Call for General Posters
Call for General Posters
Poster Session B
Tuesday, June 8 • 7:30 a.m.-8:45 a.m.
• Provider Profiling in New York State and Patient Use of
Information about Healthcare Quality
Richard Adams, Ph.D., Joseph Boscarino, Ph.D, M.P.H.
Presented by: Richard Adams, Ph.D., Research Associate,
Division of Health and Science Policy, New York Academy of
Medicine, 1216 Fifth Avenue, New York, NY 10029-5293; Tel:
212.822.7290; Fax: 212.822.7369; E-mail: radams@nyam.org
Research Objective: Examine patient use of healthcare quality
information when selecting a physician or hospital. Study also
assesses how demographic factors, access to health
insurance, and having a regular physician relate to the
evaluation and use of such healthcare information.
Study Design: All English speaking adults (18 years old or
older) who lived in the state of New York and had telephones
were potential study participants. The sample was selected
using random-digit dialing of telephone numbers. Once an
eligible household was contacted, one adult per household
was randomly selected to be interviewed. Interviews were
conducted in September, 2002. Sample weights were
developed to correct for potential selection bias related to the
number of household telephone numbers and the number of
persons in the household.
Population Studied: Adults living in New York State in 2002,
with 1001 completed surveys.
Principal Findings: First, only 20% of New Yorkers used
healthcare information which they hear or read from various
sources to make healthcare decisions. Second, individuals
living in New York City and Long Island, women, employed
respondents, the more educated, Whites, the more affluent,
and individuals living in a high healthcare utilization
household recall seeing or hearing information about doctors
from more sources than their upstate, male, older,
unemployed, less educated, and nonwhite counterparts or for
individuals who live in a low utilization household. A similar
set of associations were found for reporting more sources of
information about hospital quality of care. Third, respondents
report seeing or hearing healthcare information about doctors
most often on the television (11%), in newspapers (11%), and
via word of mouth (11%). The same three outlets were also
given as the main sources of healthcare information about
hospitals (16%, 16%, and 12%, respectively). Survey
participants were most likely to use quality of care information
to make healthcare decisions that they heard from their social
network (59%) and healthcare professionals (60%). They
were the least likely to use information from health plans or
insurance companies, the NY Department of Health’s Internet
site, or independent researchers from healthcare institutions.
Finally, when selecting a new physician, respondents would
again use information from other doctors (62%) and their
social network (53%).
Conclusions: Analyzing a representative sample of New York
State healthcare consumers, we found that relatively few use
information about the quality of doctors and hospitals when
making health care decisions. Access to information about
doctors and hospitals varies by demographic group, with men,
the poor, and people of color less likely to report hearing or
seeing quality of care information. Of particular interest was
the finding that few of these consumers would turn to
independent ratings of doctors and hospitals or to the NY
Department of Health’s Internet site to gather quality of care
information. Thus, physician profiling and ratings are
necessary, but insufficient, steps to improve medical care.
Unless groups advocating these types of assessments achieve
a higher level of information accessibility and the actual use of
such information by consumers, it seems unlikely that
improved quality of care will result from these efforts.
Implications for Policy, Delivery or Practice: Information
about doctors or hospitals needs to be tailored to particular
social demographic groups, with men and people of color
especially in need for greater information. To improve access
to care, research needs to explore the specific reasons why
whites and women recall more sources of healthcare
information. We also need to assess why consumers do not
find information on government internet sites or independent
ratings of doctors and hospitals by healthcare researchers
useful when making decisions about healthcare.
Primary Funding Source: RWJF, New York State Office of
Science, Technology, and Academic Research
• Organizational Sharing Arrangements and
Rehospitalization Rates in Rural Areas
Joseph Angelelli, Ph.D., Mary Fennell, Ph.D., Susan Campbell,
M.S.
Presented by: Joseph Angelelli, Ph.D., Assistant Professor,
Health Policy & Administration, Penn State, 116 Henderson,
University Park, PA 16802; Tel: 814.865.5177; Fax: 814.863.2905;
E-mail: jangel@psu.edu
Research Objective: To examine changes in sharing
arrangements between rural hospitals and freestanding
nursing homes between 1997, 200 and 2003 and investigate
whether such relationships are related to the risk of
rehospitalization for Medicare beneficiaries treated in rural
hospitals.
Study Design: Sharing relationships between rural hospitals
and nursing homes are summarized by nine questions
concerning the sharing of administrative staff, medical staff,
nursing staff, lab services and medical records integration.
Sharing arrangements are related to rehospitalization rates in
aggregate (at the hospital-nursing home pair level) as well as
in multivariate models where the outcome is a patient-level
rehospitalization event.
Population Studied: Responses from a nationally
representative sample of nearly 500 discharge planners
interviewed in 1997, 2000 and 2003 are linked to Medicare
Part A inpatient and skilled nursing facility claims from the
same years.
Principal Findings: The number of sharing arrangements
increased significantly between 1997 and 2000, while
rehospitalization rates decreased. A modest positive effect of
sharing arrangements on the odds of rehospitalization was
observed in a cross-sectional multivariate model based on all
first-choice freestanding nursing homes in the year 2000, but
not 1997. 2003 results are in the process of being analyzed.
Conclusions: The external shocks of Balanced Budget Act of
1997 coincided with a period of increased clinical and
administrative integration between rural hospitals and
freestanding nursing homes.
Implications for Policy, Delivery or Practice: The finding
concerning a link between sharing arrangements and reduced
rates of rehospitalization is suggestive and warrants future
study in the context of other patient and facility-related factors.
Primary Funding Source: NIA
• Work Group Identification: Perceptions of Nurses
Working in Acute Care
Mary Anthony, Ph.D., Amany Abdrbo, MSN, Allan Garland,
M.D.
Presented by: Mary Anthony, Ph.D., Associate Professor,
Nursing, Case Western Reserve University, 10900 Euclid
Avenue, Cleveland, OH 44106-4904; Tel: 216.368.0462; Fax:
216.368.3542; E-mail: mxa25@case.edu
Research Objective: Effective workgroups provide better
quality of care, service to patients, and are less likely to make
errors. Nurses, in acute care, work in groups on nursing units
and have task interdependencies that require them to work
together within and across shifts. Whether shift or the nursing
unit defines workgroup formation is important to leaders in
developing workgroup processes. As part of a larger study,
the purpose of this pilot study was to describe who nurses
perceive to be their workgroup and whether this varies by
demographic and workplace characteristics.A descriptive
design using survey methodology was used. Twenty nurses
working in ICUs in each of three hospitals were randomly
selected to represent all hospital ICUs and shifts by an on-site
study liaison who distributed the surveys either in person or
via nurse mailbox. Two follow-up letters were distributed.
Data collection remains in process. However, of the 60
nurses asked to participate, 21 have returned the survey.
Nurses were asked to identify which group they primarily feel
most part of: the nursing department of the hospital, nurses
on their unit or, nurses on their shift.
Study Design: A descriptive design using survey methodology
was used. Twenty nurses working in ICUs in each of three
hospitals were randomly selected to represent all hospital
ICUs and shifts by an on-site study liaison who distributed the
surveys either in person or via nurse mailbox. Two follow-up
letters were distributed. Data collection remains in process.
However, of the 60 nurses asked to participate, 21 have
returned the survey. Nurses were asked to identify which
group they primarily feel most part of: the nursing
department of the hospital, nurses on their unit or, nurses on
their shift.
Population Studied: . Most respondents were female (n=20,
95%), had a baccalaureate degree in nursing (81%) and on
average were 35.2 years old (SD = 9.2). Nurses worked an
average of 37.1 hours per week (SD = 5.6) in ICUs that had an
average of 11.3 beds and were characterized as being surgical
intensive care units (n = 13; 62%). Equal numbers of nurses
worked the day (n = 7; 33.3%) or night shift (n =7; 33.3%) while
23.8% (n = 5) rotated shifts. Most nurses worked 12 hours
shifts (n = 18; 85.7%).
Principal Findings: The preliminary findings are: Nurses
primarily identified that all nurses working on their unit (n= 13)
were their relevant work group while approximately one third
(n =7) considered that nurses on their shift as being their
workgroup. Only one respondent identified the nursing
department as the workgroup. Using chi-square analysis,
there was no statistically significant difference among which
group nurses felt primarily a part of and the shift they worked
or the type of ICU in which they practiced. Similarly, ANOVA
also showed there was no statistically significant difference
among which group nurses identified with and the number of
hours they worked, the length of the shift, or the number of
beds in the ICU.
Conclusions: Although the sample size was small, most
respondents identified all nurses working on their nursing unit
as being the group to which they felt most a part of. This
perception was not significantly different when compared with
demographic and workplace characteristics.
Implications for Policy, Delivery or Practice: With the
limitations of the RN supply, leaders are challenged to develop
effective initiatives to understand how quality can be achieved.
Correctly specifying the relevant workgroup is fundamental to
understanding how work group effectiveness achieves better
outcomes. A larger study is underway to assess whether
essential work group processes vary by shift.
• Potentially Inappropriate Psychotropic Use in the Elderly:
Characteristics and Associated Outcomes
Rajender Aparasu, MPharm, Ph.D., Jane Mort, Pharm.D
Presented by: Rajender Aparasu, MPharm, Ph.D., Associate
Professor, College of Pharmacy, South Dakota State
University, Box 2202 C - 1 Administration Lane, Brookings, SD
57007; Tel: 605.688.6646; Fax: 605.688.6232; E-mail:
rajender_aparasu@sdstate.edu
Research Objective: This study examined the prevalence,
correlates, and associated health care outcomes of the elderly
using potentially inappropriate psychotropic medications in
the United States.
Study Design: The research involved cross-sectional analyses
of 1996 Medical Expenditure Panel Survey (MEPS) data.
Population Studied: Analysis focused on community-dwelling
elderly (i.e., 65 years of age or older) using psychotropic
medications that should be generally avoided and medications
that should be avoided because of patients’ preexisting
condition based on Beers Criteria.
Principal Findings: According to the MEPS, an estimated
2.30 million community-dwelling elderly used a potentially
inappropriate psychotropic agent. This represents 37.86% of
all elderly using psychotropic agents (32.94% of elderly taking
psychotropics received inappropriate disease-independent
agents and 10.21 % received inappropriate disease-dependent
agents). Potentially inappropriate use among elderly taking
antidepressants, antianxiety agents and sedative/hypnotics
was 50.93%, 31.84%, and 23.49%, respectively. The
multivariate analyses revealed that correlates of potentially
inappropriate psychotropic use in the elderly were age and use
of multiple psychotropic agents. Use of potentially
inappropriate psychotropic medications was not associated
with differences in health care utilization, economic, or
humanistic outcomes in the elderly after controlling for
predisposing, enabling, and need factors.
Conclusions: Overall, the study findings suggest that
although potentially inappropriate psychotropic use is
common among the elderly receiving psychotropic agents, the
unfavorable risk-benefit ratio of these medications does not
appear to influence broad measures of health care utilization,
costs, or quality of life in the elderly.
Implications for Policy, Delivery or Practice: The potentially
inappropriate psychotropic medications examined in this
study do not appear to impact broad measures of health care
use or costs. More research is needed on health care
outcomes affected by inappropriate medications before health
policy changes can be made to guide prescribing practices
and education.
Primary Funding Source: AHRQ
• Are They The Picture of Health? An Examination of
Wellness Assessments of College Students at West
Chester University
Nicole Armstrong, BS, Tanya Morgan, BA, MS, Ph.D.
Presented by: Nicole Armstrong, BS, Graduate Assistant,
Department of Health, West Chester University, H312
Sturzebecker Health Sciences Center, West Chester, PA 19383;
Tel: 610.436.2113; Fax: 610.436.2860; E-mail:
ArmstrongATC@aol.com
Research Objective: The purpose of this study was to
examine wellness assessments completed by West Chester
University students who were enrolled in HEA 100
Dimensions of Wellness. Specifically, a variety of topics related
to the six dimensions of wellness were assessed and the
results were compiled to summarize the wellness profile of
each student enrolled in the course. The results of the
wellness assessments were compared to standard indicators
of wellness for each area to determine if there was a
significant difference between the two groups.
Study Design: Profile Plus 2002 General Version 2.1, was
used to enter data and compile an individual wellness
assessment for each person in this study. The program
provided a variety of assessments, including surveys that
could be completed using the program. Other information
was collected during the class period and with the help of the
kinesiology lab. This information included blood pressure,
body composition, timed walk/run, flexibility scores, and
strength tests. For the nutrient analysis, students were asked
to use the program to record their nutrition intake for seven
consecutive days. An exercise prescription was created using
the software package and students kept a three-week exercise
log during the semester. The data compiled from Profile Plus
was used to create a data set in SPSS for analysis. Descriptive
statistics were calculated and compared to accepted ranges of
wellness indicators to determine if students were within the
recommended standards.
Population Studied: The study examined seventy-one
students who were enrolled in three sections of a Dimensions
of Wellness course at West Chester University in West
Chester, Pennsylvania during the 2002 fall semester.
Principal Findings: Several of the categories assessed in the
study indicated that students were in the recommended
standard range. These assessment items included
cardiorespiratory endurance, muscular strength, resting heart
rate, blood pressure, and a variety of cancer and
cardiovascular risks. These findings, however, also found
areas of concern. The students in this study were above
average in the percentage of body fat and also had an average
body mass index that fell in the overweight category. Although
the caloric intake was average, the percentage of fat and
carbohydrates were above the recommended standard.
Students were found to exercise on a very limited basis and
the stress assessments indicated high levels in variety of
subcategories.
Conclusions: These findings suggest that college students,
unlike the average American population, should be concerned
about the potential for obesity. While the caloric intake was
within the recommended standard, the selection of foods with
a higher percentage of fats and carbohydrates were poor
choices that were made by the students participating in this
study. These choices have been found to be associated with a
body fat percentage and body mass index than is above the
recommended standard for a healthy lifestyle. The study also
found that low activity levels may be associated with these
findings. An increase in activity levels would also have the
potential to reducte the high stress levels that were found in
this analysis.
Implications for Policy, Delivery or Practice: This study
concurs with past research findings that indicate obesity and
the lack of regular exercise is a cause for concern. College
students are no exception, and it is suggested that every effort
should be made to include healthy nutritional options and
access to exercise and fitness equipment on campuses.
Although it is ultimately the students’ decision, an increase in
the awareness of the need to focus on healthy choices could
serve as a catalyst to begin a healthier lifestyle and a ultimately
obtain a wellness assessment that falls within the
recommended standards.
• Identifying Optimal Comorbidity Measures for Use in
Research Examining Disparities in Colon Cancer
Treatment, Costs, and Outcome
Laura-Mae Baldwin, M.D., M.P.H., Pam Green, Ph.D., William
Barlow, Ph.D., George Wright, Ph.D., Carrie Klabunde, Ph.D.
Presented by: Laura-Mae Baldwin, M.D., M.P.H., Associate
Professor, Family Medicine, University of Washington, Box
354982, Seattle, WA 98195; Tel: 206.685.4799; Fax:
206.616.4768; E-mail: lmb@u.washington.edu
Research Objective: To compare the ability of five different
comorbidity
measures derived from administrative claims to predict colon
cancer treatment, costs, and non-cancer mortality. To
determine the degree to which these measures account for
black-white disparity in treatment and outcomes. To identify
the relative contribution of inpatient and outpatient diagnoses
to the performance of these measures.
Study Design: Using Surveillance, Epidemiology, and End
Results (SEER) program data linked with Medicare claims, we
are creating five comorbidity measures using diagnoses from
selected prediagnosis inpatient,
prediagnosis outpatient, and surgical hospitalization inpatient
claims: Romano's adaptation of the Charlson index,
Elixhauser's 30-item measure, Ambulatory Diagnostic Groups,
Diagnostic Cost Groups, and Klabunde's inpatient and
physician claims indices. We have also created a surgical
length of stay (LOS) variable for comparison. Using logistic
and linear
multiple regression modeling, we are determining which
measures are the strongest predictors of adjuvant
chemotherapy use, two year mortality from
non-cancer causes, and medical costs. We are also examining
the degree to which the different measures account for blackwhite disparities in adjuvant chemotherapy use and mortality.
Last, we are determining the contribution that outpatient and
surgical hospitalization inpatient claims make to the
prediction of our outcomes.
Population Studied: 5294 black and white Medicare
beneficiaries 66 and
older reported to one of the 12 SEER cancer registries with a
diagnosis of stage III colon cancer between January 1, 1992
and December 31, 1996.
Principal Findings: Using claims from the year prior to
diagnosis, the Romano-Charlson index identifies 10.5% of
individuals and the Elixhauser measure 14.5% with comorbid
conditions. Addition of prediagnosis outpatient claims
increases the percent with comorbities to 47.1 using the
Romano-Charlson index, and to 70.2 using Elixhauser's
measure. Addition of surgical hospitalization inpatient claims
to the prediagnosis inpatient claims increases the percent with
comorbities to 35.4 using the Romano-Charlson index, and to
62.6 using Elixhauser's measure. The inpatient claims-based
Romano-Charlson index, Elixhauser measure, and the surgical
LOS are strong and significant predictors of the use of
adjuvant chemotherapy for colon cancer patients. Adding
diagnoses from outpatient claims creates a Romano-Charlson
measure that is less strongly associated with chemotherapy
use. Only surgical LOS helps account for the black-white
disparity in chemotherapy use.
Conclusions: Preliminary analyses suggest that comorbidity
measures based on inpatient and outpatient diagnoses from
administrative claims are significant predictors of colon
cancer treatment. Inpatient diagnoses alone are the strongest
predictors of treatment use in the two measures examined
thus far, even though many patients have no comorbidities
using these methods. This suggests that databases with only
inpatient diagnostic data can provide adequate comorbidity
data for use in health services research. Administrative
claims-based measures do not account for black-white
disparity in treatment use, while surgical LOS explained nearly
40% of the disparity. Additional analyses will determine
whether these findings are consistent across three other
comorbidity measures and two additional outcomes.
Implications for Policy, Delivery or Practice: This study's
results will provide health services researchers with insight
into how to use administrative claims to best measure the
contribution of health status to treatment use and health
outcomes.
Primary Funding Source: NCI
• Teaching Evidence-Based Decision-Making to the Public
Health Practice Workforce
William Baldyga, Dr.PH, Karen Peters, Dr.PH, Edie Sternberg,
M.P.H.
Presented by: William Baldyga, Dr.PH, Associate Director,
Health Research and Policy Centers, University of Illinois at
Chicago School of Public Health, 850 W. Jackson Boulevard,
Chicago, IL 60607; Tel: 312.996.0786; Fax: 312.996.2703;
E-mail: bbaldyga@uic.edu
Research Objective: Local and county level public health
practice should incorporate sound scientific decision-making
based on the best available evidence for implementing
practice activities and programs. The knowledge, skills and
ability of local health department staff to locate evidence for
programming efforts have been hampered by a lack of training
in social and behavioral health sciences, along with difficulty in
retrieving and utilizing evidence based strategies that can
inform local public health practice. To address these issues, a
training course, Evidence Based Public Health, was developed.
In order to gauge the success of the course in meeting its
stated objectives, measure participants’ perceptions of the
value and utility of the course, and track the actual use of
course material, a two-part evaluation strategy was
implemented.
Study Design: The first stage of the evaluation involved the
distribution of a pre-post questionnaire which asked questions
regarding participant confidence in performing tasks
associated with the course objectives prior to starting the
course. Each participant was asked to reply to the questions
based on a scale of 1-5 (1-not very confident to 5-very
confident). Paired T-tests were used to measure participant
change in their self-reported confidence ratings. The second
stage of the evaluation consisted of a 10-minute telephone
interview of participants three months after course
completion. A standardized interview guide was used
Population Studied: A total of 120 participants have attended
the training course. Participants include the state and local
public health workers, health care professionals from a variety
of disciplinary backgrounds and academicians.
Principal Findings: The findings from the training activity
reveal that participants have increased knowledge of evidence
based principles related to public health practice and chronic
disease prevention, learned a comprehensive approach to
program development and evaluation, and are able to access
and interpret existing data systems and methods of using
evidence based summaries. After attending the course,
participant confidence ratings were significantly higher for all
course objectives assessed (p>0.001). The most significant
increases in participants’ confidence were: 1) developing a
logic model (+1.91); 2) using the Internet to search for
evidence-based health program recommendations (+1.45);
and 3) determining what is known in the scientific literature
(+1.22). Three months after course completion, participants
are applying the course information in their daily work.
Conclusions: The Evidence-Based Public Health course has
been shown to be an effective tool in educating professionals
about evidence-based public health. This finding indicates that
the didactic lectures, practice exercises, case studies, and
computer simulations were effective teaching elements.
Course participants are more capable and confident in
performing activities related to public health practice, such as
literature searches, logic model development, quantitative
data sources and program evaluation.
Implications for Policy, Delivery or Practice: This study
showed that another way to move towards an evidence-based
approach is to provide more training to public health
professionals. These trainings can help professionals increase
their knowledge and confidence in applying evidence-based
principles in their work settings. They can also help public
health professionals build on their research skills to effectively
locate recommendations that are useful to them.
Primary Funding Source: CDC
• Why Should African American Liver Transplant
Recipients Have Poorer Survival than Others?
W. Ray Kim, M.D., M.P.H., Kiran Bambha, M.D., M.S., Rachel
Pedersen, B.S., Joanne Benson, B.S., E. Rolland Dickson,
M.D., Norah Terrault, M.D., M.P.H., Goran Klintmalm, M.D.,
Ph.D.
Presented by: Kiran Bambha, M.D., M.S., Fellow,
Gastroenterology and Hepatology, Division of
Gastroenterology and Hepatology, Mayo Clinic and
Foundation, 200 First Street, SW, Rochester, MN 55905; Tel:
507.538.0474; Fax: 507.538.3974; E-mail:
bambha.kiran@mayo.edu
Research Objective: Analyses of data from the early 1990s
from United Network for Organ Sharing (UNOS) showed that
African American (AA) patients undergoing liver
transplantation (OLT) had significantly inferior survival
compared to recipients of other races (Lancet 2002). The
reason for this disparity is unclear. Aims: To (1) evaluate
whether the racial differences in OLT outcomes persist in
more recent UNOS data; (2) examine whether recipient
characteristics explain the differences in outcome; (3)
compare survival of AA and non-AA OLT recipients and
causes of death using patient databases from high-volume
OLT centers.
Study Design: For aims 1 and 2, based on the Standard
Transplant Analysis Resource file from UNOS, data were
obtained in all adult (age>18) primary OLT recipients in the
U.S. between 1997 and 2002. Graft and patient survival was
compared across racial groups. Recipient and donor
characteristics were compared between recipients of AA and
other races. Multivariable proportional hazard analysis was
performed to compare postOLT outcomes for AA and non-AA
patients, taking into account relevant variables that known to
affect postOLT survival. For aim 3, we examined OLT
outcomes among AAs and other races using two NIHsponsored multi-center databases that prospectively enrolled
OLT recipients at 4 centers. Data were extracted in 2851 adult
patients undergoing primary OLT between 1985 and 2000.
Population Studied: Liver transplantation recipients.
Principal Findings: Data on 17,641 primary OLT recipients
were available within the UNOS database, consisting of 1340
AA patients, 15194 Caucasian, 635 Asian, and 472 “other” race.
AA recipients had significantly poorer survival than others
(p<0.01, log-rank test). Graft survival showed an identical
pattern, with survival differences continuing to widen with
longer follow-up. Re-transplantation rate was similar between
AA and non-AA recipients (5.4% vs. 5.2%, respectively). After
accounting for numerous preOLT recipient characteristics,
being AA was still associated with a 1.24-fold increased risk of
death. Within the multi-center OLT databases, the racial
distribution included 135 AA (4.8%), 2448 Caucasian, and 240
“other” race. Similar to the UNOS data, AA recipients were
younger than non-AAs (means: 43.1 vs. 49.6, p<.01).
Fulminant hepatic failure was more common (14.8% vs.
4.2%) and alcoholic (7.4% vs. 12.8%) and cholestatic (15.6%
vs. 23.6%) disease less common among AAs than non-AAs
(p<0.01). The proportion of hepatitis C was similar (21.5% vs.
23.8%). Among 2851 patients in the multi-center databases,
765 recipients died postOLT, including 35 AAs (4.6% of all
deaths). Survival was indistinguishable between AAs and nonAAs. Graft survival was also similar. Among the 716 patients
with identifiable causes of death, there was no difference
between AA and non-AA recipients.
Conclusions: Analysis of UNOS data suggests that AA
patients undergoing OLT have reduced survival compared to
those of other races. Consideration of baseline recipient and
donor characteristics fails to explain these differences.
Interestingly, in contrast to the nationwide data from UNOS,
analysis of a large cohort of carefully selected OLT recipients
cared for at high-volume transplantation centers revealed that
race had no effect on postOLT survival.
Implications for Policy, Delivery or Practice: These data
together suggest that patient selection or postOLT care in
selected centers can overcome any biologic differences that
may exist across racial categories.
Primary Funding Source: NIH/NIDDK
• Comprehensive Care for Women Veterans: Indicators of
Dual Use of VA and Non-VA Providers
Bevanne Bean-Mayberry, M.D., M.H.S., Chung-Chou Chang,
Ph.D., Melissa McNeil, M.D., M.P.H., Patricia Hayes, Ph.D.,
Sarah Hudson Scholle, Dr.PH
Presented by: Bevanne Bean-Mayberry, M.D., M.H.S., Core
Investigator, Center for Health Equity Research & Promotion,
VA Pittsburgh Healthcare System (130-U), University Drive C,
Building 28 #1A115, Pittsburgh, PA 15240; Tel: 412.688.6477;
Fax: 412.688.6527; E-mail: Bevanne.BeanMayberry@med.va.gov
Research Objective: We initiated this Department of Veterans
Affairs (VA) study to identify the health care experience factors
(e.g., provider gender, gynecological care by provider, overall
satisfaction, and use of a VA women´s clinic) that influence
dual use of VA and non-VA regular providers among women
veterans. We hypothesized that women who receive
comprehensive (general and gender-specific) care in the VA
would be less likely to demonstrate dual use and that lower
overall patient satisfaction with primary care would positively
influence dual use of VA and non-VA regular providers.
Study Design: An anonymous survey was mailed to a random
sample of women veterans from a regional network of ten VA
medical centers to evaluate satisfaction with primary care
(Response Rate 61%, N=1321). A secondary analysis of dual
use of providers was performed with the subgroup of women
(N=1051) who identified their VA regular provider. Multiple
logistic regression analyses were performed to determine the
effect of each health care experience factor on use of a non-VA
regular provider with adjustment for patient demographics,
perceived health status, VA service connection, and clustering
by site.
Population Studied: Women veterans from a regional
network of ten VA medical centers.
Principal Findings: In multivariable analyses, provision of
routine gynecological care by the VA provider (OR 0.37, 95%CI
0.22, 0.60) and use of VA women´s clinics (OR 0.56, 95%CI
0.35, 0.90) were significantly associated with a lower likelihood
of dual use. However, overall dissatisfaction (OR 1.88, 95%CI
1.04,3.41) and income (OR 1.89, 95%CI 1.32, 2.71) were the
characteristics significantly associated with an increased
likelihood of dual use.
Conclusions: Women veteran´s use of VA and non-VA regular
providers is not associated with provider gender but is
influenced by modifiable factors such as satisfaction or a
broader scope of services from a provider or clinic setting.
Implications for Policy, Delivery or Practice: Primary care
settings should promote routine gynecological care within
primary care or linked with specialized women´s clinics to
enhance coordination and comprehensiveness and, thus,
reduce fragmentation of care or potential overuse of care
across health systems.
Primary Funding Source: VA
• Congenital Heart Surgery Outcomes in Hospitals with a
High Hispanic Volume
Oscar Benavidez, M.D., M.P.P., Kimberlee Gauvreau, Ph.D.,
Kathy Jenkins, M.D./M.P.H.
Presented by: Oscar Benavidez, M.D./M.P.P., Clinical Fellow
in Pediatric Cardiology, Cardiology, Children's Hospital of
Boston, 300 Longwood Avenue, Boston, MA 02115; Tel:
617.355.6363; E-mail: oscar.benavidez@tch.harvard.edu
Research Objective: Although Hispanics are the largest
minority group in the U.S., medical service utilization among
Hispanic children is understudied. It is known, however, that
language barriers plague Hispanic patient/physician
communication and those language barriers can be a
detriment to quality of health care delivery. There is data to
support that Hispanics cared for in health care settings that
bridge socio-cultural and language barriers have better
outcomes. Hospitals that care for a high proportion of
Hispanic patients may implement these modifications to
improve health care delivery.
Our primary aim was to test the hypothesis that Hispanics
who undergo congenital heart surgery at a high Hispanic
volume hospital will have lower death rates than Hispanics
who undergo congenital heart surgery at a low Hispanic
volume hospital.
Study Design: We used data from the Healthcare Cost and
Utilization Project Kids’ Inpatient Database 2000 and
selected cases of congenital heart surgery using ICD-9-CM
codes from states with Hispanic/non-Hispanic designation,
and > 5% Hispanic populations by 2000 US Census data.
Hospitals with >30% Hispanic patients were designated as
high Hispanic volume hospitals (HH) or otherwise were low
Hispanic volume hospitals (LH). We examined geographic,
economic, and demographic differences between HH and LH
hospitals, and compared death rates for Hispanics following
congenital heart surgery at the two institution types.
Differences in mortality for Hispanics were evaluated using
generalized estimating equations, adjusting for insurance,
income, hospital volume and case mix complexity by utilizing
the Risk Adjustment in Congenital Heart Surgery method
(RACHS-1).
Population Studied: Hispanic children undergoing congenital
heart surgery in HH hospitals patients in the selected states.
Principal Findings: Among 122 hospitals, fifty (41%) were
HH hospitals; 48% of all congenital heart surgical cases
occurred in HH hospitals. All HH hospitals were urban, and
82% (41) were located in either California or Texas.
HH hospitals that perform congenital heart surgery had a
higher proportion of Medicaid patients (39.8% vs. 31.8%, p <
0.05) and a higher proportion with incomes of less than
$25,000 than LH hospitals (16% vs. 6.3% p < 0.05).
HH hospitals tended to have higher congenital heart surgical
volumes, (> 450 cases, HH 24% vs. LH 12.5%, p=0.25) but
there were no significant differences in surgical case
complexity between HH and LH. Sixty-eight percent of
Hispanic congenital heart surgery cases occur at HH hospital
compared to 39% of whites and 38% of Blacks (p<0.05). In
multivariate analyses there was no significant difference in
odds of death for Hispanics undergoing congenital heart
surgery at HH compared to LH hospitals.
Conclusions: HH hospitals provide cardiac surgery for the
majority of Hispanic, poor, and Medicaid patients with
pediatric cardiac disease. There is no significant difference in
Hispanic death rates based on a higher proportion of
Hispanic cases. Communication barriers may not be an
important determinant of in-hospital mortality for Hispanic
patients undergoing congenital heart surgery. Other
outcomes may be more affected by communication barriers.
Implications for Policy, Delivery or Practice: Policies that
impact HH hospital will impact health care delivery to the
Hispanic population.
More study is needed into other outcome variables between
these hospital types.
• Does HAART Use Increase Employment Stability?
Implications for Public Policy
Stephanie Bernell, Ph.D., Judy Shinogle, Ph.D.
Presented by: Stephanie Bernell, Ph.D., Assistant Professor,
Public Health, Oregon State University, 312 Waldo Hall,
Corvallis, OR 97331-6406; Tel: 541.737.9162; Fax: 541.737.4001;
E-mail: Stephanie.Bernell@oregonstate.edu
Research Objective: This project examines the extent to
which using HAART is associated with increases in job
acquisition for those unemployed and the extent to which
using HAART is associated with decreases in job loss for
those employed. As the degree to which HAART can influence
employment transition ultimately depends on access to the
therapy (by way of insurance type), the results have numerous
public policy implications.
Study Design: Data from the HIV Cost and Services
Utilization Study (HCSUS) were used in this study. HSCUS
collected data on 2864 individuals in 180 clinics, hospitals and
private practices in 28 urban areas and 24 clusters of rural
counties. The HCSUS design includes a baseline in-person
interview and two follow-up interviews that occurred 6 months
and 12 months after the baseline interview. Interviews began
in January 1996 and all follow-up interviews were completed
as of January 1998. For this analysis, we used data from the
baseline interview to categorize individuals as employed or
unemployed and information from the first follow-up survey
for determining job loss or acquisition.
Population Studied: HCSUS is a survey of adults (at least 18
years of age) with known HIV infection who made at least one
visit to a non-military, non-prison medical provider other than
an emergency department in the continental United States
during first two months of 1996. Women and members of
staff model health maintenance organizations were oversampled to obtain more accurate information on these subpopulations. No racial or ethnic groups were excluded from
the sample.
Principal Findings: Overall, 45% of all HAART users were
employed compared to 30% of the non-users. Individuals
taking HAART had a 5% greater probability of working and
experienced an 8% decrease in the probability of exiting
employment compared to those not taking HAART, holding all
other factors constant. HAART did not significantly impact job
acquisition. The signs and significance levels of the other
covariates are comparable to the results of prior research.
Conclusions: These results present new information
concerning the role of HAART in determining employment
status of HIV-positive individuals. The modest rate of
transition from unemployment to employment is
commensurate with earlier labor market studies on HIVpositive individuals where researchers found that
approximately two-thirds of all labor market transitions were
shifts into unemployment and despite the desire to return to
work, social stigma, medical concerns and the fear of losing
health and financial benefits outweighed the psychological and
emotional benefits of working. In addition, transitions from
unemployment to employment in the general disabled
population are infrequent, especially among those receiving
benefits related to their disability.
Implications for Policy, Delivery or Practice: As HAART has
been shown to significantly decrease job loss, it behooves
policymakers to take steps to increase access to HAART. To a
large extent, this rests with the private health insurance
industry, as 59% of the employed group had private health
insurance. One option is the use of mandate benefit laws to
ensure access to HAART. An alternative is to introduce a
mandated benefit law that would make coverage available to
consumers who opt to pay a higher premium. For the working
uninsured or underinsured there are ADAP programs, but
these do not provide coverage to all who may need them.
Many states do not contribute at all to ADAP and others
provide inadequate contributions.
Primary Funding Source: AHRQ
Population Studied: Patients who were hospitalized for
ischemic stroke at age = 65 years old and had no missing
state/county codes were included for the analysis.
Principal Findings: The analytical file had 327,793 patients
during the 6-year period. A total of 27,152 patients (8.3%) died
during hospitalization. The rate of in-hospital mortality
declined from 9.6% in 1993 to 7.3% in 1998. During the same
period, the use of SNF increased from 45.8% in 1993 to 55.2%
in 1998, while the use of home health care decreased slightly.
Medicare HMO penetration grew steadily from 7.5% in 1993
to 18.0% in 1997, but dipped to 12.2% in 1998; Medicare IPA
HMO penetration was 3.0%, 10.9%, and 6.8%, respectively, in
1993, 1997, and 1998. Multivariate analysis showed that
Medicare HMO penetration was not associated with inhospital mortality or SNF utilization, but was negatively
associated with home health utilization (p < .001). Further
analysis suggested that the effects of Medicare IPA and nonIPA HMO penetration on home health utilization differed.
Alternative specifications showed the robustness of the above
results.
Conclusions: After accounting for the censored nature of
mortality data and HMO selection, we found no evidence
suggesting that increased Medicare HMO penetration
affected in-hospital mortality for ischemic stroke. Although no
evidence showed any impact of Medicare HMO penetration
on utilization of SNF, the utilization rate of home health was
negatively associated with Medicare HMO penetration.
Additional evidence on post-stroke outcomes (including longterm follow-up of patients) is needed to fully assess the
impact of Medicare HMO penetration on stroke care.
Implications for Policy, Delivery or Practice: This study
suggests that increased Medicare HMO penetration might not
have adversely affected outcomes of in-hospital care.
Primary Funding Source: AHRQ/NRSA fellowship
• Effects of HMO Penetration on In-Hospital Mortality and
Post-Acute-Care Utilization of Ischemic Stroke
John Bian, Ph.D., William Dow, Ph.D., Elizabeth Richardson
Vigdor, Ph.D., Morris Weinberger, Ph.D., David Matchar, M.D.
• Using Administrative Databases to Estimate the
Prevalence of Sarcoidosis in North East Ohio
Wendy Cameron, M.P.H., B.A., Carol Blixen, Ph.D.., R.N.,
James Boex, Ph.D., M.B.A., Mani Kavuru, M.D., Dale Konrad,
M.B.A.
Presented by: John Bian, Ph.D., Assistant Professor,
Department of Medicine, University of Alabama at
Birmingham, MT 640, 1530 3rd Avenue S, Birmingham, AL
35294-4410; Tel: 205.934.7608; Fax: 205.934.7959; E-mail:
jbian@uab.edu
Research Objective: To understand how increased Medicare
HMO penetration affects in-hospital mortality and subsequent
use of skilled nursing facilities (SNF) and home health postacute-care (PAC) at the market level.
Study Design: Using the 1993-98 Nationwide Inpatient
Sample and county-level Medicare HMO enrollment data, we
constructed a hospital panel data set for estimation. We
focused on in-hospital mortality and, for those discharged
alive, use of SNFs and home health. The key independent
variable is Medicare risk HMO penetration. The unit of
analysis is the individual patient. Discrete-time hazard models
were used to estimate the effects of Medicare HMO
penetration on in-hospital morality, and logit models were
used to estimate the effects of Medicare HMO penetration on
utilization of SNFs and home health. Both analyses used
hospital fixed effects to control for HMO selection.
Presented by: Carol Blixen, Ph.D., R.N., Researcher, Division
of Clinical Research, Cleveland Clinic Foundation, 9500 Euclid
Avenue, Cleveland, OH 44195; Tel: 216.444.6254; Fax:
216.444.9275; E-mail: blixenc@ccf.org
Research Objective: Prevalence studies for Sarcoidosis are
difficult to conduct because it is an uncommon disease that is
difficult to diagnose. Ascertaining local prevalence rates
would allow the Sarcoidosis Center of Excellence at the
Cleveland Clinic Foundation to focus its community outreach
efforts appropriately. The goal of this project was to use
administrative data as a novel means of estimating the
prevalence of Sarcoidosis in North Eastern Ohio in Fiscal-Year
2002.
Study Design: The study was a descriptive analysis of data
collected from two administrative databases. The first data
set was obtained from the Ohio Department of Jobs and
Family Services and included Medicaid administrative data
that described the demographics and number of unique
patients with a primary or secondary diagnosis of Sarcoidosis
in North East Ohio. The Medicaid data was compared to the
Cleveland Clinic Foundation demographic data as well as the
number of patients receiving a primary or secondary
Sarcoidosis diagnosis at this institution. The prevalence rate
was calculated as P= # of cases/ Population @ a point in
time.
Population Studied: The most available Medicaid eligible
population was from Fiscal- Year 2001. At that time, there
were approximately 212,726 qualifying adults over the age of 18
in North East Ohio. The assumption was made that the
population was essentially unchanged in 2002. There were
341 Medicaid patients with a primary or secondary diagnosis
of Sarcoidosis (.002 %). In Fiscal- Year 2002 there were
455,337 patient visits to the Cleveland Clinic Foundation. Of
those, there were 1,362 patients with a primary or secondary
Sarcoidosis diagnosis (.003%).
Principal Findings: Sarcoidosis generally affects African
Americans at a higher rate than the general population. The
Sarcoidosis patients from the Medicaid cohort were
predominantly African American, n= 257 (75%), while 84
(25%) was Caucasian. In contrast, the patient population N
from the Cleveland Clinic Foundation was predominantly
Caucasian 735 (54%) and 490 (36%) were African American.
The factors that contributed to the differences in patient
demographics between the two populations were beyond the
scope of this study, but merit investigation.
Sarcoidosis in the North East Ohio Medicaid population
The prevalence of Sarcoidosis was P= 341/ 212,726 or P= .002
x 100,000 or 160.3 per 100,000 Medicaid patients.
Sarcoidosis Prevalence at the Cleveland Clinic Foundation
The prevalence of Sarcoidosis was P= 1,362/ 455,337 or P=
.003 x 100,000, or P= 299.12 per 100,000 unique patients.
Conclusions: The use of administrative data to calculate
Sarcoidosis prevalence in two large populations in North East
Ohio provided unexpectedly high rates of disease prevalence.
While the estimated prevalence of Sarcoidosis in North East
Ohio, in terms of both Medicaid data and Cleveland Clinic
Foundation data ranged between 160.3 – 299.12 cases per
100,000 persons, the expected rate in the general population
ranges between 10.9 and 35.5 cases per 100,000 in the United
States. It appears that the prevalence of Sarcoidosis is higher
than anticipated.
Implications for Policy, Delivery or Practice: Further
research will be conducted to validate the findings of this
study. However, the use of administrative data- bases may be
a cost effective tool for locating Sarcoidosis patient
populations and targeting community outreach efforts.
Primary Funding Source: Department of Health and Human
Services, Office of Minority Health
• Negotiating the Alternatives: How and Why People Use
Alternative Medicine
Machaon Bonafede, M.P.H., Nancy Chin, Ph.D. M.P.H.
Presented by: Machaon Bonafede, M.P.H., Graduate Student,
Community and Preventive Medicine, University of Rochester,
School of Medicine and Dentistry, Box 644, 601 Elmwood Ave,
Rochester, NY 14642; Tel: 585.273.2617; E-mail:
machaon_bonafede@urmc.rochester.edu
Research Objective: Studies on the use of Complementary
and Alternative Medicine (CAM) in the United States have
thoroughly explored the demographics of CAM use, but
questions of how and why people use CAM are still relatively
unexplored. Astin proposed three main hypotheses for CAM
use, those being: 1) patient dissatisfaction with conventional
medical care; 2) a need for personal control; and 3)
philosophical congruence (1998). The guiding research
question of this qualitative study was: In the context of
conventional biomedicine, how do US users of CAM make
choices about and when to consult CAM practitioners? This
study also sought to investigate the nature of CAM use and
whether CAM use is an alternative to or complement of
conventional medicine.
Study Design: Semi-structured interviews with open-ended
questions were used and refined throughout the study.
Interview topics included, but were not limited to: health
background information; relationship with and perceptions of
conventional medicine; definitions of health, healing, illness,
and wellness; characterization of relationship with CAM
practitioner; the information gap between client and
practitioner; evidence base for CAM use, and; cultural and
non-medical adoption of CAM tradition practices.
Population Studied: Three health systems-based CAM
practices, Ayurvedic Medicine, Traditional Chinese Medicine,
and Naturopathy, were selected as sources for study
participants. Thirty people participated, ten from each
practice.
Principal Findings: We found that motivators and rationales
for CAM use are multi-factorial, with no single, dominating
cause for use. Dissatisfaction with conventional medicine:
Every participant had a conventional doctor and most
participants explicitly mentioned a need for conventional
medicine. While nearly all the participants reported some
negative experience with conventional medicine, a significant
portion of participants also reported negative experiences with
CAM. A need for personal control: Many participants
expressed a strong desire to be in control of their health and
healthcare. While this characteristic is certainly not limited to
CAM users, study participants indicated that CAM validated
their concerns and legitimated them as experts of their own
bodies. Philosophical congruence: Three major types of CAM
users were identified. Incident based CAM users, utilize CAM
in response to a health need and do not incorporate any of the
non-health related aspects of the CAM tradition. Explanatory
based CAM users do not use CAM purely for symptomatic
relief. Rather, these users adopt some of the cultural norms
but still base their health care decisions from a conventional
medicine explanatory base.
Tradition based CAM users follow the social and cultural
nuances of a CAM tradition and not just the health-related
practices. These users treat conventional medicine as a
specialty and their CAM tradition as primary care.
Conclusions: We did not find dissatisfaction with
conventional medicine to be the sole driving force for CAM
use. The degree to which people choose a CAM therapy for
symptom management regardless of cultural and
philosophical content could imply dissatisfaction with
conventional care, as this is true Alternative Medicine. On the
other hand, choosing a practice for its cultural background
would imply choosing a different explanatory model for health
and healing, not necessarily indicating dissatisfaction with
conventional health care.
Implications for Policy, Delivery or Practice: CAM therapies
are seldom used as true alternative medicine as CAM is
seldom used at the exclusion of conventional medicine. CAM
may help meet needs that conventional medicine has difficulty
handling due to time and resource constraints.
considered for migraine prevention, especially in patient
populations sensitive to side effects.
• Acupuncture for the Prevention of Migraine Headaches:
A Cost-Utility Analysis
Machaon Bonafede, M.P.H., Robert Holloway, M.D., M.P.H.
• Changes in Prescribing Patterns, Medication
Management, and Hospital and Emergency Room
Utilization: The Role of an Asthma Population Disease
Management Model and Individual Asthma Care
Management
Joan Branin, Ph.D.
Presented by: Machaon Bonafede, M.P.H., Graduate Student,
Community and Preventive Medicine, University of Rochester,
School of Medicine and Dentistry, Box 644, 601 Elmwood
Avenue, Rochester, NY 14642; Tel: 585.273.2617; E-mail:
machaon_bonafede@urmc.rochester.edu
Research Objective: Acupuncture has shown promise in the
prevention of migraine headaches, a condition responsible for
over $17 billion annually in treatment costs and lost wages in
the United States. Approximately 1 in 10 Americans suffer
from migraine headaches, with an average of 1 to 3 attacks per
month. Migraine attacks, which can last up to 3 days, are
characterized by debilitating pain, nausea, and extreme
sensitivity to light and sound. Our study objectives were as
follows: 1) to estimate the incremental cost-effectiveness ratio
for acupuncture compared to standard medical treatment in
the prevention of migraines, and 2) to determine the
thresholds at which Acupuncture is or is not a cost-effective
alternative through sensitivity analysis.
Study Design: The authors constructed a static decision
model to estimate the incremental cost-effectiveness ratio
from the societal perspective. According to the literature, beta
blockers are the preferred first line therapy for migraine
prevention, warranting their inclusion as the comparator. The
study intervention was Acupuncture. The effectiveness
measure was cost per Quality Adjusted Life Year (QALY), as
determined by the mapping of SF-36 scores at different levels
of migraine attack frequency to Quality of Well Being. A
societal perspective was employed and costs included direct
medical care and lost productivity, as well as the costs
associated with treating acute migraine attacks not prevented
by the therapies. The model also incorporated a one-year time
horizon. Sensitivity analysis was performed around the
incremental cost-effectiveness ratios.
