association
Annual Survey to yield a nationally representative
sample of 5.7 million discharges from non-federal acute
care hospitals. HAI incidence data (number of cases per
1,000 inpatient days) from 2006-2007 National
Healthcare Safety Network were applied to the sample
to generate national estimate of HAI cases. In order to
capture the most prevalent and costly HAIs as
documented by literature, we restricted our analysis to
include catheter-associated urinary tract infections,
ventilator-associated pneumonia (VAP), bloodstream
infections, surgical site infections, methicillin-resistant
Staphylococcus aureus, and Vancomycin-resistant
Enterococci. Applying ICD-9-CM codes to the secondary
diagnosis and all procedure fields, we identified patients
in NIS whose infections are likely hospital-acquired. A
series of multivariate regressions (logistic regression for
mortality, generalized linear model [GLM] with Poisson
distribution for LOS, and GLM with gamma distribution
for cost) were employed to estimate the increased LOS,
mortality risk, and medical costs associated with HAIs.
Risk-adjustment variables were created based on
patient’s primary diagnosis. Additional control variables
include patient demographics, admission and payer
types, hospital characteristics, and indicator variables
reflecting whether each HAI type is present during the
stay. The impact of explanatory variables at both
hospital and discharge level was assessed through
hierarchical modeling. A business case model was set
up to estimate HAI-attributed increases in mortality,
LOS, and cost for both overall inpatient population and
selected subsets (neonatal, cardiac, oncology, surgical,
and medical pools - which were defined by patient
characteristics and ICD-9-CM codes).
Population Studied: Patients treated in acute care
hospitals in the U.S.
Principal Findings: We find that for these HAIs the
increase in annual national medical expenditures
exceeds $25 billion (in 2009 dollars). This number is at
the lower bound of the burden of HAIs reported by other
studies, but uses a more narrowly-defined subset of
HAIs. Modest reductions in HAI incidence can translate
to substantial reductions in medical costs, LOS, and
mortality - with the potential benefits varying
substantially by patient group. Using VAP as an
example, the increased cost per case varies from
$14,900 for neonatals to $1,100 for adults in general
medical pool. An average-sized hospital (160 staffed
beds that annually serve 7,000 discharges in 39,000
inpatient days) is estimated to experience 59 VAP cases
(associated with an increase of 156 bed days, $670,000
medical cost, and 3 deaths).
Conclusions: The opportunity exists for substantial
improvements in patient outcomes and hospital
performance through HAI control. Our estimates of
medical savings under-represent total hospital and
societal benefits, which may include hospital reputation
and litigation costs, bed turnaround time, increased work
load for hospital staff, pre-mature deaths, productivity
loss, and intangible costs such as pain and suffering.
Implications for Policy, Delivery or Practice: As
hospitals explore alternative approaches to reduce
incidence of HAIs, costs of each approach can be
compared to potential benefits to help reduce the HAI
burden while improving patient outcomes.
• Effect of Senior Health Center Team Care on
Patients’ Use of Outpatient and Inpatient Services in
an Integrated Health Care Network
Phuong Hoang, Ph.D. Candidate
Presented by: Phuong Hoang, Ph.D. Candidate, The
Heller School for Social Policy and Management,
Brandeis University, 129 Heather Hill Lane, Goffstown,
NH 03045; Phone: (603) 497-3458; Email:
phoang@brandeis.edu
Research Objective: In 2001, a healthcare network in
New England invested $3.8 million in a Senior Health
Center (SHC) that is based on a geriatric team care
model, where many of the services needed by elders are
provided in one location; it is one of few centers in the
U.S. offering integrated geriatric healthcare. Despite
unfavorable Medicare reimbursements for care
coordination services, the network’s CEO asserts that
the SHC is financially sustainable. One reason for its
sustainability is that it results in greater use of services
available in the network. This study measures the effect
of a healthcare network’s SHC on patients’ use of
outpatient and inpatient services offered within the
network.
Study Design: Data for this study came from the
network which consisted of patients from two models of
primary care (PC): the SHC team care (study group)
model, and the traditional PC (control group) model,
wherein care is managed by a single provider. The
outcome variables of interest (measured in dollars) are
divided into 4 categories. These are patients’ use of: 1)
physical/occupational therapy and psychiatric care 2)
radiology/ultrasound/MRI, 3) laboratory testing, and 4)
inpatient stays. The study used a study-comparison
group design over a five-year period (2002-06). The
sample consisted of 2,048 unique Medicare patients
(1,024 SHC patients and 1,024 control patients; n=7,155
person years). Patients in the control group were
randomly selected to match with patients in the SHC
group by age category, gender, health status indicators,
and number of years as a patient in the network.
Patients’ health status was estimated by using a frailty
indicator as well as the sum of Aggregated Diagnosis
Groups. Data analyses were performed using Tooze’s
correlated two-part Mixcorr model in SAS.
Population Studied: All Medicare patients in the
network.
Principal Findings: Regression results suggest that
compared to the control patients, SHC patients used
more within-network services (both in probability of use
and intensity of use) for physical/occupational therapy
and psychiatric care and radiology/ultrasound/MRI
(p=0.05). Regression results for the laboratory services
were inconclusive. Finally, regression results for the use
of inpatient stay indicate that there is no significant
difference between the two groups.
Conclusions: The healthcare network in this study saw
an increase in the use of many of its billable, ancillary
services when it supported a team care model to provide
primary care to its elderly population. Such in-network
services provide revenue to the network that helps to
offset the costs to the network for services provided by
the Senior Health Center that are not well reimbursed by
Medicare or other insurers.
Implications for Policy, Delivery or Practice: If
Medicare continues to reimburse providers based on the
fee-for-service payment system then it would be
advantageous for healthcare networks to bundle
services together to include unfavorable Medicare
reimbursement services along with favorable
reimbursement services. However, Medicare should
motivate primary care providers and organizations to
provide integrated care by directly reimbursing them for
primary care coordination support.
Funding Source(s): CDC
• Coping with Organizational Intrusions on the
Doctor-Patient Relationship: A Qualitative Study
Courtney Jackson, Ph.D.; John McKinlay, Ph.D.;
Rebecca Shackelton, Sc.M.; Lisa Marceau, M.P.H.
Presented by: Courtney Jackson, Ph.D., Research
Scientist, New England Research Institute, 9 Galen
Street, Watertown, MA 02472; Phone: (617) 972-3002;
Email: cjackson@neriscience.com
Research Objective: The Doctor-Patient Relationship
has traditionally been viewed as a dyadic, closed-system
encounter between just two parties. Increasingly,
however, various interests have been intruding on the
encounter and now shape clinical decision making. For
example, health insurance companies have developed
strict formularies, dictating tiers of prescription drugs
they will cover, mandated pre-authorizations for
procedures and treatments, and reduced
reimbursements to providers. This paper fills a gap in the
literature by using qualitative data to illuminate how
physicians cope with pressures from external forces.
Study Design: Data come from a vignette factorial
experiment designed to determine the impact of patient,
physician, and organizational characteristics on clinical
decision making. Physicians viewed two video-taped
vignettes, one featured a patient presenting with
symptoms suggestive of diabetes, while the second
featured a diagnosed diabetic patient presenting with
symptoms suggestive of an emerging neuropathy. The
design assigned physicians to view vignettes
systematically varied by patient characteristics: age - 35
versus 65; gender; SES - current or former employment
as a janitor or a lawyer; and race/ethnicity - black,
Hispanic, white. After viewing each vignette, physicians
participated in a “think-aloud,” semi-structured interview
where physicians answered open-ended questions
about their treatment goals for the patient in the second
vignette, the anticipated challenges, and predictions for
this patient.
Population Studied: This analysis includes 175
physicians in NY, NJ, and PA who completed residency
in family or internal medicine, and graduated from a US
medical school between 1969 and 1983 or between
1993 and 1999.
Principal Findings: Physicians expressed concerns
about the intrusion of health insurance imperatives: 1)
pre-approvals create inefficiencies and actually increase
costs by dictating “needless” steps before finally
approving what the physician initially proposed to do; 2)
formularies often contradict clinical guidelines,
compelling the physicians to choose less optimal
treatments and/or burden patients with higher costs; 3)
insurance industry staff, with little clinical experience,
challenge physician authority to make clinical decisions
in the patient’s interest. Physicians in our study adopted
one of five types of coping mechanisms in the face of
these external intrusions: 1) Defiance – a few stopped
accepting restrictive insurance plans; 2) Gaming the
system – some physicians described seeing patients
more frequently, by bringing patients back more often; 3)
Adaptation – some physicians created new practice
infrastructure, for example some hired NPs and/or PAs
to provide routine care, others hired administrative staff
to interface with health insurance companies; 4)
Resignation – physicians described accepting lower pay
and/or greater interference into their clinical decision
making; 5) Retreat – while not a common response,
some physicians expressed concern about doctors being
pushed out of primary care practice, choosing other
specialties, or leaving medicine all together, all because
of these external forces impacting their provision of
primary care.
Conclusions: Qualitative research on physicians’
responses to external forces provides rich illustrations to
confirm and expand on prior quantitative research.
Physicians describe the specific frustrations that have
led them to adopt a range of strategies to cope with the
increasing influence of health insurance companies on
their treatment decisions.
Implications for Policy, Delivery or Practice: This
more nuanced understanding of how physicians respond
to pressures from external forces has implications for
both practice delivery and policy. Regarding practice
delivery, the analysis points to the difficulties physicians
face in providing patient-centered care. External forces
erode trust and raise questions for patients about whose
interests physicians serve. Regarding policy, these
results can also inform health reform policy discussions.
The analysis challenges the claim that health reform will
lead to bureaucrats controlling healthcare by exposing
how external forces already interfere with the doctorpatient relationship. In addition, the paper provides
compelling examples of the contradictions inherent in
third-party payers’ existing policies and practices, which
warrant reform.
Funding Source(s): NIA
Health Care Needs and Physician Demand
Chair: Joanne Spetz
Monday, June 28 * 3:00 pm–4:30 pm
• The Burden of Depression Care: A Potential
Determinant of the Primary Care Workforce
Shortage.
Seong-Yi Baik, Ph.D.; Jeffrey Susman, M.D.; Phyllis
Panzano, Ph.D.; Junius Gonzales, M.D., M.B.A.
Presented by: Seong-Yi Baik, Ph.D., Associate
Professor, University of Louisville, KY 40202; Phone:
(513) 218-1991; Email: seongyi.baik@uc.edu
Research Objective: The United States faces deficits of
up to 44,000 primary care providers (PCPs) by 2025,
resulting in about a 29% increased workload for family
physicians and general internists for adult populations.
More than half of patients with depression seek help
from PCPs (vs. mental health specialists), and 5-40% of
primary care patients experience some form of
depression. The purpose of this research was to
understand the real-world practice reality of depression
care from the perspective of PCPs. This research was a
part of a larger NIH-funded DEED (Describing Enigma of
Evaluating Depression) project that investigated
depression care processes and influencing conditions for
PCPs’ management of depression.
Study Design: Mixed method was used with seventy indepth, in-person individual interviews, three focus
groups (with 24 providers), two surveys (per provider),
and the investigators’ field notes on office environments.
Individual interviews lasted 50- 70 minutes (up to 120
minutes); focus group interviews lasted approximately
two hours each. Interviews were audiotaped and
transcribed for analysis. We used the 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 PCPs from fifty-two
primary care offices in the Midwest: 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 PC practice environments ranging from private
solo, group, and federally-funded community health
centers. The providers’ 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,
resulting in “burden” (both emotional and productivity) on
PCPs beyond that of other medical conditions frequently
seen in PC such as diabetes and hypertension. This
burden diminished the provider’s ability to effectively
manage depression, resulting in the marginalization of
depression in PC settings as well as a perceived gap
between the ideal and the reality of depression care.
These findings were consistent among the three provider
groups. Compared to other medical conditions, several
major clinical, system, and societal barriers that are
unique to depression care were identified: absence of
objective measurement (e.g., a blood test or blood
pressure), disjointed nature of the current mental health
care system (administrative and financial carve-outs,
lack of accessibility of referral and educational
resources, inadequate reimbursement of PCPs’ time,
poor communication between mental health specialists
and PCPs), and societal stigma of depression (related to
patient’s willingness of accepting the diagnosis and
prescribed treatment).
Conclusions: Burden of depression care experienced
by PCPs not only marginalizes depression care but may
also exacerbate the primary care workforce shortage.
Implications for Policy, Delivery or Practice:
Investigating the “burden” of depression care
experienced by PCPs in real-world practice may offer
strategies for decreasing PCP workloads, potentially
helping to alleviate PCP shortages.
Funding Source(s): NIMH
• Perceived Barriers to Increasing the Supply of
Medical Residents among DIOs in New York State
Raymond Goldsteen, Dr.PH; Norman Edelman, M.D.;
Karen Goldsteen, M.P.H., Ph.D.; Stephen Colon, B.S.;
Muath Bishawi, B.S.; Samual Yagudayev, B.S.
Presented by: Raymond Goldsteen, Dr.PH., Professor
& Director, Graduate Program in Public Health,
Preventive Medicine, SUNY Stony Brook, HSC Level 3,
Room 071, Stony Brook, NY 11794-8338; Phone: (631)
444-9788; Email: raymond.goldsteen@stonybrook.edu
Research Objective: The objective of this study was to
examine the perceived barriers to increasing the supply
of medical residents among New York State hospitals
with existing residency programs. There is general
agreement that a shortage of physicians currently exists
in many areas of the U.S. and this shortfall will be
exacerbated when millions more Americans acquire
health insurance as a result of health care reform.
Medical educators have responded to the threat of a
physician shortage by increasing class sizes and
establishing new schools. However, the present ratelimiting step in the production of new physicians is the
number of persons completing residency training.
Although new federally funded residency positions have
been proposed, it is not clear whether hospitals have the
interest or ability to expand residency training programs.
Study Design: Between July and November 2009, we
surveyed all Designated Institutional Officials (DIOs) for
New York State residency programs accredited by the
Accreditation Council for Graduate Medical Education
(ACGME) except those in hospitals focused on a single
specialty (n=48). The survey asked about their interest in
expanding existing residency programs, redistributing
residents among existing residency programs, and
adding new programs. The survey was self-administered
using SurveyMonkey, an electronic survey software sent
to each DIO’s email address. We sent up to three
reminder messages, and the completion rate was 75
percent. There was no difference between responders
and non-responders with regard to hospital or residency
program size.
Population Studied: Designated Institutional Officials
(DIOs) for New York State residency programs
accredited by the ACGME.
Principal Findings: Sixteen percent of DIOs were
planning to add new programs with current funds, while
53 percent reported they would add new programs if
new governmental funds were made available [these
overlap]. Thirty one percent were planning to add new
positions to existing programs using current funds, while
50 percent would add new positions with the availability
of new funds [these overlap]. The DIOs interested in
increasing residency training perceived barriers to
expansion. For those programs wishing to expand if
additional ACGME funding was made available by
government, the perceived barriers were, in the order of
frequency, inadequate number of faculty members [both
full time and volunteer], concerns about Residency
Review Committee (RRC) approval, which usually went
along with concerns about quality of applicants, and
inadequacy of current reimbursement rates for GME. We
also asked about the desire to close or downsize
existing residency programs. About half of the DIOs
listed “stakeholder concerns” as a barrier to downsizing
or closing programs so that positions could be moved
elsewhere. The programs suggested for downsizing or
closure were all non-hospital intensive such as Family
Medicine, Dermatology, and Ophthalmology.
Conclusions: Serious barriers exist to expansion and
reorganization of residency programs in New York State
teaching hospitals.
Implications for Policy, Delivery or Practice: Simply
adding funded positions [raising the “cap”] is not likely to
enable teaching hospitals in New York to meet the
AAMC goal of a 30 percent increase in new residents,
especially in the primary care specialties. The ability of
current non-teaching facilities to make-up the difference
is unknown at the moment.
• It’s About Time: Physicians’ Perceptions of Time
Constraints in Primary Care Medical Practice in
Three National Health Care Systems
Thomas Konrad, Ph.D.; Carol Link, Ph.D.; Rebecca
Shackelton, Sc.M.; Lisa Marceau, M.P.H.; Olaf von dem
Knesebeck, Ph.D.; John McKinlay, Ph.D.
Presented by: Thomas Konrad, Ph.D., Professor,
Social Medicine, Health Policy & Administration, Cecil G.
Sheps Center for Health Services Research, 725 Martin
Luther King, Jr. Boulevard CB 7950 Univ of North
Carolina at Chapel Hill, Chapel Hill, NC 27599-7590;
Phone: (919) 966-2501; Email: konrad@schsr.unc.edu
Research Objective: This study aims to answer three
questions: (1) How does national health system affect
amounts of time allocated and required?; (2) How does
national health system affect the extent of time
pressures that physicians’ experience in context of their
everyday clinical work?; and (3) is there consistent
variation by gender and career stage? Major
transformations in health care in the more developed
world over several decades are affecting the way
physicians perform, experience, and evaluate their own
clinical work. In North America and Western Europe in
particular, an ideology of “clinical management” now
shapes and justifies managerially driven organizations of
generalist physician practices, while payers and
professional bodies pressure physicians to provide an
increasing number of preventive services, to engage in
“evidence-based” practice, and deliver “person-centered
care.” These trends are manifested in struggles over
how much time practitioners have with patients, how
they actually spend that time, and how much control they
have over their own time.
Study Design: Three parallel experiments on clinical
decision making were conducted in Germany, the United
Kingdom, and the United States with 128 physicians per
country. We asked physicians how much time they were
allocated and how much time they needed for high
quality care for a new patient appointment, a routine
consultation, and a complete physical. We also asked
them how much control they had over their time in the
office and spending adequate time with patients.
Population Studied: Primary care physicians practicing
in Germany, the United Kingdom, and the United States
(n=128 per country).
Principal Findings: German, British, and American
physicians were allocated 16 / 11 / 32 minutes for a new
patient appointment, 6 / 10 / 18 minutes for a routine
visit, and 12 / 20 / 36 minutes for a complete physical,
but felt they needed more time. Over half of German and
American physicians felt that always or usually had
control over the hours they were required to be in their
office or spending sufficient time with their patients while
less than half of British physicians felt this way.
Conclusions: Two broad conclusions can be drawn
from this study. First, German physicians had the least
time allocated and needed for each type of appointment
while American physicians had the most time allocated
and needed for each type of appointment, but are tied
with their German colleagues in their perceptions of
control over their work schedules and the amount of time
they spend with patients. In contrast British physicians
felt they had the least control over time in their office and
spending sufficient time with patients Second, although
gender and career stage may matter, there are no
consistent effects across nations.
Implications for Policy, Delivery or Practice: Further
studies are needed to surface the underlying dynamics
responsible for how physicians’ gender and career stage
affects how they cope with time constraints in different
nations.
Funding Source(s): NHLBI
• Physician Division of Labor and Patient Selection
for Outpatient Procedures
Guy David, Ph.D.; Mark Neuman, M.D.
Presented by: Mark Neuman, M.D., Clinical Scholar,
Robert Wood Johnson Foundation Clinical Scholars
Program, University of Pennsylvania, 423 Guardian
Drive, 1301 Blockley Hall, Philadelphia, PA 19104;
Phone: (215) 573-3983; Email:
neumanm@mail.med.upenn.edu
Research Objective: Freestanding ambulatory surgical
centers (ASCs) offer unique opportunities setting for the
study of patient selection by physicians. As ASCs are
physically separate from acute care hospitals, physicians
must incorporate assessments of the likelihood of a
complication necessitating hospital transfer into the
decision to offer a given procedure to an individual
patient. While patients of low to moderate risk may
safely receive care in ASCs, those at elevated risk for
complications may be more safely cared for in traditional
hospital settings. We hypothesized that the physician’s
division of labor may influence their patient selection
practices. To test this hypothesis, we compared the
average risk profiles of ASC patients receiving care from
physicians who differ in their division of labor: those
working only at ASCs (“stayers”), and those working at
both ASCs and hospital outpatient departments
(“splitters”).
Study Design: We examined 1,605,670 discharges for
colonoscopy (72.1%) and upper endoscopy (27.9%), as
identified by principal CPT codes, at ASCs in Florida
between 2004 and 2007. Linear probability models were
developed to predict values of the outpatient surgery
admission index (OSAI), a measure of outpatient
surgical risk incorporating patient age and selected
Charlson comorbidities, which we defined using ICD-9CM diagnosis codes. Splitter status was defined by a
physician-level dummy variable indicating performance
of over 95% of all procedures in an ASC (stayers) versus
performance of between 5 and 95% of all procedures in
an ASC (splitters). We excluded cases performed by
physicians performing fewer than 5% of all procedures in
ASCs. Control variables included principal CPT code,
presence of any secondary CPT codes, physician
characteristics (foreign medical graduate, years in
practice), patient characteristics (race, sex), and time
fixed-effects, and ASC fixed-effects. As selection
behaviors may be endogenous to splitter status, we
developed instrumental variable models, using as an IV
a dummy variable for completion of medical school in
Florida, which was correlated with splitter status but not
OSAI score.
Population Studied: 609 physicians performing
colonoscopies and upper endoscopies at ASCs in
Florida between 2004 and 2007.
Principal Findings: 407 splitters and 202 stayers
delivered colonoscopies and upper endoscopies at
ASCs over the period; average patient OSAI score was
lower among splitters (0.412 vs. 0.475, p<0.0001). The
regression coefficient for the splitter dummy variable was
a negative and significant (p<0.0001) predictor of OSAI
score in models incorporated procedure controls alone (0.0585), and in models adding time fixed effects (0.0578), physician controls (-0.0567), facility fixed effects
(-0.0228), and two stage least squares IV regressions (0.3103). To assess robustness of these preliminary
analyses, we conducted further analyses using alternate
cutoffs for splitter/stayer categories, dependent variables
using age alone, and alternate IVs based on training
after medical school.
Conclusions: When compared to physicians whose
practice is split ASCs and HOPDs physicians working
predominantly at ASCs provide care for patients of
greater risk at ASCs. This effect persists despite
adjustment for procedure factors, time, physician factors,
facility fixed effects, and unmeasured confounders.
Implications for Policy, Delivery or Practice: The
increased risk profiles of ASC patients receiving care
from physician stayers suggest differences in patient
selection according to physician division of labor at
ASCs. Defining the implications of differences in
selection behaviors for patient outcomes may help to
inform regulation to improve the delivery of care in
ASCs.
Funding Source(s): Leonard Davis Institute for Health
Economics, University of Pennsylvania
• To What Extent Is there a Hidden System of
Primary Care Provided by Subspecialists?
Jeongyoung Park, Ph.D.; Rebecca Lipner, Ph.D.
Presented by: Jeongyoung Park, Ph.D., Health
Services Researcher, American Board of Internal
Medicine, 510 Walnut Street, Suite 1700, Philadelphia,
PA 19106-3699; Phone: (215) 446-3501; Email:
jpark@abim.org
Research Objective: Some amounts of primary care
are provided by subspecialists possibly due to the
shortage in primary care physicians. However, the
quantity of primary care delivered by non-primary care
physicians is unknown and controversial. The goals of
this study are to examine: (1) the extent to which
subspecialists provide primary care; and (2) what factors
determine their decision to do so.
Study Design: The analyses are conducted using the
American Board of Internal Medicine (ABIM) databases
linked to the Area Resource Files. The outcome of
interest is measured by the percent of time in primary
care reported by physicians enrolled in ABIM’s
Maintenance-of-Certification (MOC) program. The
percent of time in primary care is modeled as a function
of physician-, practice-, and market-level characteristics.
The key determinants in our analysis are market
characteristics such as whether shortage of primary care
physicians in the area influences whether subspecialists
provide more primary care. We use the Two-Part model
because the outcome variable has a large fraction of
zeros with the remaining values being positive and
continuous. The first part predicts whether subspecialists
provide any primary care using the entire sample, and
the second part predicts the continuous value on the
subsample with positive values. The models are
estimated separately by subspecialty-type in internal
medicine because non-procedural subspecialists are
likely to spend more time in primary care than their
procedure-based subspecialty counterparts.
Population Studied: 16,453 subspecialists (8,120 nonprocedural and 8,333 procedural) in internal medicine
who enrolled in ABIM’s MOC program between 2006
and 2009.
Principal Findings: About 36% of subspecialists devote
some time to primary care. Among those who provide
any primary care, the average percent of time in primary
care is 35% for non-procedural and 15% for procedural
subspecialists. Although other studies have shown that
females choose primary care careers more than males,
gender does not have a statistically significant impact on
the likelihood of subspecialists providing primary care.
Interestingly, market factors (practicing in underserved
or rural areas, and shortage of primary care physicians
in the market) appear to be key determinants of
subspecialists providing primary care, and the effects
are highly significant (p<0.01). For example, practicing in
the primary care health professional shortage area (1)
increases the probability of providing any primary care
by 35%; and (2) the percent of time in primary care
(conditional on any primary care) increases by 13
percentage points. Combining the two parts, the
marginal effect of this variable is an increase in the
percent of time in primary care of about 3 percentage
points compared with the overall mean of 27%. The
effects are much larger in size for non-procedural
subspecialists than procedure-based subspecialists.
Conclusions: A substantial proportion of primary care is
provided by subspecialists. Market factors seem to be
related to subspecialists spending their time in primary
care.
Implications for Policy, Delivery or Practice: This
study contributes to an improved understanding of the
extent to which subspecialists provide primary care and
the factors influence this decision. This study also has
important implications for primary care physician
workforce policy.
Nursing Home Quality
Chair: R. Tamara Konetzka
Monday, June 28 * 3:00 pm–4:30 pm
• How Does CMS Five-Star Quality Rating System for
Nursing Homes Relate to Family Member
/Responsible Party Experience of Care?
Sule Calikoglu, Ph.D.; Carol Christmyer, R.N., M.S.;
Bruce Kozlowski
Presented by: Sule Calikoglu, Ph.D., Senior Health
Policy Analyst, Center for Long-Term Care and
Community-Based Services, Maryland Health Care
Commission, 4160 Patterson Avenue, Baltimore, MD
21215; Phone: (410) 764-8789; Email:
scalikoglu@mhcc.state.md.us
Research Objective: In 2009, the Centers for Medicaid
and Medicare Services launched a quality rating system
to help consumers to compare nursing homes using a
rating of between 1 and 5 stars. The star ratings are
calculated from three domains, which are health
inspections, staffing, and quality, and also include an
overall rating. Although moving towards a consumer
friendly, easy to understand rating system is a positive
step, the rating methodology draws criticism from the
provider community for its lack of input from consumer
satisfaction surveys. Our objective is to determine how
the five-star rating is correlated with family experience of
care in nursing homes controlling for facility size,
ownership type, percentage of Medicaid patient days,
and proportion of residents who were 85 and older.
Study Design: We used the five-star ratings
downloaded from the CMS website and the results of the
2009 Maryland Nursing Facility Family Survey.
Univariate and multiple linear regressions are used to
examine the relationship between four five-star
measures, overall rating and three domains, and family
rating of experience of care. Kappa statistic is used to
measure the degree of agreement between the family
rating and the five-star rating.
Population Studied: Our sample includes 209 Medicare
and Medicaid certified nursing homes in Maryland. We
excluded hospital-based facilities and nursing homes
with very low survey response rates from the analysis.
Principal Findings: There is a strong positive
correlation between family rating of experience of care
and two of the five star domains. Univariate regression
results revealed that compared to one-star facilities,
facilities with a five-star rating in health inspections
domain had 1.6 points higher scores in family ratings.
The difference between one-star and five-star facilities in
the nurse staffing domain was much smaller with 0.88
more points for five-star facilities compared to one-star
ones. There was no relationship between quality
measures domain and family rating of experience of
care. Facilities with an overall five star rating scored 1.12
points more than one-star facilities. Five-star categories
explained 35% of the variation in family rating.
Differences between five star categories diminished in
full models, however; the relationship between five star
rating and family rating remained statistically significant
for home health inspections and overall rating. Simple
kappa statistic revealed that the agreement between
five-star overall rating and family rating was moderate
0.24. However, weighted kappa statistic was 0.44.
Conclusions: Health inspections and overall five star
scores are related with family ratings of experience of
care. The comparison of ratings indicated that the level
of agreement between the two ratings is fair to
moderate.
Implications for Policy, Delivery or Practice: The lack
of relationship between quality measures and the family
survey is puzzling and may be due to different time
frames for collecting these measures, or that each rating
system measures different aspects of quality. The family
rating may focus more on residents’ quality of life than
the clinical measures that are rated in the quality
domain. A few facilities scored low on the family survey
but received high ratings from the five-star system,
which may indicate the value of adding satisfaction
surveys to five-star rating.
• Racial Disparities in Nursing Home Quality of Care:
A Multilevel Analysis Using 2004 National Nursing
Home Survey Data
Yu Kang, Ph.D., M.S., M.P.P., M.P.A.; Nancy Miller,
Ph.D.
Presented by: Yu Kang, Ph.D., M.S., M.P.P., M.P.A.,
Assistant Professor, Health Science and Administration,
University of Michigan, Flint, 2102 W.S. White Building,
Flint, MI 48502; Phone: (810) 762-0071; Email:
yukang@umflint.edu
Research Objective: Despite growth in our
understanding of the factors associated with health care
disparities, these disparities continue. This persistence
has led to federal action. One of the overarching goals of
Healthy People 2020 is the elimination of health
disparities. AHRQ has been tasked to identify health
disparities in the U.S. population, focusing on several
groups of interest, which include “racial, ethnic, and
socioeconomic groups.” Research on disparities in longterm care is growing. Previous studies regarding racial
disparities in nursing home quality of care are largely
about the characteristics of the facilities, varied attitudes
regarding nursing home services, and racial minorities’
payment sources. Limited work has examined the
relative contribution of individuals and facility
characteristics to the quality of nursing home care. Thus,
the objective of this study is to examine whether there
are racial disparities (Black relative to White residents) in
nursing home quality of care, using three quality
measures, falls, daily use of restraints and hospital
admissions, and exploring the extent to which individual
and facility characteristics are associated with these
quality measures.
Study Design: A Nonlinear Mixed Model (Multilevel
Model) was employed to examine both facility level and
individual level characteristics’ influence on nursing
home quality of care.
Population Studied: This study used two components
(i.e. the current resident survey and the facility survey) of
the 2004 National Nursing Home Survey data. This
study includes nursing home residents age 50 and
above, and all residents are categorized into two groups
by race, including Black (n=1,258) and White residents
(n=11,249).
Principal Findings: Although individual race was
associated with increased use of restraints and
hospitalization descriptively, this was not significant in
the multivariate findings. After controlling for
confounders, relative to individuals in facilities without
any Blacks, those in facilities with a lower (=10.08%) or
higher (>10.08%) share of Black residents were
associated with greater odds of experiencing daily use of
restraints. Medicare as the payer at admission predicted
greater odds of poor quality. Being a resident in a facility
with 20-40% or 40-60% Medicaid patients, or facilities
with clusters of beds for Alzheimer’s was associated with
greater odds of experiencing restraints and
hospitalizations. Being a resident in a facility with a
higher number of RN FTEs solely devoted to bedside
care was associated with lower odds for restraints; being
a resident in a facility with a higher percentage of RNs
that served for more than a year was associated with a
lower odds for hospitalizations.
Conclusions: Racial concentration at the facility level
and not race at the individual level appears to be
associated with poorer quality of care. Facility staffing
and payment composition were also associated with
quality of care.
Implications for Policy, Delivery or Practice: To
enhance quality of care and to reduce health care
disparities, the federal and state governments could
collaborate on actions to improve nursing staff levels.
The association of poorer quality with a higher share of
Black residents at the facility level merits additional
research, as does the association of Medicaid at the
facility with poorer quality of care.
• Effect of the Nursing Home Compare Report Card:
The “Teaching to the Test” Strategy
Dana Mukamel, Ph.D.; William Spector, Ph.D.;
Jacqueline Zinn, Ph.D.; David Weimer, Ph.D.; Richard
Ahn, M.A.
Presented by: Dana Mukamel, Ph.D., Professor,
Medicine, Health Policy Research Institute, University of
California, Irvine, 100 Theory, Suite 110, Irvine, CA
92697-5800; Phone: (949) 824-8873; Email:
dmukamel@uci.edu
Research Objective: Nursing homes provide complex
services which can be dichotomized into two domains
based on the ability of consumers to assess their quality:
clinical and hotel type services. Empirical evidence
suggests that until the advent of the Nursing Home
Compare report card, which for the first time offered
consumers easily accessible information about clinical
quality, demand for nursing home care was primarily
driven by the quality of hotel services. The publication of
the report card has changed consumers’ ability to
assess clinical quality, placing it on par with hotel quality.
The objective of this study was to examine the
hypothesis that nursing homes responding to these
changes in demand have reallocated resources from
hotel to clinical activities, i.e. shifting resources from an
activity that is not monitored to an activity that is
monitored.
Study Design: This study was based on Medicare cost
reports augmented with MDS and OSCAR data.
Following a methodology developed in previous studies,
we used cost reports data to aggregate expenditures by
cost centers into expenditures associated with hotel and
clinical activities. The ratio of these by year served as
the dependent variable. The independent variable of
interest was a dichotomous variable indicating pre/post
publication period. Additional covariates included an
annual facility case mix index and proportion of Medicare
patients, both controlling for secular trends in patient
acuity and care burden, and fixed facility effects to
account for time invariant facility characteristics.
Inference was based on robust standard errors. The
analysis was performed for the full sample, and was
repeated for samples stratified by facility characteristics
hypothesized to present stronger incentives to shift
resources: poor reported quality, low occupancy,
location in highly competitive markets, for-profit
ownership and chain affiliation.
Population Studied: 10,022 free standing nursing
homes nationwide in the 2001-2006 period, which
includes both pre and post publication years.
Principal Findings: On average, the ratio of clinical to
hotel expenditures was 0.615. It increased by 14%
(p<0.001) following the publication of the report card. As
hypothesized, the increase was larger and more
significant among nursing homes with worse reported
quality, lower occupancy, located in more competitive
markets, for-profit ownership and owned by a chain. The
shift in resources was accomplished through infusion of
new funding: Inflation adjusted hotel expenditures per
day have remained constant during the period, while
case mix inflation adjusted clinical expenditures have
increased.
Conclusions: The increase in the ratio of clinical to
hotel expenditures following publication of the Nursing
Home Compare report card suggests that nursing
homes have responded as expected, adopting a
“teaching to the test” strategy and shifting resources
from unreported, hotel quality to reported, clinical quality
domains. The response was stronger among nursing
homes facing stronger incentives.
Implications for Policy, Delivery or Practice: This
study has two important implications. First, it suggests
that nursing homes have responded to the demand
incentives created by the public reporting of clinical
quality measures. Second, because the shift in
resources was funded with new monies, it suggests that
improvement in clinical quality was not achieved at the
expense of hotel quality.
Funding Source(s): NIA
• An End-of-Life Quality of Care Measure (QM) for
Nursing Homes Based on MDS and Medicare Claims
Data
Dana Mukamel, Ph.D.; Thomas Caprio, M.D.; Richard
Ahn, M.A.; Nan Tracy Zheng, B.S.; Helena TemkinGreener, Ph.D.
Presented by: Dana Mukamel, Ph.D., Professor,
Medicine, Health Policy Research Institute, University of
California, Irvine, 100 Theory, Suite 110, Irvine, CA
92697-5800; Phone: (949) 824-8873; Email:
dmukamel@uci.edu
Research Objective: The objective of this study was to
develop a quality measure (QM) that is relevant,
appropriate and specifically designed for assessment of
end-of-life care and which can be calculated from
administrative data available for all US nursing homes.
We developed a QM based on the risk adjusted
probability of death in the hospital, reflecting the
expectation that, when appropriate, residents are better
off if they are not transferred to the hospital to die.
Study Design: MDS health assessments, linked to
hospital, hospice and Medicare enrollment files were
analyzed to predict whether death of a nursing home
resident occurred in the hospital or not. The linked
datasets were used to create for each decedent a record
including their place of death (hospital or not), type of
care (long-term or post-acute) and risk factors present
during the 90 days prior to death. The initial set of risk
factors were chosen based on review of the literature
and judgment of the geriatricians as those likely to be
appropriate reasons for hospitalization prior to death. To
optimize the use of information, and because risk
information was not missing at random, we adopted
imputation techniques based on the individual’s history,
using prior assessments and clinical logic. Five logistic,
random effect models predicting death in the hospital
conditional on risk factors for each patient/imputation
type (e.g. long-term-care+ full information, long-termcare+PPS imputation) were estimated. These models
were estimated on a development dataset and then
reevaluated on a test dataset. The QM was calculated
as the difference between the actual rate of
hospitalization prior to death and the predicted rate
which was calculated from these logistic models by
averaging the predicted probabilities for all residents in
the nursing home given their risks. The distributional
characteristics of the QM were investigated.
Population Studied: The study included 2,526,289
decedents in 15,786 nursing homes during 2003-2007.
Principal Findings: 24.3% of decedents died in the
hospital. The final estimated models showed close
agreement between the development and the test
datasets and C statistic values ranged between 0.61 and
0.69. Risk factors included age, gender, do not
resuscitate and do not hospitalize orders, and specific
diseases. The average QM for 2006 was 0.020 and the
standard deviation was 0.163. The 10th percentile was
at -0.146 and the 90th at 0.228. Following the current
CMS practice in Nursing Home Compare of not reporting
QMs for nursing homes with a sample smaller than 30,
there were only 11,648 eligible facilities. However, the
distribution of the QM was similar.
Conclusions: It is feasible to calculate a QM which
reflects quality of end-of-life care in nursing homes using
currently available administrative datasets. This QM
meets validity criteria, and shows substantial cross
sectional variation to be informative about quality.
Implications for Policy, Delivery or Practice: The QM
we present is a prototype that could be used to expand
the current set of QMs in the Nursing Home Compare
web-based report card to include end-of-life care, a
domain that is an important component of the care
provided by nursing homes and which affects about one
third of nursing home residents.
Funding Source(s): NINR
• Relationship Between Quality of Care and
Litigation Risk in U.S. Nursing Homes
David Studdert, L.L.B., Sc.D., M.P.H.; David Stevenson,
Ph.D.; Matthew Spittal, Ph.D.
Presented by: David Studdert, L.L.B., Sc.D., M.P.H .,
Professor, Population Health, University of Melbourne,
207 Bouverie Street, Carlton, Australia 3053; Phone:
+61383440646; Email: d.studdert@unimelb.edu.au
Research Objective: In the early 2000s, malpractice
claims against nursing homes soared in many areas of
the US. The costs of liability insurance also spiked,
alarming policymakers and raising questions about
whether tort reforms widely used in the acute care sector
should be extended into long term care. Given limited
knowledge about this litigation, this study aimed to test
the relationship between nursing homes’ quality of care
and their litigation profile.
Study Design: Five of the nation’s largest nursing home
chains provided data on all negligence claims (n=3,754)
made against their facilities (n=1,468) between 1999 and
2006. These data were merged with Minimum Data Set
(MDS) Quality Indicators and On-line Survey,
Certification, and Reporting (OSCAR) data. The study
dataset was constructed at the level of nursing homecalendar quarters (“facility-quarters”). For each facility,
we merged the number of negligence claims pertaining
to each quarter (with timing based on alleged incident
dates) with several MDS and OSCAR quality measures
for the corresponding quarters. MDS measures are
available by quarter; the OSCAR measure assigned to
facility-quarters came from the last inspection date. A
binary variable indicating whether one or more claims
had alleged a negligent event in the facility-quarter was
regressed on 6 quality indicators from the MDS
(fractures, falls, weight loss, dehydration, pressure
ulcers, use of restraints), and 2 deficiency measures (all
deficiencies and serious deficiencies only, both relative
to the state average) and 2 staffing measures (nurses
per resident, nurse aides per resident) from the OSCAR
dataset. Each of these 10 predictors was examined in a
separate model. The models used population-averaged
generalized estimating equations for binary outcomes;
adjusted for case-mix, chain, year, and state; and
corrected for facility-level clustering.
Population Studied: 1,468 nursing homes in 48 states.
Principal Findings: The nursing homes experienced an
average of 1 claim every 2.3 years. Collectively, the
claims resulted in $660 million in indemnity payments.
Among the 6 MDS quality indicators examined, the rate
of pressure ulcers was associated with slightly higher
odds of litigation (OR=1.01, p<0.001); the rest had no
association. Deficiencies (OR=1.02, p<0.001) and
serious deficiencies (OR=1.04, p=0.002) were positively
associated with the odds of litigation. The number of
nurse aides per resident was negatively associated with
the odds of litigation (OR=0.49, p<0.001), but there was
no association with nurse staffing. Further analysis of
quality measures that had significant associations with
litigation risk (pressure ulcers, deficiencies, serious
deficiencies and nurse aide staffing) showed that the
risks of being sued were fractionally higher for lowperforming facilities compared to average-performing
facilities, but that the risks for high-performers and
average performers were the same.
Conclusions: Tort claims against nursing homes are
not random events, as some critics have asserted.
However, the relationship between quality and liability
risk is weak, and high performance confers no protective
advantage over average performance.
Implications for Policy, Delivery or Practice: The
liability system does not provide clear incentives for high
quality care in nursing homes. Reforms that promote that
better targeting of lawsuits may be warranted.
Funding Source(s): The Australian Research Council
(supports Professor Studdert and Dr. Spittal)
Predicting and Reducing Utilization among Patients
Chair: Amy Berman
Monday, June 28 * 3:00 pm–4:30 pm
• Increasing the Efficiency and Effectiveness of
Discharge Planning Services: A Tool to Identify
Early Those with Complex Needs and Problems after
Discharge
Diane Holland, Ph.D., R.N.; George Knafl, Ph.D.;
Kathryn Bowles, Ph.D., R.N., F.A.A.N.
Presented by: Diane Holland, Ph.D., R.N., Assistant
Professor, College of Medicine, Mayo Clinic, 200
Second Street SW (EIS SL-41), Rochester, MN 55905;
Phone: (507) 255-1036; Email:
holland.diane@mayo.edu
Research Objective: The Early Screen for Discharge
Planning (ESDP) is a discharge planning decision
support tool to identify patients on admission who need
discharge planning services during their hospital stay.
The objective of the study was to determine whether the
ESDP score identifies patients who will require
discharge planning specialist services, post acute
services, and experience more problems and unmet
needs in the first week after discharge.
Study Design: Prospective, correlational survey design
was utilized. The ESDP (independent variable) was
administered by staff nurses upon hospital admission to
adult patients. The ESDP consists of 4 items: selfreported walking limitation, age, living alone prior to
admission, and level of disability. Points attached to
responses are assigned and calculated. The dependent
variables of the number of consults to discharge
planners and number of referrals to formal post-hospital
services were obtained from medical record review.
Patients’ self-reported problems and unmet needs in the
first week following discharge were assessed via mailed
survey or phone interviews using the Problems After
Discharge Questionnaire (PADQ). The PADQ captures
total problems and unmet needs in each of 8 areas
(information, personal care, household activities,
mobility, using equipment, following
instructions/directions, physical complaints, and
psychological complaints. Data were analyzed using
proportional odds model (more than 2 outcome values)
or logistic regression (2 outcome values), controlling for
whether or not the subject received a comprehensive
discharge planning assessment during their hospital
stay.
Population Studied: A convenience sample of 260
cognitively intact adults who returned home in the
community were enrolled from 4 nursing units (2 general
medical and 2 general surgical) in a large Midwest
academic medical center. The sample was stratified
based on 2005 national estimates of age categories for
hospitalized adults.
Principal Findings: The response rate was 75%. The
195 responders had an average age of 55.7 (±20.2)
years. A little more than half were admitted for surgical
reasons (55.9%) and had at least some college
education (54.4%). The majority (95.9%) were white.
The average length of stay was 5.0 (±5.6) days. Nonresponders differed significantly from responders only in
education. Non-responders were less educated than
responders (p = .018). Significantly more patients with
high ESDP scores were referred to discharge planners
during their hospitalization (p=0.0004), were referred
more often for post-hospital services (p=0.024) and
reported more total problems (p=0.0048) and unmet
needs (p=0.028) than patients with low ESDP scores.
Patients with high ESDP scores experienced
significantly more problems in the areas of unmet
information needs (p=0.0294), mobility (p=0.0165),
personal care issues (0.0038), and household activities
(p=0.0024) one week after discharge.
Conclusions: The ESDP identifies patients with
complex discharge plans who should be prioritized for
early discharge planning services using information
readily available on admission.
Implications for Policy, Delivery or Practice: Use of
this discharge planning decision support tool increases
efficiency and effectiveness by engaging and allocating
discharge planning services in a timelier and more
appropriate manner.
Funding Source(s): NINR T32 Grant Number
NR009356 Individualized Care for At-Risk Older Adults
• Delivering High Quality Care for Patients with High
Severity and Comorbidity
Katherine Kahn, M.D.; John Adams, Ph.D.; Vivian Shih,
M.S.; Diana Tisnado, Ph.D.; Neil Wenger, M.D.
Presented by: Katherine Kahn, M.D., Professor,
Medicine, David Geffen School of Medicine at UCLA,
911 Broxton, Los Angeles, CA 90095-1736; Phone:
(310) 794-2287; Email: kkahn@mednet.ucla.edu
Research Objective: Real challenges exist for
delivering high quality care within available time and
budget to the expanding number of Americans who
survive chronic diseases and advancing age with
multimorbidity. On the other hand, sicker patients may
be advantaged if they are prioritized to receive more
visits and more care.
Study Design: Using an already validated set of explicit
process measures for which better process has been
shown to predict health related quality measured by
changes in SF-12 physical scores over 30 months, we
studied the relationship between burden of illness
(severity and comorbidity) and process for 963 patients
with: ischemic heart disease, diabetes mellitus, or
asthma/ COPD. Process and burden of illness were
assessed using clinically detailed medical record and
self report data. Bivariate analyses examined how
adherence to 120 evidence-based measures distributed
across six domains varied by disease severity and a
count of up to 12 comorbidities. Ordinary least squares
regression examined the relationship between
comorbidity count, severity and body mass index (BMI)
and adherence to processes after adjusting for
demographics (age, gender, race/ethnicity), and the
number of ambulatory visits and hospitalizations.
Population Studied: Patient self-report data as well as
clinically detailed medical record review regarding 963
patients with chronic disease associated with managed
care from three west coast states were studied.
Principal Findings: Among 120 explicit process
measures, greater severity and/or comorbidity
significantly predict more adherence to 52% and less
adherence to 2% of the 120 explicit measures (p<.05).
Results are consistent across diseases. After further
adjustment with age, gender, race/ethnicity, number of
ambulatory visits, and hospitalizations, more comorbidity
and severity remain as frequent significant predictors of
better processes of care (p<.0001 for both comorbidity
and severity). However, the pattern of significant
predictors of processes varied by domain. More
comorbidity significantly predicted better process for
cognitive skills (e.g., history taking and data gathering,
p=0.02), counseling (e.g., for diet, exercise, substance
abuse, p<.0001), and medication management (e.g.,
prescription of indicated medications, p=.0012). While
severity also significantly predicted better process for
cognitive skills (p<.0001) and medication management
(<.0001); more disease severity also predicts physical
exam scores (p<.0001). High BMI predicts better
counseling scores. Neither severity, nor comorbidity
predicts procedure process scores.
Conclusions: More burden of illness is associated with
better measured processes of care. Despite concern that
comorbidities and severity of illness will detract from
patients receiving needed care, we observe more
comorbidity and more severity are associated with better
care across diseases and domains of care.
Implications for Policy, Delivery or Practice: The
delivery of poor processes to chronically ill patients
whose disease severity and comorbidity have not yet
advanced to be easily recognized, represents a missed
opportunity to improve their outcomes, just as it does for
patients who have already developed severe disease
and comorbidities. Recognizing the importance of
burden of illness as a predictor of process should
stimulate a focus within health care reform on staffing
and structures that can best support the delivery of high
quality care for patients across the spectrum of burden
of illness.
Funding Source(s): AHRQ
• Cost and Utilization Effects of Hospital-Based
Palliative Care Consultation
Joan Penrod, Ph.D.; Partha Deb, Ph.D.; R. Sean
Morrison, M.D.; Cornelia Dellenbaugh, M.P.H.; James
Burgess, Jr., Ph.D.; Carol Luhrs, M.D.
Presented by: Joan Penrod, Ph.D., Research Health
Scientist, James J. Peters VAMC, 130 West Kingsbridge
Road, Bronx, NY 10468; Phone: (718) 584-9000; Email:
joan.penrod@mssm.edu
Research Objective: Palliative care (PC) consultation
teams are prevalent in hospitals. PC consultation
improves the quality of hospital care but its effect on
costs for patients with advanced disease is unclear. The
objective of this study was to evaluate the relationship
between PC consultation and hospital costs in patients
with advanced disease.
Study Design: We conducted an observational,
retrospective cost analysis using a VA (payer)
perspective to examine costs and ICU use of PC versus
usual care for patients in five Veterans Affairs (VA)
medical centers over a two year period. We obtained
administrative and clinical data from the Veterans Health
Administration (VHA) national database. We measured
direct costs of hospital care from VA cost databases.
The key independent variable was a binary indicator for
whether the hospitalization included a palliative care
consultation. We controlled for the primary disease, age,
race/ethnicity, principal admitting diagnosis, hospital
death, comorbidities, economic status, length of stay,
and site. We employed an instrumental variable
approach to control for unmeasured characteristics that
affect both treatment and outcome. The analyses
included gamma instrumental variable regressions to
estimate treatment effects on costs and a bivariate probit
model to estimate treatment effects on the probability of
ICU use.