Population Studied: The base case used for this analysis is
the average migraineur, suffering 24 attacks per year.
Principal Findings: The incremental cost-effectiveness ratio
for acupuncture was $19, 426.24 per QALY under the basecase assumptions. In the intermediate endpoint analysis, the
incremental cost associated with a 1% reduction in migraine
frequency was $70.55. Acupuncture was found to be more
costly ($630.20 vs. $509.30) and slightly more effective
(0.68933 vs. 0.68331) in terms of Quality of Well Being.
Sensitivity analysis varied response rates, effectiveness rates,
and costs to determine cost-effectiveness thresholds based on
values found in the literature.
Conclusions: Acupuncture is a cost-effective alternative to
standard medical treatment in the prevention of migraine
headaches. Future research needs to evaluate the concurrent
use of acupuncture and conventional medical therapies in the
prevention of migraines.
Implications for Policy, Delivery or Practice: The key finding
of this study is not the point estimates generated showing
Acupuncture to be a cost-effective treatment option for
migraine prevention; rather, the key finding is that
Acupuncture is a valid treatment option that should be
Presented by: Joan Branin, Ph.D., Department Chair, Health
Services Management, University of La Verne, 2043 North
Allen Avenue, Altadena, CA 91001; Tel: 626.794.3665; Fax:
626.794.3883; E-mail: braninj@ulv.edu
Research Objective: The purpose of this research was to
investigate the effects of an asthma population disease
management model coordinated with an individual asthma
care management program for adult asthma patients on
prescribing patterns, medication management, and hospital
and emergency room utilization.
Study Design: An asthma population disease management
model coordinated with an individual asthma care
management program to monitor and facilitate treatment of
adult asthma patients was initiated at a health maintenance
organization in Southern California. Patients were enrolled in
an asthma care management program that emphasized the
use of preventative asthma control measures. These
measures included increased use of anti-inflammatory
medications and non-pharmaceutical methods such as dust
control and peak flow meter usage and better recognition of
asthma triggers. One-on-one asthma self care management
training, patient education materials, and an individualized
follow up program involving an interdisciplinary asthma team
approach were instituted. A retrospective review of medical
records and data sources was conducted before and after the
implementation of the individual asthma care management
program for adult asthma patients.
Population Studied: A total of 2,317 asthmatic patients
between the ages of 18 and 65 years of age identified as having
moderate and severe asthma and a history of hospitalizations
and emergency room visits for asthma were continuously
enrolled in the asthma population disease management
program during 2000 and 2001.
Principal Findings: There was a statistically significant
reduction in uncontrolled acute asthma episodes,
hospitalizations, and emergency room visits after the
implementation of the asthma population disease
management model coordinated with the individual asthma
care management program. There was a significant reduction
in the number of oral corticosteriod courses, the number of
prescribers, and the ratio of inhaled anti-inflammatory
medications to beta-agonist usage (p <.05). The number of
asthma hospitalizations decreased by 17.3%. Similarly, the
number of emergency room visits decreased by 22.3%. There
was a positive correlation between the number and type of
prescribers and the rate of emergency room visits (r = .68)
and hospitalizations (r = 51). Within one year of
implementation of the asthma care management program,
the number of asthma patients identified with moderate and
severe high-risk characteristics was reduced by 24%. These
findings support the findings of an earlier similar study.
Conclusions: An asthma population disease management
model and individual asthma care management can reduce
the number of prescribers and result in better medication
management and fewer emergency room visits and
hospitalizations for asthma among adult asthma patients.
Implications for Policy, Delivery or Practice: These findings
suggest that an asthma population disease management
model coordinated with individual asthma care management
can lead to (1) better self-care medication and symptom
management, (2) improved quality of care, (3) changes in
prescribing patterns, and (4) reduced hospital and emergency
room utilization.
Primary Funding Source: ULV Faculty Research Grant
• The Effectiveness of a Bedside Smoking Cessation
Intervention on Quit Rates of Hospitalized Cardiac
Patients
Joan Branin, Ph.D.
Presented by: Joan Branin, Ph.D., Department Chair, Health
Services Management, University of La Verne, 2043 North
Allen Avenue, Altadena, CA 91001; Tel: 626.794.3665; Fax:
626.794.3883; E-mail: braninj@ulv.edu
Research Objective: Research suggests that a twenty minute
intervention conducted by a trained smoking cessation
counselor will sufficiently increase the quit rate for
hospitalized patients. The purpose of this research was to
compare the effectiveness of an outpatient smoking cessation
education program and an inpatient bedside smoking
cessation intervention in increasing the quit rate with cardiac
patients at a major health maintenance organization in
Southern California. Cardiac patients receiving the bedside
smoking cessation intervention were expected to have a
higher quit rate at one-year follow-up than did those cardiac
patients receiving the outpatient smoking cessation education
program.
Study Design: The 15-20 minute bedside smoking cessation
intervention consisted of counseling by a Smoking Cessation
Specialist, patient readiness-to-change assessments, written
self-help smoking cessation materials, education on the
proper use of the nicotine patch, smoke-free hot line numbers,
and community smoking cessation resources. The content of
the outpatient education program was identical to the bedside
smoking cessation intervention. The major difference between
the two smoking cessation was the program delivery site, i.e.,
the outpatient smoking cessation education program for
cardiac patients was conducted in the facility's educational
conference room while the bedside smoking cessation
intervention was conducted at the cardiac patient's bedside.
Population Studied: Inpatient participants were 192
hospitalized cardiac patients who had an average age of 56
years, smoked 2.1 packs/per day, and a three-day length of
stay. Outpatient participants were 625 members with cardiac
conditions who had an average age of 53 years, smoked 1.5
packs/per day and participated in three 20-30 minute smoking
cessation education classes. Participants in both groups were
mostly females. Both groups were tracked for one year.
Principal Findings: There was a statistically significant
difference in the quit rate between the two groups (p<.01).
Those who participated in the bedside smoking cessation
intervention had a smoking quit rate at one-year follow-up of
66% compared to 45% for those who participated in the
outpatient education program. There was a positive
correlation between health status measured using the SF-36
general health perceptions subscale and quit rates. There was
a negative correlation between number of years smoking and
quit rates. There was no statistically significant gender,
ethnicity, or educational level differences in quit rates between
the smoking cessation programs.
Conclusions: Hospitalization of cardiac patients may provide
the ideal "teachable moment" to promote smoking cessation.
Implications for Policy, Delivery or Practice: These findings
suggest that bedside smoking cessation interventions can
lead to (1) better quit rates over a longer time period, (2)
improved quality of life, and (3) lower utilization of healthcare
resources in the future.
Primary Funding Source: University of La Verne Faculty
Research Grant
• Utilization, Cost, and Medication Management
Outcomes of an Integrated Care Intervention for
Depression
Robert Bremer, M.A., Ph.D.
Presented by: Robert Bremer, M.A., Ph.D., Post-Doctoral
Fellow, Psychiatry, University of Pittsburgh, 230 McKee Place,
Room 250, Pittsburgh, PA 15213; Tel: 412.647.4744; Fax:
412.647.4716; E-mail: bremerrw@upmc.edu
Research Objective: The purpose of this study was to
examine the effect of an integrated care intervention on health
services utilization patterns, health care costs, and adherence
to medication management.
Study Design: This study used a quasi-experimental
nonrandomized prospective design. Patients in this study
were from two separate practices within the same group
model HMO facility that serves 45,000 patients annually. They
were screened for depression using a handheld tablet
computer, the Quick Psychodiagnostics Panel (QPD), after
their provider or other clinic staff suspected depression.
Patients who screened positive were asked to enroll in the
study. Patients from the Family Medicine practice, which
serves 10,000 patients annually, were assigned to receive the
integrated care intervention (N=86). Patients in the Internal
Medicine practice, which serves 46,000 patients annually,
received care as usual (N=81). Primary care physicians in both
groups received the results of the screen.
Population Studied: Patients in the Integrated Care (IC)
group were significantly younger and had better health than in
the Screening Only (SO) group. More Integrated Care patients
were employed and both groups were mostly Caucasian and
female.
Principal Findings: No differences were found in health
services rates for primary care, medical specialty, or mental
health specialty services. Costs were not statistically different
in both groups. There were also no differences in QPD
depression scores regardless of treatment group (IC or SO)
for patients who received adequate antidepressant medication
management. But there were significant differences between
the IC and SO groups in QPD depression scores among a
subset of patients who received adequate antidepressant
medication management.
Conclusions: Although there were no statistical differences in
mental health specialty visits, there was a large increase in
visits within the Screening Only group, especially in the first
six months from baseline. This finding, although not
significant, is nonetheless interesting given previous literature
that showed screening patients alone did not change care. It is
unclear what may have facilitated patients receiving more care
from a mental health provider. Consistent with the lack of
difference in health service utilization, there were also no
differences in health care costs. This however, gives some
favor to the Integrated Care intervention. Despite the
additional cost of the intervention, there were no significant
increases in costs for this groups. Furthermore, previous
analyses of this study already showed better clinical outcomes
and better satisfaction with the Integrated Care intervention.
The antidepressant medication management findings indicate
that the Integrated Care intervention was more influential in
decreasing depression than was receiving adequate
antidepressant medication management.
Implications for Policy, Delivery or Practice: This study
indicates that even a site-based integrated care intervention
may not be prohibitively expensive. Costs for an integrated
care intervention may be even lower if this intervention is truly
more effective than adequate medication management in
reducing depression severity. More study specifically designed
to address this question should be done.
Primary Funding Source: Kaiser Permanente Colorado
Region
• Racial and Ethnic Diversity within the Primary Care
Specialties
Sarah Brotherton, Ph.D., Paul Rockey, M.D., M.P.H.
Presented by: Sarah Brotherton, Ph.D., Director, Data
Acquisition Services, American Medical Association, 515 N.
State Street, Chicago, IL 60610; Tel: 312.464.4487; Fax:
312.464.5830; E-mail: sarah_brotherton@ama-assn.org
Research Objective: It is well established that females and
minorities are more likely than males and non-minorities to
enter primary care medicine. We further describe the future
physician workforce within the primary care specialties by
examining race/ethnicity and sex of US medical school
graduates currently training in family practice, internal
medicine, obstetrics/gynecology and pediatrics.
Study Design: The American Medical Association and the
Association of the American Medical Colleges annually survey
all residency training programs accredited by the Accreditation
Council for Graduate Medical Education. Program directors
provide information on their programs and the residents
currently training in them. Over 95% of active residents had
their training status confirmed by program directors in the
Annual GME Census of 2002-2003.
Population Studied: We examined demographic
characteristics of residents (as described by their program
directors) training in 2002-2003 in family practice, internal
medicine, obstetrics/gynecology and pediatrics who had
graduated from either a US allopathic (USMD) or osteopathic
medical school (DO).
Principal Findings: In 2002-2003 there were 43,094 residents
training in these four areas from all medical schools; 29,977
(69.6%) were US graduates (USMDs or DOs). More than
half (53.3%) of US graduates in these four specialties were
female, 71% were white, 8.3% were black, 19.9% were Asian,
and 5.8% were Hispanic (of any race). The vast majority were
US born (81.8%) or were naturalized citizens (10.8%). (Of all
trainees in all programs, 40% were female, 57.1% were white,
5.6% were black, 23.7% were Asian, 6.0% were Hispanic,
63.4% were US born, and 10.9% were naturalized citizens.)
There are differences between the primary care areas for sex
and race/ethnicity. Obstetrics/gynecology (OB/GYN) and
pediatrics are majority female (76.9% and 67.7%,
respectively), family practice is evenly split, and internal
medicine is 41.1% female (p < .001). All four areas are
predominately white; however, OB/GYN has proportionately
more than twice as many black residents (15.8%) as internal
medicine (6.4%) and pediatrics (7.3%) and nearly twice many
as family practice (8.4%) (p < .001). OB/GYN also has the
highest percentage of Hispanic residents (of any race) with
7.4% Hispanic, versus 6.3% for pediatrics, 6.1% for family
practice and 4.9% for internal medicine (p < 001).
There are differences within the specialties by sex as well.
Proportionately more women than men training in all four
areas are black (family practice 10.0% vs. 4.6%; internal
medicine, 7.7% vs. 4.1%; OB/GYN 15.9% vs. 9.3%, and
pediatrics 7.9% vs. 3.4%; p < .001). Furthermore,
proportionately more men than women training in OB/GYN
are Hispanic (10.8% vs. 6.3%) (p < .001).
Conclusions: Pediatrics and OB/GYN have long been the
most popular specialties for women. These specialties
apparently also are popular among young minority (black
and/or Hispanic) physicians as well. Additional multivariate
analyses and comparisons across training years will be used
to further describe the demographic characteristics of
residents training in these specialties, as well possible trends.
Implications for Policy, Delivery or Practice: The
racial/ethnic diversity of the physician workforce fails to reflect
the US population, despite the recognition of disparities in
health care delivery. Specialties that have long been “female
friendly” also may be more accessible or of greater interest to
minority US medical students. Other specialties may need to
examine the characteristics of OB/GYN and pediatrics training
and practice in order to increase their attractiveness to
minority US medical students in the process of choosing a
specialty.
Primary Funding Source: American Medical Association
• A Chronic Disease Management Program for a
Community Health Center
Paul Burkholder, M.D., Jeanette Nolting M.P.H., Ph.D.,
Howard Zeitz, M.D., Mary Brown, M.D., Joella Warner R.N.,
MAT, CDE
Presented by: Paul Burkholder, M.D., Assistant Professor of
Clinical Medicine, University of Illinois College of Medicine at
Rockford, 1601 Parkview Avenue, Rockford, IL 61107; Tel:
815.395.5727; Fax: 815.395.5671; E-mail: pburkhol@uic.edu
Research Objective: The goal for this three-year CDM project
was to design, implement, and evaluate a diabetes care model
tailored to meet the needs of an urban community health
center.
Study Design: An urban Community Health Center (CHC)
was selected as the implementation site for a new diabetes
chronic care model. The intervention design was a hybrid of
endocrine academic detailing and center of excellence (COE)
models. The final design evolved through the process of the
CHC revising an initially proposed COE model to fit their staff
and patient needs. An urban primary care practice site was
chosen as the control site. Patient information obtained from
surveys and clinical data gathered through chart audits were
collected at enrollment, pre-intervention (pre), at 9 months,
mid-intervention (mid), and 18 months following enrollment,
post-intervention (post). Information gathered from survey
instruments included patient diabetes knowledge, health
status, self-management behaviors, self-efficacy attributes,
and satisfaction. Diabetes clinical data included HbA1c test
performed once during the intervention as well as quarterly,
diabetes flow sheet present in chart, general and complete
foot exams, SMBG log provider review, lipid panel, and urine
protein test.
Population Studied: Patients with Type 2 diabetes from a
large urban CHC (intervention group) and from primary care
practices affiliated with a large urban health system (control
group) were invited to take part in the study.
Principal Findings: The control group showed no significant
improvements in health status measures. In addition, the
control group had statistically significant improvements for 2
of the 9 diabetes clinical indicators evaluated through chart
audits. In contrast, the intervention group (CHC) showed
significant improvement on eight out of nine health status
scales and showed statistically significant improvement for all
nine diabetes clinical indicators evaluated through chart
audits. One key finding was improvement in performance of
quarterly HbA1c tests for each patient (control group 23% pre
increased to 30% post and study group 0% pre increased to
46% post).
Conclusions: The Community Health Center integrated a
hybrid diabetes chronic care model into its practice and
demonstrated an improvement in many of the outcome
indicators monitored over the period of the study. There were
improvements in two of the nine clinical indicators at the
control site, which may have resulted from internal quality
improvement efforts initiated by the health system.
Implications for Policy, Delivery or Practice: Successful
disease management intervention design needs to reflect
sensitivity towards the overall milieu and specific needs of the
practice unit and the patient target population. Effective
program design demands flexibility and a sense of partnering
in order for the practice unit to embrace ownership of the
proposed intervention. The implication for policy makers is
that pre-set, "cookie-cutter" program designs may be less
effective and may not continue to be utilized beyond
completion of the initial intervention
Primary Funding Source: State of Illinois Excellence in
Academic Medicine Award
• Organizational Culture and Clinician Attitudes towards
Evidence-Based Practice
Gregory Aarons, Ph.D., Angelina Carmazzi, B.A.
Presented by: Angelina Carmazzi, B.A., Senior Research
Assistant, Child & Adolescent Services Research Center,
Children's Hospital, 3020 Children's Way, MC 5033, San
Diego, CA 92123; Tel: 858.966.7703 Ext. 3151; Fax:
858.966.7704; E-mail: acarmazzi@casrc.org
Research Objective: Work environments can influence
human service staff member’s attitudes and behaviors. In
children’s mental health, previous studies have found an
association between work environments, service quality, and
outcomes of services. Organizational culture (OC) can be
defined as written and unwritten rules that govern behavior in
the workplace and can influence clinicians’ attitudes and work
performance. Attitudes toward adoption of evidence-based
practice in mental health settings have not been well
delineated or defined. However, recent work has identified
four domains of attitudes toward adoption of evidence-based
practice among mental health providers (Aarons, in press).
The goal of the present study was to investigate the
relationship between defensive and constructive cultures, and
clinicians’ attitudes toward the adoption of evidence-based
practice. We hypothesized that service staff at agencies with
constructive OC would endorse positive attitudes toward the
adoption of EBP and agencies with defensive OC would be
less likely to endorse such attitudes.
Study Design: We surveyed 330 mental health workers from
50 agencies in San Diego County who provide public mental
health services to children and adolescents and their families.
The surveys measured OC and attitudes toward the adoption
of evidence-based practice.
Procedures: Meetings took place between November of 2000
and July of 2001. The mental health worker surveys were
administered in a group format in which each clinician
completed the survey.
Measures: The Organizational Culture Survey (Glisson,
1999) is a 130-item questionnaire composed of 13 scales with
a reliability of .92. Six scales used in the present study
represent two clusters including defensive culture (consensus,
conformity, subservience) and constructive culture
(motivation, individualistic, supportiveness).
The Evidence-Based Practice Attitudes Scale (EBPAS; Aarons,
in press) is a 15-item measure composed of four scales with
total scale reliability of .74. The four scales represent
Divergence: the extent to which the therapist believes that
clinical experience is more important than using manualized
therapy; Openness: the extent to which the therapist is willing
to try a new intervention; Appeal: the extent to which the
therapist will adopt a new therapy/intervention if it is
intuitively appealing; and Requirements: the extent to which
the therapist will adopt a new therapy/intervention if it is
required by his/her supervisor, agency or state.
Population Studied: Participants: The mean age of the
participants was 35.7 years with females representing the
majority (76.4%). The ethnic distribution included 64.2%
Caucasian, 15.4% Hispanic, 6.9% African American, 5.7%
Asian American, 0.6% Native American, and 7.2% “other.”
The primary disciplines endorsed by respondents were
Marriage and Family Therapy (33.1%), Social Work (31.6%),
Psychology (22.8%), Psychiatry (1.6%), and “other” (10.9%).
Principal Findings: Linear regression analyses assessed the
association of each OC cluster score with the four EBPAS
scale scores. Defensive culture was positively associated with
the Divergence and Requirements scale scores. Constructive
culture was positively associated with the Appeal and
Openness scale scores.
Conclusions: Organizational culture in children’s mental
health service organizations has a significant association with
clinicians’ attitudes toward the adoption of evidence-based
practice. Specifically, organizations with defensive cultures
appear to be associated with more resistant attitudes while
constructive cultures are associated with more positive
attitudes toward adoption of evidence-based practice.
Implications for Policy, Delivery or Practice: Because OC
can affect attitudes toward innovation, it is important to
understand how to better facilitate the adoption of evidencebased practices by mental health systems, programs, and
providers. Organizational interventions can be developed to
target improvements in OC in order to create work
environments that facilitate more positive attitudes toward
adoption of evidence-based care. Further research will help
tailor organizational interventions to improve mental health
program work environments, service staff functioning, and
ultimately, outcomes for consumers of mental health services.
Primary Funding Source: NIMH
• The Comparison between the Differences in Loyalty of
Employees and Outsourcing Employees in Using Medical
Care
Shih-Ching Chao, M.S., Feng-Hui Lin, M.S., Bill Wang, Ph.D.,
Hong-I Chang, Ph.D.
Presented by: Shih-Ching Chao, M.S., Instructor, School of
Nursing, National Defense Medical Center, P.O. Box 90048510, Neihu, Taipei, Taiwan, ROC, Taipei, 114; Tel:
886.28.792.3100 Ext. 18779; Fax: 886287923109; E-mail:
shihchng@ms21.hinet.net
Research Objective: The purpose of this study was to
investigate the situation of internal customers in loyalty of
medical behaviors and attitudes, and the comparison between
the differences in loyalty pattern distribution of employees and
outsourcing employees.
Study Design: This study uses a self-drafted structural
questionnaire to collect clients’ loyalty and basic
characteristics. The measure criteria of loyalty have four items,
including attitudinal, behavioral and self-evaluated criteria,
and the validity of questionnaire’s content examined carefully
by experts.
Population Studied: The study subjects of this research are
the employees and outsourcing employees of a medical
center, surveying their attitudinal and behavioral loyalty. The
number of valid sample of the employees and outsourcing
employees is 264 and 251, return rate is 87.4% and 88.4%
respectively.
Principal Findings: The study results show that the attitudinal
and behavioral loyalty of the employees is significantly higher
than that of the outsourcing employees after controlling
gender, age, degree of education and work years. In sum, the
internal customers’ loyalty should be enhanced before
reaching the target of external customers and outsourcing
employees are important parts of the internal employees.
Conclusions: Customers’ loyalty management has become an
important issue in the field of healthcare administration
because the competition is more intense and the way of
operation has changed a lot. However, the monitor and
management of customers’ loyalty should not be limited in
external customers but should be inclusive of internal
customers. The outsourcing of non-core service of the health
care industry has become a trend because the contents of
health care services are multi-faced and profession-oriented.
That’s the reason why the outsourcing employees should also
be a focus group of customers’ loyalty management.
Implications for Policy, Delivery or Practice: We suggest
that hospitals can enhance their outsourcing employees’
medical loyalty by improving pre-job training, internal
communication and encouraging them to join in the medical
workshop.
• Informatics Support of Collaborative Care for Chronic
Illness
Amy Cohen, Ph.D., Jim Mintz, Ph.D., Alexander S. Young,
M.D., M.S.H.S.
Presented by: Amy Cohen, Ph.D., Core Investigator: Health
Services Research, MIRECC (Mental Illness Research,
Education, and Clinical Center), Greater Los Angeles VA
Healthcare Center, 11301 Wilshire Boulevard (210A), Los
Angeles, CA 90073; Tel: 310.478.3711 Ext. 40770; Fax:
310.268.4056; E-mail: ancohen@ucla.edu
Research Objective: Collaborative care for chronic illness
requires ongoing assessments and prepared proactive
practice teams. Currently, management of care in mental
health must rely on medical records that contain little reliable
clinical information. This lack of valid, routinely collected
outcomes data is one of the greatest challenges to improving
care for mental illness.
Informatics are a flexible and efficient way to improve care.
The national VA electronic medical record has been designed
to interface with locally developed applications. We developed
an informatics tool, the Medical Information Network Tool
(MINT), that is supporting collaborative care and quality
improvement in mental health.
Study Design: MINT is being evaluated in a 15-month two-VA
site randomized, controlled trial of a care model developed to
improve the quality of care in schizophrenia.
At each patient visit, a nurse systematically assesses the
patient’s “psychiatric vital signs” including symptoms, sideeffects, compliance, stressors, medical needs and
psychosocial functioning and enters this information using an
internet browser. When the physician subsequently opens the
patient’s electronic medical record, an interactive “pop-up”
window displays the current and previous assessment with
problematic issues highlighted. The window provides a
messaging interface for communication among the treatment
team and one-click access to treatment guidelines. MINT
generates reports of key clinical problems for each provider’s
panel of patients. Clinicians and managers use reports to
identify problems with individual patient’s care and to improve
access to necessary treatments. It manages a panel of
patients and providers, both for the collaborative care
intervention and the research effort evaluating it.
Population Studied: MINT is being used by two nurse quality
managers, six case managers, and 28 psychiatrists to manage
the care of more than 170 patients with schizophrenia.
Principal Findings: At the study mid-point, quality managers
have performed 713 assessments of psychiatric vital signs.
Assessments have been provided to psychiatrists by pop-up
more than 1,300 times and 670 messages have been
exchanged among team-members. In interviews with an
independent researcher, psychiatrists stated that they learned
important new information about their patients, especially
regarding patients’ social circumstances and physical health,
which focused their treatment decision-making. Team
communication was reported to have improved.
Weight gain is one of the most important side-effects of novel
medications for schizophrenia. At both sites, MINT revealed
that obesity was a serious problem, and no treatment
resources were available. Psychiatrists were alerted to change
medication regimens to minimize this side-effect, and weight
loss clinics were established. MINT also identified the underuse of Clozapine at both sites. At one site, new protocols
were established for referrals to an established clinic. At the
second site, a Clozapine clinic was started.
Conclusions: MINT supports the need in chronic illness for
accurate, timely clinical information that supports proactive
care. It helps clinicians collect, store, manage, and utilize
patient-specific information in real time and allows for
communication among the treatment team.
Implications for Policy, Delivery or Practice: The use of
informatics to support collaborative care for chronic illness is
advancing and has uses in both psychiatric and medical
illnesses.
Primary Funding Source: VA
• Veterans' Perceptions of their Health and Access to Care
the Year Following 9/11
Laurel Copeland, Ph.D., Carol Fletcher, R.N., Ph.D., Judith
Patterson, Ph.D.
Presented by: Laurel Copeland, Ph.D., Research Specialist
Health Sciences, HSR&D, VA, 2215 Fuller Road (11H), Ann
Arbor, MI 48105; Tel: 734.769.7100 Ext. 6206; Fax:
734.761.2939; E-mail: lacop@umich.edu
Research Objective: The objective of this study was to
respond to a Program Announcement from the Department of
Veterans Affairs, VA, seeking research on preparation for and
response to terrorist attacks. The VA sought to support
research that would facilitate effective, data-driven choices by
VA leadership. Areas of possible research included the
adequacy of VA's response to the medical and psychological
needs of its patient population after an attack. The current
study explored how the 9/11 disaster influenced veterans'
health, access to services, and satisfaction with care in New
York City and the Midwest in the year following 9/11/2001.
Study Design: This retrospective study used a cross-sectional,
quasi-experimental design. A random sample of outpatients
was mailed a questionnaire. Out of 56,000 veterans who
received outpatient care at either the New York VA or a
Midwestern VA, a random sample of 837 veterans was
selected. Of these, 766 had valid addresses, and 490 returned
completed surveys for a response rate of 64%.
Population Studied: The sample was 96% male and
averaged 64.5 years of age, range 19-96; SD=13.4. Most were
veterans of World War II, 28%, Korean War, 22%, or Vietnam
Era, 28%. Racial composition was 75% white, 12% black, 8%
Hispanic, 5% other race. There was significantly less racial
diversity in the Midwestern VA, 91% white vs 57% in NYC,
where veterans were also less likely to be college-educated and
more likely to be married.
Principal Findings: Those seeking care as a result of
problems related to the events of 9/11/2001 were more likely
to be in New York than the Midwest, 10% vs 3%, and were
more likely to be Vietnam vets, 13% vs. 4%. In the
multivariate model controlling for demographics, period of
service, combat status, and post-traumatic stress disorder -PTSD, veterans from NYC scored higher on perceived health
status and satisfaction that their providers listened to them,
compared to veterans in the Midwest. Patients with more
PTSD symptoms reported lower global health scores, more
symptoms related to 9/11, and less satisfaction with: care
received, quality of care, opportunity to explain their problems,
and feeling their providers listened to them. They also
reported difficulty getting an appointment as soon as they
wanted one. They were more likely to seek care outside the VA
for 9/11-related problems.
Conclusions: Proximity to the 9/11 terrorist attacks had little
relationship to patients’ perceptions of their health and
healthcare, while symptoms of PTSD had a pervasive effect.
Implications for Policy, Delivery or Practice: The study
showed that psychiatric history is more important than
physical location with respect to the effects of a disaster such
as a terrorist attack. VA patients with symptoms of PTSD may
benefit from outreach efforts following catastrophic events,
regardless of their proximity to the events. VA can use this
information for program planning for the health care needs of
veterans following national disasters, without foreknowledge
about where the crisis might arise.
Primary Funding Source: VA
• An Evaluation of Hazardous Materials Emergency
Response Planning: Implications for Policy Improvement
at the County Level in California
Muntu Davis, M.D., M.P.H.
Presented by: Muntu Davis, M.D., M.P.H., The California
Endowment Scholars in Health Policy at Harvard University,
The California Endowment, 10620 De Haven Avenue, Hansen
Hills, CA 91331; Tel: 310.776.0406; E-mail:
muntu_davis@post.harvard.edu
Research Objective: 1.) To evaluate the implementation of
current federal and state hazardous materials emergency
response planning policies at the county level. 2.) To
determine the responsibilities of the different agencies
involved in hazardous materials emergency response
planning. 3.) To identify areas for improvement
Study Design: Federal laws, California legislation, and
emergency response planning guidelines were analyzed for
legal precedence and current practice pertaining to hazardous
materials emergency response planning. Data were obtained
from the Department of Pesticide Regulation for pesticide
incidents from the years of 1999 to 2001. Census data was
obtained from the US Census Bureau for 2000. Structured
interviews with State, County and Local government agencies
responsible for planning and responding to hazardous
materials accidents were conducted, as well as interviews with
residents of Earlimart, Tulare county, California.
Principal Findings: 1. California's budget cuts have limited
the ability of emergency response agencies to prepare for
hazardous materials accidents.
2. At minimum, emergency response plans are conducted
undergo yearly reviews, which may simply include updating
phone numbers.
3. Some agencies are able to conduct tabletop exercises with a
limited number of their staff. These exercises do not test all
skills required for an actual response effort.
4. No interagency drills are performed.
5. The public and its needs, e.g. linguistic, are not included in
the planning process.
6. Bio-terrorism has a) increased funding for pre-hazard
mitigation planning and b) heightened the awareness of the
need to improve communication among different emergency
response agencies at and between different levels of
government.
7. Hazardous materials emergency response planning is not
viewed the same as bio-terrorism preparedness despite the
fact that the protocols are the same for both.
Conclusions: The legislation and guidelines reviewed are
theoretically very comprehensive and sound in terms of
outlining the process of hazardous materials planning and
response. However, as the number of agencies responding to
a hazardous materials accident increases, the chance of an
ineffective response increases. Considering this, a few
recommendations can be made to improve the current
hazardous materials emergency response system.
Implications for Policy, Delivery or Practice: The key to
effective emergency management is rapid, well planned
responses. And as first responders, county and local agencies
need to plan and to practice working together to ensure an
effective response to any type of emergency. Therefore, I
recommend the following:
1. Consolidate grant programs for emergency response efforts
into larger partnership grants given to local governments with
accountability provisions based on objective measures of
outcomes or effectiveness.
2. More state or regional oversight over county planning and
preparation, recognizing that local responders begin the
process and activation of the emergency response system in
the state.
3. Interagency drills every 2 or 3 years for improved interagency
coordination and communication.
4. Ensure that resources used for bio-terrorism preparedness
coincide with the needs for hazardous materials response
planning and preparation.
5. Pesticide-related disasters are different in nature and risks
compared with other emergencies, like a fire, flood or civil
unrest. Yet, all can be very dangerous and involve a large
number of people.
6. Inclusion of the public would enable emergency responders
to assess needs, e.g. language needs, prior to an emergency.
Primary Funding Source: The California Endowment
• Point of Service Prompts for Prescriptions
Stephen Derose, M.D., M.S., James Dudl, M.D., Victor
Benson, M.D., Richard Contreras, M.S., Randy Nakahiro,
Pharm.D, Frederick Zeal, M.D.
Presented by: Stephen Derose, M.D., M.S., Research
Scientist, Research & Evaluation, Kaiser Permanente, 100 S.
Los Robles Avenue, Pasadena, CA 91101; Tel: 626.564.3462;
Fax: 626.564.3430; E-mail: Stephen.F.Derose@kp.org
Research Objective: An automated information system to
provide physicians with evidence-based recommendations for
care at the point-of-service was evaluated for its effectiveness
in promoting prescriptions for cardiovascular disease
prevention.
Study Design: Patients who could benefit from an
angiotensin converting enzyme inhibitor (ACEI) or an HMGCoA reductase inhibitor (statin) were identified, randomly
assigned into an intervention and control group, and observed
for outpatient visits. Providers who saw patients assigned to
the intervention group were given a patient data sheet with
recommendations to prescribe indicated medications. In the
control group, the data sheet did not include the
recommendations. Dispensed prescriptions were compared
between groups.
Population Studied: 8,557 patients at high risk for
cardiovascular disease events and 1,089 primary care and
specialty physicians were studied in a large, integrated
healthcare system.
Principal Findings: Angiotensin converting enzyme inhibitors
(ACEIs) or receptor blockers (ARBs) were dispensed in 7.1% of
visits in the intervention group vs. 5.7% in the control group
(p = 0.048) following 4,678 first patient-physician encounters
during the study period. No significant difference was
observed for HMGCoA reductase inhibitors, or "statins"
(intervention 8.1%, control 7.7%), in 4,183 encounters. Data
were combined in a logistic regression controlling for the
medication recommended, number of visits and past
medication use. The odds ratio for a dispensed prescription in
the intervention group was 1.19 (95% C.I. 1.01 - 1.40).
Conclusions: An automated system that provides pertinent
data and tailored recommendations for care at the point-ofservice was found to modestly increase prescription
dispensing rates at any given visit.
Implications for Policy, Delivery or Practice: Changing
provider behavior is challenging but can be accomplished by
prompting physicians at the point-of-service using patienttailored recommendations for care. Even small effects can
produce clinically important results when combined over time.
Primary Funding Source: Merck Health Management
Services
• Short Forms to Assess Patient Trust: Factor Structure,
Validity, and Reliability
Elizabeth Dugan, Ph.D., Felicia Trachtenberg, Ph.D., Mark
Hall, J.D.
Presented by: Elizabeth Dugan, Ph.D., Senior Research
Scientist, Aging, New England Research Institutes, 9 Galen
Street, Watertown, MA 02472; Tel: 617.923.7747; E-mail:
bdugan@neri.org
Research Objective: Trust is a key element of therapeutic
relationships. Patient trust influences health outcomes
indirectly through continuity of care, adherence to treatment
regimens, and the willingness to seek care. Trust is
hypothesized to influence health outcomes directly through
the not yet well-understood mind~body pathway. Researchers
have paid increasing attention to trust as theoretical and
measurement developments have occurred, driven in part by
concern about the potential negative influence of managed
care on the doctor-patient relationship. Other causes for
concern about the doctor-patient relationship include the near
daily release of conflicting health information about diet or
lifestyle or medications, and well-publicized, yet rarely
occurring, outrageous examples of malpractice. The objective
of this study was to develop abbreviated scales to measure
trust in a physician, an insurer, and in the medical profession.
Study Design: Cross-sectional telephone survey. Key
measurement properties of the abbreviated Forms to measure
trust were evaluated. Data were analyzed to determine data
completeness, scaling assumptions, internal consistency
properties, and factor structure. Analyses were performed on
the combined populations and on three key subgroups
(elderly adults; African Americans; women).
Population Studied: Data from two samples were used. The
first was a telephone survey of a national sample of Englishspeaking adults (N=1117; mean age=49; 68% female; 5%
Hispanic; 10% African American) and the second was a
telephone survey of English-speaking managed care adult
members living in NC (N=1024; mean age=46; 55% female;
2% Hispanic; 12% African American).
Principal Findings: 1) Physician Trust 5-item Short Form
findings: African Americans were slightly less trusting of their
doctor, but not significantly so. Women were more trusting
on every single item; however the original scale showed only a
marginally significant gender difference, and the Short Form
did not show any gender difference. The very small gender
difference seems to get obscured in the Short Form.
Chronbach’s alpha=0.87 (test-retest reliability=0.71).
2) Insurer Trust 5-item Short Form findings: Chronbach's
alpha=0.84; test-retest reliability=0.73. Older adults trusted
their insurance provider more than younger adults. Binary
response validations showed that trust was related to having
any choice in selecting insurer, having enough choice in
selecting insurers, having a past dispute with the insurer, and
being in managed care. Adults with poorer mental health had
lower trust in their insurance provider.
3) Medical Profession Trust 5-item Short Form findings:
Chronbach's alpha = 0.77. On average, older adults had more
trust in the medical profession than younger adults.
Conclusions: Psychometric analyses provide strong evidence
for the soundness of the Short Forms. The Short Forms
maximize measurement precision, while minimizing
respondent burden. However, the long forms are
recommended for research where trust is the main outcome
of interest or for studies focusing on gender differences.
Implications for Policy, Delivery or Practice: The Short
Forms are brief, comprehensive and empirically validated
tools. The scales require reading levels of grades 4.3
(physician trust), 5.5 (medical profession trust), and 7.5
(health insurer trust). Because they meet the demands of
brevity, reliability, and validity the scales may be widely used
as measures of trust in a physician, the medical profession,
and an insurance provider.
Primary Funding Source: RWJF, National Institute on Aging
knowledge are important influences on consent to donation
and donation outcomes.
Study Design: Cross-sectional survey evidence was gathered
from nurses employed at eight (8) Level I Trauma Centers
with in-hospital organ procurement professionals located in
four (4) different geographic regions of the United States.
Such evidence was also gathered from nurses at six (6)
“comparison” facilities: trauma centers in which in-hospital
procurement professionals were not employed, but matched
to IHC hospitals for organ procurement organization (OPO)
service area and geographic location. A total of 618
completed surveys of nurses were obtained.
Population Studied: The population studied consisted of
nurses working in the hospital units (e.g., ER, neurology,
ICU’s) of trauma centers in which potential organ donors are
typically found.
Principal Findings: Nurses working in Level I Trauma Centers
with an IHC in comparison to those working in non-IHC
hospitals were found to have considerably more information
about specific aspects of donation (e.g., brain death). Further,
IHC hospital nurses in contrast to non-IHC hospital nurses
were found considerably more positive in their assessments of
how their local organ procurement organizations had done in
assisting hospital staff as well as in caring for families at the
time of the death of a loved one.
Conclusions: Previous research has demonstrated that the
presence of an IHC in a Level I Trauma Center in the United
States directly produces favorable donation outcomes by
making family approach more timely and more personal in
addition to making the donation process more efficient and
effective. Yet, as suggested by the present study, the presence
of an IHC in a trauma center is likely to also have an indirect
effect on favorable donation outcomes by providing nurses in
that hospital with more donation information as well as by
enhancing appreciation of the work that organ procurement
organizations do in helping hospital staff and families.
Implications for Policy, Delivery or Practice: The findings of
this study support the use of hospital-based organ
procurement professionals (“in-house coordinators”) to
enhance the supply of transplantable human organs.
Primary Funding Source: HRSA
• The Impact of In-House Coordinators on Nurses'
Attitudes Toward and Knowledge of Organ Donation
Roger Durand, M.A., Ph.D., Teresa Shafer, R.N., MSN, CPTC,
Samuel Holtzman, B.A., Nicholas Crafts, M.B.A., M.H.A.,
Kimberly Davis, R.N., CPTC, Phillip Decker, Ph.D.
• Feelings and Beliefs about Organ Donation among
African American Clergy
Roger Durand, Ph.D., Lamon Atkins, BS, Kimberly Davis, R.N.,
CPTC, Phillip Decker, Ph.D., Samuel Holtzman, B.A.
Presented by: Roger Durand, M.A., Ph.D., Professor of
Healthcare Administration, University of Houston-Clear Lake,
(Home) 3507 E. Plum Street, Pearland, TX 77581; Tel:
281.455.5448; Fax: 281.282.3136; E-mail:
Durand4321@AOL.com
Research Objective: The results of a study of the impact of
“in-hospital donation coordinators” (IHC) on nurses’ attitudes
toward and knowledge of organ donation are reported. The
study itself is part of a larger investigation of the effectiveness
of using hospital-based, procurement professionals to
enhance organ donation in Level I Trauma Centers in the
United States. Further, this research was designed to build
upon previous work showing that nurses’ attitudes and
Presented by: Roger Durand, Ph.D., Professor of Healthcare
Administration, University of Houston-Clear Lake, (home)
3507 E. Plum Street, Pearland, TX 77581; Tel: 281.455.5448; Fax:
281.283.3136; E-mail: durand4321@aol.com
Research Objective: Among African Americans in the United
States, the number of organ donors continues to be low
relative to the demand for transplantable human organs.
Among the oft-cited reasons for this continuing lower
donation rate is that many African Americans believe donation
to be against their religion. In this study the feelings and
beliefs about donation among African American clergy were
investigated. Clergy were deemed especially important to
study not only because of their influence on parishioners’ and
community religious beliefs, but also because they play a
critical role in assisting families both in grieving the loss of a
loved one as well as in making decisions about disposition of
the deceased.
Study Design: Telephone surveys were completed with 311
out of total of 440 identified clergy of African American
background using a standardized questionnaire. Of those who
were not interviewed, eighty-six (86) refused while an
additional forty-three (43) could not be contacted for various
reasons.
Population Studied: The population studied consisted of all
identified clergy of African American background residing in
Harris County (Houston), Texas, at the time of the
investigation (2003). The clergy were identified from multiple
sources, including organizational memberships, official
church sources, the Yellow Pages, as well as by means of
“snowball” procedures.
Principal Findings: Results from the survey showed evidence
of rather widespread support for organ donation among
African American clergy in Harris County. Thus, about 64
percent of such clergy indicated that donation was “very
important to the lives of people in this community” while
another 27 percent responded that it was “somewhat
important.” Yet, in some ways such support was actually
rather “soft.” A sizeable percentage was not completely
comfortable with the subject, and many were not personally
committed to donation. Finally, clergy who were Baptists in
church affiliation were somewhat more inclined to feel that
organ donation was important to people’s lives, to be
comfortable with the subject of donation, and to feel that
donation was not against their religion than were clergy of
other religious denominations or traditions.
Conclusions: Support for organ donation among African
American clergy in Harris County, Texas, was generally found
to be broad but somewhat shallow. Further, attitudes about
donation, including the feeling that donation was or was not
against one’s religion, was in part a personal feeling among
clergy and, in part, grounded in one’s religious denomination.
Implications for Policy, Delivery or Practice: The findings
and conclusions suggest that the supply of transplantable
human organs among African Americans might well be
enhanced by organ procurement organizations (OPOs)
developing educational offerings about donation for African
American clergy. They further suggest the importance of
these organizations designing educational materials for
denominational officers as well as for theological seminaries
in which African Americans frequently enroll as students.
Primary Funding Source: HRSA
• Factors Influencing Hospital Patient Safety
Achievements: An Analysis of Leapfrog Hospital Survey
Data
Catherine Eikel, Barbara Rudolph, Ph.D., Dennis Bush, Ph.D.
Presented by: Catherine Eikel, , Program Associate, , The
Leapfrog Group, 1801 K St. NW Ste 701-L, Washington, DC
20006; Tel: 202.292.6706; Fax: 202.292.6806; E-mail:
ceikel@leapfroggroup.org
Research Objective: The Leapfrog Group recommends three
patient safety practices proven to reduce preventable medical
mistakes in hospitals: computer physician order entry (CPOE),
intensivist staffing in intensive care units (ICUs), and evidence
based referral for seven high-risk procedures and conditions.
Anecdotally, there is some question regarding which factors
influence hospitals’ ability to meet Leapfrog’s rigorous
specifications for each patient safety practice. However, no
research has been done to demonstrate the actual
characteristics of hospitals that have implemented or are in
the process of implementing Leapfrog’s recommendations.
Our research presents the characteristics of hospitals at
varying levels of implementation of Leapfrog’s standards and
describes implementation trends over time.
Study Design: Leapfrog fields a voluntary online patient safety
survey through which hospitals self-report their
implementation status for each patient safety
recommendation. Survey responses are offloaded monthly for
analysis and scoring. The survey specifically targets urban
acute-care hospitals in 22 regions of the country and has been
fielded twice: v1.0 between July 2001 and March 2003 targeted
948 hospitals; v2.0 was launched in April 2003 and targeted
1,180 hospitals. Data will be collected on v2.0 through March
2004; our final analysis will analyze the full set of v2.0 data.
Survey responses show hospitals’ status on specific steps
toward meeting Leapfrog’s specifications for each
recommendation. We look at hospitals' implementation steps
based on four hospital characteristics: staffed beds, ownership
type, teaching status and community-based status. We
analyze the v1.0 and v2.0 data separately to show
implementation trends over time, as well as the characteristics
of survey non-respondents.
Population Studied: We studied all urban acute-care
hospitals from the 22 regions that were invited to participate
in The Leapfrog Group voluntary hospital patient safety
surveys v1.0 and v2.0.
Principal Findings: 557 of targeted hospitals participated in
v1.0, representing a 59% response rate. By December-end
2003, 1,104 of targeted hospitals have participated in v2.0
representing a 59% response rate; v2.0 data offloads will
continue through March 2004. 4.7% of responding target
hospitals in v1.0 of the survey are fully compliant with
Leapfrog’s recommendation for CPOE; 21.0% are fully
compliant with Leapfrog’s recommendation for ICU staffing.
Monthly scoring of v2.0 data show 4.9% of responding target
hospitals through December-end 2003 are fully compliant with
Leapfrog’s CPOE recommendation; 24.4% are fully compliant
with the ICU staffing recommendation.
Conclusions: Initial findings show an increased number of
hospitals participating in the survey and an increased
percentage of hospitals achieving full compliance with
Leapfrog’s CPOE and ICU staffing recommendations. Analysis
of the full set of v1.0 and v2.0 data, to be complete April 2004,
will describe the association between hospital characteristics,
as described in the study design, and the degree of progress
of hospitals in implementing the Leapfrog recommendations.
Implications for Policy, Delivery or Practice: Illustration of
the hospital characteristics associated with varying levels of
compliance with Leapfrog’s patient safety recommendations
will: inform discussion around the types of hospitals that have
implemented the recommendations and factors associated
with implementation. It will also provide information to
facilitate an increase in hospital implementation.
• Psychometric Testing of the Home Healthcare Nurse Job
Satisfaction Scale
Carol Hall Ellenbecker, R.N., Ph.D.
Presented by: Carol Hall Ellenbecker, R.N., Ph.D., Associate
Professor, College of Nursing and Health Sciences, University
of Massachusetts Boston, 100 Morrissey Boulevard, Boston,
MA 02125-3393; Tel: 617.287.7515; Fax: 1.617.287.7527; E-mail:
carol.ellenbecker@umb.edu
Research Objective: The purpose of this study was to refine
the items on the Home Healthcare Nurses Job Satisfaction
Scale (HHNJS) and test the psychometric properties of the
scale including construct and criterion validity, and reliability.
The specific aims of this psychometric study were:
1. Refine the items on the Home Healthcare Nurses Job
Satisfaction Scale (HHNJS)
2. Test the psychometric properties of the refined version of
the HHNJS, including construct and criterion validity, and
reliability.
3. Further explore the intrinsic and extrinsic characteristics of
home healthcare nurses’ job satisfaction.
Study Design: This was a methodological study, further
developing and testing the psychometric properties of the
HHNJS. The original HHNJS was adapted based on a review
of the empirical evidence and previous testing. Items were
added to enhance internal consistency and construct validity
of the instrument. Factor analysis was used for testing and
refinement of the theory-based assignment of items to
constructs. Reliability was assessed by Cronbach’s alpha
coefficients to determine the internal consistency of the items
comprising the scale and subscales. Criterion validity
employed the McCloskey/Mueller Satisfaction Scale (MMSS)
as the criterion instrument.
Population Studied: A convenience sample of 340 home
healthcare nurses from 10 agencies in five states (Maryland,
Virginia, Michigan, Tennessee, Washington), and the District
of Columbia participated in the study by completing the
HHNJS and the MMSS criterion instrument.
Principal Findings: Nine factors contributing to home
healthcare nurses’ job satisfaction emerged from the factor
analysis and were strongly supported by the underlying theory.
These factors included intrinsic job characteristics of:
relationship with patients, autonomy and professional pride,
group cohesion with peers, relationship with physician, and
organizational characteristics and extrinsic job characteristics
including: salary and benefits, autonomy and flexibility in
hours of scheduling, autonomy and control of work activities,
and stress and workload. Factor loadings were all above .4
and comparable or exceed the loadings for the subscales of
the MMSS. Cronbach’s alpha coefficients for each of the nine
subscales range from .64 to .83; the alpha for the global scale
was .89. Alpha scores for the HHNJS scale and subscales are
comparable to or exceed those reported for the MMSS.
Correlations of the HHNJS and MMSS resulted in an r
coefficient of .79, indicating criterion-related validity.
Additional findings suggest that job satisfaction is related to
agency affiliation and not to individual nurse characteristics
Conclusions: The HHNJS is a valid and reliable scale for
measurement of job satisfaction of home healthcare nurses.
The intrinsic and extrinsic characteristics of job satisfaction
are different for home healthcare nurses than nurses working
in other settings and support Neal’s theory of becoming a
home healthcare nurse.
Implications for Policy, Delivery or Practice: Job satisfaction
affects the quality of patient care as well as the likelihood that
a nurse will remain in her/his present job. Understanding
home healthcare nurses’ job satisfaction informs
administrators and policy makers about the quality of care
provided in the system and of the potential workforce in the
future. The HHNJS is currently being used in an RO1 – AHRQ
funded grant to develop a model of retention for home
healthcare nurses.
Primary Funding Source: Institutional Funding
• Evidence-Based Medical Technology Assessment Process
Leads to Increased Clinician Input and Satisfaction
Betty Emmert, B.S.
Presented by: Betty Emmert, B.S., Medical Policy Research
Consultant - RN, Medical Policy Research & Development,
BlueCross BlueShield of Tennessee, 801 Pine Street,
Chattanooga, TN 37402; Tel: 423.763.3843; Fax: 423.785.8149;
E-mail: Betty_Emmert@BCBST.com
Research Objective: To see if the evidence-based assessment
process for evaluation of medical technology utilized by
BlueCross BlueShield of Tennessee has increased clinician
input and clinician satisfaction. The process incorporates a
combination of evidence, experience and values. This places
an emphasis on learning from the best-appraised literature
and clinicians.
Study Design: The evidence-based research process is
predetermined. There is a review of data from major
professionally published review organizations (e.g., ECRI,
Hayes Inc, BlueCross BlueShield Association Technology
Evaluation Center). Large, randomized studies published in
peer-reviewed journals are sought. The data search is usually
contained to the last five years. Consensus statements from
large well-respected institutions (e.g., National Institutes of
Health, Centers for Disease Control, etc.) are also reviewed.
BlueCross BlueShield of Tennessee’s technology evaluation
criteria considers safety and efficacy, and provides consistent
scientific criteria. This consists of five aspects: (1) Final
approval received from the appropriate government regulatory
bodies (i.e., FDA); (2) Evidence permits conclusion about
effect on health outcomes; (3) Improves net health outcome;
(4) Must be as beneficial as established alternatives; and (5)
Improvement must be attainable outside the investigational
setting.
This study was developed to see if inviting specialty-matched
clinicians from across the state of Tennessee to participate in
a round table discussion (e.g., onsite, via telephone or video
conference) to gain input regarding practice experience and
regional standards of care regarding specific medical
technologies would increase clinician input and clinical
satisfaction with the medical technology assessment process.
A sample survey of ten medical assessments was reviewed.
The number of clinicians who were invited to participate and
the number of clinicians who actually participated was
counted. A satisfaction survey regarding the content of the
medical technology assessment was also completed by each
clinician participate.
Population Studied: BlueCross BlueShield of Tennessee
clinicians across the state of Tennessee who are health care
providers.
Principal Findings: Clinician input into the medical
technology assessment process increased clinician
satisfaction.
Conclusions: This approach to evidence-based assessment of
medical technology has led to increased clinician input for
BlueCross BlueShield of Tennessee, which has increased
clinical satisfaction with the medical technology assessment
process.
Implications for Policy, Delivery or Practice: Clinician input
and satisfaction can be increased by being invited to join in
the assessment of medical technology.
• Explicit Indicators to Measure Preventable Drug-Related
Morbidity in an Elderly Population
Richard Faris, Ph.D., Charles Hepler, Ph.D.
Presented by: Richard Faris, Ph.D., Assistant Professor,
Pharmaceutical Sciences, University of Tennessee, 847
Monroe Avenue, Suite 205R, Memphis, TN 38163; Tel:
901.448.1072; Fax: 901.448.3446; E-mail: fdlgator@yahoo.com
Research Objective: To develop evidence-based explicit
indicators of preventable drug-related morbidity (PDRM) and
use these indicators as a measure of quality in an elderly
managed care population.
Study Design: The Delphi technique was used with a 7member geriatric medicine expert panel to come to consensus
on evidence-based explicit indicators of PDRM in the elderly.
The indicators were constructed using a pattern of care and an
associated outcome. (Sample indicator: pattern of carediagnosis or history of congestive heart failure (CHF) and
patient is not on an ACE inhibitor; outcome of an ER visit or
hospitalization due to CHF.) The indicators were developed
with the intent of being used in a large managed care
organization’s (MCO) database containing both medical and
pharmacy claims. The pattern of care and the associated
outcome had to be present in the database in temporal order
to be considered a PDRM event. In addition to the
measurement of PDRM, risk factors and economic outcomes
were measured as a part of validation of the indicators. The
final step involved presenting the most common events
measured to an interdisciplinary panel of experts to assess
their use in a root cause analysis.
Population Studied: 11,711 Patients over 65 who were enrolled
in the MCO’s Medicare managed care plan for at least 12
months during an 18-month window.
Principal Findings: The Delphi panel came to consensus on
49 evidence-based indicators of PDRM. Of those elderly
patients in the study population, 966 (8.2%) had at least one
instance of PDRM as measured by the indicators. The most
prevalent PDRM events centered around CHF, asthma,
COPD, myocardial infarction and GI bleeding. Confirmatory
hypotheses showed that the presence of PDRM was
significantly associated with the number of prescriptions,
number of diagnoses, number of prescribers, the presence of
a cardiovascular agent, gender, and patients over 85. Patients
with a PDRM event used significantly more health care
resources and cost more to care for than those without an
event. The root cause expert panel developed cause-and-effect
diagrams for three different specific indicators and one
miscellaneous issue.
Conclusions: This study demonstrated the ability to develop
and use evidence-based explicit indicators to measure PDRM
in the elderly using an MCO database. The number of
patients with the pattern of care and corresponding outcome
(8.2%) is important and adds to the evidence of PDRM in
ambulatory patients. The use of the results to assess quality
issues in ambulatory care demonstrates practical application
of explicit definitions in a quality improvement structure.
Implications for Policy, Delivery or Practice: This study is
important in its development of evidence-based explicit
indicators for PDRM and linking the presence of the pattern of
care with the corresponding adverse outcome. This
methodology is an advance on the current mechanisms for
evaluating drug use in an ambulatory population. The use of
explicit indicators and a large managed care database allows
more cost-effective measurement of medication safety. This
measurement methodology may also be useful in evaluating
drug use given the new Medicare Prescription Drug Act.
Primary Funding Source: Merck Foundation
• The Relationship between Perceived Access and
Satisfaction with Care in a System Experiencing Increased
Demand
Stephen Flach, M.D., Ph.D., Peter Damiano,DDS, M.P.H.
Presented by: Stephen Flach, M.D., Ph.D., Assistant
Professor, Internal Medicine and Public Policy Center,
University of Iowa, 217 South Quadrangle, Iowa City, IA 52242;
Tel: 319.384.8266; Fax: 319.356.3086; E-mail: stephenflach@uiowa.edu
Research Objective: In 1998, the VA expanded eligibility for
care, creating new demand for services in most facilities.
Health care providers, as always, were expected to continue
providing quality care in a timely manner while allowing for
sufficient time with patients. Our objective is to examine if
there is a relationship between changes in perceived access
and changes in patients’ satisfaction with their care in a
system experiencing increased demands for services.
Study Design: We analyzed the Veteran’s Satisfaction Survey
(VSS), a longitudinal national survey of veterans who used VA
clinics. We examined three access measures: the percentage
of patients who got their appointment as soon as they wanted,
the percentage who waited too long in the waiting room, and
the percentage who spent as much time with their provider as
they wanted. Measures of patients’ satisfaction with their care
included the percent who were very or completely satisfied,
the percent who rated the quality of care as very good or
excellent, and the percent who probably or definitely would
use the VA if they had free care outside the VA. We created
difference scores measuring changes in satisfaction and
access between 1999 and 2001. We performed three ordinary
least squares (OLS) regressions to estimate the effects of
changes in access on changes in the three measures of
satisfaction. We controlled for baseline levels of access and
satisfaction, and facility-level variables representing patients’
health status, education, age, race, and gender.
Population Studied: We used aggregated, annual, facilitylevel results from the VSS for every VA facility (n = 134), and
analyzed changes in performance from 1999 to 2001.
Principal Findings: Patients had generally favorable access
and satisfaction ratings, with only small changes on average
between 1999 and 2001. However, difference scores for
individual hospitals varied considerably. OLS regressions had
good explanatory power (R2 of .67, .73, and .76 for changes in
the three measures of satisfaction). Improvements in having
sufficient time with the doctor was related to improvements in
all 3 satisfaction regressions (P < .0001); an increase of 10%
in the percent of patients who spent enough time with the
doctor improved each outcome by 6%. Improvement in the
percentage of patients who got their appointment as soon as
they wanted was related to an improved perception of quality
(P < .05); an increase of 10% improves perceived quality by
2%. Not having to wait too long in the waiting room was
related to improvements in perceived quality and satisfaction
(P < .0001); an increase of 10% improves these outcomes by
4% and 3%, respectively.
Conclusions: Following increased demands for care in the
VA, improvements in access were related to improvements in
satisfaction. Improvements in spending sufficient time with
the doctor were associated with the largest improvements in
satisfaction
Implications for Policy, Delivery or Practice: Timely access
to care and allowing for sufficient time for patients to discuss
their concern with providers remains important in systems
experiencing increasing demands for services.
Primary Funding Source: VA
• Disparities in Virologic Suppression among Patients with
HIV Infection
John Fleishman, Ph.D., Kelly Gebo, M.D., Erin Reilly, M.P.H.,
Richard Moore, M.D.
Presented by: John Fleishman, Ph.D., Senior Social Scientist,
Center for Financing Access and Cost Trends, Agency for
Healthcare Research and Quality, 540 Gaither Road, Rockville,
MD 20850; Tel: 301.427.1674; Fax: 301.427.1276; E-mail:
jfleishm@ahrq.gov
Research Objective: To examine factors associated with
successful viral suppression among HIV-infected patients
receiving highly active antiretroviral therapy (HAART)
Study Design: Medical record data for 2001 were abstracted
for 8,263 HIV-infected patients at nine site across the U.S.
providing HIV care. Viral suppression was defined as all HIV-1
RNA tests conducted in 2001 showing below 400 copies/ml.
Population Studied: This set of adult (age > 17) patients
enrolled in the HIV Research Network comprises patients in
care for HIV infection at nine clnical sites who were receiving
HAART during 2001.
Principal Findings: Thirty-nine percent achieved durable
virologic suppression. In multivariate logistic regression
adjusting for care site, women (adjusted odds ratio {AOR} =
.85), African-Americans (AOR=.85), those younger than 40
years of age (AOR=.65), those with a history of injection drug
use AOR=.87), and those with Medicare coverage (AOR=.80)
were less likely to achieve consistent virologic suppression,
compared to their respective reference groups (i.e., men,
Whites, patients older than 40, non-IDUs, and those with no
insurance). Eight percent of the sample were on regimens
containing only nucleosides, and patients receiving this
regimen were less likely to achieve suppression than those
receiving regimens containing multiple classes of drugs.
Conclusions: Failure to achieve virolgic suppression
potentially increases the risk of morbidity and mortality among
persons with HIV infection. The therapeutic benefit of HAART
is not being achieved among certain subgroups of the patient
population. This may be due to both patient behaviors (i.e.,
nonadherence) and provider behaviors (i.e., prescribing
nucleoside-only regimens).
Implications for Policy, Delivery or Practice: Previous
research has shown that certain sociodemographic subgroups
are less likely to receive HAART. The current study shows that
these same subgroups are also less likely to achieve the full
benefit of HAART. Targeted strategies to improve adherence
and to avoid nucleoside-only regimens may improve virologic
suppression in these groups. Further research is needed to
elucidate the factors that underlie group differences in
virologic suppression.
Primary Funding Source: AHRQ
• Coronary Artery Bypass Graft Surgery (CABG) Mortality
and Length of Stay (LOS) in the United Kingdom
Compared with the United States
David Foster, Ph.D., M.P.H., Sivana Heller, M.D., M.P.H.,
Janet Young, M.D., MHSA, Phillip James
Presented by: David Foster, Ph.D., M.P.H., Vice President,
Clinical Informatics, Clinical Informatics, Solucient, LLC, 5400
Data Court, Suite 100, Ann Arbor, MI 48108; Tel:
734.669.7982; Fax: 734.930.7611; E-mail:
dfoster@solucient.com
Research Objective: To compare inpatient mortality and
length of stay in coronary artery bypass graft patients in the
United Kingdom with those of similar patients in the United
States.
Study Design: Retrospective cohort using observational data.
The diagnosis coding system used in the US is ICD-9-CM; the
corresponding system in the UK is ICD-10. Therefore, we
used a diagnosis grouping system from the US Agency for
Healthcare Research and Quality (AHRQ) that is applicable to
both ICD-9-CM and ICD-10. This Clinical Classification
Software (CCS) grouping methodology was used to create 10
diagnostic categories which covered more than 99% of both
the US and UK CABG discharges. These diagnostic categories
provided a mechanism for case-mix adjustment. Patient age,
sex, number of diagnosis codes, and emergency versus
routine admission were also used to adjust for potential
confounding.
Population Studied: Inpatients in the United Kingdom and in
the United States who received a coronary artery bypass graft
surgery in the second calendar quarter of 2002 through the
first calendar quarter of 2003. There were 97,326 cases from
the US, and 16,395 from the UK included in this study.
Principal Findings: Unadjusted comparisons showed higher
LOS and mortality rates for patients who received a CABG in
the UK than for similar patients treated in the US. Adjusted
CABG mortality and LOS are both significantly higher in the
United Kingdom compared with patients in the United States.
Patients who were admitted on an emergency basis were
significantly more likely to die than routinely admitted
patients, and female and older patients were significantly
more likely to die during their stay than male and younger
patients, respectively, regardless of country where treatment
took place.
Conclusions: Adjusted length of stay, and in-hospital
mortality rates are significantly higher for similar patients
undergoing CABG surgery in the UK versus the US during the
time period under study.
Implications for Policy, Delivery or Practice: Further
international studies are needed to help explain why
differences exist in mortality and LOS between patients who
receive CABG in the UK versus those who receive this
procedure in the US.
Primary Funding Source: Sollucient, LLC
• Effect of Gender on Treatment of Acute Myocardial
Infarction
Janet Young, M.D., MHSA, David Foster, Ph.D., M.P.H.,
Sivana Heller, M.D., M.P.H.
Presented by: David Foster, Ph.D., M.P.H., Vice President,
Clinical Informatics, Solucient LLC, 5400 Data Court, Ann
Arbor, MI 48108; Tel: 734.669.7982; Fax: 734.930.7611; E-mail:
dfoster@solucient.com
Research Objective: To compare treatment of male and
female inpatients diagnosed with acute myocardial infarction
(AMI).
Study Design: Retrospective cohort study.
Population Studied: Data for 23,017 patients with a principal
diagnosis of AMI discharged between October 1, 2002 and
September 30, 2003 was extracted from ACTracker,
Solucient’s proprietary database with detailed inpatient
diagnostic, demographic, and drug information.
Principal Findings: Women with a principal diagnosis of AMI
admitted to hospitals with a catheterization lab are
significantly less likely than men to undergo surgical
intervention – either percutaneous coronary intervention (PCI)
or coronary artery bypass graft (CABG), adjusting for age,
race, payer, hospital characteristics and subendocardial
infarction (OR .698, 95% CI .657, .742). However, there was
no statistical difference in the likelihood of receiving a stent by
gender among AMI patients who underwent PCI (OR .987, 95
% CI .844, 1.155). Although women undergoing PCI were
somewhat less likely than men to receive a glycoprotein
IIb/IIIa inhibitor, this finding was not statistically significant
(OR .907 ,95% CI .812, 1.011).
Women treated medically for a transmural infarction are
significantly less likely than men to receive a thrombolytic
agent (OR .754, 95% CI .629, .904).
Conclusions: Recent data shows that women with a principal
diagnosis of AMI remain less likely than men to receive
treatments that have been reported to improve outcomes (i.e.
survival, reinfarction), including surgical intervention and
thrombolytic agents. However, women who undergo PCI are
as likely as men to receive a stent, a device which has been
reported to decrease restenosis.
Implications for Policy, Delivery or Practice: Cardiovascular
disease remains the most common cause of death in women.
Additional studies are required to determine why women are
less likely than men to receive treatments that have been
reported to improve outcomes.
Primary Funding Source: Solucient, LLC
• Racial and Ethnic Disparities in Health Insurance
Coverage among Midlife Adults with Diabetes: United
States, 1999-2002
Virginia Freid, M.S., Alan Cohen, M.A., Amy Bernstein, Sc.D.
Presented by: Virginia Freid, M.S., Health Statistician, Office
of Analysis, Epidemiology, and Health Promotion, National
Center for Health Statistics, 3311 Toledo Road, Hyattsville, MD
20782; Tel: 301.458.4220; Fax: 301.458.4038; E-mail:
vmf1@cdc.gov
Research Objective: Diabetes is a chronic and debilitating
disease that has been increasing in prevalence. Persons with
diabetes require frequent contact with the health care system.
This paper presents national data on health insurance
coverage for midlife adults 45-64 years of age with diabetes by
race and ethnicity and explores relationships between lack of
coverage for midlife adults with diabetes and race ethnicity
while controlling for socioeconomic factors and comorbid
conditions.
Study Design: Cross-sectional data from the National Health
Interview Survey, 1999-2002. Data are gathered through inperson household interviews.
Population Studied: Civilian noninstitutionalized U.S.
population 45-64 years of age.
Principal Findings: Among adults 45-64 years with physiciandiagnosed diabetes more than two-thirds had private
coverage, 12 percent had Medicaid, 11 percent were uninsured,
and 9 percent had other coverage (6 percent Medicare, 2
percent military, less than 1 percent other government). Lack
of coverage varied significantly by race and ethnicity for adults
with diabetes. Nearly one-in-four (23 percent) of Hispanic
adults with diabetes were uninsured compared with 8 percent
of non-Hispanic white and 13 percent of non-Hispanic black
adults with diabetes. Medicaid coverage for adults 45-64 years
with diabetes was higher for Hispanic adults and nonHispanic black adults than for non-Hispanic white adults.
Three-quarters of non-Hispanic white adults with diabetes had
private coverage compared with 58 percent of non-Hispanic
black adults and one-half of Hispanic adults with diabetes.
Levels of uninsurance among Hispanic adults with diabetes
mirror to some degree the higher levels of uninsurance found
for Hispanic adults. However, levels of uninsurance among
Hispanic adults with diabetes are lower than among Hispanic
adults without diabetes due to increased participation in
Medicaid and Medicare.
Logistic regression was used to investigate the relationship
between lack of coverage for adults with diabetes and race and
ethnicity while controlling for the effects of age, sex, poverty,
comorbid conditions and self-reported health status. For
uninsured adults 45-64 years with diabetes, poverty had a
strong positive effect on being without coverage. Among
midlife adults with diabetes the likelihood of being uninsured
was 8.5 times as likely for adults living below the poverty level,
and 6.8 times as likely for near poor adults as for adults with
family incomes more than twice poverty. Differences in
coverage among racial and ethnic groups were not significant
when poverty and other demographic and comorbid
conditions were included in the multivariate model.
Conclusions: Lack of health insurance is a critical problem for
adults with diabetes. Health insurance is a key determinant of
health care access and on-going access is essential for
reducing long-term complications for persons with diabetes.
Health insurance coverage is strongly associated with income.
Hispanic adults with diabetes were more likely to be
uninsured than non-Hispanic white or black adults with
diabetes but these differences appear to be more closely
associated with poverty than with race or ethnicity.
Implications for Policy, Delivery or Practice: Targeting lowincome uninsured persons with diabetes, before they age into
the Medicare program, may help reduce complications and
future expenditures.
• Health Services Use of Depressed versus Non-Depressed
Functionally Impaired Elderly Primary Care Patients
Bruce Friedman, Ph.D., Yeates Conwell, M.D., Rachel Ritz,
M.S., Brenda Wamsley, Ph.D., Gerald Eggert, Ph.D.
Presented by: Bruce Friedman, Ph.D., Assistant Professor,
Community and Preventive Medicine, Unversity of Rochester,
601 Elmwood Avenue, Box 644, Rochester, NY 14642; Tel:
585.273.2618; Fax: 585.461.4532; E-mail:
Bruce_Friedman@urmc.rochester.edu
Research Objective: To describe how health services use of
depressed, functionally impaired, elderly primary care patients
living in the community (not in nursing homes or other
institutions) compares with that of patients who are not
depressed. Few studies have examined this issue.
Study Design: A longitudinal observational design examining
health services use data from the control group (N=343) of the
Medicare Primary and Consumer-Directed Care
Demonstration. This was a randomized controlled trial in
which patients and/or their caregivers completed a daily
health care utilization diary for 27 services (Medicare,
Medicaid, and other payers, including private pay) over the 24
months that the study participants were in the Demonstration.
Data on hospital, nursing home, and assisted living use was
obtained from facilities. The baseline interview included the
Major Depressive Episode (MDE) module of the Mini
International Neuropsychiatric Interview. Chi Square tests
were used to compare probability of use of each of the 30
types of services between those with an MDE and those
without. Mean utilization among those with any use of each
service were also compared.
Population Studied: Functionally impaired elderly primary
care patients living in the community (not in nursing homes
or other institutions). Patients were recruited from primary
care practices in western New York and the Mid-Ohio Valley of
West Virginia and Ohio. To be eligible, individuals had to be
impaired in 2 activities of daily living or 3 instrumental
activities of daily living; have had a hospital admission,
nursing home admission, or Medicare home health use
during the prior year, or two emergency department visits
during the prior 6 months; and be enrolled in both Medicare
Parts A and B.
Principal Findings: One of six (16.6%, or 57 of 343) of elderly
control group patients were experiencing an MDE at baseline.
We found a statistically significant difference in probability of
use for only one of the 30 services. A higher proportion of
patients with an MDE at baseline were more likely to report
using adult day care during the next 2 years, 15.79% versus
5.94% (p=.010). Among users of services, those with an MDE
had more mean hospital (18.51 versus 15.00), nursing home
(181 versus 138), and assisted living (387 versus 245) days,
more adult day care visits (152 versus 103), outpatient physical
(PT), occupational (OT), speech, and respiratory therapy
sessions (20.85 versus 13.31), and ambulance trips (4.40
versus 2.79), and fewer psychiatrist office visits (2.00 versus
4.48), physician assistant (PA) or nurse practitioner (NP)
home visits (2.00 versus 3.12), and registered nurse (RN)
home visits (17.91 versus 22.67).
Conclusions: Functionally impaired elderly primary care
patients with an MDE at study entry used more hospital,
nursing home, and assisted living days, more adult day care
visits, outpatient therapist visits, and ambulance trips, and
fewer psychiatrist office visits, PA and NP home visits, and RN
home visits during the following two years than did patients
without an MDE.
Implications for Policy, Delivery or Practice: Practitioners
and policymakers should pay more attention to the impact of
depression on health services use among functionally
impaired elderly primary care patients, and should devise
approaches to reduce excess use of expensive services such as
hospital and nursing home care and assisted living.
Primary Funding Source: National Institute of Mental Health
• White and Black Disparities in the Burden of Disease
Related to Aging
Helen Gary, M.S.P.H., Kit Simpson, Dr.PH, Vicki Young,
Ph.D., R.Ph., Pamela Mazyck, Pharm.D.
Presented by: Helen Gary, MSPH, Research Analyst, College
of Pharmacy, Medical University of South Carolina, 280
Calhoun Street, PO Box 250144, Charleston, SC 29425; Tel:
843.876.1057; Fax: 843.792.1712; E-mail: garyh@musc.edu
Research Objective: Patients age 65 years and older are
typically classified as "senior" or ageing for purposes of
applying treatment guidelines or assessing health outcomes.
However, there is a difference in disease risk and death by age
and race, with African Americans more likely to experience
age-related conditions at earlier ages. The purpose of this
study is to identify the age at which the burden of morbidity
and mortality of diseases and conditions related to ageing is
the same for African American patients at the risk observed for
Caucasian patients age 65 years.
Study Design: We use retrospective analysis of Allostatic load
(AL) based on data from the National Health and Nutritional
Examination Survey (NHANES) 1999-2000. AL is an index of
physiologic burden, constructed from 12 laboratory test and
physical examination results: systolic and diastolic blood
pressure, HgA1C, BMI, triglycerides, HDL and total
cholesterol, albumin, C-reactive protein, fibrinogen, creatinine
clearance, and homocysteine. Others have reported a clear
increase in AL by age with AL levels reaching a plateau at age
65.
Population Studied: We studied African American and
Caucasian adult particpants from NHANES 1999-2000.
Principal Findings: We found a statistically significant
difference in the rate of increase in AL for African American
(compared to Caucasian respondents) respondents that
appear to begin at age 48-49 years. Average burden of illness
measured by AL differs for African American and Caucasian
respondents. The expected AL for a Caucasian respondent age
65 years is similar to that of an African American respondents
age 51 years.
Conclusions: This finding has serious implications for how
"aged" is defined for ageing research for minority populations.
Implications for Policy, Delivery or Practice: The
implications involve the impact age cutoff criteria may have on
the appropriate application of treatment guidelines or
assessments of health outcomes. If there are large systematic
differences in the prevalence of the pre-clinical phases of agerelated conditions between white and black patients, providers
can adapt treatment guidelines to reflect these differences.
Primary Funding Source: NIA, AHRQ
• Modeling Exposure, Reliability and Recovery in Complex
Clinical Settings
Marlene Goldman, Sc.D., Meghan Dierks, M.D., Benjamin
Sachs, MBBS, Ronald Marcus, M.D., Patricia McNamee, R.N.,
M.S.N., Luke Sato, M.D.
Presented by: Marlene Goldman, ScD, Associate Professor,
Obstetrics & Gynecology, Beth Israel Deaconess Medical
Center, 330 Brookline Avenue Kirstein 332, Boston, MA 02130;
Tel: 617.667.2933; Fax: 617.667.2924; E-mail:
mgoldman@bidmc.harvard.edu
Research Objective: Obstetrics is a high-risk environment in
which decisions are made quickly and coordinated between
obstetricians, neonatologists and anesthesia staff. Modeling
risk is extraordinarily difficult because conventional models do
not account for the complex interactions and
interdependencies between components (staff,
instrumentation, protocols, procedures, information,
communication, and scheduling cycles) that can significantly
influence provider performance and patient safety.
Study Design: In this poster we demonstrate a risk
assessment methodology to identify and evaluate the impact
of complex interactions between system factors that
contribute to variations in the process of obstetric care and
expose mother and child to risk of injury. Adaptations of
established probabilistic risk assessment (PRA)
methodologies from the nuclear engineering and industrial
domains for application in the medical domain are presented.
The strength of this methodology is the ability to capture
baseline frequencies of exposure and account for uncertainty.
Population Studied: Data to populate the model are derived
from prospective observation of 100 women in active labor,
enabling detailed capture of compound and delayed effects
and important recovery strategies that return the system to
normal function, data that are not accessible through
retrospective reviews or post-event self-reporting.
Principal Findings: The analytic phase of PRA includes
qualitative modeling of relationships, interactions, and critical
inter-dependencies between identified system factors and
quantitative estimates of risk, reliability, and likelihood of
recovery as a function of various system configurations.
Conclusions: Using the high risk setting of labor and delivery,
we will demonstrate real-world application of the PRA
technique and outline future use of mature models with
Monte Carlo simulation to identify the dominant contributors
to risk and forecast the effects of specific interventions, system
redesigns, and risk reduction strategies.
Implications for Policy, Delivery or Practice: The ultimate
goal is to use the validated model and simulated results to
plan candidate solutions and establish priorities for safety
interventions and procedures that can be implemented.
Primary Funding Source: AHRQ
• Examining Pathology Errors to Improve Patient Safety:
Pathologists Don’t Agree on the Identification of Errors
Due to Pathologist Misinterpretation
Stephen Raab, M.D., Dana Grzybicki, M.D., Ph.D., Janine
Janosky, Ph.D.
Presented by: Dana Grzybicki, M.D., Ph.D., Assistant
Professor, Pathology, University of Pittsburgh School of
Medicine, UPMC Cancer Pavilion 3rd Floor, 5230 Centre
Avenue, Pittsburgh, PA 15232; Tel: 412.623.7862; Fax:
412.523.4785; E-mail: grzybickidm@msx.upmc.edu
Research Objective: A multi-institutional study involving the
voluntary identification, reporting, and analysis of anatomic
pathology diagnostic errors detected by cytologic-histologic
correlation recently was begun (September 2002) in order to
obtain currently unavailable information about these errors
and their clinical significance. In order to gain insight into the
degree to which pathologist inter-observer variability in
identification of diagnostic errors may impact the reporting of
errors, a measurement of pathologist inter-observer variability
was performed. Pathologist inter-observer agreement for the
identification of the two major types of diagnostic errors
detected by cytologic-histologic correlation (categorized
dichotomously as either inadequate sampling of the lesion or
interpretation error by the pathologist) was measured using
the kappa statistic.
Study Design: A sample of 40 patient cases involved in a
cytologic-histologic diagnostic error (10 from each of the
participating study sites) was used. Five cases from each site
involved gynecologic specimens (Pap test cytology and
cervical biopsy specimens), and five cases involved nongynecologic specimens (bronchial wash cytology and lung
biopsy specimens). Observer identification of the major type
of error (sampling versus interpretation) involved in each case
were recorded and analyzed. Pair-wise kappa statistics were
calculated for each different pair of observers, and intra-site
agreement with the error identifications performed originally
at each site was also measured.
Population Studied: Each group of ten cases was examined
sequentially in a blinded fashion by a single pathologist at
each site who regularly performs correlations in accordance
with current, federally mandated laboratory quality assurance
requirements.
Principal Findings: Agreement between pathologists for the
major type of diagnostic error involved for this sample was
highly variable and poor, ranging from 0.80 to 0.02. No
patterns in levels of agreement were seen based on pairs of
pathologists or case site. The level of intra-site agreement also
was highly variable and poor, ranging from 0.62 to 0.21.
Conclusions: There is poor agreement not only between
pathologists at different laboratories but also between
pathologists at the same laboratory about whether individual
cytologic-histologic correlation errors involve pathologist
misinterpretation or sub-optimal specimen procurement by
clinician providers. This lack of agreement impacts how
diagnostic errors are reported for quality improvement
purposes and confounds the ability to perform inter- and
intra-institutional comparisons of error rates. Diagnostic
errors attributed to inadequacy of specimens (sampling)
essentially relegates the potential systems flaws causing the
errors to the non-laboratory realm, implying not only that
pathologist and laboratory process improvements are
irrelevant for efforts to decrease these errors but also that
opportunities do not exist for pathologist and laboratory
improvements impacting these errors. Thus, pathologist lack
of agreement also significantly confounds decision-making
regarding efforts for improvement in patient safety through
diagnostic error reduction.
Implications for Policy, Delivery or Practice: Further study
of pathologist assessment of diagnostic errors is needed.
Efforts also are needed to increase agreement among
pathologists regarding diagnostic errors in order to provide
valid error data to use for quality improvement and patient
safety efforts.
Primary Funding Source: AHRQ
• In-hospital Mortality and Beta Blocker Use among
Patients Diagnosed with ST Elevated Acute Myocardial
Infarction
Benjamin Gutierrez, Ph.D., Steven Culler, Ph.D., Chris Craver,
M.A., Steve Stemkowski, M.H.A.
Presented by: Benjamin Gutierrez, Ph.D., Senior Director,
Analytics & Research, Premier, Inc, 2320 Cascade Point
Boulevard, Charlotte, NC 28208; Tel: 704.733.5447; Fax:
704.733.4666; E-mail: ben_gutierrez@premierinc.com
Research Objective: National guidelines, including the
ACC/AHA guideline for managing acute myocardial infarction
(AMI) recommend the use of beta blockers within 12 hours of
onset of infarction. In addition, the use of beta blockers for
hospitalized AMI patients has been adopted as a hospital
quality indicator. Given the clear recommendations for the use
of beta blockers in this population, this study investigates
whether this relationship exists among all AMI patients and in
various subgroups and also describes the variation in beta
blocker use across hospitals.
Study Design: A retrospective analysis was conducted using
Premier’s Perspective database, an administrative dataset that
includes detailed billing information on drug utilization.
Procedures performed and risk factors were identified using
ICD-9 codes. Drug treatment was identified from detailed
billing codes. The chi-square statistic was used to test
unadjusted differences in mortality rates. Logistic regression
analysis was used to control for mortality risk factors.
Population Studied: The study sample consists of 74,973
patients ages 18 and older with a principal diagnosis of AMI
from 284 acute care hospitals that treated at least 50 AMI
patients between January 1, 2002 and December 31, 2002.
The study sample excluded any patients transferred in from
another acute care hospital. The AMI population was stratified
into four groups: Revascularization only, Revascularization
and Thrombolytics, Thrombolytics only and No
Revascularization or Thrombolytics.
Principal Findings: Overall, 58.8 percent were male, average
age was 68?14; and 82.7 percent received beta-blocker
medication during their hospitalization. This study found that
the use of beta blockers among hospitalized patients with
principal diagnosis of AMI was associated with a lower rate of
mortality (5.8% vs 24.6%). The AMI sample was stratified into
four groups based on type of inpatient treatment and for each
group beta blocker use was associated with lower mortality:
Revascularization only (2.6% vs 10.9%, p<0.01),
Revascularization and Thrombolytics (4.0% vs 17.5%, p<0.01),
Thrombolytics only (13.1% vs 41.6%, p<0.01), No
Revascularization nor Thrombolytics (9.3% vs 30.8%, p<0.01),
We also adjusted for age, gender and other risk factors and
found that beta blockers were still significantly associated with
lower mortality in all AMI groups (p<0.01).
Conclusions: This study is further evidence that beta blocker
use is associated wiht lower mortality for patients hospitalized
for acute myocardial infarction. The mortality benefit exists
regardless of the type of treatment received by the patient. In
addition, we found wide variation in the beta blocker use. Only
10% of the hospitals had a beta blocker rate greater than 90%.
Implications for Policy, Delivery or Practice: This study is
further evidence of the relationship between a hospital quality
indicator and a short term outcome, in-hospital mortality.
Educational and disease management programs as well as
innovative pay for quality programs should all promote the
use of beta blocker in this population.
• Further Validation of AHRQ’s Patient Safety Indicators
Benjamin Gutierrez, Ph.D., Chris Craver, M.A., Michael Vitti,
M.S., Stephen Stemkowski, M.H.A.
Presented by: Benjamin Gutierrez, Ph.D., Senior Director,
Analytics & Research, Premier, Inc., 2320 Cascade Point
Boulevard, Charlotte, NC 28208; Tel: 704.733.5447; Fax:
704.733.4666; E-mail: ben_gutierrez@premierinc.com
Research Objective: Recently, the Agency for Health Care
Research and Quality (AHRQ) released a set of patient safety
indicators (PSI). This study estimates the incidence of
potential safety-related events by applying the PSI definitions
to a large inpatient database.
Study Design: The study will compare PSI rates from the
Perspective database to published rates based on the 2000
Healthcare Cost and Utilization Project (HCUP) National
INpatient Sample (NIS).
Population Studied: The study sample consisted of 4,982,535
patients from 429 acute care hospitals with discharge dates
between January 1, 2002 and December 31, 2002 from
Premier’s Perspective database.
Principal Findings: In general, we found that the PSI rates for
the Perspective database were higher than rates from NIS.
For example, postoperative respiratory failure (0.63% vs
0.40%)and postoperative physiologic and metabolic
derangement (0.19% vs 0.09%) were substantially higher.
Failure to rescue was the only PSI to have a lower rate in the
Perspective database than in the NIS (12.84% vs 17.42%).
Conclusions: Although the PSI rates were in general higher
than the rates from HCUP, they were not much higher except
for two indicators. We plan to stratify the incidence rates by
age, gender, race and hospital characteristics.
Implications for Policy, Delivery or Practice: In general, the
PSIs appear to get consistent rates among multiple datasets.
Hospitals should test out the PSIs in their institution so they
can reliably track preventable patient safety events.
• Managed Care Patient Protection or Provider Protection?
A Qualitative Assessment
Mark Hall, J.D.
Presented by: Mark Hall, J.D., Professor, Public Health
Sciences, Wake Forest University, Medical Center Blvd.,
Winston-Salem, NC 27157-1063; Tel: 336.716.9807; Fax:
336.716.7554; E-mail: mhall@wfubmc.edu
Research Objective: Opponents of managed care regulation
allege that patient bills of rights, in reality, are provider
protections motivated by the desire to beat back the economic
onslaught of managed care. This claim is assessed through a
large qualitative study of state managed care patient
protection laws.
Study Design: State laws were reviewed and categorized, and
regulators in each state were surveyed, to determine the
pattern and content of relevant enactments as of the end of
2001. Then, in 2002, six states were selected for in-depth case
studies to reflect a range of market, demographic, and legal
characteristics. In each state, 16-24 key informants were
interviewed, including provider advocates, physician practices,
health plan managers, regulators, patient advocates, and
various industry observers. Additional interviews were
conducted from a national perspective, for a total of 138
interviews. Interviews were semi-structured, and interview
notes were analyzed using standard qualitative techniques.
Principal Findings: These laws are directed primarily to
patients’ rights and only secondarily to providers’ interests.
Enactment of these laws was rarely attributed primarily to
provider advocacy. Instead, providers aligned with
consumers, or the impetus came from legislators or
regulators. There is little evidence that, collectively or
individually, these laws have had much impact on providers’
economic concerns. Health plans are still free to form and
shape networks as they see fit, subject to competitive
constraints. Provider due process laws might suppress
deselection to some extent, but most subjects thought these
laws only marginally restrain health insurers from removing
providers they no longer want.
Conclusions: Managed care patient protection laws do not
advance a self-interested provider agenda that disables
features of managed care beneficial to consumers. Instead,
these laws appear to embody a convenient alignment of
interests among providers, patients, and lawmakers.
Primary Funding Source: RWJF
• The “Death” of Managed Care: A Regulatory Autopsy
Mark Hall, J.D.
Presented by: Mark Hall, J.D., Professor, Department of
Public Health Sciences, Wake Forest University, Medical
Center Blvd., Winston-Salem, NC 27157-1063; Tel:
336.716.9807; Fax: 336.716.7554; E-mail: mhall@wfubmc.edu
Research Objective: On the heels of widespread patient
protection legislation in the states, the managed care industry
abandoned or greatly scale back the core elements of
gatekeeping, utilization management, and financial incentives,
which are the very targets of this legislation. This article
explores whether, and to what extent, the industry’s abrupt
change in course can be attributed to these laws.
Study Design: Six states were selected for in-depth case
studies to reflect a range of market, demographic, and legal
characteristics. In addition, a focus group was conducted
with nine experienced health care lawyers from across the
country, and eight interviews were conducted at the home
offices of four of the largest national health plans. The total of
122 interviews with 179 interview and focus group subjects
consisted of: 57 people with 29 health plans or insurance
industry groups, 26 providers, 12 patient advocates, 11
insurance agents, 32 human resource managers or employer
representatives, 22 regulators (in 9 interviews), and 19 other
market participants or observers (including health care lawyers
and industry analysts).
Principal Findings: These laws were not the primary driver of
changes in managed care practices. However, patient
protection laws interacted with other social and market forces,
through complex forms of feedback and reinforcement, to
bring about more thoroughgoing change than would have
otherwise occurred.
Conclusions: Patient protection laws have had some role in
health plans loosening the reins of tightly managed care, but
only time will tell whether patients and consumers are able to
take up some of the slack by deciding themselves which
treatment options are best and when they are worth the cost.
Primary Funding Source: RWJF
• Systemic Barriers To Employment Services For Persons
with Mental Illnesses
Patricia Hanrahan, Ph.D, M.A., M.Ed., Amy Cooper, M.A.,
William Heiser, B.A., Gene Oulvey, Ph.D., Daniel Luchins,
M.D.
Presented by: Patricia Hanrahan, Ph.D, M.A., M.Ed., Research
Associate (Associate Professor), Psychiatry, University of
Chicago, 5841 South Maryland Avenue, MC3077, Chicago, IL
60637; Tel: 773.702.9697; E-mail:
phanrahan@yoda.bsd.uchicago.edu
Research Objective: To assess the success of inter-agency
collaboration between the Illinois Division of Rehabilitation
Services and the Illinois Division of Mental Health in aiding
persons with mental illnesses to become employed.
Study Design: Cross sectional survey of Illinois state agencies
and community-based organizations involved in providing
employment services to persons with mental illnesses.
Population Studied: In 2003, this mailed survey was sent to
all psychiatric specialist staff from the Illinois Division of
Rehabilitation Services (DRS) and all vocational specialist staff
under contract to the Illinois Division of Mental Health
(DMH).
Principal Findings: The response rate from DRS staff was
fairly high at 70% and moderate from DMH contractual staff
at 43%. Annually, each staff under contract to DMH referred
an average of 15 persons with mental illnesses to DRS for
employment services. DRS staff accepted only 31.5% of these
referrals, however, and only succeeded in finding work for
6.5%. This rate is far lower than that achieved in national
demonstration programs. DRS staff attributed the problem to
employer attitudes and stigma in the workplace, despite
contrary research findings on attaining competitive
employment.
Conclusions: From 60 to 70% of people with mental illnesses
would like to work and evidence-based supported employment
can place over half of this group in competitive employment
(Bond et al., 2001). Yet there were relatively few referrals for
employment services from staff under contract to the Illinois
Division of Mental Health, about fifteen per year per staff.
Further, staff from the Division of Rehabilitation Services
helped an extremely small fraction of these individuals to
attain employment (7%).
Implications for Policy, Delivery or Practice: There is an
urgent need to bridge the gap between current practices in
Illinois and research on the effective provision of supported
employment. Inter-agency collaborations have failed to help
persons with mental illnesses to find work. Evidence from
controlled studies suggests that success is likelier when
supported employment staff is closely integrated with the
mental health treatment team (Cook, 2003, Bond et al., 2001).
A possible solution would be for DRS and DMH to jointly fund
agencies that provide both mental health and employment
services rather than relying on the failed model of inter-agency
linkage agreements.
Primary Funding Source: Illinois Division of Mental Health
• Veteran Identity and Health Services Use among Native
American Veterans
Nancy Harada, Ph.D., Valentine Villa, Ph.D., Nancy Reifel,
DDS, M.P.H., Ruth Bayhylle, MLIS
Presented by: Nancy Harada, Ph.D., Associate Director of
Evaluation, Geriatric Research, Education, and Clinical Center,
VA Greater Los Angeles Healthcare System, 11301 Wilshire
Boulevard, Los Angeles, CA 90073; Tel: 310.268.4294; Fax:
310.268.4052; E-mail: nharada@ucla.edu
Research Objective: (1) To describe the military experience of
Native American veterans, and (2) to explore how a variety of
factors related to veteran identity, such as combat exposure
and war period, influences their decisions regarding VA health
services use.
Study Design: Nine focus groups were conducted with Native
Americans veterans. Participants also completed a brief
questionnaire asking about demographic characteristics,
health status, and health services use.
Population Studied: 89 Native American veterans ranging in
age from 32 to 87 years.