Population Studied: The sample included 3321
veterans hospitalized between October 1, 2004 and
September 30, 2006 with advanced disease, including
metastatic solid tumor, central nervous system (CNS)
malignancies, metastatic melanoma, locally advanced
head and neck cancer, locally advanced pancreatic
cancer, HIV/AIDS with at least one the following
secondary diagnoses: hepatoma, cirrhosis, lymphoma,
cachexia or other cancer, congestive heart failure (CHF)
or chronic obstructive pulmonary disease (COPD) and
either two or more hospitalizations in any six months of
the study period or one or more ICU admissions for CHF
or COPD.
Principal Findings: The average daily total direct
hospital costs were $464 a day lower for the 606
patients receiving palliative compared to the 2715
receiving usual care (p<0.001). Palliative care patients
were 43.7 percentage points less likely to be admitted to
ICU during hospitalization compared to usual care
patients (p<0.001).
Conclusions: PC consultation for patients hospitalized
with advanced disease results in lower hospital costs
and less utilization of intensive care compared to similar
patients receiving usual care. Selection on unobserved
characteristics plays an important role in the
determination of costs of care. PC consultation during an
inpatient stay for advanced disease influences costs, in
part, through the focus of palliative care teams on
meeting with patients and/or families to establish goals
of care and treatments that are concordant with the
goals, including lower intensity treatments.
Implications for Policy, Delivery or Practice: This
study adds to prior research on the benefits of PC
consultation by showing that palliative care is associated
with substantial reductions in hospital costs of patients
with serious, life-limiting illness, a growing proportion of
admissions. Effective palliative care during
hospitalization is associated with a judicious use of
inpatient resources, particularly for the ICU. Our findings
coupled with those indicating better patient and family
outcomes with PC suggest both a cost and quality
incentive for hospitals to develop and expand PC
programs.
Funding Source(s): VA
• Understanding and Identifying Target Populations
for Integrated Care
Walter Wodchis, Ph.D.; Ximena Camacho, M.Sc.; Irfan
Dhalla, M.D., M.Sc.; Elizabeth Lin, Ph.D.; Astrid
Guttman, M.D., M.Sc.; Geoff Anderson, M.D., Ph.D.
Presented by: Walter Wodchis, Ph.D., Associate
Professor, Health Policy Management and Evaluation,
University of Toronto, 155 College Street, Suite 425,
Toronto, M6J3G4, Canada; Email:
walter.wodchis@utoronto.ca
Research Objective: Populations with high health
utilization rates who move from one sector of the health
care system to another, particularly following acute
hospitalizations, may represent opportunities to improve
quality and reduce the burden and costs on the health
care system. Successful interventions to improve
transitions between care providers have demonstrated
effectiveness in targeted populations at specific study
sites (e.g. Mary Naylor and Eric Coleman). This study
examines the population prevalence of similar
populations, the risk factors for additional acute care use
and the effect of rapid post-acute follow-up by
community-based providers.
Study Design: Retrospective Cohort Analysis
Population Studied: This study used population health
administrative databases from Ontario, Canada that
include nearly all health care contacts for Ontarians.
Seeking to replicate target populations for proven care
transition interventions this study selected individuals
who were admitted to acute care between April 1, 2006
and March 31, 2007 with a diagnosis among those
reported in published care transition intervention
randomized controlled trials. In addition, we limited the
study to adults over the age of 65 and included patients
with two or more ambulatory care sensitive conditions
(ACSC). We followed patients’ health care utilization for
365 days after their acute care discharge. We measured
several patient characteristics, emergency (ED) and
inpatient (IP) readmission in 30 and 90 days and total
system utilization and costs (visit-specific costs based on
resource-intensity weights and provincial expenditure
data). We used regression analyses to examine the
association between patient characteristics and postacute follow-up care on ED visits and IP readmissions
that occurred between 7 days post-acute discharge and
30 and 90 days.
Principal Findings: A total of 39,978 individuals met the
study criteria. IP readmission rates were 13% and 22%
in 30 and 90 days respectively while ED visits in the
same intervals were 23% and 38% respectively. These
rates were highest among patients with ACSC. Among
patients discharged home and readmitted to acute care
after 7 days, the total number of medications, prior (30
day) acute hospitalization and risk-scores were positively
associated with risks of ED visits and IP readmissions in
any subsequent period during the first 90 days following
acute care discharge. A new drug prescription during
hospitalization was associated primarily with earlier ED
and IP use. Follow up visits by home care nurses within
1 day (AOR=-.70) and visits to a primary care physician
(AOR=0.85) within one week following acute care
discharge were strongly protective against additional
acute care and very consistent across all observation
periods.
Conclusions: Medication use is an important predictor
of additional acute (IP and ED) utilization within 90 days
of discharge among target populations while rapid home
care and primary care visits are strongly protective
against additional acute hospital care.
Implications for Policy, Delivery or Practice: The total
annual cost to the province for this cohort was $1.4
Billion or just over 3% of the total healthcare budget.
Providing policies that effectively encourage medication
reconciliation and rapid community care follow-up (as
prescribed by proven interventions) are likely to lead to
reductions in additional high cost acute care.
Funding Source(s): Ontario Ministry of Health and Long
Term Care
Providers, Patients, and Families: Effects of
Perspectives, Interactions, and Communications on
Engagement
Chair: Lauren McCormack
Monday, June 28 * 3:00 pm–4:30 pm
• Assessing Cultural Perspectives on Health Care
Quality
Ann Bagchi, Ph.D.; Raquel af Ursin, M.B.A.; Alicia
Leonard, B.A.
Presented by: Ann Bagchi, Ph.D., Senior Health
Researcher, Health, Mathematica Policy Research, 600
Alexander Park, Princeton, NJ 08540; Phone: (609)
716-4554; Email: abagchi@mathematica-mpr.com
Research Objective: The Consumer Assessment of
Healthcare Providers and Systems (CAHPS®) surveys
have become a cornerstone for evaluations of health
care quality across health plans and settings. However,
CAHPS® and other quality surveys were developed
through research with native-born populations
representative of persons from mid- to upper-level
socioeconomic status. Despite adaptations to improve
the cultural competency of these surveys, it is unclear
how well they address the needs and preferences of
members of racial and ethnic minority groups. This study
examined whether cultural differences exist in the
concept of health care quality and how such differences
could affect consumer engagement in care and health
care decision making.
Study Design: We conducted eight 90-minute focus
groups that were divided into two 45-minute segments.
In Segment 1, we showed a video depicting a health
care encounter between a white, male physician and an
elderly, Asian (non-Indian), female patient. We used the
same video (“A Somatic Complaint,” from Kaiser
Permanente’s Cultural Issues in the Clinical Setting
video series) for each group in order to ensure that all
participants viewed exactly the same encounter.
Participants were asked to rate the quality of care
depicted in the video based on questions adapted from
CAHPS® and other health quality surveys. In Segment
2, the focus group moderator led a more general
discussion with the participants regarding how they think
about quality in health care.
Population Studied: We conducted two focus groups
each with adults (ages 18 or older) from the following
four racial/ethnic groups: whites, African Americans,
Latinos, and Asian Indians. To ensure consistency in
research methods across groups, the study recruited
only English-speaking participants.
Principal Findings: The following concepts were
identified across all four ethnic groups as the most
significant components of quality in health care
encounters: waiting times, patient-provider
communication, a doctor’s technical skills, and a doctor’s
respect for patients. However, there were variations in
how participants conceptualized these terms. For
example, African Americans said that in communicating
with patients, physicians should take time to show
familiarity with the patient and his or her family during
medical encounters, whereas Indians were more likely to
say that physicians should be evaluated on their
technical skills rather than their bedside manners. In all
of the focus groups with African Americans, Latinos, and
Asian Indians, participants speculated that cultural
barriers between the physician and patient in the video
negatively affected their ability to communicate; white
respondents said that cultural differences had nothing to
do with what they also judged to be poor communication.
Conclusions: Conceptions of factors that affect health
care quality vary across racial and ethnic groups.
Existing quality surveys do not adequately capture the
factors considered important to members of minority
groups.
Implications for Policy, Delivery or Practice: The
results of this study suggest that concepts such as
language access, health literacy, and discrimination
affect the ratings of health care quality by members of
racial and ethnic minority groups. Enhancing trust and
respect between patients and providers by addressing
these differences can improve communication and lead
to greater consumer engagement in care.
Funding Source(s): RWJF
• Consumer Engagement and the Provider
Encounter
Grant Martsolf, R.N., M.P.H., Ph.D. Candidate
Presented by: Grant Martsolf, R.N., M.P.H., Ph.D.
Candidate, Graduate Student, Health Policy and
Administration, Penn State University, 501A Ford
Building, University Park, PA 16802; Phone: (814) 4820792; Email: grm153@psu.edu
Research Objective: “Consumer engagement” has
become an important tool for improving care of patients
with chronic disease. There is no consensus, however,
regarding the types of interventions that might contribute
to improving consumer engagement across a range of
behavioral areas. One approach has focused on
promoting community-level consumer engagement
through chronic disease education campaigns, social
marketing, and/or user-friendly public reports of
physician quality. Other interventions, however, have
focused on changing the culture of physician practice
and orient physician encounters toward promoting
engagement among their patients. There has been,
however, a paucity of studies testing the relationship
between characteristics of the day-to-day provider
encounter and the full range of consumer engagement
behaviors using large-scale, generalizable data of
patients with chronic disease.
Study Design: We conceptualize engagement as the
performance of behaviors from four different domains:
healthy behaviors, self-management behaviors, medical
encounter behaviors, and consumeristic behaviors.
Using logistic regression, we estimate the crosssectional association between 12 behaviors (drawn from
each of these 4 behavioral domains) and the quality and
content of the provider encounter including ‘patientcenteredness’, self-management teaching, and wellness
teaching.
Population Studied: The population for this paper
includes a nationally-representative sample 8,079
individuals with chronic disease. This sample was drawn
for a large consumer survey administered as part of the
evaluation of the Robert Wood Johnson Foundation’s
Aligning Forces for Quality (AF4Q) project.
Principal Findings: Individuals who reported that their
physician provided self-management teaching were
more likely to be involved in asking questions during
their visit, maintain a low fat diet, read food labels,
exercise, regularly measure blood pressure and blood
sugar and be compliant with their medications. Patients
who reported that their physician offered wellness
teaching were more likely to ask questions during their
visit, maintain a low fat diet, read food labels, exercise,
and regularly check their blood pressure. Patients whose
physician scored highly on the ‘patient-centeredness’
measure were more likely to ask questions during the
visit and be medication compliant.
Conclusions: The quality and content of the provider
encounter were significantly associated with a number
and variety of ‘consumer engagement’ behaviors.
Implications for Policy, Delivery or Practice: Although
many engagement interventions are organized at the
community-level or through mass media (ie. internet), it
is important remember that the physician practice
remains a key leverage point in promoting engagement
among individuals with chronic disease. Scholars and
practitioners interested in promoting consumer
engagement would be well served by working with
clinical practices to create within them a culture of
support and, also, knitting self-management and
wellness teaching into the fabric of office visits.
Funding Source(s): RWJF
• Assessing the Impact of Increasing Physician Use
of Patient-Centered Communication on Patient
Satisfaction
Matthew Testa-Wojteczko, B.A.; Charles Phelps, Ph.D.;
Peter Veazie, Ph.D.; Ronald Epstein, M.D.
Presented by: Matthew Testa-Wojteczko, B.A.,
Doctoral Candidate, Community and Preventive
Medicine, University of Rochester, 601 Elmwood, Box
644, Rochester, NY 14642; Phone: (585) 275-9496;
Email: matthew_testawojteczko@urmc.rochester.edu
Research Objective: The purpose of this study was to
ascertain whether the increasing emphasis on patientcentered communication (PCC) within the medical
literature is becoming more prevalent within
contemporary doctor-patient interactions, as assessed
by the patients themselves. Among other features, PCC
urges physicians to engage with their patients via open,
honest dialogue and therapeutic partnering in medical
decision making, thus encouraging patients’ to take an
active, engaged role in their own medical care.
Study Design: Many of the theorized benefits of PCC
follow from the presumptively greater level of patient
satisfaction provided by PCC than by the more didactic
approach that was formerly the norm in physician
communication training. Because PCC-style
communication has only recently appeared within
medical training curricula, we hypothesized that more
recent medical school graduates were more likely to use
such approaches in their medical practice than less
recent graduates. We thus expected to find higher levels
of patient satisfaction along certain key communication
dimensions among patients who see more recently
graduated physicians. There could be a selection effect
among patients with a longstanding relationship with
their physicians; such patients may be satisfied with their
physicians irrespective of physician use of PCC. This
project addressed this by controlling for length of the
doctor-patient relationship. We used physician and
patient survey data from previous work to assess length
of the doctor-patient relationship, years out of medical
school at study inception, and satisfaction measures
culled from a general patient satisfaction survey and the
American Board of Internal Medicine patient satisfaction
survey. Each satisfaction variable was a five-level Likert.
The effect of recentness of graduation was determined
via ordered logistic regression, controlling for length in
years of doctor-patient relationship.
Population Studied: This project employed data from
the Assessment of Doctor-Elderly Patient Transactions
(ADEPT) study, a multisite study in which primary care
physicians and their patients aged 65+ years were
surveyed and their interactions videotaped to assess
qualitative aspects of physician-elderly patient
relationships. We used the ADEPT survey data
previously mentioned, resulting in ~400 interactions
across ~35 physicians, with ~10 patients per physician.
Principal Findings: Controlling for length of physicianpatient relationship, physician graduation year
significantly influenced patients’ perceptions of
physicians’ tendencies towards “letting you tell your
story; listening carefully; asking thoughtful questions; not
interrupting while you’re talking” (p<.001), “discussing
options with you; asking your opinion” (p<.003) and
“telling you during the physical about what s/he is going
to do and why; telling you what s/he finds” (p<.011), and
on “how do you rate Dr. ____ on showing interest in you
as a person” (p<.018).
Conclusions: The recentness of physicians’ medical
training seems to influence the degree to which they
employ certain elements of PCC, as measured by
patients’ satisfaction levels. Yet many factors underlie
patients’ satisfaction with physicians. Also, recentness of
physicians’ graduations may capture more than scope of
training. These are preliminary findings which warrant
further investigation.
Implications for Policy, Delivery or Practice: Because
the PCC-oriented patient satisfaction measures
employed in this study were plausibly influenced by
shifts in medical training, this work suggests medical
curriculum design as a relevant vector for policy
intervention.
Funding Source(s): University of Rochester
Department of Community and Preventive Medicine
• Regional Cultures and Health Outcomes:
Implications for Consumer Engagement
Jackson Williams, M.P.A., J.D.
Presented by: Jackson Williams, M.P.A., J.D., Health
Care Administration, University of Maryland, UM,
College Park, MD 20782; Email: jwilli28@hotmail.com
Research Objective: What explains variations in
avoidable hospitalizations and medication compliance
observed at the population level? Is it economic
incentives or immutable cultural characteristics of the
population? If it is largely the latter, could policy
interventions such as wellness incentives for patients or
shared savings for providers lead to inequitable
outcomes or unintended consequences? Do indicators
such as Hofstede Cultural Dimension scores, used in
studies of organizational behavior, offer insights for
health services research and policymakers?
Study Design: Health outcome measures (medication
compliance, obesity, ambulatory care-sensitive hospital
admissions, readmissions) regressed on cultural
characteristics data from US General Social Survey and
World Values Survey exploring cultural variations on two
dimensions (Traditional/Secular-Rational Values and
Social Capital). In terms of theory, the study design
applies political science constructs—e.g., Inglehart's
Traditional/ Secular-rational dimension of culture,
Putnam's social capital dimension of culture-- to models
of social and behavioral theory in public health (culturalEdberg, individual- Heckman).
Population Studied: 12 industrialized nations; 50 US
States
Principal Findings: Cultural characteristics, quantifiable
through aggregated survey data, appear to better
explain medication compliance in 12 industrialized
nations and success in avoiding hospitalizations for
chronic conditions and readmissions in the US than do
economic variables. Regional variation in healthy
behaviors probably reflects differing norms prevailing in
different cultures relating to risk aversion and time
preference (long-term vs. short-term orientation).
Conclusions: Policy or insurance design interventions
that stress consumer responsibilities for “desirable
behaviors” apply cognitive tools to decisionmaking
affected by non-cognitive thought processes. While risktaking is deemed an undesirable trait in health
behaviors, it is considered a laudable trait in
encouraging entrepreneurship or enlistment in an allvolunteer military. Inasmuch as there appear to be
widely diverse views about risk-taking and time
preference among different regional subcultures, it is not
clear that a “failure of rationality” underlies variation.
Arnold Schwarzenegger’s health reform proposal may
have been telling when it described its wellness
incentive provisions as encouraging a “California
lifestyle”—and one perhaps not appropriate to impose in
other regions.
Implications for Policy, Delivery or Practice:
Policymakers assume the purpose of health care is to
improve long-term health but many Americans may feel
its purpose is providing immediate “rescue.” Two policy
interventions that engage patients in improving long term
health outcomes are wellness incentives and awarding
"shared savings" to physicians for better health
outcomes achieved through patient engagement in
chronic illness care. Wellness incentives at the national
level challenge federalism because they may disrespect
local preferences yet have nationwide fiscal
consequences. Congress would expand shared savings
pioneered by the PGP demo to voluntary Accountable
Care Organizations and Medical Homes. However,
different cultural predispositions to healthy behaviors
may make shared savings a better bet for physicians in
some regions than in others. Indeed, viewing the
locations of PGP demo sites on Lieske's US regional
subculture map and the Ezzoni-Murray US mortality map
suggests that physicians already intuitively sense which
populations can more easily produce shared savings.
Voluntary chronic care programs are unlikely to attract
physician participation uniformly across the US.
• Family Presence in Routine Physician Visits and
the Patient-Physician Relationship: A Review and
Synthesis of the Literature
Jennifer Wolff, Ph.D.; Debra Roter, Dr.PH.
Presented by: Jennifer Wolff, Ph.D., Associate
Professor, Health Policy and Management, Johns
Hopkins University, 624 North Broadway, Baltimore, MD
21205-1996; Phone: (410) 502-0458; Email:
jwolff@jhsph.edu
Research Objective: Older adults are commonly
accompanied to routine physician visits, primarily by
adult children and spouses. The objective of this study is
to describe the dynamics and consequences of patient
accompaniment and to develop a framework to articulate
the pathways by which patient-family-physician
exchanges relate to patient self management and quality
of care outcomes.
Study Design: We conducted a comprehensive review
and synthesis of the literature describing patient
accompaniment to routine physician visits. Meta-analytic
techniques were used to summarize study results,
including attributes of unaccompanied and accompanied
patients and their companions, medical visit processes,
and patient outcomes.
Population Studied: Two types of evidence were
examined: (1) observational studies of audio and/or
videotaped triadic physician visits (n=9 studies; 1,047
patients) and (2) surveys of patients, families, and/or
physicians (n=7 studies; 15,240 patients) to ascertain
experiences, expectations, and preferences for family
companion presence and behaviors in routine physician
visits.
Principal Findings: The weighted mean rate of
accompaniment to routine adult physician visits was
37.2% in 12 contributing studies. Accompanied patients
were on average 70 years of age, and were significantly
older and more likely to be female, less educated, and in
worse physical and mental health than unaccompanied
patients (all contrasts p<0.0001). Companions were on
average 63 years of age, predominantly female (79.4%),
and spouses (54.7%) or adult children (32.2%) of
patients. Accompanied patient visits were significantly
longer (r=0.19; p<0.0001; n=6 contributing studies), but
verbal contribution to medical dialogue was comparable
when accompanied patients and family companion were
compared with unaccompanied patients (r=0.02; p=0.36;
n=3 studies). Physicians engaged in more biomedical
information giving when a companion was present
(r=0.17; p=0.005; n=3 studies). Patient self management
and quality of care outcomes were favorable for
accompanied relative to unaccompanied patients
(r=0.09; p<0.0001; n=5 studies) and accompanied
patients whose family companion were more (versus
less) verbally active (r=0.15; p<0.0001; n=3 studies).
Based on study results, an elaborated quality of care
framework was developed to relate the mechanisms by
which the presence and behaviors of a family companion
during physician visits influences interpersonal rapport,
information giving, and decision-making, as well as
patient self management and health care outcomes.
Conclusions: This study establishes that family
companions are commonly present in adults’ routine
physician encounters and that they tend to accompany
patients who are older, less educated, and who have
more extensive physical and mental health needs than
patients who are unaccompanied. The presence of a
companion was found to have a bearing for both
communication processes and consequences of care.
Implications for Policy, Delivery or Practice: The
generally favorable effect associated with patient
accompaniment suggests practical benefits might be
achieved from more systematic recognition and
integration of companions in chronic care delivery
processes. Results from this study in concert with the
conceptual framework that is presented suggest several
directions for interventions aimed at optimizing family
involvement in routine physician visits – in terms of
facilitating information exchange to enhance patient and
provider understanding, prompting patient involvement in
decision-making, and in regard to quality of care metrics
such as adherence, safety, and efficiency.
Funding Source(s): NIMH
Qualitative Studies on Disparities
Chair: Keith Elder
Monday, June 28 * 3:00 pm–4:30 pm
• Patient-Provider Relationships among South Asian
Breast Cancer Survivors
Neetu Chawla, M.P.H.; Beth Glenn, Ph.D.; Roshan
Bastani, Ph.D.
Presented by: Neetu Chawla, M.P.H., Research
Associate; Doctoral Candidate, Health Services, UCLA,
650 Charles Young Drive South, A2-125 CHS, Box
956900, Los Angeles, CA 90095; Phone: (310) 8257430; Email: nchawla@ucla.edu
Research Objective: Breast cancer is the most
commonly diagnosed cancer among South Asian
women and is the leading cause of cancer-related
mortality among this population. Very limited research
has been conducted on breast cancer treatment
experiences within this group, particularly with respect to
the patient-provider relationships. Therefore, this
preliminary study seeks to understand the importance of
relationships between South Asian breast cancer
survivors and their cancer providers.
Study Design: As part of an ongoing study, a total of 30
semi-structured, in-depth interviews are being conducted
among South Asian breast cancer survivors in California.
Study participants are being recruited using a number of
strategies, including flyers posted at community venues
(e.g. temples, mosques, grocery stores), word-of-mouth,
and in-person recruitment at community events (e.g.
festivals, health fairs). All interviews are being conducted
in English and in-person by an interviewer trained
according to protocol outlined by the UCLA Institutional
Review Board. With participant permission, interviews
are audiotaped for later transcription. On average,
interviews last between 60 and 90 minutes. Preliminary
results from qualitative interviews with 15 South Asian
breast cancer survivors were examined for emergent
themes within the domain of patient-provider
relationships. Themes were identified by analysis of
frequency and intensity. The majority of the 15 women
were diagnosed within the past 5 years, first-time
survivors, and originally from India. The average age of
women was 51 years.
Population Studied: South Asian women ages 18 and
older with a prior diagnosis of breast cancer residing in
the state of California.
Principal Findings: Several key themes emerged in the
preliminary analysis, including the importance of
communication and trust with providers, availability of
time with providers, and the concordance of patient and
provider gender. In addition, many women described the
importance of receiving culturally-tailored information,
including culturally-specific diet and exercise
recommendations and the use of complementary and
alternative medical practices to alleviate side effects of
treatment. Several women, particularly those from higher
socioeconomic backgrounds, felt that providers involved
them in decision-making as much as they desired.
However, other women described feeling rushed and
having inadequate information to make important
treatment decisions, such as whether to pursue
lumpectomies or mastectomies.An additional theme that
emerged from these data was that many women from
higher socioeconomic backgrounds had spouses or
family relatives who were physicians that provided
additional information to them throughout the process of
their breast cancer treatment. Therefore, physicians
residing in the social networks of survivors played a
supplementary role in providing cancer-related
information and assisting with treatment decisions for
this population.
Conclusions: South Asian women described the
importance of culturally-tailored approaches to cancer
care and certain provider characteristics (i.e. gender,
trust, communication) in describing their relationships
with their cancer providers. Physicians within the social
networks of breast cancer survivors also provided
important sources of cancer-related information.
Implications for Policy, Delivery or Practice: Cancer
providers should make efforts to provide culturally
relevant services to South Asian women, provide the
appropriate amount of information, and adequately
involve them in treatment decision-making.
Funding Source(s): NCI
• The NIH Diversity Mandate: How Clinic Culture
Undermines Minority Inclusion in Cancer Trials
Daniel Dohan, Ph.D.; Galen Joseph, Ph.D.
Presented by: Daniel Dohan, Ph.D., Associate
Professor, Philip R. Lee Institute for Health Policy
Studies, UC San Francisco, 3333 California Street Suite
265, San Francisco, CA 94118; Phone: (415) 476-0751;
Email: daniel.dohan@ucsf.edu
Research Objective: The NIH Revitalization Act of 1993
mandates outreach and inclusion of ethnic/racial
minorities in clinical research including cancer clinical
trials. Since the Act’s passage, there has not been a
substantial increase in minority participation in cancer
trials. We examined the role of clinic culture
(organizational and professional) in trials enrollment
processes to try to shed light on why the Act has not
more substantially re-shaped patterns of cancer clinical
trials enrollment.
Study Design: Multi-site comparative ethnography
using participant-observation and in-depth interview data
to document how organizational and professional culture
shapes trials enrollment processes. We identified a priori
and emergent themes to examine three explanations
proposed for the Act’s lack of impact: weak enforcement,
uneven support among clinician-researchers, and
barriers to participation among minority patients.
Population Studied: Nine outpatient oncology clinics in
3 distinct settings in Northern California: private practice
(2 clinics), academic medicine (4 clinics), and public
safety-net (3 clinics).
Principal Findings: The clinics we studied lacked a
robust system for recruiting diverse patients to trials, e.g.
clinician-leaders who encouraged and supported
recruitment, information systems to track recruitment,
and culturally-tailored resources. Strengths and
weaknesses varied by site. Private practice had neither
clinician-leaders nor information systems in place – a
reflection of the lack of Act enforcement – but a wellsupported and diverse research staff provided culturallytailored resources. The academic clinics faced pressure
to comply with the Act and implemented basic
information systems to do so. However, clinicians did not
prioritize minority recruitment, and few culturally-tailored
resources were available. In the safety net, some clinic
leaders championed minority recruitment, but many
clinicians resisted it. Culturally-tailored resources were
available to support clinical care but only reluctantly
extended to research, and there were no information
systems.
Conclusions: We found evidence that all three factors –
weak enforcement, uneven support among clinicians,
and a failure to address patient-side barriers – impeded
the establishment of a successful program for minority
recruitment. Clinician support appeared a central
weakness. Clinicians’ reasons for not supporting minority
recruitment varied in the three settings we studied, but
lack of clinician support was the only factor that limited
recruitment in all our research sites. Lack of clinician
support hampered recruitment even when the Act was
enforced (academic center) and resources were devoted
to address patient-side barriers (private practice and the
safety net).
Implications for Policy, Delivery or Practice: Despite
attempts at enforcement and to address patient barriers
to enrollment, the NIH Act has had little impact on the
composition of individuals enrolled on cancer trials. Our
study suggests that increasing clinician-researcher
support for the Act may be needed. Strict enforcement of
the Act and an improved infrastructure for tracking
results might motivate clinician-researchers to pay more
attention to the diversity of the patients they recruit to
trials. Educational interventions could bolster clinicians’
appreciation and support for of minority recruitment.
Without improving clinicians’ commitment to the Act’s
goal of increased diversity, however, addressing patientside barriers to participation in cancer trials may provoke
little change in actual enrollment.
Funding Source(s): American Cancer Society
• Collection of Race, Ethnicity, and Primary
Language Data: Awareness and Perspectives of
Hospital CEOs, Leaders and Staff
Romana Hasnain-Wynia, Ph.D.; Sunitha Mutha, M.D.;
Sarah Rittner, M.A.; Elizabeth Jacobs, M.D.,M.P.P.; Amy
Wilson-Stronks, M.P.P.
Presented by: Romana Hasnain-Wynia, Ph.D.,
Director, Center for Healthcare Equity, Institute for
Healthcare Studies, Northwestern University, Feinberg
School of Medicine, 750 North Lake Shore Drive 10th
Floor, Chicato, IL 60611; Phone: (312) 503-5509;
Email: r-hasnainwynia@northwestern.edu
Research Objective: Disparities in quality of care
remain a challenge in the US. Addressing disparities in
hospitals requires leaders and staff to be aware of the
problem. Previous work has shown that hospital leaders
often do not believe disparities exist within their
institutions, though they rarely have data to support this
perception. Collecting accurate demographic data is
essential for raising awareness of disparities,
documenting where problems exist, implementing
targeted interventions and demonstrating improvement.
We examine hospital CEOs, leaders, and staff’s
awareness and perspectives of systematic collection and
use of demographic data as part of a national study,
“Hospitals, Language, and Culture: A Snapshot of the
Nation,” conducted by The Joint Commission
Study Design: Cross sectional qualitative study using
face-to-face semi-structured interviews and a 26 item
pre-site visit survey
Population Studied: Interviews were conducted with
hospital CEOs, senior leaders (chief quality officer, chief
medical officer) and cultural and linguistic (C&L) services
department personnel in 60 US hospitals. Surveys were
completed by a knowledgeable staff member from each
hospital.
Principal Findings: In the pre-site visit survey, 82% of
hospitals reported collecting race and or ethnicity data,
85% reported collecting primary language data and 42%
reported collecting all three . During key informant
interviews, only 7.5% of hospital CEOs, 5.3% of senior
leaders, and 23.3% of C&L personnel stated that
race/ethnicity data were collected at their hospital.
Fifteen percent of CEOs, 28.1% of senior leaders and
68.3% of C&L personnel stated that patient’s primary
language data were collected. None of the CEOs
responded their hospital routinely collect all three
compared with 3% of senior leaders and 8% of staff.
Based on qualitative analysis, we identified that data
were used to: 1) identify problems with existing services,
2) determine the need for new or expanded services, 3)
evaluate the effectiveness of services or care, or 4) learn
more about specific populations. Notably, demographic
data were rarely used to assess quality or reduce
disparities. We use quotes to provide additional context
for discrepancies in awareness and perceptions of data
collection.
Conclusions: Awareness of race, ethnicity, and
language data collection varies across hospital staff with
CEOs and other leaders being less aware than
personnel from cultural and linguistic services
departments. There is a substantial discrepancy in
awareness of data collection between pre-site visit
surveys and interviews which may be due to more
knowledge of the individual who completed the
survey.Our prior national survey found that over 80% of
hospitals report collecting race/ethnicity and language
data, which corresponds with the pre-site visit survey
results. Yet our interview data suggest this percentage is
either misleadingly high or that leadership and staff
remain relatively unaware of their hospital’s data
collection practices.
Implications for Policy, Delivery or Practice: It is
important to raise the awareness of hospital leaders and
staff about the importance of systematic race, ethnicity,
and primary language data collection. Awareness affects
knowledge which, in turn, can shape a hospital’s
priorities and policies. . Leaders are pivotal in setting
priorities. They need to be aware and engaged in order
to move their organizations to improve quality and
reduce disparities.
Funding Source(s): The California Endowment
• Board Engagement with Quality and Disparities in
Care at Minority-Serving U.S. hospitals
Ashish Jha, M.D., M.P.H.; Arnold Epstein, M.D., M.A.
Presented by: Ashish Jha, M.D., M.P.H., Associate
Professor, Health Policy and Management, Harvard
School of Public Health, 677 Huntington Avenue,
Boston, MA 02115; Phone: (617) 432-5551; Email:
ajha@hsph.harvard.edu
Research Objective: Reducing racial disparities is an
important policy goal but we have relatively few proven
solutions to affect this change. Increasingly,
policymakers have focused on the leadership of
healthcare organizations, especially boards of directors,
as levers to improve quality of care. Given that a large
proportion of black patients receive care in a small
number of hospitals, understanding how boards of these
organizations engage in quality of care would be very
helpful. Yet, we know nothing about these boards’
engagement with quality and whether they see quality of
care as a priority.
Study Design: We identified U.S. minority-serving
hospitals (those in the top decile of proportion of elderly
black patients). We surveyed all of minority-serving
hospital board chairpersons and a national sample of
chairpersons from other hospitals (those in the second
through tenth decile of proportion of black patients, i.e.
non-minority-serving).
Population Studied: Chairpersons of boards of acutecare U.S. hospitals.
Principal Findings: Of the 922 chairpersons
(representing 1,000 acute-care hospitals) surveyed, 312
oversaw hospitals designated as “minority-serving” while
610 oversaw “non-minority-serving” hospitals. We
received responses from 79% of minority-serving
hospitals and 78% of non-minority-serving hospitals.
Board chairpersons from minority-serving hospitals were
less likely to report that they: have moderate or
substantial expertise in quality of care (68% versus 79%,
p=0.04); have a formal training program for their board
that covers quality (26% versus 36%, p=0.07); and rate
quality of care as one of the top two priorities for board
oversight (48% versus 57%, p=0.09) or CEO
performance evaluation (40% versus 50%, p=0.05).
Board chairpersons from minority-serving hospitals were
also less likely to report that quality of care was on the
agenda at every meeting (60% versus 68%, p=0.13) and
were substantially less likely to report reviewing
dashboards with quality information on a regular basis
(66% versus 81%, p<0.001) compared to non-minorityserving hospitals. Finally, while the majority of board
chairpersons agreed with the statement that disparities
in care existed broadly among U.S. hospitals, only 14%
of those from minority-serving hospitals (and 8% of nonminority-serving hospitals) agreed with the notion that
disparities exist at their institution. However, only 9% of
all board chairpersons reported that they examined
quality data stratified by race and 6% examined patient
satisfaction data by race. Results were unchanged when
adjusted for location (urban vs rural), teaching status,
and size.
Conclusions: Chairpersons of boards of minorityserving hospitals are less likely to be familiar with,
receive training in, or prioritize quality of care than
chairpersons of boards of non-minority-serving hospitals.
Most chairpersons did not believe that disparities were a
problem at their institution, although they generally did
not examine quality or satisfaction data by race.
Implications for Policy, Delivery or Practice: The low
levels of engagement with and knowledge about quality
of care issues among board chairpersons of minorityserving hospitals suggest that Boards may be an
important target to improve the care and outcomes of
minorities and non-minorities who receive hospital care
at these institutions.
Funding Source(s): Rx Foundation and the Hauser
Center for non-profit governance at Harvard University
• Disparities in Cardiac Rehabilitation Use: Exploring
the Reasons for Minorities’ Underutilization
Hannah Katch, Ph.D., Holly Mead, Ph.D.
Presented by: Hannah Katch, Ph.D., Assistant
Research Professor, School of Public Health & Health
Services, Department of Health Policy, George
Washington University Medical Center, 2121 K Street,
NW, Suite 200, Washington, DC 20037; Phone: (202)
994-8615; Email: khmead@gwu.edu
Research Objective: Despite the clear benefits of
cardiac rehabilitation (CR) as a secondary prevention
program, CR is greatly underused with less than 30
percent of eligible patients participating in a CR program.
Minority patients are even less likely to be referred to
CR, and often do not use these programs when they are
referred. This study has two principal objectives: 1) to
explore the underlying reasons for underuse of CR in
black and Hispanic patients by identifying and examining
barriers that may contribute to lower referral and uptake
rates and 2) to identify how provider- and system-level
factors either impede or support CR use in this patient
population.
Study Design: We performed a qualitative study
consisting of eight focus groups and eight one-on-one
interviews with a total of 61 minority patients to explore
reasons for not using available CR programs. We also
conducted one-on-one interviews with 18 providers to
look at provider- and system-level barriers to CR referral.
Patients and providers were recruited from three health
systems with high volumes of cardiac patients, racially
and ethnically diverse patient populations and
established CR programs. We used NVivo qualitative
software to perform thematic content analysis of the
focus groups and interviews.
Population Studied: Focus group participants and
interviewees were low-income black and Hispanic
patients who had experienced at least one of six CRqualifying cardiac events as specified by AHA. Providers
who participated in the study were cardiologists, CR
directors and CR staff of the participating health
systems.
Principal Findings: We grouped the most frequently
discussed patient barriers to CR use into four major
categories: 1) limits on insurance coverage; 2)
insufficient support and information from physicians,
including the absence of referrals; 3) underestimation of
the need for CR; and 4) anxiety around exertion after a
cardiac event. We also identified four provider- and
system-level barriers to referrals: 1) lack of consistent
referral practices despite clinical practice guidelines; 2)
physician stereotyping and subjectivity based on patient
characteristics that influence referral decisions; 3)
financial disincentives to referral; and 4) physicians
undervaluing the benefits of CR.
Conclusions: We identified a number of patient-level
barriers that suggest why low-income minority patients in
our study do not use CR services. Many of these
obstacles are embedded in the system, including access
barriers and lack of referrals. Others can be attributed to
lack of education and support from physicians. The
provider-level findings support the patient findings, but
more clearly identify the clinical, procedural and financial
dynamics that may lead to patient barriers and underuse
of CR by low-income, minorities.
Implications for Policy, Delivery or Practice: Results
from the study have identified factors in the delivery of
care where changes can be made to increase referral to
and uptake of CR services. Most significantly, the
reinforcement of evidence-based referral guidelines
accompanied by rigorous performance measurement
could result in more consistent referral practices that
reduce subjectivity. In addition, this work informs the
debate around payment reform, suggesting that a
bundled episode-of-care model could reduce financial
disincentives that lead to providers not referring patients
who would benefit from CR.
Funding Source(s): Pfizer Foundation Fellowship in
Health Disparities
Vulnerable Populations in Medicare
Chair: Stuart Guterman
Monday, June 28 * 3:00 pm–4:30 pm
• Medicare Prospective Payment and the Volume and
Intensity of Skilled Nursing Facility Services
David Grabowski, Ph.D.; Christopher Afendulis, Ph.D.;
Thomas McGuire, Ph.D.
Presented by: David Grabowski, Ph.D., Associate
Professor, Harvard Medical School, Health Care Policy,
180 Longwood Avenue, Boston, MA 02115; Phone:
(617) 432-3369; Email: grabowski@med.harvard.edu
Research Objective: In 1998, Medicare adopted a per
diem Prospective Payment System (PPS) for skilled
nursing facility (SNF) care, which was intended to deter
the use of high-cost SNF rehabilitative services. The
average SNF per diem decreased under the PPS, but
because payments were constructed on a per diem
basis with increasing payment for greater therapy
minutes, the ability of the PPS to deter the use of highintensity services was questionable. In this study, we
present evidence on how the PPS affected the volume
and intensity of SNF Medicare services.
Study Design: We employ both “differences-indifferences” and “differences-in-differences-indifferences” approaches to examining the implications of
the adoption of the SNF PPS for Medicare volume and
intensity of services. We assess the reliability of our
basic inferences in several ways including an
examination of contemporaneous data for non-Medicare
residents who were not directly affected by these policy
changes and facilities with staggered implementation of
the SNF PPS.
Population Studied: Our evaluations are based on both
national facility-level data from the Online Survey
Certification and Reporting (OSCAR) system and
resident-level data from New York State the Minimum
Data Set (MDS).
Principal Findings: Using multiple identification
strategies, our analyses suggest that the SNF PPS led
to a short-term decrease in the volume of Medicare SNF
patients, but an increase in the intensity of Medicare
patients admitted to SNFs. There was little effect of the
SNF PPS on length-of-stay. When subsequent Medicare
policy changes increased the generosity of SNF
payment, we found that the volume of SNF patients
returned to pre-PPS levels. When taken together, our
volume and intensity results suggest that SNF PPS did
little to curb the rate of growth of SNF expenditures.
Conclusions: Our results indicate that Medicare volume
decreased under PPS, but rehabilitative services and
therapy minutes increased while length-of-stay remained
relatively constant. Not surprisingly, when subsequent
Medicare policy changes increased payment rates,
Medicare volume far surpassed the levels seen in the
pre-PPS period.
Implications for Policy, Delivery or Practice: Although
the PPS is termed a prospective system, there are
several aspects of the system that still resemble a costbased system. The one-time decrease in expenditures
under the PPS shifted costs on to a lower trajectory,
saving billions of dollars over the last decade. However,
other than the one-time cost decline, the PPS did little to
bend the cost curve downwards. Moving forward, if
policymakers want to limit inefficient SNF service use
and curb Medicare SNF payment growth, further
payment reform will be necessary.
Funding Source(s): NIA
• Potentially Avoidable Hospitalizations among
Medicare Home Health and Skilled Nursing Patients
Ann Meadow, Sc.D.; Judy Sangl, Sc.D.; William Ross,
Ph.D.
Presented by: Judy Sangl, Sc.D., Health Scientist
Administrator, Center for Patient Safety and Quality
Improvement, Agency for Healthcare Research and
Quality, 540 Gaither Road, 3rd Floor, Rockville, MD
20850; Phone: (301) 427-1308; Email: jsangl@ahrq.gov
Research Objective: Hospital admissions are common
for many Medicare beneficiaries after they enter home
health care or a skilled nursing stay. Some
hospitalizations may be preventable with better clinician
care and monitoring available in these settings. We
measured and tracked over a six-year period potentially
avoidable hospitalizations, as a possible quality
indicator, and compared that outcome with total
hospitalizations.
Study Design: AHRQ’s Prevention Quality Indicators
flag as potentially preventable selected acute stays
using principal diagnoses, procedure codes, and
condition-specific exclusion criteria. In this observational
study, we used Medicare claims to measure PQI
hospitalizations and all-cause hospitalizations for 30
days from each patient’s earliest home health or nursing
facility admission within each year.
Population Studied: 100% of Medicare FFS HH and
SNF users.
Principal Findings: PQI rates were similar for patients
who received HH and SNF services--below 5%--though
the time trends differed. The PQI rate in HH fell from
4.7% to 3.9% during 2001 - 2006 (trend p< .0001). PQI
admissions accounted for a decreasing proportion of
total hospitalizations, reaching 26% by 2006. PQI
declines in HH were statistically significant for individual
racial/ethnic groups, except for Asians (p=.1673). The
PQI rate in SNFs increased from 3.9% to 4.7% during
2000 - 2005 (trend p<.0001). PQI admissions accounted
for a fairly constant proportion of total admissions, about
31%. All racial/ethnic subgroups participated similarly in
these uptrends, except for North American Natives
(p=.1923). Cross-sectional comparisons showed certain
minority groups--non-Hispanic Blacks and Hispanics in
SNF--were at excess risk of PQI events, while others
had relatively low risk, particularly Asians receiving HH.
For both settings, males had at least a 20% higher risk
of a PQI hospital stay than females. In HH, PQI and total
hospitalizations varied little by age. In SNFs, PQI
hospitalizations increased (p<.0001) while all-cause
hospitalizations decreased (p<.0001) with age. Our HH
data included Medicare program eligibility. ESRD
beneficiaries had PQI and all-cause hospitalization risk
twice as high as other eligibility categories (p<.0001).
Additionally, the aged ESRD subgroup experienced
unchanging PQI outcomes (trend p=.0528) and a 13%
increase in all-cause hospitalizations during the six years
(trend p<.0001). A prior PQI acute care stay (up to 30
days before first day of HH/SNF admission) strongly
raised the risk of subsequent PQI events in both settings
(HH OR=2.9, p<.0001; SNF OR=2.1, p<.0001).
Conclusions: PQI hospitalizations are a surprising
fraction of total hospitalizations in the two settings.
Variation by race/ethnicity suggests healthcare quality
disparities may exist in nursing home settings. Agerelated increases marked SNF PQI rates as well.
Implications for Policy, Delivery or Practice: In SNFs,
the high PQI fractions suggest that stemming the
worsening hospitalization rates may be aided by
focusing efforts on patients with conditions especially
sensitive to clinician care and monitoring. This is
particularly true for subgroups at highest risk, the oldest
old and those with a prior PQI stay. Even though PQI
rates are on the decline in HH, they still account for onequarter of hospitalizations. As in SNFs, focusing on highrisk subgroups, such as patients with a prior PQI stay
and ESRD beneficiaries, may prove especially fruitful in
reducing hospitalization rates.
• Drug Utilization Patterns for Diabetics Enrolled in
Part D Plans: Does the Low Income Subsidy Matter?
Bruce Stuart, Ph.D.; Amy Davidoff, Ph.D.; Xianghua Yin,
M.D.; Linda Simoni-Wastila, B.S.P., Ph.D.; Jalpa Doshi,
Ph.D.
Presented by: Bruce Stuart, Ph.D., Professor, Peter
Lamy Center on Drug Therapy and Aging, University of
Maryland Baltimore, 202 Arch Street, Baltimore, MD
21201; Phone: (410) 706-5389; Email:
bstuart@rx.umaryland.edu
Research Objective: Our objective is to determine
whether the Part D low income subsidy (LIS) influenced
use and adherence with medications commonly
prescribed to Medicare beneficiaries with diabetes in
2006. We had 2 counter hypotheses: (1) that utilization
and adherence with antidiabetic drugs, ACE-inhibitors
and ARBs, and antihyperlipidemic drugs might be lower
among LIS enrollees because of their lower
socioeconomic status and higher disease burden, and
(2) that utilization might be higher among LIS recipients
because they face much lower cost sharing compared to
those in standard Part D prescription drug plans (PDPs).
Study Design: We tested these hypotheses using 2006
data from the Medicare Chronic Condition Warehouse
random 5% sample of PDP enrollees diagnosed with
diabetes. We constructed 2 subsamples, one with and
the other without LIS benefits based on administrative
records. We then compared the 2 groups on 3 drug
utilization measures: (1) any use of medications within
each of the three drug classes, (2) duration of therapy
(DOT) during the year, (3) medication possession ratio
(MPR) within the DOT episode. Because the two groups
had markedly different characteristics, we used a
propensity score (PS) algorithm to identify matched pairs
with similar age, sex, race, region, diabetes severity,
comorbidities, and utilization of selected Medicare
services.
Population Studied: The study sample comprised
151,460 diabetics continuously enrolled in Medicare Part
A, Part B, and Part D PDP plans for the entire year.
Two-thirds received LIS benefits (N=100,502), and the
remaining one-third (N=50,958) did not. Exact matches
to five decimal points on the estimated PS generated
analytic samples of 20,478 each with very similar
characteristics.
Principal Findings: The unadjusted LIS sample had
much larger concentrations of beneficiaries receiving
SSDI (35.2% versus 10.5%), blacks (23.3% versus
5.9%), and females (69.0% versus 60.5%). In
unadjusted comparisons, a larger percentage of LIS
enrollees used anti-diabetic agents (71.6% versus
68.9%), but fewer used ACE-inhibitors/ABRs (64.2%
versus 65.9%) and antihyperlipidemics (58.4% versus
64.2); p<.001 in each case. The 2 groups had similar
unadjusted DOT values for antidiabetic drugs (293 days
for LIS enrollees versus 296 days for non-LIS enrollees),
ACE-inhibitors/ARBs (286 versus 284 days), and
antihyperlipidemics (271 versus 277 days). Mean MPR
values clustered between 0.87 and 0.91 for all 3 drug
classes with no important distinctions between the LIS
and non-LIS groups. After PS adjustment, the
proportions using drugs in each class slightly favored
beneficiaries without LIS, but the magnitude of the
differences were small (1% for antidiabetic drugs, 4% for
ACE-inhibitors/ARBs, and 2% for antihyperlipidemics),
and there were no meaningful differences in DOT and
MPR values between the 2 groups.
Conclusions: Medicare beneficiaries with diabetes
enrolled in PDP plans in 2006 had similar patterns of
drug use and adherence whether enrolled in LIS or not.
Implications for Policy, Delivery or Practice: There
was no support for the hypothesis that LIS beneficiaries
with diabetes were disadvantaged by their lower
socioeconomic status and higher disease burden. By the
same token, we found no support for the hypothesis that
lower cost sharing conditionally increases drug use and
adherence in this population.
Funding Source(s): CWF
• Comparing Post-Acute Care Outcomes in Elderly
Trauma Patients
Lok Wong, M.H.S.; Judy Kasper, Ph.D.
Presented by: Lok Wong, M.H.S., Doctoral Candidate,
Health Policy & Management, Johns Hopkins Bloomberg
School of Public Health, MD Phone: (202) 210-3332;
Email: lokwong@jhsph.edu
Research Objective: Post-acute care services play an
increasingly important role in the recovery and long-term
outcomes of elderly patients who are at risk for
functional limitations and disability after a traumatic
injury such as a fall or car accident. However few studies
have compared outcomes of elderly trauma patients
from institutional and community-based post-acute care
settings. The purpose of this study is to evaluate the
effectiveness of post-acute care among elderly patients
with hospitalized for a traumatic injury. We assessed the
impact of four post-acute care settings - inpatient
rehabilitation facilities (IRF), skilled nursing facilities
(SNF), home health and outpatient rehabilitation on
patients' functional and quality of life outcomes.
Study Design: A pre-post quasi-experimental study
design was used to compare outcomes of elderly trauma
patients discharged to four PAC settings (IRF, SNF,
Home Health and Outpatient Rehabilitation) after the
initial hospitalization. Patient outcomes were evaluated
at 3 and 12 months including death, hospital readmissions, physical and mental health (SF-36),
Activities and Instrumental Activities of Daily Living (ADL
and IADL), neighborhood mobility, and nursing home
admission by 12 months. Pre-injury health and function,
and prior living arrangement were assessed in the
patient survey. We employed two-stage regression
equations to model the selection of post-acute care, then
model the effect of post-acute care on outcomes. To
adjust for severity and case-mix differences, we first
identified propensity-score matched samples. Propensity
score models included patient variables for age, gender,
race/ethnicity, comorbidities (Charlson), injury severity
and type, coma status, trauma complications, pre-injury
health status and function, living arrangements, length of
hospital and ICU stay, as well as hospital characteristics
– hospital ownership type, size, trauma center, teaching
hospital, ownership of IRF, and county-level data availability of IRF and SNF beds in a county. We then
conducted logistic regression on the propensity-score
matched samples to estimate differences in outcomes
between settings.