Principal Findings: Despite negative experiences during their
military service, the majority of Native American veterans
shared a positive veteran identity and expressed a sense of
pride about their military experience. There were some
differences between war periods, with Vietnam veterans
expressing less pride than veterans of other wars. Almost
46% of participants reported having a service-related illness or
injury. Almost one-third (28.2%) used the Indian Health
Service (IHS) exclusively for their healthcare, followed by those
who used both IHS and VA services (23.5%), followed by VAOnly Users (21.2%).
Conclusions: Native American veterans highly identify with
their military service, but many of them turn to IHS for their
medical care.
Implications for Policy, Delivery or Practice: Our data
support the current VA policy of strengthening coordination
with IHS to ensure that the medical needs of Native American
veterans are addressed.
Primary Funding Source: VA
• Five-Year Snapshots of IMG Presence in the US, 1981
through 2001
L. Gary Hart, Ph.D., Amy Hagopian, Ph.D., Meredith Fordyce,
PhC, Karin Johnson, Ph.D.
Presented by: L. Gary Hart, Ph.D., Professor, Family
Medicine, University of Washington, Box 354982, Seattle, WA
98195-4982; Tel: 206.685.0402; Fax: 206.616.4990; E-mail:
hagopian@u.washington.edu
Research Objective: Profile the role of international medical
graduate (IMG) physicians in the U.S. over the last 20 years
with regard to specialty, geography, demographics, trends and
changes.
Study Design: We're using AMA masterfile data from the
years 1981, 1986, 1991, 1996, and 2001 to do both snapshots
and longitudinal analyses of physicians trained abroad.
Population Studied: All physicians trained outside of the
U.S. (but not including Canada, by convention) and licensed
to practice medicine in the U.S. now.
Principal Findings: The portion of IMGs who are in generalist
practices has grown from 34% in 1981 to 52% in 2001 and
they have generally grown older and a larger portion are
female. About 70% of IMGs practice in the same 10 states
that have always had more IMGs. The origin countries have
changed over time, although there are still a relatively small
number of world medical schools that contribute large
numbers of IMGs to the U.S.
Conclusions: The number of IMGs in the U.S. has grown
significantly, although the proportion of total physicians
remains about about 1 in 4. While they come from virtually
every country in the world, and their profiles have changed
somewhat over time, there are still some sending countries
that remain signficant sources of IMGs (India, Pakistan,
Philippines). The role of Caribbean graduates has increased
over time, as well, although these are thought to be mostly
U.S. citizens.
Implications for Policy, Delivery or Practice: The U.S.
continues to rely heavily on IMGs for our physician workforce,
and recent policy signals from Congress and the
Administration indicate that this reliance will continue for
some time. In the absence of a policy that allows for
increasing the numbers of students who can be trained at
U.S. medical schools, it will be important to continue to
monitor and understand the workforce that we import from
abroad. Various U.S. health workforce organizations with
interests in policy have advocated for a decrease in IMGs
(COGME, AAMC, others), but this change has not occurred.
Primary Funding Source: HRSA
• The Meaning of Interruptions between Physicians and
Patients: Effects on the Physician-Patient Relationship
Kelly Haskard, B.A., Robin DiMatteo, Ph.D., John Heritage,
Ph.D.
Presented by: Kelly Haskard, B.A., Graduate Student,
Department of Psychology, University of California, Riverside,
900 University Avenue, Riverside, CA 92521; Tel:
949.887.0520; E-mail: kelly_haskard@hotmail.com
Research Objective: Within the context of primary care
physician-patient interactions, much research has
documented the effect of physician behavior (both verbal and
nonverbal) on the patient’s “telling of their story” in the
medical encounter. Interruptions (of the patient by the
physician, and of the physician by the patient) are of particular
interest because of their potential for influencing both affect
and meaning in the encounter. Both in the opening and
discussion of the patient’s presenting concern, as well as
throughout the entire interaction, interruptions have
demonstrable effects on communication effectiveness. This
study explores aspects of interruptions and simultaneous
speech (including intentionality, control or dominance, and
success at “grabbing the floor”) in the context of primary care
interactions. The relationship with physician and patient
affective nonverbal behaviors is examined. Research questions
of interest include the following: 1) Do interruptions in the
opening segment predict later interruptions? 2) Are patients
more likely to be interrupted when they introduce psychosocial
compared with biomedical topics? 3) Are certain nonverbal
behaviors related to the likelihood of being interrupted? 4) Are
interruptions more frequently accidental/unintentional rather
than intentional? 5) Does the occurrence of physician
interruption correlate with negative physician nonverbal
behaviors?
Study Design: Cross-sectional, correlational study. Using the
first five minutes of videotaped primary care physician-patient
interactions, interruptions and associated characteristics were
rated and coded by three individuals using a coding scheme
developed for this study based on the work of several past
researchers. Nine additional raters completed ratings of
various qualities of communication behavior (passive vs.
active, warm vs. cold, engaged vs. unengaged, etc.) in the
following channels of communication: video with no sound,
full length audio, and content-filtered audio.
Population Studied: As part of a larger study, ninety primary
care patient visit videotapes and audiotapes were obtained
from 20 medical office sites in the Western U.S. Represented
are 54 male and 36 female physicians, and 38 male and 52
female patients.
Principal Findings: Correlations were found between certain
negative physician behaviors and rates of interruptions
including the following: closed-ended questions, interruption
in the problem solicitation, discussion of psychosocial
information, and success at taking the floor from the patient.
More positive physician nonverbal behaviors were associated
with use of open-ended questions, lower rates of
interruptions, and higher rates of overlapping or accidental
simultaneous speech. Patients nonverbally rated as more
anxious were more likely to be interrupted and after less time
speaking. More dominant patients were less likely to be
interrupted and to lose the floor in speaking. Certain patient
characteristics were also associated with higher rates of
patient interruptions of the physician.
Conclusions: The meaning of verbal interruptions has been
extensively investigated in past research. This study uses
correlations with nonverbal behaviors to achieve a more
complete understanding of what interruptions mean and the
degree to which they are intentional, and serve as a means of
exerting dominance or control, or instead result from
participant enthusiasm and engagement. The consequences
of these interruptions for interpersonal interaction in the
physician-patient relationship are several.
Implications for Policy, Delivery or Practice: This study
addresses issues of patient-centered care, active listening of
physicians to their patients, and the importance of attention to
nonverbal cues. Implications include the centrality of effective
communication to both physicians and patients in the medical
encounter and the relationship of interruptions to other
aspects of verbal and nonverbal behaviors. Implications for
physician education are many.
Primary Funding Source: AHRQ
• The Benefits of Transfer Guidelines for Pediatric Trauma
in Pennsylvania
Christopher Hollenbeak, Ph.D., Jennifer Findeis-Hosey, B.S.,
Robert Cilley, M.D., Stanley Kurek, D.O., Andreas Meier, M.D.,
Peter Dillon, M.D., M.S.
Presented by: Christopher Hollenbeak, Ph.D., Assistant
Professor, Surgery and Health Evaluation Sciences, Penn State
College of Medicine, 500 University Drive, H113, Hershey, PA
17033; Tel: 717.531.5890; Fax: 717.531.4185; E-mail:
chollenbeak@psu.edu
Research Objective: Pediatric trauma systems are designed
to enhance the timely transfer of seriously injured children to
tertiary trauma centers with expertise in pediatric care.
However, because of the large number of injured children and
the geographic rarity of specialized centers, injured children
are treated in a variety of settings. The purpose of this
research was to model formal guidelines for transferring
pediatric patients between trauma centers and predict
potential reductions in overall mortality in a statewide system.
Study Design: Mortality was modeled using logistic
regression, stratified by type of trauma center (level II adult,
level I adult, and pediatric trauma centers). Estimated
coefficients were used to model the mortality that could be
expected under hypothetical guidelines that would have
transferred patients to a pediatric trauma center.
Population Studied: Using data from the Pennsylvania
Trauma Outcome Study (PTOS), we studied 24,172 pediatric
trauma patients admitted to registered trauma centers in
Pennsylvania between 1996 and 2002.
Principal Findings: The mortality rate across all centers
during this time period was 4.0%. The actual mortality rate
for pediatric patients was 3.0%, 8.2% and 4.4% at pediatric,
level I and level II trauma centers, respectively. The model
predicted that overall mortality would have remained at 4.0%
if all patients age <1 had been treated at a pediatric trauma
center. However, the model predicted a drop in the overall
mortality rate from 4.0% to 3.8% if all patients age <1 or with
a penetrating injury had been transferred. The model
predicted drop from 968 deaths to 876 deaths, or a further
drop in overall mortality to 3.6%, had patients with an injury
severity score > 14 been treated at a pediatric trauma center.
Conclusions: This study suggests that guidelines mandating
the transfer to a pediatric trauma center of pediatric trauma
patients less than 1 year of age, with penetrating injuries, and
with ISS scores > 14 would have saved the lives of 92 children
in Pennsylvania between 1996 and 2002.
Implications for Policy, Delivery or Practice: Outcomes for
pediatric trauma are likely to be enhanced if statewide trauma
systems would mandate the transfer of certain severely injured
children to pediatric trauma centers.
• Processes Contributing to Failure to Rescue in Acute
Care Hospitals
Linda Hughes, Ph.D., R.N., Barbara Mark, Ph.D., R.N., FAAN
Presented by: Linda Hughes, Ph.D., R.N., Research Associate
Professor, School of Nursing, University of North Carolina at
Chapel Hill, Carrington Hall, CB # 7460, Chapel Hill, NC
27599; Tel: 919.960.5167; Fax: 919.843.3168; E-mail:
lchughes@email.unc.edu
Research Objective: Failure to rescue, defined as death
following the occurrence of an adverse event during
hospitalization, has been identified as a nurse sensitive
outcome. Studies have documented lower failure to rescue
rates in hospitals with low nurse-patient ratios. This finding
has been attributed to an inability to provide close patient
surveillance when staffing is inadequate. However, failure to
rescue also occurs when staffing is adequate, suggesting the
need to explicate the underlying processes that contribute to
the occurrence of this outcome. The purpose of this study was
to describe nurse-identified processes contributing to failure
to rescue in acute care hospitals.
Study Design: The descriptive mode of qualitative inquiry
with application of the critical incident technique was used.
Individual interviews were conducted with experienced critical
care nurses who described actual or impending failure to
rescue situations encountered in their work setting. Situations
were limited to those where a delay occurred in responding to
a clinical event in which action was warranted due to changes
in the patient’ s status.
Population Studied: The sample included 13 critical care
nurses with at least one year of experience as a registered
nurse, employed at least 20 hours each week in direct patient
care, and assigned to their current unit a minimum of six
months.
Principal Findings: Processes contributing to failure to rescue
included failure to notify the physician, failure to obtain an
appropriate physician response, and failure to initiate
immediate action as indicated by the situation. Failure to
notify the physician resulted from failures of surveillance or a
failure to intensify patient monitoring as indicated by the
clinical situation and failures of interpretation or a failure to
recognize and interpret relevant clinical cues. Failure to obtain
an appropriate physician response occurred when the nurse
was unsuccessful in communicating the seriousness of the
patient situation during telephone contact with a physician.
Finally, all participants described patient events when a
physician was not readily available but immediate action was
warranted. Even in situations where these nurses knew with
complete certainty the immediate action that was needed, they
were subject to policies and regulations that constrained them
from acting without physician authorization.
Conclusions: Failure to rescue can occur even when close
patient surveillance has been provided and clinical cues have
been appropriately interpreted. These findings suggest that
effective nurse-physician communication and a dynamic
approach to decision making in organizations, characterized
by situational flexibility in the authority to act, may be
instrumental in minimizing failure to rescue in acute care
hospitals.
Implications for Policy, Delivery or Practice: Explicating the
underlying processes that lead to failure to rescue is essential
to the development of targeted interventions and managerial
strategies designed to minimization this outcome. Such
interventions must focus on factors that facilitate the ability of
the nurse to appropriately monitor patients and interpret
clinical cues, but also must address organizational constraints
that restrict nurses from responding in a timely fashion to
adverse patient events.
Primary Funding Source: National Institute for Nursing
Research
• Burnout and Work Environments of Public Health
Nurses Involved in Mental Health Care
Hirohisa Imai, M.D., Hiroyuki Nakao, Ph.D., Masaki Tsuchiya,
M.D., Yoshiki Kuroda, M.D., Takahiko Katoh, M.D.
Presented by: Hirohisa Imai, M.D., assistant professor, public
health, Miyazaki Medical College, 5200 Kihara, Kiyotake,
Miyazaki, 889-1692; Tel: 81.985.85.0874; Fax: +81.985.85.6258;
E-mail: hiroimai@post.miyazaki-med.ac.jp
Research Objective: This study examined whether prevalence
of burnout is higher among community psychiatric nurses
working under recently introduced job-specific work systems
than among public health nurses (PHNs) engaged in other
public health services. Work environment factors potentially
contributing to burnout were also identified.
Study Design: Two groups were examined. The Psychiatric
group comprised 525 PHNs primarily engaged in public
mental health services at public health centers (PHCs) that
had adopted the job-specific work system. The Control group
comprised 525 PHNs primarily engaged in other health
services. Pines' Burnout Scale was used to measure burnout.
Respondents were classified by burnout score into three
groups: A (mentally stable, no burnout); B (positive signs, risk
of burnout); and C (burnout present, action required). Groups
B and C were considered representative of “burn-out”. A
questionnaire was also prepared to investigate systems for
supporting PHNs working at PHCs, and to define emergency
mental health service factors contributing to burnout.
Population Studied: A total of 448 PHCs are operated by
prefectures in Japan. Of these, 356 have adopted job-specific
work systems. Community psychiatric nurses working at 329
PHCs were requested to participate in this survey. A total of
133 PHCs had only one PHN engaged in public mental health
services. For these institutions, that PHN was selected to
participate in the present study. The remaining 196 PHCs had
two or more PHNs engaged in public mental health services.
Under these circumstances, two PHNs were randomly
selected as participants. A total of 525 PHNs primarily
engaged in public mental health services were therefore
selected, forming the Psychiatric group. The Control group
comprised 525 PHNs (1-2 nurses selected at random from
each of the 327 stations) from the same PHCs.
Principal Findings: Final respondents comprised 785 PHNs.
Prevalence of burnout was significantly higher in the
Psychiatric group (59.2%) than in the Control group (51.5%).
Responses indicating lack of job control and increased annual
frequency of emergency overtime services were significantly
correlated with prevalence of burnout in the Psychiatric group,
but not in the Control group.
Conclusions: Prevalence of burnout is significantly higher for
community psychiatric nurses than for PHNs engaged in
other services. Overwork in emergency services and lack of job
control appear to represent work environment factors
contributing to burnout.
Implications for Policy, Delivery or Practice: Recently, the
government has devised a new plan that emphasizes
facilitating discharge from hospital and resumption of social
activity for about 72,000 patients who can be discharged if
some conditions are satisfied, from among the about 330,000
patients currently hospitalised in psychiatric facilities. To
enable these patients to be discharged from hospital, a system
must be established that can not only accept discharged
patients, but also cope with the emergency care needs of
discharged patients. PHNs will undoubtedly play central roles
in any such system. Improvements in work environment are
therefore a matter of urgency. If current environments remain
unimproved, even more serious problems of burnout among
community psychiatric nurses will result, compromising the
well-being of nurses and patients alike.
Primary Funding Source: Japan Public Health Association
• An Examination of the Tendinosis/Tendinitis Paradigm in
Recent Literature
Daniel Immekus, SPT, Trish Hutchinson, EdD FACSM
Presented by: Daniel Immekus, SPT, Graduating Student
Physical Therapist, Department of Physical Therapy, Angelo
State University, 2601 West Avenue N (PO Box 10923, ASU
Station), San Angelo, TX 76909; Tel: 325.942.2545,
325.944.8834; E-mail: dimmekus@uwalumni.com
Research Objective: The purpose of this review of literature
from 1993 to 2003 was to examine current views on diagnosis
and histological changes associated with tendon overuse
injury, and the tendinosis/tendinitis paradigm.
Study Design: Literary searches of the MEDLINE, CINAHL,
British Journal of Medicine, American Journal of Sports
Medicine, and Sports Medicine databases were performed
using the keywords: tendinitis, tendinosis, tendonopathy,
overuse, repetitive motion, diagnosis, histological samples.
Population Studied: Studies meeting inclusion criteria were
clinical trials that examined histological samples or imaging
techniques able to distinguish inflammatory condition from
degenerative condition in tendons.
Principal Findings: Of 255 articles found, 34 met inclusion
criteria. The majority of studies (25 of 34) confirmed evidence
of tendon degeneration. Histological changes found included
hypervascularization, evidence of tenocyte death and
fibroblast activity, collagen derangement and chemical
evidence of degeneration in overused, injured tendons. Four
studies found evidence of a true tendinitis condition, though
within tendon-bone interfaces only with concurrent calcium
deposits. Five studies found evidence of a parateninitis
condition (inflammatory process in the paratendon sheath), 6
studies described a tendinosis condition but used the term
tendinitis. Two studies found evidence of bursitis, and one
study found evidence of stress fractures. Of the 34 included
studies, 9 studies found combinations of the above
pathological processes.
Conclusions: There is apparent a shift in the literature,
showing a greater recognition of the degenerative tendon
condition of tendinosis as the more likely process occurring
with overuse, repetitive motion injury, rather than tendonitis.
Parateninitis is also a commonly occurring condition when
tendons are subjected to a repetitive, overuse injury.
Tendinitis, or inflammation of tendon tissue, in its purest
sense, is now thought to be a very rarely occurring condition.
Implications for Policy, Delivery or Practice: It is necessary
to perform studies to determine the treatment of tendon
disorders in the clinical environment; to survey what approach
or philosophy clinicians currently adopt when encountering
overuse tendon injury.
It is also necessary to further study, treatments that can
address reversal of the degenerative process of tendinosis.
Primary Funding Source: Combination of student and
university funding
• Relationships among HMO Penetration, Financial
Pressure, and Academic Health Center Hospital
Performance
Marian Jamison, Ph.D., M.B.A.
Presented by: Marian Jamison, Ph.D., MBA, Associate
Professor, School of Nursing, Graceland University, 1401 W
Truman Road, Independence, MO 64050; Tel: 816.833.0524;
Fax: 816.833.2990; E-mail: jamison@graceland.edu
Research Objective: With the growth of managed care in the
mid 1990s, academic health center (AHC) hospitals began to
implement changes in their structure, culture, and business
practices. Little systematic study has been done on how AHC
hospitals responded to the changing economic environment.
The purpose of the study was to examine the relationships
among HMO penetration, financial pressure, and changes in
AHC hospital performance over the period from 1995 to 1997.
A specific objective was to determine the role of financial
pressure in the relationships between HMO penetration and
changes in the following dimensions of AHC hospital
performance: revenues, expenses, patient mix, and input use.
The period from 1995 to 1997 was chosen because it
represents a time when enrollments in HMOs were
continuing to grow and the reimbursement cuts called for in
the Balanced Budget Act of 1997 had not yet materialized.
Study Design: A correlational, retrospective designed was
used. Data sources included the Center for Medicare and
Medicaid Services Minimum Cost Data Tapes, and Interstudy
Publications.
Population Studied: The study includes 112 integrated AHC
hospitals. The AHC hospitals were identified in January 1997
as integrated by the Association of American Medical
Colleges’ Council on Teaching Hospitals and Health Systems.
Principal Findings: Financial pressure was found to exert a
moderating function in the relationships between HMO
penetration and changes in total inpatient discharges, total
operating expenses (in public AHC hospitals only), Medicare
inpatient discharges (in private AHC hospital only), total
patient discharges, available facility beds, and full-time
employees. After controlling for hospital competition, changes
in AHC hospital performance were modeled as a function of
hospital ownership, HMO penetration, financial pressure, the
interaction between financial pressure and hospital ownership,
the interaction between HMO penetration and hospital
ownership, and the interaction between financial pressure and
HMO penetration.
Conclusions: Most of the observed relationships between
HMO penetration and the outcome variables were moderated
by either financial pressure or hospital ownership. Without
checking for interactions between HMO penetration and the
two variables, important relationships could have gone
undetected.
Implications for Policy, Delivery or Practice: Findings from
the study could help AHC administrators and policy makers
better understand the role of hospital ownership and financial
pressure in the relationship between HMO penetration and
change in AHC hospital performance. The identification of
factors that stimulate organizational change, and an
understanding of how they work may help AHC administrators
transition their organizations for success in an unstable
environment. Such findings also would help policy makers
understand the impact of economic and political decisions on
AHC hospital performance.
• Quality of Life of Newly Diagnosed Prostate Cancer
Patients
Ravishankar Jayadevappa, Ph.D., Sumedha Chhatre, Ph.D.,
Katarina Johnson, B.A., Bernard Bloom, Ph.D., Bruce
Malkowicz, M.D.
Presented by: Ravishankar Jayadevappa, Ph.D., Research
Assistant Professor, Department of Medicine, University of
Pennsylvania, 224, Ralston-Penn Center; 3615 Chestnut Street,
Philadelphia, PA 19104-2676; Tel: 215.898.3798; Fax:
215.573.8684; E-mail: jravi@mail.med.upenn.edu
Research Objective: Quality of life has become an integral
part of cancer outcome research. Multiple factors
(demographic, clinical, social and economic) influence the
Health Related Quality of Life (HRQoL) and must be assessed
for effective management and treatment of diverse prostate
cancer (PC) patients. Little information is available regarding
effects of differential treatment patterns for ethnic or age
groups on quality of life of newly diagnosed PC patients. The
objective of this study is to analyze the variations in HRQoL of
newly diagnosed PC patients by ethnicity and age over a 3month follow-up.
Study Design: For this prospective study, we recruited 316
newly diagnosed PC patients from the urology clinics of an
urban academic hospital and Veterans Administration
hospital. Participants completed SF-36 and UCLA-PCI surveys
prior to their treatment, and at 3-month follow-up.
Demographics and HRQoL were compared across ethnicity
using t-test and chi-sq. Log linear regression model was used
to assess factors associated with general and PC-specific
HRQoL. Independent variables were age, ethnicity, treatment
facility, income, marital and surgical status.
Principal Findings: Caucasians (C) had significantly higher
income, education and were more likely employed. For
Caucasians there was no significant variation in education by
age (some college or greater: <65 C = 75.2%, = >65 C =
73.81%), however African Americans (AA) showed significant
variation (among <65 AA, 51.11% had some college or greater;
in the = >65 AA, 80% were high school graduates).
Caucasians and AA showed no important variation in marital
status by age, however more AA lived alone than Caucasians.
Type of treatment varied significantly across ethnicity; more
Caucasians received surgery (71.25% C vs. 44.19% AA, p =
.0009) whereas more AA received radiation treatment (13.13%
C vs. 25.58% AA, p = .047). Baseline mean scores of general
HRQoL demonstrated that AA were substantially less healthy
by all physical, psychological and social measures. The PCspecific HRQoL did not differ by ethnicity. At 3-months,
general HRQoL scores remained significantly higher for
Caucasians except for vitality, mental health, and social
function. The mean scores for both groups in general HRQoL
and PC QoL declined from baseline levels, though the groups’
relative divergence narrowed. PC-specific QoL demonstrated
important differences by ethnicity. Caucasians reported
significantly greater bowel function (87.86 C vs. 81.47 AA, p =
0.02) and less bowel bother (88.75 C vs. 78.41 AA, p = 0.006),
while AA reported significantly greater sexual function (20.74
C vs. 29.06 AA, p = 0.045). Regression analysis for baseline
data indicated that income and presence of other illnesses
were significantly positively associated with general health and
physical function. Regression analysis for the 3-month followup data indicated that patients receiving surgery
demonstrated significant negative association with urinary
function.
Conclusions: Variations exist at baseline characteristics and
HRQoL of newly diagnosed PC patients by ethnicity. At 3-
month, the variations in HRQoL by ethnicity narrowed as
HRQol for both the ethnic groups declined.
Implications for Policy, Delivery or Practice: Assessment of
HRQoL and comorbidities is crucial for effective management
of PC.
Primary Funding Source: Department of Defense Prostate
Cancer Research Program
• Practice Variation in Physical Therapy: Development of a
Causal Model Using the Disorder Adhesive Capsulitis of
the Shoulder
Dianne Jewell, Ph.D., PT, Stephen Mick, Ph.D., Thomas Wan,
Ph.D., Daniel Riddle, Ph.D., PT
Presented by: Dianne Jewell, Ph.D., PT, Assistant Professor,
Physical Therapy, Virginia Commonwealth University, PO Box
980224, Richmond, VA 23298-0224; Tel: 804.828.0234; Fax:
804.828.8111; E-mail: dvjewell@vcu.edu
Research Objective: Variation in physical therapy services
(PTPV) has been observed but research is limited. Proposed
explanations for variation in hospital utilization include
physician practice style, medical resource supply and
community socioeconomic status. The purposes of this study
are to: 1) determine to what extent variation occurs in the
physical therapy (PT) management of one orthopedic
condition; 2) examine the causal relationship between PTPV
and practitioner, organizational, and community
characteristics; and 3) explore the impact of PTPV on selected
clinical outcomes.
Study Design: We use factor analysis to reduce 60 PT
treatment options into meaningful intervention categories for
analysis. Treatment variation is defined as deviation above
the average factor score within each intervention category.
The latent constructs PT Practice Style, Rehabilitation
Resource Availability, Community Socioeconomic Status,
PTPV, and Risk Adjusted Physical Function are validated by
confirmatory factor analysis. A causal model comprised of
these five constructs is tested at the provider and clinic level,
with clinics nested within counties to account for contextual
effects, using multilevel modeling. We included patient and
PT characteristics, as well as clinic ownership and payer mix,
as mediating factors in the model.
Population Studied: Adult patients (n=1,195; mean (sd) age =
55.4 (12.4) years) with one complete episode of PT care for the
diagnosis adhesive capsulitis of the shoulder from January 1,
1998 – December 31, 2000 are studied. We selected this
condition because it typically has an idiopathic onset and an
unpredictable recovery timeframe. Patients were treated by
256 PTs (mean (sd) years of experience = 8.1 (7.0)) in 145
outpatient PT clinics unequally distributed across the 4 US
Census Bureau regions. Counties in which the PT clinics are
located are comprised predominantly of individuals who are
white, employed, high school graduates living in households
with incomes above the poverty line. Patient, PT and clinic
data are provided by Focus On Therapeutic Outcomes,
Incorporated, a private, for-profit medical rehabilitation
outcomes management company. Data for county-level
socioeconomic indicators are obtained from the US Census
Bureau.
Principal Findings: Postural Correction, Joint Mobility, Pain
Reduction, Spasm Reduction, Flexibility and Exercise are the
intervention categories identified for adhesive capsulitis.
Variation in PT interventions for adhesive capsulitis ranges
from 15-217%. PT Practice Style is a significant predictor of
PTPV (r=.15) at the practitioner level of analysis; however,
Community Socioeconomic Status is the only significant
predictor (r=.33) when the data are aggregated to the clinic
level. Higher practice variation appears to result in lower Risk
Adjusted Physical Function at the PT level of analysis (r=.14).
Conclusions: These findings confirm the existence of PTPV in
the management of patients with adhesive capsulitis. Greater
treatment variation may result in poorer risk-adjusted clinical
outcomes for patients with this condition, suggesting that
efforts to reduce PTPV may improve quality of care.
Implications for Policy, Delivery or Practice: Future study of
practice variation would benefit from inquiry into allied health
care services as well as multi-level analysis of potential
sources in order to target remediation strategies appropriately.
• Attainment of Therapeutic Goals in Patients with
Hypertension and Dyslipidemia in the Department of
Veterans Affairs: A Multicenter Study
Michael Johnson, Ph.D., Rebecca Beyth, M.D., MS, Kenneth
Pietz, Ph.D., David Battleman, M.D., M.Sc.
Presented by: Michael Johnson, Ph.D., Assistant Professor of
Medicine, Baylor College of Medicine, Veterans Affairs
Medical Center, Houston Center for Quality of Care and
Utilization Studies, 2002 Holcombe Boulevard, Houston, TX
77030; Tel: 713.794.8608; Fax: 713.748.7292; E-mail:
grant.soanes@envisionpharma.com
Research Objective: To determine the proportion of patients
with isolated or concomitant hypertension (HTN) and
dyslipidemia (DYS) who attained their therapeutic goals for
these conditions, in a general US veteran population and
among a subset of these patients with diabetes mellitus (DM).
Study Design: Computerized diagnostic, pharmacy,
laboratory, and vital sign records were searched in this
retrospective cohort study. Treatment patterns for
antihypertensive and lipid-lowering agents were recorded at 1
year. Goal attainment for blood pressure (BP) and low-density
lipoprotein cholesterol (LDL-C) was also measured at 1 year.
Blood pressure and LDL-C goals were defined according to the
Sixth Report of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure
(<140/90 or <130/85 mmHg depending on cardiovascular
[CV] risk factors) and the guidelines of the National
Cholesterol Education Program, Third Adult Treatment Panel
(<160, <130, or <100 mg/dL depending on CV risk factors),
respectively. Separate analyses were conducted in patients
with DM.
Population Studied: Data were obtained for all patients seen
for any reason from October 1, 1998 to September 30, 2001 at
6 medical centers of the Department of Veterans Affairs
(southcentral US, VISN 16). More than 214,000 prevalent
cases were identified from a total of 352,000 patients
screened. Inception cohorts of over 42,000 patients, newly
diagnosed with isolated or concomitant HTN/DYS, were
evaluated. The mean (SD) age of patients was 60.7 (12.2)
years, and 94.6% of participants were male.
Principal Findings: Of the patients with HTN, 41.2% reached
their BP goal, and 24.9% of patients with DYS reached their
LDL-C goal at 1 year. Only 13.3% of patients with concomitant
HTN/DYS attained their goals for both BP and LDL-C. Among
patients with concomitant HTN/DYS who also had DM, 9.9%
reached their goals for both BP and LDL-C. Over a quarter of
patients with concomitant HTN/DYS (25.9%) did not receive
medical therapy for either condition during the first year
following diagnosis.
Conclusions: Over half of all patients failed to attain their
therapeutic goals. In patients with concomitant HTN/DYS,
dual goal attainment was very low. Treatment patterns varied
widely across this population. Approximately 80% of patients
with concomitant HTN/DYS were uncontrolled for at least 1
clinical parameter, 1 year after initiating treatment for these
conditions.
Implications for Policy, Delivery or Practice: The
undertreatment and poor goal attainment observed in this
study suggests that much should be done to improve the
management of patients with HTN and DYS in the veteran
population. Physicians and patients should be made aware of
both the increased risk of CV disease in patients with multiple
CV risk factors and the need for, and benefits of, a
multifactorial approach to treatment. Interventions designed
to both improve treatment rates and adherence/persistence
with antihypertensive and lipid-lowering therapies might also
be considered.
Primary Funding Source: VA, Pfizer, Inc.
• Prevalance of Concomitant Hypertension, Dyslipidemia
and Associated Cardiovascular Disease in the Veterans
Affairs Healthcare System: A Multicenter Study
Michael Johnson, Ph.D., Rebecca Beyth, M.D., MS, Kenneth
Pietz, Ph.D., Paul Healey Sr., M.D., David Battleman, M.D.,
M.Sc.
Presented by: Michael Johnson, Ph.D., Assistant Professor of
Medicine, Baylor College of Medicine, Veterans Affairs
Medical Center, Houston Center for Quality of Care &
Utilization Studies, 2002 Holcombe Boulevard, Houston, TX
77030; Tel: 713.794.8608; Fax: 713.748.7292; E-mail:
grant.soanes@envisionpharma.com
Research Objective: To determine the prevalence of isolated
or concomitant hypertension (HTN) and dyslipidemia (DYS)
in a US veteran population and among a subset of these
patients who also had diabetes mellitus (DM), and to
compare the occurrence of cardiovascular (CV) related events
in patients with single versus multiple CV risk factors.
Study Design: We conducted a retrospective cohort study.
Prevalence estimates were derived from diagnostic, pharmacy,
laboratory, and vital sign information. Hypertension was
defined according to the Sixth Report of the Joint National
Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure. Dyslipidemia was defined
in accordance with the National Cholesterol Education
Program, Third Adult Treatment Panel guidelines. A similar
analysis was undertaken in high-risk patients with DM.
Population Studied: Six inpatient and outpatient medical
centers of the Department of Veterans Affairs (southcentral
US, VISN 16) were studied. A total of 352,603 patients, seen
for any reason from October 1998 to September 2001, were
assessed. Over 90% of patients were male and mean (SD)
age was 57.7 (15.1) years.
Principal Findings: Over 60% of patients had HTN or DYS.
The prevalence of concomitant HTN/DYS was approximately
32%. Among patients with concomitant HTN/DYS, the rate of
myocardial infarction was more than tripled compared with
patients with either condition alone (9.8% for patients with
concomitant HTN/DYS, 3.1% for those with HTN only, and
2.8% for those with DYS only), and this increased to 11.4% in
patients who also had DM. Similarly, 13.3% of patients with
concomitant HTN/DYS had cerebrovascular disease
compared with 7.6% of those with HTN and 4.0% of patients
with DYS. Seventeen percent of patients had DM and twothirds (66.3%) of these patients had concomitant HTN/DYS.
The rate of CV disease was higher among patients with DM
than in those without this condition.
Conclusions: The prevalence of concomitant HTN/DYS was
very high in this population of US veterans. Patients with
concomitant HTN/DYS were found to be at much greater risk
for CV disease and stroke than those with HTN or DYS alone.
Implications for Policy, Delivery or Practice: Our
observations highlight the importance of diagnosing and
treating all CV risk factors in order to effectively reduce the
development of CV disease. These observations are in
accordance with recent therapeutic guidelines, which highlight
the need to treat all CV risk factors aggressively. The accurate
identification of the true burden of CV disease, including the
presence of multiple chronic conditions, is essential in order
to provide the healthcare system with the necessary
information for resource allocation to effectively manage these
conditions.
Primary Funding Source: VA, Pfizer, Inc.
• A Path Model of Caregiving Demands, Resourcefulness,
and Cardiovascular Response in Black Caregivers
Chu-Yun Lu, Ph.D. Student, M.S., R.N., Piyatida Junlapeeya,
Ph.D. Candidate, M.S., R.N.
Presented by: Piyatida Junlapeeya, Ph.D. Candidate, M.S.,
R.N., Research Assistant, School of Nursing, University of
Maryland, Baltimore, 13031 Town Commons Drive,
Germantown, MD 20874; Tel: 240.686.0211; Fax:
240.686.0211; E-mail: pjunl001@son.umaryland.edu;
cxl349@yahoo.com
Research Objective: To analyze the direct and indirect
relationships of blood pressure and related variables based on
the Livingston's sociopsychophysiological model in Black
Caregivers Cardiovascular Responses dataset.
Study Design: Secondary data from Black Caregivers and
Noncaregivers Cardiovascular Responses dataset was used to
test the sociopsychophysiological model (Livingston, 1994).
The sociopsychophysiological model emphasizes on the
interaction of demands and filter resource capability (FRC).
The FRC would buffer stressful demands, and thus improve
health outcomes in Black caregivers. The FRC has several
essential components, including learned resourcefulness,
social support, coping, and perception. In the current analysis,
24-hour mean SBP was selected to manifest the health
outcome in Black caregivers.
Population Studied: The Black Caregiver and Noncaregivers
Cardiovascular Responses Dataset is a 3-year longitudinal
study. The current analysis only employed the first year Black
caregivers group (N=203) to evaluate the
sociopsychophysiological model, because it had the largest
sample size.
Principal Findings: The data for this analysis included 203
Black caregivers who provided continuing in-home care,
including 48 spouse caregivers, 106 adult child caregivers, and
39 other relatives or friends. The age of caregivers ranged from
22 to 87, with a mean of 56.25 (SD=13.37). The age of care
recipients ranged from 51 to 102, with a mean of 78.06
(SD=8.33). Black caregivers in this dataset, on average, were
educated and relatively young with moderate comorbidities
(mean 1.87) and less likely to exercise (24% reported exercise
regularly). Although the data showed a high degree of
caregiving demands and perceived cost, they also
demonstrated a high level of learned resourcefulness, social
support, and perceived caregiving reward. Finally, subjects’ 24
hour systolic blood pressure (SBP) indicated good conditions
(mean SBP 130 ± 16 mmHg). Path analysis was performed to
test the model. Demographic variables, including age,
hypertension history, and exercise, and daily hassles had direct
relationships on 24-hour mean SBP. Age, hypertension, and
daily hassles were positively related to 24-hour mean SBP (ß=
.25, .24, .18, p= .002, .002, .029, respectively). Exercising
regularly, and learned resourcefulness were negatively related
to 24-hour mean SBP (ß= -.14, -.15, p= .042, .026,
respectively). In the FRC, after controlled other variables, only
learned resourcefulness had direct relationship on 24-hour
mean SBP (ß= -.15, p= .026), but not social support, coping,
and perceived receptions. Demographic and caregiving
demand variables explained 27% of variance of 24-hour
systolic blood pressure, and the FRC only explained 3.7% of
variance. Together, they were counted 30.8% of variance of 24hour mean SBP.
Conclusions: Black caregivers who were older, had
hypertension history, or had a higher level of daily hassles
were more likely to experience a higher level of 24-hour mean
SBP. On the other hand, exercising regularly and report a
higher level of learned resourcefulness would more likely
report a lower level of 24-hour mean SBP.
Implications for Policy, Delivery or Practice: For Black
caregivers, although aging would increase the risk of
hypertension, they could lower the risk by exercising regularly,
managing their daily hassles, and learning available resources.
• The Current Status of Health Promotion Policy about
Antismoking on Elementary, Junior, and High Schools in
Gangwon-do in Korea
Chun-Bae Kim, M.D., Ph.D., Joung-Sook Ahn, M.D., Ph.D.,
Hea-Kung Hur, Ph.D., Jun Ho Park, M.P.H., Eun-Joung Park,
LL.B, Eun-Po Jeon, M.P.H
Presented by: Chun-Bae Kim, M.D., Ph.D., Visiting Professor
(Associate Professor), Clinical Outcomes Research Center
(Department of Preventive Medicine), University of Minnesota
School of Public Health (Yonsei University Wonju College of
Medicine), D-351 Mayo (Box 197), 420 Delaware Street S.E.,
Minneapolis, MN 55455-0392; Tel: 612.625.7417; Fax:
612.624.8448; E-mail: kimxx360@umn.edu
Research Objective: The purpose of this study was to
investigate the current status of health promotion policies
about antismoking, and the relationship between policy
status, enforcement of smoking restrictions and perceptions
of smoking behaviour among teachers.
Study Design: This study design is the cross-sectional study
and the self-developed questionnaire is used.
Population Studied: A representative sample of 173 teachers
school inspectors from 150 elementary junior high schools in
Gangwon-do in Korea was surveyed during Gangwon-do
Office of Education's antismoking and temperance training
course in 2002 (response rate 60.7%). One staff member
from each school was also analyzed regarding school
antismoking polices for students and teachers in several
locations within and outside the school building.
Principal Findings: The results showed that 118 elementary
junior high schools (78.7%) had an antismoking policy and
more schools had a written policy on student antismoking
than on teacher antismoking. Most schools (92.4%) in the
sample banned smoking by students, but 52 schools (44.1%)
allowed smoking by teachers in restricted areas. However,
teachers reported seeing smoking sometimes in the toilets
(42.7%) or the playground (40.0%) among students and
sometimes in the staff room (31.3%) or about every day on
school premises (52.7%) among teachers. Irrespective of the
type of policy or restrictions on smoking, the association
between having a ban on student/teacher smoking and
teachers' perceptions of student/teacher smoking in school
was not significant.
Conclusions: In conclusion, we suggest that most schools
must have explicitly an antismoking policy on both students &
teachers and enforce consistently a ban in promoting a
healthy school environment (smoke-free schools).
Implications for Policy, Delivery or Practice: Antismoking
policy on school must be continuously applied to both
students and teachers.
Primary Funding Source: A grant of 2002 Health Promotion
Project in Wonju City Public Health Center
• Societal Costs of Menstruation and Its Implication in
Health Care System
Yasuki Kobayashi, M.D., Takashi Fukuda, Ph.D., Kunihiko
Hayashi, Ph.D.
Presented by: Yasuki Kobayashi, M.D., Professor, Department
of Public Health, University of Tokyo, Graduate School of
Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 1130033; Tel:
81.3.5841.3490; Fax: 81.3.3816.4751; E-mail: yasukik@m.utokyo.ac.jp
Research Objective: Although menstruation influences daily
activities of women in their reproductive ages, few studies on
its impact on the society and health care system have been
conducted. The purposes of this study are to estimate the
societal costs of menstruation and to discuss its implication
in the Japanese health care system.
Study Design: We conducted a survey of reproductive-aged
Japanese women by the following manner; first, we randomly
selected 100 municipalities, according to their population size
and geographic location, from all the 7 prefectures of the
Kanto region, including Tokyo, in Japan. Second, 100 women
between the ages of 20 and 49 were randomly selected in
each municipality, using the official resident registry of each
municipality government, and the number of the total subjects
was 10,000. Third, anonymous questionnaires were used to
collect data on their age, occupation, age at menarche, parity,
menstrual pattern, degree of pain (dysmenorrhea), use of
analgesics, absence from work or school, and consultation
with physicians. Finally, using the survey results, we
estimated the costs of analgesics and the lost productivities
due to dysmenorrhea.
Population Studied: 4,230 subjects responded to the survey
(the response rate: 42%). The response rate by age was 33%
(20-24 years old), 37% (25-29), 43% (30-34), 47% (35-39), 48%
(40-44), and 47% (45-49). The percentage of full-time workers
was 21%, that of part-time workers 18%, and that of
housewives 33%. Among all the respondents, 38% regularly
used analgesics due to the pain of menstruation, and 12%
consulted with physicians and/or received treatment.
Principal Findings: Average work loss due to the pain of
menstruation for the past 6 months varied by age and job (at
the maximum, 1.89 days per person for housewives between
the ages of 25 and 29, and at the minimum, 0.37 days per
person for part-time workers between the ages of 45 and 49).
Using the average wages of full-time or part-time workers, and
estimated productivities of housewives, the lost productivities
due to the pain of menstruation for the past year was 153
billion yen for both full-time and part-time workers, and that
for housewives 225 billion yen. Adding the costs of analgesics
(50 billion yen), the societal costs due to menstruation were
428 billion yen per year, excluding the costs of medical
services.
Conclusions: The societal costs related to menstruation were
approximately US$4 billion (US$1=108 Japanese yen) per year,
and most of the costs were the lost productivities due to the
pain of menstruation.
Implications for Policy, Delivery or Practice: The
questionnaire survey also revealed that nearly 90% never saw
a physician nor received any treatment. If there are unmet
needs for proper medical services at reasonable costs among
women suffering from dysmenorrhea, the total societal costs
could be decreased through a reduction in the lost
productivities.
Primary Funding Source: Grant-in-Aid for Scientific Research
and Health Sciences Research Grants
• Physician Retirement Intentions and Trends:
Implications for Supply
Thomas Konrad, Ph.D., James Cultice, B.S., Tim Dall, M.S.
Presented by: Thomas Konrad, Ph.D., Research Associate,
Sheps Center for Health Services Research, University North
Carolina at Chapel Hill, CB#7590, 725 Airport Road, Chapel
Hill, NC 27599; Tel: 919.882.2165; Fax: 919.966.3811; E-mail:
konrad@mail.schsr.unc.edu
Research Objective: As a large physician cohort approaches
traditional retirement age, health policy makers need to
understand how secular changes in US physician
demographics, employment settings, and work expectations
influence physician retirement patterns and thereby future
supply. We examine recent data on physicians’ retirement
intent, variables affecting intent, and actual retirement to
assess the sensitivity of future physician supply to plausible
alternative assumptions about physicians’ retirement patterns
and working life expectancy.
Study Design: The 1997 Physician Worklife Survey (PWS), a
nationally representative sample of US physicians’ retirement
plans, provided correlates of retirement intent overall and
within demographic, work setting, income, and specialty
strata; a 2003 PWS resurvey gathered data on retirement
behavior. The American Medical Association Physician
Masterfile (AMA-PM) for 1991 through 2001 and Current
Population Survey (CPS) provide alternative retirement rates
for use in the Bureau of Health Professions' (BHPr) Physician
Supply Model (PSM). Standard survival analysis techniques
estimated physician working life expectancy under alternative
assumptions about retirement patterns. The PSM was used
to test the sensitivity of projected physician supply to various
retirement assumptions.
Population Studied: US physicians
Principal Findings: Low correlations were found between
1997 PWS retirement intent and both 2003 AMA-PM
retirement status and self-reported retirement status in 2003,
suggesting that many intending to retire had changed their
minds. AMA-PM retirement rates were found to be slightly
higher in the mid 1990s than in the early to mid 1980s for
both males and females, though lower at every age than for
the general working population. IMGs are older when they
retire than are USMGs; women retire at a younger age than
men among both USMGs and IMGs, though their average age
at retirement has risen from the early to-mid 1980s. More
recent AMA-PM data suggest that physicians are retiring at
older ages, possibly a real trend towards delaying retirement
or an artifact of changes in methods of updating the AMA-PM.
CPS-based physician retirement rates exceed AMA-PM based
rates. The projected supply of physicians in 2020 is about 8%
(70,000) higher when using AMA-MF based retirement rates
rather than CPS- based rates.
Conclusions: Our findings contradict common views that
physician working life expectancy has declined as a growing
fraction of them are women, salaried, and challenged by
managed care and malpractice concerns. Robust analyses,
replicated using several pairs of adjacent years in the 1990-95
AMA-PM data, found that physicians spend more time in
practice, and live longer even while those who choose to retire
do so at a slightly younger age. Distinct separation rates for
USMGs and IMGs for both males and females should be
applied in supply forecasts.
Implications for Policy, Delivery or Practice: The separation
patterns of physicians are important determinants of future
physician supply. Physicians’ expressions of retirement
intentions are not highly accurate predictors of future
behavior. Our results can inform the shortage/surplus debate
by suggesting that supply is growing more rapidly than has
been supposed by many observers.
Primary Funding Source: HRSA
• Relationship among Health Status, Health Behaviors and
Health Practices of Adults in a Korean Poor Area
Jung Jeung Lee, M.D., Ph.D., Choong Won Lee, M.D., Ph.D.
Presented by: Jung Jeung Lee, M.D., Ph.D., Assistant
professor, Department of Preventive Medicine and Public
Health, School of Medicine, Keimyung University, 194,
Dongsan-dong, Jung-gu, Daegu, 700-712; Tel:
82.53.250.7009,7492; Fax: 82.53.250.7494; E-mail:
jjlee@dsmc.or.kr
Research Objective: The problems of health in poor peoples
are various and difficult things to solve it. They are highly
susceptible to chronic disease because of bad environment
and It is hard to access to medical services because of their
Socio-demographic status. Therefore, it is important to
address the problem of prevention of chronic disease and
health promotion aspect.
The purpose of this study was to determine the relationships
among the health status, health behaviors and health
practices of poor people in urban slum area in Korea.
Study Design: cross-sectional study
The study sujects were asked to answer the survey
questionnaires modified for Korean from behavioral risk factor
surveillance system of Centers for Disease Control and
Prevention USA and other survey questionnaires .
Population Studied: The subject of this study were 298 poor
peoples who live in poor area in Daegu metropolitan city in
Korea.
Principal Findings: (1) There were significant relationships
between health status (prevalence of chronic disease and
perceived general health) and socio-demographic factor such
as occupation, existence of spouse, number of family
educational level, type of medical security. (2) There were
some relationships between health risk behaviors such as
smoking, drinking and obesity and health status of subject
especially in female obesity.(3) There were relationships
among health concern activity, prevalence of chronic disease
and some social factor such as educational level and
occupation. (4) There were relationships among health
practice, health concern activity, health status and sociodemographic factors of subject.
Conclusions: This study suggest that health status, sociodemographic status, health concerns and health promotion
activity of study populations were associated.
Implications for Policy, Delivery or Practice: It is very
important things supporting the poor people in the level of
community and nation to practice healthy behaviors
themselves.
• Youth Risk Behavior Survey of Students at a University in
Korea
Jung Jeung Lee, M.D., Ph.D., Choong Won Lee, M.D., Ph.D.
Presented by: Jung Jeung Lee, M.D., Ph.D., Assistant
professor, Department of Preventive Medicine and Public
Health, School of Medicine, Keimyung University, 194,
Dongsan-dong, Jung-gu, Daegu, 700-712; Tel:
82.53.250.7009,7492; Fax: 82.53.250.7494; E-mail:
jjlee@dsmc.or.kr
Research Objective: The purpose of the study was to see how
prevalent the risk behaviors of Korean university students
using Youth Risk Behavior Surveillance System(YRBSS)
developed by the Centers for Disease Control and
Prevention(CDC).
Study Design: cross-sectional study compare the freshmen
with senior student.
Population Studied: Translation and modification for Korean
students of the YRBS were carried out March 2003 and the
modified YRBS were administered to students of 4-year
college in Daegu metropolitan city. The number of students
used at final analysis was 619(male :212(freshmen: 101, senior
students : 111) female : 407(freshmen: 146, senior students :
261)).
Principal Findings: Over 50% of university students rarely or
never used safety belt. and there were no significant difference
between freshmen and senior students.
363 of students had ridden a bicycle during 12 months
preceding the survey. of these students, almost
students(male : 99%, female: 100%) were rarely or never wore
a bicycle helmet. During the 12 months preceding the survey,
22.8% male freshmen had felt so sad or hopeless almost every
day for =2weeks in a row that they stopped doing some
usually activities and there were no significant difference
between freshmen and senior students.
Male student in grades 2, 3 and 4(89%) were significantly
more likely than freshmen(42%) to have ever tried cigarette
smoking.
Almost male students had had =1 drinks of alcohol during
their lifetime(lifetime alcohol use) and almost male
freshmen(95%) and senior student(95%) had =1 drinks of
alcohol on =1 of the 30 days preceding the survey(current
alcohol use).
Conclusions: These results suggest that some risk behaviors
be very prevalent in a korean university students.
Implications for Policy, Delivery or Practice: The priority
health-risk behaviors, which contribute to the leading cause of
mortality and morbidity among youth and adult, often are
establish during college age, extend into adulthood, are
interrelated.
• Factors Related with Screening Behaviors of Breast and
Cervical Cancers Among Rural Women in Korea
Pock-Soo Kang, Ph.D., Kyeong-Soo Lee, Ph.D., Jeong-Don
Park, Ph.D.
Presented by: Pock-Soo Kang, M.D., Ph.D., 317-1 Daemyungdong, Nam-gu. Daegu 705-717, Republic of Korea
Research Objective: This study was conducted to evaluate
the rate of cancer screening in women residing in a rural area
in Korea, the factors related with this rate and the change in
this rate according to cancer related publicity projects
conducted for a 2-year period, and to elucidate the factors
affecting the change in this rate.
Population Studied: The study was done on 400 women
residing in Goryeong-county in Korea through interviews
between September 1999 to November 2001. After selecting
11 dongs(villages)using the systematic cluster sampling
method from 137 dongs reported in the annual statistical
report, all women between the ages of 30 years to 69 years
residing in these 11 dongs were included in the study.
Principal Findings: During the two-year study period, the rate
of screening increased from 23.8% to 36.8% for breast cancer
and from 63.5% to 67.0% for cervical cancer. According to age
group, the rate of screening for breast cancer increased by
18.6% in women in their 40's and was least increased in
women in their 60's at 10.1%. For cervical cancer, the rate
increased by 10.2% in women in their 30's but by 2.3-2.4% in
other age groups. According to marital status, the rate in
married women with spouses increased by 14.5% and 5.2% for
breast cancer and cervical cancer, respectively.
According to the number of family members, the screening
rate for breast cancer increased significantly as the number
increased. However, the screening rate for breast cancer
increased only by 7.5% in women living alone, showing a
relatively lower increase compared with other age groups. As
for the change in the rate for cancer screening according to
health habits, the rate increased significantly by 13.5% in nonsmokers for breast cancer and by 6.7.% in smokers for cervical
cancer. The rate showed no change according to the presence
or absence of family history of breast cancer and cervical
cancer, but did change significantly depening on the presence
or absence of risk factors for cancer occurance.
The results of multiple logistic regression analysis showed
that significant variables affecting breast cancer screening
behavior were age, the number of family members, experience
of having gone through screening for the past one year, and
the experience of having had a hepatitis vaccination and body
mass index. For cervical cancer, were age, marital status and
smoking habit were significant variables.
Conclusions: To raise the rate of cancer screening in women
in local community and to efficiently conduct projects of
screening for breast cancer and cervical cancer, the high risk
groups (including women with no experience of cancer
screening, women in their 50's, women who do not well carry
out disease prevention activities such as health screening
hepatitis vaccination, low-income women, women living
alone, and women with family history) should actively be
included in these projects. In order to remove factors
preventing women from screening, free screening should be
continually provided to women in high risk group who are
older than 50 years of age and live alone, and follow-up
management is necessary in women with these cancers.
At the same time, it is important to raise the people's
understanding of the importance of going through screening
and regular screening for breast cancer and cervical cancer by
providing health education through the media or lectures
and/or by distributing publicity pamphlets on cancer related
information and conducting campaigns related with this
subject.
Implications for Policy, Delivery or Practice: It is necessary
to establish specific plans to improve the rate of cancer
screening by conducting studies not only on the rate of cancer
screening but also on cancer screening behaviors, such as
regular screening or follow-up management of women with
cancer.
• Prevalence and Related Factors of Knee Osteoarthritis of
Rural Women in Korea
Pock-Soo Kang, Ph.D., Kyeong-Soo Lee, Ph.D., Joong-Hwan
Seo, Ph.D.
Presented by: Kyeong-Soo Lee, Ph.D., Assistant Professor,
Preventive Medicine and Public Health, Yeungnam University
College of Medicine, 317-1 Daemyung-dong, Namgu, Daegu,
705-711, Daegu; Tel: 82.53.620.4375; Fax: 82.53.653.2061;
E-mail: kslee@med.yu.ac.kr
Research Objective: This study was performed to determine
the prevalence of knee osteoarthritis according to the criteria
of diagnosing knee osteoarthritis in rural women in Korea and
the factors related with this disease.
Study Design: Survey was done on general characteristics of
these subjects, disease history, family history, health behavior,
seating life style, and activity of daily living(ADL). Data were
also collected on weight, height, blood pressure, blood sugar
level, total serum cholesterol level, bone density and knee Xray exam was performed.
Population Studied: The data obtained from 200 out of 258
women (77.5% survey rate) older than 40 years of age residing
in 5 dongs(villages) in Goryeong-county in Korea by random
cluster sampling from September to October 2002.
Principal Findings: Knee osteoarthritis was determined
positive according to the Kellgren and Lawrence classification
and knee pain. Among these subjects, 71.0% showed more
than grade 2 in radiologic finding and the rate of knee pain
according to the survey was 67.0%. The rate of subjects
meeting the criteria of knee osteoarthritis was 54.0%.
According to multivariate analysis, the prevalence of knee
osteoarthritis increased with age. The prevalence of knee
osteoarthritis in those farming people and people working in
household industry was significantly high at 58.9% compared
with people working in other areas. The prevalence of knee
osteoarthritis showed a significant relationship with the family
history and past history of knee injury and knee
surgery(p<0.01), and diabetes mellitus(p<0.05).
The score of ADL was significantly different in the subjects
with knee osteoarthritis compared with normal
group(p<0.05). When the presence of knee osteoarthritis and
the period of the life style of seating down on the floor were
compared, a significant difference was present between the
osteoarthritis group and normal group. As for metabolic
factors, the blood sugar level, bone density, and body mass
index(BMI) were significantly different in the osteoarthritis
group compared with normal group.
When multiple logistic regression analysis was performed with
the presence of knee osteoarthritis as the dependent variable,
the prevalence of knee osteoarthritis was significantly affected
by older age, subjects farming or working in household
industry, the history of knee injury, the history of surgery,
higher blood sugar level, and higher BMI.
Conclusions: The prevalence of knee osteoarthritis was very
high of rural women in Korea. And the knee osteoarthritis was
significantly affected by older age, subjects farming or working
in household industry, the history of knee injury, the history of
surgery, higher blood sugar level, and higher BMI.
Implications for Policy, Delivery or Practice: These subjects
need an intervention through self-care programs such as
exercise for preventing osteoarthritis, weight control, and
physical therapy for pain control programs, other exercise
programs strengthening knee joints, and guidelines when
working in vinyl houses.
• The Impact of National Health Insurance Scheme on
People's Health Status in Taiwan
Jwo-Leun Lee, Ph.D., Lin Lin, Ph.D., Blossom YJ Lin, Ph.D.,
Hong-Dar I Wu, Ph.D.
Presented by: Jwo-Leun Lee, Ph.D., Associate Professor,
Health Care Administration, China Medical University
(Taiwan), 91 Hsueh Shih Road, Taichung, 404; Tel:
+886.4.22053366 Ext. 7234; Fax: +886.4.22019901; E-mail:
jllee@mail.cmu.edu.tw
Research Objective: This research has three objectives. The
first is to evaluate if the National Health Insurance scheme
which is implemented in 1995 in Taiwan improves the general
health status of people. The second objective is to evaluate the
impact of the NHI scheme on the health indicators in Taiwan.
The third is to explore the impact of the NHI scheme on the
avoidable mortality rate in Taiwan.
Study Design: For the first objective, the general health status
of Taiwan people between 1994 and 2002 is analyzed. The
general health status is measured by the short-form 36 scores
of people between these two years. For the second objective,
health indicators in Taiwan are analyzed by time series
method. The health indicators include life expectancy, infant
mortality rate, neonatal mortality rate, and maternal mortality
rate from 1959 to 2001. For the third objective, the avoidable
mortality rate in Taiwan is analyzed, using the statistical data
from 1974 to 2001.
Population Studied: The mortality data are collect from the
governmental statistical records. Two national samples of
people in Taiwan are interviewed in 1994 and 2002 to collect
the short-form 36 scores of general health status.
Principal Findings: The results show that comparing with the
general population or people not enrolled in health insurance
scheme in 1994, the 2002 population have no significant
different physician component scores of SF-36 questionnaire,
but have significantly lower mental component scores of SF-36
questionnaire by 0.3 to 0.4 standard deviations. Similar results
are found if the population is confined in the geographical
middle area of Taiwan. Using the life expectancy, infant
mortality rate, neonatal mortality rate, maternal mortality rate,
and preventable mortality rate as indicators, the time series
analysis of AR models show that there is no significant
difference between the predicted and observed data from 1995
to 2001. Some reasons are also discussed in the study.
Conclusions: From the SF-36 scores, this study fails to find
the evidence of positive impact of the NHI scheme on the
health status of the general population in Taiwan. This study
either fails to find the evidence of positive impact of the NHI
scheme on the general or some specific health indicators in
Taiwan.
Implications for Policy, Delivery or Practice: The
compulsory national health insurance scheme may not be the
major factor for affecting people's health status. Some other
health promotion programmes are desired to improve
national health status.
Primary Funding Source: Ministry of Health, Taiwan
• The Utilization Rate of Chinese Medicine in Taiwan: An
Application of Survival Analysis
Jwo-Leun Lee, Ph.D., Hong-Dar I Wu, Ph.D., Chao-Chin
Chang, Ph.D., Horng-Shu Hao, Ph.D., Chunhuei Chi, Sc.D.
Presented by: Jwo-Leun Lee, Ph.D., Associate Professor,
Health Care Administration, China Medical University
(Taiwan), 91 Hsueh Shih Road, Taichung, 404; Tel:
+886.4.22053366 Ext. 7234; Fax: +886.4.22019901; E-mail:
jllee@mail.cmu.edu.tw
Research Objective: This study aims to overcome two main
limitations from previous studies of Chinese medicine
utilization in Taiwan. The first limitation is that most of them
can only inform the situation of local population due to the
lack of national sample. The second is that some studies
cannot have enough variables, health status for example, for
data analysis because of using the claim data of National
Health Insurance only. There are serous methodology
problems as well. Almost all of previous studies record the
utilization within various time periods, from two weeks to
twelve months. This makes the results of previous studies
incompetable in terms of utilization rate.
Study Design: Both questionnaire interview data and national
health insurance claim data for each person are collected.
Survival analysis is used in this study to include recurrent
events in different time periods. The Aderson-Gill model is,
therefore, used for the repeated event history analysis.
Population Studied: A national sample of 1106 persons is
selected.
Principal Findings: The utilization rate of ambulatory care of
Chinese medicine in Taiwan is estimated to be 22.1% in six
months. The other sample means of Chinese medicine use
are 0.818 visits per year for ambulatory care, 14 US dollars per
year for expenditure. Among the user of Chinese medicine,
24.5% of them use 5 or more visits. Elderly persons, people
with household income per year between 4 to 12 thousand US
dollars, and those having regular source of Chinese medicine
services and living in geographical areas with more Chinese
medicine doctors, are found to be significant determinants of
the utilization. The variables regarding health status are not
found to be significant in the model. These variables include
having chronic dieses, physician component score and mental
component score of the health status measures.
Conclusions: The cumulated utilization rate of Chinese
medicine physician visit in Taiwan is 6.8%, 10.5%, 14.3%,
17.2%, 19.9%, and 22.1% in one to six months, respectively.
Implications for Policy, Delivery or Practice: Comparing
with the previous data, the utilization rate of Chinese medicine
visits does not increase in Taiwan. This trend in the demand
side should inform the policy for resouces allocation in the
supply side.
Primary Funding Source: Ministry of Health, Taiwan
• The Relationship among Time Preference, Health Status
and Substance Use
Jwo-Leun Lee, Ph.D.
Presented by: Jwo-Leun Lee, Ph.D., Associate Professor,
Health Care Administration, China Medical University
(Taiwan), 91 Hsueh Shih Road, Taichung, 404; Tel:
+886.4.22053366 Ext. 7234; Fax: +886.4.22019901; E-mail:
jllee@mail.cmu.edu.tw
Research Objective: This study aims to explore the
relationship among time preference, the cumulative
consumption of tobacco, alcohol and betel, and general health
status. Theoretically, so far there is very limited understanding
on the relationship between time preference and other
variables. Empirically, health education is the most common
reaction of the public health workers when facing the issues of
substance consumption such as tobacco. This reaction
ignores the effect of time preference on health behavior, and
the fact that health education cannot influence the time
preference of individuals. This research is likely to challenge
the concept of health education and the way public health
workers attack the behavior of substance consumption.
Study Design: Time preference is measured by the trade-off
between sickness days at present and those one years later.
Health status is measured by the short-form 36 questionnarie.
The substance use is measured by the cumunative
consumption of tobacco, alcohol and betel. The two-stage
least square estimation is used for regression model.
Population Studied: A natinal sample of 500 general
population and 200 aboriginals are interviewed.
Principal Findings: The time preference rates are 2.27% and
3.60% for aboriginals and general population, respectively, but
variances are too large to find the significant difference
between them. The regression shows that time preference will
significantly affect tobacco consumption, but will not affect
alcohol and betel consumption. Health knowledge will
significantly affect alcohol consumption, but will not affect
tobacco and betel consumption.
Conclusions: Time preference is a more important factor than
health knowledge for affecting tobacco consumption. Health
knowledge, on the other hand, is more important than time
preference for affecting alcohol consumption.
Implications for Policy, Delivery or Practice: To influence
the time preference of people should be considered in tobacco
control policy. Health education can still be the main strategy
for controlling alcohol consumption.
Primary Funding Source: National Science Council, Taiwan
• Reported Job Satisfaction by VHA Nursing Personnel and
the Impact of Response Rate
Yu-Fang Li, Ph.D., R.N., Anne Sales, Ph.D., R.N., Nancy Sharp,
Ph.D., Gwendolyn Greiner, M.P.H., M.S.W.
Presented by: Yu-Fang Li, Ph.D., R.N., Research Health
Sciences Specialist, Department of Veterans Affairs, VA Puget
Sound Health Care System, 1660 S. Columbian Way, Seattle,
WA 98108; Tel: 206.768.5383; Fax: 206.764.2935; E-mail:
yufang.li@med.va.gov
Research Objective: Job satisfaction is a key factor in
retaining adequate nursing staff in hospital. Most studies on
job satisfaction in nursing have been conducted using selfreported surveys, and response rates are often low. As low
response rates cause concern about the validity of the data
gathered, it is important to examine the effect of response
rates on survey results. This study examined job satisfaction
reported by different types of nursing personnel and the
influence of response rates on nurse responses regarding job
satisfaction, burnout, and adequacy of staffing.
Study Design: This research is part of the Nurse Staffing and
Patient Outcomes (NSPO) Study in the Veterans Health
Administration (VHA). A total of 11,338 nursing personnel at
124 VHA medical centers responded to a job satisfaction
survey administered by the Nurse Staffing and Patient
Outcomes Project between February and June 2003. Facility
return rates ranged from 9.2% to 87.6%. Using the 75th
percentile (40% return rate) to stratify, the facilities were
stratified into low and high response rate hospitals.
Instruments included the Nursing Work Index-Revised (NWIR), the Maslach Burnout Inventory (MBI) and questions on
overall satisfaction, pay satisfaction, and job-related stress.
The association between facility-level job satisfaction and job
category, adjusted by facility return rates, was tested using
multivariate analyses. Satisfaction scores were compared to
responses from nurses from federal hospitals who
participated in the year 2000 National Sample Survey of
Registered Nurses (RNs only) and the 2001 VHA All Employee
Survey (all nursing personnel by job category).
Population Studied: Nursing personnel (RNs, LPNs, and
Nurse Aides) working at VHA Medical Centers with acute
inpatient units.
Principal Findings: Nurses at high-response-rate hospitals
were more satisfied with the “foundation of quality nursing
care” measured by the NWI-R than their counterparts at lowresponse-rate hospitals [F(7,437)=3.17, p<.01]. Satisfaction with
other aspects of the work environment did not differ by
response rates. Nurses at the 124 medical centers had low to
moderate levels of burnout and reported unfavorably on
staffing and resource adequacy regardless of job category. The
emotional exhaustion component of burnout on the MBI was
higher for RNs than for licensed practice nurses or Nurse
Aides. RN responses on overall job satisfaction, satisfaction
with pay, and job-related stress were concordant between the
NSPO study and the 2001 VHA All Employee Survey. RN
participants in the NSPO project were more satisfied with
their job overall than RNs who participated in the 2000
NSSRN survey.
Conclusions: In this study, except for the NWI-R component
“foundation of quality nursing care”, job satisfaction did not
differ by response rate. Nurses were least satisfied with
staffing and resource adequacy and RNs reported a higher
level of burnout than other nursing staff.
Implications for Policy, Delivery or Practice: Staffing and
resource adequacy remain a critical issue for nursing
management at VHA and non-VHA hospitals. Issues on job
satisfaction need to be investigated separately by job
categories. Further research is needed to investigate bias in
survey results due to non-response, although low response
rates may not bias findings to a great extent.
Primary Funding Source: VA
• Selection Bias into Health Plans with Specific
Characteristics
Su-Ying Liang, Ph.D., Kathryn Phillips, Ph.D., Laurence Baker,
Ph.D., Hui-Chen Wang, Ph.D.
Presented by: Su-Ying Liang, Ph.D., , Clinical Pharmacy,
University of California, San Francisco, 3333 California Street,
San Francisco, CA 94143; Tel: 415.514.0457; Fax: 415.502.0792;
E-mail: sliang@itsa.ucsf.edu
Research Objective: Selection bias and endogeneity of
insurance choice are inherent concerns for modeling health
care utilization. Previous selection bias studies examining
broad health plan categorizations are inconclusive and such
broad categorizations are no longer as useful in
understanding utilization in today’s health care system. The
objective of this paper was to investigate potential selection
bias into plans with specific characteristics and to test the
endogeneity of insurance choice in estimating health care
utilization.
Study Design: Data were from the 2000 Medical Expenditure
Panel Survey and the linked 1998/1999 National Health
Interview Survey. We used a model of mammography
utilization as an example to illustrate our empirical strategies
for examining selection bias into plans with specific
characteristics, e.g., gatekeeper requirements. Standard probit
and linear probability models were estimated as base models
(e.g., as if there is no selection bias). Endogeneity of plan
choice was examined using two-stage instrumental variables
and bivariate probit models. We first identified instrumental
variable candidates based on a priori theory and then used a
systematic procedure to select proper instrumental variables.
Diagnostic tests, including the tests of over-identifying
restriction and goodness-of-fit, were performed to ensure the
validity and relevance of our instrumental variables.
Population Studied: The study population contained a
nationally representative sample of adult female ages 40 and
over.
Principal Findings: We observed a positive association
between gatekeeper requirements and mammography
utilization (p=0.03) in single equation regressions. Based on
our descriptive analyses, we cannot rule out the potential of
selection bias into plans with gatekeeper requirements as
there were differential characteristics between individuals
enrolled in gatekeeper and non-gatekeeper plans. However,
we did not find that the use of the two-stage instrumental
approach would improve the point estimates obtained from
standard single equations. Two instrumental variables that
passed the validity and relevance criteria were used: the
household out-of-pocket insurance premium from the prior
year, and whether the employer contributed to insurance
premium from the prior year. The endogeneity test suggests
that the gatekeeper variable can be treated as exogenous
(p=0.53). When jointly estimating the system of the health
plan choice and mammography utilization equations, we
cannot reject the null hypothesis that the residuals of the two
equations are uncorrelated (p=0.20).
Conclusions: Studies that are interested in modeling the
effect of insurance on health care utilization need to consider
examining potential of selection bias based on plan
characteristics. However, using the MEPS/NHIS data, we did
not find evidence that correcting for any selection bias
improved the estimates.
Implications for Policy, Delivery or Practice: Our results
suggest that selection bias into plans with gatekeeper
requirements may not be a serious concern when considering
the potentially joint decision with one strongly recommended
preventive service. However, further research is needed to
understand the decision process of health plan choice in
today’s system, e.g., which plan attributes play a role, and how
different dimensions of health care utilization may be
influenced.
Primary Funding Source: NCI, Agency for Healthcare
Research and Quality
• Determinants of Establishment of Hopsital-based Home
Care Units in Taiwan
Blossom Yen-Ju Lin, Ph.D., Ming-Ching Chou, B.S., M.S.
Presented by: Blossom Yen-Ju Lin, Ph.D., Assistant Professor,
Institute of Health Service Management, China Medical
University, 91 Hsueh Shih Road, North District, Taichung,
404; Tel: 886.922.709359; Fax: 886.4.22019901; E-mail:
yenjulin@mail.cmu.edu.tw
Research Objective: This study was aimed to test a
theoretical model of the predictors of the establishment of
hospital-based home care units in Taiwan.
Study Design: This is a cross-sectional study using individual
hospitals as unit of analysis. The analysis used data from 2001
National Long-Term Care Association Report and 2001 Taiwan
Hospital Annual Survey of Service Utilization for 487 hospitals
identified from the Taiwan National Hospital Accreditation
List (1998-2001). Market-level data came from 2001 Taiwan
Health and Vital Statistics published by National Department
of Health. Logistics regression analysis was used to examine
the effects of hospital size, ownership, accreditation status,
teaching status, system/network membership, service
diversity, inpatient days, discharges, surgery volume, physician
manpower, and the market-level factors such as location,
senior population percentage and competition on the
establishment of hospital-based home care units in Taiwan.
Population Studied: 487 hospitals were identified from the
Taiwan National Hospital Accreditation List (1998-2001) as
studied hospital population, excluding the hospitals closed in
the study period.
Principal Findings: The establishment of hospital-based
home care units is significantly related to hospital size,
ownership, accreditation status, teaching status,
system/network membership, service diversity, inpatient days,
discharges, surgery volume and physician manpower. In
addition, market senior population percentage and market
competition also play important roles in the establishment of
hospital-based home care units in Taiwan.
Conclusions: The establishment of hospital-based home care
units was significantly influenced by the environment and
hospital characteristics. Larger hospital sizes, more diverse
services, private-owned, teaching status, larger physician
manpower, and so on are related to the establishment of
hospital-based home care units. Also, Taiwan hospitals
operate in the markets with more competition and higher
senior population percentage tend to establish hospital-based
home care units.
Implications for Policy, Delivery or Practice: The payment
pressures imposed by Taiwan Hospital Global Budget, the
elder population, and market competition have driven hospital
providers into thinking about another way to enhance their
organizational survival. Based on the theoretical model, this
study might propose a prediction model for Taiwan hospitals
to diversify into their owned home care units.
Primary Funding Source: Taiwan National Science Council
• Performance Analysis of Taiwan Hospitals from a
Organizational Integration Perspective
Blossom Yen-Ju Lin, Ph.D., Ying-Chen Yeh, B.S., M.S.
Presented by: Blossom Yen-Ju Lin, Ph.D., Assistant Professor,
Institute of Health Service Management, China Medical
University, 91 Hsueh Shih Rd., North District,, Taichung, 404;
Tel: 886.922.709359; Fax: 886.4.22019901; E-mail:
yenjulin@mail.cmu.edu.tw
Research Objective: This study is aimed to examine the effect
of hospital organizational types classified as independent
entities, systems, networks, and hospital system-network
mixed entities, on hospital performance.
Study Design: This is a cross-sectional study using individual
hospitals as unit of analysis. The 2002 national survey was
conducted to classified Taiwan hospitals into four types:
independent hospitals, hospital systems, hospital networks,
and system-network mixed hospitals. Hospital system is
defined as hospitals that have unified ownership of affiliated
hospitals; and hospital network refers to hospitals that are
contractual affiliations of other hospitals. The data of
individual hospital classification types were then merged with
official dataset including 2002 Taiwan Hospital Annual Survey
of Service Utilization and 2002 Taiwan Health and Vital
Statistics for market level data. Multivariate analysis was used
to examine the effects of four hospital types on hospital
performance measured as hospital discharges, surgery
volume, and outpatients, controlling with hospital size,
ownership, accreditation status, teaching status, service
diversity, physician manpower, and the market-level factors
such as location, population size and competition.
Population Studied: 487 hospitals were identified from the
Taiwan National Hospital Accreditation List (1998-2001) as
studied hospital population, excluding the hospitals closed in
the study period.
Principal Findings: Multivariate analyses demonstrate that
organizational characteristics such as hospital size,
accreditation status, teaching status, and physician manpower
positively influence service utilization of surgery volume,
discharges and outpatients. Hospital service diversity and
hospital market such as population size and location are
related to hospital utilization of outpatients. Hospital system
and/or networks are shown higher service utilization in
surgery volume and inpatients; however, hospital system
and/or networks are not related to higher service utilization of
outpatients.
Conclusions: The study concludes that hospital
organizational characteristics play an important role in
hospital performance measured as hospital surgery volume,
discharges and outpatients. However, the market level factors
in this study are not significantly related to hospital
performance.
Implications for Policy, Delivery or Practice: Under the
payment pressures imposed by Taiwan Hospital Global
Budget, hospital systems or networks have become popular
organizational types these years. From a practical perspective,
this study showed that different hospital types (i.e.,
independent entities, systems, networks, and system-network
mix) do have diverse performance. It is suggested to
understand the mechanisms that driven hospital performance
diversity in the future.
Primary Funding Source: Taiwan National Science Council
• Small-area Indicators of Racial Residential Segregation
Add Value to Traditional Measures in Explaining Health
Effects
David Litaker, M.D., Ph.D., Joseph Sudano, Ph.D., Natalie
Colabianchi, Ph.D.
Presented by: David Litaker, M.D., Ph.D., staff physician,
Medicine, Louis Stokes VA Medical Center, 10701 East
Boulevard, Cleveland, OH 44106; Tel: 216.844.8104; Fax:
216.844.3313; E-mail: wrightlit@aol.com
Research Objective: Much of the research examining links
between health status and social characteristics has relied on
aggregate health outcome rates, cross sectional design and
coarse operational measures that do not reflect exposure at
level more proximate to the individual. The purposes of our
study was to compare the Dissimilarity (D) index, a traditional
measure of racial residential segregation (RRS), and two
census tract (CT)-based indicators reflecting distributional
inequality and racial density in explaining health status change
over time at the individual level.
Study Design: Longitudinal data from the Health and
Retirement Study were obtained to explore factors associated
with change in self-reported overall health (SROH) from 1992
to 2000. CT and MSA data from the 1990 US census were
used to calculate a new measure reflecting the relative
proportion of minorities in the CT to the surrounding MSA (S
index). A similar approach was used to determine relative
racial density (C index). Because of the skewness of both
indices, values were organized into three categories reflecting
low (<75th percentile), medium (75-90th percentile) and high
(>90th percentile) segregation. After adjusting for age, race,
gender, and baseline report of SROH in 1992, we compared
coefficients for D, S, and C index categories generated from a
series of multilevel logistic regression models for SROH in
2000, in which measures were introduced singly and in
combination. Data fit was assessed and compared across
models.
Population Studied: A sample of community-dwelling adults,
age 51-61 years at the initial interview
Principal Findings: Complete data on SROH were available
for 6658 individuals residing in 1303 census tracts,
geographically dispersed throughout the United States.
Separately the S and C indices were independently associated
with change in health status although D was not. Although S
and C indices remained independently associated with health
status when combined with D, a statistical association with D
could not be demonstrated. After discounting for the number
of parameter estimates in each model, fit was best for models
including all three measures.
Conclusions: CT-based measures of RRS add substantial
value to traditional measures in understanding the effects of
this macro-social process on health status obtained directly
from the individual. Previous studies using the D index may
have underestimated these effects.
Implications for Policy, Delivery or Practice: Measures of
RRS that more accurately reflect health effects at the individual
level are needed in planning and deploying comprehensive
policy initiatives to reduce disparities in health.
Primary Funding Source: VA
• Doubly Disadvantaged: Younger Racial/Ethnic Minorities
with Cardiovascular Diseases Benefit Less Often from
Secondary Prevention
David Litaker, M.D., Ph.D., Siran Koroukian, Ph.D., Joseph
Frolkis, M.D., Ph.D., David Aron, M.D., M.S.
Presented by: David Litaker, M.D., Ph.D., Staff Physician,
Medicine, Louis Stokes VA Medical Center, 10701 East
Boulevard, Cleveland, OH 44106; Tel: 216.844.8104; Fax:
216.844.3313; E-mail: dxl25@cwru.edu
Research Objective: Racial disparities exist in cardiovascular
disease (CVD) prevention, but non-clinical factors other than
race may also influence the care individuals receive or
implement, compounding disparities further. The objective of
this study was to identify factors potentially contributing to
racial disparities in cardiovascular outcomes through an
exploration of utilization patterns in lipid-lowering agents
(LLA), an established secondary preventive pharmacological
intervention for cardiovascular diseases (CVD) and their
relationship to other non-clinical characteristics.
Study Design: Medicaid enrollment and claims 1992-1999
were the primary data sources for this secondary analysis.
LLA claims in the 12 months preceding and after the first date
of service for a CVD diagnosis or procedure in each
individual’s claims history were used to reflect previous or
new LLA use and long-term adherence. Stratified bivariate
analyses and multivariable logistic regression models were
used to explore mediating and moderating relationships
within use patterns related to patients’ age, gender, and race.
Population Studied: A cohort of non-institutionalized, fee-forservice Ohio Medicaid beneficiaries with uninterrupted
eligibility, CVD identified from claims data using selected
ICD9-CM codes, and no medical contraindications to LLA use.
Principal Findings: Of 19106 cohort members with CVD,
3934 (20.6%) used LLA previously. Among those without
previous use, 1598 (10.5%) filed a new LLA claim. Of 5532
previous or new users, 2998 (54.2%) filed >6 claims for refills,
indicating long-term adherence. In stratified analyses,
younger minorities were less likely than whites to have used
LLA previously (X2=61.0, p<0.001), to have filed new LLA
claims (X2=21.7, p<0.001), or to have adhered to LLA over an
extended period once treatment was started (X2=49.9,
p<0.001). In a multivariable model, long-term adherence was
lowest for minority adults <40 years (adjusted odds ratio 0.17
[0.04, 0.68], p<0.001).
Conclusions: Our data confirm the underutilization of LLA as
a secondary preventive strategy for CVD. The potential future
consequences of under-use fall most heavily, however, on
younger minority adults with CVD who receive or adhere to
this therapy least often despite reduced financial barriers and
similar access to health care.
Implications for Policy, Delivery or Practice: Future tailored
interventions to promote delivery and adherence to preventive
care will be better guided by identification of subgroups that
currently benefit least. As a standalone strategy, improved
access to medications through universal health care or
expansion of existing programs may not adequately address
existing disparities in preventive care and their consequences.
Primary Funding Source: VA
• Comparing Physician Efficacy, Attitudes, and Reported
Delivery of Service With Observed Performance: Is It
Reasonable to Expect Consistent Results for Different
Preventive Services?
David Litaker, M.D., Ph.D., Susan Flocke, Ph.D., Kurt Stange,
M.D., Ph.D.
Presented by: David Litaker, M.D., Ph.D., Staff Physician,
Medicine, Louis Stokes VA Medical Center, 10701 East
Boulevard, Cleveland, OH 44106; Tel: 216.844.8104; Fax:
216.844.3313; E-mail: dxl25@cwru.edu
Research Objective: Behavioral theory suggests that
knowledge shapes one’s attitudes, perceptions of
effectiveness (efficacy) in undertaking certain tasks, and
subsequent actions. The uniformity of these relationships in
different areas of prevention is uncertain, but represents
important information about health care providers needed to
guide the development of interventions that increase delivery
of preventive services by physicians. To explore this area of
uncertainty, we assessed the size, direction, and significance
of correlations between clinicians’ attitudinal characteristics,
self-reported behavior, and directly observed cancer screening
and cardiovascular prevention behavior.
Study Design: Cross-sectional data from the Direct
Observation of Primary Care was used to examine delivery of
U.S. Preventive Services Task Force recommended services.
Observation of patient encounters by study nurses and
medical record review were used to document provision of
preventive services. Indicators were computed for each patient
reflecting the extent to which they were up to date on four ageand gender-specific preventive services relating to cancer or
cardiovascular disease: Papanicolau (PAP) smears, prostate
specific antigen (PSA) testing, advice on smoking cessation,
and use of aspirin for cardiovascular disease prevention. For
each physician in the study, the mean proportion of observed
patients that were up to date on these services was calculated.
Attitudinal characteristics toward prevention were determined
by asking physicians to rate their efficacy in delivering the
selected tasks and the importance of performing each.
Estimates for the proportion of eligible patients in clinicians’
practices typically receiving the selected services were
obtained through self-report. Data were analyzed using
bivariate correlations with the physician as the unit of analysis.
Population Studied: 128 family physicians and 2708
established patients of the practice,
aged 18 years or older
Principal Findings: Significant correlations between physician
efficacy and cancer screening with PAP smears and PSA tests
were present (r=.28, p=.001 ;r=.24, p=.006 , respectively),
while those with smoking cessation advice or use of aspirin
for secondary cardiovascular prevention were not. A
significant correlation between physicians’ importance rating
for PSA screening was present (r=.238, p=.007) although this
was not the case for PAP smears, counseling smokers to quit,
or for the use of aspirin. Finally, significant correlations were
present between physician estimates of rate of cancer
screening services (r=.27, p=.003; r=.18, p=.048 for PAP and
PSA, respectively), while correlations with smoking cessation
advice and use of aspirin were absent.
Conclusions: Reasons for stronger correlations between
physicians’ attitudinal characteristics and the delivery of
cancer prevention-related services than for cardiovascular
diseases are unclear, but may more directly reflect patients’
apprehension about cancer and more frequent demand for
these services. Further exploration using qualitative
techniques may be useful in explaining these results.
Implications for Policy, Delivery or Practice: Relatively small
and inconsistent correlations between physician report and
direct observation in four services common to the primary
care setting suggests that the theoretical link between
knowledge, attitudes, efficacy and practice may be moderated
by clinical area. Further, clinician report of efficacy alone may
be insufficient information upon which to base tailored
interventions that enhance prevention service delivery.
Primary Funding Source: VA
• Comparing Patient Safety in Rural and Urban Hospitals
by Bed Size
Stephenie Loux, M.S., Susan Payne, Ph.D., M.P.H., Ira
Moscovice, Ph.D., Astrid Knott, Ph.D.
Presented by: Stephenie Loux, M.S., Research Analyst,
Institute for Health Policy, Muskie School of Public Service,
509 Forest Avenue, PO Box 9300, Portland, ME 04104; Tel:
207.780.5774; E-mail: sloux@usm.maine.edu
Research Objective: Patient safety is an important national
issue. Nearly one half of US hospitals are rural. To date, there
has been little attention to patient safety in rural hospitals,
especially small hospitals. Information is needed to target
interventions to improve patient safety. Our objective was to
determine how patient safety varies, by bed size, a) among
rural hospitals and b) between rural and urban hospitals.
Study Design: Using the 2000 Healthcare Cost and
Utilization Project (HCUP) National Inpatient Sample (NIS),
we calculated mean observed and risk-adjusted rates for 19
patient safety indicators (transfusion reaction was excluded)
for rural and urban hospitals by bed size. Rates were risk-
adjusted for patient sex, age-sex interactions, comorbidities
and diagnosis-related group (DRG) clusters. We classified
HCUP hospitals by actual bed size, obtained from the AHA
Survey, rather than using the pre-classified hospital bed size
variable in the HCUP dataset. T-tests were used to determine
statistically significant differences in rates (at p<.01).
Population Studied: Of the 994 rural and urban hospitals,
264, primarily in the South, lacked AHA identifiers in the 2000
HCUP database and so lacked actual bed size. We studied the
remaining 730 rural and urban hospitals. Hospitals were
classified into three categories: small (<50 beds), medium (5099 beds) and large (100 or more beds).
Principal Findings: Compared to large rural hospitals, small
rural hospitals had statistically significantly lower rates of
potential patient safety events for 4 of the 19 PSIs (foreign
body left during procedure, iatrogenic pneumothorax,
infection due to medical care, and post-operative hip fracture).
Significant differences were not detected for the remaining
PSIs. When compared to large urban teaching hospitals, large
rural hospitals had statistically significantly lower rates for 5
PSIs (death in low mortality DRGs, decubitus ulcer, infection
due to medical care, post-operative physiologic or metabolic
derangement, and post-operative thromboembolism). No
other significant differences were found.
Conclusions: Existing databases can be used to identify areas
for intervention to improve patient safety in rural hospitals
and issues for special attention for selected PSIs. The results
suggest that, for selected PSIs, there is considerable over lap
in patient safety issues between rural and urban hospitals.
Implications for Policy, Delivery or Practice: Bed size, in
addition to location and teaching status, affects patient safety
for selected PSIs and should be considered by policy makers
in targeting interventions to improve patient safety.
Primary Funding Source: AHRQ and Office of Rural Health
Policy
• Cigarette Smoking and Preventive Health Screening in a
Commercially Insured Population
Michael Manocchia, Ph.D., Julia Finkelstein
Presented by: Michael Manocchia, Ph.D., Health Services
Researcher, Health and Wellness Division, Blue Cross and
Blue Shield of Rhode Island, 15 LaSalle Square, Providence, RI
02903; Tel: 401.459.5965; Fax: 401.459.5078; E-mail:
manocchia.m@bcbsri.org
Research Objective: BACKGROUND: The association
between cigarette smoking and health protection behavior
(indicated by preventive health screenings) was evaluated
among a commercially insured, adult population, age 40-75.
Study Design: METHODS: The sample contains a sub-set of
the managed care, health risk assessment database [MCHRA]
maintained at Blue Cross and Blue Shield of Rhode Island
[BCBSRI]. The MCHRA data was collected from 2000-2003.
Bi-variable and logistic regression analyses were performed to
evaluate the association between smoking status (never,
current and former) and preventive health screenings.
Population Studied: Commercially insured males and
females age 40-75, (n=14,503).
Principal Findings: RESULTS: Using multi-variable logistic
regression models, current smokers were significantly less
likely to have the following preventive screening/tests
compared to those who have never smoked: age 40-75 year
old women, for mammography (adjusted odds ratio [AOR]
.56, p<.0001) for Pap testing (AOR .62, p<.0001) and for
clinical breast exam (AOR .65, p<.0001); age 50-75 year old
males for PSA tests (AOR .51, p<.0001); total sample age 4075 for cholesterol tests (AOR .64, p<.0001), blood pressure
tests (AOR .70, p<.0008); eye exams (AOR .62, p<.0001), and
for flu vaccinations (AOR .81, p<.0002); and for the total
sample age 50-75 for FOBT tests (AOR .73, p<.0002) and for
bowel exam/sigmoidoscopy (AOR .67, p<.0001).
Conclusions: CONCLUSIONS: The findings indicate a strong
association between smoking status and preventive health
screening/tests. Interestingly in this case, compared to data
published from national data sets, health insurance is
controlled for and yet gaps in rates of screening persist.
Implications for Policy, Delivery or Practice: Even with
health care coverage controlled for, cigarette smoking
continues to impact the rate to which the commercially
insured protects their health through screening. Health plans
should design awareness programs to combat differential
rates in screening in relation to smoking status.
Primary Funding Source: Internal BCBSRI funding.
• Illness Seriousness, Coping, and Well-Being among
Women with Systemic Lupus Erythematosus
Gayle Weaver, Ph.D., Corron Marks, B.A.
Presented by: Corron Marks, B.A., Graduate Research
Assistant, Division of Rehabilitation Sciences, University of
Texas Branch, 301 University Boulevard, Galveston, TX 775551137; Tel: 409.772.8222; Fax: 409.747.1638; E-mail:
cmmarks@utmb.edu
Research Objective: Crisis theory is used to examine how
people cope with major life crises such as an illness and
provides a framework for understanding the impact on their
well-being. This study focused on systemic lupus
erythematosus (SLE) as the stressor because of its life
threatening, unpredictable, and chronic nature. The purposes
of this study are to: 1) examine the association between
perceived illness seriousness (SLE intrusiveness, SLE stress, &
SLE status) and coping strategies (active, passive, spiritual; &
energy conservation); and 2) explore the extent to which
coping strategies and perceived illness seriousness predict
global well-being (physical and mental well-being, & life
satisfaction).
Study Design: The study involved a descriptive, crosssectional research design. All participants were interviewed
face-to-face, with interviews lasting about an hour and a half.
A structured questionnaire was designed to measure four
types of coping (via factor analysis), perceived seriousness of
SLE, sociodemographic characteristics, and global well-being.
Population Studied: Eighty-three women participated in the
study. They were recruited through a local lupus chapter of
the Lupus Foundation in Houston, Texas. The mean age was
46.5 yrs (range 22-76), with over half of the being White (58%),
married (59%), and unemployed (57%). Over half indicated
that diagnosis took only about a year and two thirds had lived
with lupus 10 years or less.
Principal Findings: SLE seriousness was found to be
moderate, in that 68% viewed their SLE status as somewhat
stable, 46% reported SLE as somewhat stressful, and 39%
reported SLE as somewhat intrusive. Passive coping was
significantly correlated with all three illness seriousness
variables. Global physical well-being was significantly
predicted by SLE status, SLE stress, SLE intrusiveness, and
passive coping (adjusted r2=.48). Global mental well-being
was significantly predicted by SLE status, SLE intrusiveness,
and passive coping (adjusted r2=.23). Life satisfaction was
significantly predicted by SLE status and active coping
(adjusted r2=.33).
Conclusions: Findings revealed that perceived illness
seriousness has a strong association with global physical and
mental well-being. In addition, low worriers reported greater
physical and mental well-being, more stable SLE status, and
lower SLE stress and intrusiveness than do high worriers.
Also, low active coping was linked to low global mental wellbeing and life satisfaction.
Implications for Policy, Delivery or Practice: Successful
adjustment to lupus is important for disease management.
An understanding of the coping styles that are related to
better health outcomes will help health care professionals
intervene more effectively with their patients to cope with
lupus and other challenging diseases.
Primary Funding Source: School of Allied Health Sciences
(UTMB)
• Gender Differences in Career Progression and Career
Satisfaction Among Graduates of a Midwestern M.H.S.A.
Program
Justin Matus, Ph.D., M.B.A., N. Martin MacDowell, Dr.PH,
M.B.A.
Presented by: Justin Matus, Ph.D., MBA, Assistant Professor,
Health Services Administration, Xavier University, 3800
Victory Parkway, Cincinnati, OH 45207-7331; Tel: 513 745.1912;
Fax: 513.745.4301; E-mail: matus@xavier.edu
Research Objective: This article examines variation in factors
influencing career success among women in contrast to men
health services manager alumni.