Population Studied: This study used data collected
from the National Study of Costs and Outcomes of
Trauma (NSCOT) – a national study of a sample of
trauma and non-trauma hospitals in US metropolitan
areas. This analysis examined 1048 elderly patients
ages 65-84 years hospitalized with moderate-severe
trauma (excluding hip fractures) in 2001 and 2002 who
were discharged alive to a post-acute care setting. Study
data included hospital charts, Medicare claims, patient
surveys and county-level information from the Area
Resource File.
Principal Findings: We will present effect estimates
comparing differences in outcomes between elderly
trauma patients discharged to institutional vs.
community-based post-acute care.
Conclusions: This study identifies which post-acute
care settings have better short and long-term functional
outcomes, and reduce the risk of nursing home
admission.
Implications for Policy, Delivery or Practice: The
study findings will be of interest to Medicare policymakers, hospital discharge planners as well as postacute care providers to identifypost-acute care settings
that improve seniors' long-term function and minimize
loss of independence. Most studies of post-acute care to
date have only examined 30-day hospital readmissions
or short-term outcomes. This study will help patients,
families and providers to select post-acute care services.
Funding Source(s): AHRQ
Comparative Effectiveness Research: Perspectives
and Policy Applications
Chair: Sally Stearns
Monday, June 28 * 4:45 pm–6:15 pm
• Health Care Innovations in an Era of Comparative
Effectiveness Research
Emily Carrier, M.D., M.S.; Eugene Rich, M.D.; Hoangmai
Pham, M.D., M.P.H.
Presented by: Emily Carrier, M.D., M.S., Senior Health
Researcher, Center for Studying Health System Change,
600 Maryland Avenue SW, Suite 550, Washington, DC
20024; Phone: (202) 250-3533; Email:
ecarrier@hschange.org
Research Objective: To examine policy options in the
implementation of comparative effectiveness research
(CER) that would best support development of desirable
innovations in health care services and processes.
Study Design: Qualitative interviews of key informants
obtained through a series of structured round-table
discussions. Major themes were distilled and coded
through consensus among four researchers.
Population Studied: Respondents were selected from
the following groups: experts in health economics, patent
policy, medical decision-making, and international
models of CER; venture capitalists; manufacturers of
pharmaceuticals, biologics and devices; clinicians who
develop innovative procedures, biomedical researchers
(including those studying rare diseases and pediatric
illness); representatives of clinical research networks;
public and private insurers, regulators, and consumer
advocates (including those for underserved populations).
Principal Findings: We will discuss how the
expectation of a comparative effectiveness evaluation
could affect decisions regarding investments and
product development, and how innovators produce initial
evidence of efficacy. We will present the advantages and
disadvantages of alternatives in the design of a CER
program that could affect different types of clinical
innovations. These design features include: the different
roles of funding the research costs of CE evaluations on
innovations among innovators, insurers, the central CER
entity and/or agencies in HHS; as well as options for
who selects specific CER research questions relevant to
innovations, study methods and outcome measures. We
will also assess the implications of different approaches
to financing the costs of the innovation (therapy or care
process) itself during CE evaluations. Finally, we will
discuss the relative strengths of different approaches
ensuring equitable access for patients to CER
participation and to the innovation itself, considering the
role of disease registries and research networks,
clinician and patient incentives for CER participation,
potential effects of CER on producers’ pricing policies,
and the implications for insurers’ coverage decisions.
We will highlight how the impact and implications of CER
for innovations may differ in the US from the experience
of other countries.
Conclusions: Widespread adoption of CE analysis in
the U.S. could dramatically change the way innovative
health care interventions are developed, marketed, and
adopted. However, the details of how CER is funded and
implemented will determine its ultimate impact.
Implications for Policy, Delivery or Practice: The
American Recovery and Reinvestment Act (ARRA) has
budgeted $1.1 bn for the development of CER, and
health reform legislation passed by both houses of
Congress call for the creation of a CER authority to
commission and coordinate research. Widespread
provider utilization of comparative effectiveness research
to guide treatment decisions could significantly alter the
marketplace for pharmaceuticals, devices and other
innovations, and could change manufacturers’
calculations with respect to investing in research and
new product development. This, in turn, could potentially
shape future treatment options available to patients. This
study will inform the many key decisions in CER
implementation not directly addressed by current
legislation that could shape future innovation in
pharmaceutical, device, and biologic markets, as well as
new care processes.
Funding Source(s): National Institute for Health Care
Reform
• The Impact of the Newly Proposed United Network
for Organ Sharing Simultaneous Liver Kidney
Transplantation Policy on Post-Transplant Survival:
A Comparative Effectiveness Analysis
Yaojen Chang, Dr.PH.; Anton Skaro, M.D., Ph.D.;
Colleen Jay, M.D.; Larry Manheim, Ph.D.
Presented by: Yaojen Chang, Dr.PH., Postdoctoral
fellow, Institute for Healthcare Studies, Northwestern
University, 750 North Lakeshore Drive 10th Floor,
Chicago, IL 60611; Phone: (312) 503-5568; Email: ychang@northwestern.edu
Research Objective: Currently, United Network for
Organ Sharing (UNOS) policy does not include listing
requirements for simultaneous liver kidney transplant
(SLK) candidates. There is great variation amongst
transplant centers regarding the indication for performing
SLK transplant. The transplant community has raised
concerns related to increasing numbers of SLK
transplants and their impact on the available pool of
grafts. This study aims to estimate incremental gain/loss
in survival of SLK transplant recipients under
implementation of the proposed UNOS SLK transplant
policy, in comparison with survival of SLK transplant
recipients based on liberal SLK utilization practices.
Study Design: The Markov decision model was
constructed to simulate a hypothetical cohort of patients
with end-stage liver disease with concomitant renal
insufficiency. Each candidate in the model underwent
one of the following transplant strategies: (1) liberal
utilization of SLK transplant and (2) the proposed UNOS
SLK transplant policy. According to the UNOS SLK
transplant policy, only liver transplant candidates
meeting strict criteria which are consistent with
unrecoverable kidney function would receive SLK
transplant. Liver transplant candidates not satisfying
these criteria with potentially recoverable kidney function
would undergo liver transplant alone (LTA). In the model,
the LTA and SLK transplant recipients who do not
recover kidney function within the first 3 post-transplant
months were then placed on the kidney transplant
waiting list. Chronic liver failure and chronic kidney
failure could occur post-transplant in either (SLK/LTA)
strategy. Liver re-transplant and kidney re-transplant
were included in the model for acute and chronic graft
failure post-transplant. The simulation period was 10
years. Survival of candidates in each transplant strategy
was estimated by running 10,000 microsimulation trials.
The values and ranges of parameters in the model are
based on UNOS and Scientific Registry of Transplant
Recipients (SRTR) data and published literature.
Principal Findings: The model demonstrates an
average survival for SLK transplant recipients of 66.8
months and 64.1 months under the liberal utilization
strategy and the proposed UNOS policy, respectively.
The incremental loss in survival for SLK transplant
recipients was 2.7 months with the implementation of the
proposed UNOS policy. The sensitivity analysis varying
the probability of SLK reveals an incremental loss of
survival for SLK transplant recipients of 7.3 months, 4.3
months, and 2.4 months where the probability of SLK
was 0.1, 0.4, and 0.7, respectively.
Conclusions: Implementation of the proposed UNOS
SLK transplant policy would cause a decrease in survival
for liver transplant candidates with concomitant renal
insufficiency.
Implications for Policy, Delivery or Practice: Under
the proposed UNOS SLK transplant policy, only SLK
candidates who meet rigorous listing requirements can
receive SLK transplant. Consequently, the number of
SLK transplants will decrease, but the number of
available kidney grafts for patients on the kidney waitlist
will increase. The UNOS SLK transplant policy will be
successful if life-years saved from kidney transplant
recipients due to more available kidney grafts are
greater than life-years lost from liver transplant recipients
due to fewer SLK transplants.
Funding Source(s): NIDRR grant number
H133P080006
• Will Reducing Variation in Hospitalization Bend the
Medicare Cost Curve? If So, Where Do We Start?
Julie Donohue, Ph.D.; Walter Linde-Zwirble, M.S.; Mark
Roberts, M.D., M.P.P.; Amber Barnato, M.D., M.P.H.;
Derek Angus, M.D., M.P.H.
Presented by: Julie Donohue, Ph.D., Assistant
Professor, Health Policy and Management, University of
Pittsburgh, 130 DeSoto Street, Crabtree Hall A613,
Pittsburgh, PA 15261; Phone: (412) 624-4562; Email:
jdonohue@pitt.edu
Research Objective: Regional variation in inpatient
treatment intensity and spending in Medicare is offered
as a primary indicator of inefficiency in US healthcare.
Variation is due in part to inadequate evidence on what
works best for preventing and treating disease, a
problem comparative effectiveness research is meant to
address. Reducing variation can only lead to reductions
in health care costs, however, if comparative
effectiveness research is targeted at conditions that are
both costly and variable. Our objectives were to (1)
characterize variation in Medicare hospitalization rates
across hospital regions, (2) identify high cost/high
variability conditions as potential targets for comparative
effectiveness research funding, and (3) estimate the
magnitude of reductions in variation in hospitalization
rates necessary to address Medicare’s financing
problems.
Study Design: We conducted a retrospective, crosssectional analysis of variation in hospital admission rates
by base-diagnosis-related group (DRG) (standardized by
age, sex and race) and Medicare costs for beneficiaries
65 and older in 2007. After excluding DRGs with too few
cases to permit comparison across hospital referral
regions (HRRs) our analytical sample included 240 base
DRGs accounting for 9.3 million hospital admissions and
$96 billion in Medicare costs. We divided HRRs into
quintiles based on the standardized hospitalization rate
for each DRG. We then identified as “high impact” those
DRGs above median in both relative hospitalization rates
and costs. We estimated admissions and expenditures
averted from reducing variation for our “high impact
DRGs” and compared those estimates to projected
shortfalls between revenues and expenditures in the
Medicare Hospital Insurance Trust Fund.
Population Studied: Medicare population age 65 and
older with a hospital admission in 2007.
Principal Findings: In 2007, the median cost per baseDRG was $152 million and ranged from $6.5 million to
$5.2 billion. The median relative rate of hospitalization in
the top compared to the bottom quintile of HRRs was 3.3
and ranged from 2.2 to 9.6. We identified 55 DRGs with
higher than median costs and higher than median
relative hospitalization rates. These 55 “high impact”
DRGs were equally divided between medical and
surgical DRGs, and accounted for 30.6% of all hospital
admissions and 37.1% of inpatient costs. Reducing
variation in hospitalization rates for the 55 high impact
DRGs by having each of the top 4 quintiles adopt the
hospitalization rate in the next lowest quintile would
result in 808,000 fewer admissions (a 28% reduction for
these DRGs) and would lower Medicare costs by $8
billion.
Conclusions: Medicare hospitalization rates are highly
variable at the DRG-level. Many of the highest cost
DRGs also have a high degree of variation in the rate of
hospitalization across hospital referral regions. These
high cost/high variability DRGs are good potential
targets for comparative effectiveness research.
Implications for Policy, Delivery or Practice: Were
policy makers to target high impact conditions for
comparative effectiveness research substantial savings
could be achieved but only through significant reductions
in the rate of hospital admission. Given that it may take
several years to generate and disseminate information
on comparative effectiveness, this approach to reducing
variation is unlikely to reduce Medicare cost growth in
the short run.
Funding Source(s): AHRQ, NIH
• Physician Views on the Use of Comparative
Effectiveness Research
Salomeh Keyhani, M.D., M.P.H.; Alex Federman, M.D.,
M.P.H.
Presented by: Salomeh Keyhani, M.D., M.P.H.,
Assistant Professor, Health Policy, Mount Sinai School
of Medicine/James J. Peters Bronx VAMC, 1 Gustave L.
Levy Place, New York, NY 10128; Email:
salomeh.keyhani@mountsinai.org
Research Objective: Comparative effectiveness
research has been promoted as a vehicle to improve
health care quality and decrease costs. However, there
is no provision in current health care reform legislation to
use this information to establish guidelines that govern
physician practice in part because of the concern that
this research could be used to ration care and restrict
physician practice. Physician support for comparative
effectiveness research will play an important role in how
this research is used and implemented; however, their
views have never been elicited. We conducted a national
physician survey and examined physician’s views on the
use and importance of data generated from comparative
effectiveness research.
Study Design: We conducted a national, mailed survey
of physicians between June and October, 2009 to
assess physicians’ views on healthcare reform. Survey
content was developed through expert consensus and
questions were refined through cognitive interviews with
16 physicians from multiple specialties and practice
backgrounds. Four items were developed to address
comparative effectiveness research: 1) “National
guidelines should be developed to guide physician
practice”; 2) “If national guidelines are established,
comparative effectiveness data should be used in their
development” 3) “Comparative effectiveness data will be
used to restrict my freedom to choose treatments for my
patients” and 4) “The availability of comparative
effectiveness data would improve the quality of care
provided to patients”. We calculated the response rate
using standard methods. To assess potential nonresponse bias, we compared the characteristics of
respondents and non-respondents using data available
in the AMA Master file. Agreement with the four
statements was measured on a 5-point Likert scale
ranging from strongly agrees to strongly disagree. We
report the percentage of physicians that agree with each
statement. We also examine differences in agreement
with the four items by specialty using chi square
statistics.
Population Studied: From the American Medical
Association Physician Masterfile, we randomly selected
equal numbers of physicians within four groups:
generalists (585), medical specialists (620), surgeons
(618), and other specialties (593). Physicians in training
and from U.S. territories were excluded from the
analysis.
Principal Findings: The response rate was 50.8%.
Survey respondents were slightly older than nonrespondents (52.0 vs. 50.4 years, p<.001). There were
no significant differences by gender, geographic
location, specialty category, or type of practice. More
than half ( 57.2%) of physicians believed that national
guidelines should be developed to guide physician
practice and 77% of physicians believed that
comparative effectiveness data should be used in the
development of these guidelines. Almost two thirds
(65.5%) of physicians agreed with the statement that
comparative effectiveness data will be used to restrict
physician practice. At the same time, over half of
physicians (55.5%) believed that this data will improved
the quality of care provided to patients and only 16%
disagreed with this statement. There were no statistically
significant differences across specialties across these
four items. A majority of generalists (56.8%), medical
subspecialists (56.9%), surgical subspecialists (52.3%)
and other specialists (55.1%) (p=0.47) agreed that this
data can be used to improve the quality of care.
Conclusions: A majority of physicians support the
establishment of national guidelines and support the use
of comparative effectiveness research in the
development of these guidelines. Furthermore, while
physicians believe that this data can be used to limit
their autonomy, they also recognize that comparative
effectiveness data can improve the quality of care
delivered to patients.
Implications for Policy, Delivery or Practice: Even
though current legislation does not include provisions for
guideline establishment from comparative effectiveness
research and restricts its use for Medicare coverage
decisions, there appears to be majority support among
physicians for the establishment of guidelines using this
data. This support will play an important role in ensuring
that comparative effectiveness research can live up to its
promise of improving the quality of care and reducing
costs.
Funding Source(s): RWJF
Key Issues in the Delivery of Substance Abuse
Services
Chair: Tami Mark
Monday, June 28 * 4:45 pm–6:15 pm
• Changes in Addressing Tobacco Use by U.S.
Physicians at Ambulatory Visits, 2005-2007
Asaf Bitton, M.D.; Nancy Rigotti, M.D.; Alan Zaslavsky,
Ph.D.; John Ayanian, M.D., M.P.P.
Presented by: Asaf Bitton, M.D., Clinical and Research
Fellow, Department of Health Care Policy; Division of
General Medicine, Harvard Medical School and Brigham
and Women's Hospital, 180 Longwood Avenue, Boston,
MA 02115; Phone: 617 432 1134; Email:
abitton@partners.org
Research Objective: Tobacco use is the leading U.S.
cause of preventable death, and most tobacco users see
a physician each year. Previous studies suggested that
ambulatory physicians’ rates of addressing tobacco use
plateaued as of 2003. Given mounting evidence that
brief tobacco counseling effectively increases cessation,
and the introduction of a widely marketed new smoking
cessation medication in 2006, we hypothesized that
rates of identifying and counseling tobacco users would
increase over time.
Study Design: The main outcomes for this retrospective
cross-sectional analysis were the proportion of visits in
which tobacco use was ascertained, and the proportion
of visits in which a smoker was counseled on tobacco
use. We compared these unadjusted outcomes on a
yearly and pooled basis with chi square tests, and used
logistic regression models to adjust for age, sex, race,
region, insurance type, physician type (primary care,
specialist), visit type (acute, chronic, preventive), and
patient type (seen in past year, seen >1 year prior, new).
The analysis adjusted for complex survey design using
SUDAAN software.
Population Studied: We analyzed all ambulatory visits
by adults age 18 and older during 2005-2007 in the
National Ambulatory Medical Care Survey (NAMCS), a
nationally representative cross-sectional survey of visits
to U.S. office-based physicians.
Principal Findings: Among 87,835 ambulatory visits
during 2005-2007, the proportion in which patients were
asked about tobacco use dropped from 66.9% in 2005 to
58.7% in 2007 (P=0.004), and counseling for tobacco
users decreased from 25.2% in 2005 to 19.3% of visits
in 2007 (P=0.046). In fully adjusted analyses, physicians
were significantly less likely to report asking about
tobacco use at patient visits in 2007 than in 2005
(Adjusted Odds Ratio (AOR) 0.71; 95% CI 0.57, 0.89).
Counseling rates for tobacco users dropped during the
same time period but not significantly so (AOR 0.71;
95% CI 0.49, 1.01). Men were less likely than women to
be asked about tobacco use (AOR 0.92; 95% CI 0.86,
0.99) but tobacco user counseling rates did not differ
(AOR 1.07, 95% CI 0.92, 1.25). Relative to patients age
35-64 years, those age 18-34 were more likely to be
asked (AOR 1.12; 95% CI 1.02, 1.23) but less likely to
be counseled (AOR 0.77; 95% CI 0.62, 0.94). Primary
care physicians were more likely than specialists to ask
about tobacco use at visits (AOR 1.33; 95% CI 1.13,
1.57) and to counsel smokers about tobacco use (AOR
2.37; 95% CI 1.83, 3.07). Compared to patients in the
Northeast, those in the West were less likely to be asked
about tobacco use (AOR 0.68; 95% CI 0.50, 0.92), and
less likely to be counseled (AOR 0.58; 95% CI 0.40,
0.86).
Conclusions: Identification of tobacco use and
counseling for current smokers during ambulatory visits
to U.S. physicians has decreased since 2005. Significant
regional, demographic, and physician specialty variation
exists regarding tobacco use identification and
counseling at ambulatory visits.
Implications for Policy, Delivery or Practice: Given
the ongoing delivery gap in providing evidence-based
tobacco counseling, recent federal meaningful use
criteria mandating that future outpatient electronic
medical records track tobacco use may spur physicians
to increase counseling about tobacco use.
Funding Source(s): HRSA
• Medicaid Funded Treatment for Opioid Addiction
Treatment: Should Buprenorphine be Rationed?
Robin Clark, Ph.D.; Mihail Samnaliev, Ph.D.; Jeff Baxter,
M.D.
Presented by: Robin Clark, Ph.D., Director of
Research, Center for Health Policy and Research,
University of Massachusetts Medical School, 333 South
Street, Shrewsbury, MA 01545; Phone: (508) 856-4226;
Email: robin.clark@umassmed.edu
Research Objective: Buprenorphine is a comparatively
expensive medication for opioid addiction. Many states
are moving to limit access to buprenorphine as a cost
saving measure. This study compares total Medicaid
expenditures and outcomes for beneficiaries with opioid
addiction who use buprenorphine, methadone or
outpatient drug free treatment in an environment without
prior authorization requirements or limits on use.
Study Design: We used Massachusetts Medicaid
(MassHealth) claims to follow beneficiaries initiating
opioid addiction treatment episodes from 2003 through
2007. MassHealth did not place restrictions on initiation
or duration of buprenorphine use during this period.
Individuals were grouped by type of treatment they
received: methadone maintenance, buprenorphine, or
outpatient drug-free. Avenuerage monthly combined
Medicaid expenditures and use of relapse-related
services (detoxification, emergency rooms or
hospitalization for substance abuse treatment) and death
were the primary outcome measures studied. Data were
analyzed using an intent-to-treat design, which assigned
members to their initial treatment group for a six-month
period and allowed multiple episodes of treatment.
Generalized estimating equations including a large
number of covariates were used to model outcomes over
time. Two analyses were conducted : one following
patients from the initiation of treatment, and another
beginning the six month follow up with the second month
following treatment. The second model was designed to
eliminate instances in which patients only received
detoxification
Population Studied: All MassHealth members with a
claims-based opioid addiction diagnosis between 2003
and 2007. 10, 248 members had at least one episode of
buprenorphine treatment, 16, 691 had an episode of
methadone treatment and 13,768 had an outpatient
drug-free treatment episode. Combined, there were
51,600 treatment episodes during the study period.
Principal Findings: Buprenorphine treatment was
significantly less expensive than methadone regardless
of whether episodes begin with the first or second month
and in both logged and untransformed models
(p<.0001). Expenditure results were mixed for the
outpatient drug-free group. Odds of relapse were higher
for buprenorphine than methadone in all cases
(p<.0001) and higher for outpatient drug free than for
either buprenorphine or methadone (p<.0001). There
was no difference between buprenorphine and
methadone in the odds of death during the six month
period. However, patients enrolled in outpatient drugfree treatment had significantly higher death rates than
buprenorphine (p<.005/ p<.008). Further analysis
indicated that members using buprenorphine had
somewhat different characteristics than those using
methadone.
Conclusions: Although medication costs are higher for
buprenorphine than for methadone maintenance,
buprenorphine is less expensive than methadone when
all Medicaid treatment is considered. Methadone is
somewhat more effective in preventing relapse and the
two treatments are similar in their impact on mortality.
Buprenorphine and methadone are both superior to
outpatient drug-free treatment in preventing relapse and
death.
Implications for Policy, Delivery or Practice: States
should re-examine efforts to limit access to
buprenorphine. Because the supply of methadone
treatment is severely limited in most states, restricted
access to buprenorphine could shift more patients to
outpatient drug-free treatment or to no treatment, both of
which are likely to increase relapse-related service use
and mortality.
Funding Source(s): RWJF
• Coordinating Primary Care and Substance Abuse
Treatment Services
Deborah Gurewich, Ph.D.; Donald Shepard, Ph.D.;
Jenna Sirkin, M.A.; Galina Zolotusky, M.A.
Presented by: Deborah Gurewich, Ph.D., Research
Scientist, Scheider Institutes for Health Policy, Brandeis
University, 415 South Street, MS 035, Waltham, MA
02454-9110; Phone: (781) 736-3836; Email:
gurewich@brandeis.edu
Research Objective: Our understanding of effective
models for coordinating primary care and substance
abuse (SA) treatment services is limited, raising
concerns among policy makers about the fragmentation
of the delivery system. Community Health Centers
(CHCs) are considered among the few provider groups
that are pioneering efforts to integrate care, and thus
may provide useful models for the rest of delivery
system. Our research objective was to determine the
organizational arrangements CHCs adopt for
coordinating primary care and SA treatment services;
and to assess the relative success of these different
approaches.
Study Design: We developed and implemented a mail
survey to determine whether and how CHCs coordinate
SA treatment services with primary care. The survey
assessed the scope of outpatient services provided
asking the CHC whether it offered each of four services
(assessment and diagnostics, counseling and therapy,
intensive outpatient, and detox). The survey also
measured the delivery mode used, quantified as the
number of services provided on site (vs. off-site referral).
We used 2002-2004 fee-for-service (FFS) Medicaid
claims and logistic regression analysis to compare the
outcomes of care by type of care coordination using The
Washington Circle measures of initiation and
engagement. The models controlled for gender, age,
race, and state and included a quadratic term for on-site
services to test for non-linear relationships.
Population Studied: We sent the survey to 155 CHCs
operating in California, Massachusetts, Texas; 86%
responded. The patient sample included 24,603
treatment episodes for drug or alcohol abuse in patients
served by the CHCs that responded to the survey.
Principal Findings: Over 97% of CHCs provided one or
more outpatient SA treatment services (and 60%
provided all four), either on-site or through off-site
referral relationships. Half of CHCs provided at least one
service on site and 12% provided 3 or 4 services on site.
Scope of services alone, regardless of delivery mode,
was not significant for initiation or engagement. We
found 1 or 2 services provided on site generated no
significant benefit, while 3 or 4 services on site resulted
in significant improvements in initiation (p<0.05) and
engagement (p=0.0008). Episodes treated in CHCs that
offered 4 SA treatment services on site were more likely
to lead to initiation (20% more) and engagement (32%)
versus those in CHCs with no on-site services.
Conclusions: Almost all CHCs provide some SA
treatment services (through on site or referral). CHCs
offering the majority of SA treatment services on site
achieved better care outcomes for patients with SA
disorder than CHCs with half or less services on site.
Implications for Policy, Delivery or Practice: The
results of our study argue for more community-based
primary care providers to offer outpatient SA treatment
services on-site. CHCs with sufficient resources should
offer all 4 services on site. Other CHCs only able to offer
1 or 2 services on site may do better by focusing their
resources on strengthening off-site referral relationships.
Funding Source(s): RWJF
• Characteristics and Costs Outcomes of Insured
Patients Treated with Extended-Release Naltrexone
or Oral Alcohol Dependence Medications
Tami Mark, Ph.D., M.B.A.; David Gastfriend, M.D.;
Henry Kranzler, M.D.; Mady Chalk, Ph.D.; Leslie
Montejano, B.A.
Presented by: Tami Mark, Ph.D., M.B.A., Director,
Analytic Strategies, Thomson Reuters, 4301 Connecticut
Avenue, NW Suite 330, Washington, MD 20008; Phone:
(301) 214-2211; Email:
Tami.Mark@thomsonreuters.com
Research Objective: There are four FDA-approved
alcoholism medications: disulfiram, naltrexone,
acamprosate, and extended-release naltrexone (XRNTX). This study used observational data to evaluate the
utilization and cost outcomes of insured patients treated
with alcohol dependence medications or no medication.
Study Design: Data were from Thomson Reuter’s
MarketScan Commercial insurance claims database
which contains information from millions of enrollees
annually. Outcomes were measured six months after
index and included medication possession ratio (MPR),
detoxification admissions and days, alcohol-related
admissions and days, ED visits, psychiatric and
substance abuse outpatient visits and charges for
detoxification and alcohol-related inpatient stays. Two
sets of analyses were conducted: (1) Persons with an
alcohol use disorder and no use of any alcohol
medication (n=4,047) were compared to persons with an
alcohol use disorder and use of any of the four
medications (n = 4,730). The samples were propensityscore matched on demographics, clinical characteristics
and prior use of alcohol and psychiatric services. (2) The
four medications were compared (XR-NTX n = 275;
naltrexone n = 2,064 acamprosate n = 5,068; disulfiram
n = 2,076) using inverse probability weighting.
Population Studied: Individuals with alcohol
dependence.
Principal Findings: The probability of any detoxification
admission, alcohol-related admission, and ED visit and a
substance abuse or psychiatric visit was significantly
higher among no medication users than medications
users. XR-NTX users had a significantly higher MPR
than acamprosate users. Patients using any medication
had fewer detoxification days and alcoholism-related
inpatient days. Among medication users, XR-NTX was
associated with significantly lower detoxification costs
(per 1000 patients over 6 months) versus oral
naltrexone, disulfiram and acamprosate (Detox: $0.60million vs. $1.48-million, $1.08-million, $1.40-million;
respectively; P<0.01 for XR-NTX vs. naltrexone and
acamprosate).
Conclusions: Individuals receiving alcoholism
medications had significantly and substantially lower
detoxification and hospitalization utilization rates than
similar patients who received no medication. Of the
approved medications, XR-TX had lower costs for
detoxification and alcoholism hospitalization days.
Implications for Policy, Delivery or Practice:
Comparative effectiveness information is important to
understand the relative benefits of alcoholism
medications.
Funding Source(s): Alkermes, Inc.
• Measuring Performance in Use of
Pharmacotherapy for Substance Use Disorders
(SUD) in Three Different Health Systems
Cindy Thomas, Ph.D.; Deborah Garnick, Ph.D.;
Constance Horgan, Ph.D.; Claire Spettell, Ph.D.; Kay
Miller, M.P.H.; Alexander Harris, Ph.D.
Presented by: Cindy Thomas, Ph.D., Associate
Research Professor, Schneider Insistutes for Health
Policy, Brandeis University, 415 South Street MS035,
Waltham, MA 02454; Phone: (781) 736-3921; Email:
cthomas@brandeis.edu
Research Objective: Pharmacotherapy for substances
use disorders (SUD) is one of eleven evidence-based
practices identified by the National Quality Forum for
SUD treatment. Use of SUD pharmacotherapy in officebased practice, including buprenorphine for opioid
dependence, and naltrexone, disulfiram and
acamprosate for alcohol abuse and dependence, is low,
but increasing. Currently there are no standardized
measurement tools for measuring use of this evidencebased practice in general or specialty treatment settings.
The growing use of SUD pharmacotherapy provides an
opportunity for developing approaches to assessing its
use, and for driving quality improvement. This study is a
pilot test of SUD performance measures developed by
the Washington Circle, applied in private sector health
plans, Medicaid programs, and the Veterans’ Health
Administration.
Study Design: This is a claims-based study of utilization
of medications for substance use disorders (naltrexone
[short and long acting], disulfiram, acamprosate and
buprenorphine). Rates of medication use, persistence
(number of prescriptions, proportion of days covered
after initiation to end of coverage period), and clinical
follow-up, are compared across populations.
Population Studied: Insured adults age 18-64 in 20062008 with identified substance abuse diagnoses or who
were on SUD medications, were drawn from the
following national insurer databases: Aetna health plans
(n=44,000); MarketScan private health plans (n=66,000)
and four Medicaid state programs (n=28,000); and the
national Veterans’ Administration health system.
Principal Findings: Rates of medication use vary
widely across health systems, and by specific disorder
being treated (alcoholism or opiate dependence). In
2007, alcoholism treatment medications use ranged from
5.9 percent of individuals in Medicaid plans to 17.1
percent in private health plans; buprenorphine use
ranged from 7.0 percent in Medicaid to 39.7 percent in
private health plans. The average annual number of
days covered by prescriptions also ranged widely by
medication and by system, with both alcohol and drug
treatment reflecting different treatment patterns,
particularly for buprenorphine, which is often used for
brief periods. Clinical follow up after initiation of
medication treatment is inconsistently documented, with
generally low rates of follow-up. Results from the
Veterans’ Administration will also be compared to those
reported above.
Conclusions: Pilot testing indicates that applying
performance measures for use of pharmacotherapy for
SUD is feasible and practical, in public and private
claims-based health systems. The rate of use of SUD
pharmacotherapy varies across insured populations.
With low and varying patterns of use, SUD
pharmacotherapy may be most amenable to
measurement of prevalence of use, rather than more
detailed measures of continuity and follow up.
Implications for Policy, Delivery or Practice:
Measuring and reporting use of SUD pharmacotherapy
can be an important driver of this evidence based
practice. Developing and promoting use of standardized
measurement tools to assess use of pharmacotherapy in
SUD will fill an important gap in monitoring this practice.
As SUD medication use evolves, measures for
performance should continue to be refined.
Funding Source(s): CSAT, NIDA
Role of Organizations and Management in Quality
Improvement
Chair: Sara Singer
Monday, June 28 * 4:45 pm–6:15 pm
• Hospital Performance in 30-Day Risk-Standardized
Mortality: The Role of Organizational Strategies and
Context
Elizabeth Bradley, Ph.D.; Erica Spatz, M.D.; Emily
Cherlin, M.S.W.; David Berg, Ph.D.; Harlan Krumholz,
M.D., S.M.; Leslie Curry, Ph.D., M.P.H.
Presented by: Elizabeth Bradley, Ph.D., Professor,
Department of Health Policy and Management, Yale
School of Public Health, 60 College Street, New Haven,
CT 06520-8034; Phone: (203) 785-2937; Email:
Elizabeth.bradley@yale.edu
Research Objective: Hospitals in the US show a twofold variation in 30-day risk-standardized mortality rates
for patients with acute myocardial infarction (AMI),
indicating that even after adjusting for case mix, hospital
mortality rates differ markedly. In studies of hospital-level
variation, a substantial portion of the variation in riskstandardized mortality rates remains unexplained even
after adjusting for case-mix, volume, teaching status,
geographic location, socioeconomic profile of patients,
and performance on quality process measures. Our
objective in this paper was to generate hypotheses
about what may further explain this variation, with
particular attention to organizational strategies and
context.
Study Design: We conducted a qualitative study of
hospitals in the US during 2009. We selected hospitals
that ranked in the top 5% of 30-day risk-standardized
mortality after AMI for the two most recent years of data
(2005-2006 and 2006-2007); we selected hospitals in
the bottom 20% for contrast. We conducted site visits
and in-depth interviews in randomly selected hospitals,
augmenting the sample purposefully to ensure diversity
in teaching status, size, geographic location, and
socioeconomic profiles of patients. We continued
additional site visits until we reached theoretical
saturation. Analyses employed the constant comparative
method and were conducted by a multidisciplinary team,
and Atlas Ti software facilitated data organization and
retrieval.
Population Studied: We conducted site visits and indepth interviews at 14 hospitals (10 top performers and
4 lower performers) that treated at least 15 patients per
year with AMI with primary percutaneous coronary
intervention. We interviewed 201 hospital staff including
physicians (n=20), nurses (n=65), other clinical
personnel (n=35), and management staff (n=81).
Principal Findings: Several features of the
organizational context were prominent in the top
performing hospitals and less apparent in the bottom
performing hospitals. These included a shared goal of
excelling in cardiology care, a focus on problem solving,
strong communication and coordination among
workgroups within and across disciplinary and
departmental boundaries, and prompt data feedback
regarding performance targets. We found limited
evidence for specific strategies or processes for
organizing and delivery care. The presence of potentially
important strategies such as rapid response teams, case
management systems, and information technologies, did
not differ markedly between top and bottom performing
hospitals.
Conclusions: Top performing hospitals were
distinguished by a set of contextual factors consistent
with organizational behavior and theory, rather than
specific strategies or programs
Implications for Policy, Delivery or Practice:
Elevating hospital performance in complex metrics such
as mortality rates may require more than specific
programs and strategies. Based on this exploratory,
qualitative study, we hypothesize that the more complex
organizational features of how groups work together,
how communication takes place, the use of data
feedback, and the degree of problem solving and
innovation fostered in the organization may be
paramount to achieving top performance in survival rates
after AMI. This work provides policy-makers, clinicians,
and managers new evidence about the importance of
organizational context in influencing quality of clinical
care and patient outcomes.
Funding Source(s): AHRQ, Commonwealth Fund
• Strategies for Improving Hospital Quality and
Efficiency: Lessons from Eight Hospitals
Sally Holmes, M.B.A.; Alan Cohen, Sc.D.; Joseph
Restuccia, Dr. P.H.; Michael Shwartz, Ph.D.; Jedediah
Horwitt, M.P.H.;
Presented by: Sally Holmes, M.B.A., Senior Research
Fellow, Health Policy Institute, Boston University, 53 Bay
State Road, Boston, MA 02215; Phone: (617) 353-4523;
Email: skholmes@bu.edu
Research Objective: To understand the factors driving
hospital performance and to identify quality improvement
(QI) strategies and best practices that offer lessons and
tools for hospitals to employ in improving their
performance.
Study Design: As part of a larger study of quality and
efficiency in U.S. hospitals, we performed case studies
of eight hospitals selected on the basis of four
performance measures calculated from publiclyavailable data (mostly 2005) and two 2006 survey-based
measures: risk-adjusted inpatient mortality for the AHRQ
inpatient quality indicators; risk-adjusted efficiency; CMS
adherence to process of care measures for three
conditions (acute myocardial infarction, heart failure, and
pneumonia); HCAHPS® patient satisfaction measures
(2006 – 2007); and survey-assessed patient care quality
by hospital chief quality officers (CQOs) and front-line
clinicians. For each hospital, we averaged its ranks
across all six measures to produce an overall averagerank composite. Data were stratified by bed size and
region, and arranged in quintiles for cross-metric
comparison. Hospitals in the top quintile on the
composite were considered high performers, and
hospitals in the middle quintile were considered average
performers. We selected for study five high performers
and three average performers. Visits to the eight
hospitals occurred between November 2008 and
February 2009. Each two-day visit involved a threeperson team that interviewed 15-20 people per hospital,
including top leaders, department heads, and front-line
clinicians.
Population Studied: Study hospitals initially were
drawn from a sample of 470 hospitals that had
responded to a 2006 survey of CQOs and front-line
clinicians regarding hospital QI activities. However, only
253 had reported sufficient HCAHPS and CMS
performance data. From these 253 hospitals, we
identified and recruited two large (= 400 beds) high
performers (South and West regions), two medium-sized
(100 – 399 beds) high performers (Midwest and
Northeast regions) and one small (25 – 99 beds) high
performer (Midwest region). High performers were
recruited in order of their rank within bed-size category.
Avenuerage performers were recruited to match at least
one high performer in terms of bed size, region,
metropolitan/non-metropolitan location, and teaching
status.
Principal Findings: Preliminary findings suggest that
average-performing hospitals engage in many of the
same QI activities as high performers but do so to a
lesser degree and with less intensity. Key factors
differentiating high performers from average performers
include: leadership and organizational commitment to QI
goals; an organizational culture and set of values that
facilitate improvement; and resource levels sufficient to
support improvement efforts.
Conclusions: High performers appear to have: stable,
visionary, and strongly committed leadership; shared
value systems that support an improvement-focused
organizational culture; and ample resources for investing
in information technology and launching improvement
efforts that further the hospital’s QI goals. Avenuerage
performers seem hampered by: poor financial conditions
and limited resources for improvement work; leadership
turnover; and cultural divisions that remain from past
mergers of constituent organizations.
Implications for Policy, Delivery or Practice: Even a
50-bed hospital with committed leadership, a QI-focused
culture and adequate resources can be high-performing
on multiple measures. However, payment reform may be
needed to assure that hospitals facing severe financial
conditions, particularly safety net providers, are able to
achieve high performance levels.
Funding Source(s): CWF
• Assessing the Selection, Procurement and
Adoption of Innovative Technologies to Fight Health
Care Associated Infections in 12 NHS Trusts Across
England
Yiannis Kyratsis, D.V.M., D.I.C., M.Sc., Ph.D.; Raheelah
Ahmad, B.Sc., D.I.C., M.Sc., Ph.D.; Alison Holmes,
M.D., M.P.H., Ph.D.
Presented by: Yiannis Kyratsis, D.V.M., D.I.C., M.Sc.,
Ph.D., Research Fellow, Faculty of Medicine, Imperial
College London, 2nd Floor Hammersmith House,
Hammersmith Hospital Campus, Imperial College
London, London, W12 0NN, England; Phone:
+00442083833277; Email: y.kyratsis@imperial.ac.uk
Research Objective: The emergence of healthcareassociated infections (HCAI) has become a significant
risk to the safety of patients and healthcare providers.
Global prevalence of HCAIs among inpatients is
estimated at 5-10 per cent. The health and financial
impact is significant, to patients, families and health
systems. Innovative technologies and interventions have
the potential to make a real difference in reducing levels
of HCAIs. However, despite strong evidence of
effectiveness novel approaches or technologies are not
always adopted. A prime example of the ‘evidence practice gap’. Our key objective therefore was to explore
how managers select and adopt innovative technologies
to combat HCAI. We also explore the construction of
‘evidence’ by healthcare managers when making the
selection of innovative technologies. Managers, here
include clinicians and non-clinicians. Emphasis is also
placed on the facilitating or constraining influence of
contextual factors on the above decision making process
using an ‘innovation-adoption framework’ co-developed
by the lead author.
Study Design: We employed a comparative multiple
case study design, with embedded units of analysis at
the level of Strategic Health Authorities and NHS Trusts.
This methodology allowed a holistic approach, taking
into account the meaningful characteristics of real-life
events. Replication logic across cases explores and
tests emerging themes. The study applies primarily
qualitative methods of inquiry.
Population Studied: We undertook over 40 semistructured interviews (multi-level, multi-stakeholder,
purposive sample of key informants from diverse
localities) in 12 Trusts – 11 Acute and 1 Primary Care –
across England that cover all 10 Strategic Health
Authorities (the administrative divisions in the UK NHS)
in England.
Principal Findings: A variety of innovative technologies
have been selected and variably adopted by the
participating NHS Trusts. The evidence of technologies’
effectiveness and their anticipated impact and benefits,
have been perceived differently across the cases. A
dynamic interplay among the perceived characteristics of
the innovative technologies, adopting actors’
organizational and professional background, and
institutional conditions shaped decision making. We
found differences between academics, diverse
communities of health professionals and managers in
what constituted ‘evidence’ and optimum interventions.
We mapped trust performance indicators, history,
‘innovation-averse/leading’ behaviour, as well as wider
contextual factors. Technology selection and adoption
were influenced by factors such as Trust’s policies,
strategic plans, departmental budgets, competing clinical
and organizational priorities, established norms, and
dissimilar evaluation and monitoring procedures. These
either impeded or facilitated the selection and adoption
of innovative technologies irrespective of available
scientific evidence.
Conclusions: The process of technology adoption was
largely influenced by inter and intra-professional
dynamics including disproportionate influence by diverse
uni-professional communities of practice, motives of
individual and collective actors. Organizational context
including available capacity, leadership, and
organizational tradition shaped the social construction of
evidence in each case, which mediated technology
adoption.
Implications for Policy, Delivery or Practice: A broad,
detailed analysis of professional, organizational and
health system elements is required when introducing
innovations, enabling better understanding of the factors
that influence adoption and implementation. Initiatives
informed by simplistic situational analysis, may
experience resistance, as the most important causes of
resistance to the uptake and assimilation of innovations
are overlooked. Our analytic framework and findings
have immediate and important implications for health
care providers, funders and consumers.
Funding Source(s): NHS Purchasing and Supply
Agency
• Beyond the Volume-Outcome Relationship:
Deliberately Learning to Improve
Ingrid Nembhard, Ph.D., M.S.; Anita Tucker, D.B.A.;
Richard Bohmer, M.B., M.P.H.; Joe Carpenter, M.S.;
Jeffrey Horbar, M.D.
Presented by: Ingrid Nembhard, Ph.D., M.S., Assistant
Professor, School of Public Health/School of
Management, Yale University, 60 College Street, P.O.
Box 208034, New Haven, CT 06520-8034; Phone: (203)
785-3778; Email: ingrid.nembhard@yale.edu
Research Objective: The well-documented quality
problems in healthcare organizations have created an
imperative to identify effective strategies for improving
quality of care. While the strategy of learning-by-doing
has offered some benefits as evidenced by studies
linking cumulative volume to patient mortality, research
also shows that this strategy has not uniformly enhanced
the level of performance for healthcare organizations. As
a result, healthcare professionals and organizations
have sought information on alternative strategies they
may use to enhance their performance. We examine
whether the use of deliberate learning activities (e.g.,
dry-runs) offers performance benefits beyond those
provided by cumulative volume (i.e., experience, with
performance measured by risk-adjusted patient mortality
rates. Additionally, we assess whether the effectiveness
of deliberate learning activities depends on a critical
interaction in workgroups, interdisciplinary collaboration.
Study Design: We conducted a longitudinal study of 23
hospital neonatal intensive care units (NICUs). We
collected data from two sources: (1) an organizational
assessment survey completed by staff in the NICUs, and
(2) a NICU-patient database maintained by the Vermont
Oxford Network (VON), a professional association for
NICUs. The first source provided data on the use of
seven deliberate learning activities and interdisciplinary
collaboration in the NICU. The NICU database provided
data on NICU characteristics (e.g., cumulative volume
and teaching status) as well as patient demographics
and mortality. We tested the effect of using deliberate
learning activities and interdisciplinary collaboration
within the NICU using clustered, logistic regression
models to account for the correlation between infants
treated in the same NICU and our binary outcome
measure, patient mortality.
Population Studied: We used data collected from 1,440
healthcare professionals (46% percent of staff
contacted) from 23 NICUs in the United States and
Canada. All of the NICUs were members of a quality
improvement collaborative sponsored by VON. During
the four-year study period (2001-2004), the NICUs
treated more than 4,200 extremely low birthweight
infants who weighed less than 2.2 pounds.
Principal Findings: We found that the use of deliberate
learning activities is positively associated with reduced
risk-adjusted mortality rates, after accounting for
cumulative volume. Moreover, our data showed that the
use of deliberate learning activities was associated with
reduced mortality equivalent to the benefit of cumulative
experience (20% reduction in mortality). Contrary to
prediction, interdisciplinary collaboration mediated,
rather than moderated, the relationship between the use
of deliberate learning activities and mortality.
Conclusions: The use of deliberate learning activities
provides performance benefits beyond those gained
from cumulative volume, in part because their use
fosters the interdisciplinary collaboration needed for
high-performance in healthcare.
Implications for Policy, Delivery or Practice: Our
results reinforce the importance of professionals and
organizations engaging in deliberate learning activities to
improve performance. Moreover, our results suggest that
the use of deliberate learning activities should not be
considered secondary to reliance on cumulative volume
as a performance improvement strategy, as their use
has an equivalent effect on mortality. The finding that the
use of seven, specific deliberate learning activities
cultivates interdisciplinary collaboration among staff is
particularly useful for managers who have struggled to
identify concrete means for increasing interdisciplinary
collaboration, a key determinant of quality of care.
Funding Source(s): Harvard Business School Division
of Research
Use of Survey and Administrative Data to Track
Sources of Disparities
Chair: Vickie Mays
Monday, June 28 * 4:45 pm–6:15 pm
• National Trends and Black/White Differences in
Obstetrical Quality Indicators and Inpatient Maternal
and Neonatal Mortality
Elizabeth Howell, M.D., M.P.P.; Stephanie Guillerme,
M.S.; Paul Hebert, Ph.D.; Alan Moskowitz, M.D.; Natalia
Egorova, Ph.D.
Presented by: Elizabeth Howell, M.D., M.P.P,
Assistant Professor, Health Evidence & Policy, Mount
Sinai School of Medicine, One Gustave L. Levy Place,
Box 1077, New York, NY 10029; Phone: (212) 6599567; Email: elizabeth.howell@msnyuhealth.org
Research Objective: To evaluate national trends in
Agency for Healthcare Research and Quality (AHRQ)
obstetrical related quality indicators (QI) and inpatient
maternal and neonatal mortality. To examine whether
obstetrical related QI differ for Blacks and Whites and
whether such differences may explain persistent racial
disparities in maternal and neonatal inpatient mortality
rates.
Study Design: This is an observational cohort study
examining obstetrical hospital QI and inpatient maternal
and neonatal mortality rates using the Nationwide
Inpatient Sample (NIS) database. We used 4 AHRQ’s
patient safety indicators (birth trauma- injury to neonate,
obstetric trauma with and without instrument and during
cesarean delivery), 4 inpatient QI (cesarean section
delivery, primary cesarean section, uncomplicated
vaginal birth after cesarean section (VBAC), and all
VBACs), and 1 prevention QI (low birth weight) to
evaluate the dataset. Proportions were analyzed by Chisquare test and trends by Poisson regression analysis.
We computed Black and White risk-adjusted rates
controlling for age, DRG and comorbidities as specified
by AHRQ. We then compared Black vs. White specific
risk adjusted rates for QI and mortality.
Population Studied: We examined all deliveries, births,
and deaths using the Nationwide Inpatient Sample (NIS)
from the AHRQ’s Healthcare Cost and Utilization Project
from 1998 through 2007. The NIS sample is a stratified
sampling representing 20% of US community hospitals
from up to 40 states.
Principal Findings: Obstetrical QI changed over the
study period and racial differences in obstetrical quality
and mortality were evident. Patient safety indicators
improved with birth trauma injury to neonate declining by
80% (8.1 to 1.7 per 1000 live births, p<.0001) and
obstetrical trauma decreasing by 21% (188 to 148 per
1000 vaginal deliveries with instrument, p<.0001).
Patient safety indicators were better for Blacks than
Whites and racial differences decreased over time. By
2007, Blacks had lower rates of injury to neonates than
Whites (1.6 vs. 1.9 per 1000 live births, p=.004), and
lower rates of obstetric trauma (95.9 vs.144.5 per 1000
vaginal deliveries with instrument, p<0001). Changes in
inpatient QI were evident for Blacks and Whites:
cesarean deliveries increased and vaginal births after
cesarean sections decreased for both populations.
Obstetrical prevention QI, as measured by low birth
weight, increased 13% (54.3 to 61.6 per 1000 live births,
p<.0001). Blacks had higher rates of low birth weight
than Whites over the study period, and in 2007 low birth
weight occurred at nearly twice the frequency in Black
than White newborns (102.5 vs. 57.1, p<0.0001).
Inpatient maternal and neonatal mortality did not change
substantially during the study period, with persistently
higher rates of both seen in Blacks compared with
Whites (20.6 vs. 5.9 per 100,000 deliveries, p<0.0001
and 7.1 vs. 2.7 per 1000 births, p<0.0001, respectively in
2006).
Conclusions: Obstetrical patient safety indicators
improved but inpatient maternal and neonatal mortality
did not change substantially during the 10-year study
period. Despite improvements in some parameters of
obstetrical quality for both Blacks and Whites, racial
disparities in maternal and neonatal mortality persisted.
Racial differences in obstetrical quality indicators did not
explain trends in maternal or neonatal mortality.