Study Design: Each subject was mailed a package that
included a cover letter explaining the purpose of the study and
the methodology being used for assuring a respondent’s
anonymity, the survey instrument, a stamped return envelope,
and a stamped reply post card with the respondent’s name.
The survey instrument was a two part, self-administered
questionnaire. The first section asked contained 12 basic
demographic questions and an overall career satisfaction
question. The second part comprised 14 questions using a 5
point Likert-scale.
Population Studied: A convenience sample of 833 graduates
of the M.H.S.A. program comprised the study population.
The list of names and addresses of these graduates were
obtained from the alumni association. These 833 graduates
include members from every graduating class since the
program’s inception, a span of over 40 years. The list
however does not include every student who graduated from
the program rather only those students who have maintained
some contact with the alumni association within
approximately the past five years. Since the program’s
inception there have been approximately 1,500 graduates.
Principal Findings: Factor analysis using Varimax rotation
indicated three variables defined as effort, environment and
perception each accounting for 18.18 percent, 16.23 percent
and 10.95 percent of the variance respectively. Independent
sample t-tests comparing male versus female scores for
factors effort, environment, and perception indicated no
statically significant difference for effort; however there were
statistically significant differences for environment and
perception. Using a list-wise selection procedure a subsample of 167 cases was further analyzed. Factor scores for
Effort, Environment, and Perception were calculated and
entered into a regression model to predict career satisfaction.
All three factors entered the model at a significance level .05
or less.
Conclusions: We think beyond pointing out what many of us
probably already suspected, that men and women see some
parts of the world differently, that there are substantive
implications for academic programs and the profession. For
academic programs, areas of the curricula such as
professional development and diversity leadership training
need to emphasize not only these differences highlighted
here, but to take steps to open a dialogue on areas such as the
environment and perceptions and the role that they play in
one’s career progression. Likewise it is very encouraging and
worth reinforcing the message that things such as effort,
educational credentials, and taking on visible tasks contribute
to one’s career success.
Implications for Policy, Delivery or Practice: Leaders of
health care organizations should take note of the significant
role that the workplace environment and perceptions play in
an employee’s career progression. This is especially true as
one considers the economic impact of employee turnover and
loss of qualified people because of an environment that the
leaders can in fact influence and change. We also need to ask
why in this study’s findings are a woman’s understanding of
perceptions and the role it plays so different than a man’s? Is
it possible that the competence and potential of a woman is
underestimated, and if so why? And how do we change those
conditions? Yet, we must also recognize that the world of
perceptions is three dimensional and that men and women
interact in this same space. To suggest that only men need to
do something would be narrow and short-sighted on our part.
We think that women too need to be very much self-aware that
these differences do exist and develop accordingly their own
strategies to ensure that their potential, their competence
does indeed get recognized and utilized appropriately.
Ultimately, the true measure of change will be neither a male
or female issue; rather, we hope and believe it will be a
leadership issue implemented by the next generation of health
care managers.
Primary Funding Source: Ed Arlinghaus Grant
• Title not provided
Pamela Mazyck, B.S., PharmD, Jennifer Mazyck-Brown,
Pharm.D
Presented by: Pamela Mazyck, B.S., PharmD, Assistant
Professor, Pharmacy Practice, College of Pharmacy, Medical
University of South Carolina, 280 Calhoun Street, Charleston,
SC 29485; Tel: 843.792.4731; Fax: 843.792.1712; E-mail:
mazyckpj@musc.edu
Research Objective: To demonstrate that use of a look-alikesound-alike (LASA) network-based monitoring service
(RxSafety Advisor) will increase pharmacists and technicians
awareness of potential LASA medication errors.
Study Design: Descriptive study of the rate of change in pre
and post-tests scores among pharmacists and technicians
after a eight week intervention of RxSafety Advisor. In this
study, we assessed pharmacists and technicians knowledge of
LASA medications before and after the initiation of the
RxSafety Advisor. The RxSAfety Advisor alert service sends
selective alerts based on the likelihood, or whether the dosing
information looks normal for the prescription-the same
process a pharmacist would go through for look-alike-soundalike errors if he or she could remember if all of the possible
look-alike-sound-alike pairs and typical doses for every drug
involved.
Population Studied: Pharmacists and technicians employed
by a major retail pharmacy chain within the states of North
and South Carolina.
Principal Findings: Data were collected between May August 2003. In a population of pharmacists and technicians
from all of the participating stores, the overall socre for the
components of the pre and post-test were as follows: the
overall score for matching and completion increased by 15
points (p=0.043) for pharmacists, by 9 points (p=0.065) for
technicians and by 13 points (p =0.052) for pharmacists and
technicians combined. Fifty-three pharmacists and seventyfive technicians completed the LASA pretest. Of the 53
pharmacists, the overall scores were 58, 48 and 65 for
matching, completion and matching & completion
respectively. In addition, the overall pre-test scores for the
technicians were 54, 32 and 58 for the respective parameters.
The LASA post-test participants consisted of thirty-six
pharmacists with scores of 60, 61 and 80 for matching,
completion and matching & completion respectively and
technicians scored as follows: 57, 50 and 67 for the parameters
respectively.
Conclusions: RxSafety Advisor provides the capability to
reduce medication errors at the point of dispensing and
enhance patient safety. Use of this look-alike-sound-alike
network based monitoring service will increase pharmacists
and technicians awareness of potential LASA medication
errors.
Implications for Policy, Delivery or Practice: Utlization of
RxSafety advisor is an example of an error minimization
strategy that provides the capability to reduce medication
errors at the point of dispensing and enhance patient safety. It
is likely that pharmacists will do better at intercepting
medication errors involoving look-alike and sound-alike drugs
if armed with the appropriate tools, such as computerized
systems designed to check for flawed drug orders. RxSafety
Advisor is one of the first databases to afford pharmacists the
ability to recognize potential look-alike-sound-alike medication
errors.
Primary Funding Source: AHRQ, NDCHealth
• The Effects of Health Policy on Nursing and Patient
Outcomes in New Zealand
Barbara McCloskey, DNSc.
Presented by: Barbara McCloskey, DNSc., Yale School of
Nursing, 10 New Lebbon Road, Sandy Hook, CT 06482; Tel:
203.270.8648; Fax: ; E-mail: mcclosba@yahoo.com
Research Objective: In 1993, New Zealand (NZ)
implemented policies aimed at improving access and
controlling costs in the country’s nationalized health care
system by converting operations to a corporate business style.
The policies incorporated three major strategies: reliance on
market competition, generic management, and
managerialism. In the U.S.A. context, this is “reengineering”.
The purpose of this study was to examine the influence that
the policies had on outcomes potentially sensitive to nursing
in NZ’s public hospitals through their influence on
characteristics of the nursing workforce.
Study Design: The study design was an interrupted time
series using administrative hospital encounter data and survey
data on NZ nurses. The interruption was the 1993
implementation of the health care restructuring policies. The
occurences of 14 outcomes potentially sensitive to nursing
were tracked for each study year. The outcomes were
mortality, failure to rescue, average length of stay (ALOS) and
11 clinical outcomes: central nervous system complications;
decubitus ulcers; deep vein thromboses and pulmonary
emboli; pneumonia; urinary tract infections; sepsis; shock;
upper gastrointestinal bleeding; pulmonary failure;
physiologic/metabolic derangement; and surgical wound
infections. Three characteristics of the nursing workforce were
examined for each year: the number of full time equivalents
(FTEs), the hours worked by the FTEs, and the skill mix.
Relationships between outcomes potentially sensitive to
nursing and characteristics of the nursing workforce were
analyzed using autoregression analysis.
Population Studied: Medical and surgical encounters from
1989 to 2000 from all public hospitals in New Zealand (N=3.3
million inpatient discharges) and survey data on all New
Zealand nurses employed in medical and surgical areas in NZ
public hospitals (N=51,000 nurse responses) were analyzed.
Principal Findings: After 1993, nursing FTEs and nursing
hours in NZ public hospitals decreased 36% while average
length of stay (ALOS) decreased approximately 20%. The
combination of a downsized nursing workforce and a
decreased ALOS meant that nursing workloads increased.
Nearly all of the clinical outcomes increased dramatically after
1993 while mortality decreased approximately 35% and failure
to rescue decreased approximately 40%. Autoregression
statistics were consistently significant for the relationship
between nursing and outcomes over time.
Conclusions: The decreases in mortality and failure to rescue
coupled with the increased clinical outcome rates following
the implementation of the 1993 restructuring policies indicate
that as workloads increased nurses’ focus changed from
preventing adverse events to lifesaving.
Implications for Policy, Delivery or Practice: The results of
this study are intended to inform policy makers, employers of
nurses, and nursing leaders about how health care
restructuring influences patient outcomes through its
influence on nursing.
Primary Funding Source: Sigma Theta Tau International,
Delta Mu Chapter
• Employee and Patient Perceptions of Quality
Mark Meterko, Ph.D., David Mohr, Ph.D., Gary Young, J.D.,
Ph.D., Martin Charns, D.B.A.
Presented by: Mark Meterko, Ph.D., Manager, Survey Unit,
HSR&D Management Decision and Research Center,
Veterans Health Administration, VA Medical Center (152-M),
150 South Huntington Avenue, Boston, MA 02130; Tel:
617.232.9500 Ext. 4608; Fax: 617.232.6140; E-mail:
mark.meterko@med.va.gov
Research Objective: Considerable research has been
conducted regarding the relationship between patients’
perception of the quality of their care and the perceptions of
clinicians and others in the healthcare system. However, the
results have been contradictory in part because of differences
in the populations studied and the methods used. The goal of
the present study was to examine the degree of congruence
between patient and employee perceptions of quality of care in
a large healthcare system using a consistent methodology.
Study Design: Employee and patient perceptions of quality
were measured using independent paper and pencil
questionnaires. The employee instrument consisted of 162
agree/disagree Likert-scale items representing 14 specific
domains of work life plus overall job satisfaction. Staff were
also asked to evaluate the quality of patient care and service at
their facility. Data from two patient satisfaction surveys were
also utilized. The inpatient survey consisted of 76 items
representing nine specific domains of care including access,
staff courtesy, continuity of care, and physical comfort. The
outpatient survey consisted of 66 items representing similar
domains. Both surveys utilized three-point response scales
such as: (1) Yes, completely; (2) Yes, somewhat; (3) Not at all.
Population Studied: The employee survey was distributed
anonymously to all employees of the Veterans Health
Administration (VHA) from mid-October to mid-December,
2001; 74,662 (37%) responded. The patient surveys were
mailed to a random sample of 175 inpatients and 175
outpatients from each VHA medical center nation-wide.
Response rates of 65% and 74% among inpatients and
outpatients, respectively, were obtained. Aggregate scores
were computed for 117 acute care hospitals and 134 outpatient
sites.
Principal Findings: Very strong correlations were observed
between employee and patient perceptions of the quality of
care: .65 (inpatient) and .46 (outpatient). By contrast,
correlations between overall employee job satisfaction and
patient perceptions of the quality of care were much weaker
.23 (inpatient) and .10 (outpatient). Preliminary examination
of specific employee survey dimensions has shown diversity
acceptance among employees to be most strongly correlated
with patients’ ratings of the quality of care (r=.51, p<.0001).
Additional multivariate analyses will be conducted to more
carefully examine the relationship between the specific
dimensions of employee satisfaction and specific dimensions
of patient satisfaction.
Conclusions: In general, VHA employees did have an
accurate grasp of what patients’ thought of the quality of care
provided at their facilities. By contrast, patient judgments of
quality of care were not strongly related to employees’ overall
job satisfaction. Employee satisfaction with several specific
work dimensions such as diversity acceptance that might be
collectively described as indicative of the “civility” of the
workplace were, however, significantly related to patient
satisfaction.
Implications for Policy, Delivery or Practice: Results
suggest that a key element of a service climate, an accurate
perception of the customer’s perspective by service providers,
is indeed possible, and that employees may even be able to
serve as proxies for patients in the identification of quality
problems. Further, it does appear that “happy workers mean
happy customers” with regard to several specific aspects of
employee work life.
Primary Funding Source: VA
• Key to Chronic Care Management – Effective PatientPhysician Communication
Subhasis Misra, M.B.B.S, M.S.
Presented by: Subhasis Misra, M.B.B.S, M.S., Patient
Education Coordinator, Quality Improvement, Rush University
Medical Center, 1653 W. Congress Parkway, Chicago, IL 60612;
Tel: 312.942.6068; Fax: 312.942.8748; E-mail:
Subhasis_Misra@rush.edu
Research Objective: To identify strategies that improve
patient-physician communication in chronic care
management.
Study Design: The role of patient-physician communication
in chronic care management is framed and defined. Certain
models of interaction between the physician and patients and
their outcomes based on various factors are studied.
Subsequently various managerial and organizational strategies
to improve communication are presented and analyzed.
Population Studied: Literature Review. Previous research and
reviews on the subject of patient-physician communication are
studied in-depth from textbooks, journals, MEDLINE search
and from authoritative information available on the Internet.
Principal Findings: Effective communication, a vital link in
the patient-physician relationship in chronic care can be
hampered by cultural and gender differences, healthcare
consumerism and demands of managed care. However
strategies that can help improve communication are 1)
developing focus groups on specific chronic conditions, 2)
supporting email and telephone interactions, 3) increasing
training of physicians to make them more aware of the need
and benefits of constant communication, 4) educating
patients to ask and solicit more information on their care, 5)
advocate reimbursements for phone and email interactions
for physicians, 6) taking help of social workers to ensure
regular follow up and get alerts on flare ups.
Conclusions: Although difficult, positive and constant patientphysician communication especially in chronic care delivery
can be the norm and should be approached diligently.
Implications for Policy, Delivery or Practice: Effective
patient-physician interactions can lead to better clinical and
patient satisfaction outcomes in chronic care settings.
Primary Funding Source: Department of Health Systems
Management, Rush University Medical Center.
• Interdisciplinary Healthcare Workforce – The Team of the
Present and Future
Subhasis Misra, M.B.B.S, M.S.
Presented by: Subhasis Misra, M.B.B.S, M.S., Patient
Education Coordinator/Instructor, Quality
Improvement/Health Systems Management, Rush University
Medical Center, 1653 W. Congress Parkway, Chicago, IL 60612;
Tel: 312.942.6068; Fax: 312.942.8748; E-mail:
Subhasis_Misra@rush.edu
Research Objective: To evaluate the roles, benefits,
difficulties and opportunities of an interdisciplinary healthcare
workforce.
Study Design: The concept of an interdisciplinary healthcare
workforce is explored and defined. The various constituents of
the workgroup are identified and their multifaceted roles are
analyzed. The benefits, difficulties and opportunities
associated with such a work group is then studied.
Population Studied: Literature Review. Previous research and
reviews on the subject of interdisciplinary healthcare workforce
group are studied in-depth from textbooks, journals,
MEDLINE search and from authoritative information available
on the Internet. Real life example of the patient education
committee in a tertiary care, academic medical center is used
as a prototype of an interdisciplinary healthcare workforce.
Principal Findings: The patient education committee is
comprised of a diverse group of people with skill sets that
complements each other. All the members have shared goals
and visions. A lot of unique inputs are obtained and there is
better coordination of the work to be done. The workforce is
able to undertake projects for small departments which
otherwise would have been beyond the individual unit. There
is also a system of checks and balances that ensures that the
project in hand is well proportioned and doesn’t lag behind
due to any particular group. There are considerable cost
savings, as employees become the consultants for the project.
However there can be the difficulty of dealing with a large
group of people with different agendas and time frames and
hence there is ample opportunity to develop negotiating and
time management skills. There is also the need to take on
leadership roles for successful completion of a project.
Conclusions: An interdisciplinary healthcare workforce
requires an organized structure and should be well
represented with a variety of healthcare professionals. This
holistic approach to healthcare is beneficial for the patients
and also to the organization.
Implications for Policy, Delivery or Practice: Teamwork,
which is at the essence of an interdisciplinary workforce, can
lead to better coordination of care for the patient.
Primary Funding Source: Department of Health Systems
Management, Rush University Medical Center.
• Concordance among Family Members in the
Measurement of the Quality of Dying
Richard Mularski, M.D., Molly Osborne, M.D., Ph.D., Linda
Ganzini, M.D., M.P.H., J. Randall Curtis, M.D., M.P.H.
Presented by: Richard Mularski, M.D., Fellow in Health
Services; Staff Physician, Medicine; Pulm/CCM and Health
Services, VA Greater LA Health Care System & UCLA, 11301
Wilshire Boulevard, mail code 111G, Los Angeles, CA 90073;
Tel: 310.478.3711 Ext. 44647; Fax: 310.268.4933; E-mail:
rmularsk@ucla.edu
Research Objective: Improving end-of-life care requires
accurate indicators of the quality of dying. Many dying
patients are too ill to report on the dying experience, so
evaluations rely on a family member’s report. If family
members are the source of information for quality
measurement of the dying process, the extent of agreement
among family members on quality ratings of key experiences
needs to be documented and understood. The purpose of this
study was to measure the agreement among family members
who rate a loved-one’s dying experience.
Study Design: A cross-sectional study was conducted by
recruiting from all deaths recorded during calendar year 2000
at two academic institutions. Two to five family members
were recruited for an in-person interview assessing the quality
of their loved-one’s dying experience. Concordance of
responses among family members was measured using
intraclass correlation coefficient (ICC) and was assessed for
frequency and rating components of the QODD’s individual
items, for two global ratings that measure the quality of dying
and the quality of the moment of death, and for a computed
total quality of dying score.
Population Studied: We administered the Quality of Dying
and Death (QODD) instrument to family members of patients
who died in the intensive care unit (ICU) of a university
teaching hospital with 47 ICU beds and an academic Veterans
Affairs Medical Center with 21 ICU beds. Families were eligible
if at least two people age 21 years or older reported having
visited with the decedent for at least six hours in the ICU
before death.
Principal Findings: We completed interviews with 94 family
members of 38 patients (35% of eligible ICU patients). The
overall quality score was 60 of 100 possible points. The
overall quality measure demonstrated moderate agreement
among family members (ICC 0.44). Variability on individual
items ranged from ICC 0.15 to 1.0 and demonstrated more
agreement for frequencies of events (ICC 0.54) than on
determinations of quality (ICC 0.32). We found low
agreement among family members in their responses to how
often pain was under control (ICC = 0.26) and in the quality
effect of having treatment preferences followed (ICC 0.22).
Conclusions: We documented moderate agreement but
important variability among family raters in aspects shown to
be valid quality indicators of end-of-life care. Potential sources
for the variability among the family participants may include
differences in the minute-to-minute experiences with their
loved-one in the ICU, differences in the interpretations of
those experiences, or error in memory or recall.
Implications for Policy, Delivery or Practice: These results
suggest that policy-makers and investigators should be
cautious in using data from subjective quality measures of
end-of-life care if such data are gathered from only one family
rater. If confirmed, these results suggest that AHRQ and
NIH, and ultimately CMS, should encourage quality assessors
to use multiple raters to generate more comprehensive endof-life measurement data to more accurately reflect the quality
of end-of-life care. Future research should endeavor to
understand the variability among family raters and its
influence on obtaining accurate and comprehensive
assessments of the quality of dying and death.
Primary Funding Source: This study was supported by grants
from the Northwest Health Foundation, the American Lung
Association of Oregon, the General Clinical Research Center of
Oregon Health and Science University by National Institute of
Health grant PHS 5 M01 RR00334.
• Effect of Referral Status and Distance from Care on
Episodes of Illness Classification
James Naessens, M.P.H., Stephanie Anderson, BS, Rosa
Cabanela, Ph.D.
Presented by: James Naessens, M.P.H., Clinical Associate,
Health Care Policy & Research, Mayo Clinic, 315 Pavilion,
Rochester, MN 55905; Tel: 507.284.5592; Fax: 507.284.1731;
E-mail: naessens@mayo.edu
Research Objective: Explore the differences in local versus
distant patients using an episode of illness grouper.
Study Design: Computer software which creates episodes of
illness provides promising tools for understanding and
improving the health care services delivered by both primary
care and specialty care providers. However, most tools have
been created using health plan or insurer data. Using data
from a large multi-specialty group practice, we examine some
of the differences between local, regional and distant patients
with one episode of illness classification system.
Population Studied: Data on all patients seen at a large,
Midwestern multi-specialty group practice in April 2003 were
processed through an episode of illness classification system.
Patients were classified by distance traveled from home: local
(<=50 miles), regional (51-120 miles) and distant (121+ miles).
Patients were also identified as physician-referred or as selfreferred.
Principal Findings: A total of 147236 unique episodes were
generated by the system, 87575 (59%) local, 44087 (30%)
distant and 15574 (11%) regional. . Self-referred patients
represent 68% of these episodes. Not surprisingly, the
distribution of types of episodes varies by distance traveled.
Local patients have both more episodes identified as acute
problems (55% of all local episodes vs. 46% of regional and
48% of distant) and more episodes identified as well care
(11% of local vs. 7% of regional and 9% of distant)episodes.
Further analysis will be presented comparing types of
episodes at a more specific diagnostic level across geographic
region and across referral category. Episodes affecting the
muskoskeletal and cardiovascular systems will also be
analyzed to determine if the severity, rate of hospitalization or
level of diagnostic and therapeutic intensity differs by region
or referral type within episode type.
Conclusions: Episodes provide a tool, more precise than
population-based measures and less prone to billing and
delivery artifacts than encounter-based measures for
examining health care utilization and quality for providers and
health systems. However, the episode classification schemes
may need to have more precise definitions to result in useful
tools to be applicable for specialty care.
Implications for Policy, Delivery or Practice: Episodes
should be further enhanced to enable their applicability for
health services research. Special attention needs to be
provided to more diagnostic specificity to provide a useful tool
for specialty care.
• The Economic Inpatient Burden of Multiple Gestation
Families: A Population-Based Study in Massachusetts
Angela Nannini, NP, Ph.D., Milton Kotelchuck, M.P.H., Ph.D.,
Mary Barger, CNM, M.P.H., Wanda Barfield, M.D., M.P.H.,
Kay Tomashek, M.D., M.P.H., Steve Evans, M.P.H.
Presented by: Angela Nannini, NP, Ph.D., Assistant
Professor, Nursing, Northeastern University, 27 Washington
St., Beverly, MA 01915; Tel: 978.921.0125; Fax: 978.921.0125; Email: a.nannini@neu.edu
Research Objective: We compare the economic inpatient
burden for families with twins and higher order multiples
(HOM) to families with singletons from antenatal through
postpartum/neonatal periods. Since the increased costs of
multiple gestations are generally attributed to higher rates of
prematurity we also examine the economic inpatient burden
of twins and HOMs stratifying by gestational age
Study Design: Using longitudinally linked birth certificate to
hospital discharge, and observation stay data from the
antenatal through the postpartum/neonatal periods we
compare total charges and mean total charges for twin, higher
order multiple and singleton families. After stratifying for
gestational age we compare mean total inpatient charges for
each family group and mothers and infants in each group.
Mean length of stay for antenatal, delivery, and postnatal
stays, and antenatal and postnatal hospitalization rates are
also compared. Further analyses will control for facility level,
delivery method, and key demographic characteristics.
Population Studied: All births in MA from 1998-2001
including 314,161 singletons, 6612 twin pairs and 350 higher
order multiple family groups.
Principal Findings: Twins and higher order multiples account
for 2% of families giving birth in Massachusetts but account
for 10% of charges. Differences for mean charges for twin and
HOM mothers compared to singleton mothers increased as
gestational age increased. Differences for mean infant
charges for multiple gestations increased after 32 weeks
particularly for HOM infants who showed exponential
increases. Overall, total economic inpatient burden was 5
times higher for twins and over 17 times higher for HOM as
compared to singleton families.
Conclusions: This first population-based study that considers
antenatal, delivery and postpartum/neonatal charges for
inpatient and observation hospital stays associated with
multiple births shows that the increased economic burden of
multiple gestations is not only related to higher rates of
prematurity. Reducing prematurity in twins and HOMs will
decrease significantly the overall economic burden of multiple
gestations since these infants are the most costly. However
differences between singleton and multiple gestation groups
increase as gestational ages increase, so these families will
still be more costly than comparable singleton families.
Implications for Policy, Delivery or Practice: Policy makers,
providers and consumers considering use of reproductive
technologies should work on solutions to prevent multiple
gestations particularly HOMs and join with others to prevent
prematurity for all infants.
Primary Funding Source: CDC
• Variations in Out-of-Pocket Healthcare Costs for
Medicare Beneficiaries in HMOs and Medigap
Lauren Nicholas, B.S., Brian Biles, M.D., M.P.H.
Presented by: Lauren Nicholas, B.S., Research Assistant,
Center for Health Services Research and Policy, George
Washington University, 2021 K Street NW, Suite 800,
Washington, DC 20006; Tel: 202.530.2364; Fax: 202.530.2336;
E-mail: lhn@gwu.edu
Research Objective: To determine whether Medicare+Choice
plans or Medicare Supplement policies are more cost-effective
for beneficiaries by health status in 2004.
Study Design: Average annual out-of-pocket spending for
Medicare+Choice beneficiaries in the two HMOs with the
largest market shares in metropolitan areas with high rates of
Medicare managed care penetration were compared to out-ofpocket spending estimates for beneficiares enrolled in
Medigap Plan F, the most popular supplement, in these cities.
Estimates are based on plans currently available as of January
1, 2004. Spending estimates for the M+C plans are calculated
by HealthMetrix Research, Inc. and estimates for Medigap
plans are calculated using the HealthMetrix methodology and
quote for AARP/United HealthCare community-rated Medigap
policies.
Population Studied: Thirteen major Medicare+Choice
markets around the country were studied, including the ten
markets with the highest penetration rates for HealthMetrix
data was available and three additional markets which we have
studied in earlier site visits. As there is considerable
geographic variation in the Medicare+Choice program,
findings from these cities are illustrative of national trends but
not necessarily representative of experiences in all
communities nationwide.
Principal Findings: Medicare managed care plans limit outof-pocket spending for beneficiaries in good and fair health
relative to Medigap. However, in eight of the thirteen markets
studied, average out-of-pocket spending is lower for Medigap
enrollees. Differences between Medigap and HMOs ranged
from a few hundred to a few thousand dollars annually.
Conclusions: As payments to Medicare+Choice plans have
not kept pace with rising healthcare costs, health plans have
trimmed benefits and offered benefit packages that may
encourage favorable risk selection. Consequently, Medicare
managed care plans in some communities are not as good a
value as Medigap Plan F for beneficiaries in poor health.
Implications for Policy, Delivery or Practice: Contrary to
popular belief, Medicare managed care plans do not
necessarily shelter beneficiaries from most out-of-pocket
health care costs. Beneficiaries may accept a limited provider
network in anticipation of HMO cost containment and find
that they still pay more out-of-pocket with an M+C plan. These
findings should be used to ensure that beneficiaries in poor
health are adequately protected from high healthcare costs
under Medicare Advantage.
Primary Funding Source: CWF
• Underinsurance among Children with Special Health
Care Needs
Donald Oswald, Ph.D.
Presented by: Donald Oswald, Ph.D., Associate Professor,
Psychiatry, Virginia Commonwealth University, Box 980489,
Richmond, VA 23298-0489; Tel: 804.828.9900; Fax:
804.828.2645; E-mail: doswald@vcu.edu
Research Objective: The issue of underinsurance is
increasingly being recognized as critical for children with
special health care needs (CSHCN). This population is likely
to have substantially increased health care expenditures,
compared to their typical peers, and is at risk for delayed or
deferred care due to insufficient insurance coverage. The
present study analyzed national SLAITS CSHCN Survey data
to characterize the status of children with special health care
needs with respect to the adequacy of their insurance
coverage.
Study Design: Economic and attitudinal definitions of
underinsurance were operationalized using items from the
CSHCN survey, as alternatives to the “adequacy of insurance”
core outcome defined and operationalized by MCHB. Using
these alternative definitions, national and state-level
underinsurance rates were calculated for children with special
health care needs and for typical peers. Logistic regression
models were employed to determine whether status (CHSCN
vs. non-CSHCN) was a significant predictor of
underinsurance.
Population Studied: The population under investigation is
children with special health care needs in the United Stated. A
national sample of children with special health care needs was
investigated using recently-released SLAITS CSHCN Survey
data. The survey also included a sample of typical (i.e., nonCSHCN) children that serve as a comparison group.
Principal Findings: Alternative algorithms illustrate the
conclusion that underinsurance rates vary substantially,
depending on the definition and the manner in which the
definition is operationalized. Underinsurance rates for CSHCN
and typical children are different and the extent of such
differences is dependent upon the definition and the
algorithm used to operationalize underinsurance.
Conclusions: Underinsurance rates are difficult to interpret
unless accompanied by a clear operational definition of the
construct. Nonetheless, differences in underinsurance rates
exist between children with special health care needs and
typical children.
Implications for Policy, Delivery or Practice: Such
differences yield important policy and research implications.
Higher rates of underinsurance among children with special
health care needs suggests a need to re-examine the notion of
equity in health care access and quality for this population.
Primary Funding Source: HRSA
• Qualitative Assessment of Resident Physicians' Training
and Preparedness to Deliver Cross Cultural Care
Elyse Park, Ph.D., Joseph Betancourt, M.D., M.P.H., Minah
Kim, Ph.D., Angela Maina, B.S., Joel Weissman, Ph.D.
Presented by: Elyse Park, Ph.D., Instructor, Institute for
Health Policy, Massachusetts General Hospital, 50 Staniford
Street, 909, Boston, MA 02114; Tel: 617.724.6836; Fax:
617.724.4738; E-mail: epark@partners.org
Research Objective: The Institute of Medicine Report
“Unequal Treatment” cited cross-cultural training as a
mechanism to address racial and ethnic disparities in health
care, but little is known about residents' preparedness to
provide quality care to diverse populations or the barriers they
face in practice. This study explores residents' perceptions of
1) their preparedness to deliver care to diverse patients; 2) the
barriers they face in delivering such care; and 3) the
educational climate for cross-cultural training at their
institution.
Study Design: Seven focus groups and 10 individual
interviews were conducted with 58 resident physicians across
the country. Groups and interviews were recorded and
transcribed. Thematic content analyses were performed.
Population Studied: Residents in six specialties.
Principal Findings: Residents reported wide variability in
perceived preparedness (knowledge, attitudes, skills) to deliver
cross-cultural care across specialties. Many residents tended
to view cross-cultural care as it relates to language and found
it difficult to conceptualize culture in broader terms.
Nevertheless, many felt the need to increase their own selfawareness and acquire knowledge about cultural norms,
family, and religious beliefs. Some residents reported that
they had developed certain methods of coping with the
challenges of caring for diverse patients, including assessing
patient comprehension and beliefs about the cause of illness,
and recognizing visual cues and body language. Barriers to
delivering care included language difficulties, mistrust, family
interference, and religious differences. Residents cited many
negative health implications resulting from poor cross-cultural
communication.
When asked about the educational climate for cross-cultural
care at their institution, the level of support and value for
cross-cultural care varied by specialty. Although there was an
overall sense of endorsement for cross-cultural care, the sense
was that this was a low priority. In addition, there was little
awareness and availability of resources. Many residents
learned through informal mechanisms, such as talking to
other residents and interacting with diverse patients, and
reported little formal training during residency. Residents
wanted more formal training in cross-cultural care
(communication/idiom training, working with interpreters)
but expressed concern that culture-specific training can lead to
stereotypes. They also recommended informal training
mechanisms (diversifying faculty, learning from
multidisciplinary staff).
Conclusions: There is little formal training for residents in
cross-cultural care. Rather, they obtain cross-cultural skills
while on the job. As a result, many developed coping
behaviors, rather than skills based on best practices.
Residents had developed some skills to deliver cross-cultural
care, but levels of preparedness varied. Although residents
felt that they needed more culturally-specific knowledge, there
was a strong sense that they should not engage in culturallyspecific treatment. Overall educational climates at the
residents’ institutions did not prioritize cross cultural training
and practice.
Implications for Policy, Delivery or Practice: Training
environments need to augment formal and informal training
mechanisms to enhance residents’ preparedness to deliver
cross-cultural care if the medical profession is to achieve the
goals set by the IOM.
Primary Funding Source: CWF, The California Endowment
• Development of an Enabling Services Database at
Community Health Centers
Heidi Park, Ph.D., Rosy Chang Weir, Ph.D.
Presented by: Heidi Park, Ph.D., Research Associate, The
New York Academy of Medicine, 1216 Fifth Avenue, New York,
NY 10029; Tel: 212.419.3525; E-mail: hpark@nyam.org
Research Objective: Enabling services are provided by
community health centers to increase access and quality of
care for their diverse and vulnerable populations. However,
there is currently little known about enabling services and non
systematic method for collecting data on these services. The
purpose of this project is to better understand enabling
services and their impact on health care of underserved Asian
Americans and Pacific Islanders at health centers.
Study Design: This pilot study was conducted at four health
centers serving primarily Asian Americans and Pacific
Islanders in three states: New York, Washington and Hawaii.
The sites provide variation in geographical location, and AAPI
composition. Semi-structured interviews were conducted faceto-face and by telephone with enabling services providers at
each health center to gather qualitative data. Quantitative data
was collected on enabling services, which includes patient
information and encounter data, and is capable of linkage with
other databases at the health center for further analysis.
Population Studied: Asian Americans and Pacific Islanders at
Community Health Centers
Principal Findings: From interviews with enabling services
providers at the four health centers, we have categorized
enabling services into eight categories for the purposes of this
project. These categories include case management
assessment, case management treatment and planning,
referral, interpretation, transportation, eligibility assistance,
health education and outreach. These services include
assisting patients in getting referrals, adhering to treatment,
and arranging for payment of care not covered by insurance.
The method of delivering each enabling service varies by
health center. Enabling services indicated that their patients
often require more than one enabling service to access care,
and their medical needs are complex. The new data collection
process implemented through this project shows that on
average, there were 1.7 enabling services per user,and the
length of encounter was 22 minutes. The most common
enabling service was interpretation for two health centers,
transportation for one health center, and eligibility assistance
for one health center.
Conclusions: Enabling services are critical to the delivery of
care at community health centers that serve Asian American
and Pacific Islander populations. They include various types of
services often provided by different methods, and utilization of
services varies by health center. The new data collection
process developed by this project has the ability to show
utilization patterns at health centers.
Implications for Policy, Delivery or Practice: It is necessary
to obtain better data on enabling services, especially at health
centers that disproportionately serve diverse and underserved
populations who often rely on these services for access to
care. Although enabling services are import to care at health
centers, these services are generally underfunded and not
reimbursed. Further study is needed to evaluate the cost
effectiveness of these services to help health center
management allocate resources, as well as to better understan
the impact of these services on health care.
Primary Funding Source: MetLife Foundation
• The Relationship of Oral Health and Diabetes - Results
from a Study in the Latino Community
Karen Peters, Dr.PH, Anne Koerber, DDS, Ph.D., Esther Vega,
B.S., Kathija Noorllah, B.S., Isther Torres, B.S., John Crawford,
DDS
Presented by: Karen Peters, Dr.PH, Assistant Professor,
Center for Rural Health Professions, University of Illinois
College of Medicine - Rockford, 1601 Parkview, Rockford, IL
60607; Tel: 815.395.5906; Fax: 815.395.5781; E-mail:
kpeters@uic.edu
Research Objective: The American Academy of
Periodontology position paper on Diabetes and Periodontal
Diseases (AAP 1996) concludes that the evidence supports a
relationship between diabetes and periodontal diseases especially in patients with poorly controlled diabetes. In
addition, diabetes is a significant risk factor for periodontal
disease and other oral infections. In order to optimize health
outcomes, persons with diabetes and their health care
providers must understand the relationship between diabetes
and oral health. These issues may account for some of the
health disparity evident in the Latino population with its
higher prevalence of diabetes and poor oral health. This study
solicited Latino community views on the relationship of
periodontal diseases and diabetes, including how to convey
that relationship to the community.
Study Design: A series of four focus groups with 38 Spanishspeaking participants were conducted in a community-based
setting. The members were invited to read a paragraph
concerning the bidirectionality of diabetes and periodontal
diseases. Subsequent discussion around the paragraph’s
meaning and potential impact on the Latino community was
captured via conventional focus group methodology.
Population Studied: The target audiences for the focus
groups were: 1) Male and female high school students; 2)
Parents of young children; 3) Older adults; 4) Adults with
diabetes. Participants were recruited from a community area
in Chicago with a large concentration of Latinos.
Principal Findings: The participants feel that literacy is
enough of an issue that the word should be put out by word of
mouth, making the information into "juicy gossip" and asking
people to spread the word to their families and neighbors.
They feel that written information would be of less value.
Information in Spanish is a must. They are all unaware of any
link between diabetes and oral health. They report that they
don't get any diabetes information from their dentists and no
oral health information from their doctors. According to the
focus groups, there is little use of herbalists for treatment of
diabetes or oral problems. The older focus group participants
also report feeling discriminated against in public clinics by
some of the employees. The women seem very concerned
about getting information to their families, especially
information about diabetes.
Conclusions: While many of the same themes emerged from
the focus group discussions among the different groups,
some differences were noted based on demographic
characteristics. For example, while word of mouth strategies
were suggested by all groups, males prefer to learn this
information from co-workers or at their place of work. In
contrast, females had a preference for getting information
from neighbors or relatives. These differences suggested the
need for tailored strategies to deliver health education/health
promotion information to this community.
Implications for Policy, Delivery or Practice: Focus groups
provided a start on seeking means of communicating within a
Latino community on the relationship of diabetes and oral
health. Because there is little information known about the
relationship between diabetes and oral health at the
community and provider levels, community-based and clinical
education interventions are needed to increase awareness of
this relationship as potential strategies to reduce health
disparity in the Latino population.
Primary Funding Source: CDC
• Influenza Vaccination among Elderly Asian Americans
Judy Chen, M.D., Nadereh Pourat, Ph.D., Allison Diamant,
M.D., Marjorie Kagawa-Singer, Ph.D.
Presented by: Nadereh Pourat, Ph.D., Senior Research
Scientist, UCLA Center for Health Policy Research, 10911
Weyburn Avenue, #300, Los Angeles, CA 90024; Tel:
310.794.2201; Fax: 310.794.2686; E-mail: pourat@ucla.edu
Research Objective: To examine the rates of influenza
vaccination among Asian American elderly and explore the
predictors of this vaccination.
Study Design: Our study population was drawn from the
2001 California Health Interview Survey, a random digit dial
population-based telephone survey conducted in English,
Spanish, and 5 Asian languages. We assessed receipt of
influenza vaccination among persons 65 years and older by
race, and used multivariate logistic regression to control for
age, marital status, years living in the U.S. English proficiently,
education, insurance, income, usual source of care, number of
physician visits, use of other preventive services, presence of
chronic medical conditions, and health status.
Population Studied: Over 11,400 adults 65 years and older
completed the interview among whom 692 adults were of
Asian descent.
Principal Findings: About three quarter of Asian Americans
reported having received an influenza vaccine in the past year,
in comparison to 69% of non-Hispanic Whites, 52% of African
Americans, and 54% of Latinos. This higher rate remains after
controlling for other confounders such as socioeconomic and
demographic factors. The predictors of influenza vaccination
among Asian American elderly include having a usual source
of care and supplemental Medicare coverage.
Conclusions: Our results show high rates of influenza
vaccination among Asian American elderly independent of
demographics, socioeconomic and health status factors. The
results confirm the importance of usual source of care and
supplemental Medicare coverage in predicting this
vaccination, even though influenza vaccination can be
obtained free of charge in most cases.
Implications for Policy, Delivery or Practice: The insight
gained on examining the high rates of influenza vaccination
among Asian American elderly, may identify effective
approaches in increasing receipt of influenza vaccination
among other ethnic populations and increasing the receipt of
other preventive services among Asian Americans.
Primary Funding Source: RWJF
• Work-Related Injuries, Poor Health and Early Retirement:
A Preventable Adverse Outcome?
Glenn Pransky, M.D. MOccH, Katy Benjamin, Ph.D.
Presented by: Glenn Pransky, M.D. MOccH, Director, Center
for Disability Research, Liberty Mutual Research Institute, 71
Frankland Road, Hopkinton, MA 01748; Tel: 508.497.0234;
Fax: 508.435.8136; E-mail: glenn.pransky@libertymutual.com
Research Objective: To identify the frequency of occupational
injury-induced early retirement, factors associated with this
outcome, and prevention opportunities.
Study Design: Prospective population-based cohort study
Population Studied: All New Hampshire workers over age 55
with work-related injuries over a 14 month period, resulting in
lost time from work
Principal Findings: 1449 injured workers over age 55
responded (63% response rate); half had lost at least one day
of work. Of these, 55 (11%) said that that they would have to
retire early because of their work injury . Early retirees had
comparatively worse pre-injury health, twice as many sickness
absences in the past five years, and were 1.5 times more likely
to have had a back injury as their presenting complaint. Their
pre-injury job satisfaction was significantly worse, and postinjury they experienced more negative employer responses,
less satisfaction with their medical care, and had more
difficulty arranging work accommodations. At the time of the
survey (on average, six weeks post-injury) their measures of
physical and mental health, work function and concerns about
future work abilities were significantly worse than other older
workers.
Conclusions: Workers with injury-related forced early
retirement differ significantly from other older workers with
work injuries. Pre-injury factors appear to be as important as
type and severity of injury.
Implications for Policy, Delivery or Practice: These risk
factors can be identified early on in the course of post-injury
care, and can serve as an important focus for early, intensive
interventions that could prevent adverse outcomes.
Primary Funding Source: Nat INst Occ Safety and Health
• Influencing Demand while Controlling Supply: The
Impact of Office Copayments in a Prepaid, Integrated
Delivery Environment
Mary Price, M.A., Richard Brand, Ph.D., Bruce Fireman, M.A.,
Joseph Newhouse, Ph.D., Joe Selby, M.D., M.P.H., John Hsu,
M.D., M.B.A., MSCE
Presented by: Mary Price, M.A., Sr. Consulting Data Analyst,
Division of Research, Kaiser Permanente Northern California,
3914 114th Lane NW, Coon Rapids, MN 55433; Tel:
763.422.3814; Fax: 763.422.3814; E-mail: Maggie.Price@kp.org
Research Objective: Patients are paying for a greater share of
their health care costs, even in prepaid integrated delivery
systems (IDS). There, however, is limited data on how the
cost-sharing influences behavior in these prepaid settings. We
examined the effect of various levels of an office visit
copayment on office and emergency department (ED) visit
rates.
Study Design: In a retrospective cohort study using
automated clinical databases, we examined the effect of office
copayment level on office and ED visit rates in 2001. All
subjects had commercial insurance and were members of the
Kaiser Permanente Northern California (KPNC) health plan.
We classified the copayment into four categories: free care or
no copayment, $1-9, $10-19, and $20-30 per office visit. We
compared relative rates of office and ED visits by copayment
level using a Poisson mixed-effects model applied to monthly
utilization counts, adjusting for age, gender, co-morbidity and
month.
Population Studied: There were 1,755,574 subjects with
commercial insurance in 2001. Of these subjects, 19.0% had
no copayment, 39.7% had a $1-9 copayment, 40.5% had a
$10-19 copayment, and 0.8% had a $20-30 copayment per
office visit. The mean ED copayments in these groups were
$5.87, $27.56, $36.00, and $39.70 respectively. This cohort is
part of a larger study on the clinical and economic
ramifications of cost-sharing.
Principal Findings: The unadjusted office visit rates per 100
person-years were 469, 430, 400, and 379 in the no
copayment, $1-9, $10-19, and $20-30 copayment groups
respectively; the unadjusted ED visit rates per 100 personyears were 19, 17, 17, and 17. After adjustment, the relative rate
of office visits decreased 9.1% with the $1-9 copayment
(RR=0.909, 95% CI: 0.905 – 0.913), 12.7% with the $10-19
copayment (RR=0.873, 95% CI: 0.869 – 0.877), and 18.7% with
the $20-30 copayment (RR=0.0.813, 95% CI: 0.798 – 0.828).
Similarly, ED visits decreased 10.2% in the $1-9 group
(RR=0.898, 95% CI: 0.887-0.909), 11.6% in the $10-19 group
(RR=0.884, 95% CI: 0.874, 0.895), and 8.6% in the $20-30
group (RR=0.914, 95% CI: 0.868, 0.963).
Conclusions: These data suggest that moderate office
copayment levels are associated with lower office visit rates.
Despite these reductions in office use, ED visit rates did not
seem to increase.
Implications for Policy, Delivery or Practice: Cost-sharing
appears to influence patient demand for office visits, even in a
prepaid, integrated delivery setting. Moreover, the reduction in
demand does not appear to lead to substitution with more
costly emergency services. Further research is needed to
assess the potential clinical and economic effects, i.e. to
assess whether patient cost-sharing for office visits is safe and
how much money it really saves.
Primary Funding Source: AHRQ
• Four Scales to Measure Desired Health Outcomes
Related to Cancer Nursing Care: Development and Pilot
Testing
Laurel Radwin, R.N., Ph.D., Michelle Washko, M.S., Kathryn
Suchy, R.N., B.S., Kerri Tyman, R.N., B.S.
Presented by: Laurel Radwin, R.N., Ph.D., Assistant Professor,
Nursing, University of Massachusetts Boston, 100 Morrissey
Boulevard, Boston, MA 02125; Tel: 617.287.7572; E-mail:
laurel.radwin@umb.edu
Research Objective: Several studies have revealed that
suboptimal nurse staffing is associated with adverse patient
outcomes. The association between the quality of nursing care
and desired health outcomes, however, remains incompletely
understood. The purpose of this study was to develop and
pilot test scales to measure desired outcomes of cancer
nursing care.
Study Design: Twenty-two cancer patients who participated in
a grounded theory study identified four desired outcomes of
excellent nursing care. Fortitude is the patient’s strength and
willingness to bear the effects of cancer treatments as well as
the symptoms of the disease. Trust is the patient’s confidence
that care is appropriate, reliable, and will be as successful as
possible. Authentic self-representation is the patient’s sense of
genuine self-portrayal. Optimism is the patient’s beliefs that
the patient has made appropriate choices regarding
treatment, and the patient’s feelings of hopefulness about
treatment outcomes.
Scales were developed to measure each outcome. Items
operationalized a nurse or patient activity or a patient feeling,
and respondents rank the frequency of each activity or feeling.
Items were revised following feedback from eight experts who
reviewed the initial items for content validity and six cancer
nursing care recipients who participated in cognitive
interviews. The four outcomes scales, encompassing a total of
18 items, were psychometrically tested using MAP-R for
Windows software.
Population Studied: Sixty-six (54%) of 123 community-based
cancer support organization attendees who indicated they had
recently received nursing care returned the scales by mail. The
sample was approximately 77% female; mean age=53.3 years,
(SD=12.57); White, 97.0%; attended college, 80%.
Principal Findings: Internal consistency reliability measured
as Cronbach’s alpha was 0.81 for the Fortitude Scale
(Fortitude); 0.75 for Cancer Patient Optimism Scale
(Optimism). With one item removed from each, alpha was
0.81 for the Trust in Nurses Scale (Trust), and 0.71 for the
Authentic Self-Representation Scale (Authenticity).
Item-level missing data ranged from 0% to 4.5%, suggesting
items were not objectionable or difficult to answer. Responses
potentially ranged from 0 to 100. Means ranged from 67.62
(SD=20.42) for Authenticity to 87.75 (SD=12.36) for Trust. No
scale had a complete range of scores, as each lacked the
lowest possible score. Respondents at the ceiling score (100)
were: Trust, 19.4%; Fortitude, 11.3%; Authenticity, 6.3%; and
Optimism, 1.6%.
All items except one from Authenticity met the criterion itemscale correlation of > 0.40, indicating acceptable convergent
validity. The Cronbach’s alpha for each scale considerably
exceeded the correlation of that scale with the other scales,
indicating that each scale measured a distinctive concept. All
but one item (Authenticity) had acceptable item-discriminant
validity as measured by the standard error of the correlation.
Conclusions: The results of this study indicate that initial
estimates of the psychometric properties of four scales
measuring desired outcomes of cancer nursing care are
acceptable. Further psychometric testing with large samples is
recommended.
Implications for Policy, Delivery or Practice: The Institute of
Medicine asserted that desired health outcomes are a key
component of quality care. These scales provide a mechanism
to measure important aspects of the quality of cancer nursing
care.
Primary Funding Source: AHRQ
• The Effects of Race and Ethnicity on Access to Mental
Health Services
Kai-Li Tsai, Ph.D., Patrick Rivers, Ph.D., M.B.A., Saundra
Glover, Ph.D.
Presented by: Patrick Rivers, Ph.D., MBA, Assistant Professor,
School of Health Administration & Policy, Arizona State
University, P.O. Box 874506, Tempe, AZ 85287-4506; Tel:
480.965.2363; Fax: 480.965.6654; E-mail:
patrick.rivers@asu.edu
Research Objective: To assess the impact of structural,
financial and severity barriers on the differential access of
Mental Health services among adults by race. Study
examined the influence of health insurance, availability of
community medical resources, and transportation, and access
to care on the racial and ethnic variations in utilization and
outcomes of Mental Health services.
Study Design: The authors conducted secondary data
analysis in the 1998-1999 Community Tracking Study (CTS)
household survey. Logistic regression models were used to
the show the patterns of mental health service-seeking
behavior and to examine whether the use of mental health
services varied among racial and ethnic groups. The
dependent variable, mental health service visit, is a dummy
variable representing whether or not the person made a
mental health service visit in the past 12 months. Chi-square
analyses were also performed to examine the independence
between mental health services and the explanatory variables
Population Studied:
Principal Findings: The use of mental health services is
dependent on ethnicity/race, age, gender, education, family
income level and insurance status. Blacks and Hispanics
show significant lower utilization pattern in mental health
service than the White counterpart. Lower income groups
make fewer mental health visits than people in higher income
levels. There were no significant effects of race/ethnicity on
access to mental health services for people with or without a
diagnosis of depression.
Conclusions: Findings of the study support the findings of
the 2003 report of the U. S. Surgeon General documenting the
unmet mental health needs of minorities in America.
Racial/ethnic minorities face particular difficulties in accessing
mental health services related to financial and structural
barriers.
Implications for Policy, Delivery or Practice: This study
supports the importance of identifying the difference in access
to mental health services among racial and ethnic groups.
This study also provides results for policy makers to
understand better those influencing factors that cause barriers
to mental health services. Further studies will be suggested to
develop strategies and programs to minimize the disparity in
access to mental health services, especially for the vulnerable
groups.
• Covariates of Post Traumatic Stress Symptoms from the
1998 Bombing of the American Embassy in Nairobi Kenya:
Similarities with and Differences from Findings in the
United States
Madeline Robertson, J.D., M.D., Robert Broyles, Ph.D., Carol
North, M.D., M.P.E., Pushpa Narayanan, M.B.B.S., Hemant
Patel, M.D., Betty Pfefferbaum, M.D., J.D.
Presented by: Madeline Robertson, J.D., M.D., Associate
Professor, Health Administration and Policy, OUHSC/College
of Public Health, P.O. Box 26901, Oklahoma City, OK 73190;
Tel: 405.271.2115 Ext. 37076; Fax: 405.271.1868; E-mail:
madeline-robertson@ouhsc.edu
Research Objective: The objective of this study was to
examine the covariates of the number of post traumatic stress
symptoms from the 1998 bombing of the American Embassy
in Nairobi Kenya.
Study Design: The study adopted the individual as the unit of
analysis and was based on the responses of 205 Kenyans to a
questionnaire that was administered between 33 and 42
months following the explosion. Probit analysis was used to
examine a dependent variable that measured the number of
symptoms reported by the individual. The focus of the study
was on twenty two retrospectively reported post traumatic
stress symptoms experienced in the previous week. A value of
one was recorded for each symptom if the individual
experienced it “sometimes” or “often” during the past week.
Values of the dependent variable resided on a range extending
from zero to twenty two. The covariates consisted of the
respondent’s demographic attributes, major source of
information concerning the explosion, initial response and
proximity to the bombing, and the individual’s experience with
traumatic events prior to and following the explosion. A set of
binary variables also identified individuals who experienced
the loss of a friend, the loss of a relative, or the loss of a friend
and a relative. The reference category consisted of
respondents who did not experience the loss of a friend or
relative.
Population Studied: The study group consisted of 205
Kenyans who sought mental health services related to the
bombing of the embassy. The survey was completed by
participants in the presence of a mental health clinician or
research assistant who explained the study, obtained informed
consent, and clarified questions as needed.
Principal Findings: The Probit analysis indicates that the
number of post traumatic stress symptoms was greater
among women and those who reported the death of a friend,
a relative, or a relative and a friend. Further, the findings
indicate that the number of symptoms was greater among
respondents who were in close proximity to the bombing and
among those who reported intense initial reactions to the
bombing. In addition, the findings indicated that respondents
who were exposed to a greater number of traumatic events
following the bombing also reported a greater number of
symptoms. However, patients who were exposed to a greater
number of traumatic events prior to the bombing reported a
fewer number of symptoms.
Conclusions: While not examining the diagnosis of post
traumatic stress disorder (“PTSD”), the findings in this
African sample support the diagnostic criteria and are
consistent with some findings derived from U.S. disaster
samples. Consistent with diagnostic criteria for PTSD, physical
proximity and interpersonal relationships with direct victims,
and intense subjective reactions were related to post
traumatic stress symptoms. Similar gender differences are
commonly observed in studies of U.S. disaster populations
though the finding of fewer posttraumatic stress symptoms in
those with prior trauma is not consistent.
Implications for Policy, Delivery or Practice: The results
suggest some cross cultural similarities in reactions to
disaster trauma which may be useful in guiding the planning
of services, but also indicate a need to examine these
populations for differences.
Primary Funding Source: United States Agency for
International Development ("USAID")
• Genetic Influences on Usual Source of Care and Health
Behavior
James Romeis, Ph.D., Hong Xian, Ph.D., Qiang Fu, Ph.D.
Presented by: James Romeis, Ph.D., Professor of Health
Services Research, Health Management and Policy, School of
Public Health, 3545 Lafayette Ave., St. Louis, MO 63104-1314;
Tel: 314.977.8148; Fax: 314.977.1674; E-mail: romeisjc@slu.edu
Research Objective: The overall goal of the study is to assess
genetic and environmental influences on usual source of care
and health behavior.
Study Design: Classical twin design using telephone survey
and tri-variate analytical model fitting methods.
Population Studied: The Vietnam Era Twin Registry - a
community sample of middle age, middle class all male twins
[n=2936 pairs].
Principal Findings: The analysis indicates that there are
moderate unique and common genetic effects for conditon
[alcohol dependence], usual source of care and health
behavior [appropriate contact with usual source of care and
compliance with MD instructions].
Conclusions: The data reinforces previous research designed
to assess the the relative importance of genes and
environmental influence on help-seeking and use of services.
Genetic effects are not trivial and should be incorportated in
our models if our theories are to advance.
Implications for Policy, Delivery or Practice: Health services
research has mostly ignored behavioral genetics in explaining
individual differences in health behavior. As the magnitude of
genetic influences increase, serious consideration needs to be
given to altering interventions to account for this important
source of variation.
Primary Funding Source: NIAAA
• Carotid Endarterectomy Utilization and Mortality in Ten
States
Shadi Saleh, Ph.D. M.P.H., Edward Hannan, Ph.D.
Presented by: Shadi Saleh, Ph.D. M.P.H., Assistant Professor,
Health Policy, Management and Behavior, SUNY-Albany, One
University Place, Rensselaer, NY 12144; Tel: 518.402.0299; Fax:
; E-mail: ssaleh@albany.edu
Research Objective: Studies that examined the rates of and
mortality following carotid endarterectomy (CEA) mainly were
confined to a limited geographical location and/or population.
The primary purposes of this study are to examine the
variation of risk-adjusted in-hospital mortality rates following
CEA in ten states, and utilization rates per capita of CEA.
Study Design: An analysis of hospital discharge data from ten
states extracted from the Agency for Health Research and
Quality’s national database, Healthcare Cost and Utilization
Project (HCUP) was conducted.
Population Studied: Patients who had CEA (code 38.12 of the
International Classification of Diseases, Ninth Revision) listed
as the principal procedure were identified and included in the
study.
Principal Findings: The rates of CEA per capita were found to
differ among the ten states examined. No significant
association was detected between geographic location and the
adjusted risk of in-hospital mortality. Gender, age, type of
admission and several comorbidities were found to be
significant risk factors.
Conclusions: Rates of CEA per capita differ among states.
However, geographical location does not affect the likelihood
of risk-adjusted mortality following the procedure.
Implications for Policy, Delivery or Practice: It is important
to examine regional differences in prevalence and mortality
rates of major procedures. Findings from such studies can
serve as benchmarks of access and quality that states
(regions) can measure their performance against.
• Cost-Effectiveness of Case Management in Substance
Abuse Treatment
Shadi Saleh, Ph.D., M.P.H., Thomas Vaughn, Ph.D., Samuel
Levey, Ph.D., Laurence Fuortes, Ph.D., Tanya Uden-Holmen,
Ph.D., James Hall, Ph.D.
Presented by: Shadi Saleh, Ph.D. M.P.H., Assistant Professor,
Health Policy, Management and Behavior, SUNY-Albany, One
University Place, Rensselaer, NY 12144; Tel: 518.402.0299;
E-mail: ssaleh@albany.edu
Research Objective: The purpose of this study, which is part
of a larger clinical trial, was to examine the cost effectiveness
of case management for individuals treated for substance
abuse in a residential setting.
Study Design: Clients who agreed to participate were
randomly assigned to one of four study groups. Two groups
received face-to-face case management and one
telecommunication case management, while the fourth was
the control group.
Population Studied: Clients in the residential treatment
program were recruited to the study if they met any of the
following criteria: 1) had more than one drug or alcohol related
offense, 2) had a breathalyzer test with a blood alcohol
content of 0.2 or higher, or 3) were involved in a drug or
alcohol related accident.
Principal Findings: Using a ratio of cost to days free from
substance abuse, the case management groups were less
cost-effective than the control group at 3 months, 6 months,
and 12 months. The telecommunication case management
was least cost-effective of the three case management
conditions.
Conclusions: Results from the analysis revealed case
management is not cost effective as a supplement to
traditional drug treatment over a 12-month follow-up period.
Implications for Policy, Delivery or Practice: This study
emphasizes the need for use of evidence-based interventions
with substance abuse treatment clients whenever possible.
Clinical wisdom can guide when data are not available, but
studies on effectiveness and cost-effectiveness should help
identify these evidence-based interventions and lead to better
methods to evaluate these models. As public and private
agency budgets respond to the changing goals of funding
agencies, data on effectiveness and cost-effectiveness will
become even more important and possibly required in the
near future.
Primary Funding Source: NIDA
• Population- and Community-based Health Services
Research: Applications for Health Promotion and Disease
and Injury Prevention Using Historical New Jersey,
Statewide Health Statistics Reports from 1877 to the
Present
Marcia Sass, Sc.D., Mark Fulcomer, Ph.D., Michael Holton,
Carla Hirschmann
Presented by: Marcia Sass, Sc.D., Health Systems and Policy
Division, University of Medicine and Dentistry of New Jersey
(UMDNJ), 32 Rebecca Court, West Trenton, NJ 08628-3343;
Tel: 609.771.9086; E-mail: sassmm@umdnj.edu
Research Objective: Objectives: (1) To convey the
applications of historical health statistics reports to current
time series morbidity and mortality trends, evaluation of
public health issues, structural/organizational evolution of
public health agencies, and workforce development activities;
to describe steps in the development of the historical New
Jersey health statistics files; and to describe uses of the files
for workforce development and other health services research
activities.
Based on three large historical bibliographies, this
presentation describes how the resulting information can be
used in courses such as epidemiology and applied statistics
for workforce development and/or in direct applications to
current public health activities. With their development
described earlier (Fulcomer et al., 2002), two of the collections
continue to expand. Tracing its origins back to 1969, the first
bibliography now includes over 1,000 citations on
discriminant functions, classification, and related topics up
until 1978. Started in 1981 and more recently benefiting from
students’ projects, a second collection related to infant
mortality currently exceeds 300 titles. Beginning in 1999 as a
subset of the infant mortality collection, but treated separately
as its own complete grouping of source documents with the
epidemiology courses in 2002, a third historical bibliographic
project incorporates annual health statistics reports for New
Jersey dating back to 1877. Among the first published
population-based reports of health statistics in the United
States, the third collection offers fascinating, early glimpses
into treatments of health issues such as smallpox and anthrax
that have recently re-emerged as global concerns. Beyond
providing many “real” examples (e.g., time series of mortality
rates), these historical collections also give students and
public health professionals valuable perspectives on the
emergence of health policy and planning, including licensing
requirements for physicians, hospitals, clinics, and other
entities, mental health aspects, early references to health
disparities and surprisingly detailed descriptions of events
across geographic areas.
Research efforts included completion of the copying of the
images of over 40,000 pages found in the 130 volumes of
historical, statewide health statistics reports for New Jersey
published over the period from 1877 to the present. By June
2004, all of these volumes will have been scanned and
converted to PDF formats. Despite their admittedly historical
foci, the collections have some noteworthy current public
policy applications, including (a) identification and medical
diagnosis, (b) investigations of health disparities, and (c)
rapid and legally appropriate (e.g., with respect to notification
of diseases, quarantines) responses to epidemics. These
reports have been used in training of both undergraduate and
graduate MPH students and other public health professionals
and clearly provide guidance for the public health workforce in
terms of considerations in dealing with past and future
population-/community-based public health events. Other
states might consider the value of undertaking such an
endeavor in terms of the potential public health contributions.
• Effects of Children's Health and Mental Health Status on
Medicaid Enrollment
Robert Saunders, M.P.P.
Presented by: Robert Saunders, M.P.P., Research Associate,
Human & Organizational Development, Vanderbilt University,
Box 90 GPC, Nashville, TN 37203; Tel: 615.322.8284; Fax:
615.322.1141; E-mail: robert.c.saunders@vanderbilt.edu
Research Objective: To examine the extent to which health
and mental health status influence disenrollment and reenrollment in Medicaid among children and adolescents. The
analysis also considers whether being in a managed care
environment affects the degree of these relationships.
Study Design: Data come from the Tennessee-Mississippi
site of the SAMHSA-funded Managed Care for Vulnerable
Populations Study. This study employs a quasi-experimental
non-equivalent no-treatment control group design. The
analysis estimates 6- and 12-month exit-from-Medicaid
probabilities using discrete-time hazard models. The
dependent variable is “exit from Medicaid.” The key
independent variables are health status (Child Health
Questionnaire, Body Mass Index), mental health status (Child
Behavior Checklist and Columbia Impairment Scale), and
managed care (Tennessee is managed care; Mississippi is feefor-service). We consider initial status as well as changes in
health status over time. The analysis controls for prior history
of Medicaid enrollment and service use, other personal
characteristics, and household and economic factors. For the
subset of youth who exit, we also consider subsequent re-entry
probabilities.
Population Studied: This analysis used a sample of children
and adolescents, ages 4-17, enrolled in Medicaid in Tennessee
and Mississippi (n=1012). Sampling weights provide
representative estimates for each state’s Medicaid population.
Data were collected from 1997 to 1999.
Principal Findings: Youth who are in better physical and
mental health are significantly more likely to leave Medicaid,
controlling for other factors. In addition, among those who
leave Medicaid, those who re-enroll subsequently are in worse
health. The effect of physical and behavioral health status on
disenrollment was similar between youth served in managed
care and fee-for-service Medicaid systems.
Conclusions: Health and mental health status are key omitted
variables in analyses of insurance transitions, particularly
disenrollment and plan-switching analyses. The analysis
demonstrates that not only are healthier children more likely
to leave Medicaid, but they are also less likely re-enroll. This
indicates substantial problems of adverse retention and
adverse selection in both Medicaid programs.
Implications for Policy, Delivery or Practice: Recent
research on managed care plan switching indicates health and
mental health status affect switching among privately insured
individuals and Medicare managed care enrollees, but far less
is known about children and Medicaid enrollees. If
disenrollment (and re-enrollment) decisions are related to
health status, states may face problems of adverse retention
and adverse selection that compound crowd-out problems,
leading to escalating capitation rates. It also raises potential
quality of care issues, as disenrollment from Medicaid has
been shown to result in deterioration in health that, when
individuals re-enroll, leading to greater expected treatment
costs for states.
Primary Funding Source: NIDA
• The Self-Reported Changes Associated with the
Determination of Disability Claims for Posttraumatic
Stress Disorder
Nina Sayer, Ph.D., Michele Spoont, Ph.D., David Nelson,
Ph.D.
Presented by: Nina Sayer, Ph.D., Investigator, Center for
Chronic Disease Outcomes Research, VA Medical Center, One
Veterans Drive, Minneapolis, MN 55417; Tel: 612.467.4623;
Fax: 612.727.5699; E-mail: nina.sayer@med.va.gov
Research Objective: To examine the impact of disability claim
determination on quality of life and interest in receiving
medical services from the claimants' perspective.
Study Design: Mail survey of individuals seeking disability
status for Posttraumatic Stress Disorder(PTSD) through the
Department of Veterans Affairs (VA) who had participated in a
separate study 18-months earlier (at the time of claim
initiation) in which demographic and claim-related beliefs
were ascertained. Survey materials included the Claim
Determination Impact Survey which asks claimants to
evaluate the effects of claim outcome on their functioning,
emotional well-being and attitudes (Chronbach’s alpha = .93).
Population Studied: 304 of the 429 veterans surveyed
returned study materials. Respondents were from more
advantaged backgrounds than nonrespondents. As a result of
this claims process, 196 responders reported receiving VA
disability benefits for PTSD, 59 reported being denied benefits
and 42 reported that their claim outcome was still pending.
Principal Findings: Not surprisingly, on average, those
awarded benefits report improvement and those not awarded
report worsening consequent to claim determination. Older
veterans reported more improvement related to receiving
disability benefits than their younger counterparts. However,
the award of disability benefits was not universally associated
with self-reported improvement. A subgroup of those granted
benefits (16%) reported worsening consequent to receiving
disability benefits for PTSD. These veterans were more likely
to be younger than 65 years. Nonwhites reported more
worsening consequent to claim denial than Whites,
suggesting that the denial may have more of a negative
impact on ethnic minorities. Additionally, baseline ratings of
the investment in obtaining disability benefits and pessimism
about the claim process were associated with magnitude of
worsening among those without disability benefits. Of
possible concern given that the VA is often used by veterans
without other means for obtaining medical care, about a third
of those not awarded disability benefits for PTSD reported
decreased interest in going to the VA for treatment and in
therapy. Surprisingly, a small subgroup (n = 14) reported
improvement consequent to not obtaining disability status on
the basis of PTSD.
Conclusions: The outcome of the VA disability claims process
is not a neutral event. Most of those awarded benefits,
particularly older veterans, report improvement, while most of
those without benefits, particularly nonwhites whose claims
are denied, report worsening related to the PTSD claim
determination. Those who are very invested in obtaining
disability benefits and those who are particularly negative
about the claims process when they file their claim may
experience more extreme negative reactions in response to
not receiving disability benefits. These findings also indicate
that receiving disability status is not always experienced as a
positive event, particularly for working-age adults. Similarly,
there was some indication that for some veterans, not
receiving disability status may have some beneficial effects.
Implications for Policy, Delivery or Practice: Further
research on the impact of claim determination is warranted so
that individuals with disabilities and those whose jobs involve
helping them can make use of evidence-based information on
the risks and benefits of participating in a disability system.
Future studies should also determine whether those denied
benefits are in need of targeted interventions.
Primary Funding Source: VA
• A Brief Motivational Intervention with Alcohol Patients
Nina Chychula, R.N., Ph.D, Cecilia Sciamanna, R.N., M.S.N.,
Arthur Alterman, Ph.D, John Cacciola, Ph.D, Iradj Maany,
M.D., Joel Martin, Ph.D.
Presented by: Cecilia Sciamanna, R.N., M.S.N., Adult Nurse
Practitioner, Behavioral Health Service MHC-116, Philadelphia
VAMC, University and Woodland Avenue, Philadelphia, PA
19104; Tel: 215.823.4300 Ext. 6568; Fax: 215.823.4040; E-mail:
Sciamanna, Cecilia@Philadelphia.MED.VA.GOV
Research Objective: This study aimed: 1)to determine if
alcohol use and treatment drop out rates of patients during 12
weeks of the standard outpatient treatment are reduced to a
greater extent in the experimental group, receiving
Motivational Interventions for a Recovery At Risk (MIRA), than
in the control group receiving just standard treatment; 2)to
examine and determine whether post abstinence/stablization
symptoms are reduced to a greater extent over 12 weeks in the
experimental group than in the control group.
Study Design: This study was a prospective, randomized,
controlled pilot trial of 77 subjects involved in the Intensive
Outpatient Program(IOP). A total fo 34 subjects, 17 active
treatment subjects and 17 control subjects completed the 12
week follow up assessments. The independent variable is the
treatment intervention, the Motivational Intervention for a
Recovery At Risk, vs a control group.
The MIRA intervention was provided over 6 weeks by primary
care nurse practitioners as an adjunct to the standard drug
free group therapy based 28 day IOP. The MIRA behavioral
strategies provide active and immediate feedback that patients
need to structure their recovery efforts. It included completion
of weekly assessments including the Recovery At Risk
Inventory (RARI) and the Recovey Activity Scale (RAS) once
weekly for 6 weeks and at 8 and 12 weeks. Controls received
the standard IOP program and completed the same weekly
assessment.
Population Studied: The population studied were veterans
enrolled in the Intensive Outpatient Program at the
Philadephia VAMC Addiction Recovery Unit with a primary
diagnosis of alcohol dependence. Two thirds of the subjects
had a secondary diagnosis of cocaine dependence. Exclusion
criteria included those with any history of opioid, THC, or
sedative hyponotic dependence.
Principal Findings: The results of the scores from the
Recovery At Risk Inventory demonstrated the presence of post
abstinence/stabilization symptoms throughout the 12 week
period of time in the study, or 6 weeks of treatment and follow
up at week 12.
The MIRA intervention group were able to attain and maintain
therapeutic gains regarding recovery based activities over the
12 week period as shown by increase in scores on the
Recovery Activity Scale.
The treatment intervention group was more likely to attend the
Intensive Outpatient Program sessions than the control
group.
The intervention group improved faster than the control group
on their RARI scores and maintained this improvement over
the 12 week follow up. Though not statistically significant, the
MIRA group tended to have greater decreases of illicit drugs
over 12 weeks
Conclusions: This study incorporates an efficient and feasible
primary care treatment to newly abstinent veteran patients,
who are "at-risk" to relapse and drop out from treatment and
who continue to burden the VA system with repeated
utilization of inpatient and outpatient resources. The MIRA
intervention shows promise as a primary care motivational
treatment given that substance abuse patients are likely to
return to their primary care providers who serve as the first
line access to health care
Implications for Policy, Delivery or Practice: The potential
exisits for the future that the MIRA model may be used in
primary care settings as a free standing model. The two
instruements, the Recovery At Risk Inventory, (RARI) and the
Recovery Activity Scale, (RAS), will undergo continued
instrument development.
One future research direction hopes to examine extending the
MIRA intervention beyond the first 12 weeks of abstinence.
Primary Funding Source: VA
• Treatment for Alcoholism among Elderly Medicare
Beneficiaries: Who is Treated and How Much Does
Treatment Cost?
Kristine Pringle, M.S., Ph.D. Candidate, Dennis Shea, Ph.D.
Presented by: Dennis Shea, Ph.D., Department Head and
Professor of Health Policy and Administration, Pennsylvania
State University, 116 Henderson Building, University Park, PA
16802; Tel: 814.863.5421; Fax: 814.863.2905; E-mail:
dgs4@psu.edu
Research Objective: This study asks what factors are
associated with alcoholism treatment use among elderly
Medicare beneficiaries who are diagnosed with alcoholism
and produces national cost estimates for alcohol treatment.
Study Design: Claims data from the Medicare Current
Beneficiary Survey (MCBS) are used in conjunction with the
Area Resource File and the Uniform Facility Data Set to
examine predisposing, enabling, need, and health care
system-level factors influencing treatment. The dependent
variable for alcohol treatment was derived from a combination
of ICD-9, CPT-4 and HCPCS codes. We employ a two-part
model, using logistic regression to examine the factors
associated with treatment and generalized gamma regression
to estimate treatment costs.
Population Studied: The MCBS includes over 10,000
individuals aged 65 and older. Due to the likely differences in
case-severity, as well as alcohol treatment use and costs, we
excluded 834 individuals who resided in nursing homes for the
entire year, leaving a total of 10,115 community-dwelling
elderly. Then, ICD-9 codes 291 (alcoholic psychoses), 303
(alcohol dependence), and 305 (alcohol abuse) were used to
select the sample of individuals with diagnosed alcoholism.
Individuals in the MCBS sample with one or more of these
ICD-9 diagnosis codes in their Part A or Part B Medicare
claims records are considered to have diagnosed alcoholism.
As per the above criteria, the number of individuals with
diagnosed alcoholism is 189 out of 10,115 or 1.87 percent of
the sample.
Principal Findings: This research suggests that about half
(52.6%) of elderly individuals diagnosed with alcoholism
receive any treatment for alcoholism, and certain groups of
elderly may be at high risk of under-treatment. Willingness to
contact a physician may be related to predisposing factors,
such as age, race, education, and marital status; enabling
factors, such household composition, income, and insurance;
need factors, such as co-morbidities; and health care system
factors, such as the supply of substance abuse treatment
facilities. In addition, treatment may be more expensive and
less accessible in rural areas. Predicted costs of alcoholism
treatment for individuals diagnosed with alcoholism and with
treatment costs greater than zero are $9,714.16.
Conclusions: These relationships represent an important first
step in reducing the current unmet need for alcohol treatment
among the elderly, but future research is needed to better
understand the barriers to treatment initiation, compliance,
and completion.
Implications for Policy, Delivery or Practice: Results of the
study particularly highlight the need for targeted interventions
to increase treatment seeking among those already diagnosed
with alcoholism. Such interventions may reduce the need for
later medical hospitalizations caused by the complications of
alcohol abuse or dependence, especially among those with
recent onset.
• The Effect of Intervention on Family Caregivers of
Persons with Dementia
Shu-Feng Shi, Ph.D., Bing-Long Wang, Ph.D., Yi-Yun Lin, M.S.
Presented by: Shu-Feng Shi, Ph.D., Assistant Professor,
School of Nursing, National Defense Medical Center, 4F, 161,
Minchuan E Road, Section 6, Taipei, 114; Tel: 886.2.87923100
Ext. 18761; Fax: 886.2.87923109; E-mail:
fennishi@mail.ndmctsgh.edu.tw
Research Objective: The increase in longevity and number of
persons in our population surviving to 65 years and older has
made family caregiving a pressing issue. A significant number
of persons with dementia receive care outside of institutions
at considerable physical and emotional cost to their families.
It is imperative that burdens of family
caregiving be addressed. This study proposed to test
interventions designed to reduce the negative effects of
caregiving. The interventions were expected to have an effect
on the caregivers. Caregiver's changes were expected in social
support, burden, and knowledge of dementia. The study was
performed to examine patterns of change over time, and to
identify the optimal interventions which may benefit family
caregivers with specific characteristics.
Study Design: The study was a quasi-experimental design.
The experimental group received a health education protocol
of caregiving of persons with dementia and nurseline
intervention, and the control group received routine
information only. The study included five stages. First stage
was to understand family caregivers' burden and their need in
health education. Second stage was to design a protocol of
health education for family caregivers of persons with
dementia. Third stage was a pre-test to validate the protocol of
health education. Fourth stage was to perform the study. Final
stage was a post-test taken at one week and four weeks after
intervention.
Population Studied: Thirty-three and thirty-two caregiverpersons with dementia dyads in the experimental and the
control groups were recruited from the clinics randomized to
conditions. Caregivers will be caring for the persons with
dementia 65 years of age or older living in the home
environment, and reported by the caregiver as having difficulty
with dressing, eating, or bathing. Caregivers were of both
genders. Measurements were taken at one week and four
weeks.
Principal Findings: The results of the study indicated that two
groups had no difference in demographic data. There were no
significant difference between the experimental group and
control group in the scores of the Clinical Dementia Rating
(CDR), Mini-mental Status Examination ( MMSE), revised
memory and behavior problem checklist (RMBPC), knowledge
related dementia, social support , and caregiver
burden(p>.05)in the pretest. A significant difference between
two groups in knowledge of dementia(p<.05)was found . The
results didn’t show the significant differences between the
experimental and control groups in social support and
caregiver burden(p>.05). But the burden of interpersonal
relationships in experimental group did have a significant
difference between the first and the second post-test(p<.05).
In social support of the being assisted conditions , there was a
significant difference in the experimental group between the
pre-test and the first post-test(p<.05). In the experimental
group, “informational support” had significant differences
between the pre-test and the first post-test and between the
first post-test and the second post-test(p<.05); “instrumental
support”had a significant difference between the pre-test and
the first post-test(p<.05). The need levels in social support
showed a significant difference between the first and the
second post-test(p<.05)in both of groups.
The findings of the study showed that “CDR”
, “RMBPC”, and “the need levels in social support”had
positive effects on the caregiver's burden, and “MMSE” had a
negative effect on social burden and patient dependence.
Conclusions: The intervention for primary family caregivers of
persons with dementia was performed by multidimensional
teaching methods including an individual health education, a
guide manual, and a nurseline. It directly increases caregivers'
knowledge of dementia and maintains the effects of the health
education. In addition, it also indirectly promotes caregivers’
social support and improves the quality of care for dementia
patients living in the home environment.
Implications for Policy, Delivery or Practice: The findings of
this study indicated that the health education really improved
family caregiver's knowledge in caring dementia patient. We
suggest that providing dementia's health education clinic and
periodically holding a group education in hospital are good
ways to help dementia's family in requiring related knowledge
and sharing their experiences of caring dementia patient.
The protocol of health education provided some information
for family caregiver about policies related to resources
required of social welfare and medication pay for dementia.
From interviewing, most of family caregivers thought that
obtaining the pay from the Bureau of National Health
Insurance for medication is difficult. The expense of
medication for dementia is a heavy burden for the family.
Therefore, we hope the Bureau of National Health Insurance
could consider the economic status of family and develop
better and more appropriate policies to benefit the dementia
in the future.
Primary Funding Source: National Defense of Medical
Center in Taiwan
• Can We Talk? Priorities for Patient Care Differed among
Health Care Providers
Bradley Evanoff, M.D., Jennifer Sledge, M.S.W., Patricia Potter,
Deborah Grayson, Laurie Wolf, Suart Boxerman
Presented by: Jennifer Sledge, M.S.W., Research Coordinator,
Center for Nursing Research, Barnes-Jewish Hospital, 4579
Laclede, #429, St. Louis, MO 63108; Tel: 314.454.8573; Fax:
314.454.7508; E-mail: jas4626@bjc.org
Research Objective: Effective communication among
members of the healthcare team is vital to quality patient care.
Poor communication may lead to medical errors or
substandard quality of care. The research objective of this
study is to assess communication between members of the
healthcare team which include physicians(MD), registered
nurses(RN), and patient care technicians(PCT) caring for the
same patient on the same day.
Study Design: The research team randomly selected 437
inpatients from 6 nursing divisions and attempted to
interview each team member in the morning and afternoon.
Each member of the team was asked if they could identify by
name the other members of the team? Each member of the
team was then asked to identify what their top three priorities
or goals were on that day for that patient.
Population Studied: Patients room numbers on each unit
were randomly selected. Once the room number was
selected, having been on the unit 24 hours, they becam
eligible for the study. The interviewer then identified the MD,
RN and PCT assigned for the care of that patient.
Principal Findings: In the morning, 27% of MD's could name
the RN caring for the patient and 39% of the RN's could name
the MD responsible for the same patient. In the afternoon,
49% of MDs and 52% of RNs reported discussing the patient
with each other. Frequency of agreement on the top three
priorities of care for each patient was measured. In 17% of the
cases there was full agreement on priorities between MD and
RN, partial agreement in 53% of cases and no agreement in
30% of the cases.
Conclusions: Perceived priorities for care differed greatly
between members of the health care team. Verbal
communicatioin between the team, especially between MDs
and RNs, did not occur consistently; this lack of consistent
verbal communication is likely to impair patient care. We
have begun interventions to improve direct communication
between health care professionals.
• Immunization Requirements for Childcare Programs: Are
They Enough?
Carol Stanwyck, M.Ed., Ph.D., Mareen Kolasa, R.N., M.P.H.,
Kate Shaw, M.S.
Presented by: Carol Stanwyck, M.Ed., Ph.D., Epidemiologist,
NIP, CDC, 1600 Clifton Road NE, E62, Atlanta, GA 30333; Tel:
404.639.8308; Fax: 404.639.3266; E-mail: cea9@cdc.gov
Research Objective: School immunization legislation has
resulted in high vaccination coverage rates and low rates of
vaccine preventable disease among school children. Similar
legislation has been directed toward children in licensed and
regulated childcare programs. The purpose of this
investigation was to compare immunization coverage among
children in and not in childcare.
Study Design: The National Immunization Survey (NIS), a
random-digit-dialing telephone survey, collected information
on children aged 19 through 35 months, including data on
enrollment in childcare. Data were analyzed retrospectively
to determine coverage at 24 months and at the time of the
survey. Children were considered up-to-date (UTD) if they had
received all recommended immunizations for their age.
Population Studied: Children, 19 through 35 months old, who
were either childcare or never in childcare.
Principal Findings: Of the eligible NIS respondents, about
41% had a child in childcare at the time of, or prior to, the
survey. Retrospective analysis of children at 24 months
showed no significant differences in coverage between those
in and not in childcare (73.1% vs. 71.9%). Likewise, analysis of
coverage at the time of the survey revealed no significant
differences (76.4% vs. 72.6%).
Conclusions: Immunization legislation and regulations have
been successful in increasing coverage rates in the school
population. Similar legislation for childcare facilities appears
not to have been as effective.
Implications for Policy, Delivery or Practice: Given these
findings, it seems that new strategies are needed to increase
coverage in preschool children. Strategies with different
intervention points (e.g., childcare center, parents, health
departments, and licensing agencies) need to be tested.
• The Impact of Pharmacist Review to Increase Cost
Effectiveness: The PRICE Clinic for Low-Income Elderly
Marilyn Stebbins, Pharm.D., Greg Speicher, Pharm.D.,
Jonathan Agnew, Ph.D., Helene Levens Lipton, Ph.D.
Presented by: Marilyn Stebbins, Pharm.D., Associate Clinical
Professor/Pharmacy Utilization Manager, Clinical Pharmacy,
UC San Francisco School of Pharmacy/CHW Medical
Foundation, 3400 Data Drive, Rancho Cordova, CA 95670; Tel:
916.379.2907; Fax: 916.379.3045; E-mail: mstebbin@chw.edu
Research Objective: In 2001, a pharmaceutical care model,
the PRICE (Pharmacist Review to Increase Cost-Effectiveness)
Clinic, was introduced in a large physician-owned medical
group in Northern California to address the issue of
prescription drug price burdens on the elderly. The objectives
of this research were to evaluate the cost-savings obtained by
the elderly enrolled in this program and to identify and
quantify the interventions that led to the cost savings
Study Design: Pre/post analysis of select outcome variables
among patients receiving the pharmaceutical care
intervention. The two major outcome measures were out-ofpocket drug costs and percent generic prescribing rate.
Information about the number and types of interventions, plus
drug class involved, was recorded. Also collected was the
number of patients who had, or had planned to, discontinue
their medications due to cost. Retrospective database review
was performed.
Population Studied: All Medicare-eligible patients > 65 years
old who self-referred or were referred by their clinician to the
PRICE Clinic in 2001.
Principal Findings: 294 patients were seen in the PRICE
Clinic in 2001, with an average of six prescriptions per patient,
and an average of 2.3 interventions per patient. The out-ofpocket drug costs decreased from $192 to $93 per patient, a
49% decrease. The percent generic prescribing rate increased
from 49% to 59%. The most common interventions included
patient assistance programs, pill splitting, switching to generic
drugs, and switching to lower-cost drugs in the same class.
Interventions most often occurred within these drug classes:
statins, ace-inhibitors, calcium channel blockers, respiratory
products, diabetes medications and hormone replacement
therapy. Of the 294 patients seen, 72 stated that they had or
had planned to discontinue a medication due to cost.
Conclusions: The PRICE Clinic model for pharmaceutical care
significantly decreased out-of-pocket drug expenses, increased
generic drug utilization and prevented seniors from
discontinuing medications due to cost. Employing a series of
pharmaceutical cost interventions (a generally underutilized
approach), that combined drug utilization management with
patient and physician education, yielded these significant
results.
Implications for Policy, Delivery or Practice: Even with the
recent passage of a Medicare outpatient prescription drug
benefit, out-of-pocket prescription drug costs will remain a
burden to payers (both insurers and individuals). Other than
the use of Pharmacy Benefit Managers (PBMs), there is
currently no system in place "on the ground" to guide
prescribing behavior. In general, studies of PBMs have failed
to demonstrate that they offer significant value. (Lipton et al.
1999; Lipton et al. 2000). In contrast, the PRICE Clinic model
may produce more immediate results and is likely easily
replicated. It should be adopted by Medicare managed care
plans and institutional providers of pharmacy services to lowincome elderly and may have similar benefits for other
populations.
• Open Space Technology: A Catalyst for Outcome
Planning
Geoffrey Swain, M.D., M.P.H., Bevan K. Baker, CHE, Patricia
Fenton, M.A., Maria Monteagudo, M.B.A., Seth Foldy, M.D.
Presented by: Geoffrey Swain, M.D., M.P.H., Associate
Medical Director, City of Milwaukee Health Department, 841
N. Broadway, Room 315, Milwaukee, WI 53202; Tel:
414.286.8172; Fax: 414.286.5990; E-mail:
gswain@milwaukee.gov
Research Objective: To evaluate whether Open Space
Technology (OST), originally developed as means of
organizing meetings of up to 1000 individuals, would be both
effective and cost-effective in propelling an outcome planning
process within a large local public health agency with a matrix
organizational structure.
Study Design: OST methods were identified for the City of
Milwaukee Health Department’s 2004 outcomes planning
through the ADDIE process (Analyze, Design, Develop,
Implement and Evaluate). Results from utilizing OST were
compared with previous years’ results on the following items:
1. Did results of the outcomes planning align with the
mission, vision, values and overall strategic plan of the City of
Milwaukee Health Department (MHD)? 2. Did the OST
process help managers operationalize outcomes, develop
strategies to meet those outcomes, remain focused on long
term planning, promote individual passion as well as
accountability, and deal effectively with both internal and
external issues? 3. Did OST support collaboration across all
divisions? 4. Was the OST process cost-effective?
Population Studied: A total of 62 managers representing all
seven (7) MHD divisions attended the sessions, which were
conducted over one and a half days at an off-site location. The
managers developed the days’ agenda as a group, creating
different session topics focused on developing plans that
would support their divisions, and the department overall, in
attaining the previously identified key outcomes.
At agreed-upon times, self-identified group leaders convened
and led their respective, concurrent sessions. Other
participants selected sessions based on areas of interest, and
could change or join a new session at any time.
Principal Findings: OST enabled MHD to deal with
enormously complex public health planning issues in a very
concise time frame. A total of 23 meetings with 62 different
managers were held within a 12-hour period. As a result of the
OST process, each division manager developed a
comprehensive plan to meet key divisional and departmental
goals.
Organizational morale and managers’ attitudes toward
outcome planning were enhanced. This was highlighted by a
confidential survey of the 62 managers that yielded 80
comments, of which 54 were positive and only 26 were
constructive or critical regarding the use of OST as a tool to
drive the outcome planning process.
A historical review of the department’s outcome planning
consultant costs indicated that over $10,000 had been
expended in previous years to support the development of an
integrated outcome plan. In comparison, OST expenditures
totaled approximately 1/10 of the cost and saved months of
staff meeting time.
Conclusions: OST, which has reasonably low operating cost,
is a powerfully efficient tool to identify desired outcomes,
address strategies and implement them a large, matrix
organization. It represented an extremely effective way for
MHD to clarify outcomes and strategies while causing
knowledge to permeate the entire management team broadly
and swiftly.
Implications for Policy, Delivery or Practice: OST appears to
be an efficient and effective vehicle for outcomes planning in
public health departments as well as other large, matrix
organizations. It rapidly and efficiently brings together the
best thinking from those passionate about the organization
and its future.
• Turning the Tide: A Community Based Approach to
Developing Successful Intervention Strategies for At-Risk
Adolescents.
Patricia Sweeney, R.N., M.P.H., JD, Ralph Ricci, M.S.
Presented by: Patricia Sweeney, R.N., M.P.H., JD, Visiting
Assistant Professor, Center for Public Health Practice,
University of Pittsburgh, 3109 Forbes Avenue #210,
Pittsburgh, PA 15260; Tel: 412.383.2231; Fax: 412.383.2228; Email: psweeney@pitt.edu
Research Objective: To review community studies, reports
and data sets reporting on the prevalence of risk factors which
are precursors to adolescent substance abuse, pregnancy,
school dropout, delinquency, and violence. The findings and
data from these sources were compared to national and state
data and were synthesized into a strategic plan outlining
intervention tactics and modalities to assist at-risk adolescents
and their families.
Study Design: Representatives from government, juvenile
justice, social services, health care, law enforcement,
education, religion, ethnic and minority groups, civic
organizations, public health, media and families, were
intentionally recruited to join the community planning team.
The 120 member team was divided into 6 work groups. Data
was collected and analyzed to identify the most significant risk
factors present in the community. Community assets to
address risk factors were assessed, the juvenile justice system
decision making processes were analyzed, and the legal and
policy issues constraining cross system collaboration were
studied. Plenary meetings were held to synthesize the finding
of each team and then a strategic plan of intervention tactics
and modalities was developed.
Population Studied: The target population was the youth and
families residing in Mahoning County, OH, an economically
challenged community of 240,000 in Northeast Ohio.
Principal Findings: The reviews of evidence analyzed by the
teams showed that the four areas of greatest risk for youth
and families in Mahoning County, Oh include: 1) extreme
economic deprivation, 2) parental involvement in the problem
behavior, 3) early and persistent antisocial behavior, and 4)
youth who feel disenfranchised and as a result demonstrate
alienation and rebelliousness. With minor exceptions, social
and community services were adequately available to meet
these youth and family needs. However, systemic issues were
identified which universally affected commitment to reducing
risk: community acceptance of crime, systemic community
prejudice and isolationism
Conclusions: The need to create a set of strategies to address
the issues reported in the Findings was the paramount
conclusion of the planning team. Specifically, this study shows
that adequately addressing adolescent risk factors requires
cross-system, cross-community cooperation to identify and
alter existing institutional and attitudinal barriers. Such
systematic changes are required to build trust and change the
community culture away from a culture of acceptance and
tolerance of crime and prejudice to a culture that exemplifies
strong character and quality of life for all members of the
community.
Implications for Policy, Delivery or Practice: Community
planning efforts which focus solely upon the direct service
needs of youth and families fail to address the societal
conditions which underlie the risk factors. Developing
strategic intervention to address these issues far exceed
traditional community planning initiatives. Funders and
community planners need to recognize that such systematic
changes require long term assistance and support and a long
term commitment from community leaders.
In Mahoning County, Ohio, this commitment to address
systemic and attitudinal problems has resulted in increased
community capacity to collaboratively address community
issues, and successfully secure funding for needed services
and has resulted in the successful implementation of the
identified strategic interventions
Primary Funding Source: U.S. Department of Justice and the
Ohio Department of Youth Services
• Expected Use of VA Services: A Reliable Predictor of
Actual Use?
Cayla Teal, Ph.D., Iris I-Lien Wei, Dr.PH, Beth Virnig, Ph.D.,
Robert Morgan, Ph.D.
Presented by: Cayla Teal, Ph.D., Postdoctoral Fellow,
Houston Center for Quality of Care and Utilization Studies,
Veterans Affairs Medical Center, 2002 Holcombe Boulevard
(VA 152), Houston, TX 77030; Tel: 713.794.8548; Fax:
713.748.7359; E-mail: cayla.teal@med.va.gov
Research Objective: Studies of VA health policies often rely
on statements about the likelihood of future VA service use.