Implications for Policy, Delivery or Practice: Although
factors other than obstetric quality may contribute to
persistent maternal and neonatal disparities, our inability
to find a relationship between standard quality indicators
and variation in mortality was disconcerting as it might
suggest that current indicators are not sufficiently
sensitive for guiding quality improvement.
• Race/Ethnicity Disparities in Direct-To-Consumer
Advertising (DTCA): Findings from a National Survey
Doohee Lee, Ph.D., M.P.H..; Charles Begley, Ph.D.
Presented by: Doohee Lee, Ph.D., M.P.H.., Associate
Professor, Management, Marketing, MIS, Marshall
University, 100 Angus E. Peyton Drive, Charleston, WV
25303; Phone: (304) 746-1973; Email:
leed@marshall.edu
Research Objective: The United States and New
Zealand are the only two industrialized countries in the
world that permits Direct-To-Consumer Advertising
(DTCA) of prescription drugs. DTCA has been a popular
topic in the United States for the past decade, but
disparities in how Americans experience DTCA have
been lightly investigated. The present study seeks to
understand the association between race/ethnicity and
various aspects of DTCA.
Study Design: This cross-sectional study is based on
secondary analysis of data from the Public Health
Impact of Direct-to-Consumer Advertising of Prescription
Drugs Survey conducted in 2001- 2002 by researchers
at Harvard University/Massachusetts General Hospital
and Harris Interactive. Hispanics (n=314) and African
American patients (n=345) were compared to White
patients (n=2,155) with respect to their exposure and
response to DTCA. Descriptive analyses (chi-square
test, T-test, and ANOVA) were performed to detect
differences and multivariate logistic regression was
conducted to test whether race/ethnicity remained
significant in explaining differences while controlling for
other factors (gender, age, education, and health
insurance).
Population Studied: A nationally representative sample
of 2,814 American adults (>=18 years of age).
Principal Findings: Findings reveal that Hispanics
(60%) and African Americans (74%) were less likely than
Whites (89.1%) to be exposed to DTCA (p<.001), were
more likely to be influenced by DTCA (e.g., exercising
more often [69.7%, 66.7% vs. 57.5%, p<.001] and taking
a prescription medicine as advised [60.3%, 55.3% vs.
42.4%, p<.001], taking more personal control over their
health care [80.2%, 85.5% vs. 73.5%, p<.001]), and
were more positive about health benefits of DTCA
exposure. Compared to Whites, African Americans were
also more likely to ask their physicians for a DTCA
prescription drug (40% vs. 30%, p<.05) and be refused
(37.8% vs. 22.1%, p<.05), which raises an issue about
the impact of DTCA on provider-patient relationships. In
a multivariate logistic regression analysis, race/ethnicity
remained significant in predicting DTCA exposure while
controlling for gender, age, education, and health
insurance. Both African Americans (OR=0.25, p<0.001)
and Hispanics (OR=0.68, p<0.05) were less likely than
Whites to be exposed to DTCA. Race/ethnicity was not
significant in predicting that DTCA prompted patients to
talk to their doctors about DTCA prescription drugs, but
(only Hispanic patients) remained significant in
predicting that DTCA prompted patients to talk to their
physicians about treatment changes (OR=0.62, p<0.05)
after controlling socioeconomic variables, suggesting
that Hispanic patients were less likely than Whites to talk
with their doctors when exposed to DTCA about
treatment options. The confounding factors did not
mediate the finding that DTCA encouraged minority
patients to discuss treatment options with their doctors.
Conclusions: Racial disparities exist in DTCA at the
national level.
Implications for Policy, Delivery or Practice: DTCA of
pharmaceuticals is still a controversial topic, but no
DTCA debate, to date, has included the racial disparity
issue. Industry and policymakers must make efforts to
address racial gap in DTCA. Future studies are needed
to assess impact of DTCA on ethnic disparity.
• The Role of Generational Status in Quality of
Diabetes Management among Mexicans in California
Ninez Ponce, Ph.D., M.P.P.; Selena Ortiz, M.P.H.;
Debra Perez, Ph.D.
Presented by: Selena Ortiz, M.P.H., Ph.D. Student,
Health Services, UCLA, University of California Los
Angeles Box 951772, 31-254B CHS, Los Angeles, CA
90095; Phone: (510) 459-2887; Email:
seortiz@ucla.edu
Research Objective: Diabetes disproportionately
affects the Mexican population in the US, with Mexican
Americans more than twice as likely to have diabetes as
non-Latino whites. Mexicans span the demographic
continuum of recent immigrants to native-born
Americans whose families have been in the US for
several generations. For this largest Latino group in the
US, we hypothesized that generational status is
consequential in predicting their quality of diabetes care,
and potentially, in reducing diabetes disparities in the
US.
Study Design: Using weighted multivariate logistic
regression, we determined the effect of generational
status on five diabetes care process measures adjusting
for age, gender, poverty level, educational attainment,
English proficiency and insurance status per
generational level. Four levels of generational status
were constructed: first generation immigrant; second
generation (US-born with two foreign-born parents);
generation 2.5 (US-born with one foreign born parent
and one US-born parent); and third generation (US-born
with two US-born parents). Care process measures
include receipt of an annual doctor’s visit, an HbA1c test,
an eye exam with dilated pupils, a foot exam, and an
influenza vaccination within the past year. We also
assessed receipt of a hypertension diagnosis,
overweight/obesity, communication difficulties with their
physician, and the amount of weekly exercise.
Population Studied: Mexican adults with diabetes age
18 and older (n = 4539) from a pooled sample of the
California Health Interview Surveys 2005 and 2007.
Principal Findings: Although the odds of being
diagnosed with diabetes is higher when compared to first
generation Mexicans (OR 1.42; 95% CI: 1.03 – 1.94),
third generation Mexicans had reduced odds of receiving
an annual eye exam (OR .52; 95% CI: .28 - .93). Second
generation Mexicans had reduced odds (OR .53; 95%
CI: .29 - .95) of receiving an annual foot exam than first
generation Mexicans. However, both second and third
generation Mexicans had increased odds of receiving an
annual HbA1c exam (OR 2.23; 95% CI: 1.00 – 4.97 and
OR 2.87; 95% CI: 1.30 – 6.36 respectively). No
significant differences were found in receiving an annual
doctor visit or flu vaccine per generational status. For the
outcome measure, both second and third generation
Mexicans had increased odds of being diagnosed with
hypertension (OR 1.76; 95% CI: 1.07 – 3.08 and OR
1.87; 95% CI: 1.09 – 3.22 respectively). Generation 2.5
Mexicans had decreased odds of experiencing
communication difficulties with their primary care
provider (OR .12; 95% CI: .03 - .45) than first generation
Mexicans. No significant differences were found in the
amount of weekly exercise and overweight/obesity per
generational status.
Conclusions: Increasing generational status of
Mexicans with diabetes in the US is significantly
associated with fewer communication difficulties with
providers. However, this improved communication does
not appear to translate into better diabetes management
for four of our five processes of care measures.
Furthermore, while increasing generational status is
significantly associated with receiving more HbA1c tests,
it is also associated with an increase in hypertension
diagnosis, controlling for all other factors.
Implications for Policy, Delivery or Practice: Our
results suggest that data collection on generational
granularity can enhance health system improvements in
the care of diabetes among Latinos in the US.
Funding Source(s): RWJF
• Literacy Level of Medicaid Applications and Child
Medicaid Retention Rates: Comparison Across 50
States
Susmita Pati, M.D., M.P.H.; Jane Kavanagh; Lihai Song,
M.S.; Kathleen Noonan, J.D.; Xianqun Luan, M.S.
Presented by: Susmita Pati, M.D., M.P.H., Assistant
Professor of Pediatrics, General Pediatrics, The
Children's Hospital of Philadelphia, 34th Street and Civic
Center Boulevard, CHOP North, Room 1534,
Philadelphia, PA 19106; Phone: (267) 426-5056; Email:
pati@email.chop.edu
Research Objective: Gaps in health care coverage for
children have been associated with poor child health
outcomes. As studies have identified literacy-related
difficulties as one of the primary barriers to Medicaid
enrollment and retention, this study compares the
literacy level of Medicaid applications across all 50
states and quantifies the association between the
application literacy level and child Medicaid retention
rates.
Study Design: Retrospective cohort study combining
state-level Medicaid application and renewal process
data with administrative child Medicaid eligibility data for
all 50 states. Medicaid renewal applications were
obtained from internet searches of state department of
health services websites and phone and email surveys
with Medicaid staff. The literacy level of each application
was measured using Readability Studio© software.
Administrative Medicaid eligibility files for children (1-18
yrs) from 2001-2002 were obtained from the Center for
Medicare and Medicaid Services. Retention rates for
each child (percentage of the 24 month observation
period with coverage) were analyzed in relation to
individual and state-level variables. Individual variables
included age, gender, race/ethnicity, presence of chronic
conditions, state of residency and Medicaid eligibility
category (i.e. categorically needy, medically needy,
foster care, supplemental security income [SSI]).
Population Studied: All children (1-18 yrs) from all 50
states and Washington, DC enrolled in Medicaid at any
point in 2001-2002.
Principal Findings: In 2008, 46 states had reading level
guidelines for Medicaid information. Of these, 21(45.7%)
states’ applications failed to meet their guidelines on any
of three literacy tests administered (Flesch-Kincaid, New
Fog, FORCAST). Of the 17 states’ applications that met
their state’s guideline on at least one test, none passed
all three tests. Additionally, 91.5% of applications scored
at or above a 5th grade reading level. Among the 7
states with archived Medicaid applications from 2002,
proportional hazards regression models showed that a
child’s risk of disenrollment from Medicaid in a 24-month
period increased 46.9% for every grade level increase of
the application.
Conclusions: Nearly half of state Medicaid renewal
applications fail to comply with state literacy guidelines
and more than 90% are written above a 5th grade
reading level. With each grade level increase in the
literacy level of the application, there is a significant
increase in a child’s risk of disenrollment from Medicaid.
Implications for Policy, Delivery or Practice: Given
that 40 million U.S. adults read below a 5th grade
reading level, efforts to improve retention in public
programs by addressing literacy-barriers to the renewal
process merit serious consideration. Federal and state
monitoring and program improvement efforts should
ensure compliance with existing Medicaid reading-level
guidelines and incorporate new standards as mandated.
Funding Source(s): National Institute of Child Health
and Human Development
• Disparities in Patient-Physician Relationships for
Obese Individuals
Christine Ferguson, J.D.; Patrick Richard, Ph.D., M.A.;
Patrick Richard, Ph.D., M.A.; Jennifer Leonard, J.D.;
M.P.H.; Anna Muldoon, M.S.
Presented by: Patrick Richard, Ph.D., M.A., Assistant
Research Professor, Health Policy, The George
Washington University, 2021 K Street, Washington, DC
20006; Phone: (202) 994-4176; Email:
Patrick.richard@gwumc.edu
Research Objective: Recently, researchers have begun
to explore whether patient-physician relationships vary
depending on individuals’ body mass index (BMI). These
are timely research and policy questions because
disparities in patient-physician relationships may be
associated with lower rates of access to care including
important preventive services and poorer quality of care
for obese persons, which may result in negative health
consequences such as increased morbidity and
mortality. However, studies in this area have relied
mostly on physicians’ perspectives, small nonrepresentative samples, and findings are not consistent
across primary care settings.
Study Design: We pooled three waves of data from the
2005-2007 Medical Expenditures Panel Survey (MEPS)
to increase the sample size. We constructed a binary
variable for obesity status coded as 1 if BMI>30, and 0
otherwise. Underweight individuals (BMI<18.5) were
excluded from the sample. Chi Square tests were used
to examine associations between patient-physician
relationships and BMI. Logistic regression models were
used to examine the relationship between obesity status
and patient-physician relationships. We used appropriate
sampling weights that account for the MEPS complex
survey design to compute robust standard errors of the
estimates.
Population Studied: We restricted the analytic sample
to 11984 unique individuals who are between 20 and 74
years old with non-missing observations, have a usual
source of care, and have received care from the primary
care physicians cited above.
Principal Findings: Results from Chi square analyses
show that obese persons are more likely to report that
their physicians did not treat them with respect (5.7% vs.
4.7%, p<0.05), did not spend enough time with them
(10.4% vs. 9.3%, p<0.10), and did not involve them in
treatment decisions (12.8% vs. 10.7%, p<0.01)
compared to non-obese patients. Stratified analyses by
gender show that male obese patients are more likely to
report that their physicians did not spend enough time
with them (10.1% vs. 8.41%, p<0.10) compared to male
non-obese patients. Similarly, female obese patients
reported that their physicians did not involve them in
treatment decisions (14.1% vs. 10.8%, p<0.01).
Furthermore, logistic regression analyses that controlled
for age, gender, race, insurance status, income, and
education show similar results.
Conclusions: We found that higher BMI is significantly
associated with physicians showing less respect, and
spending less time with patients. Patients with higher
BMI are also less likely to be involved in treatment
decisions made by their physicians.
Implications for Policy, Delivery or Practice: To
improve patient-physician relationships policies may
target providing diversity and sensitivity training to
physicians in clinical settings and as part of their medical
education. Further research is needed to assess the
impact of poor patient-physician relationships on health
care access, quality, and health outcomes for obese
individuals.
Health Insurance Markets and Competition
Chair: Bradley Herring
Tuesday, June 29 * 8:00 am–9:30 am
• The Effect of Banning Prior Authorization for
Emergency Medical Services on Treatment Intensity
and Health Outcomes
Yaa Akosa Antwi, M.Phil.
Presented by: Yaa Akosa Antwi, M.Phil., Ph.D.
Candidate, Heinz College, Carnegie Mellon University,
5000 Forbes Avenue, Hamburg Hall Room 243,
Pittsburgh, PA 15213; Phone: (412) 965-5296; Email:
yoa@andrew.cmu.edu
Research Objective: Prior authorization for emergency
medical services was a policy imposed by some
managed care organizations in the early 1990s to
contain health care costs. We examine whether Act 155,
passed by Wisconsin in 1997, banning prior
authorization requirement for emergency medical
services had any effect on treatment intensity and health
outcomes. We consider the effect of the law on (1) how
long a patient has to wait before a principal procedure is
performed (a measure of delay associated with seeking
permission before treatment), (2) hospital charges and
length of stay (a measure of treatment intensity), (3)
interhospital transfer rate (a measure of interference by
managed care since a response to seeking authorization
could be transfer to a network hospital), and (5) mortality
(a consequence of poor quality care associated with
seeking prior authorization).
Study Design: We use individual level data on severely
injured auto accident victims in Wisconsin from 1994 to
2002. We identify the effect of the law by using a
difference-in-difference methodology that compares two
groups of patients. We consider patients with managed
care health insurance, who are directly affected by the
law, and patients with fee-for-service health insurance,
who are not directly affected by the law. The estimation
controls for observable characteristics such as accident,
patient, and hospital characteristics that are likely to be
correlated with our outcome variables.
Population Studied: We use individual level data on
severely injured auto accident victims with managed
care or fee-for-service insurance admitted to the hospital
via the emergency room in Wisconsin from 1994 to
2002. This is a sample of about 13,142 admissions.
Principal Findings: In the four years after Act 155 was
implemented, waiting time before a principal procedure
is performed decreased by about half a day.
Interhospital transfer rate decreased by 15% (p < 0.05)
and thirty-day mortality decreased by about 24% (p <
0.05). This corresponds to about 40 lives saved in
Wisconsin as a result of passing the law. Extrapolating
this to the US population implies that the law saved
about 2,100 lives. Act 155 did not have a statistically
significant effect on overall hospital charges and length
of stay.
Conclusions: Act 155 significantly reduced delay
associated with seeking permission before treating
emergency patients. The law did not have an effect on
overall hospital charges and length of stay but saved a
significant number of lives.
Implications for Policy, Delivery or Practice: The
results indicate in some circumstances, the type of
insurance a patient has could have a significant effect on
the type of treatment. In addition, it emphasizes the fact
that while cost containment might be a worthwhile goal it
should not be at the expense of lives.
Funding Source(s): Carnegie Mellon University
Graduate Small Project Help (GUSH)
• Creating Affordable Choices Within a National
Insurance Exchange
Melinda Beeuwkes Buntin, Ph.D.; Christine Eibner,
Ph.D.; Carter Price, Ph.D.; Alice Beckman, B.A.; Amado
Cordova, Ph.D.; Federico Girosi, Ph.D.
Presented by: Christine Eibner, Ph.D., Economist,
Economics and Statistics, RAND Corporation, 1200
South Hayes Street, Arlington, VA 22202; Phone: (703)
413-1100 ext. 5913; Email: chrissyeibner@hotmail.com
Research Objective: If passed, health reform legislation
will almost certainly include a national or state-based
health insurance exchange” through which individuals
can shop for and purchase insurance. However, without
appropriate risk equalization, adverse selection within
the exchange could lead to high prices and reduced
enrollment, and could undermine the goals of health
care reform. In this analysis, we used the RAND
COMPARE microsimulation model to assess the impact
of various risk equalization strategies on enrollment,
prices, government spending, and sustainability of plans
within a national health insurance exchange.
Study Design: We modeled a national health insurance
exchange containing three health plans with actuarial
values (AVs) of 0.57, 0.74, and 0.91. The exchange was
coupled with an individual mandate, a Medicaid
expansion, and subsidies for individuals with incomes
under 400 percent of the federal poverty line. We then
analyzed the impact of risk adjustment payments and
federal reinsurance on outcomes including enrollment,
price, and plan choice. We also considered an implicit
risk equalization strategy in which the lowest income
individuals—who tend to be relatively young—are
subsidized in higher AV plans within the exchange.
Population Studied: The model linked data from the
Survey of Income and Program Participation (SIPP), the
Medical Expenditure Panel Survey (MEPS) and the
Society of Actuaries (SOA) to develop a synthetic
population of individuals with realistic health
expenditures.
Principal Findings: Without risk equalization, only the
lowest AV plan is sustainable. Risk adjustment
payments allow all three plans to remain viable, but also
raises premiums. The combination of risk adjustment
payments and federal reinsurance achieves high
enrollment with relatively low premiums and all plans
surviving, but reinsurance increases federal government
spending. Finally, the implicit risk equalization strategy
achieved by subsidizing lower income people in higher
AV plans is unstable, and can lead to low AV plans
having higher premiums than higher AV plans. The latter
result reflects that fact that higher income people who
receive subsidies in the low AV plan tend to be older and
less healthy than people who are subsidized in the
higher AV plans.
Conclusions: Preserving a selection of plans within a
national health insurance exchange will require some
form of risk equalization. However, risk equalization
policies can have unintended consequences if they are
not developed carefully. Simulation modeling can allow
us to determine the effect of various risk equalization
policies on key outcomes including enrollment, premium
price, plan choice, and government spending.
Implications for Policy, Delivery or Practice: Risk
equalization has not featured prominently in the health
care reform debate thus far, but we expect it will become
more important as health care reform moves into the
implementation phase. Our results show that risk
equalization policies can discourage cherry-picking
behavior and lead to the sustainability of multiple plan
options within a national health insurance exchange.
Further, simulation modeling can be used to analyze the
effects of specific risk equalization strategies on
outcomes that are important to policy makers.
Funding Source(s): CWF
• The Price Sensitivity of Medicare Beneficiaries
Thomas Buchmueller, Ph.D.; Richard Hirth, Ph.D.; Kyle
Grazier, Ph.D.; Edward Okeke, Ph.D.
Presented by: Richard Hirth, Ph.D., Professor, Health
Management and Policy, University of Michigan School
of Public Health, 1415 Washington Heights, Ann Arbor,
MI 48109-2029; Phone: (734) 936-1306; Email:
rhirth@umich.edu
Research Objective: For many years, leading Medicare
reform proposals have been based on the concept of
managed competition, which relies on price-sensitive
consumer demand as a mechanism for inducing price
competition among health plans. A key parameter for
understanding the potential impact of moving to such a
system is the premium elasticity of demand. While a
number of studies have estimated elasticities for nonelderly workers, the literature provides less evidence on
price sensitivity of Medicare beneficiaries. Therefore, we
seek to determine the sensitivity of Medicare
beneficiaries to plan prices within an employersubsidized health benefit program.
Study Design: We exploit quasi-experimental variation
in premiums generated by the University of Michigan’s
adoption of a fixed dollar contribution policy in 2005. This
new policy led to a substantial increase in premium
contributions. However, because of an earlier policy,
individuals retiring before January 1, 1987 were exempt
from having to make any contribution toward their
coverage. The interaction of these two policies creates
within-plan variation in premiums, which is critical for
obtaining unbiased elasticity estimates.
Population Studied: This study uses data from the
University of Michigan's retiree health benefit program
for the years 2002 to 2006 to estimate the effect of outof-pocket premiums on the health plan choices of elderly
Medicare beneficiaries. To minimize sample
heterogeneity and to isolate the effect of the price
differences caused by the policy reforms, we focus the
analysis on individuals who retired just after January 1,
1987—our treatment group—with those retiring just
before this date—our control group.
Principal Findings: In 2002, when the pre- and post1987 retirees faced the same prices, the distribution of
health plan enrollment was similar, with most retirees
enrolled in a fee-for-service plan. Premium contributions
for this plan increased significantly after the fixed dollar
contribution went into effect in 2005 and the percentage
of the treatment group enrolled in this plan decreased
significantly as retirees switched to lower cost plans. In
contrast, there was very little change in enrollment
among retirees in the control group. To take into account
the full variation in price and to control for other factors
affecting plan choices, we estimate several different
discrete choice regression models. These models
confirm a negative and statistically significant effect of
price, with elasticities of plan choice ranging from -.10 to
-.12 for single retirees and -.22 to -.27 for married
retirees. Price elasticities varied substantially across
plans.
Conclusions: We find that prices matter for plan choice
among Medicare retirees but they matter significantly
less than they do for working employees. This suggests
that estimates of price elasticity obtained from samples
of working employees do not generalize well to the
retired population. We also find evidence of
heterogeneity in price responsiveness.
Implications for Policy, Delivery or Practice: The
success of Medicare plan choice as a policy instrument
to induce price competition and satisfy heterogeneous
preferences relies on the presumption of price
responsiveness on the part of enrollees. The results of
this study may also have some indirect applicability to
understanding proposals to allow early Medicare buy-ins
or provide choice to early retirees through insurance
exchanges.
Funding Source(s): Blue Cross Blue Shield of Michigan
Foundation
• The Effect of Health Insurer Seller and Buyer
Concentration on Consumer Welfare: An Empirical
Analysis
Laurie Bates, Ph.D.; Rexford Santerre, Ph.D.; James
Hilliard, Ph.D.
Presented by: Rexford Santerre, Ph.D., Professor of
Finance and Healthcare Management, Finance,
University of Connecticut, 2100 Hillside Avenue, Unit
1041, Storrs, CT 06269; Phone: (860) 486-6422; Email:
rsanterre@business.uconn.edu
Research Objective: To investigate if health insurers
possess market power in either their output or input
markets.
Study Design: Uses multiple regression analysis to
examine how the health-insurer Herfindahl Hirschman
Index at the state level influences premium volume,
percent of the population with either individuallypurchased or employer-provided insurance, measures of
hospital output, and measures of the prices and
employment levels of various medical inputs such as
doctors and nurses. Two stage least squares estimates
are derived given the endogeneity of market
concentration by using large merger-induced changes in
concentration. Control variables include income,
population, hospitals per capita, firms per capita, and
firm-size distribution along with many other demographic
variables such as education, age, race, and poverty.
Population Studied: Uses a panel data set of states
and the District of Columbia over the years from 2000 to
2007
Principal Findings: Health insurers exploit their market
power on the seller-side of the health insurance
marketplace but the restriction of output only takes place
in the individually-purchased market segment.
Simulations suggest that an increase of the healthinsurer HHI by 200 points results in 700,000 individuals
losing individually-purchased health insurance. Premium
volume rises as a result given an inelastic demand for
health insurance. In addition, the findings imply that
health insurers practice monopsony power in the market
for general practitioners. In particular, a 200 point
increase in the health-insurer HHI reduces the number of
general practitioners by as much as 9 percent according
to the results. Finally, the evidence suggests that health
insurers’ exercise monopoly-busting power in the
hospital services industry.
Conclusions: Health insurers exploit market power in
both their input and output markets.
Implications for Policy, Delivery or Practice: Policymakers should promote more competition in health
insurance markets by allowing interstate purchasing of
health insurance and more aggressively enforcing
antitrust laws against large mergers among health
insurers. General practitioners should be granted an
antitrust waiver so they can negotiate collectively with
health insurers.
• Evaluation of the Georgian Voluntary Health
Insurance Market: What Role Does Adverse
Selection Play?
Adam Sirois, M.P.H.; Hugh Waters, Ph.D.
Presented by: Adam Sirois, M.P.H.,
Associate/Student, International Health, Johns Hopkins
University, 1908 Bank Street, Baltimore, MD 21231;
Phone: (410) 340-5125; Email: asirois@jhsph.edu
Research Objective: The primary objective of the
research is to determine if there is adverse selection in
the population which chooses to enroll in the new
Voluntary Health Insurance Plan (VHI) in the Republic of
Georgia.
Study Design: Two sets of data will be co-analyzed by
the Johns Hopkins study team. These include a dataset
from the Social Security Agency (SSA) which provides
demographic information and enrollment date of the
enrollees in the VHI and datasets from private insurance
companies that provide information about their
respective VHI caseloads, patient mix, date of
enrollment and date of initial use of services. Descriptive
statistics and multiple logistic regression models will be
used, with adverse selection as the primary outcome of
interest. A range of continuous and binary variables will
be analyzed to determine if there is a causal link
between them and adverse selection into the risk pools.
Variables include age, sex, date of enrollment into the
VHI, date of first utilization of service, geographic region,
rural, urban areas, health status, education level, and
economic status. The model will control for the key
covariates and their interactions and will estimate the
relationships between the independent variables and the
outcome of interest. Maintenance and review of all data
will be carefully protected to ensure patient/insured
confidentiality according to Institutional Review Board
standards and JHSPH data security guidance.
Population Studied: 122,000 people from every region
of Georgia have joined the Voluntary Health Insurance
plan (VHI) during its initial open enrollment period in
2009. The study population included all of the enrollees.
Principal Findings: Preliminary findings reveal that
there is adverse selection among the population that
joins the fund. Older people with chronic diseases are
joining the VHI and utilizing services immediately
following the wait period of one month.
Conclusions: The study was important to analyze the
initial enrollment period for the Voluntary Health
Insurance Plan to: a) identify if there is adverse
selection, b) determine the attributes that characterize
the adverse selection, and c) mitigate the role of adverse
selection by identifying potential policy responses. This
study provides research-based evidence that can be
used to improve the efficiency of the VHI and develop
policy papers that add value to the implementation of the
program.
Implications for Policy, Delivery or Practice: This
report will be useful to the Ministry of Health, Labor and
Social Affairs, World Bank, and private insurance
companies that administer the VHI. This study is the first
review of the VHI and will have important implications for
policy, delivery and practice. Policy recommendations
are needed that would improve the efficiency and
effectiveness of the VHI while expanding the plan to
reach more clients. Findings will also be used to
determine enrollment and utilization patterns between
the insurance companies which will be used as a proxy
to measure their performance. The study provides
evidence based research that allows for informed
decision making by policy makers in the Republic of
Georgia and will provide lessons learned that can be
applied in other countries in economic transition from low
to middle income. This research also serves as an
example of effective public/private partnership which has
important policy ramifications in the health sectors of
both developing and developed countries.
Funding Source(s): Johns Hopkins University
Health Reform: State Lessons and National
Estimates
Chair: Jon Gabel
Tuesday, June 29 * 8:00 am–9:30 am
• Premium and Cost-Sharing Subsidies under Health
Reform: Implications for Coverage, Costs, and
Affordability
Bowen Garrett, Ph.D.; Lisa Clemans-Cope, Ph.D.;
Matthew Buettgens, Ph.D.
Presented by: Lisa Clemans-Cope, Ph.D., Research
Associate, Health Policy Center, The Urban Institute,
2100 M Street NW, Washington, DC 20037; Phone:
(202) 261-8850; Email: lclemans@urban.org
Research Objective: A major task in the effort to craft a
final health reform bill that can be passed in both Houses
of Congress is to balance government costs against
making health insurance affordable for low- and middleincome families. We simulate the effect of different
premium and cost-sharing subsidy schedules on
household financial burdens and government costs,
within the context of comprehensive health reform.
Study Design: Using the Urban Institute’s Health
Insurance Policy Simulation Model (HIPSM), a detailed
microsimulation model of the health care system, we
estimate coverage, costs, and household financial
burdens under legislation proposed by the Senate
Finance Committee and under two alternative premium
and cost-sharing subsidy schedules: those specified in
the Senate Leadership bill, and those specified in H.R.
3962, passed by the House of Representatives. We
simulate the effect of changes in the premium and costsharing subsidies holding all other features of the Senate
Finance Committee (SFC) bill constant. We will update
our findings based on the provisions of any final health
reform legislation.
Population Studied: Coverage and aggregate cost
results include the non-institutionalized population of the
United States under age 65. The analysis of household
financial burdens focuses largely on those who would
purchase health insurance coverage directly through a
new health insurance exchange (the exchange). The
vast majority of the subsidies would be spent on these
enrollees.
Principal Findings: We find that the number of
uninsured would drop from 49 million to about 19 million
people under the SFC bill and that the uninsured would
decrease by less than half a million more under
subsidies of the Senate Leadership bill and by about
another 2 million with the subsidies specified in the
House bill. Government subsidy costs (in $2009) under
the SFC bill are estimated at approximately $24 billion.
Corresponding costs using the subsidies of the Senate
Leadership bill would be $27 billion and costs using
subsidies of the House Bill would be approximately $39
billion. Family health care costs (premiums plus out-ofpocket spending net of subsidies) for those buying
nongroup coverage through the exchange would vary
considerably by income and across the reform options.
Under the SFC bill, the median low-income family (with
an income of 133 to 199 percent of the federal poverty
level [FPL]) would spend 7 percent of its income on
health care, while the median family with somewhat
higher income (200 to 299 percent of the FPL) would
spend 11 percent of its income. Those at the 90th
percentile of the spending distribution, families with
greater health care needs and older adults, would face
higher burdens due to additional out-of-pocket costs and
the effects of 4:1 age rating bands. While premiums
generally account for most of household health care
costs, the burden of out-of-pocket cost-sharing for those
with the highest expenses can reach above 10 percent
of income under the SFC bill. Compared to SFC bill
subsidies, the Senate Leadership bill subsidies would
decrease family health care cost burdens by about 1
percent of income for those between 200 to 399 percent
of the FPL compared with the SFC bill. Substituting the
premium and out-of-pocket subsidy schedules from the
House bill would do more for lower-income families—
decreasing median family health care cost burdens by
about 2 percent of income for those between 133 and
299 percent of the FPL. Under the House bill subsidies,
much larger reductions in financing burden would occur
among higher spenders due to the additional costsharing subsidies that would be provided. A further
targeted increase in cost-sharing subsidies beyond
those in the House bill can significantly decrease the
burdens faced by the highest health care spenders
below 400 percent of the FPL while expanding coverage,
at an additional annual cost of about $4 billion to the
government.
Conclusions: Each option presented here would greatly
reduce the number of uninsured and make health
insurance more affordable for millions of Americans.
This analysis shows that health care cost burdens under
the Senate Finance Committee bill can be substantial for
those with incomes from 200 to 499 percent of the FPL,
particularly for those with significant health care needs.
Expanded premium and cost-sharing subsidies under
H.R. 3962 or the “enhanced” schedule could reduce the
largest burdens for these groups, and doing so would
increase overall coverage as well as government costs.
Implications for Policy, Delivery or Practice: The
levels of premium and cost-sharing subsidies greatly
determine how affordable insurance coverage and
access to medical care would be for families under
reform. This analysis shows that health care cost
burdens can be substantial for those with modest
incomes and significant health care needs. Affordability
in turn would affect compliance with the individual
mandate. Without broad compliance, it would be difficult
to maintain the proposed insurance reforms that depend
on broad risk pools. Ultimately, public support for the
reforms will be related to the extent to which coverage
and the direct costs of care are considered affordable,
making it critical to balance such concerns with the
government costs associated with comprehensive health
care reform.
Funding Source(s): RWJF
• Auto-Conversion to Coverage at Wisconsin’s
BadgerCare Plus Launch: Lessons and a Simulation
Under National Eligibility Scenarios
Thomas DeLeire, Ph.D.; Lindsey Leininger, Ph.D.;
Donna A Friedsam, M.P.H.
Presented by: Thomas DeLeire, Ph.D., Associate
Professor, Population Health Sciences, University of
Wisconsin, 760 WARF Building, 610 Walnut Street,
Madison, WI 53726; Phone: (608) 263-4881; Email:
deleire@wisc.edu
Research Objective: The aims of this paper are: 1)
estimate the number of parents with children already
enrolled in public coverage who could potentially be
autoconverted into Medicaid, 2) estimate the total
number of potentially newly eligible adults so as to
determine the fraction that are potential autoenrollees,
and 3) estimate the fraction of potential autoenrollees
who were previously uninsured. In February 2008,
Wisconsin launched substantial reforms to its Medicaid
and SCHIP programs, including a large-scale eligibility
expansion. The Wisconsin Department of Health
Services, prior to program launch, applied the new
eligibility algorithm to existing cases within state
administrative databases. The process resulted in the
automatic conversion of eligibility status among many
previously ineligible applicants and formerly ineligible
family members of current enrollees. This
“autoconversion” effort yielded over 40,000 new
enrollees (roughly 2/3 of whom were adults) into public
coverage, representing well over half of new enrollment
in the first month of BadgerCare Plus. The current
federal health care legislation relies extensively on
expansion of Medicaid eligibility to previously ineligible
adults in order to increase coverage. Low-income
parents, many with children currently enrolled in
Medicaid, may represent an appreciable portion of the
newly eligible population, and thus represent a promising
target group for automatic enrollment into coverage. The
extent to which eligibility may change for low-income
adults under proposed federal legislation differs across
states, because of state-level variation in adults’
eligibility for Medicaid/SCHIP.
Study Design: Data are drawn from the 2008 American
Community Survey (ACS). The design of the ACS
supports state-level estimates of health insurance
coverage, so we are able to estimate the number of
newly eligible low-income parents with children enrolled
in public coverage—the “autoconversion group” of
interest—separately for each state. We then estimate
the proportion of all newly eligible adults that belong to
the autoconversion group, again by state. The sources
of current insurance coverage for the autoconversion
group are also computed.
Population Studied: Estimates are created under two
scenarios: first under the assumption that Medicaid
eligibility would be extended to all adults with incomes
under 133% of the federal poverty level (FPL), reflective
of the proposed threshold in the House of
Representatives; and, alternatively, under the
assumption that eligibility would be extended to all adults
with incomes under 100% FPL, reflective of the Senate’s
proposal.
Principal Findings: Using the 133% FPL threshold,
preliminary estimates suggest that approximately 10% of
newly eligible adults nationally could potentially be autoenrolled into coverage. This proportion ranges from 4%
to 17% among the 32 states that currently set parental
eligibility below the proposed threshold. Within the
autoconversion group, 46% are currently uninsured.
Conclusions: Autoconversion has proven success in
enrolling newly eligible populations into Medicaid. It
holds considerable promise as an implementation tool
for both federally-mandated and state-initiated eligibility
expansions.
Implications for Policy, Delivery or Practice: Newly
eligible parents of children currently enrolled in public
coverage are an exemplar population for whom
autoconversion may be feasible to implement in many
states and for whom the impact on uninsurance could be
substantial.
Funding Source(s): RWJF, Wisconsin Department of
Health Services
• The Impact of San Francisco’s Employer Health
Spending Requirement: Findings from the Labor and
Product Markets
Arindrajit Dube, Ph.D.; Carrie Hoverman Colla, M.A.;
William Dow, Ph.D.; Thomas William Lester, Ph.D.
Presented by: Arindrajit Dube, Ph.D., Assistant
Professor, Economics, Thompson Hall, University of
Massachusetts, Amherst, MA 01003; Phone: (510) 6846733; Email: adube@econs.umass.edu
Research Objective: To estimate the effect of San
Francisco's employer health spending requirement
(which went into effect in January 2008) on the labor and
product markets. We evaluate the impact on
employment and payroll, and also pass-through of the
cost to consumers.
Study Design: We use a difference-in-difference
strategy by comparing changes in trends in San
Francisco to those of neighboring counties that did not
implement any comparable new employer mandate. We
used data on five counties surrounding San Francisco as
a control group (Alameda, Contra Costa, Marin, San
Mateo, and Santa Clara). Our pre period consists of the
1990q1 to 2007q4, while the post period consists of
2008q1 to 2009q1, most recent data available. The data
comes from the Quarterly Census of Employment and
Wages collected by the BLS. We also surveyed
restaurants in San Francisco to estimate the incidence of
a mandate-specific surcharge imposed by some
restaurants in the city.
Population Studied: We chose to focus our attention on
the private sector industries most impacted by the
employer requirement: Retail Establishments (NAICS
codes 44-45), Accommodation and Food Services (72),
Eating and Drinking Places (722), as well as overall
private sector employment. These low wage sectors are
also were wage offsets are less likely due to minimum
wage constraints.
Principal Findings: Employment patterns in San
Francisco did not change appreciably following the
policy as compared to control counties in most empirical
specifications. This was true for most affected industries,
as well as overall private sector employment. The results
are robust to inclusion of county-specific time trends and
alternative business cycle controls. About 25% of
restaurants imposed surcharges of around 4% of the bill.
Conclusions: While it is still somewhat early, the
employer health spending requirement in San Francisco
did not lead to appreciable job losses in the five quarters
following its implementation. It appears that part of the
incidence of the mandate falls on consumers as
evidenced by the use of surcharges by many
restaurants.
Implications for Policy, Delivery or Practice: While it
is difficult to ascertain the external validity of results from
a single city, the experience in San Francisco suggests
that employer health spending mandates may be an
effective way of expanding coverage without causing
disemployment among intended beneficiaries.
Funding Source(s): RWJF, UC LERF, UC CPAC
• How Health Reform Affected the Health Care Safety
Net in Massachusetts
Emily Jones, M.P.P., Ph.D. Candidate; Leighton Ku,
Ph.D., M.P.H.; Peter Shin, Ph.D., M.P.H.; Fraser Byrne,
M.A.
Presented by: Emily Jones, M.P.P., Ph.D. Candidate,
Research Associate, Dept. of Health Policy, George
Washington University, 2021 K Street, NW, Washington,
DC 20006; Phone: (202) 994-4240; Email:
emjones@gwu.edu
Research Objective: This study assesses the effect of
the Massachusetts state health reform, Chapter 58, on
the health care safety net and its users, particularly
community health centers (CHCs). Findings from the
Bay State may have implications for the potential
impacts of national health reform. A key question is how
the status of safety net providers changes as the percent
of uninsured people fall.
Study Design: In 2008-9, we analyzed administrative
data about CHCs in Massachusetts (from the Uniform
Data System, UDS) and conducted site visits. In 200910, we are continuing and expanding the research
scope. In addition to the previous components, we will
conduct focus groups and analyze recent survey data of
health care utilization in Massachusetts, including some
new questions designed and added to the
Massachusetts Health Reform Survey. The scope will be
extended beyond CHCs to also include safety net
hospitals and other community providers, such as
community mental health agencies.
Population Studied: Safety net providers, including
CHCs, hospitals and other providers, and their patients.
Principal Findings: Census and other survey data
show that the percent of Massachusetts residents who
are uninsured fell sharply after implementation of health
reform in 2006. Preliminary analyses of UDS data reveal
CHC caseloads have grown steadily after health reform,
rising from 431,005 in 2005 to 534,503 in 2008. The
proportion of uninsured CHC patients fell from 35.5% to
21.4%, while the proportion of health center patients with
Medicaid, CHIP or Commonwealth Care rose from
38.4% to 50.8%. Per capita revenues and costs both
grew appreciably after health reform, but the net margins
hovered close to zero. The percentage of uninsured
Massachusetts residents who received care at health
centers grew from 22 percent in 2006 to 36 percent in
2007. Analyses will be substantially expanded by June
2010. Preliminary data suggest that financial conditions
at some safety net hospitals have deteriorated, but this
may be due to recession-related state budget cuts, not
health reform.
Conclusions: The health care safety net continues to
be a vital component of the health delivery system, even
when far fewer are uninsured. Preliminary analyses
suggest that many of the uninsured who gained
insurance still receive care at safety net facilities and a
larger share of those who remain uninsured may be
obtaining care from the safety net. Payment rates for
safety net providers under Medicaid and Commonwealth
Care are critical factors for the status of safety net
providers.
Implications for Policy, Delivery or Practice: This
suggests there is a gradual transformation of the role of
safety net providers post-health reform. Although they
are still critical providers for the uninsured, they are also
key providers for the newly insured who continue to have
serious underlying health and social problems. It will be
important to consider transitional and long-term payment
arrangements for safety net providers under Medicaid
and other forms of insurance
Funding Source(s): Blue Cross Blue Shield of
Massachusetts Foundation
• Child Medicaid Enrollment Trends: Comparison
Across 50 States
Susmita Pati, M.D., M.P.H.; Jane Kavanagh; Lihai Song,
M.S.; Kathleen Noonan, J.D.; Xianqun Luan, M.S.
Presented by: Susmita Pati, M.D., M.P.H., Assistant
Professor of Pediatrics, General Pediatrics, The
Children's Hospital of Philadelphia, 34th Street and Civic
Center Boulevard, CHOP North, Room 1534,
Philadelphia, PA 19106; Phone: (267) 426-5056; Email:
pati@email.chop.edu
Research Objective: Gaps in child health insurance
coverage have been associated with delays in obtaining
necessary medical care. Despite various state and
federal efforts to streamline Medicaid enrollment for
children, many eligible children experience gaps in
coverage. This study compares child Medicaid
enrollment patterns across all 50 states and determines
the effect of individual characteristics and state-level
processes on child Medicaid retention patterns.
Study Design: This is a retrospective cohort study
combining state-level Medicaid renewal process data
with 50-state administrative Medicaid eligibility data for
children (1-18 yrs) obtained from the Center for
Medicare and Medicaid Services. State-level
characteristics (i.e. renewal frequency, continuous
eligibility policy) were obtained from internet searches,
Kaiser Family Foundation data, and surveys with
Medicaid staff. Enrollment trends were analyzed in
relation to individual and state-level variables.
Population Studied: All children (1-18 yrs) in all 50
states and Washington, DC enrolled in Medicaid at any
point in 2001-2002.
Principal Findings: Nationally, young and non-Hispanic
white children were at slightly higher risk of
disenrollment than their peers. Children with chronic
conditions were 30.5% less likely to be disenrolled than
their healthy peers. Children in foster care and those
with SSI were 52.8% and 38.1% less likely, respectively,
to be disenrolled than income-eligible children. The
mean duration of Medicaid coverage for a child in a 24month period was 20.1 months. This duration varied
greatly among states from 14.2 (SE=9.04) months in
Georgia to 22.0 (SE=3.78) months in South Carolina.
The percentage of children with one or more gaps in
Medicaid coverage ranged from 31.5% in South Carolina
to 80.4% in Oklahoma with a national mean of 48%. The
length of each individual gap was likewise variable from
4.2 (SE=3.18) months in Alaska to 7.1 months in Utah
(SE=4.59) and Virginia (SE=4.97) with a national mean
of 5.8 (SE=3.65) months. Proportional hazards
regression models demonstrate that children living in
Nevada were most at risk of experiencing gaps in
coverage and children living in South Carolina were least
at risk. In states requiring 6-month eligibility
recertifications, children were 31.5% more likely to
experience a gap than in states with annual renewals.
Recipients in states without 12-month continuous
eligibility were 17.5% more likely than others to
experience a gap.
Conclusions: There are significant disparities between
states in child Medicaid coverage duration and risk of
disenrollment from Medicaid.
Implications for Policy, Delivery or Practice: The
state-level disparities observed in Medicaid enrollment
patterns warrant additional research and policy review to
understand the state-level characteristics that underlie
state differences (e.g., program standards, governance).
In particular, states with high coverage rates might be
reviewed in short-term to identify promising practice and
policy factors.
Funding Source(s): National Institute of Child Health
and Human Development
Home- and Community-Based Care
Chair: Peter Kemper
Tuesday, June 29 * 8:00 am–9:30 am
• Income and the Utilization of Long-Term Care
Services
David Grabowski, Ph.D.; Gopi Shah Goda, Ph.D.; Ezra
Golberstein, Ph.D.
Presented by: David Grabowski, Ph.D., Associate
Professor, Harvard Medical School, Health Care Policy,
180 Longwood Avenue, Boston, MA 02115; Phone:
(617) 432-3369; Email: grabowski@med.harvard.edu
Research Objective: Although many individuals receive
some long-term care coverage under Medicaid and a
small number of individuals purchase private coverage,
long-term care represents the largest source of
catastrophic costs for the elderly. In this context, an
individual’s income may be an important determinant of
the utilization of various long-term care services. The
objective of this paper to examine the effect of income
on long-term care utilization.
Study Design: This paper estimates the impact of
income on the long-term care utilization of elderly
Americans using a natural experiment based on the
“notch” cohort that led otherwise similar retirees to
receive significantly different Social Security payments
based on their year of birth. By exploiting this exogenous
shift in income, we avoid bias arising from unobserved
characteristics that are correlated with both an
individual’s income and their propensity to use long-term
care services, an advantage over previous studies.
Population Studied: Data from the 1993 and 1995
waves of the AHEAD. The AHEAD is a longitudinal
survey of community-based elderly individuals born in
1923 or earlier and their spouses, regardless of age. The
baseline data that comprise the 1993 wave of the
AHEAD survey were collected between October 1993
and July 1994 on 8,222 individuals from 6,047
households.
Principal Findings: We estimate models of instrumental
variables and find that an increase in income lowers
nursing home use but increases the utilization of paid
home care services. Specifically, a $1,000 increase in
income raises the likelihood of home care by 3.4
percentage points (or 30.3% relative to the mean) and
decreases the likelihood of nursing home use by three
percentage points (or 33.6% of the mean). Social
Security income was not systematically related to the
provision of informal care across the different
specifications, and we find evidence that part of the shift
away from nursing home use and towards paid home
care services is due to a substitution effect.
Conclusions: The magnitude of our estimates suggests
that moderate reductions in post-retirement income
would significantly alter long-term utilization patterns
among elderly individuals.
Implications for Policy, Delivery or Practice: In the
context of the recent economic recession, future
reductions in post-retirement income could dramatically
alter elderly individuals’ patterns of long-term care
service utilization. Moreover, because individuals
generally prefer long-term care in the least restrictive
setting possible, there may also be important welfare
effects as individuals transition across long-term care
settings such as informal care from family and friends,
paid home care, assisted living facilities and nursing
homes.
• Using Community Health Workers to Target Home
and Community-Based Long-Term Care: A
Propensity Score Analysis of Economic Impact
Glen Mays, Ph.D., M.P.H.; Holly Felix, Ph.D., M.P.A.;
Kate Stewart, M.D., M.P.A.; Naomi Cottoms, M.A.; Mary
Olson, D.Div.
Presented by: Glen Mays, Ph.D., M.P.H., Professor,
Health Policy and Management, University of Arkansas
for Medical Sciences, 4301 West Markham Street, Little
Rock, AR 72205; Phone: (501) 526-6647; Email:
gpmays@uams.edu
Research Objective: Consumer preferences and court
rulings have pressured state Medicaid programs to
expand home and community-based services (HCBS) as
alternatives to institutional long-term care. Despite their
lower per-capita costs, many HCBS expansions have
failed to reduce long-term care (LTC) spending because
small decreases in nursing home utilization often are
more than offset by increased HCBS spending on
individuals who would not have entered a nursing home
in the absence of HCBS. Moreover, the complexity of
local HCBS delivery systems may limit access to care for
individuals who are at greatest risk for nursing home
entry. This study evaluates the economic impact of the
Arkansas Community Connector Program (CCP), a
novel Medicaid demonstration program that uses
community health workers (CHWs) to identify
community-dwelling adults with unmet LTC needs and
link them to needed HCBS.
Study Design: A quasi-experimental design was used in
which Medicaid recipients participating in CCP are
observed one year prior to their participation and up to
three years after participation, and compared to a similar
group of Medicaid residents residing in five nonintervention counties located in the same region of the
state. Propensity score matching was used to ensure a
close match between CCP participants and the
comparison group on pre-participation measures of
demographics, case mix, and service use. Multivariate
difference-in-difference estimation is used to estimate
program effects.
Population Studied: The study included a total of 919
elderly and disabled adult Medicaid recipients residing in
the service area within the rural, underserved area of
Arkansas’ Mississippi River Delta region and served by
CCP during 2005-2008. Participants were propensitymatched to 944 comparison group members residing in
the Delta outside the CCP service area. In both groups,
two-thirds were female and three-fourths were African
American.
Principal Findings: Multivariate estimates indicate that
the CCP program resulted in a 23.8 percent reduction in
annual Medicaid spending per program participant over
the three-year demonstration period (p<0.01), with most
of this reduction occurring in the second and third years
following program participation. CCP participants were
more likely to use home and community-based LTC
services while incurring lower average nursing home
expenditures than their counterparts in the comparison
group.
Conclusions: Results suggest the CCP program
achieved its intended effect of enhancing access to
HCBS for disabled and elderly residents of rural,
underserved areas within Arkansas, thereby reducing
the need for institutional care and achieving cost-savings
for the Medicaid program. Estimates indicate the
program generated a net savings of $2.6 million for the
state Medicaid program, or a return on investment of
$2.92 per dollar invested in the program. Further study
will be required to examine the persistence of initial cost
savings over time and to test the generalizibility of
findings to other settings.
Implications for Policy, Delivery or Practice: Findings
add to the handful of studies showing savings CHW
programs can generate and suggest the CHW model
may be an efficient mechanism for targeting home and
community-based services to low income persons at risk
for nursing home entry, particularly in rural and
underserved areas.
Funding Source(s): Enterprise Corporation for the
Delta
• Recruitment, Retention, and Job Satisfaction
among Personal Care Attendants in Massachusetts
Karen Schneider, Ph.D.; James Maxwell, Ph.D.; Anna
Graves, B.A.; Jaya Mathur, B.A.; Tom Mangione, Ph.D.;
Christine Bishop, Ph.D.
Presented by: Karen Schneider, Ph.D., Sr. Research
Scientist, JSI Research and Training Institute, Inc., 44
Farnsworth Street, Boston, MA 02210; Phone: (617)
482-9485; Email: kschneider@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, training, and
supervising workers. They are allowed to hire anyone,
including family members, to work as paid caregivers.
The purpose of this study is to evaluate the recruitment
and retention issues as well as job satisfaction among
PCA workers.
Study Design: A 30-minute telephone survey was
conducted with a random sample of PCA workers.
Survey questions were taken from evaluations of other
state PCA programs and direct service workers.
Population Studied: Interviews were completed with
515 PCA workers in 2009. One third of the surveyed
PCA workers were family members of consumers and
women comprised 81% of the analytic sample. In terms
of the age, 19% of the workers were younger than 35,
37% were 35 to 55 years, and 44% were 55 years and
older.
Principal Findings: PCA workers were most frequently
recruited through informal mechanisms such as being
recommended by a family member (46.8%) or being
approached by a consumer (21.7%), compared to formal
mechanisms such as the newspaper (7.4%) or online
employment services (1.6%). With respect to retention,
72% percent of PCA workers reported that they were
“not at all likely to leave their job in the next year,” and
13% were unsure. For those at least somewhat likely to
leave their PCA job, 30% were planning on switching
careers, 18% were planning on going back to school,
15% were either moving out of the area or having
personal health issues, 13% had consumers who were
getting better or moving on to a nursing home, and 7%
were planning on retiring. In terms of overall job
satisfaction, PCA workers were overwhelming satisfied,
with 70% being very satisfied and 23% being somewhat
satisfied. Three percent were neutral in their feelings and
another 3 percent expressed dissatisfaction with their
job. Sixty percent of PCAs would definitely recommend
their job to a friend or acquaintance, and 27% would
probably recommend it. Frequently cited problems
included not getting paid more for staying longer in the
job (66%), not getting insurance through the PCA
program (47%), not getting a higher wage for more skill
(54%), and current wage (54%).
Conclusions: Results from this survey show that
retention of PCA workers may be less of a problem than
state policymakers initially expected, demonstrated by
the fact that most people intend to stay in their current
PCA job. Many PCAs in the survey had stayed in their
jobs for more than five or ten years. In general, PCA
workers were satisfied with their jobs, and would
recommend it to others with an interest in the field. PCAs
describe a number of benefits of the job related to their
desire to help others. Compensation issues were the
frequently mentioned problems with the program.
Implications for Policy, Delivery or Practice: PCAs
recommended that compensation should be restructured
and benefits enhanced. PCAs expressed an interest the
establishment of career ladders that would allow them to
enhance their skill and income potential, while staying in
the long term care field.
Funding Source(s): Massachusetts PCA Quality Home
Care Workforce Council
• Is Informal Care Dynastic? The Role of Genetics
and Preferences in Long-Term Care Insurance
Decisions
Courtney Van Houtven, Ph.D.; Norma B. Coe, Ph.D.
Presented by: Courtney Van Houtven, Ph.D.,
Assistant Professor, HSR&D/General Internal Medicine,
VA/Duke, 508 Fulton Street, Durham, NC 27514;
Phone: (919) 286-6936; Email:
courtney.vanhoutven@duke.edu
Research Objective: Long-term care is one of the
biggest financial risks facing the elderly today yet very
few people—10% of 65 year olds—insure against the
risk of needing LTC. In parallel, public long-term care
costs are high and expected to increase. It is imperative
for policymakers to understand more about the future
demands for long-term care arrangements and who
bears the costs in order to plan for the future. Very little
work predicting LTC expenditures incorporates informal
care (IC). IC has implications for long-term care costs,
health, and economic well-being. IC reduces Medicare
long-term care for care recipients, yet IC causes mental
and physical health problems and reduced labor force
participation among caregivers. Because 22-54 million
persons in the U.S. provide IC, understanding how
caregivers are planning for their own long-term care is
paramount. This paper asks two main questions: (1)
Does providing IC change an individual’s own
perceptions of future care needs? (2) Does providing IC
increase the take-up of private LTC insurance? Changes
in expectations about LTC among caregivers will have
distinct implications for the future cost of LTC and can
inform us about whether the negative economic and
health effects of IC are dynastic or limited to one
generation.
Study Design: In our longitidunal analysis, we construct
separate probit models for two outcomes: (1) Chance of
ever entering a nursing home and (2) Currently have
LTC insurance. Models control for ever providing IC,
demographics, health, risk-aversion, number of children,
wealth, and wave. The type of care recipient and
caregiver help us disentangle whether changes in
outcomes are explained by one’s perceived genetic risk
of needing LTC or a change in preferences for LTC. The
genetic effect is found by comparing effects on the two
main outcomes for different care recipients (parents
versus inlaws), and the preferences effect by comparing
different caregivers (oneself to one’s siblings).
Population Studied: Using the Health and Retirement
Survey from 1996-2006, the sample includes individuals
65 and above who did not have LTC insurance prior to
caregiving (N= 41,807 person-waves of data).
Principal Findings: While caregiving itself does not
have an independent effect on LTC insurance uptake,
being a caregiver changes one’s expectations for future
long-term care use. Caregiving leads to higher
expectations for formal care. The negative burden of
being a caregiver leads to a preference shift for LTC,
rather than the information that caregivers gain
knowledge about their own genetic risk for LTC.
Conclusions: Our findings suggest very different LTC
arrangements in the future, with a much greater reliance
on formal LTC among caregivers. The burden of informal
care explains the shift in preferences for formal LTC.
This shift also suggests that the negative health and
wealth effects of caregiving will be limited to one
generation and not be dynastic.
Implications for Policy, Delivery or Practice:
Incorporating the preferences of informal caregivers into
LTC expenditure models would help improve the
accuracy of expenditure predictions and be more useful
for policymakers.
Funding Source(s): Hartford Foundation
• Analysis of a Claims-Based Hospitalization
Measure for Home Health
Christianna Williams, Ph.D.; Alan White, Ph.D.; Barbara
Bell
Presented by: Alan White, Ph.D., Principal Associate,
Abt Associates, 4620 Creekstone Drive, Suite 190,
Durham, NC 27703; Phone: (919) 294-7719; Email:
alan_white@abtassoc.com
Research Objective: The Home Health Compare
website reports a hospitalization measure derived from
Outcome and Assessment Information Set (OASIS)
data. A claims-based hospitalization measure may
provide more objective and accurate data. We compared
results from OASIS and claims-based hospitalization
measures and assessed a measure based on potentially
avoidable hospitalizations.
Study Design: We linked OASIS data to claims-based
inpatient records from the Home Health Datalink file for
the same episode. We analyzed agreement between the
OASIS and claims-based measures, explored different
time period specifications for the claims-based measure,
and tested how well the risk-adjustment model
developed for the OASIS measure performed for the
claims-based measure. Potentially-avoidable
hospitalizations were identified based on the
specifications developed by the Agency for Healthcare
Quality and Research (AHRQ). These are
hospitalizations that stem from conditions considered
largely avoidable and/or manageable if treated in a
timely fashion with outpatient physician and other
medical support services.
Population Studied: We used a 10% random sample of
home health beneficiaries who had payment episodes in
2004-2005.
Principal Findings: The prevalence of hospitalizations
during care episodes was 30.9% for the OASIS
measure, higher than the 25.2% rate based on claims
(although 30.7% of episodes had a hospitalization within
7 days of episode end). Agreement between the OASIS
and claims-based measures was quite high. For the
claims-based measure with the same time period
specification as the OASIS measure, there was
agreement as to the presence/absence of a hospital
admission in 91.9% of episodes. Based on primary
diagnosis, 9.8% of episodes had a potentially avoidable
hospitalization, meaning that only 32.1% of
hospitalizations were classified as potentially avoidable.
Based on primary or secondary diagnoses, nearly 90%
of all episodes with any hospitalization were classified as
having a potentially avoidable hospitalization. Total
payments associated with these hospitalizations
exceeded $3 billion. The OBQI risk adjustment model
applied to the claims-based measure performed quite
well, with area under the ROC curve (c-statistic)
exceeding 0.7 in all cases. The model did not perform as
well for the potentially avoidable hospitalization
measure, suggesting a need for development of a
different risk-adjustment model.
Conclusions: We found substantial agreement between
the OASIS and claims-based measure, suggesting that
the OASIS-based measure is a valid one, albeit because
providers may already be reporting hospitalizations that
occur after the home health episode ends. The claimsbased measure may be preferable because it permits
specification of potentially avoidable hospitalizations and
hospitalizations that began after the end of the home
health episode. Limitations of the claims-based measure
include lags in data availability and its limitation to feefor-service utilization. Given the relatively good fit of the
current risk-adjustment model to the claims-based
measure, it is not clear that development of a new model
is warranted. However, a new model would be required
for a measure based only on potentially-avoidable
hospitalizations.
Implications for Policy, Delivery or Practice: The
research establishes the validity of the OASIS-based
hospitalization measure. Further research may be
appropriate before this measure is used in a pay-forperformance system.
Funding Source(s): CMS
Incentives for Providers: Long-Term Impact and
Unintended Consequences
Chair: R. Adams Dudley
Tuesday, June 29 * 8:00 am–9:30 am
• Assessing Unintended Consequences in Pay for
Performance
Cheryl Damberg, Ph.D.; Kristiana Raube, Ph.D.; Erin
dela Cruz, B.S.; Allen Fremont, Ph.D.; Marc Elliott, Ph.D.
Presented by: Cheryl Damberg, Ph.D., Senior
Researcher, RAND Health, 1776 Main Street, Santa
Monica, CA 90407; Phone: (310) 393-0411; Email:
damberg@rand.org
Research Objective: This study examined potential
unintended consequences of P4P in further exacerbating
disparities. Hypotheses: physician groups that were
exposed to P4P and served a greater proportion of
disadvantaged patients (e.g., lower income such as
higher proportion of Medicaid, lower education levels,
minority, non-English speaking) would: 1) perform less
well under P4P, 2) receive smaller per capita incentive
payments relative to groups with fewer disadvantaged
patients, and 3) be less well resourced in terms of their
base capitation payments.
Study Design: Using health plan patient-level data for
158 physician groups in the CA Integrated Healthcare
Association’s (IHA) P4P program, we imputed indirect
estimates of race/ethnicity and other SES characteristics
at the Census block level (Elliott et al. 2009). The
patient-level race/ethnicity and SES data were
aggregated across patients within groups and used to
characterize groups on the basis of indicators of
disadvantage (i.e., low education, low income, %
Medicaid patients, higher proportion of racial and ethnic
minority patients). We constructed, using an
opportunities model, an overall clinical composite from
the 2007 group-level clinical performance measures. We
ran multivariate regression models to test the
relationship between clinical performance and indicators
of disadvantage, controlling for group structural
characteristics (IPA/Medical group, group size, #
practice sites, % of Medicaid enrollment), and base
capitation rates. Correlations were computed on the
relationship between base capitation rates and
performance levels, and between capitation rates and
level of disadvantage.
Population Studied: 158 physician groups with HMO
and POS commercial clinical results data participating in
the California IHA P4P program
Principal Findings: Groups varied significantly in the
socio-economic and demographic characteristics of their
patient populations. The average percent of a PO’s
patient population of non-white race/ethnicity is 53.7%
(SD=20.8%, range from 9.3% to 95.7%). Avenuerage
median incomes by group ranged from $31,000 to
$85,000 (M=$53,000, SD=$11,000) and percent of
individuals without a high school diploma ranging from
8.0% to 62.5% (M=24.6%, SD=10.1%). We observed a
moderate negative correlation between performance and
having a more disadvantaged patient population (higher
percentage of patients of minority background (r= -0.36,
p<.0001), lower educational status (r= -0.40, p,.001),
lower income (r= -0.50, p<0.001). Capitation rates were
also negatively correlated for groups with more
disadvantaged patient populations. Regression model
results (R2=.49) show that controlling for group type,
size of group, and capitation rate, groups that served
more challenging patient populations performed more
poorly on clinical quality measures (and in turn received
lower incentive payments). A $1,000 decrease in
average median household income was associated with
a 0.20 decrease in a group’s clinical performance score
(p=0.03). Additionally, POs with Medicaid populations
greater than the sample median (as a percent of total
enrollment) had clinical scores an average of -5.96
percentage points below other POs (p=.012).
Race/ethnicity shows the expected directional effect, but
was insignificant (ß= -0.02, p=0.68). Capitation rates
were negatively associated with clinical performance
(p<0.005).
Conclusions: Physician groups with larger
concentrations of disadvantaged patient populations
performed less well on the clinical measures, resulting in
lower incentive payments. Furthermore, the
“disadvantaged” groups were less resourced to take
care of patients given lower capitation rates, and the
lower capitation rates were significantly associated with
worse performance.
Implications for Policy, Delivery or Practice: Given
fewer resources to manage more challenging patients
(lower capitation rates and lower incentive payments as
a function of poor performance), consideration should be
given to addressing how to best support groups that
serve larger concentrations of disparate patient
populations within the context of performance-based
accountability schemes. Alternative incentive schemes
should be examined as a means to distribute incentive
payments differently to incent provider groups to close
the disparity gap in performance.
Funding Source(s): RWJF
• The Long-Term Impact of the UK’s Pay-forPerformance Scheme on Incentivized and
Unincentivized Aspects of Care
Tim Doran, M.B.Ch.B., B.Sc., M.P.H., M.D.; Evan
Kontopantelis, Ph.D.; David Reeves, Ph.D.; Martin
Roland, M.D.
Presented by: Tim Doran, M.B.Ch.B., B.Sc., M.P.H.,
M.D., Clinical Lecturer, Health Policy, Harvard School of
Public Health, 677 Huntington Avenue, Boston, MA
02115; Phone: (617) 432-3271; Email:
tdoran@hsph.harvard.edu
Research Objective: The Quality and Outcomes
Framework (QOF), introduced in 2004, links
remuneration for family practices in the UK to a range of
quality of care indicators. Practices generally performed
well in the first year of the scheme, but three main
concerns remain: i) quality of care might have been
improving prior to scheme, so high performance may not
represent genuine improvement; ii) any improvement
might be short-term in nature; and iii) quality of care for
non-incentivised activities might have been adversely
affected. We compared changes in achievement trends
after implementation of the incentive scheme for
indicators included in the scheme with changes for
indicators not included.
Study Design: Multi-level multivariate regression. We
analysed 48 quality of care indicators nested in three
categories: a) 28 ‘fully incentivised’ indicators, i.e.
included in the original QOF; b) 13 ‘partially incentivised’
indicators, i.e. where either the condition or the activity
was included in the QOF; c) 7 ‘unincentivised’ indicators,
i.e. where neither the condition nor the activity was
included in the QOF. Annual achievement rates for 150
family practices were calculated for each indicator, and
transformed to the logit scale to reduce ceiling effects.
We measured: i) short-term uplift - the difference
between the achievement rate predicted from the preincentive trend and actual achievement in 2004/5 (the
first year of the scheme); ii) long-term uplift - the
corresponding difference in 2006/7 (the third year of the
scheme).
Population Studied: 660,565 patients registered with a
nationally representative sample of 150 English family
practices between 2000 and 2007.
Principal Findings: In the pre-incentive period (2000/1
to 2002/3) achievement rates increased for 46 of the 48
indicators. There were significant uplifts in the first year
of the incentive scheme (2004/5) for 27 of 28 fully
incentivized indicators, 3 of 13 partially incentivized
indicators and 1 of 7 unincentivized indicators.
Achievement rates for incentivized indicators plateaud
after 2004/5, and by 2006/7 there were significant uplifts
for just 15 fully incentivized, 1 partially incentivized and 1
unincentivized indicators. Achievement was significantly
below projections for 6 fully incentivized, 9 partially
incentivized and 2 unincentivized indicators. Long-term
uplifts for individual indicators ranged from -2.6%
(95%CI: -3.3% to -1.9%) to 20.1% (95%CI: 18.3% to
21.7%) for incentivized indicators, -9.7% (95%CI: -11.5%
to -7.9%) to 11.7% (95%CI: 9.2% to 14.0%) for partially
incentivized activities, and -12.8% (95%CI: -14.8% to 10.9%) to 8.1% (95%CI: 6.0% to 10.1%) for
unincentivized activities.
Conclusions: Quality of care was improving before the
introduction of the incentive scheme. The incentives
resulted in short-term increases in the rate of quality
improvement for most incentivised activities, after which
quality plateaud. For partially incentivized and
unincentivized indicators the incentive scheme had little
impact – either positive or negative – in the first year, but
thereafter the rate of improvement declined, so that by
2006/7 quality was worse than projected from preincentive trends.
Implications for Policy, Delivery or Practice: The
positive impacts of pay-for-performance schemes may
be confined to directly incentivized activities and may be
short-term in nature.
Funding Source(s): University of Manchester
• Unintended Effects of Public Reporting: Selective
Discharge from Nursing Homes
R. Tamara Konetzka, Ph.D.; Dan Polsky, Ph.D.;
Elizabeth Stuart, Ph.D.; Rachel Werner, M.D., Ph.D.
Presented by: R. Tamara Konetzka, Ph.D., Assistant
Professor, Dept of Health Studies, University of Chicago,
5841 S Maryland, MC2007, Chicago, IL 60637; Phone: (
773) 834-2202; Email: konetzka@uchicago.edu
Research Objective: Prior studies have examined
whether public reporting of quality causes providers to
select healthier patients for treatment. Patient selection
is usually conceived of as occurring on admission, as
quality is usually measured for all of a provider’s
patients. In some settings, however, quality is measured
only at a single point in time, and thus providers may
select patients for inclusion in public reporting by
selectively discharging sicker patients before the point of
measurement. Our objective is to assess whether
selective discharge occurred when public reporting-Nursing Home Compare--was instituted for nursing
homes in 2002. Selective discharge to the hospital is of
key interest, as rehospitalizations are costly and often
risky for frail elderly individuals.
Study Design: Nursing Home Compare post-acute
quality is measured only after 14 days of a post-acute
stay, though approximately 40 percent of patients do not
stay that long. We identify selective discharge
associated with public reporting by assessing whether
the number of discharges occurring prior to the 14-day
cutoff increased; whether increased rehospitalizations
were concentrated among those that were potentially
discretionary; whether pilot states that implemented
Nursing Home Compare earlier experienced increased
rehospitalizations earlier; and whether increased
rehospitalizations were concentrated among patients
that were at high risk for bad outcomes on reported
measures. All analyses used linear probability models
with facility fixed effects. Propensity score matching was
used to control carefully for changes in patient severity
over time.
Population Studied: Post-acute residents of skilled
nursing facilities nationwide during 1999-2005. We
merge clinical assessments from the nursing home
Minimum Data Set with corresponding Medicare claims,
resulting in 9 million patient-level observations from
8,137 skilled nursing facilities.
Principal Findings: After Nursing Home Compare was
implemented, discharges just before the 14-day cutoff
increased relative to discharges on day 15 or just after.
Furthermore, among discharges before the 14-day
cutoff, potentially discretionary hospitalizations
increased, while there was no change in potentially
nondiscretionary hospitalizations; thus, increased patient
severity is not a plausible explanation. The estimated
magnitude of effect is 0.5 percentage points,
representing a 4 percent increase in 14-day
discretionary hospitalizations from a base of 12 percent.
Finally, the increases in discharge prior to the 14-day
cutoff occurred earlier for pilot states, corresponding to
the earlier launch of public reporting in these states, and
were greater for residents most at risk for bad outcomes
on reported measures.
Conclusions: Nursing home providers appear to be
responding to nursing home report cards by selectively
discharging sicker post-acute residents to the hospital to
improve scores. The magnitude of effect is modest but
meaningful.
Implications for Policy, Delivery or Practice: Although
the potential for provider selection has always been a
concern in the use of public reporting to improve health
care quality, few prior studies have assessed this
phenomenon rigorously and results have been mixed.
This study underscores the importance of monitoring
selection behavior and, in the case of nursing homes,
suggests that the use of 14-day assessments, while
convenient, may have unintended and costly
consequences. Their use would best be coupled with a
rehospitalization measure to counter this incentive.
Funding Source(s): Agency for Healthcare Research
and Quality
• Does P4P Discriminate Against Hospitals That
Serve Vulnerable Populations?
Eugene Kroch, Ph.D.; Kathy Belk, B.A.; Danielle Lloyd,
M.P.H.
Presented by: Eugene Kroch, Ph.D., Senior Fellow,
Leonard Davis Institute of Health Economics, University
of Pennsylvania, Philadelphia, PA 19104; Phone: (215)
689-2240; Email: ekroch@wharton.upenn.edu
Research Objective: Pay-for-performance (P4P) is the
mechanism that CMS has proposed to transform
Medicare from a passive payer of claims to an active
purchaser of care. The objective of this analysis is to
examine whether the CMS/Premier Hospital Quality
Incentive Demonstration (HQID) P4P awards and
recognitions disproportionately accrue to hospitals of
specific types or those that serve certain segments of
the patient population.
Study Design: This study analyzed performance
variation among HQID participants by three hospital
attributes: safety-net status, facility location (urban/rural),
and size. Performance variation is tracked three ways: 1)
number of hospitals receiving payment and public
recognition, 2) composite quality score (CQS), and 3)
CQS improvement over three years. This analysis
considered two definitions of safety-net hospitals: 1) a
disproportionate share hospital patient percent greater
than 15% and 2) an operating disproportionate share
hospital payment adjustment greater than 11.75% (340b
threshold).
Population Studied: This analysis examined process
and outcome measures from more than 250 HQID
participants over three years in five clinical areas – acute
myocardial infarction (AMI), congestive heart failure
(CHF), coronary artery bypass graft (CABG),
pneumonia, and hip/knee replacement.
Principal Findings: Safety net hospitals, regardless of
how defined, received fewer awards and less recognition
in the first two project years. Over three years the DSH
effects attenuated for hospitals receiving awards, but not
for hospitals receiving recognition. Location and size had
no systematic relationship with either payment awards or
public recognition. The evidence does not support a
performance disadvantage for safety net hospitals in
CABG, AMI, CHF and hip/knee replacement, where any
initial discrepancies largely disappeared by the third
year. The strongest performance results appear for
pneumonia, where all methods of segmenting hospitals
show statistically significant lower scores among safety
net hospitals which did not dissipate across time. In AMI,
CHF, CABG, and hip/knee replacement there is little
evidence to support a differential rate of improvement
among safety net hospitals. The strongest performance
results were in the pneumonia population where all
methods of segmenting hospitals show statistically
significant greater improvement in CQS scores among
safety net hospitals. Hospital location had no effect on
improvement rates. Improvement for CHF and hip/knee
replacement happened faster for smaller hospitals early
on, however this difference disappeared over time.
Conclusions: The findings support a general concern
that certain types of hospitals, especially those that
disproportionately treat vulnerable populations, benefited
less from payment incentives and public recognition.
Nevertheless, in our study these disparities dissipated
somewhat over time. By the third year of the
demonstration, evidence for statistically significant
disparity for top performance depended on the definition
of safety net, even though disparities in public
recognition persisted.
Implications for Policy, Delivery or Practice: These
findings have three major implications. First, the
evidence that certain types of hospitals take longer to
adjust to payment reform suggests that implementation
of P4P programs should be gradual to allow them time to
realign their priorities. Second, the finding that the
recognition gap did not disappear, even while the award
gap did, suggests that money matters. Third, these
results support the movement towards rewarding
improvement and crossing thresholds, not just top
performance.
• Financial Incentives Faced by Physicians Who
Treat Minorities and the Poor
Monica Peek, M.D., M.P.H.; Alyna Chien, M.D., M.S.; G.
Caleb Alexander, M.D., M.S.; Hui Tang, M.S.; Marshall
Chin, M.D., M.P.H.; Hoangmai Pham, M.D., M.P.H.
Presented by: Monica Peek, M.D., M.P.H., Assistant
Professor, Section of General Internal Medicine, The
University of Chicago, 5841 S. Maryland Avenue, MC
2007, Chicago, IL 60637; Phone: (773) 702-2083;
Email: mpeek@medicine.bsd.uchicago.edu
Research Objective: Policymakers have embraced
pay-for-performance and other approaches to valuebased purchasing as a core element of a redesigned
payment system. Yet concerns linger regarding whether
and how such programs might affect physicians who
treat disadvantaged populations such as racial/ethnic
minorities and the poor. Our objective was to examine
whether physicians with high proportions of minority/poor
patients have differential exposure to: (1) financial
incentives and (2) performance measures linked to these
incentives.
Study Design: We used data from the 2004-05
Community Tracking Study Physician Survey, a national
survey of non-federal physicians, to conduct multivariate
logistic regression analyses that describe associations
between primary predictor variables (i.e. the
percentages of African-American patients, Hispanic
patients, patients with language barriers, and practice
revenue from Medicaid) and outcomes of interest: 1)
financial incentives (i.e. fixed versus variable
compensation), and 2) performance measures (e.g.
productivity) linked to these incentives.
Population Studied: Non-federal physicians with
patient care > 20 hours a week. Residents and fellows
were ineligible, as were non-clinical specialties (e.g.
radiology).
Principal Findings: Physicians with high proportions of
minority/poor patients were significantly less likely to be
exposed to financial incentives than other physicians.
For example, those with > 50% revenue from Medicaid
had nearly half the odds of having variable
compensation than physicians with < 5% revenue from
Medicaid (adjusted OR 0.57; 95% CI, 0.35-0.94).
Physicians with the highest proportion of Hispanic
patients had nearly half the odds of exposure to financial
incentives than physicians with the lowest proportion of
Hispanic patients (adjusted OR: 0.57; 95% CI, 0.32,
0.98). Among physicians facing variable compensation,
those with high proportions of minority/poor patients
were less likely to have their incentives linked to
performance measured on productivity and more likely to
that measured on patient satisfaction, quality of care, or
cost profiling. For example, physicians with 25-49%
Hispanic patients had twice the odds as physicians with
< 5% Hispanics to have incentives measured on patient
satisfaction (adjusted OR: 2.01; 95% CI, 1.31-3.10) or
quality of care (adjusted OR: 2.08; 95% CI, 1.37-3.16).
Physicians with > 50% African-American patients had
twice the odds as physicians with < 5% AfricanAmerican patients to have their performance measured
by cost profiling (adjusted OR: 2.01; 95% CI, 1.21, 3.33).
Conclusions: Physicians who care for large
percentages of racial/ethnic minorities and the poor have
exposure to fewer, and different, financial incentives
than other physicians.
Implications for Policy, Delivery or Practice: In
approaching physicians caring for such populations,
insurers may need to emphasize incentives offered to
the medical practice as a whole, if individual physicians
are less likely to face direct incentives from their
employer. In addition, the performance measures may
need to complement or counterbalance the incentives
those physicians already face. For example, cost
profiling may have little desirable effect on the quality of
care for poor and minority patients, and may be more
appropriate for physicians treating fewer of these
patients. Payment reforms are more likely to improve
care quality and reduce disparities if their designs take
into account the range of experiences with financial
incentives across different subgroups of physicians.
Funding Source(s): National Institute for Diabetes and
Digestive and Kidney Diseases (NIDDK)
Service Use and Outcomes of Care for Vulnerable
Populations with Behavioral Health Problems
Chair: Nancy Hanrahan
Tuesday, June 29 * 8:00 am–9:30 am
• Are Returning Veterans with Alcohol and Drug
Dependency Participating in Reintegration
Programs?
Jennifer Humensky, Ph.D.; Denise Hynes, Ph.D.; Neil
Jordan, Ph.D.; Kevin Stroupe, Ph.D.
Presented by: Jennifer Humensky, Ph.D., PostDoctoral Fellow, Center for Management of Complex
Chronic Care, Edward Hines Jr VA Hospital, 5000 S.
Fifth Avenue (151H), Building 1, B251, Hines, IL 60141;
Phone: (708) 202-5863; Email:
Jennifer.Humensky@va.gov
Research Objective: Veterans returning from the wars
in Iraq and Afghanistan have a high prevalence of
behavioral health problems, including substance use
disorders (SUDs), and these rates have been increasing
substantially over the course of the Gulf War II period
(Seal et al., 2009). Veterans struggling with SUDs may
face a number of problems adjusting to civilian life,
including difficulties with maintaining employment and
inter-personal relationships. The VA offers a number of
treatment programs to help veterans reintegrate into
civilian life, including care management programs,
vocational rehabilitation programs, and tele-mental
health treatment. Our research objective was to
characterize veterans with SUDs who receive
reintegration services and to examine whether individual
characteristics predicted use of these services.
Study Design: We analyzed data from the VA’s
National Patient Care outpatient databases. We used
multivariate logistic regression to examine the use of
reintegration services for veterans with alcohol and drug
dependence. We controlled for demographics, income,
insurance status, combat experience, percent of service
connected disability and VA facility.
Population Studied: We examined all veterans ages 35
and younger who received outpatient treatment in VA
facilities in FY 2009 – about 4.9 million outpatient
encounters, comprising 355,692 unique patients. This
sample was predominantly male (81%), 18% AfricanAmerican and 12% Hispanic. About 80% were
uninsured, and the average household income was
about $18,000. About 3% of outpatient encounters were
for diagnoses of alcohol abuse and about 6% were for
diagnoses of drug dependence or non-dependent abuse
of drugs. About 3% of outpatient encounters were for
care management services, 2% were for tele-mental
health, and 1% were for vocational rehabilitation. The
sample excludes veterans not receiving outpatient care,
or not receiving VA care.
Principal Findings: Veterans with alcohol dependence
had greater odds than other VA patients of receiving
vocational rehabilitation (OR=1.23, p<0.001) and telemental health treatment (OR=1.75, p<0.001) but had
lower odds of receiving care management services
(OR=0.62, p<0.001). Persons with drug dependence or
non-dependent abuse of drugs had greater odds of
receiving tele-mental health (OR=1.72, p<0.001) but had
lower odds of receiving care management (OR=0.80,
p<0.001) and vocational rehabilitation (OR=0.96,
p<0.08). Male veterans had greater odds of receiving
vocational rehabilitation (OR =2.53, p<0.001), care
management (OR=1.42, p<0.001), and tele-mental
health (OR=1.08, p<0.001), compared to females.
Conclusions: Veterans with alcohol and drug abuse
problems have been less likely to receive care
management services. Additionally, female veterans
have been less likely to utilize reintegration services.
Implications for Policy, Delivery or Practice: This
study highlights areas in which veterans may be underutilizing available services. The findings may also be
applicable to understanding the use of health care
services, particularly care management and tele-mental
health, among persons with substance use dependency
in other health care settings. Further research is needed
to assess barriers to accessing services and how these
barriers can be overcome.
• Health Care and Employment Experiences of
Medicaid Buy-In Participants with Psychiatric
Disabilities
Su Liu, Ph.D.; Sarah Croake, M.P.P.; Bonnie O'Day,
Ph.D.
Presented by: Su Liu, Ph.D., Senior Researcher,
Mathematica Policy Research, 600 Maryland Avenue
SW, Suite 550, Washington, DC 22201; Phone: (202)
264-3499; Email: susu_cal@yahoo.com
Research Objective: Until recently, little attention has
been given to the employment experiences of people
with psychiatric disabilities and the continuous health
care they may need to support work. Some assume
mental illness creates cognitive and other deficits that
hinder employment prospects, others believe the job
stress could easily increase psychiatric symptoms; when
in fact, many individuals with severe mental illness do
work, and employment can play important roles in their
recovery. Nevertheless, they face many barriers, one of
which is the concern that working will result in the loss of
public health insurance. The Medicaid Buy-In (MBI)
program, currently offered by more than 40 states, is
designed to tackle this barrier by allowing people with
disabilities to “buy into” the Medicaid program when
higher earnings would normally make them ineligible.
This study provides a profile on people with psychiatric
disabilities who are working and participating MBI,
through which, policy considerations are suggested to
assure adequate care and improve employment
opportunities for this population.
Study Design: MBI participants were identified using
state-submitted individual-level program enrollment data.
To make certain that participants had experienced a
severe psychiatric disability, we linked the enrollment
data with Social Security Administration data to identify
those who had received Supplemental Security Income
or Social Security Disability Insurance because of a
mental illness. Comparison was made between them
and all other MBI participants in terms of demographic
characteristics, employment status, earnings and
Medicare/Medicaid service use and expenditures.
Multivariate regressions were conducted to examine how
disabling conditions, among other factors influence
employment and earnings of participants.
Population Studied: 215,712 individuals who
participated in MBI for at least one month between
January 1997 and December 2008. Nearly one in three
participants have been diagnosed with schizophrenia,
major affective disorders or other mental disorders.
Some analyses included a subset of the population,
given data constraints.
Principal Findings: MBI participants with psychiatric
disabilities are more likely to use Medicaid and Medicare
services (particularly prescription drug), but incurred
lower per member per month expenditures, compared
with other participants. Controlling for other individual
characteristics and state-level factors, we found
participants with severe mental illness were almost twice
as likely to be employed as those with musculoskeletal
impairments; however, once they’re employed, they
earned $379 less annually. Better employment
outcomes were also found among younger participants.
Conclusions: With continuous health care coverage
and other supports, people with psychiatric disabilities
can work, though they may rely more on medication to
manage the illness. They may also accept entry level or
part-time employment as a first step in their recovery,
evidenced by higher employment rate but lower
earnings, compared with other MBI participants.
Implications for Policy, Delivery or Practice: MBI
represents an attractive public program option for people
with psychiatric disabilities who want to work and
increase earnings without the risk of losing public
medical benefits, which are essential to keep them
healthy enough to work. States that currently don’t have
the program should consider implementing one.
Additionally, Youth with psychiatric disabilities may
benefit more from MBI and reach higher earnings
potential. Ongoing support is needed to better serve this
population.
Funding Source(s): CMS
• Revisiting the De Factor U.S. Mental Health
Services System
Tami Mark, Ph.D.; Jeffrey Buck, Ph.D.; Rita VandivortWarren, M.S.W.; Katie Levit, B.A.; Elizabeth Stranges,
B.A.; Cheryl Kassed, Ph.D.
Presented by: Tami Mark, Ph.D., Director, Analytic
Strategies, Thomson Reuters, 4301 Connecticut
Avenue, NW Suite 330, Washington, DC 20008; Phone:
(301) 214-2211; Email:
Tami.Mark@thomsonreuters.com
Research Objective: In an article published in 1978,
Regier, Goldberg, and Taube provided comprehensive
data on the service settings in which people receive
mental health treatment. The authors described the
system as a largely unorganized “de factor” system
because of the absence of any national- or state-level
approach to coordinating mental health services. In this
analysis we revisit the analyses by Regier and
colleagues to describe how the system has changed, in
particular, focusing treatment in community hospitals
and physicians prescribing.
Study Design: We examined the extent to which care is
provided in community hospitals is provided in specialty
psychiatric units or general medical surgical medical
(“scatter beds”). Analyses also determined the variation
in psychiatric unit utilization across the states. We used
2000-2007 data from the Medicare Cost Reports and the
HCUP-SID to identify hospitals with psychiatric units. A
subset of the psychiatric unit designations were
validated using internet searches. This second analysis
focused on the percent of psychotropic prescriptions
written by non-psychiatrists. Data was from the August
2006- July 2007 IMS’ National Prescription Audit (NPA)
Plus database. The NPA Plus consists of transaction
records from approximately 36,000 retail pharmacies,
representing about 70% of all retail pharmacies, which
when weighted, represent all prescriptions filled in retail
outlets in the US. Using a separate sample of retail
pharmacy transactions that includes the physician’s
Drug Enforcement Administration number, IMS assigns
physician specialty information to obtain an estimate of
the total number of prescriptions filled in retail
pharmacies by medical specialty.
Principal Findings: We estimate that 94% of
discharges from community hospitals were from
psychiatric units and only 6% were from scatter beds. In
stark contrast, Reiger et. Al. estimated that 47% of
persons treated for mental disorders in community
hospitals were treated in scatter beds and the other 53%
were treated in psychiatric units. Thus, in terms of
community hospital care, the system has moved away
from providing care in general settings towards more
exclusive use of psychiatric units. In contrast, the
significant role of nonpsychiatrists report by Regier and
colleagues continues today. Regier et al. found that 47%
of physician office visits for a psychiatric disorders were
to nonpsychiatrist physicians and 53% to psychiatrists.
Data indicate that 59% of outpatient psychotropic
prescriptions are written by nonpsychiatrists, including
51% of antipsychotics, 66% of stimulants, 79% of
antidepressants, and 87% of anxiolytics.
Conclusions: These finding highlight the important role
of community hospital psychiatric units in providing
inpatient care to persons with psychiatric diagnoses and
raises questions about access in regions with a limited
number of hospitals with psychiatric units. They also
point to the need for more extensive training of
nonpsychiatrists in psychiatric treatment.
Implications for Policy, Delivery or Practice: Although
the mental health system is very different now, the
conclusions of Regier and colleagues hold true today
“there is a need both for further integration of the general
health and mental health care sectors and greater
attention to the appropriate division of responsibility that
will maximize the availability and appropriateness of
services for persons with mental disorder.”
Funding Source(s): Substance Abuse and Mental
Health Services Administration
• Gaps in Continuity of Care: Homelessness and
Incarceration among Medicaid Psychiatric Patients
Eve Moscicki, Sc.D., M.P.H.; Joyce West, Ph.D., M.P.P.;
Donald Rae, M.A.; Farifteh Duffy, Ph.D.; Maritza RubioStipec, Ph.D.
Presented by: Eve Moscicki, Sc.D., M.P.H., Director,
Practice Research Network, Amer Psychiatric Institute
for Research & Education, 1000 Wilson Boulevard,
Arlington, VA 22209; Phone: (703) 907-8660; Email:
emoscicki@psych.org
Research Objective: There are currently no systematic
clinical data rigorously characterizing Medicaid
psychiatric patients who become homeless or
incarcerated. This study examined risk and identified
potential gaps in continuity of care for homelessness and
incarceration in a large clinical sample of psychiatric
patients in ten states.
Study Design: The observational, cross-sectional, study
collected physician-reported, clinically-detailed data
using practice-based research methods. Multivariate
logistic regression models examined odds of
homelessness and incarceration controlling for
sociodemographic and clinical characteristics.
Population Studied: 4,866 psychiatrists in ten states
were randomly selected from the AMA Physician
Masterfile; 61% responded; 34% met study eligibility
criteria of treating Medicaid patients their last typical
workweek, and reported clinically detailed data on 1,625
systematically-selected patients.
Principal Findings: Overall rates in the past year were
11.6% for homelessness (SE=1.3%) and 13.4% for
incarceration (SE=1.3%), with higher rates among
males, non-whites, and young adults aged 18-30 years.
Patients diagnosed with substance use (43% homeless,
38% incarcerated), alcohol use (36% homeless, 25%
incarcerated), and schizophrenia (24% homeless, 22%
incarcerated) disorders were at considerable risk. Onethird of public and private inpatients experienced
homelessness; one-third of pubic inpatients experienced
incarceration; nearly one in five experienced both.
Approximately one-quarter of patients with emergency
department (ED) visits also experienced homelessness
or incarceration. Patients with severe substance use
(64% homeless, 37% incarcerated), psychotic (33%
homeless, 24% incarcerated), or manic (28% homeless,
23% incarcerated) symptoms or violent ideation or
behavior (32% incarcerated) were also at substantial
risk. Logistic regression models indicated that patients
who had severe substance use symptoms, ED visits, or
were treated in the public sector had 2.0 (95% CI 1.33.1) to 6.1 (95% CI 2.1-17.9) increased odds of
homelessness or incarceration. Patients who
discontinued their medication had 2.4 (95% CI 1.3-4.4)
increased odds of homelessness or incarceration.
Patients with problems with co-payments or with
suicidality also had significantly greater likelihood of
homelessness.
Conclusions: These findings highlight vulnerable subgroups of Medicaid psychiatric patients at considerable
risk for homelessness and incarceration who have fallen
through states’ mental health and social services
systems, and identify opportunities for targeted
intervention and improved services delivery. Patients
receiving hospital or ED care, with substance use
disorders, severe psychiatric symptoms, or problems
accessing medications warrant increased attention.
Implications for Policy, Delivery or Practice: This
study suggests inpatient facilities and EDs treating
Medicaid psychiatric patients could play a broader role in
identifying and preventing homelessness and
incarceration through improved discharge planning and
care coordination. The findings highlight potential gaps
in the mental health treatment infrastructure for patients
with substance use, psychotic disorders, and psychiatric
symptom exacerbation. As state and national health care
reforms are considered, special attention for this
population is needed related to housing, 24-hour crisis
intervention care, substance use treatment programs,
and more effective models of care engagement,
coordination, and management.
Funding Source(s): American Psychiatric Foundation
through a consortium of industry supporters, including
Astra Zeneca, Bristol Myers Squibb, Eli Lilly, Forest,
Janssen, Pfizer and Wyeth. The investigators had
complete discretion and control over the study design,
and conduct.
Implications for Policy, Delivery or Practice: These
findings provide new evidence to support existing
consensus recommendations (i.e. expert opinion) from
the U.S. Department of Health and Human Services
stating that peer support be a fundamental component of
recovery-oriented mental health treatment.
Funding Source(s): NIMH
Treatment and Prevention: Results from Simulation
Studies
Chair: Anthony Lo Sasso
Tuesday, June 29 * 8:00 am–9:30 am
• Efficacy of Peer Support Interventions for
Depression: A Meta-Analysis
Paul Pfeiffer, M.D., M.S.; Michele Heisler, M.D., M.P.A.;
John Piette, Ph.D.; Mary Rogers, Ph.D.; Marcia
Valenstein, M.D., M.S.
Presented by: Paul Pfeiffer, M.D., M.S., Psychiatrist,
Psychiatry, University of Michigan, 4250 Plymouth Road,
Ann Arbor, MI 48105; Phone: (734) 232-0070; Email:
ppfeiffe@umich.edu
Research Objective: To assess the efficacy of including
peer support in the treatment of depressed patients.
Study Design: A systematic review of the literature was
conducted to identify randomized controlled trials which
compared changes in depression symptoms following a
peer support intervention with either usual care or an
active control condition. Meta-analyses were conducted
to generate pooled standardized mean differences in
measures of depressive symptoms among peer support
interventions compared with usual care and cognitive
behavioral therapy.
Population Studied: 869 depressed participants were
included in studies comparing peer support to usual
care, and 301 depressed participants were included in
studies comparing peer support to group cognitive
behavioral therapy. All participants were identified as
having significant depressive symptoms by validated
depression measures. Most studies were of particular
subgroups of depressed patients such as those with
post-partum depression or depression and a major
medical comorbidity.
Principal Findings: Based on the pooled results from
eight studies, peer support interventions were superior to
usual care in reducing depressive symptoms, with a
pooled standardized mean difference (SMD) of -0.60
(95% CI: -0.98, -0.21; p=0.002). Among seven studies
which compared peer support to group cognitive
behavioral therapy, there was not a statistically
significant difference between the two interventions, with
a pooled SMD of 0.10 (95% CI: -0.20, 0.39 p=0.53).
Conclusions: Based on the available evidence, peer
support interventions are associated with significantly
greater reductions in depression symptoms when
compared to usual care, but not when compared with
cognitive behavioral therapy.
• Using Insights from Clinical Medicine to Improve
Federal Health Care Cost Estimates: The Case of
Diabetes
Elbert Huang, M.D.; Michael O'Grady, Ph.D.; Anirban
Basu, Ph.D.; James Capretta, M.A.
Presented by: Michael O'Grady, Ph.D., Senior Fellow,
Health Policy, NORC/University of Chicago, 4350 E-W
Highway, Suite 800, Bethesda, MD 20814; Phone: (301)
634-9333; Email: mogrady@uchicago.edu
Research Objective: Debate surrounds the scoring of
prevention interventions by the Congressional Budget
Office and CMS’s Office of the Actuary. For most
interventions the upfront costs can be estimated, but outyear reductions in spending are hard, if not impossible to
estimate. This is particularly a problem with chronic
illnesses like diabetes where complications often do not
emerge for many years. Current economic and actuarial
models also cannot easily capture the cost implications
of clinical interventions that can change the trend in
disease progression. In addition, current federal cost
projection models are constrained by ten-year cost
estimates which capture increases in near-term
intervention costs, but not possible reductions in longterm costs.
Study Design: We developed a novel population-level
model for projecting future incidence and prevalence of
both obesity and diabetes, as well as direct spending on
diabetes. Rather than using either traditional economic
or actuarial modeling, we used epidemiological modeling
typically used to predict clinical outcomes. The model
matches predicted clinical outcomes with the spending
associated with those outcomes to generate spending
estimates under alternative clinical interventions. This
allows the model to be used in the federal budget
process to estimate the cost implications of alternative
policies. The model employs a Markov design that
simulates individuals’ movement across different health
states based on obesity trends and the natural history of
diabetes and its complications over the next 25 years.
We also discuss the potential changes in the federal
budget process needed to capture the full impact of
these interventions.
Population Studied: The study population is 24 to 85
year old patients with diabetes characterized by CDC’s
NHANES and NHIS surveys.
Principal Findings: The number of people with diabetes
will grow from 23.7 million to 44.1 million over the next
25 years. During the same period, annual diabetes
related spending is expected to increase from $113
billion to $336 billion State-of-the-art diabetes
management interventions can improve clinical
outcomes for these patients and in some cases reduce
spending. For the youngest cohort ages 24-30, the
intervention arm had 6 percent less spending than the
control arm over the 25 year period. For the two cohorts
ages 31-40 and 41-50, spending was close to constant.
For the oldest cohorts, ages 51-60 and 61-64, spending
increased modestly – 5 percent and 2 percent
respectively.
Conclusions: The burden of chronic diseases like
diabetes will grow in the coming decades and have
significant impacts on both the lives of Americans and
the financial viability of federal health-care programs,
especially Medicare. It is important that policymakers
have the most reliable and relevant information available
as they wrestle with these difficult issues. This study
develops a new approach for estimating the incidence of
diabetes and related health care costs in the future and
to use it to stimulate a discussion on ways to improve
the information base and process for policymaking.
Implications for Policy, Delivery or Practice:
Epidemiological modeling for federal cost projections is a
new area. We believe that models that integrate clinical
epidemiology and trial data can improve understanding
among policymakers of the dynamics of disease
progress and realistic expectations regarding the health
and cost benefits of alternative scenarios.
Funding Source(s): The National Changing Diabetes
Program
• Modeling Potential Savings from Prevention
Barbara Ormond, Ph.D.; Brenda Spillman, Ph.D.;
Timothy Waidmann, Ph.D.
Presented by: Barbara Ormond, Ph.D., Senior
Research Associate, Health Policy Center, The Urban
Institute, 2100 M St NW, Washington, DC 20037;
Phone: (202) 261-5782; Email: bormond@urban.org
Research Objective: To develop a model that can
estimate potential medical expenditure savings from
prevention interventions over a range of federal budgetrelevant time periods.
Study Design: Using a diagnosis-specific expenditure
trend based on an analysis of Medical Expenditure
Panel Survey data for selected medical conditions and a
variety of population groups, we model the likely effect of
prevention activities targeted at childhood asthma,
smoking-related illness, and obesity-related illness. The
modeled interventions include both community and
clinical services. Potential savings are compared with
prevention program cost estimates from the literature to
estimate net costs or net savings.
Population Studied: A representative sample of the US
population, 2003-2007
Principal Findings: (1)Net savings are possible through
investment in in-home environmental assessment and
amelioration targeted at children with moderate to
severe asthma. Despite high and variable intervention
costs, medical expenditure savings can be large in the
short run; collateral benefits may be seen in school
achievement and caretaker work attendance.
(2)Potential medical expenditure savings related to
community interventions depend greatly on community
characteristics, including the level of disease prevalence,
community leadership, and sustainable funding.
(3)Potential savings from reductions in overweight/
obesity (particularly among children) and in smoking
depend greatly on the costs of the associated
interventions, about which there is little strong evidence.
Conclusions: (1)Well-designed and carefully
implemented prevention interventions can contribute to a
reduction in medical expenditures over the short and
medium run. Long-term savings could be achieved with
sustained funding. (2)Careful targeting of prevention
interventions can contribute to a reduction in health
disparities across racial and economic groups.
(3)Modeling continuing reductions in smoking and its
associated costs depends on assumptions about the
similarities between current smokers and those
influenced by past efforts that may or may not be valid.
(4)Evaluation of prevention efforts going forward should
explicitly include documentation of the costs of the
intervention (total and per capita or per community, as
appropriate) exclusive of the associated research costs.
Implications for Policy, Delivery or Practice:
(1)Quanitfying the potential savings from prevention
interventions can provide important information for
budgeting at the federal and other levels. (2)Successful
"bending" of the cost curve may require actions both
inside and outside the health system. (3)Modeling the
effect of prevention on expenditures is likely to identify
gaps in our knowledge about the costs and the long- and
short-term effects of interventions, thus providing
guidance for needed research.
Funding Source(s): ASPE
• Diabetes in California: Why Lowering Its
Prevalence by 2020 Is Unlikely
Lu Shi, Ph.D.; Jeroen Van Meijgaard, M.A.
Presented by: Lu Shi, Ph.D., Senior Analyst, Health
Services, UCLA, 3271 Sawtelle Boulevard, Apartment
106, Los Angeles, CA 90066; Phone: (315) 395-8025;
Email: lushi.pku@gmail.com
Research Objective: Setting a feasible ten-year goal for
disease control is important for planning and evaluating
public health interventions. Modelers have shown that
diabetes prevalence is likely to increase for the
foreseeable future even if there is no increase in
incidence, due to the lifelong nature of the condition and
progress in early detection and disease management.
This study explores what might be a feasible goal in the
next decade for California's diabetes prevention.
Study Design: We use a Microsimulation model that is
calibrated to represent demographics and population
health, including health behaviors and disease
outcomes, of the California population. We use the
model to forecast diabetes prevalence under different
scenarios in 2020. The first scenario assumes no further
increase in obesity for the cohorts entering their
adolescence after 2003. The second scenario assume
an annual decrease in the body mass index for cohorts
entering their adolescence after 2010. The third scenario
builds on the second by further assuming an increase of
physical activity among subpopulations that have lower
physical activity to eliminate racial-ethnic disparities in
physical activity among all residents in California.
Outcomes in diabetes prevalence, obesity prevalence
and life expectancy were compared across scenarios.
Population Studied: The California population, stratified
by gender, race/ethnicity and age, was included in the
study.
Principal Findings: The three scenarios' predicted
diabetes prevalence in 2020 are 9.03%, 9.00%, and
9.00%, respectively. However, the second and the third
scenario both predict longer life expectancy in 2020
(78.80 and 79.20) as compared with the first scenario
(78.78). The 2020 obesity prevalence in the second
scenario (14.51%) is lower than in the first scenario
(18.16%), while the third scenario yields an obesity
prevalence of 16.19%.
Conclusions: We have assumed ideal intervention
results in physical activity and childhood obesity when
we construct our alternative scenarios, yet these
scenarios do not yield a substantially lower prevalence in
diabetes by 2020. First, the aging of California
population and the increasing proportion of high-risk
demographic groups in the state's population contribute
to the increase of diabetes prevalence, while the obesity
increase since the 1980s in the entire population will
continue to have an impact on future diabetes incidence.
Secondly, lower BMI and more physical activity make
people with diabetes live longer (and thus increase the
diabetes prevalence in the population), even though low
BMI and more physical activity are also set up to
decrease the onset of diabetes in our model. This
mechanism, whereby physical activity could increase the
overall diabetes prevalence, is further exemplified in our
simulated result that eliminating physical activity gap in
the third scenario increases the overall obesity
prevalence from the second scenario.
Implications for Policy, Delivery or Practice: If we
observe a continuing rise in diabetes prevalence in the
population in the coming decade, this does not
necessarily mean that prevention interventions have
been unsuccessful. The effect of risk factor modification
on overall prevalence takes longer than a decade to
show up. For the year of 2020, more specific goals like
improving early detection of diabetic and pre-diabetic
cases may be more feasible and easier to evaluate.
Funding Source(s): RWJF
• Lifetime Medical Expenditures Associated with
Physical Activity and Overweight – A Simulation
Approach
Jeroen van Meijgaard, M.A.
Presented by: Jeroen van Meijgaard, M.A., Health
Services, UCLA School of Public Health, CHS 61-253,
Box 951772, Los Angeles, CA 90095-1772; Phone:
(310) 206-6236; Email: jeroenvm@ucla.edu
Research Objective: Physical activity and obesity are
both strong predictors of morbidity and mortality in the
short and long term. These behaviors also change over
the life course of individuals. There is little data available
to analyze the long term impact of physical activity and
obesity on expenditures. Using simulation modeling of
health behaviors and associated expenditures over the
life course of individuals it is possible to construct
lifetime expenditure patterns conditional on health
behaviors. The objective of this study is to evaluate and
validate this approach to better understand total lifetime
expenditures associated with physical activity and
obesity.
Study Design: We used a microsimulation model to
construct individual lifetime histories of simulated
individuals that represent the population of the United
States. Behaviors, relative risks and expenditures (2005
constant dollars) were modeled conditional on gender,
race/ethnicity, age and birth cohort. Additionally relative
risks and expenditures were modeled conditional on
health behaviors. Associations were estimated using
data from the National Health Interview Survey (NHIS
1997-2006),the Medical Expenditure Panel Survey
(MEPS 1998-2007), the NHIS-HPDP supplement (1990,
1991) with linked mortality data and estimates from the
literature to obtain relative risks of physical activity and
body mass index on mortality. Tracking information on
the evolution of physical activity and obesity over the life
course was obtained from longitudinal data and
prospective analyses presented in the literature. All
analyses control for variables not explicitly included in
the simulation model, including income, education,
insurance status, smoking and alcohol consumption.
Population Studied: The non-institutionalized adult
population of the United States, stratified by gender,
race/ethnicity and age.
Principal Findings: Increases in the body mass index
(BMI) increase direct personal medical expenditures.
However because increases in BMI also increase the
risk of mortality, the impact of BMI on lifetime medical
expenditures is not monotone. We find that among men
future lifetime medical expenditures, conditional on
current level of obesity, increase with BMI until BMI is
equal to 35, and subsequently decrease for higher BMI.
Among women expenditures continue to increase,
although the pace slows at higher BMI. We estimate that
for 65 year old men the remaining lifetime expenditures
are between $102,000 (normal weight) to $128,000
(severely obese), while for 65 year old women
expenditures range from $118,000 to $174,000. For
physical activity we find that lifetime medical
expenditures increase with physical activity; the lower
mortality risk from higher physical activity is not offset by
lower annual expenditures.
Conclusions: Validation of our simulation model against
observational studies for specific populations show that
simulation models can be a useful tool to estimate long
term expenditures when only short term follow data is
available. Although lower BMI leads to lower lifetime
medical expenditures, improvements in physical activity
may lead to higher lifetime medical expenditures due to
improved longevity.
Implications for Policy, Delivery or Practice:
Programs that aim to increase physical activity and/or
reduce obesity should consider the long term impact on
total expenditures, taking into account changes in risk
profiles as well as changes in health care services
utilization to create realistic expectations about future
medical expenditures.
Clinical, Social, and Policy Interventions to Reduce
Disparities
Chair: Thomas Sequist
Tuesday, June 29 * 9:45 am–11:15 am
• Does Patient Navigation Improve Satisfaction with
Health Care and Reduce Medical Mistrust among
Native American Cancer Patients in the Northern
Plains?
B. Ashleigh Guadagnolo, M.D., M.P.H.; Kristin Cina,
B.S.; Daniel Petereit, M.D.
Presented by: B. Ashleigh Guadagnolo, M.D., M.P.H.,
Assistant Professor, Radiation Oncology, The University
of Texas M.D. Anderson Cancer Center, 1515 Holcombe
Boulevard, Unit 97, Houston, TX 77030; Phone: (713)
563-2341; Email: aguadagnolo@gmail.com
Research Objective: : Native Americans (NA) in the
Northern Plains suffer disparately high cancer mortality
rates compared with the general US population and NA
in other regions of the US. Published data shows that
NA in South Dakota exhibit higher levels of medical
mistrust and lower satisfaction with health care than their
non-Native American counterparts, perhaps contributing
to lower rates of screening and health care utilization.
We hypothesized that patient navigation (PN) for NA
cancer patients may improve satisfaction with health
care and reduce medical mistrust.
Study Design: This was a pre-post cohort design
survey study to evaluate impact of PN on healthcare
experience of NA cancer patients. The PN program
provides culturally-competent navigators to assist
patients with navigating cancer therapy, obtaining
medications, insurance issues, communicating with
medical providers, and travel and lodging logistics.
Navigators included trained lay community members
(both NA and non-NA) as well as individuals with formal
health care training (e.g., R.N.). Lakota language
services and educational material were available. All
patients received PN services throughout cancer
treatment. The survey instrument was administered prior
to cancer treatment and after treatment completion. The
instrument assessed medical mistrust and satisfaction
with health care and consisted of two Likert-type scales.
Psychometric performance data for this instrument has
previously been published in a peer-reviewed study
demonstrating medical mistrust and satisfaction
differences among NA and white patients in this
population.
Population Studied: 46 adult NA, newly-diagnosed
cancer patients in Rapid City, SD, who participated in a
culturally-tailored PN program during their cancer
treatment. Recruitment was hospital-based.
Principal Findings: Response rate among eligible NA
asked to participate was 85%. Median age was 60.5
years (range, 24-86 years). Forty-six percent (21
patients) had income levels below the federal poverty
line. Ten patients (22%) had less than a high school
education. Primary payor of medical bills was as follows:
Medicare, 31%; Veterans Administration, 22%;
Medicaid, 20%; Indian Health Service, 18%; private
insurer, 9%. Paired t-test revealed significant
improvement in mean scale score for satisfaction with
health care after patient navigation relative to baseline
scores (p=0.0001) However, there was no change in
mean scale scores for medical mistrust in the postnavigation survey relative to baseline scores (p=0.25).
Conclusions: NA cancer patients who received PN
services during their cancer treatment showed
improvement in levels of satisfaction with health care
compared with pre-navigation baseline scores for
satisfaction with health care. However, no improvements
were observed in levels of medical mistrust among after
PN.
Implications for Policy, Delivery or Practice: PN may
improve the quality of health care experience for NA
cancer patients in a community which has previously
been shown to exhibit relatively low levels of satisfaction
with health care. Research is needed into whether this
improvement in satisfaction translates to better treatment
adherence or improved outcomes. PN by culturally and
linguistically competent navigators did not lead to an
improvement in medical mistrust. More research is
needed into both the role mistrust plays in contributing to
health disparities and factors that may mitigate it in this
vulnerable population.
Funding Source(s): NCI
• Exploring the Health and Well-Being of Individuals
Who Apply for Subsidized Housing: Opportunities to
Reduce Health Disparities of the Near Poor
Ahuva Jacobowitz, B.A.; Elyzabeth Gaumer, M.A.
Presented by: Ahuva Jacobowitz, B.A., Research
Coordinator, Housing Policy Research and Program
Evaluation, NYC Department of Housing Preservation
and Development, 100 Gold Street 5-B10, New York, NY
10038; Phone: (212) 863-8053; Email:
ahuva.jacobowitz@gmail.com
Research Objective: This study examines the
characteristics of near poor applicants to a subsidized
housing site in New York City. By analyzing baseline
data about applicants’ health and health behaviors, we
are able to assess if affordable housing may have
unintended health benefits for the marginalized
population of the near poor.
Study Design: This paper uses baseline pilot data that
were obtained for households who applied for housing at
a single affordable housing development in
Greenpoint/Williamsburg Brooklyn in November, 2007.
87.1% of households completed the self-administered
questionnaire (SAQ) (n=887), which asked about
housing conditions, neighborhood satisfaction and
amenities, financial well-being, physical and mental
health, and health behaviors. These data were combined
with administrative data from the housing application to
gain additional information on the household.
Population Studied: Members of lower socioeconomic
strata consistently experience greater risk for a wide
range of negative health outcomes. Housing is the single
largest, and least flexible, critical expense most
households incur in a lifetime. Low-income households
with little purchasing power, particularly in high-cost
markets such as New York City, may be more likely to
live in sub-standard conditions that directly impact health
and safety. Obtaining affordable housing of adequate
quality might be especially difficult for near poor
households because their slightly higher incomes might
render them ineligible for housing assistance that is
targeted towards households in poverty. Since housing
and neighborhood conditions have the potential to
reduce health disparities through a complex combination
of mechanisms, providing affordable housing for the
near poor of New York City presents an opportunity for
intervention.
Principal Findings: A large proportion of households
reported delaying at least one kind of health care in the
previous year. Three-quarters of those who delayed
health care delayed dental care, 40% delayed medical
care, 20% delayed prescription drug purchases, and
over 7% delayed mental health treatment. Those
households that spend at least 30% of their income on
rent (the typical definition of affordability) were 1.9 times
more likely to postpone healthcare due to financial
reasons (p<.001). Approximately half of the households
paid more than 30% of their income toward rent at the
time of application. 25.51% of households reported at
least one case of asthma diagnosis. Asthma diagnosis
was significantly correlated with reports of maintenance
deficiencies in the home. Our respondents reported
substantially higher rates of poor housing conditions–
more than double the citywide prevalence rates for
heating breakdown, pest infestation, and peeling paint.
Overall, 78.2% of the households who responded to the
survey reported at least one housing condition problem
and 8.7% reported all four problems.
Conclusions: By limiting the amount of money
households must spend on rent, in addition to providing
safe, quality, and affordable housing, subsidized housing
can make an impact beyond providing adequate shelter.
Implications for Policy, Delivery or Practice:
Subsidized housing may help to mitigate health
disparities for the near poor as well as have the potential
to address important public health issues. Housing and
health agencies should coordinate activities to help
address the needs of the near poor.
Funding Source(s): The John D. and Catherine T.
MacArthur Foundation
• A Randomized Controlled Trial of Patient
Navigation to Promote Colorectal Cancer Screening
In Community Health Centers
Karen Lasser, M.D., M.P.H.; Jennifer Murillo; Sandra
Lisboa, B.A.; Naomie Casimir; Lisa Valley-Shah, R.N.,
Karen Emmons, Ph.D.; Robert Fletcher, M.D., John
Ayanian, M.D., M.P.P.
Presented by: Karen Lasser, M.D., M.P.H., Clinician
Investigator, Medicine, Boston Medical Center, 801
Massachusetts Avenue, Boston, MA 02118; Phone:
(617) 414-6688; Email: karen.lasser@bmc.org
Research Objective: Patient navigation interventions
have been shown to increase colorectal cancer (CRC)
screening rates among adults in underserved
communities, but prior randomized controlled trials
(RCTs) of patient navigation have not included
substantial numbers of Haitian Creole and Portuguesespeaking patients. Our objective was to conduct a RCT
of patient navigation to promote CRC screening among
six community health centers in greater Boston with
substantial numbers of Haitian Creole and Portuguesespeaking patients.
Study Design: In an RCT of the effectiveness of patient
navigation to increase CRC screening rates, we included
patients aged 50–74 who were overdue for CRC
screening according to national guidelines. We excluded
patients with significant comorbid medical disease (e.g.
severe coronary artery disease, chronic obstructive
pulmonary disease, or congestive heart failure), and
patients who had documentation of active substance use
or severe mental illness on their problem list. With
stratified randomization by health center and language
(English, Portuguese, Haitian Creole, Spanish), we
assigned 465 patients from six community health centers
in greater Boston to receive the intervention or usual
care. Intervention patients received an introductory letter
from their primary care provider with educational
material followed by phone calls from a languageconcordant navigator. Navigators (n = 3) were
community health workers trained to identify and
address patient-reported barriers to CRC screening
identified in a prior qualitative study of this community.
Individually tailored interventions included patient
education, assistance with procedure scheduling or
completion of fecal occult blood testing, explanation of
instructions for bowel preparation, and help with
insurance coverage. The primary outcome was
completion of colorectal cancer screening 12 months
post-enrollment; 9-month outcomes are presented
below. We performed chart reviews blinded to the
intervention assignments to determine rates of CRC
screening. In an intention-to-treat analysis, we used chisquare tests to compare proportions between groups.
Population Studied: A total of 465 patients 50-74 years
of age overdue for colorectal cancer screening,
randomized to intervention, n=235, vs. usual care
control, n=230, groups.
Principal Findings: Most of the 465 enrolled patients
were female (61%) and non-white (53%), with an
average age of 61.5 years; 33% had private insurance.
Almost half of patients (48%) spoke English, while the
remaining spoke Portuguese (20%), Haitian Creole
(18%), and Spanish (14%). Patients in the intervention
(n=235) and control (n=230) groups did not differ
demographically. Over a 9-month period, intervention
patients were more likely to undergo any CRC screening
than control patients (29.8% vs. 17.0%, p=.001), and
were also more likely to be screened by colonoscopy
(23.4% vs. 10.9%, p=<.001). 17 intervention patients
had adenomas on colonoscopy; four of these patients
had high-risk lesions (villous features or >=3 adenomas).
Among control patients, 8 had adenomas and 2 had
cancer. The proportion of patients with adenomas or
cancer did not differ between groups (p=.43). In prespecified subgroup analyses, the navigator intervention
was beneficial for the following subgroups when
comparing intervention vs. control patients: non-English
speaking patients, patients > age 60, white patients, and
privately insured patients (all p<.05); the intervention
was similarly effective in men and women.
Conclusions: Patient navigators significantly improved
CRC screening rates among ethnically and linguistically
diverse patients served by community health centers.
Implications for Policy, Delivery or Practice: Future
research will need to address whether health systems
can afford navigation to achieve this degree of benefit,
outside of the RCT setting. Studies that include patients
with substance use and mental illness are also
warranted.
Funding Source(s): American Cancer Society
• Hypertension Control through Social Networks
Fadia Shaya, Ph.D., M.P.H.; Clyde Foster, R.N.;
DeLeonardo Howard, M.P.H.; Xia Yan, M.Sc.; Nicole
Norman, M.P.H.; Confidence Gbarayor, M.P.H.; Wallace
Johnson, M.D.; Elijah Saunders, M.D.
Presented by: Fadia Shaya, Ph.D., M.P.H., Associate
Professor, School of Pharmacy, Pharmaceutical Health
Services Research, University of Maryland Baltimore,
220 Arch Street, 12th floor, Room 01-204, Baltimore, MD
21201; Phone: (410) 706-5392; Email:
fshaya@rx.umaryland.edu
Research Objective: African Americans have lower
hypertension control rates and higher cardiovascular
disease mortality rates than Caucasians. We examined
how a social networking peer approach to hypertension
management could improve blood pressure (BP) control,
among minority patients.
Study Design: This is a longitudinal cohort study.
Patients in the intervention group enrolled relatives or
friends in the hypertension education program and
attended monthly education sessions as teams. Patients
in the control group followed usual care. BP and other
clinical indicators were taken at baseline and every 3
months, for up to 15 months. Adjusted Cox proportional
hazards models were used to compare time to achieve
goal: systolic blood pressure (SBP) <140 and diastolic
blood pressure (DBP) <90, or SBP <130 and DBP <80
depending on the presence of diabetes or other
comorbidities) between the two groups controlling for
confounders and clusters of patients.
Population Studied: Patients with uncontrolled
hypertension, 18 or older, African Americans or other
racial or ethnic minorities.
Principal Findings: A total of 384 subjects were
included in the study; half in the intervention group. The
majority (95%) were African American and 62% males.
The baseline BP levels were 149/90 mmHg and 145/88
mmHg in the control and intervention groups
respectively (p > 0.18). After controlling for baseline BP,
gender, race, age, diabetes, smoking and patient
clusters, we found that patients in the intervention group
reached goal at a rate 2.16 times (95% CI: 1.05-4.43)
higher than that in the control group. Higher baseline
SBP (HR=0.94, 95% CI: 0.91-0.98), higher baseline
DBP (HR=0.95, 95% CI: 0.92-0.99), diabetes (HR=0.15,
95% CI: 0.03-0.69) were significantly associated with
longer time to achieve the goal.
Conclusions: Social networks help control
hypertension: patients who approached hypertension
management with their peers, within their self-selected
social networks were much more likely to achieve blood
pressure control, and in a shorter time than patients in
usual care.
Implications for Policy, Delivery or Practice: These
findings have implications for clinical and public health
interventions capitalizing on social networks, to design
and implement cardiovascular and possibly other health
promotion programs for minority populations.
Funding Source(s): CareFirst BlueCross BlueShield
Foundation
Measuring Quality and Efficiency in Large Health
Care Systems
Chair: Paul Shekelle
Tuesday, June 29 * 9:45 am–11:15 am
• Relationship of Hospital Quality and Cost per Case
in Hawaii
Jack Ashby, M.H.A.; Deb Juarez, S.C.D.
Presented by: Jack Ashby, M.H.A., Director of Hospital
Research, Care Management, Hawaii Medical Service
Association (HMSA), P.O. Box 860, Honolulu, HI 96814;
Phone: (808) 952-7551; Email: jack_ashby@hmsa.com
Research Objective: To determine whether quality of
care as measured by a composite of the quality
indicators used in the pay-for-performance (P4P) system
of a large private insurer in Hawaii is correlated with allpayer cost per case in the covered hospitals.
Study Design: The insurer, which covers more than half
the population of Hawaii, uses five quality indicator sets
in its P4P covering clinical process, patient satisfaction,
complication rates, and rated quality improvement
projects. Using 2008 data, all quality scores were
expressed as index values relative to the state average.
The measures within each set were weighted equally
and the five measure sets were weighted as they are in
the P4P scoring system. A 2008 standardized cost per
case measure was developed for all non-federal acute
care hospitals in Hawaii, California, and Washington,
using all-payer data from Medicare cost reports and
each state’s data consortium. Costs were adjusted for
geographic price differences using CMS’s wage index
and COLA, and for case-mix/severity using MS-DRGs.
Then a multivariate regression model was developed to
determine the effect on cost per case of variables
thought to be outside of hospital control. A statistically
significant relationship was found for teaching intensity,
and the resulting coefficient was used to standardize
costs for Hawaii hospitals. Two other variables
hypothesized to have an effect on cost per case—share
of low-income patients and Medicare share of
discharges—were not found to be significant and
therefore were not used for the standardization. The
significance of the correlation between the quality and
cost per case measures was examined using Pearson’s
chi-squared tests.
Population Studied: The analysis included 13
hospitals. The only acute care facilities in Hawaii that
were excluded from the study are a women’s and
children’s hospital (for which many of the quality
indicators were not applicable), several critical access
hospitals (which treat insufficient numbers of patients for
reliable quality measurement), and a military hospital
and Kaiser Foundation hospital that do not treat patients
covered by the subject private insurer.
Principal Findings: There was significant variation in
standardized cost per case among Hawaii hospitals,
ranging from $9,002 to $16,471. Wide variation also
existed for most components of the composite quality
index. Our main analyses found a significant negative
correlation between our quality and cost measures (r = 0.65, p = 0.015), despite the small sample size.
Conclusions: Our results provide strong evidence that
in Hawaii, delivering high quality care is associated with
lower unit costs. This is consistent with findings from the
Premier Medicare Pay-for-Performance Demonstration.
Implications for Policy, Delivery or Practice:
Policymakers are looking to P4P programs to not only
improve the quality of care, but to help bring hospital
cost growth under control. Quality metrics are also
playing an important role in plans for bundled payment,
which is also intended to help slow health care costs.
Evidence that hospitals achieving high quality scores
have below average costs helps build the case that
programs that encourage widespread quality
improvement can contribute to cost containment.
Unfortunately, we were unable to analyze the costquality relationship in Hawaii hospitals over time due to
the lack of consistent quality data. However, we intend to
extend our analysis forward as data become available.
• A Novel International Framework for PrivacyEnhanced Data Processing, Exchange and Pooled
Analysis of Disease Registers: The European
BIRO/EUBIROD Projects
Fabrizio Carinci, M.S.; Concetta Tania Di Iorio, M.Law;
Massimo Massi Benedetti, M.D.
Presented by: Fabrizio Carinci, M.S., Senior
Biostatistician, Serectrix snc, Via Gran Sasso 79,
Pescara, 65121, Italy; Phone: +390854429188; Email:
research@fabcarinci.net
Research Objective: Health information in Europe is
overwhelming albeit still underutilized for policy and
planning. During the last years, the European
Commission has made a substantial effort to produce a
well defined portfolio of health indicators for 27 Member
States. However, the regular production of comparable
indicators is still hampered by significant fragmentation
of data sources and inconsistency of analytical
procedures across the national and regional levels.
European treaties and privacy laws challenge the
opportunity to integrate and link the existing data at the
upper level. The aim of the BIRO/EUBIROD projects is
to propose a sustainable solution to overcome the
existing gap through the application of a systematic
approach for homogeneous data processing and
consistent statistical analysis across different policy
levels.
Study Design: The BIRO project was submitted and
approved by the European Commission in 2005. It
included a multidisciplinary panel of representatives from
seven European countries (Austria, Cyprus, Italy, Malta,
Norway, Romania and Scotland). Tasks included a
clinical review, data dictionary, privacy impact
assessment and fully operational software featuring
database and statistical engines, communication
software, and a dedicated web portal.
Population Studied: Cutting edge population-based
diabetes registers routinely recording medical records for
an overall population of 250,000 patients.
Principal Findings: total of N=54 evidence-based
parameters/indicators were targeted. A common dataset
was defined to include N=45 patient items and N=22
clinical site descriptors. An XML data dictionary included
all definitions and the range of tables required.
Standardized data were loaded in a Postgres database.
A report template included N=72 indicators classified
according to demographic and clinical characteristics,
health system, population, and risk adjusted indicators.
Privacy impact assessment allowed to identify the best
architecture for transnational data exchange. Two-level
R statistical routines were developed to equally produce
results for local registers and to deploy de-identified
aggregate tables transmitted to a central server.
Cumulative data is loaded in a central Postgres
database and further processed to deliver a global report
fully consistent with local outputs. Results are uploaded
to a EU web portal repository every 6 months.
Evaluation from a distinguished panel of independent
experts was extremely positive. BIRO software is
released as GPL.
Conclusions: The BIRO project sets new standards for
public health information systems through an innovative
architecture for data exchange and automated delivery
of standardized diabetes indicators. Its sequel
"EUBIROD", started in september 2008 with confirmed
co-funding from the SANCO Directorate of the European
Commission. The project will apply the system in 20
countries and produce results that will compiled in the
European Diabetes Report in late 2010. All products are
available at http://www.biro-project.eu and
http://www.eubirod.eu.
Implications for Policy, Delivery or Practice: The
BIRO system allows to flexibly integrate new sources
and add new partners to the collaboration, as
demonstrated by the recent inclusion of the International
Diabetes Federation in EUBIROD that will allow testing
BIRO on a global scale. A key dissemination element,
the BIRO Academy, will train regional managers from
different backgrounds to using and producing policyrelevant health indicators. The general validity of the
idea will allow application in Europe and beyond, and
tranferability to other disease areas.
Funding Source(s): European Commission
• National Changes in Patients’ Experience of
Hospital Care over the First Three Years of HCAHPS
Jacqueline Chow, Elizabeth Goldstein, Ph.D.; Marc
Elliott, Ph.D.; William Lehrman, Ph.D.; Laura Giordano,
R.N., M.B.A.; Megan Beckett, Ph.D.; Christopher Cohea,
M.S., Paul Cleary, Ph.D.
Presented by: Elizabeth Goldstein, Ph.D., Director,
Division of Consumer Assessment and Plan
Performance, Centers for Medicare and Medicaid
Services, 7500 Security Boulevard, Baltimore, MD
21244; Phone: (410) 786-6665; Email:
Elizabeth.Goldstein@hhs.cms.gov
Research Objective: To assess the extent and
uniformity of improvement in HCAHPS scores in the first
three years of public reporting.
Study Design: Using data corresponding to the March
2008, 2009, and 2010 public reports of the HCAHPS
survey of patient experiences, we employ linear
regression models to examine within-hospital trends for
the ~2800 hospitals reporting each of three
nonoverlapping intervals, adjusting for patient-mix and
survey mode. Additional models employ interaction
terms to assess the uniformity of improvement across
hospital characteristics. We also examine the extent to
which the characteristics and scores of ~1000 hospitals
that did not participate in the first (voluntary) public
reporting differ from those of hospitals that did. We
report results for nine HCAHPS measures, scored
linearly as means: six multi-item composites
(communication with nurses, communication with
doctors, responsiveness of hospital staff, pain
management, communication about medicines, and
discharge information), two stand-alone report items
(cleanliness and quietness of the hospital environment),
and a global assessment (recommendation).
Population Studied: Approximately 5.8 million
inpatients discharged from acute care hospitals between
October 2006 and June 2009.
Principal Findings: There were modest but meaningful
improvements for 8 of 9 measures (p<0.01) in the first
year among initially participating hospitals, with the
already high-scoring doctor communication composite
being the exception. The magnitude of improvement was
relatively uniform across measures, with the greatest
improvement for discharge information and low-scoring
staff responsiveness, and the smallest improvement for
recommendation. These improvements were also fairly
uniform across hospital size, location, and ownership. In
the second year, there was significant improvement for
the same 8 measures, with the magnitude of
improvement similar to the previous year for most
measures, but larger for nurse communication and
recommendation. Discharge information and staff
responsiveness showed the greatest two-year gains,
corresponding to 9-10 percentile points of rank.Simple
cross-sectional comparisons (not within hospitals) would
have overstated the true improvement, since the
hospitals participating in the second but not the first year
of public reporting scored significantly higher in that
second year on 7 of 9 measures (p<0.001), probably
because they were much more likely than initially
participating hospitals to have fewer than 50 beds, a
factor associated with much higher HCAHPS scores.
Conclusions: Despite initial concerns in some quarters,
health care entities may be able to use HCAHPS
feedback to improve patient experience. Over two years,
hospitals improved 8 of 9 measures by 3 to 10 percentile
points, with the greatest improvement in the most
specific, actionable measures of patient experiences.
Implications for Policy, Delivery or Practice: Some of
the observed improvements may be due to the initiation
of hospital quality improvement efforts as a result of the
public reporting of the measures. Changing overall
patient impressions may have lagged improvements in
specific experiences, because consumers may form their
impressions about hospitals based on reputational
factors. Accelerated improvement in nurse
communication in the most recent year may reflect
staffing changes or training initiatives. Comparative
information may have been particularly motivating in the
broader context of health care system reform efforts,
including current/anticipated HCAHPS integration into
local and national pay-for-performance/value-based
purchasing approaches.
Funding Source(s): CMS
• More "Bang for the Buck"? Measuring State
Medicaid Spending Efficiency
Debra Lipson, M.H.S.A.; Timothy Lake, Ph.D.; Su Liu,
Ph.D.; Margaret Colby, M.P.P.; Sarah Turchin, B.A.
Presented by: Debra Lipson, M.H.S.A., Senior
Researcher, Mathematica Policy Research, Inc., 600
Maryland Avenue, S.W., Suite 550, Washington, DC
20024; Phone: (301) 244-0399; Email:
dlipson@mathematica-mpr.com
Research Objective: Growth in Medicaid costs
consistently outpaced state tax revenues over the past
decade, accelerating in 2009 by 8 percent. Although
largely attributable to recession-related enrollment
increases, recent spending growth has led policymakers
to question whether public dollars are spent as efficiently
as possible. This study aims to construct measures of
Medicaid spending efficiency to gauge and compare
states’ performance in gaining greater value.
Study Design: Based on a literature review and input
from an expert panel, we defined efficiency for the
Medicaid program as the value achieved: higher quality
for the dollars spent. To quantify this concept, we
developed 28 quality-cost measures comprised of: (1)
Medicaid-specific quality or access measures, derived
from HEDIS or other survey data, and (2) associated
costs for the population represented by each quality
measure, computed from Medicaid Analytic Extract and
administrative cost data. States’ measures were arrayed
on scatterplots, correlation coefficients computed, and
results compared for stability across three years (20042006). State scores on individual measures were ranked
using criteria that distinguished least efficient (high
cost/low quality) from most efficient (low cost/high
quality) relative to the median.
Population Studied: Efficiency measures were
examined at the state level. Since Medicaid covers
diverse groups whose costs and quality indicators vary
widely, we divided the population into subgroups: adults,
children, people with developmental disabilities, and
nursing facility residents. Due to lack of data, the number
of states in each measure ranges from 15 to 50.
Principal Findings: Across all states, overall per
member per month (PMPM) costs varied by a factor of
three ($272 to $860); the largest variation ($2,057 to
$8,274) was for people with disabilities using long-term
care. Variation in quality measures was smaller with
most states clustered around the median. Taking
children ages 0-17 as an example, state PMPM costs
ranged from $141 to $556 in 2006, and a corresponding
quality measure—percent with a preventive visit in the
past year—ranged from 81.7% to 97.5%. We found only
3 significant correlations between spending and quality
across the 28 measures. In 2004-2006, six states
consistently ranked among the most efficient (higherthan-median quality at lower-than-median costs) and
nine states among the least efficient (lower-than-median
quality at higher-than-median costs).
Conclusions: While variation in Medicaid spending is
high, some states appear to get more “bang for the
buck”—better quality with lower per-beneficiary costs—
than other states. Comparable Medicaid-specific quality
data are scarce so more data are needed to understand
variation in value to facilitate improvements.
Implications for Policy, Delivery or Practice: As a
pioneering effort to measure Medicaid efficiency, the
results of this study offer initial benchmarks to assess
the value of state spending relative to quality. In contrast
to cost-cutting methods like reductions in benefits or
eligibility which may harm quality or access, our finding
that costs and quality were not generally correlated
suggests there may be ways to manage spending
without sacrificing quality. Qualitative case studies will
be conducted in six states to understand the factors that
might explain state performance. Development of new
Medicaid-specific quality measures under CHIPRA and
other initiatives may increase availability of state data.
Funding Source(s): U.S. DHHS, ASPE (Asst. Secretary
for Planning and Evaluation)
• Antibiotic Prescribing Guideline Adherence in
General Practice: Organizational Characteristic or
Practice Preference?
Uzor Ogbu, M.D., M.Sc.; Onyebuchi Arah, M.D., Ph.D.;
Liset van Dijk, Ph.D.; Dinny DeBakker, Ph.D.; Karien
Stronks, Ph.D.; Gert Westert, Ph.D.
Presented by: Uzor Ogbu, M.D., M.Sc., Doctoral
Candidate, Social MEdicine, Academic Medical Center,
University of Amsterdam, Meibergdreef 9, Amsterdam,
1105AZ, Netherlands; Phone: +31205664511; Email:
u.c.ogbu@amc.uva.nl
Research Objective: Performance frameworks use
selected indicators to represent overall quality of care.
High performance levels on quality of care indicators
may reflect a practice wide approach to quality, in which
case it would be reflected across indicators. However,
documented performance levels may also reflect the
likelihood that the recommended best practices coincide
with the practice preferences of healthcare facilities and
providers. Using four antibiotic prescribing guidelines,
we examined the relationship between various indicators
of guideline adherence rates among general (or primary
care physician practices) practices in order to distinguish
organizational uptake of guidelines from practice
preferences.
Study Design: In this retrospective study, we estimated
prescribing guideline adherence rates for four conditions
(bacterial skin infections, acute throat pain, sinusitis,
urinary tract infections) in general practice. Three
indicators advocated restrictive prescribing (bacterial
skin infections, acute throat pain, sinusitis) and one was
related to first choice prescribing (urinary tract
infections). Pearson’s correlation coefficient was used to
examine the pairwise practice-level association between
prescribing guideline adherence indicators. We also
used random-intercept-only multilevel analysis to
examine the associations between practice-level
adherence rates of any three prescribing guideline
adherence indicators, and adherence to the fourth
guideline-recommended prescribing behavior. The
multilevel regression models were adjusted for patient
characteristics such as age, gender, type of insurance
and number of episodes, and practice characteristics
such as practice size and type.
Population Studied: The study was based on records
from over 75 general practices participating in the
Netherlands Information Network of General Practice
from 2002 to 2005. We examined individual episodes of
bacterial skin infection (30,757), acute throat pain
(28,544), sinusitis (39,648), and urinary tract infections
(75,300).
Principal Findings: At the practice-level, the
correlations between the restrictive prescribing indicators
were positive and ranged from 0.52 to 0.57. The
strongest correlation, 0.57, was between the adherence
to the sinusitis and acute throat pain guidelinesrecommended prescription. The relationship between
the first-choice indicator and the restrictive indicators
was low and negative with the correlation coefficients
between - 0.27 and - 0.29 . The correlation coefficient
between urinary tract infections and sinusitis was - 0.29.
In the multilevel model, when adherence rates of any of
the three guidelines was modeled with adherence to the
fourth as an outcome, the odds ratios (OR) and 95%
confidence interval (CI) for the restrictive indicators were
between 1.01 (1.00 – 1.01) and 1.02 (1.01 – 1.03). The
association with the first-choice indicator was between
OR 0.98 (95% CI 0.98 – 0.98) and OR 1.00 (95% CI
0.99 – 1.00).
Conclusions: In view of the weaker than expected
correlation between guideline adherence rates and the
limited effect of performance rates on any guideline on
adherence to another, guideline adherence does not
appear to be an organizational characteristic among
general practices.
Implications for Policy, Delivery or Practice: In the
absence of evidence elucidating links between process
measures, the selection of indicators to represent quality
of care should be sufficiently broad in order to paint a
more accurate picture.
Funding Source(s): Dutch National Institute of Public
Health and the Environment (RIVM).
Patient-Centered Medical Homes and Patient
Characteristics
Chair: Melinda Abrams
Tuesday, June 29 * 9:45 am–11:15 am
• Pennsylvania Statewide Implementation of Multipayer Supported Patient Centered Medical Home
Improves Diabetes Care
Robert Gabbay, M.D., Ph.D.; Michael Bailit, M.M.;
Edward Wagner, M.D., M.P.H.; Linda Siminerio, R.N.,
Ph.D.
Presented by: Robert Gabbay, M.D., Ph.D., Professor,
Penn State Institute for Diabetes and Obesity, Penn
State College of Medicine College of Medicine, 500
University Drive, Hershey, PA 17033; Phone: (717) 5313592; Email: rgabbay@psu.edu
Research Objective: The Patient Centered Medical
Home (PCMH), which incorporates the Chronic Care
Model (CCM), is being implemented with widespread
enthusiasm but limited outcomes data to date. Despite
recognition that the CCM improves outcomes, it
generally has been adopted within large health care
organizations in part due to the mismatch between who
bears the cost of implementation and who receives the
financial benefits from care improvement. Lessons
learned in PCMH practice transformation guided by the
CCM are critical to better define optimal approaches.
Study Design: We report a unique statewide, multipayer-based implementation of the CCM and PCMH in
Pennsylvania (PA) facilitated by the Governor’s Office
for Health Care Reform (GOHCR). The GOHCR used its
authority to convene, facilitate and lead design of the
initiative providing participating insurers and providers
with anti-trust protection. It also has provided ongoing
oversight. The focus of the intervention is on
transforming primary care delivery with diabetes as the
primary initial prototype chronic illness based on its high
cost, morbidity, and clear evidence-based guidelines.
This is the largest multi-payer statewide implementation
of the PCMH, and even more unique as a large CCM
initiative enhanced by major multi-payer-based provider
incentives. Primary care practices implement the CCM
over 3 years through regional Breakthrough Series
learning collaboratives supported by Improving
Performance in Practice (IPIP) coaches and significant
infrastructure payments by the State’s 17 leading
insurers to implement the CCM and achieve NCQA
PCMH recognition. Uniform registry-based monthly
reporting of IPIP diabetes measures is required in
practice agreements.
Population Studied: The intervention involves 102
practices with 518 providers across PA. We present first
year outcomes from the initial 25 primary care practices
from the southeastern region of PA.
Principal Findings: There was a significant increase in
yearly diabetes complication screening rates (foot exams
- 50 to 69 %, nephropathy screening - 62 to 83 % and
self-management goals from 50 to 78 %) with
recommended statin use increasing from 36 to 57 % and
improvements in key clinical measures (A1C, BP, and
LDL cholesterol). Leading practice changes include
reorganizing for team-based care, incorporation of selfmanagement support and education, planned visits, and
office huddles.
Conclusions: Practice redesign based on CCM and
PCMH, leveraged by significant reimbursement
changes, comprehensive practice transformation and
technical support, hold significant promise for improving
chronic illness care including diabetes.
Implications for Policy, Delivery or Practice: As the
PCMH and CCM are implemented in various health care
environments, optimal implementation must be
considered. Multi-payer reimbursement changes,
practice coaches, and monthly quality data reporting can
enhance transformation. State government can play a
critical role in spreading PCMH by convening multiple
payers and provider groups to develop infrastructure
support for PCMH implementation.
• Do Patients Want What PCMHs Give? An
Exploration of Chronically Ill Patients’ Priorities in
Care and How They Align with the PCMH Model
Holly Mead, Ph.D.; Ellie Andres, M.P.H.
Presented by: Holly Mead, Ph.D., Assistant Research
Professor, School of Public Health & Health Services,
Department of Health Policy, The George Washington
University Medical Center, 2121 K Street, NW, Suite
200, Washington, DC 20037; Phone: (202) 994-8615;
Email: khmead@gwu.edu
Research Objective: The Patient-Centered Medical
Home (PCMH) model has gained significant interest as a
system-level innovation with the potential to contribute
marked improvements in health care quality while
reducing health care costs. The PCMH model provides
comprehensive, coordinated care in a setting that
encourages patient-physician partnerships. In theory, the
PCMH model would be particularly well-suited for
serving chronically ill, socially disadvantaged patients
who are frequent users of the health care system and
require easily accessible, well-coordinated care to
effectively manage their conditions. This study seeks to
evaluate the fitness of the seven core principles of the
PCMH model for patient care from the perspective of
socioeconomically disadvantaged patients with chronic
illness.
Study Design: As part of a national project on
disparities in cardiac care, we convened 33 focus groups
with a total of 387 participants to explore patients’
perceived barriers and facilitators of care. All focus
group participants suffered from a heart condition or
related chronic illness. We conducted thematic content
analysis to identify key elements representing
participants’ perceived notions of patient-centered care.
Population Studied: Participants in the focus groups
were predominantly minority patients with low socioeconomic status who suffered from a chronic heart
condition. Participants were recruited from primary care
centers or specialized heart care clinics (e.g. cardiac
rehabilitation or heart failure clinics) in 10 cities across
the country.
Principal Findings: We identified five major priorities for
care that participants emphasized as essential in
supporting the care of their conditions. These priorities
include: 1) continuity of care, 2) coordination of care, 3)
provider support and partnerships, 4) affordable access
to recommended services and treatments, and 5)
linkages to community networks of support.
Conclusions: Many of the elements of care prioritized
by participants in the focus groups were consistent with
the core principles of the PCMH. Participants
emphasized the importance of continuity and
coordination in their care, as well as patient-provider
relationships. However, two issues of critical concern -those of affordable access to care and community
linkages -- do not appear to be fully developed by the
PCMH. In our study, the cost of care was the greatest
barrier to care for this population. This issue often
influenced patients’ ability to obtain the other core
principles of patient-centered care, including
comprehensive, coordinated, high-quality care.
Additionally, participants emphasized linkages to
community-based resources as necessary supports for
care management. Such linkages often appeared to be a
defining distinction between patients who felt in control
of their disease and those who did not.
Implications for Policy, Delivery or Practice: affirms
that the principles of the PCMH are consistent with the
needs and desires of socially disadvantaged, chronically
ill patients. However, it suggests the need to address the
cost of care and to improve community linkages in order
to provide truly patient-oriented care. As health reform
unfolds, patient-centered medical homes need to
consider how to use expected reimbursement changes
and greater insurance coverage to their advantage to
ensure that cost does not become a barrier to patientcentered care. In addition, as a model, the PCMH should
promote linkages to community networks as a standard
of care.
Funding Source(s): RWJF
• Understanding the Case-Mix of Patient-Centered
Medical Homes in Ontario, Canada.
Lyn Sibley, Ph.D.; Richard H. Glazier, M.D., M.P.H.;
Brian Hutchison, M.D., M.Sc.
Presented by: Lyn Sibley, Ph.D., Fellow, Department
of Health Policy, Management, and Evaluation,
University of Toronto, 155 College Street - 425, Toronto,
M5T 3M6, Canada; Phone: (416) 978-5017; Email:
lyn.sibley@utoronto.ca
Research Objective: Several innovative models for
primary care delivery have recently been introduced in
Ontario, Canada. Some of these models have features
in common with the patient centered medical homes that
are growing in popularity in the United States.
Specifically Family Health Teams (FHTs) are
multidisciplinary teams that are organized and
incentivized to provide patient-centered comprehensive
primary care to enrolled patients. Despite the growing
popularity of FHTs and other primary care patient
enrollment models in Ontario, little is known about the
burden of illness of enrolled patients. This study
presents a method for summarizing the casemix of
primary care rosters, and evaluates variations in roster
casemix between three different primary care model
types.
Study Design: This study uses administrative data
collected by the Ontario Ministry of Health and LongTerm Care. The study sample was identified as those
physicians who belonged to a primary care patient
enrollment group on August 31, 2008. Each physicians’
enrolled patients were assigned a morbidity weight using
the Johns Hopkins Adjusted Clinical Groups (ACG)
Case-mix System and diagnosis data from the previous
two years. The casemix of each roster was summarized
by a Standardized ACG Morbidity Index (SAMI) which
was calculated as the standardized average morbidity
weight of all patients on the roster. The SAMIs for each
physicians’ roster were compared across and within the
three types of patient enrollment models: fee-for-service,
non-team based capitation, and team-based capitation
(i.e. FHTs).
Population Studied: This study included all patients
who were enrolled to a rostering physician practice on
August 31, 2008 in the Canadian province of Ontario.
Principal Findings: The study sample includes 6,034
physician rosters which consisted of 7,048,187 patients.
The mean SAMI of fee-for-service rosters was higher
than the SAMI for both types of capitation groups
(1.15±0.34 vs. 1.06±0.25 and 1.06±0.31; p<0.001). The
interquartile range of the fee-for-service rosters (1.300.93) was greater than both of the non-team based
capitation rosters (1.20-0.88), and team-based capitation
rosters (1.18-0.88). The 95th percentile of the fee-forservice rosters was 1.74 with the other two groups
having a 95th percentile of 1.52.
Conclusions: The rosters of physicians in enhanced
fee-for-service groups had a higher average morbidity
burden and greater variation in morbidity than the rosters
of both types of capitation groups. The cross-sectional
nature of this study does not permit conclusions about
causation. It, therefore is not known if physicians in
capitation based models selectively enrolled patients
with a lower burden of illness; if physicians who already
had a healthier patient population were more likely join
this kind of practice; or if the services provided in teambased models improved the health status of patients,
resulting in a lower burden of illness.
Implications for Policy, Delivery or Practice: Being
able to easily and reliably measure morbidity burden
allows decision makers to identify and fairly reimburse
physicians whose patients have a higher burden of
illness. Current research is underway to evaluate how
the morbidity burden of rostered patients has changed
over time and what payment incentives are associated
with these changes.
Funding Source(s): Health System Performance
Research Network, Ontario Canada
• Cost-Related Medication Adherence and Patients’
Experience with the Chronic Care Model
John Zeber, Ph.D.; Luci Leykum, M.D.; Krista Bowers,
M.D.; Raquel Romero, M.D.; Michael Parchman, M.D.
Presented by: John Zeber, Ph.D., Investigator /
Assistant Professor, Psychiatry, Veterans Affairs HSRD /
UTHSCSA, 7400 Merton Minter Boulevard, San Antonio,
TX 78229; Phone: (210) 617-5300; Email:
zeber@uthscsa.edu
Research Objective: Medication adherence is a
significant problem for patients with diabetes, one
frequently exacerbated by financial considerations.
Fortunately, provider and organizational factors (e.g.,
improved therapeutic alliance or clinical microsystem
performance) can mitigate medication cost burdens.
Research suggests that patients who are highly engaged
in their care have better adherence, significantly
improving clinical outcomes. Implementation of the
Chronic Care Model in primary care should result in
more activated patients who participate in their
treatment. This study examines the relationship between
patients’ experience of the CCM and its relationship with
cost-related medication adherence burden.
Study Design: Cross-sectional surveys from a large
randomized trial in progress were administered as part
of a study aim regarding how practice facilitation efforts
influence better implementation of the chronic care
model (CCM). Cost-related adherence burden (CRAB)
was measured with a 5-item scale developed and
validated by Piette and colleagues, where higher scores
reflect more cost-related medication restrictions. The
CCM was measured by the well-validated Patient
Assessment of Chronic Illness Care (PACIC) survey, a
20-item instrument assessing perceptions of the primary
care treatment environment. Each item was scored on a
1-5 Likert scale, with higher PACIC values indicating that
patients experienced care delivery that was more
consistent with the CCM. Random effects models
controlling for nesting of patients within clinics analyzed
the association between CRAB and perceived elements
of the chronic care model.
Population Studied: Patients with diabetes or other
chronic medical illness presenting for care in 18 small,
autonomous primary care offices in South Texas.
Principal Findings: To date, 1377 patients with a
chronic health condition completed both baseline
surveys. The mean study population age was 50.1
years, with 65% women and approximately 50% of
Hispanic ethnicity; while overall self-reported health
status was good, 45% acknowledged poor medication
adherence behavior, with nearly 30% claiming some
cost-related problems. The CRAB scale mean was 1.50
(SD 0.82), with an overall PACIC mean of 3.02 (SD
1.25). In multivariable models also adjusting for age,
sex, education and ethnicity, CRAB was inversely
associated with the total PACIC score (OR=1.17).
Higher subscales scores for patient activation
(OR=1.26), problem solving (OR=1.16), and practice
design (OR=1.26) were also associated with fewer costrelated problems pertaining to medication adherence.
Conclusions: Patients experiencing care more
consistent with elements of the chronic care model had a
lower cost-related adherence burden, up to a 25%
reduction per incremental increase in treatment
delivered via the CCM. Specifically, this finding was true
for individuals who reported that their treatment team
actively involves them in clinical decision-making and
provided information that enhances understanding of
their care.
Implications for Policy, Delivery or Practice: Although
the prevalence of poor medication adherence in chronic
illness patients is widely understood, the specific role of
cost-related problems is less appreciated. Clinical efforts
to develop highly activated and involved patients can
successfully mitigate the ramifications of financial
pressures. Community providers should better recognize
and openly discuss the burden of medication cost
problems while focusing treatment efforts in accordance
with proven chronic care treatment delivery.
Provider Markets and Competition
Chair: Adam Atherly
Tuesday, June 29 * 9:45 am–11:15 am
• Variations in Prices for Physician Services
Laurence Baker, Ph.D.; Anne Royalty, Ph.D.; Kate
Bundorf, Ph.D.
Presented by: Laurence Baker, Ph.D., Professor of
Health Research and Policy, Health Research and
Policy, Stanford University School of Medicine, HRP
Redwood Building, 259 Campus Drive, Room 110,
Stanford, CA 94305; Phone: (650) 723-4098; Email:
laurence.baker@stanford.edu
Research Objective: Prices are a key determinant of
health care spending. Anecdotal evidence suggests that
there are substantial variations in physician fees across
geographic areas, across physicians within geographic
areas, and even in the same physician practice across
different payers. A good understanding of fee variation
patterns could shed light on questions about the
performance of markets and about cost containment
options, but evidence on patterns of fee variation is
lacking. We use a large dataset of claims from private
health insurers to examine patterns of variations in
prices paid by health plans to doctors for a set of
common medical procedures.
Study Design: Data come from the Thompson Reuters
MarketScan data for 2006, which include claims data
from the health plans of large employers. The data
report the actual amount paid to the doctors for each
claim. We extracted all claims from plans that pay
doctors using FFS for 17 common physician services in
100 large MSAs in order to characterize the amount of
variation in fees for identical services. We decompose
observed variance into components that reflect variation
across MSAs and variation within MSAs. We
characterize patterns of variation across different kinds
of services (e.g. evaluation and management vs
diagnostic testing). We characterize patterns of variation
across MSAs and use regression analysis to examine
correlates of fees across areas.
Population Studied: Physician fees for the care of
patients covered by FFS plans (principally PPOs) offered
through large employers in 100 large MSAs. (N=~12.2
million claims total)
Principal Findings: There is a considerable amount of
variation in the fees paid to physicians for identical
services. For example, even after trimming the data to
exclude very high and low payments, the difference
between the 90th and 10th percentile of fees for a given
procedure is typically about equal to the median. Only
about one third of this variation can be explained by
variation across MSAs -- a large portion of the variation
can be observed across physicians within the same
MSAs. Patterns of variation tend to be similar across
different kinds of services. Analysis of correlates of
patterns across geographic areas is ongoing, and is
expected to include regression analysis of the
relationship between physician supply, market structure,
and demographic characteristics and physician fees.
Conclusions: Variations in private insurance payments
to physician for the same services are widespread and
substantial. Some fee variation exists systematically
across markets, suggesting that features of markets
(e.g. number of providers, market structure) may explain
some variations. But, much of the variation occurs within
MSA, suggesting that characteristics of individual
physicians and health plans (and interactions between
them) are likely to be important. Reductions in fees paid
at the high end of the distribution appear capable of
generating substantial savings, though this may be
politically difficult to achieve.
Implications for Policy, Delivery or Practice: Efforts to
better understand and influence variations prices for
health care services may provide useful policy
approaches.
Funding Source(s): RWJF
• Health Care Specialization and Asymmetric
Competition: The Dynamics of Surgery Center and
Hospital Entry
Michael Housman, Ph.D.
Presented by: Michael Housman, Director of Applied
Science; Pascal Metrics Inc.; 1025 Thomas Jefferson
Street NW; Suite 420 East; Washington DC 20007
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 tend to enter markets in
which there are nearby hospitals. Hospitals tend to
produce higher rates of procedure demand and attract a
higher supply of physicians while allowing ASCs to
recruit hospital-based surgeons and cherry pick the
healthiest patients. For these same reasons, hospitals
may avoid markets that are served by ASCs. To that
end, this study aims to understand how ASCs influence
market entry by general hospitals and how hospitals
influence market entry by ASCs. This phenomenon has
implications for the ability of hospitals to treat vulnerable
populations and cross-subsidize less profitable lines of
service.
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 negative binomial models to evaluate the
different impact of each factor on: (1) ASC entry; and (2)
hospital entry.
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: ASCs tend to enter markets in
which there are high levels of ASC density (p < 0.01) but
tend to avoid markets with high levels competition from
hospitals (p < 0.05). Hospitals, on the other hand, not
only tend to avoid markets with high levels of
competition from hospitals (p < 0.05), they also avoid
markets with high levels of ASC density (p < 0.01).
These effects appear to be influenced by geographic
location in that local market conditions affect entry
patterns more strongly than diffuse conditions.
Conclusions: Both ASCs and hospitals appear to avoid
direct competition with other outpatient facilities.
However, ASCs appear to seek out markets being
served by hospitals while hospitals tend to avoid markets
being served by ASCs.
Implications for Policy, Delivery or Practice: These
findings have major implications since ASC and hospital
entry may affect patient access to care. Moreover,
market entry by 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 ASC and hospital entry patterns.
Funding Source(s): AHRQ
• Does the Number of Contracts Matter? Managed
Care Contracts and Physicians’ Career Satisfaction,
Hours, and Income.
Dan Ly, B.A.; Sherry A. Glied, Ph.D.
Presented by: Dan Ly, B.A., Harvard Kennedy School,
10 Akron Street, Unit. 101, Cambridge, MA 02138;
Phone: (615) 478-2666; Email:
dan_ly@hks11.harvard.edu
Research Objective: When physicians complain about
the hassles associated with managed care, they often
report having to deal with multiple insurers, forms, and
guidelines – functions of the number of contracts the
physician has. The existing research literature on the
effects on physicians of managed care contracting,
however, has focused on the share of revenue from
managed care, rather than on the number of contracts.
This paper examines how contracting itself affects: 1)
career satisfaction; 2) hours spent in practice; 3) the
share of hours in medicine outside patient care (a proxy
for administrative time); and 4) income.
Study Design: Data consisted of all physicians working
at least 20 hours per week in the first 4 rounds of the
nationally representative Robert Wood Johnson
Foundation Community Tracking Study (CTS) Physician
Survey. Analyses were conducted separately for primary
care physicians (PCPs) and non-PCPs. Multivariate
logistic and linear regressions (controlling for share of
revenue from managed care, Medicare, and Medicaid,
charity care hours, practice group type and size, other
physician characteristics, year, and site) were performed
to assess the relationship between contracting and
outcomes. To address the possible endogeneity of
managed care contracting, the analyses were repeated
using instrumental variables. The area Herfindahl
concentration index of insurers, obtained from the AMA
reports on insurer concentration, was used as an
instrument.
Population Studied: 37,679 physicians (22,325 PCPs
and 15,354 non-PCPs) in 60 US sites across 4 time
periods (1996-97, 1998-99, 2000-01, 2004-05).
Principal Findings: There was considerable variation in
contracting practices. 8% of physicians had no contracts
with managed care organizations; 28% held 1-5; 43%
held 6-15; and 2% held over 50. After controlling for the
share of revenue from different sources, a greater
number of contracts was associated with more hours
spent in total in medical practice, more hours spent in
patient care (for PCPs), and a larger share of hours
spent in non-patient care (for both PCPs and nonPCPs). Primary care physician incomes did not vary
consistently with contracting, but specialists with many
contracts had incomes 20% higher than those with very
few contracts. There was no relationship between the
number of contracts and career satisfaction in either
physician group.
Conclusions: Increased numbers of contracts appear to
be associated with increased numbers of patient care
hours and an increased share of hours spent in nonpatient care activities. For specialists, contracting also is
associated with increases in total income.
Implications for Policy, Delivery or Practice:
Contracting with multiple insurers does appear to
increase administrative time for physicians. Thus,
innovations to reduce the contracting costs associated
with multiple insurers (administrative and procedural
simplifications, for example) have the potential to reduce
the number of hours physicians spend in these activities.
• Physicians’ Investments in Equipment for
Diagnostic Testing, Imaging, and Medical
Procedures
James Reschovsky, Ph.D.; Hoangmai Pham, M.D.,
M.P.H.
Presented by: James Reschovsky, Ph.D., Senior
Health Researcher, NA, Center for Studying Health
System Change, 600 Maryland Avenue, SW, Suite 550,
Washington, DC 20024; Phone: (202) 484-9200; Email:
jreschovsky@hschange.org
Research Objective: Flat reimbursements and pricing
distortions have led many physicians to become more
entrepreneurial by purchasing or leasing medical
equipment formerly in the domain of hospitals, radiology
practices, and other specialized facilities. As a result,
diagnostic testing, imaging, and procedures have grown
dramatically among Medicare beneficiaries and other
patients. Yet few data are available on which providers
benefit from delivering these services. We assessed the
prevalence of ownership or leasing by individual
physicians and practices in ancillary equipment,
indentifying physician subgroups most likely to report
such investments.
Study Design: Analysis of the nationally representative
2008 Health Tracking Physician Survey (RR=62%).
Physicians reported their personal and/or practice’s,
ownership/leasing of five categories of equipment. We
estimated separate multivariable models for each type of
investment, and for the number of investment categories
(0-5), adjusting for specialty, practice
type/size/ownership, revenue sources, compensation
methods, and market characteristics.
Population Studied: 4,720 non-Federal physicians
spending at least 20 hours per week in patient care
(excluding radiologists, pathologists, and
anesthesiologists).
Principal Findings: About six in 10 physicians are in
physician-owned, community-based practices. Among
these, rates of equipment ownership/leasing were 28%
for lab equipment, 24% for x-rays, 19% for advanced
imaging, 31% for non-invasive procedure equipment,
and 13% for invasive procedure equipment. Rates
increase with practice size, although even among
solo/two physician practices, 10% report
ownership/leasing of advanced imaging and invasive
procedure equipment, and a quarter report interest in
non-invasive procedure equipment. As expected,
specialty influenced the number and type of equipment
owned, with surgical and procedural specialists reporting
highest rates of equipment ownership/leasing, except for
lab equipment and x-rays. These relationships were
reinforced in multivariate analyses. Moreover,
multivariate results suggest that equipment
ownership/leasing of all kinds was significantly higher in
markets perceived as very competitive in terms of
attracting/retaining patients relative to those in noncompetitive markets (ORs from 1.3 to 1.6, p<0.01).
Some types of investments were associated with
exposure to various types of compensation incentives;
payer mix; and patient socioeconomic indicators.
Conclusions: Investments by physician practices in
ancillary equipment - including capital-intensive
equipment for advanced imaging or invasive procedures
- is prevalent, particularly among physician-owned,
community-based practices. Greater equipment
ownership/leasing in perceived competitive markets
suggests physicians are using equipment as a means to
induce demand when patient supply is limited.
Implications for Policy, Delivery or Practice:
Loopholes in Stark laws have permitted substantial
physician investment in ancillary equipment. Impacts
may be greater patient convenience, but also overuse of
various diagnostic tests and procedures with associated
costs. Recently announced Medicare physician fee
schedule changes could moderate incentives for certain
services such as cardiac procedures and advanced
imaging and health care reform legislation would have
further impacts on payment policy, especially for high
volume growth services. Whether implementation of
these policies results in physicians divesting from
ancillary equipment (and lower growth in service volume)
will depend on the nature of policy changes, local market
conditions, and whether providers face incentives that
reward productivity in the aggregate. Regardless, the
business strategies of a large percentage of physicians
are likely to be affected.
• Hospital Concentration, Pricing, and Profitability in
Orthopedics and Cardiology
James Robinson, Ph.D.; Samuel Tseng, Ph.D.; Alexis
Pozen, M.A.
Presented by: James Robinson, Ph.D., Professor and
Director, Berkeley Center for Health Technology,
University of California, 247 University Hall, Berkeley,
CA 94720-7360; Phone: 5106420564; Email:
james.robinson@berkeley.edu
Research Objective: To analyze the association
between hospital market concentration and financial
performance for orthopedic, spine, and cardiac surgery
patients, controlling for disease severity, hospital
characteristics, and other factors.
Study Design: Multivariate regression analysis of
commercial pricing (reimbursement) and contribution
margin (profit) per case, using the patient as unit of
observation, as a function of market concentration (HHI),
procedure volume, detailed measures of severity of
illness, and other patient, hospital, and market
characteristics.
Population Studied: 24,000 patients undergoing any of
six major procedures (hip replacement, knee
replacement, lumbar or cervical fusion, insertion of
cardiac rhythm management device (e.g., pacemaker,
defibrillator), cardiac valve replacement in 48 hospitals in
2008.
Principal Findings: Patients undergoing major surgical
procedures generate substantially higher revenues and
profit margins in concentrated than more competitive
hospital markets (p<.01). Hospital revenues and
earnings are substantially higher for commercially
insured than Medicare patients (p<.01). Surgical
complications significantly increase costs per case
(p<.01).
Conclusions: Market concentration permits significantly
higher hospital prices for commercially insured patients,
allowing those institutions to subsidize the care for
Medicare enrollees.
Implications for Policy, Delivery or Practice: Market
concentration and the associated high prices and profits
explain the interest by both community hospitals and
physician-owned specialty hospitals to expand their
orthopedic, spine, and cardiac service lines. Anti-trust
policy that reduced prices would reduce this attraction,
but also the ability of hospitals to subsidize Medicare
patient care.
Funding Source(s): California Healthcare Foundation
Systems Analysis of Service Delivery
Chair: Peter Jacobson
Tuesday, June 29 * 9:45 am–11:15 am
• Local Health Department Changes in Service:
Relationships to Health Disparities
Betty Bekemeier, Ph.D., M.P.H., R.N.; David
Grembowski, Ph.D., M.A.; Young Ran Yan, R.N., M.P.H.
Presented by: Betty Bekemeier, Ph.D., M.P.H., R.N.,
Assistant Professor, Psychosocial & Community Health,
University of Washington School of Nursing, Box
357263, Seattle, WA 98195-7263; Phone: (206) 6168411; Email: bettybek@u.washington.edu
Research Objective: The activities that local public
health departments (LHDs) conduct have changed over
time. One change is evident in the trend among LHDs to
have transitioned from clinical activities such as primary
care to more population-based services such as injury
prevention and community assessment. We know little
about how this shift in services impacts health outcomes
or what types of public health services most effectively
reduce health disparities. This study investigated
changes in LHD services and how changes in services
are associated with changes in mortality disparities.
Study Design: We conducted a regression analysis of
secondary data using an exploratory panel time series
design. While controlling for other factors, we used LHD
services to estimate ecologic associations between
changes to services in 1993 and in 2005 and changes in
1993-2005 Black-White disparities for all-cause mortality
and infant mortality measured at the county level.
Services directly provided by LHDs were examined
relative to change in breadth of activity within each of 10
domains of service and whether domains increased,
decreased, or maintained breadth of activity from 1993
to 2005. Latent class variables were also created to
characterize LHDs by their change in service provision
across a majority of program domains (i.e. growing
specific service areas versus shrinking or remaining
stable).
Population Studied: The sample studied was made up
of 558 county or multi-county “common local areas,”
created to link records across data sources representing
county-level data for LHDs and their jurisdictions. As
health outcomes were measured in terms of Black-White
mortality disparities, only counties with statistically
measurable Black mortality were included in the sample.
As a result, the population studied over-represents
southern and large metropolitan areas.
Principal Findings: Increases in the breadth of
Maternal Child Health activities (e.g. family planning,
prenatal care) and in the breadth of Health Services (e.g.
primary care, mental health) had significantly beneficial
relationships with reductions in Black-White mortality
disparities for 15-44 year olds. Increases in the breadth
of Health Services were also associated with a
significant improvement in Black-White infant mortality
disparities. The LHDs in 71.8% of the common local
areas in the study sample, maintained or decreased the
breadth of service in a majority of the program domains
in their departments. There were no significant
relationships with change in Black-White mortality
disparities, however, by jurisdictions characterized as
those that tended to increase the breadth of their
services (28%) versus those that remained
stable/declined across the broad set of services.
Conclusions: It is not yet clear how national trends
regarding changes to LHD practice impacts our most
vulnerable populations. This study suggests, however,
that investments made by LHDs to increase the breadth
of certain direct services, primary care-related and
maternal child health-focused activities, may have the
most immediate beneficial relationship to reducing
Black-White mortality disparities for young adults.
Implications for Policy, Delivery or Practice: LHD
leaders are eager for evidence to support decisions
regarding changes made to local service delivery. This
study has implications for practice that suggest certain
individually-focused services such as maternal child
health and primary care, may be particularly important
investments for reducing disparities among young
adults.
Funding Source(s): Pfizer Scholars Grant in Public
Health
• Network Structures and Research Collaboration in
a Statewide Cancer Coalition
Judith Keagy, M.H.A.; Keith Provan, Ph.D.; Scott
Leischow, Ph.D.
Presented by: Judith Keagy, M.H.A., Research
Associate/Doctoral Student, Government and Public
Policy, University of Arizona, 6025 N. Mardelle Circle,
Tucson, AZ 85704; Phone: (520) 444-2321; Email:
jkeagy@email.arizona.edu
Research Objective: Networks are frequently viewed as
important for moving innovation beyond the boundaries
of individual organizations and enhancing translational
research. This study examines collaborative
relationships among organizations participating in cancer
research activities in Arizona under the auspices of
Arizona Department of Health Services' (ADHS)
statewide cancer control coalition. Research questions
focus on the following: How does network structure in
this coalition network compare with that of service
implementation networks operated by the same state
agency? Does the structure of network relations differ
when research activities are differentiated by type? Is
position in the coalition's research network related to the
organization's mission?
Study Design: Data were collected in 2007 from
organizations involved in research using surveys of key
informants in each organization. Using network analysis
methods, we examined the structure of each type of
network as well as the relationship between network
position and the importance of cancer research to each
organization’s mission. Each organization reported their
collaborative relationships with every other organization
in the Coalition for each of three types of cancer
research activities, discovery, development, and delivery
(3D), consistent with the 3D research continuum
developed by the National Cancer Institute.
Population Studied: The study population included 18
of the 21 organizations involved with the statewide
coalition and engaged in aspects of cancer research
falling into one or more of the 3D continuum categories.
The organizations in this network included, in addition to
the convening state public health agency, academic
institutions and research institutes, health care delivery
organizations, and support/advocacy agencies.
Principal Findings: Network analysis showed that the
coalition leader (ADHS) was not central to the network
structure, in contrast to other research on public/private
service implementation networks. Network ties were
densest when cancer research focused on delivery and
discovery. Development research linkages were much
less dense. Despite similarities in density, the centrality
structures for the discovery and delivery networks were
quite different; but both were positively correlated with
the development network. Centrality in the discovery and
development networks was positively related when
organizations rated their cancer research as essential to
their mission, but commitment to cancer research was
not as important in the delivery network.
Conclusions: The research demonstrated how network
analysis can be used to understand the extent to which
organizations involved in cancer research are able to
collaborate both within and across the 3D continuum.
Findings suggested substantial differences in network
structures and in network involvement, depending on the
type of research being conducted, while also
demonstrating the importance of organizational mission
in network structure and position.
Implications for Policy, Delivery or Practice: This
study can provide guidance to state public health
officials in their efforts to develop heterogeneous
coalitions of diverse health organizations within their
state and demonstrates how network analysis can assist
in strategic planning by identifying where linkages
already exist and where gaps and barriers lie. The
findings also suggest important implications for the role
of public health agencies in these kinds of chronic
disease coalition networks, in contrast to the role they
play in developing public/private service implementation
networks governed by direct funding and contractual
relationships.
Funding Source(s): Arizona Cancer Center
• Local Variation in Public Health Responses to
H1N1: A Role for Accreditation?
Glen Mays, Ph.D., M.P.H.; Mary Davis, Dr.PH.,
M.S.P.H.; Cammie Marti, B.S.N., M.P.H.; Brittan
Williams Wood, M.P.H.; John Wayne, Ph.D.; James
Bellamy, C.N.M.T., M.P.H.
Presented by: Glen Mays, Ph.D., M.P.H., Professor
and Chairman, Department of Health Policy &
Management, University of Arkansas for Medical
Sciences, 4301 W. Markham Street, #820, Little Rock,
AR 72205; Phone: (501) 526-6633; Email:
gpmays@uams.edu
Research Objective: Accreditation of public health
agencies has received considerable policy attention
because of its potential to promote consistency,
interoperability, and effectiveness in practice. While a
national accreditation program is still under
development, state-based programs exist in North
Carolina and several other states. The 2009 outbreak of
novel H1N1 influenza provided an opportunity to test the
preparedness and response capabilities of public health
agencies and to compare the responses of accredited
and non-accredited agencies. This study seeks to (1)
describe the nature and timing of local public health
responses to H1N1 in North Carolina; (2) compare the
responses taken by accredited and non-accredited
agencies; and (3) identify factors that facilitated and
inhibited local responses.
Study Design: We used a retrospective case-control
study design with nine NC local public health
jurisdictions stratified by accreditation status and
matched based on size and H1N1 case volume. Detailed
data on response activities were obtained through a
closed-form questionnaire administered to local
preparedness coordinators, and through on-site focus
groups held with organizations involved in H1N1
activities in each community from August through
September 2009. Factor analysis was used to group
more than 200 individual response measures into six
domains of activity, with separate measures constructed
for (1) the scope and (2) the timing of response activities
performed in each domain. Bayesian latent-variable
models for multiple indicators were used to compare the
scope and timing of H1N1 responses across agencies,
using specifications that allowed responses to vary
based on accreditation status, domains of activity, and
community-level random effects.
Population Studied: The study included five accredited
local public health agencies and four non-accredited
agencies in North Carolina that met selection criteria
based on accreditation status and confirmed H1N1
cases as of June 2009, as well as matching criteria
based on population size and demographic
characteristics of the counties served by each agency.
Principal Findings: Agencies varied widely in the scope
and timing of their H1N1 activities. Accredited agencies
performed a significantly larger scope of activities in
response to the H1N1 outbreak compared to nonaccredited agencies (p<0.05), and these differences
were apparent across all domains including planning,
incident command, investigation, communication, and
response and mitigation activities. Additionally,
accredited agencies appeared to implement these
activities more rapidly than nonaccredited agencies,
particularly for incident command and investigation
activities (p<0.05). Focus group data suggested that the
strength of relationships among local H1N1 responders
and the ability to organize and redeploy local public
health workers and medical reserve volunteers were
perceived as important mediating factors in local
response activities.
Conclusions: Findings suggest that public health
accreditation programs may be effective in motivating,
facilitating, and/or documenting enhanced preparedness
capacities among agencies that undergo accreditation.
How much of these differences are due to self-selection
of capable agencies to undergo accreditation vs. agency
improvement efforts in response to accreditation
standards remains for further investigation.
Implications for Policy, Delivery or Practice:
Accreditation may be a productive mechanism for
recognizing and/or improving the preparedness and
response capacities of local public health agencies,
particularly if standards are designed to reinforce local
interorganizational relationships and workforce
capabilities.
Funding Source(s): CDC, The Robert Wood Johnson
Foundation
• From Anecdotes to Archetypes: A Systems
Analysis of the Sustainability of Community-Based
Interventions
Tina Anderson Smith, M.P.H.; Beverly Tyler, B.A.;
Amanda Phillips Martinez, M.P.H.; Ethan Joselow,
M.P.H.; John Butts, M.P.H.; Karen Minyard, Ph.D.
Presented by: Beverly Tyler, B.A., Sr Research
Associate, Georgia Health Policy Center, 14 Marietta
Street, Atlanta, GA 30303; Phone: (404) 413-0288;
Email: btyler@gsu.edu
Research Objective: To describe the extent to which
federally-funded community-based demonstration
programs have been sustained post fundng and to
identify recurrent patterns that influence long-term
impact.
Study Design: A mixed-methods historical assessment
using qualitative and quantitative methods to analyze
telephone interviews with community coalitions that
received grant funding from the Federal Office of Rural
Health Policy. Systems thinking tools and mapping are
utilized to describe archetypes which describe recurrent
patterns of community coalition behavior and outcomes
related to program and organizational impact and
sustainability. All interviews were audio taped and
transcribed. Community stories were analyzed using an
inductive coding system to facilitate the identification of
predictive factors related to impact and sustainability.
Quantitative results are integrated with themes emerging
from the qualitative analysis.
Population Studied: 132 community based
organizations and coalitions that received either Rural
Health Outreach or Rural Health Network Development
grants in 2000, 2002, and 2004 from the Federal Office
of Rural Health Policy. All grantees received funding to
implement community-based interventions to address
rural health access, health improvement, or
infrastructure needs.
Principal Findings: 78% of the community based
demonstration programs were sustained beyond the
federal three-year funding cycle. Conventional definitions
of sustainability, generally narrowly defined as
programmatic or organizational continuation and
solvency, are inadequate to reflect the legacy of federal
investments in community based efforts to transform
local health systems and improve health. This paper
describes the range of impact sustained in study
communities - program, coalition, broader community
benefits - as well as the means by which efforts have
been sustained. Sustainable impact is influenced by a
combination of critical dynamics encompassing the
people and organizations involved, the intervention, the
context, and strategic vision. Although community stories
are nuanced and vary greatly, 8 archetypes emerged
from the analysis. Case examples illustrate.
Conclusions: The 8 identified archetypes describe a
range of recurrent experiences which appear to be
predictive of long-term sustainability.
Implications for Policy, Delivery or Practice: The use
of systems thinking tools and mapping promotes greater
understanding of the sustainability and impact of
federally-funded, community-based health and health
system improvement initiatives. Archetype diagrams
may enable stakeholders at local, state and federal
levels to identify opportunites for leveraging resources to
achieve a sustainable impact on health and health
systems.
Funding Source(s): HRSA
Consumer Applications of Health Information
Technology
Chair: Kathryn Bowles
Tuesday, June 29 * 11:30 am–1:00 pm
• Participation in an E-Pharmacovigilance System to
Monitor Ambulatory Patients for Adverse Drug
Events
Jennifer Haas, M.D., M.S.P.H.; Aarthi Iyer, M.P.H.; E.
John Orav, Ph.D.; Gordon Schiff, M.D.; David Bates,
M.D., M.Sc.
Presented by: Jennifer Haas, M.D., M.S.P.H.,
Associate Professor, General Medicine, Brigham and
Women's Hospital, 1620 Tremont Street, Boston, MA
02120; Phone: (617) 525-6652; Email:
jhaas@partners.org
Research Objective: The safety of prescription drugs,
particularly drugs recently approved by the Food and
Drug Administration (FDA), represents a major public
health concern. There is growing concern recognition of
the limitations of passive surveillance systems to detect
adverse drug events (ADEs) in clinical practice. Accurate
ascertainment of ADE’s requires an active, real-time
system that monitors the symptoms experienced by
individual patients so that these data can be aggregated
to look for symptoms that occur at greater than the
expected rate among populations taking a medication.
Interactive voice response (IVR) technology, integrated
with an electronic health record (EHR), has the potential
to systematically contact large numbers of patients to
assess adherence as well as symptoms. However,
relatively few studies have examined the “reach” of IVRbased interventions to monitor patients who have not
previously been formally contacted or enrolled in a study
to assess their eligibility or willingness to participate. Our
objective was to demonstrate the “reach” of an
interactive voice response (IVR) system, “epharmacovigilance,” to systematically monitor symptoms
experienced by ambulatory patients prescribed one of 31
medications, and to evaluate whether there were
sociodemographic or clinical differences in our ability to
contact certain populations using this technology.
Study Design: Prospective automated survey
conducted in English November 2008 - June 2009, with
a follow-up survey done 3 months later if the target
medication was still listed on the patient’s active
medication list.
Population Studied: Patients receiving a prescription
for a target medication from a primary care physician at
one of 11 participating primary care clinics in the greaterBoston area were eligible to participate.
Principal Findings: 902 patients participated,
representing 43.3% of contacted patients and 25.7% of
potentially eligible patients with a working phone. Of
patients contacted, those who were > ages 66 years
were most likely to participate (50.6%), and those ages
46 – 55 years were least likely to participate (33.6%).
Hispanics had the lowest rate of participation (24.5%) of
any racial/ ethnic group, were more likely than any other
racial/ ethnic group to not have a working phone, and
had the highest rate of hanging up on the call. Patients
receiving medications for more personal conditions (e.g.,
erectile dysfunction) were less likely to participate than
those taking other types of medications. Of the 902
patients who completed the initial survey, 723 (80.2%)
were eligible for re-survey 3 months later because the
target medication was still listed as active in their
medication list in the EHR. Seventy percent of patients
contacted participated in the follow-up survey which
represented 52.9% of potentially eligible individuals.
Conclusions: IVR technology can be used to reach
large numbers and a meaningful proportion of patients to
perform ambulatory e-pharmacovigilance for public
health purposes, particularly for older individuals.
Implications for Policy, Delivery or Practice: Our
study suggests that an IVR system can be integrated
with an EHR to provide e-pharmacovigilance for a broad
spectrum of patients. Future work will address whether
data collected using this type of system can be
effectively and accurately used to detect ADEs, or lead
to meaningful changes in patient management resulting
from earlier recognition of medication-related problems.
Funding Source(s): AHRQ
• Biased Assimilation of Personalized Health Risk
Calculator Information
Christopher Harle, Ph.D.; Julie Downs, Ph.D.; Rema
Padman, Ph.D.
Presented by: Christopher Harle, Ph.D., Assistant
Professor, Health Services Research, Management and
Policy, University of Florida, P.O. Box 100195,
Gainesville, FL 32610; Phone: (352) 273-6081; Email:
charle@phhp.ufl.edu
Research Objective: Risk calculators, applications that
use statistical models to deliver individualized health risk
estimates, are popular tools for communicating disease
risks to consumers on the Internet. However, there has
been insufficient research conducted in natural settings
to describe the impact of risk calculators on the beliefs
and behaviors of health consumers. This paper
describes an organizational field experiment that
evaluated the impact of risk calculators on employees’
risk perceptions, risk information seeking, and health
service utilization decisions in the context of a realistic
health promotion setting.
Study Design: In a field experiment, participants were
randomly assigned to a non-personalized control
website, a personalized non-interactive risk calculator, or
a personalized interactive risk calculator. The websites
were modeled after a sample of high-profile online risk
calculators published by reputable health information
providers. The two personalized risk calculators
estimated participant’s risk of undiagnosed pre-diabetes
and presented that risk numerically, graphically, and
relative to average. The personalized interactive risk
calculator also provided feedback on how hypothetical
behavior changes would affect participants’ risk levels.
Population Studied: The study was conducted at a
private university in the mid-Atlantic United States
employing approximately 4,800 faculty and staff. All
employees were eligible to participate in the study.
Participants were recruited through the university’s
Human Resources and Benefits Office (HR). In
conjunction with other advertising for the university’s
annual employee health fair, HR promoted this study as
an online health campaign and encouraged employees
to visit a website containing information about important
disease risks.
Principal Findings: Participants were more likely to
underestimate their pre-diabetes risk after they received
risk information than they were before using the
websites. This increase in underestimation was
marginally stronger for participants assigned to the risk
calculator conditions. A cluster analysis was used to
segment employees based on their prior risk perceptions
and their calculated risk. This revealed an asymmetry in
post-intervention assimilation of risk information between
participants that received unexpectedly low risk
assessments and participants that received
unexpectedly high risk assessments. Two clusters of
participants who initially underestimated their risk
showed relatively little propensity to change their risk
perceptions, while a segment of participants who initially
overestimated their risk showed large decreases in risk
perceptions. Further, the personalized risk calculators
led to decreased risk information seeking as measured
by click activity, and there were no between-condition
differences in participants’ propensities to utilize followup health services.
Conclusions: This study indicates that publicly available
risk calculators may be further decreasing average risk
perceptions for commonly underestimated diseases,
such as diabetes, as well as reducing consumers’
engagement with risk information. The asymmetric
response of underestimating and overestimating
participants was consistent with prior demonstrations of
unrealistic optimism and motivated reasoning.
Implications for Policy, Delivery or Practice: This
research suggests that popular approaches to disease
risk communication consumers on the Internet do not
influence most consumers. Designers of consumeroriented risk communication tools should consider
tailoring information based on consumers' prior risk
perceptions.
Funding Source(s): McDowell Research Center University of North Carolina at Greensboro
• Young and Well-Connected: Patient Electronic
Health Record Use
Jie Huang, Ph.D; Vicki Fung, Ph.D; John Hsu, M.D.,
M.B.A., M.S.C.E.
Presented by: Jie Huang, Ph.D, Statistical
Demographer, Center for Health Policy Studies, Kaiser
Permanente Division of Research, 2000 Broadway,
Oakland, CA 94612; Phone: (510) 891-3571; Email:
Jie.Huang@kp.org
Research Objective: Patient electronic health records
(EHR) could improve the quality and safety of care, yet
early studies suggest only limited patient use. Other
studies highlight the difficulty of communicating with
patients outside of the clinic, especially with results of
diagnostic tests. We examined the levels of use of a
web-based tool to review laboratory test results, as well
as characteristics of users during the first four years of
test result component of a web-based EHR, within a
large integrated delivery system.
Study Design: The health system implemented the
web-based patient lab reporting function in 2006, which
was part of a commercially available EHR. All patients
had free access, but needed to sign up for secure
access. Previous surveys suggest that internet access
was very high (>75%) in this population. Patients could
view only laboratory tests with values within the normal
range. Patients and clinicians also could communicate
electronically through another component of the EHR.
We estimated the percentage of patients who had
viewed lab test results online in each year among
patients who had any lab test ordered in each year,
between 2006 and 2009. Using logistic regression
models, we examine the association between use and
patient characteristics including age, gender,
neighborhood socioeconomic status (SES),
race/ethnicity and preferred language (English vs. nonEnglish). We defined neighborhood SES using 2000
U.S. Census information on income and education at the
block group level.
Population Studied: The study population included
adult patients (aged 18 or older) who had any lab test
ordered, 2006 to 2009.
Principal Findings: In 2006, 1.65 million adult patients
(70% of adult patients) had at least one lab test ordered;
among these patients, 15.6% of them viewed a test
result online. This percent increased to 27.1% in 2007,
39.5% in 2008, and 47.2% in 2009. In multivariate
analyses among patients with any lab test in 2009,
compared with patients age 65+, younger patients were
more likely view their test results online (e.g., OR=2.44,
95%CI:2.41-2.46 for age 30-39). In addition, females
(OR=1.18, 95%CI:1.18-1.19), patients with English as
their preferred language (OR=2.52, 95%CI:2.49-2.55),
and patients living in non-low SES neighborhood
(OR=1.68, 95% CI: 1.66-1.69) were more likely to view
their test results online. In contrast, compared with
patients of White race/ethnicity, patients of Non-White
race/ethnicity were less likely to view test results online
(OR=0.36, 95%CI:0.36-0.37 for Black, OR=0.43,
95%CI:0.42-0.43 for Hispanic, OR=0.69, 95%CI:0.680.70 for Asian). These associations were similar in all
study years.
Conclusions: Patient use of a web-based EHR to
review normal laboratory results increased substantially
between 2006 and 2009; most recently, half of patients
in this delivery system were using this function. Despite
free access to the EHR and the test reporting function,
there remain substantial differences in actual use across
a number of socio-economic characteristics.
Implications for Policy, Delivery or Practice: Patient
use appears to be increasing substantially for electronic
health records in general, and particularly laboratory
results reporting in particular. The observed differences
in use suggest worrisome variations in access despite
the lack of any financial barriers.
Funding Source(s): AHRQ
• Putting the E-Visit to the Test: From Concept to
Clinic
Trista Johnson, Ph.D.; Denise Scott, M.M., B.A.;
Thomas Landholt, M.D.
Presented by: Denise Scott, M.M., B.A., Manager HIT
Consulting, HIT Services, Masspro, 245 Winter Street,
Waltham, MA 02451; Phone: (781) 419-2896; Email:
dscott@masspro.org
Research Objective: In 2007, a pilot study was
commissioned by the Office of the National Coordinator
to test the feasibility and cost neutrality of Medicare
reimbursement for the use of e-visits. Current usage
experience in the marketplace suggests productive use
of e-messaging within a clinic outside the scope of a
strictly defined e-visit. Some suggest that the use of
secure messaging is cost-effective, even without a
reimbursement-for-visit plan, for reasons of increased
access and reduction in overhead. Therefore, the pilot
was designed to give incentive for clinical use of emessaging and to learn from provider behavior by
analyzing overall usage, in addition to the e-visit itself.
Population Studied: The pilot participants included over
100 primary care providers from a large metropolitan
healthcare delivery system in Portland Oregon and a
large rural delivery system in Eastern Maine
Principal Findings: The most prominent finding was
that the initial definition of an e-visit required revisions in
order meet the challenges of clinicians in active practice.
Discussions of case examples faced by pilot physicians
provided insight to formulate a clearer definition that
could be used more broadly. The providers identified
several issues for discussion: 1) whether communication
of laboratory or test results are an e-visit, 2) whether
referrals to specialists are an e-visit, and 3) what level of
detail is needed in an e-visit care plan. The initial
definition required the e-visit to be patient initiated and
this also required clarification. The definition continued to
be scrutinized and adjusted throughout the project and
as the definition evolved, it also became clear that an
E&M form of reimbursement is strained to provide fair
compensation for the use of secure messaging. Another
finding was that a consistent and auditable billing
mechanism was necessary. It needed to include a clear
chart document, in order to capture the electronic visit
exchange between patient and provider, and to provide
justification for the level of reimbursement. Many current
EHR systems require a patient visit/appointment to be
scheduled in order to bill for the encounter. This
requirement has been a challenge with e-visits, since
there is not an actual pre-scheduled appointment
associated with them.
Implications for Policy, Delivery or Practice: The
project team overcame a number of implementation
issues, both clinically and administratively. The authors
will give an overview of the pilot’s e-visit definition
evolution, and data will be presented regarding use
patterns by patients and physicians, the different level of
adoption by providers within the same practice and the
various types of medical issues managed through evisits. Many current billing systems will need to undergo
refinement to allow for billing of these new e-visit
services in an efficient way. The adjustments made and
the findings will assist others as they consider
incorporating the use of e-visits as a means to increase
access in the patient centered care environment.
Suggested future study should involve physician
engagement, refining the financial incentive plan for the
use of e-messaging, and the limitations of a strict
definition for an e-visit.
Funding Source(s): ONC
Costs, Outcomes, and Utilization of Long-Term Care
Chair: Courtney Van Houtven
Tuesday, June 29 * 11:30 am–1:00 pm
• Hospitalization Risk in Nursing Homes: Does Payer
Source Matter? Lessons from Four States
Shubing Cai, Ph.D.; Dana Mukamel, Ph.D.; Peter
Veazie, Ph.D.; Paul Katz, M.D.; Helena Temkin-Greener,
Ph.D.
Presented by: Shubing Cai, Ph.D., Community and
Preventive Medicine, University of Rochester, 601
Elmwood Avenue, Rochester, NY 14642; Phone: (585)
275-0369; Email: shubing_cai@urmc.rochester.edu
Research Objective: Nursing home (NH) originating
hospitalizations are costly; many are considered
unnecessary and may lead to further health
deterioration. Controlling for health status, Medicaid
residents have been found to have a higher risk of
hospitalization than private-pay residents, but the
reasons for this difference are not clear. This study
disentangles the within-facility disparities from the
across-facility variations in hospitalization risks between
Medicaid and private-pay residents and investigates the
impact of financial incentives.
Study Design: A retrospective statistical analysis of
administrative data, including the Minimum Data Set
(MDS), Medicare and Medicaid claims files, state
Medicaid cost reports, and OSCAR data.
Population Studied: The study includes 226,907 NH
residents from CA, NY, OH and TX in CY 2003: all
eligible LTC residents with either Medicaid or private-pay
payer status. The unit of analysis is the individual
resident. Hospitalization is the dependent variable
(dichotomous). Individual payer status and facility payermix are the main variables of interests. Additional
covariates include individual patient risk factors and
facility characteristics. Nonlinear models are fit to
investigate payer-related within-facility disparities versus
across-facility variations. The analyses are stratified by
state and facility ownership; and responses to financial
incentives are tested statistically to make inferences
about hypotheses regarding the impact of Medicaid bedhold polices and facility ownership on NHs'
hospitalization decisions.
Principal Findings: Controlling for health conditions,
Medicaid residents are more likely to be hospitalized
than private-pay residents, both due to within-facility
disparities and across-facility variations. Payer-related
within-facility disparities in hospitalization risks exist in
most facilities. For example, in for-profit CA NHs,
Medicaid residents have 23% higher odds of
hospitalization than private-pay residents (P<0.01). The
within-facility disparities are modified by facility
characteristics (e.g. ownership) and state Medicaid
policies (e.g. bed-hold policy). Across-facility variations
are also detected in most facilities. NHs with a higher
concentration of Medicaid residents are more likely to
hospitalize their residents, regardless of residents’ payer
status (i.e. 10% increase in facility payer-mix increases
the OR of hospitalization by 11% in for-profit CA NHs,
P<0.01). Adjusted hospitalization rates for Medicaid and
private-pay residents vary across states, but are not
necessarily influenced by state Medicaid rates,
especially in for-profit facilities (i.e. hospitalization rate
for Medicaid residents in for-profit OH facilities is not
significantly different from that in for-profit CA facilities,
although the Medicaid rate is higher in OH than in CA).
Conclusions: For-profit facilities are more likely to be
affected by financial incentives than not-for-profit
facilities with respect to hospitalization decisions. Bedhold policy may create an important financial incentive
for NHs to hospitalize Medicaid residents more often.
The higher hospitalization rates experienced by
Medicaid residents are very likely unnecessary since
these decisions are not based on clinical factors,
especially with respect to within-facility disparities
between Medicaid and private-pay residents.
Implications for Policy, Delivery or Practice: To
reduce the within-facility disparities, strategies that
integrate Medicaid and Medicare financial incentives
may need to be considered. To minimize variations
across facilities, strategies that provide subsidies for
NHs with large concentrations of Medicaid residents,
linked to continuous performance evaluations, may be
considered.
Funding Source(s): NIA
• Geographic Concentration and Correlates of
Nursing Home Closures: 1999-2008
Zhanlian Feng, Ph.D.; Michael Lepore, Ph.D.; Mary
Fennell, Ph.D.; Melissa Clark, Ph.D.; Denise Tyler,
Ph.D.; David B. Smith, and Vincent Mor, Ph.D.
Presented by: Zhanlian Feng, Ph.D., Assistant
Professor, Center for Gerontology and Health Care
Research, Brown University, 121 South Main Street,
Providence, RI 02912; Phone: (401) 863-9356; Email:
zhanlian_feng@brown.edu
Research Objective: Several studies have examined
factors associated with nursing home (NH) closures,
examining structural and organizational characteristics of
the facility. Little is currently known, however, about the
geographic patterns of NH closures. This paper
addresses two questions: (1) Are NH closures spatially
clustered? (2) If so, are geographic concentrations
related to local community characteristics such as
racial/ethnic population mix and concentration of
poverty?
Study Design: NH closure is defined as voluntary or
involuntary termination from the Medicare/Medicaid
programs as reported in the OSCAR. First, a cumulative
indicator per facility is created for whether the facility
was ever closed over the ten-year period, and bivariate
associations are examined between this indicator and
zip-code level percentage of minority population and
percentage of population in poverty (each ranked in
quartiles). Second, the Gini coefficient is used to
measure the extent of concentration of cumulative NH
closures across all MSAs. Lastly, spatial clustering
patterns of NH closures across zip codes within selected
MSAs, both annually and cumulatively over the study
period, are illustrated using GIS mapping tools.
Population Studied: All Medicare/Medicaid certified
NHs in the US, obtained from the Online Survey
Certification and Reporting (OSCAR) database, from
1999 to 2008 (N=18,031 unique facilities). Zip code and
Metropolitan Statistical Area (MSA) level population data
on racial/ethnic composition and income levels are from
Census 2000.
Principal Findings: Over the ten-year period under
study, 2,679 (or 15% of all facilities) NH closures were
reported. The cumulative closure rate is significantly
higher in zip code areas with a higher percentage of
black population: 10% in zip code areas ranked in the
bottom quartile of percent blacks, as compared to 11%,
15% and 17% in zip code areas in the second, third and
top quartiles, respectively. There is a similar gradient in
closure rates by the percent of Hispanic population. The
closure rate in zip code areas with the highest level of
poverty (top quartile) more than doubled that in zip code
areas with the lowest poverty (bottom quartile)—19% vs.
9%. The Gini coefficient for cumulative closures across
MSAs is 0.78, suggesting a high level of geographic
concentration. Within MSAs with a high density of
closures (e.g. Boston), it is common to observe a cluster
of closed homes in inner-city zip-code areas at the urban
core.
Conclusions: NH closures tend to be geographically
concentrated in areas with a higher proportion of
racial/ethnic minority populations and in areas with
concentrated poverty.
Implications for Policy, Delivery or Practice: If NH
closures disproportionately impact both disadvantaged
facilities (as documented in previous studies) and
disadvantaged communities (as shown in this study)—
which often coexist geographically—and considering the
lack of alternative, home and community based longterm care services in areas of concentrated closures,
then the event of closures may cause “triple jeopardy” to
the vulnerable, frail elderly residents from those closed
facilities. Thus, the impact of NH closures on both the
residents and local communities warrants close
monitoring.
Funding Source(s): NIA
• Quality Development in Long-Term Care: An
Overview of European Approaches
Henk Nies, Ph.D.; Kai Leichsenring, Ph.D.; Roelf van der
Veen, M.D.; Ricardo Rodrigues, M.A.; Elisabeth Hirsch
Durrett, M.Sc.; Laura Holdsworth, M.A.; Michel Naiditch
et al., Ph.D.
Presented by: Kai Leichsenring, Ph.D., Senior
Researcher and Consultant, Health and Long-Term
Care, European Centre for Social Welfare Policy and
Research, Berggasse 17, Vienna, 1090, Austria; Phone:
+43131945050; Email: leichsenring@euro.centre.org
Research Objective: This paper is one of the first
results of an ongoing project on ‘Health systems and
long-term care for older people in Europe – Modelling
the INTERfaces and LINKS between prevention,
rehabilitation, informal care and quality of services’
(INTERLINKS) which is co-ordinated by the European
Centre and co-funded by the European Commission’s
7th Research Programme. The focus of this paper is on
one of the objectives: to analyse how the emerging longterm care (LTC) systems within European welfare states
are dealing with issues of quality assurance in various
settings of LTC for older people.
Study Design: Literature reviews and document
analysis, input by national expert panels from Austria,
Finland, France, Italy, Slovenia, Spain, Sweden,
Switzerland, The Netherlands and England. A European
overview was developed by all participating researchers
and presented to a European Sounding Board (20
experts) that provided additional input and feedback.
Population Studied: Quality assurance and
development systems and policies in LTC for older
people in ten European countries.
Principal Findings: Quality assurance approaches,
quality management and quality improvement programs
constitute facets of emerging and changing LTC systems
in Europe. In the context of governance based on new
public management approaches aimed at increasing
choice and competition, mechanisms to control quality
have been introduced. An important role in designing
and implementing the preconditions for quality
management is played by private non-profit and
commercial provider organizations. In some countries,
explicit public policies have been designed to encourage
quality improvement and efficiency gains by increasing
transparency and advancing evidence-based practice. A
common trend from inspection to self-assessment and
third-party certification was observed. However, public
purchasers, providers and user organizations are
struggling with designing and implementing quality
measurements and benchmarking, particularly when it
comes to results-oriented performance indicators and
the quality of ‘chains of care’ with respective interfaces
between individual services or facilities. Legal
regulations, often reflecting an uncoordinated mix of
responsibilities between health and social care as well
as between central, regional and local authorities, are
thus mainly based on the definition of structural
minimum standards of individual services or facilities
with a limited impact on ‘whole systems’ quality
development.
Conclusions: Quality development and the search for
efficiency in LTC are still mainly based on experiences
from either health care approaches and/or classical
quality management mechanisms. Specific tools for
quality assurance and development along the ‘chain of
care’ and respective interfaces with the health system
need further endeavours, with specific research, training
and education to show the usefulness of proactive
quality management across the sector.
Implications for Policy, Delivery or Practice: Public
authorities are challenged to govern emerging ‘quasimarkets’ in social and health services, while striving
towards more coordinated LTC systems. This challenge
calls for quality management and benchmarking which
represent the most important tools to steer provider
systems that are increasingly based on marketmechanisms. It will be necessary to enable
management, staff and users of LTC services to reflect
upon better ways to assess and improve quality within a
quality of life perspective.
Funding Source(s): European Commission, DG
Research, 7th Framework Programme of Research
• Does the RUGs III Case Mix System Adequately
Capture the Cost Burden of Post Acute Patients in
Nursing Homes?
William D. Spector, Ph.D.; Dana Mukamel, Ph.D.; Rhona
Limcangco, Ph.D.; Heather Ladd, M.S.
Presented by: Dana Mukamel, Ph.D., Professor,
Medicine, Health Policy Research Institute, University of
California, Irvine, 100 Theory, Suite 110, Irvine, CA
92697-5800; Phone: (949) 824-8873; Email:
dmukamel@uci.edu
Research Objective: Medicare currently pays for post
acute patient care in nursing homes based on the RUGs
(Resource Utilization Groups) III case-mix methodology.
It is important that these payment groups be well aligned
with the costs of caring for the patients in them, to avoid
creation of perverse incentives – incentives to avoid
admission of expensive patients or incentives to limit
services in order to cut costs. To examine this issue, this
study was designed to determine whether the RUGs III
system captures all the cross sectional variation in
nursing home costs due to patient case-mix or whether a
higher percent of post acute patients adds an additional
cost burden.
Study Design: This study utilized Medicaid cost reports
data, augmented with MDS and economic census data.
We estimated hybrid cost functions in which the
dependent variable was log of total costs and
independent variables included in addition to the
traditional covariates, outputs and wages, the percent of
Medicare skilled care inpatient days. Outputs were
measured by RUGs III case-mix adjusted inpatient days;
linear, squared and cubed terms to allow for both
increasing and decreasing returns to scale. Because the
choice to admit post-acute care patients is likely to be
endogenous with the cost of caring for them, we used an
instrumental variable (IV), capturing the rehabilitation
business activities in the zip code in which the nursing
home is located, and two-stage least square (2SLS)
estimation technique. Based on the coefficient estimate
we calculated the marginal costs of a 1 percentage point
increment in Medicare census. To assess which specific
services contribute to the incremental costs due to
Medicare patients, we repeated the analysis for specific
cost centers, and calculated the contribution of each to
the total marginal cost.
Population Studied: 946 free standing (87% of all)
nursing homes in California in 2005.
Principal Findings: On average, 11% of nursing homes
days were Medicare, post-acute. The IV performed well,
with an incremental F(1,939)=16.6 in the first stage
regression. The basic cost function relationships
between costs and case mix adjusted days and wages
were as expected and the R2 were 0.94 for the OLS and
0.87 for the 2SLS. Based on the IV model, Medicare
days were significantly associated with costs (p<0.000)
even when controlling for RUGs case-mix. The marginal
cost of a one percentage point increase was estimated
at $116,123 or about 2.0% of annual costs for the
average facility. Analysis by cost center found that the
increase was mainly due to additional expenses for
rehabilitation, pharmacy, RNs, laboratory, and
administration.
Conclusions: RUGs III case-mix does not fully explain
cost variation.
Implications for Policy, Delivery or Practice: This
study confirms concerns raised by MEDPAC regarding
the adequacy of the RUGs III case-mix system and
emphasizes the need to replace it by a better calibrated
case-mix system. This study should be repeated, when
the RUGs IV system has been in place for several years,
to determine if it has corrected the shortcomings of
RUGs III and the resulting disincentives of the current
system or if further refinements are needed.
Funding Source(s): NIA
• Where Do Nursing Home Residents Die: A National
Study CY2003-2007
Helena Temkin-Greener, Ph.D.; Tracy Nan Zheng, B.S.;
Jessica Mastalski, B.S.; Dana Mukamel, Ph.D.
Presented by: Helena Temkin-Greener, Ph.D.,
Associate Professor, Community and Preventive
Medicine, University of Rochester School of Medicine,
Box 644, 601 Elmwood Avenue, Rochester, NY 14642;
Phone: (585) 275-8713; Email: Helena_TemkinGreener
Research Objective: In the US, ~1.6 million people live
in nursing homes (NH) and each year there are about
500,000 deaths among these residents. By 2020, the
proportion of deaths occurring in NHs is expected to
reach 40%. While NHs are emerging as a major place of
death, little is known about the care decedents receive at
the end-of-life (EOL). Our study objectives are to: 1)
explore longitudinal and cross-sectional variations in
EOL hospitalizations among NH residents; 2) identify the
magnitude of Medicare spending associated with these
hospitalizations; and 3) examine the association
between hospice use, presence of advance directives
and the probability of NH residents dying in hospitals.
Study Design: We use the Chronic Care Warehouse
(CCW) data (100%) for residents who died in NHs, or
shortly following discharge, in inpatient hospitals,
hospice, or elsewhere. The data used to identify this
population of decedents include: the Minimum Data Set
(MDS), Medicare Denominator, Inpatient Hospital, and
Hospice claims. Decedents are classified as either shortterm (post-acute) or long-term (custodial) NH residents.
Population Studied: Study population consists of
residents who died in the NH or within 8 days of
discharge. It includes 2,530,680 decedents in 16,000+
facilities, over a 5-year period (CY2003-2007).
Principal Findings: Between 2003 and 2007, the
proportion of residents who were transferred to a
hospital and died there has remained stable at slightly
over 20%; with a minor decline among the long-term and
an equally minor increase among the short-term
residents. During this time we observe a significant
increase in the proportion of decedents receiving
hospice prior to death, from 25.4% in 2003 to 36.9% in
2007. This trend is consistent for both short and longterm residents. Considerable cross-sectional variations
in hospice use and place of death continue to persist.
For example, in 2007, the proportion of long-term
residents who died in a hospital ranged from less than
5% in Utah to over 30% in Mississippi and the District of
Columbia. In 2007, Medicare spent over $943 million on
hospitalizations incurred by these decedents in the last
30 days of life alone, 50% of which is attributable to
hospitalizations ending in death. Furthermore, our
findings suggest that individuals’ treatment preferences
such as hospice use and presence of advance directives
maybe associated with fewer hospital deaths and lower
Medicare costs.
Conclusions: The proportion of NH residents who die in
hospitals continues to be persistently high. However, we
find significant increases in hospice use at the EOL
among these residents. If this trend continues and
becomes more pervasive, declines in Medicare costs
and improved quality of care for NH decedents may
result.
Implications for Policy, Delivery or Practice: The
current health reform debate includes discussions about
EOL care. Anecdotal evidence has suggested that NHs
often transfer dying residents to hospitals. This study
offers evidence to inform this debate. In particular, it
identifies a persistent trend in hospital as a place of
death for 1 in 5 NH residents, suggesting serious policy
and ethical implications that should be considered.
Funding Source(s): National Institute of Nursing
Research
New Evidence on Consumer Driven Health Plans
Chair: Stephen Parente
Tuesday, June 29 * 11:30 am–1:00 pm
• The Effects of Consumer Directed Health Plans on
Vulnerable Populations: A Multi-Employer MultiInsurer Study
Amelia Haviland, Ph.D.; Susan Marquis, Ph.D.; Neeraj
Sood, Ph.D.; Roland McDevitt, Ph.D.
Presented by: Amelia Haviland, Ph.D., Statistician,
Economics and Statistics, RAND Corporation, 4570 Fifth
Avenue, Suite 600, Pittsburgh, PA 15218; Phone: (412)
683-2300; Email: haviland@rand.org
Research Objective: To determine what impacts high
deductible and consumer directed health plan
(HD/CDHP) designs have on the healthcare costs and
use of low income and chronically ill enrollees, whether
these impacts vary from those for less vulnerable
enrollees, and the implications for benefit and subsidy
design in a reformed health care system.
Study Design: To address the limited scope of prior
studies, this study uses a new dataset with enrollment
and claims data, 2004-2006, from 60 large employers
offering health insurance plans from 129 different
carriers. The resulting analysis dataset includes more
than 100,000 families in HD/CDHP plans and 2 million
comparison families. Outcomes are examined at the
household or “insurance unit” level. Utilization and costs
are examined overall and for different types of care and
HD/CDHPs are examined for people in plans with
varying deductible levels. Low income families are
identified based on geocoded median household income
and families with chronically ill members are identified
based upon the diagnoses of chronic conditions with the
highest costs and cost growth. Characteristics controlled
for include family structure, risk scores, geocoded
race/ethnicity, and actuarial values of plans. Selection is
addressed in three ways: (1) comparison families are
drawn from employers that did not offer HD/CDHPs (2) a
difference-in-difference modeling strategy is employed
wherein each family acts as it’s own control (3) a rich set
of demographic and health related information is
available and controlled for.
Population Studied: Full time employees and
dependents of 34 large firms offering high-deductible
health plans and 26 control firms offering only traditional
HMOs and PPOs. Employers were selected to yield a
diverse sample in terms of regions, industries, wage
levels, and insurance carriers; employers offering
HD/CDHPs were chosen to provide variation in
deductible levels, personal account offerings, employer
contributions, and penetration of high-deductible plans.
Principal Findings: We found that chronically ill families
enrolling in a high deductible plan ($1000 or greater for
an individual plan) for the first time spent 17% less than
similar families in conventional plans, a more moderate
reduction than that for non-chronically ill families
(difference is significant at p = 0.02). At moderately high
deductible levels (between $500-1000 dollars for an
individual plan) the reductions were smaller for both
chronically ill and non-chronically ill families and did not
differ significantly between these family types. We found
that low income families enrolling in a high (moderately
high) deductible plan for the first time spent 19% (6%)
less than comparable families in control plans, and these
decreases did not differ significantly from those of higher
income families.
Conclusions: In the first year, high deductible plans are
associated with similarly lower cost growth for lower and
higher income families and more moderate reductions
for the chronically ill. We will add findings regarding how
personal accounts (HSA/HRA) affect spending and
utilization, including utilization of preventative care
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 vulnerable
populations such as the low income and chronically ill.
Funding Source(s): RWJF, California Healthcare
Foundation
• High Deductible Health Plans and the Cost and
Utilization of Maternity Care Services
Katy Kozhimannil, Ph.D., M.P.A.; Haiden Huskamp,
Ph.D.; Amy Johnson Graves, M.P.H.; Stephen
Soumerai, Sc.D.; Dennis Ross-Degnan, Sc.D.; Frank
Wharam, M.B., B.Ch., M.P.H.
Presented by: Katy Kozhimannil, Ph.D., M.P.A.,
Research Fellow, Department of Population Medicine,
Harvard Medical School, 133 Brookline Avenue, 6th
Floor, Boston, MA 02215; Phone: (617) 509-9202;
Email: kbackes@fas.harvard.edu
Research Objective: Childbirth is the leading reason for
hospitalization in the United States, and maternity care
comprises a major expenditure for many American
families and health insurance programs. The rapid
growth of high deductible health plans may impact outof-pocket costs and quality of maternity care. The
objective of this study is to evaluate the impact of a
transition to a high deductible health insurance plan on
the costs and utilization of maternity care.
Study Design: This study uses a pre/post study design
with a control group and a difference-in-differences
analysis to examine the effect of an employer-mandated
insurance transition on total costs (sum of expenditures
by insurer and member) and out-of-pocket costs
(member copayment and deductible expenditures) for
maternity and delivery care, and also utilization of
prenatal, delivery, and postpartum services.
Population Studied: Data for this study come from
medical claims for 2,409 women who delivered babies
between October 1, 2001 and November 30, 2007 and
were insured by a Massachusetts health plan through
employer-sponsored programs. Employers mandated a
switch from a traditional HMO to a high-deductible health
plan for 229 of these women (86 delivered babies prior
to the insurance transition and 143 after). A control
group of 2180 women remained in traditional HMO plans
(711 delivered before the index date and 1569 after).
Principal Findings: Mean total costs of maternity care
for high-deductible members were $9761 for those who
delivered prior to the insurance transition and $9997 for
those who delivered after, compared to a change from
$9731 to $10,434 for HMO members, a relative
decrease of 11.5% (p=0.1143). The changes in out-ofpocket costs for maternity and delivery care among
women who delivered after switching to high deductible
health plans were 106% (p<0.001) and 45% (p<0.001)
higher, respectively, than changes in HMO member
costs. Delivery after transition to a high-deductible health
plan was not associated with changes in the odds of
receiving early prenatal care (OR 1.02 [95% CI 0.323.20]), recommended number of prenatal visits (OR 1.64
[95% CI 0.89-3.02]), or a postpartum visit after delivery
(OR 0.74 [95% CI 0.42-1.32]).
Conclusions: High deductible benefit design produced
higher out-of-pocket costs for maternity and delivery
care. Combined expenses paid by members and the
health plan were unchanged for maternity and delivery
care after transition to a high deductible health plan.
Switching to a high deductible plan did not impact
maternity care utilization.
Implications for Policy, Delivery or Practice: Growth
of high deductible health plans has been increasing
steadily over the past few years and may accelerate
following the passage and implementation of national
health care reform. Transition to high-deductible plans is
associated with substantial increases in out-of-pocket
expenses for maternity-related care, but not with
adverse impacts on recommended prenatal and
postpartum care.
Funding Source(s): Department of Population Medicine
Pyle Postdoctoral Fellowship
• Health Savings Accounts and Health Care
Spending
Anthony LoSasso, Ph.D.; Mona Shah, M.S.; Bianca
Frogner, Ph.D.
Presented by: Anthony LoSasso, Ph.D., Professor,
Health Policy and Administration, University of Illinois at
Chicago, 1603 W Taylor, Chicago, IL 60612; Phone:
(312) 413-1312; Email: losasso@uic.edu
Research Objective: The impact of consumer-driven
health plans (CDHP) has primarily been studied in a
small number of large, self-insured employers, but this
work may not generalize to the wide array of firms that
make up the overall economy. The goal of our research
is to examine effects of Health Savings Accounts (HSAs)
on total, medical, and pharmacy spending for a large
number of small and mid-sized firms.
Study Design: We employ difference-in-differences
generalized linear regression models to examine the
impact of switching to HSAs. Claims data were
aggregated to enrollee-years. The setting allows us to
verify our results by estimating an "intent-to-treat" model.
Population Studied: Health plan administrative data
from a national insurer were used to measure spending
for 76,310 enrollees over three years in 709 employers.
All employers began offering a HSA-eligible plan either
on a full replacement basis or alongside traditional plans
in 2006 and 2007 after previously offering only traditional
plans in 2005.
Principal Findings: For total spending, HSA enrollees
spent roughly 5-7% less than non-HSA enrollees. For
pharmacy spending, HSA enrollees spent 6-9% less
than traditional plan enrollees. More of the spending
decrease was observed in the first year of enrollment.
Conclusions: Our work represents the most robust
design in the literature to date examining the impact of
CDHP on spending. The results suggest that CDHP
benefit designs have a small but economically
meaningful effect on health care spending.
Implications for Policy, Delivery or Practice: Our
findings are consistent with the notion that CDHP benefit
designs affect decisions that are at the discretion of the
consumer, such as whether to fill or refill a prescription,
but have less effect on care decisions that are more at
the discretion of the provider. It will, however, be
important to monitor the type of care that is reduced in
the face of increased cost-sharing and the health
consequences of those reductions.
• Insurance or Savings: Implications of Individual
Health Accounts in China
Guan Gong, Ph.D.; Hongmei Wang, Ph.D.; Lingli Xu
Presented by: Hongmei Wang, Ph.D., Assistant
Professor, Health Services Research and
Administration, College of Public Health, University of
Nebraska Medical Center, 984350 Nebraska Medical
Center, Omaha, NE 68198-4350; Phone: (402) 5599413; Email: hongmeiwang@unmc.edu
Research Objective: As an important reform of China’s
health care system, the implementation of individual
health accounts (IHAs) is in an attempt to effectively
reduce moral hazard problem and suppress the
increasing growth of health care expenditures. But a
potential drawback of this scheme is inequality in income
distribution featured with unequal IHAs balance
accumulation: healthy people will accumulate large IHAs
balances, while sick people, especially chronic patients,
will accumulate nothing. Hence, the scheme may look
like a saving plan to the healthy and medical-insurance
plan to the chronically ill. This paper explores the
implication of IHAs in China on the increased inequality
risk, measured by variation in IHAs balance
accumulation at the end of lifetime.
Study Design: Our analysis is based on the longitudinal
health expenditure data in Kunshan city, Jiangsu
province in China from year of 2005 to 2007. The data
illustrate the enormous variation in health care costs in a
single year and the persistence of individual
expenditures from one year to the next. We estimated a
statistical four-part model on the possibilities of incurring
health costs including further impatient cost and the
subsequent expenditures paid for outpatient care and
inpatient care. Comparisons with actual data suggest
that the model captures well the pattern of health care
expenditures. Using this model to simulate the lifetime
distribution of individual heath expenditures, we
evaluated the variation in IHAs balances at the end of
individual lifetime.
Population Studied: The longitudinal data used in this
study is from the individual health care and health
insurance record which is managed by Bureau of Social
Insurance in Kuanshan city. The sample in the data is
randomly selected by individual’s social security number.
Totally, we have 6355 enrollees in the sample, aged
from 16 to 74 in 2005 and continuingly insured over
three-year period between 2005 and 2007.
Principal Findings: The empirical results show that
although the scheme would produce a range of balances
across enrollees at the early ages, approximately 58% of
enrollees would end up with nothing in IHAs at the end
of lifetime; 58 percent of persons left zero in their IHAs at
their death; 78 percent of persons have balances less
than 1000 RMB; 87 percent of persons left with the ratio
of balance to aggregate funds deposited in the IHAs
lower than 10%. Specially, more women will deplete
their IHAs contributions and left with less accumulations
at the end of lifetime than their counterpart men.
Conclusions: These outcomes suggest to us that such
plan is equitable in a large part from the perspective of
high concentration of the end-of-life IHAs balances in
low levels; the IHAs primarily serve as self-insurance
purpose for enrollees, especially for women.
Implications for Policy, Delivery or Practice: Debate
persists about the unavoidable inequality of IHAs
scheme in the measure of the variation in IHAs balance.
Our study shows that IHAs balance, in fact, can be equal
in a large part that most beneficiaries will left with
nothing in IHAs. But the out-of-pocket payments may
vary largely and cause serious inequality. Therefore, the
effect of IHAs scheme on equality of income distribution
is complicate and has to be examined with specific
situation and health insurance policies.
• The Effects of High-Deductible Health Plan on
Medical Care Spending
Yuting Zhang, Ph.D.; Aiju Men, M.S.; Wei Wang, M.S.;
Drian Day, Ph.D.; Judith Lave, Ph.D.
Presented by: Yuting Zhang, Ph.D., Assistant
Professor, Health Policy and Management, University of
Pittsburgh, 130 DeSoto Street, A664 Crabtree,
Pittsburgh, PA 15261; Phone: (412) 383-5340; Email:
ytzhang@pitt.edu
Research Objective: The high-deductible health plan
(HDHP) has emerged as a recommended component of
health reform. However, evidence is limited on its impact
on medical spending. We study the annual changes in
total, out-of-pocket, plan payment medical spending
before and after individuals switched to HDHP products
from traditional preferred provider organizations (PPOs),
relative to changes in comparable individuals stayed in
PPOs.
Study Design: In 2006, 9 large employers in
southwestern Pennsylvania started to offer HDHPs in
addition to to PPOs through a large insurance company.
We obtained information on enrollment, characteristics
of health plans, and medical claims through the
insurance company in 2005-2007. We used a pre-postwith-a-comparison-group approach to evaluate the
effects of HDHP on medical spending. Our intervention
groups consisted of members who enrolled in PPOs in
2005 and switched to a HDHP, either individual or family
policy, in 2006 or 2007. The comparison groups
consisted of members who remained in PPOs in the
same firms. We used propensity score weighting to
balance each intervention group with its pairwise control
group, individual or family policies. We also used firmlevel fixed-effect models to control for unobserved
characteristics within a firm, such as levels of health
savings account, incentives to enroll in a HDHP plan,
culture, and type of employees.
Population Studied: We studied employees and their
dependents who were continuously enrolled in the
insurance company in 2005-2007.
Principal Findings: Annual out-of-pocket spending permember increased immediately after joining HDHP,
$148 (95% CI 125-171) in individual policies and $179
(95% CI 166-192) in family policies, after controlling for
the trend in the comparison group. Among 1,934
members in family policies who enrolled in PPOs in 2005
and HDHPs in 2006-2007, their 2006 total medical
spending increased slightly from 2005, a similar trend as
the comparison group. In 2007, however, their medical
spending declined; thus, joining HDHP was associated
with a decrease of $171 (95% CI 22-319), relative to the
comparison group. Among 1,327 members in family
policies who enrolled in PPOs in 2005-2006 and HDHPs
in 2007, joining HDHP again was associated with an
immediate increase in out-of-pocket spending by $173
(95% CI 28-317), but no effect on medical spending was
observed first-year post- HDHP. Data from enrollees in
individual polices show a similar pattern but with wider
confidence intervals due to small sample size.
Conclusions: Members paid higher out-of-pocket after
switching to HDHP. No savings in total medical spending
was observed in 1st-year post- HDHP, but a small
decline was observed in 2nd-year post- HDHP. Plan
payment was reduced because of cost-shifting to
patients.
Implications for Policy, Delivery or Practice: HDHPs
lead to a shift of Medical care costs from the plan to the
consumer. Members pay higher out-of-pocket spending
in HDHP in return for lower premium. It is not clear that
HDHP leads to decreases in overall medical spending.
Potential savings relying on consumer-side incentives
might not be as easily realized as many hope.
Funding Source(s): University of Pittsburgh
New Findings in Children's Mental Health Services
Chair: Frances Lynch
Tuesday, June 29 * 11:30 am–1:00 pm
• Racial/Ethnic Differences in Mental Health Service
Use Among Adolescents with Major Depression
Janet Cummings, Ph.D.
Presented by: Janet Cummings, Ph.D., Assistant
Professor, Health Policy and Management, Emory
University, 1518 Clifton Road NE, Suite 610, Atlanta, GA
30322; Phone: (404) 727-1175; Email:
jrcummi@emory.edu
Research Objective: Major depression is one of the
most common mental health problems among
adolescents and is associated with substantial morbidity,
functional impairment, and mortality. If left untreated,
major depression can lead to substantial health and
developmental consequences across the lifespan.
Although higher rates of unmet need for mental health
services have been documented for minority
adolescents, little is known about the role of
race/ethnicity in the receipt of treatment for major
depression among this population. This study examines
whether there are differences in mental health service
use among non-Hispanic White, Hispanic, Black, and
Asian adolescents who experienced a major depressive
episode (MDE) in the past year.
Study Design: Three years of cross-sectional data
(2006-2008) were pooled from the National Survey on
Drug Use and Health to derive a nationally
representative sample of 53,883 adolescents between
the ages of 12 to 17. Weighted probit regressions were
estimated to examine whether racial/ethnic minorities
were less likely to receive: (1) any treatment for MDE,
(2) prescription medication for MDE, (3)
treatment/counseling from a mental health (MH)
specialist (e.g. psychiatrist) for MDE, and (4) counseling
in a school setting. Regression models controlled for
age, gender, family income, family structure, insurance
status, alcohol use, and health status.
Population Studied: 4,362 adolescents with MDE
during the previous year.
Principal Findings: Among adolescents with MDE, only
38% received any treatment, 26% received treatment
from a MH specialist, 16% took prescription medication
for MDE, and 25% received counseling at school.
Compared to Whites, Blacks were less likely to receive
any treatment (risk difference [RD]= -0.09; p<0.01),
treatment from a MH specialist (RD= -0.04; p=0.09), and
prescription medication for MDE (RD= -0.12; p<0.001).
However, no difference was observed in the likelihood of
receiving school-based counseling among Blacks and
Whites (RD=0.02; p=05). Asians were less likely than
Whites to receive any treatment for MDE (RD= -0.15;
p=0.06), treatment from a MH specialist (RD= -0.11;
p=0.01), prescription medication for MDE (RD= -0.11;
p<0.001), and school-based counseling (RD= -0.13;
p<0.001). Surprisingly, Hispanics were significantly more
likely than Whites to receive treatment for MDE across
all outcome measures.
Conclusions: Although there is substantial unmet need
for mental health treatment among all adolescents with
MDE, Asians and Blacks are significantly less likely to
receive treatment than Whites. A notable exception to
this pattern of findings is the lack of difference in the
likelihood of receiving school-based counseling between
Blacks and Whites. Lastly, Hispanics have the highest
rates of MDE treatment among adolescents.
Implications for Policy, Delivery or Practice: Results
underscore important racial/ethnic differences in unmet
need for treatment among adolescents with MDE.
Providers in health care and school settings should
consider developing outreach programs and tailoring
services to address the higher levels of unmet need
among Asian and Black adolescents. Furthermore,
because services provided in schools can reduce
barriers to treatment such as transportation and cost,
policy makers should consider investing more resources
in school-based mental health programs to help reduce
the high level of unmet need for MDE treatment among
adolescents.
• Bipolar Spectrum Disorders in Commercially
Insured Children: Prevalence of Diagnoses and
Treatments Received
Stacie Dusetzina, B.A., Ph.D. Candidate; Richard
Hansen, Ph.D.; Morris Weinberger, Ph.D.; Joel Farley,
Ph.D.; Betsy Sleath, Ph.D.; Bradley Gaynes, Ph.D.
Presented by: Stacie Dusetzina, B.A., Ph.D.
Candidate, NRSA Pre-Doctoral Fellow, Eshelman
School of Pharmacy, University of North Carolina at
Chapel Hill, 4423 Talcott Drive, Durham, NC 27705;
Phone: (919) 475-2615; Email:
Stacie_Dusetzina@unc.edu
Research Objective: To provide epidemiologic
information on the prevalence of bipolar spectrum
disorders and treatments received by commercially
insured children. There is a lack of information
concerning national trends in the diagnosis and
treatment of bipolar spectrum disorders among children.
Nearly all of the evidence to date has focused on small
patient samples, limiting the ability of researchers to
detect diagnosis and treatment patterns that may exist in
the population.
Study Design: A retrospective cohort was constructed
using MarketScan Commercial Claims and Encounters
database from 2005 - 2007. Repeated cross-sections
were taken for each study year to estimate the
diagnostic prevalence of bipolar spectrum disorders.
Medication use was summarized as therapies prescribed
within 30 days after the last diagnosis. Psychotropic
medication use was defined as the use of any of the
following drug classes: lithium, anticonvulsants,
antipsychotics, antidepressants or stimulants.
Population Studied: Patients were included if they were
under the age of 18 at the time of their most recent
bipolar diagnosis and if they had either one inpatient or
two outpatient insurance claims for a bipolar spectrum
disorder. All bipolar spectrum disorders (Bipolar I,
Bipolar II, Bipolar Unspecified, or Cyclothymia) were
included. Patients with medical conditions that mimic
mania or those that complicate the treatment of bipolar
disorder were excluded. Finally, patients were excluded
from the medication-related analyses if their pharmacy
data were not available or if they were not continuously
insured from the time of diagnosis to 30 days after
diagnosis.
Principal Findings: The diagnostic prevalence of any
bipolar spectrum disorder increased from 2005 to 2006
by approximately 8% and remained stable from 2006 to
2007. In 2007, 16,641 children received a diagnosis for a
bipolar spectrum disorder among the 6.3 million enrolled
children (0.26%). There were 11,219 children included in
the medication-related analyses for 2007, 11,076 in
2006, and 10,565 in 2005. Overall, psychotropic
medication use was common across each study year
with similar treatment rates for each spectrum disorder 64.1% (Bipolar I), 62.9% (Bipolar II), 64.8% (Bipolar
Unspecified), and 60.7% (Cyclothymia). Most patients
used either 1 class or 2 classes of psychotropic
medications (average rates were 42.1% and 38.1%,
respectively), while 19.8% used 3 or more classes.
Among medication users, antipsychotic use was most
common (52.9%), followed by anticonvulsant use
(46.0%), antidepressant use (38.2%) and stimulant use
(31.6%). Use of lithium and conventional antipsychotic
agents was low with average use over the three years of
12.4% and 0.65%, respectively.
Conclusions: The diagnostic prevalence of bipolar
disorder in commercially insured children has increased
over recent years. Most patients receive medications
from either one or two psychotropic medications classes,
with a majority of patients receiving antipsychotic and
anticonvulsant agents. Prescribing of antidepressants is
common, although most recommendations for treatment
warn against co-prescribing of antidepressants in this
population.
Implications for Policy, Delivery or Practice:
Currently there is little guidance available to clinicians for
treating bipolar spectrum disorders in children and few
approved treatments for managing bipolar disorder in
this population. Understanding medication use in this
population will inform future guideline development and
provide targets for clinical trials testing.
Funding Source(s): AHRQ
• Risk Adjusting Residential Treatment Outcomes
with Clinical Factors
Neil Jordan, Ph.D.; Jielai Ma, Ph.D.; Richard Epstein,
Ph.D.; Scott Leon, Ph.D.; Brice Bloom-Ellis, M.S.W.
Presented by: Neil Jordan, Ph.D., Research Assistant
Professor, Psychiatry & Behavioral Sciences,
Northwestern University, 710 N Lake Shore Drive Suite
904, Chicago, IL 60067; Phone: (312) 503-6137; Email:
neil-jordan@northwestern.edu
Research Objective: There is an increasing emphasis
by public payers on accountability and quality of mental
health care. Government funders are using outcomes
data to assess provider/program performance &
influence payment rates. An important challenge for
these pay-for-performance (P4P) initiatives is that not all
providers are alike, nor do their caseloads remain the
same over time. Also, differences in outcomes across
providers reflect more than just differences in quality.
Risk adjustment (RA) is a method that accounts for
group differences when comparing non-equivalent
groups on outcomes. RA models in children’s mental
health are still emerging. One study (McMillen et al
2008) of RA in youth residential treatment recommended
including measures of clinical functioning, MH
diagnoses, and/or MH need as risk adjustors. The
purpose of this study is to determine whether the
addition of these types of variables improves a RA
model for youth residential treatment (RT) outcomes.
Study Design: This study uses a retrospective cohort
design and administrative data from the Illinois
Department of Children & Family Services. There are 2
study outcomes: (1) treatment stability (TS), which is
measured as the % of days at the facility and not on run,
in a psychiatric hospital, or incarcerated, and (2) 180-day
post-discharge placement stability (PDPS), a
dichotomous measure indicating whether the youth was
discharged to a less restrictive setting and sustained that
subsequent placement for 180 days. The risk adjustment
model includes prior child system involvement variables
(aggressive symptoms and antipsychotic use, juvenile
detention or corrections, runaway, psychiatric
hospitalization) and clinical measures from the Child and
Adolescent Needs & Strengths scale (CANS) (Lyons,
1999). Exploratory factor analysis was used to parse the
59 CANS items into factors that were added to the risk
adjustment model. Principal components analysis with
varimax rotation yielded a 7-factor solution
(externalizing, trauma, sexuality, school problems,
juvenile justice interactions, acculturation, internalizing).
Linear and logistic regression models, respectively, were
used to determine whether these clinical factors
improved the RA model for TS and PDPS.
Population Studied: The study population includes
youth in state custody receiving RT services from 45
residential treatment and group home providers
participating in a performance-based contracting
initiative in Illinois. The sample includes 943 youth with
an RT placement during 2006 or 2007 and clinical data
prior to the RT spell. The sample was 61% male, had a
mean age of 14.5, and was 55% African-American.
Principal Findings: For both study outcomes, all 4 prior
child system involvement variables were statistically
significant predictors of poor TS and PDPS. School
problems and internalizing behavior were significant
predictors of poor TS. Externalizing behavior and school
problems were significant predictors of poor PDPS.
Conclusions: Adding clinical measures to risk
adjustment models containing prior child system
involvement characteristics significantly improves these
models for predicting youth RT outcomes.
Implications for Policy, Delivery or Practice: Optimal
risk adjustment models for youth residential treatment
outcomes should include clinical needs variables, which
explain additional variation in these outcomes beyond
variation explained by prior child system involvement
variables. Future research should explore the impact of
P4P initiatives on quality of residential treatment.
Funding Source(s): Illinois Department of Children &
Family Services
• Patterns of Care Following ADHD Treatment
Initiation
Bradley Stein, M.D., Ph.D.; Laura Kogan, Ph.D.; Gary
Klein, M.S.; Joel Greenhouse, Ph.D.; Jane Kogan,
Ph.D.; Abigail Schlesinger, M.D.
Presented by: Laura Kogan, Ph.D., Assistant
Professor, University of Pittsburgh School of Medicine,
One Chatham Center, 112 Washington Place, Suite 700,
Pittsburgh, PA 15219; Phone: (412) 402-8752; Email:
koganjn@ccbh.com
Research Objective: Attention Deficit and Hyperactivity
Disorder (ADHD) is one of the most common chronic
childhood psychiatric disorders. While prior crosssectional studies have examined the prevalence of
pharmacologic and non-pharmacologic interventions for
children with ADHD, there is a paucity of data regarding
how the receipt of different treatment modalities for the
treatment of ADHD evolve after treatment initiation. This
study examines factors associated with different patterns
of treatment among children initiating treatment for
ADHD.
Study Design: Using service utilization and pharmacy
claims data from a large non-profit managed behavioral
health organization in a large Mid-Atlantic state, we
studied treatment patterns of children initiating ADHD
treatment. ADHD treatment initiation was defined as use
of ADHD medications or mental health specialty services
with a primary diagnosis of ADHD with no mental health
services or psychotropic medications in the 90 days
before the first observed ADHD treatment. We
categorized the initial type of ADHD treatment received
by children as 1) PCP prescribed medications/no
specialty mental health care (PCP meds/No MH), 2)
Specialty mental health care without medications
(MH/No meds), or 3) a combination of specialty mental
health care and medication (MH/Meds). We use KaplanMeier survival curves to display the time until patients
who initially start on a single treatment modality either
add or switch to the other treatment modality, as well as
to display the time until patients drop out of treatment,
Cox proportional hazard models are used to investigate
the effect of covariates on dropping out or switching to
other treatment modalities, and a multi-state Markov
model to estimate the probability of a patient moving
between different treatment modalities.
Population Studied: 2084 Medicaid-enrolled children
(age 6-12) who initiated ADHD treatment between
October 2006-December 2007.
Principal Findings: 47% of children of initiated ADHD
treatment with MH/No meds, 38% of children with PCP
meds/No MH, and 14.6% of children with MH/Meds.
Children initiating treatment with MH/No meds added
medications significantly sooner than children initiating
treatment with PCP meds/No MH added MH specialty
care. Within the first 6 months after initiating treatment,
the most common type of intervention is medications
without specialty mental health care, and approximately
a third of children have discontinued treatment.
Conclusions: We found that substantial numbers of
children initiate ADHD treatment with either mental
health specialty care without medications or medications
prescribed by a PCP without mental health specialty
care, but that the types of interventions children receive
frequently changes during the treatment episode.
Approximately one-third of children have discontinued
treatment within 6 months, and among the remaining
children, medication without mental health specialty care
is the most common intervention.
Implications for Policy, Delivery or Practice:
Efficacious pharmacologic and non-pharmacologic
treatments for ADHD exist. Our findings documenting
relative frequent shifts in the types or modalities of care
received by children initiating ADHD treatment may
hamper the effectiveness of efficacious ADHD
interventions. Better understanding how care evolves,
and the impact of relatively frequent shifts in the delivery
of different types of treatment, are critically important
steps as we seek to improve the care provided to
children with ADHD being treated in community settings.
Quality and Efficiency: Focus on Safety
Chair: Robin Weinick
Tuesday, June 29 * 11:30 am–1:00 pm
• Validating the Patient Safety Indicators in the
Veterans Health Administration
Ann Borzecki, M.D., M.P.H.; Haytham Kaafarani, M.D.,
M.P.H.; Shibei Zhao, M.P.H.; Qi Chen, M.P.H.; Susan
Loveland, M.A.T; Amy Rosen, Ph.D.
Presented by: Ann Borzecki, M.D., M.P.H., physicianresearcher, Health Policy and Management, Boston
University, 200 Springs Road (152), Bedford, MA 01730;
Phone: (781) 687-2870; Email: amb@bu.edu
Research Objective: The Agency for Healthcare
Research and Quality (AHRQ) Patient Safety Indicators
(PSIs) use administrative data to screen for potential
inpatient adverse events. Several of these indicators
have recently been endorsed by the National Quality
Forum as hospital quality measures. However, the
validity of such measures in different systems, including
the Veterans Health Administration (VA), is unclear. As
part of a comprehensive PSI validation study, we are
currently evaluating the criterion validity of thirteen PSIs;
this study reports on results from two PSIs: 1)
postoperative hemorrhage or hematoma (PHH) and 2)
post-operative respiratory failure (PRF).
Study Design: This was a retrospective observational
study using 2003-2007 inpatient administrative and
electronic medical record data from 28 VA hospitals.
Hospitals were selected based on geographic diversity
and observed PSI rates. We applied the AHRQ PSI
software (v.3.1a) to administrative data to identify cases
suspected of having PHH or PRF. To determine the
positive predictive value (PPV; i.e., the proportion of
flagged cases that were true positives) of these
indicators, trained nurses conducted chart reviews of
112 flagged cases for each PSI from sample hospitals,
using standardized chart abstraction tools. Based on
previously reported PPV estimates, this sample number
was selected to ensure reasonably narrow PPV
confidence intervals ([CIs]; range=10 to 20%).
Physicians performed additional false positive analysis
to determine the strengths and weaknesses of each PSI.
Inter-rater reliability was also measured between two
nurse abstractors.
Population Studied: Veterans receiving VA inpatient
acute care at 28 selected hospitals from 2003 through
2007.
Principal Findings: The PPVs for PHH and PRF were
72% (95% CI, 63-80%) and 80% (72-87%), respectively.
Inter-rater reliabilities were >90% for both indicators. For
PHH, 32% of false positives were related to a procedure
occurring during a prior admission (present on admission
[POA]), 23% represented a hemorrhage identified and
treated during the original procedure as opposed to postoperatively; 16% had no identified hemorrhage or
hematoma, 13% represented hemorrhages or
hematomas that did not require management (meant to
be excluded per the indicator definition). For PRF, 55%
of false positives were due to patients being kept on a
ventilator following surgery without any documented
respiratory distress presumably as a precaution,
including for potential hemodynamic instability (2 cases)
or airway protection following neck surgery (1 case);
28% appeared to be due to documentation errors or
coding inaccuracies, 9% represented patients whose
first operating room procedure was a tracheostomy, and
9% experienced respiratory problems preoperatively
(both latter 2 scenarios are meant to be excluded per the
indicator definition).
Conclusions: The PSI algorithms for PHH and PRF
demonstrated relatively high predictive values for
detecting “true” events. The PHH’s PPV could be
improved by relatively simple means, such as use of a
POA indicator and codes representing the timing of the
bleed. Both indicators could be improved through more
accurate coding.
Implications for Policy, Delivery or Practice: The
accuracy and usefulness of these PSIs for quality
measurement could be improved by coding
enhancements, such as adoption of “POA” codes, and
by better training of coders in general adverse event
coding and in specific post-procedure complication
coding.
Funding Source(s): VA
• Measuring the Cost of Hospital Adverse Patient
Safety Events
Kathleen Carey, Ph.D.; Theodore Stefos, Ph.D.
Presented by: Kathleen Carey, Ph.D., Associate
Professor; Economist, Health Policy and Management,
Boston University School of Public Health; VA Center for
Health Quality, Outcomes and Economic Research, 715
Albany Street, Boston, MA 02118; Phone: (781) 6872140; Email: kcarey@bu.edu
Research Objective: The Institute of Medicine recently
forewarned the American public of the significant risk of
medical errors associated with inpatient care in U.S.
hospitals. In an era of rapidly escalating hospital costs,
concern over the breadth of errors also raises economic
issues. While the objective of patient safety is to prevent
harm to patients, only efficient utilization of resources will
allow the maximum safety benefits to be realized. This
paper addresses the question of the cost consequences
of patient safety lapses in acute care hospitals operated
by the U.S. Department of Veterans Affairs (VA). It
draws on VA’s comprehensive patient costing systems
to measure the excess cost associated with nine unique
hospital adverse safety events, in order to evaluate the
relative potential for cost savings across a range of
potentially preventable medical errors.
Study Design: We measured the incidence of nine
adverse events according to the Patient Safety Indicator
algorithms of the Agency for Healthcare Research and
Quality. Patient level cost regression analyses applied
generalized linear modeling (GLM) techniques to
measure the association between the adverse events
and costs, controlling for age, gender, co-morbidities,
and hospital teaching and geographic status. A separate
model was estimated for each of the nine adverse
events: decubitus ulcer, iatrogenic pneumothorax,
selected infections due to medical care, postoperative
hemorrhage or hematoma, postoperative respiratory
failure, postoperative pulmonary embolism or deep-vein
thrombosis, postoperative sepsis, postoperative wound
dehiscence, and accidental puncture or laceration.
Through the GLM approach, we tested the sensitivity of
results to VA’s two distinct costing systems: the bottomup Decision Support System that builds on estimates of
the local costs of specific inputs and the top-down
system of average patient costs developed by VA’s
Health Economics Resource Center (HERC).
Population Studied: The study setting was 472
thousand hospitalizations that took place in 114 acute
care hospitals operated by the VA during fiscal year
2007 (FY07).
Principal Findings: DSS costing appeared to better
characterize the high cost of patients that experienced
adverse events than did HERC costing. The excess cost
of a hospitalization due to adverse safety events ranged
from $9,448 for accidental puncture or laceration (or
133% of average cost for the population at risk for that
event) and $42,309 for infection due to medical care (or
256% of average cost for the population at risk for that
event). The total excess cost estimate to the VA system
for the nine adverse events in FY07 was $166 million.
Conclusions: The GLM results suggest that the excess
cost of nine different adverse patient safety events for
VA patients are much higher than previously estimated.
Implications for Policy, Delivery or Practice: The
results of this study contribute to growing evidence of a
clear business case for system wide investments in
patient safety.
Funding Source(s): VA
• The Relationship Between Chronic Illness Care
Quality and Current and Future Resource Use: An
Application of NCQA’s HEDIS Relative Resource Use
and Quality Measures
Beth Virnig, Ph.D.; David Knutson, M.S.; Schelomo
Marmor, M.P.H.
Presented by: David Knutson, M.S., Senior Research
Fellow, Division of Health Policy and Management,
University of Minnesota School of Public Health, 420
Delaware Street, SE, MMC 729, Minneapolis, MN
55455; Phone: (651) 766-0953; Email:
dknutson@umn.edu
Research Objective: The Relative Resource Use
(RRU) measures developed by the National Commission
on Quality Assurance (NCQA) are the first standardized
measures that define efficiency of health plans. They
can be combined with measures of quality from the
Healthcare Effectiveness Data and Information Set
(HEDIS). RRUs measure total annual resource use
using standard prices for cohorts of individuals who are
in a HEDIS quality performance measure denominator
population for six chronic condition categories: diabetes,
cardiovascular diseases, chronic obstructive pulmonary
disease, uncomplicated hypertension, asthma, and low
back pain. The research objective of this component of a
larger study was to use HEDIS RRU and quality
measures to determine the relationship between quality
and cost for Medicare patients with diabetes; and to
determine whether prior quality performance predicts
future resource use.
Study Design: Data sources for this study are: (1)
HEDIS comprehensive diabetes care measure set data
submitted by Medicare managed care plans for reporting
years 2007 and 2008 (based on 2006 and 2007
experience); (2) RRU measures for reporting plans for
year 2007 and 2008. The analysis focused on three
quality indicators: the percentage of individuals with
diabetes who had evidence of annual glycosyated
hemoglobin (A1c) screening, low-density lipoprotein
(LDL) screening, and retinal eye exams performed. RRU
indicators included the total standard price per member
per month (PMPM) for cohorts of members (e.g. age and
gender) collected by NCQA. Plans were grouped into
HMO, HMO/POS combined, POS and PPO. Pearson
and Spearman rank correlations were calculated for
quality and RRU measures to determine the stability of
the relationships across the measures in a given year. A
linear regression model was used to predict the
relationship between quality in 2007 and resource use in
2008. All models controlled for percent of members with
type 1 and type 2 diabetes co-morbidity, plan type, and
region.
Population Studied: Adults ages 18 to 75 with diabetes
enrolled in Medicare managed care plans. 141 plans
reporting HEDIS quality measures and RRUs for both
2007 and 2008 which had no more than one missing
quality or RRU variable were included.
Principal Findings: Overall, within year correlations
among quality measures were strong ranging from 0.49
between LDL and eye exams to 0.72 between LCL and
A1c. Increased A1c testing was associated with
decreased inpatient care costs. As LDL screening
increased, inpatient and pharmacy resource use
decreased. Rates of eye exams in 2007 were not
associated with resource use in 2008.
Conclusions: While higher quality in components of
diabetes care seems to predict lower subsequent
resource use, the broader relationship between quality of
care and resource use remains complex, requiring a
deeper understanding of the causal mechanisms
involved.
Implications for Policy, Delivery or Practice:
Developing a true efficiency measure that directly links
health care resource inputs with quality outcomes has
long been a goal of health policy leaders. Policy
implications include an increased plan level emphasis on
providing a higher level of quality care for Medicare
diabetes patients with deeper understanding of the
resource use inputs required and also potential impact
on future resource use.
Funding Source(s): RWJF, HCFO
• The Critical Importance of Comorbidity in
Assessing Health Disparities and Trends Using
Ambulatory Care Sensitive Hospitalizations
Barry Saver, M.D., M.P.H.; Sharon Dobie, M.C.P.,
M.D.; Pamela Green, M.P.H., Ph.D.; Ching-Yun Wang,
Ph.D.; Laura-Mae Baldwin, M.D., M.P.H.
Presented by: Barry Saver, M.D., M.P.H., Associate
Professor, Family Medicine and Community Health,
University of Massachusetts Medical School, 55 Lake
Avenue North, Worcester, MA 01655; Phone: (774) 4433458; Email: Barry.Saver@umassmed.edu
Research Objective: Ambulatory care sensitive
hospitalizations (ACSHs) are frequently used as
measures of timely access to ambulatory care. We
explored how predisposing, enabling, and need factors,
particularly comorbidity, affected assessments of
differences and time trends in ACSHs associated with
race and ethnicity.
Study Design: Retrospective, longitudinal cohort study
Population Studied: SEER-Medicare control subjects
aged 66+ from 1993-1999; ~125,000 subjects/year.
Principal Findings: We modeled occurrence of at least
1 acute or chronic ACSH in a year, using the AHRQ
Prevention Quality Indicator definitions, with logistic
regression using GEE to adjust for multiple years of
observation among individuals. We used the previous
year’s claims to derive the individual flags used to
compute the Romano-Charlson comorbidity index, plus
hypertension. Additional predictors included age,
gender, disability status, residence, geocoded income
and education surrogates, county-level service
availability, and continuity of care. For acute ACSHs,
unadjusted, all groups showed substantial upward
trends: whites increased 31%, blacks increased similarly
but had rates ~30% higher than whites, Hispanics
started out similar to whites but increased over 60%, and
Asians/PIs started out 52% lower than whites and rose
over 100%. Fully-adjusted models eliminated the secular
increases for whites, blacks, and Hispanics and
attenuated differences between Asians/PIs and whites,
with blacks and Asians/PIs no longer significantly
different from whites. Most of the changes could be
accounted for by comorbidity and age. For chronic
ACSHs, changes were even more dramatic. Unadjusted,
whites showed a nonsignificant, 6% decline, while other
groups all had substantial increases: rates for blacks
rose from 78% (1993) to 124% (1999) higher than
whites, Hispanics from 6% to 52% higher, and
Asians/PIs from 54% lower to 6% lower. Full adjustment
markedly depressed rate estimates for later years, with
whites, blacks, and Hispanics all showing downward
trends - an approximately 45% decline for whites and
blacks. For Asians/PIs, the upward trend vanished, with
rates 16% lower than whites in 1993 and 26% higher
than whites in 1999. Nearly all of the changes were
accounted for solely by comorbidity. With full adjustment,
blacks remained consistently 30%-50% more likely to
experience a chronic ACSH than whites.
Conclusions: For ACSHs, conclusions about time
trends and racial/ethnic differences varied substantially
depending on adjustment, with individual comorbidity
overwhelming all other factors.
Implications for Policy, Delivery or Practice: ACSH
rates are driven far more strongly by comorbidity than
any other factor and ACSH-based analyses comparing
different groups may be invalid if they do not carefully
control for comorbidity.
Funding Source(s): NCI
• Patient Safety: Measuring All Inpatient Injuries Not
Present on Admission and Their Risk Factors
Lok Wong, M.H.S.; Nancy Sonnenfeld, Ph.D.; Barbara
Resnick, Ph.D.,C.R.N.P., F.A.A.N.
Presented by: Lok Wong, M.H.S., Department of
Health Policy & Management, Johns Hopkins Bloomberg
School of Public Health; Email: lokwong@jhsph.edu
Research Objective: Injuries occurring during a
hospitalization, such as patient falls or procedural
trauma, are important patient safety events that can
impact length of stay and patient outcomes. Although
provider-level measures do report patient falls, patient
safety measures derived from population-level
administrative data have focused on adverse events
attributed to medical care, but not traumatic inpatient
injuries. Although Medicare is now focusing on “hospitalacquired conditions” due to patient falls and trauma,
these do not incorporate all possible injury types. Thus,
the burden and impact of all inpatient injuries have not
been evaluated. The purpose of this study is to describe
the magnitude and types of inpatient injuries in two
states.
Study Design: Using all ICD-9-CM injury diagnosis
codes (800-999) and the present-on-admission indicator,
we identified incident inpatient injuries among nondelivery hospital discharges in California and New York.
A clinical expert panel - comprising a surgeon,
anesthesiologist, geriatric nurse, two general specialty
physicians and two patient safety and coding experts
was convened to identify cases to be excluded, e.g.
principal trauma cases where the injury not present-onadmission may have been an error. E-codes were also
examined to identify the cause of the injury. We
conducted descriptive analyses (frequencies and
tabulations) of inpatient injuries by patient subgroups
and by types of injuries, including complications of
medical care used in patient safety indicators.
Population Studied: The study examined all hospital
discharges, excluding newborns and deliveries (23
million) from the Healthcare Cost and Utilization Project
2003-2006 State Inpatient Databases for California and
New York.
Principal Findings: Inpatient injuries not present-onadmission were identified in 2.4% of non-delivery
hospital discharges in California and New York over the
four-year period. Rates were higher among those 65
years of age and older than younger adults (3.4% vs.
2.3%) Rates were similar by gender, but varied by
race/ethnicity, with rates highest among whites (2.7%)
and lowest among Hispanics (1.2%). Most injuries not
present on admission (86.4%) were coded as
complications of medical care or devices; the remaining
inpatient injuries (13.6%) comprised injuries from other
external causes (4.8%), superficial injuries (2.4%) and
open wounds (2.0%), as well as Medicare-defined
patient falls and trauma - fractures (1.6%), crushing
(1.0%), intracranial injury (0.2%) and burns (0.2%).
Conclusions: Our data confirm that complications of
care are important sources of inpatient injury. We also
observed other types of inpatient traumatic injuries that
can be identified using the present-on-admission
indicator. Moreover, our comprehensive approach
identified traumatic injuries not included in the narrower
Medicare definition of hospital-acquired patient falls and
trauma.
Implications for Policy, Delivery or Practice: This
study demonstrates that the present-on-admission
indicator in conjunction with all injury diagnoses in
hospital discharge data may be used to identify rates of
inpatient injuries on a population basis for surveillance
and monitoring. Next steps include estimating national
rates, assessing variation across states and hospitals,
and evaluating impact of these injuries on length of stay.
These analyses would help policy-makers, hospitals and
clinicians to identify and implement opportunities for
prevention.
Funding Source(s): CDC