Our objective was to evaluate the utility of an anticipated use
rating (“How likely are you to use a VA facility for your health
care needs over the next 12 months?”) for predicting
subsequent actual VA use.
Study Design: We used data from the South Florida Health
and Health Services Use Survey (conducted in early 1999) and
VA utilization records for 1,166 veterans. The rating of
anticipated use offered four possible responses – “very
unlikely,” “somewhat unlikely,” “somewhat likely,” and “very
likely.” Contingency table analyses were used to examine the
relationship between anticipated and actual VA use.
Population Studied: The population under study was male
veterans. The 1166 participants included 667 "VA users"
(those who had some VA use in the prior five years) and 478
“non-users”(those with no VA use in the prior five years).
Principal Findings: Expectations about VA use were accurate
predictors of actual use for VA users (those who had utilized
the VA in the prior five years) (X2 (3) = 252.31, p < .001,
Cramer’s V = 0.624, p < .001). Among VA users, our
dichotomized scale (“very/somewhat unlikely” vs.
“very/somewhat likely”) had a sensitivity and specificity of
0.79 and 0.84, respectively, and positive and negative
predictive values of 0.90 and 0.68, respectively. VA users
were significantly more likely than non-users to anticipate
future VA service use (t (965.2) = -25.5, p < .001). For VA nonusers, over 90% of respondents clustered into one cell (no
anticipated use/no actual use), making estimation of
predictive accuracy problematic.
For all participants, regardless of previous VA use, the
expected use item functioned linearly. That is, as the
likelihood of anticipated use increased, so did the percentage
of participants that subsequently utilized VA services. Of
those participants who thought it “very unlikely” that they
would use VA services, only 11.4% used VA services in the next
12 months. Of those who endorsed “somewhat unlikely,”
“somewhat likely” and “very likely,” 26.6%, 65.8%, and 91.9%
(respectively) subsequently utilized VA services.
Conclusions: Ratings of anticipated use of VA services are
reliable estimators of actual future VA use for those having
previously utilized the VA.
Implications for Policy, Delivery or Practice: A measure of
anticipated VA use is a useful indicator of future actual use for
studies of veterans with previous experience using VA
services. Further, this measure’s linear relationship to
subsequent actual use and interval-like measurement qualities
offer the possibility of more powerful analytic strategies in
future use.
Primary Funding Source: VA
• Examining How Physicians’ Perception and Career
Satisfaction be Affected by HMO Penetration and Levels of
Market Competition
Kai-Li Tsai, Ph.D., Patrick Rivers, Ph.D., M.B.A.
Presented by: Kai-Li Tsai, Ph.D., Assistant Professor, Nursing
& Health Sciences, Texas A&M University, ST 314A, 6300
Ocean Drive, Corpus Christi, TX 78412; Tel: 361.825.3429; Fax:
361.825.3491; E-mail: ktsai@falcon.tamucc.edu
Research Objective: To determine the effects of managed
care penetration rate and market competition level on the
physicians’ practice attitude/perception and career satisfaction
toward their clinical practice and autonomy.
Study Design: This study examines the impact of HMO
penetration and market competition on physician’s perceived
professional autonomy, practice constraints, and career
satisfaction. A modified structure-conduct-performance
paradigm was applied to the health care industry in order to
investigate the impact of HMO penetration and competition
level on physicians’ perception and satisfaction after
controlling for factors like financial control and incentive
through utilization review or other cost-containment policies.
The outcome variables are physicians’ satisfaction toward
practice autonomy, time allocation, income and career
satisfaction in general. The main predictor variables are
market characteristics (i.e., managed care penetration rate and
level of competition- Herfindahl Index). Other control
variables include environmental, patient, and institutional
characteristics. Multivariate regression analysis was
conducted to examine the effects on physicians’ perception
and satisfaction from levels of competition and HMO
penetration rate.
Population Studied: Data comprise physician survey
component from Community Tracking Study (CTS), and
Interstudy data for managed care penetration rate and market
competition level. The CTS physician survey contains
observations for more than 12,000 physicians who practice in
60 randomly selected communities (51 metropolitan areas
and 9 non-metropolitan areas).
Principal Findings: The results indicate that with the
increased HMO penetration rate and competition, physicians
are less likely to feel satisfied with their career choice.
Physicians’ satisfaction also decrease significantly in their
satisfaction with the time allocation, clinically practice
autonomy and income, when there is an increase in HMO
penetration rate and competition level becomes more intense
in the market.
Conclusions: These findings suggest that when faced with
intense competition, physicians may respond in ways
associated with reducing their perceptions of professional
autonomy and decreasing their satisfaction in their time
allocation, income and career satisfaction as a whole.
Implications for Policy, Delivery or Practice: While these
findings raise concerns about the HMO penetration and
competition, further research is needed before resorting to
legislation or other policies to prohibit particular types of
arrangements between HMOs and physicians.
• Bioterrorism Preparedness: A Planning Instrument for
Selecting an Alternative Medical Care Site
Sheri Eisert, Ph.D., Carrie Vinci, M.Sc., Stephen Cantrill, M.D.,
Peter Pons, M.D.
Presented by: Carrie Vinci, M.Sc., Project Manager, Health
Services Research, Denver Health Medical Center, 777
Bannock, MC 8701, Denver, CO 80204; Tel: 303.436.5973; Fax:
720.932.8485; E-mail: carrie.vinci@dhha.org
Research Objective: To develop a valid and reliable tool for
use by bioterrorism and disaster planners that assists in the
identification and ranking of potential alternative medical care
sites to meet surge capacity needs.
Study Design: This Rocky Mountain Regional Care Model for
Bioterrorist Events (RMBT) Working Group met four times
during October 2002 through September 2003 to address
medical surge capacity issues and needs for Federal Region
VIII (Colorado, Montana, North Dakota, South Dakota,
Wyoming and Utah). Hospital engineers and facility personnel
were presented with the infrastructure requirements for an
alternative care site as outlined by the Department of Defense.
This expert team identified additional factors that should be
considered in selecting an alternative care site, with input
from the RMBT Working Group. An alternative care site
selection tool was designed by transposing the factors into a
matrix with relative weights. The weights were based on a 5point scale that compares the site factor to that of a hospital.
For instance, if the potential site was a high school, “Is the
ventilation system similar to a hospital or less adequate than
that of a hospital?” This tool was validated through a tabletop
exercise with the RMBT Working Group members.
Population Studied: The RMBT Working Group was
comprised of members from the Federal: US Northern
Command; US Air Force Office of Surgeon General,
Homeland Security Office, and Development Center for
Operational Medicine; Colorado US Air Force, Army and
National Guard Bases; US Public Health Service; National
Disaster Medical System (NDMS) and the Department of
Veteran Affairs Medical Center; State: 6 State Departments of
Public Health, hospital associations, and a rural health
representative; and Local: 3 county health departments;
Denver Mayor’s Office of Emergency Management, Center for
Public Health Preparedness (DCPHP), and Metropolitan
Medical Response system (MMRS); and all hospitals/health
systems in the Denver Metro area.
Principal Findings: Augmentation facility sites should be
identified and ranked in advance of a medical disaster to
enhance preparedness. The use of existing buildings and
infrastructure (schools, hotels, recreation facilities, etc.) may
be the most effective and efficient approach to addressing
surge needs and the degree to which each potential site can
address surge needs will vary on the type of event and the
number of people affected. It is important that the planning
tool be simple, flexible and readily transferable to planners.
Conclusions: During a surge event, current hospital capacity
will not meet immediate resource demand. This tool has
important implications for health, disaster and bioterrorism
planners in that it allows a straightforward approach to preselecting potential alternative care sites. This site selection
tool provides a quantitative, customized and simple
methodology for identifying the “best” site based on relative
ranking. The tool is available at:
http://www.denverhealth.org//bioterror/tools.
Implications for Policy, Delivery or Practice: This tool is
useful for a hospital to plan for alternative cares sites in
compliance with JCAHO and MEMS. This tool may also be
helpful to use in a planning team including: fire, law, Red
Cross, security, and hospital personnel, such as the Local
Emergency Planning Commission (LEPC).
Primary Funding Source: AHRQ
• The Impact of a Skills-Based Substance Abuse Prevention
Counseling Program in Post-Traumatic Brain Injury
Patients
Martha Vungkhanching, Ph.D., A.W. Heinemann, Ph.D., M.J.
Langley, Ph.D., M. Ridgely, M.S.
Presented by: Martha Vungkhanching, Ph.D., Postdoctoral
Research Fellow, Feinberg School of Medicine, Northwestern
University, 339 E. Chicago Ave, Wiebodlt Hall, # 705, Chicago,
IL 60611; Tel: 312.503.0437; Fax: 312.503.2936; E-mail: mvkching@northwestern.edu
Research Objective: The study was conducted as part of a
demonstration project to develop treatment approaches for
the management of substance abuse following TBI.
Study Design: Thirty-five participants were recruited for a
treatment group and 103 participants for a no-treatment
comparison group. Treatment participants received 12
individual counseling sessions. Participants were assessed at
baseline (Wave 1), treatment completion (Wave 2) and at
follow-up one year post-baseline (Wave 3). The comparison
group completed all three assessments at time periods
corresponding to the treatment group.
Frequency and quantity of alcohol and drug use were
measured using the Alcohol and Drug Inventory. Coping
skillfulness was measured using a modified version of the
Adaptive Skills Battery, which assessed coping effectiveness in
various situations involving negative emotional states, such as
anger, frustration, conflict, social pressure to use substances
and cue-exposure to substances. The Positive Affect Negative
Affect Scale was used to measure affect.
Population Studied: Treatment group members were
recruited from four vocational rehabilitation centers and the
no-treatment comparison group members from outpatients
regional rehabilitation center.
Principal Findings: A greater proportion of participants in the
treatment group completed the Wave 3 assessment (74.3% vs.
50.5%). At baseline, participants were on average 33 and 35
years of age for the treatment and comparison groups,
respectively; predominantly male (80% and 71%, respectively),
Caucasian (97% and 73%, respectively), and never married
(65% and 54%, respectively). Traffic injury was the most
common cause of injury in both the treatment (73%) and
comparison (59%) groups. Participants in the treatment
group sustained more severe brain impairment than the
comparison group, as indicated by significantly lower scores
on the Galveston Orientation and Amnesia Test (Raw mean
scores 77.4 vs. 89.6 respectively). The treatment group
members were more likely to be employed at baseline than
were the control group members (90% vs. 37%). Treatment
participants reported a significant decrease in substance use
at Wave 2 (p < .05) and Wave 3 (p < .01), and demonstrated a
higher rate of abstinence from alcohol use at follow-up
compared to control participants (24% vs. 9%, respectively).
Conclusions: Treatment completion was associated with
significant decreases in substance use and increases in coping
skills, but positive affect levels and employment rates were not
associated with treatment completion. The lack of evidence for
an increase in employment rate may be due to the impact of
other variables on employment status not related to the
treatment intervention, such as functional impairments.
Implications for Policy, Delivery or Practice: The significant
changes observed in reduced alcohol and substance use
indicate that treatment intervention holds promise for
individuals with traumatic brain injuries. It is encouraging that
the treatment group evidenced improvements over the
comparison group despite having more severe cognitive
impairments at baseline. Future studies should include a
randomly selected, larger sample of participants in both
treatment and comparison groups.
• Provision of Family Therapy, Individual, and Group
Psychotherapy to a State-Wide Population of Medicaid
Patients with Schizophrenia
James Walkup, Ph.D., Wenhui Wei, MA, Usha Sambamoorthi,
Ph.D., Stephen Crystal, Ph.D.
Presented by: James Walkup, Ph.D., Associate Professor,
IHHCPAR, Rutgers University, 30 College Avenue, New York,
NY 08901; Tel: 212.724.8362; E-mail: jaywalks@aol.com
Research Objective: To use state Medicaid administrative
data to examine associations between patient characteristics
and patterns of provision of individual, group, and family
therapy provided to patients with diagnosed schizophrenia.
Study Design: The study used personal summary information
and claims data from State Medicaid Research files for
Georgia. Using paid Medicaid claims, patients with
schizophrenia were identified based on International
Classification of Diseases 9th revision, Clinical Modification
(ICD9) codes, psychotherapy services were derived using the
Physician’s Current Procedural Terminology, 4th Edition (CPT4) codes, and medical comorbidity was assessed by applying
the Charlson Comorbidity Index to identify and assign weight
to a range of medical disorders. County level information on
availability of psychiatrists was obtained by merging claims
with the Area Resource File. Chi-square statistics and logistic
regressions were used to test for subgroup differences in the
prevalence and types of psychotherapy provided individuals
following an initial claim indicative of schizophrenia.
Population Studied: Georgia Medicaid patients 18-65 years
old with a claim indicative of schizophrenia (N=6.005) from a
designated credible source who were eligible and alive for the
full study year (1995). Patients enrolled in an HMO or in
Medicare were excluded.
Principal Findings: Of the 6,005 eligible patients diagnosed
with schizophrenia, only 25% (N=1517), had claims indicative
of at least one of the three psychosocial services studied in the
observation period. (More than three quarters of patients
were followed for more than 10, of the possible 12, months.)
Chi-squared tests showed that people were more likely to
receive psychotherapy if they were White, younger, not eligible
b/c of blind/disabled, had OTP psychiatrist in residence
county, had medical comorbidity. Therapy was also more
common among those receiving antipsychotic treatment,
particularly those prescribed both typical and atypical types
during observation period.. Among those who received any
psychotherapy, most (n=1075, 71%) received only individual
psychotherapy; 14% (n=219) received only group or family
psychotherapy, and 15% (n=223) received individual and either
group or family psychotherapy (or both). Chi-squared tests
showed that African Americans receiving psychotherapy were
more likely to receive only group or family psychotherapy.
Those who didn't have OTP psychiatrist in their county were
more likely to receive only individual psychotherapy.
Conclusions: Consistent with prior studies finding gaps in
provision of psychosocial services, we see low levels of family
therapy, group, and individual psychotherapy, despite
evidence supporting the value of psychosocial services to
patients with schizophrenia. We also found variation in types
and patterns services delivered.
Implications for Policy, Delivery or Practice: Efforts should
be made to identify financial, organizational, and clinical
barriers to appropriate provision of psychosocial services.
Primary Funding Source: Foundation for Group
Psychotherapy
• Differences in Income between Male and Female
Physicians
Shu-Feng Shi, Ph.D., Bill Bing-Long Wang, Ph.D., Thomas
Wan, Ph.D.
Presented by: Bill Bing-Long Wang, Ph.D., Director, Planning
and Administration, Tri-Service General Hospital, 325 ChengKung Road, Sec. 2,Taipei, 114; Tel: 882.2.23683468; Fax:
001.886.2.87927014; E-mail: billwang@ndmctsgh.edu.tw
Research Objective: To reexamine the current state of
physicians’ income by gender.
Study Design: Cross- sectional analysis using data from 199899 Community Tracking Study physician telephone survey was
conducted by the Gallup Organization. Data were mostly
collected from physicians practicing in 60 randomly selected
communities, allowing analyses to be conducted at both the
national and community level. Multinominal logistic
regression was performed to explore the effect of gender on
physician income of overall medical career.
Population Studied: A nationally representative sample of
12,280 direct patient care physicians. The survey response rate
was 61%.
Principal Findings: Multivariate analyses demonstrate that
each income level compares to $300000 or more(the highest
level), female physicians are 13.61, 14.05, 5.66, 2.68, 1.98
times(significant) of male physicians. Female physicians are
still easily in the lower income( $0 to $49999, $50000 to
$99999, $100000 to $149999) compared with male
physicians.
Conclusions: Male physicians have earned more than female
physicians, even after differences in the work time, specialty,
practice setting, and other characteristics are taken into
account.
Implications for Policy, Delivery or Practice: Differences in
income between male and female physicians have existed for
a while. It is argued that, among physicians involved in a
broad range of practice settings, income are unequal for men
and women.
Primary Funding Source: RWJF
• The Effect of Clinical Autonomy on Physicians' Income
Shu-Feng Shi, Ph.D., Bill Bing-Long Wang, Ph.D., Thomas
Wan, Ph.D.
Presented by: Bill Bing-Long Wang, Ph.D., Director, Planning
and Administration, Tri-Service General Hospital, 325 ChengKung Road, Sec. 2, Taipei, 114; Tel: 882.2.23683468; Fax:
001.886.2.87927014; E-mail: billwang@ndmctsgh.edu.tw
Research Objective: To examine clinical autonomy associated
with physicians' income of overall medical career.
Study Design: Cross- sectional analysis using data from 199899 Community Tracking Study physician telephone survey was
conducted by the Gallup Organization. Data were mostly
collected from physicians practicing in 60 randomly selected
communities, allowing analyses to be conducted at both the
national and community level. Multivariate analysis were
performed to explore the effect of clinical autonomy on
physician income of overall medical career.
Population Studied: A nationally representative sample of
12,280 direct patient care physicians. The survey response rate
was 61%.
Principal Findings: Multivariate analyses demonstrate that
clinical autonomy in terms of physicians make clinical
decision in the best interests of patients without the possibility
of reducing income, and they feel that the level of
communication I have with colleagues about the patients
whom I refer or who are referred to me is sufficient to ensure
the delivery of high quality of care turbulence positively
influence the physicians' incomes (p<0.05).
Conclusions: This study shows that physicians, who can
make clinical decisions in the best interest of patients without
reducing income or maintain postive levels of communication
with medical colleagues, earn higher income.
Implications for Policy, Delivery or Practice: The present
study suggests that physicians are maintaining incomes
without changing their autonomy. Physicians are more apt to
make clinical decisions in the best interest of patients without
reducing income, and maintain postive levels of
communication with medical colleagues to ensure the delivery
of high quality of care. The patients are more apt to accept
high quality of care provided by physicians, and they are more
satisfied.
Primary Funding Source: RWJF
• Has Managed Care Adversely Affected Physicians
Income?
Shu-Feng Shi, Ph.D., Bill Bing-Long Wang, Ph.D., Thomas
Wan, Ph.D.
Presented by: Bill Bing-Long Wang, Ph.D., Director, Planning
and Administration, Tri-Service General Hospital, 325 ChengKung Road, Sec. 2,Taipei, 114; Tel: 882.2.23683468; Fax:
001.886.2.87927014; E-mail: billwang@ndmctsgh.edu.tw
Research Objective: To examine managed care associated
with physicians' income of overall medical career.
Study Design: Cross- sectional analysis using data from 199899 Community Tracking Study physician telephone survey was
conducted by the Gallup Organization. Data were mostly
collected from physicians practicing in 60 randomly selected
communities, allowing analyses to be conducted at both the
national and community level. Multivariate analysis were
performed to explore the effect of managed care on physician
income of overall medical career.
Population Studied: A nationally representative sample of
12,280 direct patient care physicians. The survey response rate
was 61%.
Principal Findings: Multivariate analyses demonstrate that
managed care in terms of accepting more Medicare managed
care patient, accepting more private or commercial insurance
plans including managed care plans, and accepting more
managed care plans, physicians get higher income(p<0.01).
Conclusions: This study shows that the more physicians
accepted Medicare managed care patients, private or
commercial insurance plans including managed care plans,
and number of managed care plans, the more physicians earn
the earnings.
Implications for Policy, Delivery or Practice: Our findings
do not confirm the prevailing concern that physicians’
incomes decline. On the contrary, physicians participating in
managed care have earned more than their counterparts.
Primary Funding Source: RWJF
• A Randomized Trial of the Effectiveness of Community
Swimming and Golf Programs in Improving Symptoms,
Fitness, and Quality of Life in Children with Asthma
Michael Weisgerber, M.D., Glenn Flores, John Meurer, Stuart
Berger, M.D., Earnestine Willis, M.D., M.P.H., Michael
Danduran, M.S., Vanessa Brown, Maureen O'Reilly, Katie
Webber, Sandy Tomany
Presented by: Michael Weisgerber, M.D., Clinical Instructor of
Pediatrics, Medical College of Wisconsin, 8701 Watertown
Plank Road, Milwaukee, WI 53226; Tel: 414.456.4611; Fax:
414.456.6385; E-mail: mweisger@mcw.edu
Research Objective: Asthma is the most prevalent childhood
chronic condition, affecting more than 6 million US children.
Previous research has shown that swimming increases
cardiorespiratory fitness and is less asthmogenic than other
forms of exercise. Nevertheless, no RCTs have been
performed to either compare the effectiveness of swimming
versus other forms of exercise or evaluate the potential link
between fitness and improving asthma outcomes. Our
objective was to compare the effectiveness of an aerobic
exercise swimming, S, with a non-aerobic exercise golf, G, in
improving selected childhood asthma outcomes, including:
symptoms; fitness; quality of life, QOL; frequency of
exacerbations; and need for urgent asthma physician visits
Study Design: Recruitment letters were sent to homes of
children diagnosed with asthma residing in high asthma
prevalence zip codes. Families attended an informational
meeting, completed baseline questionnaires, and the child
was randomized to either S or G. Each exercise intervention
lasted 8 weeks; lessons were held 3 times a week in 1-hour
sessions. Post-intervention surveys were administered upon
completion of the exercise programs. A subset of participants
also completed pre and post fitness testing.
Population Studied: Children targeted for participation in the
program were those 7 to 14 years old with mild, moderate, or
severe persistent asthma living in high asthma prevalence, low
income areas because these children are most in need of
creative methods of improving asthma symptoms and quality
of life.
Principal Findings: 29 children in the swimming group and
21 children in the golf group completed the program. There
were no baseline inter-group differences in asthma severity,
race, family income, BMI, or baseline fitness. S and G had
similar effects on fitness, symptoms and quality of life.
Analysis of the combined groups revealed a decrease in
asthma symptoms severity scores from 9.07 to 7.33, p=.001;
improved QOL scores from 5.08 to 5.49, p=0.04; improved
parental QOL from 4.93 to 5.28, p=.006; decreased number of
participants requiring acute physician office visits for asthma
from 41 to 17 percent, p=0.03. The subset who performed
fitness testing had increased exercise tolerance time of .56
minutes on the treadmill, p=0.02. 98 percent of parents were
satisfied to extremely satisfied with the intervention. In 1050
person-sessions of S and G, only 6 episodes of dyspnea,
which resolved with albuterol MDI, occurred.
Conclusions: Swimming and golf programs can result in
significant reductions in childhood asthma symptoms and
physician office visits; improved QOL of participants and their
parents; and improved fitness among participants. The swim
group did not differ significantly from the golf group on any
measure. Parents of participating children were highly
satisfied and likely to recommend the programs to others.
Swimming and golf were well tolerated and safe, even among
participants with severe asthma.
Implications for Policy, Delivery or Practice: These findings
suggest health care professionals should recommend S or G
to children with asthma as these programs may help improve
their symptoms and quality of life. These results also provide
evidence to support the funding of such programs in
communities that do not have accessible S or G programs for
asthmatic children in low income families.
Primary Funding Source: Medical College of Wisconin,
Children's Hospital of Wisconsin Foundation
• Maintaining The Florida KidCare Statewide
Communication Link
Michelle White, M.A., Jodi Ray, M.A.
Presented by: Michelle White, MA, Research and Program
Services Coordinator, N/A, The Lawton and Rhea Chiles
Center, 3111 E Fletcher Avenue, Tampa, FL 33613; Tel:
813.974.8272; Fax: 813.974.8889; E-mail: mwhite@hsc.usf.edu
Research Objective: This poster session highlights the
development and implementation of “Maintaining Florida
KidCare Statewide Communication Link,” the statewide
communication link preserved by the Florida Covering Kids
and Families project after the demise of the Florida
Department of Health (DOH) Florida KidCare Outreach
project.
Study Design: In July 2003, the Florida Legislature eliminated
budget authority for the DOH to leverage private sector and
federal dollars to conduct legislatively mandated policy
coordination, collaboration, and promotion of appropriate
health care utilization through local outreach for Florida
KidCare. Until that time the state outreach project funded
seventeen statewide regional sites throughout Florida. The
DOH was responsible for providing technical assistance in the
form of trainings, regular policy updates, reporting to the
agencies on local level issues, developing marketing materials,
coordinating media campaigns, collecting and providing
enrollment and outcome data, forming community
partnerships, and coordinating outreach efforts statewide.
Population Studied: Until the end of June 2003 the regional
projects provided outreach, training, and technical assistance
to front-line community-based organizations that had direct
contact with families whose children were uninsured. The
program focused on In-reach and retention activities, and
appropriate use of health care services. Key elements of the
program were the promotion of attending well-child visits and
keeping children insured. A variety of specialized outreach
activities were targeted to underserved populations to reduce
racial and ethnic disparities in health care.
Principal Findings: In July 2003, the Covering Kids and
Families (CKF) project, funded through a grant of the Robert
Wood Johnson Foundation, agreed to maintain the regular
communication link between those outreach sites that were
able to continue servicing their communities by obtaining
alternate funding and the state agency partners. Currently,
there are 18 communities throughout the state that are
continuing Florida KidCare outreach; four of those sites are
local projects funded through the CKF state project.
Conclusions: Primarily through electronic communication,
the community sites are able to stay informed of Florida
KidCare program updates, community partnerships, media
coverage, wait list information, outreach activities, state and
federal policy updates, and meeting notices. The outreach
coordinators are able to communicate with state agency
representatives through the CKF project staff. The CKF project
staff is able to collect information from the local sites to
develop community partnerships, coordinate Back-To-School
media activities, offer technical support in the form of
trainings, and ensure that a coordinated outreach, retention
and education effort is implemented. . This electronic link
serves as a method of collecting and disseminating data, while
maintaining the flow of communication on the program
statewide.
Implications for Policy, Delivery or Practice: The Florida
KidCare program has a wait list as of December 30, 2003 of
about 89, 770 children, of which approximately 63,000 are
Title XXI eligible. This situation has significant implications for
health policy; practice and financing that inspire the
continuation of the Florida KidCare outreach program. In
order to sustain and improve the Florida KidCare program, the
communication link must maintain its capacity as a vehicle for
immediate information exchange and assistance between
consumers and providers.
Primary Funding Source: RWJF
• Analysis of Case Mix to Determine Prospective Medicare
Rates for Rural Primary and Consumer-Directed Chronic
Care
Darryl Wieland, Ph.D., M.P.H., Tom Brown, Ph.D., Rebecca
Boland, M.A., Brenda Wamsley, Ph.D., Gerry Eggert, Ph.D.,
Joan Van Nostrand, Ph.D.
Presented by: Darryl Wieland, Ph.D., M.P.H., Research
Director, Geriatrics Services, Palmetto Health Richland, Nine
Medical Park, #630, Columbia, SC 29203; Tel: 803.434.4330;
Fax: 803.434.4331; E-mail: darryl.wieland@palmettohealth.org
Research Objective: To develop and validate a case-mix
typology based on clients’ assessed diseases, impairments,
psychosocial characteristics, and disabilities, in order to form
the basis of setting an annually adjustable Medicare rate for a
waivered program of prepaid consumer-directed primary and
chronic care in rural areas of New York (ACCESS), and West
Virginia and Ohio (Connect Care).
Study Design: The dataset comprised comprehensive
assessment variables at admission for all clients during the
program’s demonstration phase. Grade-of-membership [GoM]
analysis of admission variables was used to determine
disease-impairment-disability types and the degrees of
membership of individual subjects in the pure types. The
typology was validated against clients’ demographic
characteristics and subsequent attrition information and
resource utilization. Medicare and total chronic care rates
were developed for each state separately to account for
interstate variations in case mix and retention probabilities,
and FY2003 unit prices and service use patterns.
Population Studied: Elderly and disabled community
residents of catchments in rural upstate NY and the mid-Ohio
valley [WV and OH], who were Medicare parts A & B eligible,
moderately-to-severely physically or cognitively impaired, and
prior high-volume users of Medicare services (n=1,605).
Principal Findings: Ten clinical admission profiles were
identified from 1,605 admissions, characterizing the variation
in terms of disease burden, impairments, and disabilities in
the cohort. The third most prevalent profile (10.3% of the total
cohort membership) is highly representative of the younger
adult (age < 55) disabled population. The remaining nine can
be grouped into an elderly cognitively intact, decision-capable,
six-type series, and an elderly cognitively and decisionimpaired three-type series. The types vary in prevalence by
state and area. Content and predictive validity are
demonstrated for the typology. For example, the more
disabled types were generally predictive of more non-Medicare
nursing home utilization. After adjustment for attrition, the
total annual estimated payments ranged from $15,381 in WV,
through $17,997 in OH, to $20,687 in NY. Annualized
Medicare payment estimates ranged from $10,956 in WV,
through $13,028 in NY, to $13,573 in OH.
Conclusions: GoM classification produced a clinically valid,
annually adjustable basis for Medicare rate setting for the
ACCESS and Connect Care programs. New admissions can be
classified into the existing profiles, and their retention and
utilization can be tracked. With ongoing linkage to service
utilization and annual updating of Medicare unit costs, rates
can be kept current.
Implications for Policy, Delivery or Practice: Managed,
consumer-directed care for rural elderly and disabled
populations has promise for improving their access to costeffective care. Improved methods for adjusting capitation
payments to variable case-mix, payment region, time, service
delivery patterns, and unit costs are necessary for their
variability and the confidence of payers and consumers.
Primary Funding Source: HRSA, CMS
• Patients’ Perceptions of Safety in US Hospitals
Robert Wolosin, Ph.D.
Presented by: Robert Wolosin, Ph.D., Research Associate,
Research and Development, Press Ganey Associates, Inc., 404
Columbia Place, South Bend, IN 46601; Tel: 574.232.3387; Fax:
574.232.3485; E-mail: rwolosin@pressganey.com
Research Objective: The Institute of Medicine’s 1999 To Err
is Human indicated the extent to which patients in American
hospitals face harm from caregivers. Reported harms ranged
from inconsequential to catastrophic. It was estimated that
between 44,000 and 98,000 Americans die in hospitals
annually because of preventable medical errors. On January 1,
2003, the Joint Commission on the Accreditation of
Healthcare Organizations implemented 2003 National Patient
Safety Goals. Given current publicity and industry emphasis
on patient safety, it is important to understand how patients
themselves perceive how safe and secure they feel while
hospitalized. This study describes patients’ perceptions of
personal safety in US hospitals. Characteristics of patients,
hospitalizations, and hospitals were used as independent
variables to investigate perceived safety. Correlations between
perceived safety and other patient satisfaction issues are
presented.
Study Design: All data and measures come from Press Ganey
Inpatient surveys processed in the first nine months of 2003.
Standardized questionnaires were mailed to hospitalized
patients shortly after discharge. Response rate was about 25%.
Items were rated on a 5-point scale from very poor (1) to very
good (5). The custom question “Degree of safety/security felt
in hospital” is used by 462 US hospitals. Results are based on
survey responses from 597,124 patients from 447 acute care
hospitals whose Medicare provider number could be
ascertained.
Population Studied: Inpatients treated in US hospitals during
2003.
Principal Findings: Univariate analyses showed that patients’
perceptions of their safety and security varied significantly with
patients’ demographic characteristics, events during
hospitalization, and hospital parameters. Age and gender
interacted in that older males (50-79 years) felt safer than
younger ones, but younger females (up to 34) felt safer than
older ones. Patients given more information about rights, etc.
at registration felt safer than those given less information;
patients without roommates felt safer than patients with
roommates. Hospitals differed significantly as to perceived
safety; means varied from 4.0 to 4.8. Perceptions of safety
were negatively correlated (-.29) and (-.40) with hospital bed
size and adjusted length of stay, respectively, and positively
correlated (.25) with hospital profitability. They correlated
positively and highly with ratings of personal dimensions of
care and overall ratings of care.
Conclusions: Patient perceptions of safety and security vary
systematically and can be predicted from patient
characteristics, events during hospitalization, and hospital
parameters. Staff attention to the patient’s person through
sensitivity to problems caused by illness and hospitalization,
and staff response to concerns and complaints create
perceptions of safety.
Implications for Policy, Delivery or Practice: Hospitals have
control over a number of processes related to perceptions of
safety and security. Hospitals can maximize their patients’
perceptions of safety and security by globally attending to the
personhood of patients: offering information about life
support, patient rights and organ donation at registration;
demonstrating sensitivity to the inconvenience caused by
health problems and hospitalization; responding to concerns
and complaints of patients; and attending to their emotional
and spiritual needs of patients, as well as their needs for
privacy.
Primary Funding Source: Press Ganey Associates, Inc.
• Health Outcome Evaluation of Utah’s Primary Care
Network (PCN): A New Medicaid Waiver
Wu Xu, Ph.D., Mike Martin, M.B.A.
Presented by: Wu Xu, Ph.D., Director, Utah Department of
Health, Utah Office of Health Care Statistics, P.O. Box
144004, Salt Lake City, UT 84114-4004; Tel: 801.538.7072; Fax:
801.538.9916; E-mail: wxu@utah.gov
Research Objective: Utah’s Primary Care Network (PCN) is
the first Medicaid 1115 waiver program in the nation to provide
primary care coverage with donated hospital and specialty
care for the uninsured, low-income adult population. This
study intends to measure the program’s impact on PCN
enrollees’ self-reported health outcomes and assess the
enrollees’ satisfaction with the program.
Study Design: Data sources are self-health assessment
surveys conducted among PCN enrollees during pre- and
post-PCN enrollment periods. The assessment questions are
adopted from the SF-12 health status, BRFSS, and CAHPS
surveys. Ten health indicators are generated from each survey,
serving as outcome measures. Individuals’ pre- and postassessment records will be linked. Bivariate preliminary
analysis has been conducted to measure the changes in
enrollees’ health indicators after 12 months of PCN coverage.
Multivariate analysis will be conducted to determine
contributing factors for improving enrollee health status.
Population Studied: The PCN Program provides coverage to
adults, 19 to 64 years old, with family incomes below 150
percent federal poverty level. As of December 31, 2003, 18,814
people were enrolled. The pre-enrollment assessments were
administrated among all PCN applicants (N=9,984) from July
to December 2002. The post-enrollment assessment survey is
being conducted among 3,000 samples of renewed PCN
enrollees from July – December 2003. The post-survey will
complete data collection in March 2004.
Principal Findings: Based on preliminary data for the firstquarter PCN re-enrollees, no statistically significant changes
on physical and mental health status are found among those
enrolled in the program for 12 months. The percent of PCN
enrollees who have been previously-diagnosed with one or
more chronic conditions increased from 64.7% in preenrollment assessment to 74.5% after enrolling in PCN for 12
months. Approximately 55% of enrollees reported that they
received routine care for themselves in the six months prior to
PCN enrollment; however, 74 % of PCN enrollees obtained
routine care after PCN enrollment. More enrollees said that
they had no problem receiving needed care in the postassessment than in the pre-assessment (48% vs. 30%). With
the tobacco intervention, the percent of smokers declined
from 30.4% to 26.8%. Comprehensive analysis will be
conducted in April 2004.
Conclusions: The PCN program has reached its enrollment
target within 17 months, indicating that the primary care
coverage were welcomed by the uninsured population. The
new coverage reduced access barriers to primary care for PCN
enrollees who were diagnosed by a health professional as
having one or more chronic conditions. Also, a slight
modification of risk behavior (tobacco use) has been
observed. The 12-month evaluation period is too short to
demonstrate significant results of the program impact. Future
follow-up study is needed.
Implications for Policy, Delivery or Practice: With limited
financial resources, primary care coverage can serve more
uninsured adults than that under an ideal comprehensive
coverage. Initially, the covered primary care will expand the
need for uncovered acute or specialty care. Policy makers have
to anticipate and respond to this challenge. If an adult
population has universal primary coverage, acute care needs
for the adult population may be reduced in the long run.
Primary Funding Source: HRSA and State Funds
Presented by: Yu Xu, Ph.D., Assistant Professor,
Community/Mental Health Nursing, University of South
Alabama, 1504 Springhill Avenue, Mobile, AL 36688; Tel:
251.434.3454; Fax: 251.434.3995; E-mail: yxu@usouthal.edu
Research Objective: This descriptive study examines the
knowledge, attitudes, and health behaviors related to cancer
risks, prevention, and early detection in Southeast Asian
Americans along the Central Gulf Coast.
Study Design: An investigator-designed survey was
conducted at community sites to identify aggregate-specific
cancer risks. An investigator developed survey instrument was
used for this study. The instrument was based on the Alabama
Comprehensive Cancer Control Plan: 2001-2005, and the
monographs on the evaluation of carcinogenic risks of various
agents by the International Agency for Research on Cancer,
and the Centers for Disease Control and Prevention’s
Behavioral Risk Factor Surveillance System.
Population Studied: The survey included 332 volunteer
Southeast Asian community residents age 18 or older.
Principal Findings: About 8% of those surveyed reported a
diagnosis of hepatitis. Smoking prevalence for men was
40.51% (compared to 3.01% for women), with a mean of 12.4
cigarettes per day for all current smokers. The average age of
initiating smoking was 17.6 years. 42% reported living with at
least one family member who was smoker. 31.2% identified
themselves as drinkers. Drinking amount varied significantly
between the genders, with an average of 9.6 drinks per week
for male drinkers and 4.0 for female drinkers. 76.3% reported
no protective measures against sunlight at all. There were
noted deficits of cancer knowledge and utilization of cancer
screening services. Only 31.4% of all surveyed were aware that
a test could be performed to check for colorectal cancer; even
fewer (21.2%) age 50 and older had never had the test. 30.4%
of surveyed women did not know that they could use selfbreast examination to detect breast cancer, and 33.7% did not
perform it at all. 29.1% did not know that Pap smear could
detect cervical cancer and 38% had never had it done,
although 48.4% identified no difficulties in getting a Pap test.
Conclusions: This study documented the specific cancer risks
of Southeast Asian Americans along the Central Gulf Coast:
high prevalence of hepatitis, high smoking and drinking rates
in men, extended ultraviolet light exposure without protection,
poor knowledge of cancer screenings, and low colorectal and
prostate cancer screening rates. Significant gaps still remain
between the objectives of the Alabama Comprehensive Cancer
Control Plan: 2001-2005 and the achieved progress in the
areas of colorectal and prostate cancer screenings and
tobacco use in men. Also, it documented significant
knowledge deficit regarding cancer and cancer screenings.
Implications for Policy, Delivery or Practice: This study
demonstrated the need for initiatives on cancer-related
education in this underserved population, especially in the
areas of colorectal and prostate cancer prevention and early
detection. Further, it supported the need to explore the best
ways to reach this hard-to-reach population.
Primary Funding Source: Sigma Theta Tau International and
the University of South Alabama Research Council
• Cancer Risks of Southeast Asian Americans along the
Central Gulf Coast
Yu Xu, Ph.D., M. Candice Ross, Ph.D., Rebecca Ryan, Ed.D.
• Demographic and Behavioral Factors Associated with
Body Mass Index among Nebraska Adults
Liyan Xu, M.S., Jeff Jonkman, Ph.D., Keith Mueller, Ph.D.,
Wanqing Zhang, M.Ed.
Presented by: Liyan Xu, M.S., Health Data Analyst,
Department of Preventive and Societal Medicine, University of
Nebraska Medical Center, 984350 Nebraska Medical Center,
Omaha, NE 68198-4350; Tel: 402.559.4191; Fax: 402.559.7259;
E-mail: liyanxu@unmc.edu
Research Objective: Investigate demographic and behavioral
factors associated with self-reported weight status of adults in
Nebraska.
Study Design: Using data from the Behavioral Risk Factor
Surveillance Survey for Nebraska 1998, 2000, 2002. 18
variables which may affect the human Body Mass Index,
including gender, race, education, work, household income,
martial status, fruit and/or vegetable consumption, leisure
time activity and diabetes status, were selected in this study.
Propensity score method was used to balance the background
covariates between a variety comparison groups (e.g. by race,
by education, by income, by physical activity, and by diet).
Population Studied: Nebraska adults aged 18 or above were
included in this analysis. This sample included 8098 subjects
(4741 females and 3357 males). The mean age of the sample
was 48.51, and the mean BMI was 26.67.
Principal Findings: The comparison groups generated using
propensity scores were well balanced with respect to all
collected baseline covariates in this study. Identified risk
factors which could affect the Body Mass Index included race
(black or white), education, leisure time activity and
consumption of at least four daily servings of fruit and/or
vegetables: 1. Body Mass Index (BMI) was higher (28.86
versus 26.63, p<0.001) for black race than for white race. 2.
BMI was higher (27.19 versus 26.44, p<0.001) for people aged
25 and above who have less than a college degree than for
people who have at least a college degree. 3. Compared with
people who have leisure time activity, the BMI for people with
no leisure time activity was 0.80 units more on average (27.21
versus 26.41, p<0.001). 4. Compared with people consuming
at least four servings of fruit and/or vegetable, the BMI for
people consuming less than four servings was 0.35 units more
on average (26.80 versus 26.45, p=0.0052). Factors that do
not affect the BMI in this study included race (white or
Hispanic), and household income: 1. No significant difference
existed between Hispanic race and white race (26.68 versus
26.63, p=0.5431). 2. In a simple t-test, the BMI was
significantly different between groups with household income
less than $35,000 and household income more than $35,000
(26.79 versus 26.54, p=0.03). However, after adjustment for
selected baseline covariates, there was no significant
difference between these two groups (p=0.6639).
Conclusions: About 60% of Nebraskans are overweight or
obese. Significant risk factors for higher BMI include black
race, lower education, lower consumption of fruits and
vegetables, and having no leisure time activity.
Implications for Policy, Delivery or Practice: Increased body
weight was associated with increased disease and disability
occurrence. While the prevalence of overweight/obesity has
increased for all population, disparities still exist.
Overweight/obesity prevention programs need to be targeted
to some specific populations.
• Racial Disparity in Access to New Advances in
Pharmacotherapy
Vicki Young, Ph.D., R.Ph.
Presented by: Vicki Young, Ph.D., RPh, Fellow in Outcomes
Research, College of Pharmacy, Medical University of South
Carolina, 280 Calhoun Street, PO Box 250144, Columbia, SC
29425; Tel: 843.876.1057; Fax: 843.792.1712; E-mail:
youngvm@musc.edu
Research Objective: The purpose of this study was to
examine disparities in access to new advances in
pharmacotherapy, taking several disease states into account.
Study Design: This study involved the use of the South
Carolina Medicaid database (claims and eligibility data) and
employed a retrospective cohort design. Patients within this
database who had a new diagnosis for which one of the
relevant pharmaceuticals could be prescribed were identified
and followed forward for a period of time. The relevant
pharmaceuticals were selected via a two-step selection
process involving the Food and Drug Administration drug
approval database and an expert panel. Logistic regression
was used to assess the likelihood of receiving the advanced
therapy based on race.
Population Studied: African Americans and Caucasians, from
the ages 19 to 63, enrolled in the South Carolina Medicaid
Program from 1992 to 1998 were studied.
Principal Findings: There were 39 individuals with
osteoporosis, 85 individuals with migraine, 186 individuals
with hyperlipidemia, and 706 individuals with diabetes who
met the inclusion and exclusion criteria. The odds ratios for
osteoporosis (OR 1.217, CI (0.265, 5.587)) and migraine (OR
1.517, CI (0.424, 5.432)) indicated that African Americans were
more likely than Caucasians to receive the advanced therapy,
but the confidence intervals were broad. The odds ratios for
hyperlipidemia (OR 0.575, CI (0.311, 1.063)) and diabetes (OR
0.836, CI (0.570, 1.226)) indicated that African Americans were
less likely than Caucasians to receive advanced therapy, these
confidence intervals were also broad.
Conclusions: The results of the analyses conducted by
medical condition showed no statistically significant
differences in access to drug therapy. The strong point
estimates for African Americans with hyperlipidemia and
diabetes regarding the likelihood of receiving the advanced
therapy compared to Caucasians warrant further study.
Implications for Policy, Delivery or Practice: The current
study explored disparities in access to newly released
advances in drug therapy across disease states. Research with
this focus is limited and more research in this area is needed
to more accurately quantify the extent of disparities. Once
disparities are quantified, explanations for and policies to
eliminate the disparities can be more effective.
Primary Funding Source: AHRQ, South Carolina
Commission on Higher Education
• Coenzyme Q10: A Promising Treatment for Alzheimer’s
Disease?
A. Joyce Young, M.D., David Steffens, M.D., P. Murali
Doraiswamy, M.D.
Presented by: A. Joyce Young, M.D., Post Doctoral Fellow,
Psychiatry, PREMIER Program Duke University Medical
Center, 114 Crosswood Drive, Durham, NC 27703; Tel:
919.957.7985; Fax: 919.681.7504; E-mail:
young109@mc.duke.edu
Research Objective: The goal of this study was to determine
the feasibility of Coenzyme Q10 as an effective treatment for
patients with Alzheimer’s disease. CoQ is involved in
enzymatic reactions necessary for oxidative phosphorylation in
the inner mitochondrial membrane. Deficiency of CoQ is
associated with oxidative DNA and protein damage in nerve
cells in-vitro. CoQ has been shown to inhibit atherosclerosis in
ApoE knockout mice and to diminish hippocampal damage in
animal models of ischemia.
Study Design: We conducted a systematic review of all
articles in Medline 1965 to September 2003, to determine the
potential benefits of CoQ for preventing and/or treating
Alzheimer's disease.
Population Studied: Elderly patients who were diagnosed
with Parkinson's disease, Alzheimer's disease or other
neurodegenerative mitochondrial disease, and were treated
with CoQ
Principal Findings: We found no published controlled clinical
trials of CoQ in AD. To date, there have been four published
pilot clinical trials of CoQ for other neurodegenerative
disorders involving a total of less than 200 subjects. A
sixteen-month multi-center trial of 80 subjects with
Parkinson’s disease found that, CoQ 300-1200 mg/day,
tended to slow progression compared to placebo. Higher
doses tended to show greater efficacy. Adverse effects were
minimal, and domains that showed benefits were function,
motor symptoms and cognition.
Conclusions: There is limited, but emerging evidence that
CoQ may be a promising adjunctive therapy for some
neurodegenerative disorders. Because mitochondrial
dysfunction has been postulated in AD, a randomized
controlled trial of CoQ appears warranted.
Implications for Policy, Delivery or Practice: The prevalence
of dementia continues to increase, with AD being the most
common type. In 1997, it was reported to be the seventh
most common cause of death in the US, its incidence
doubling every five years. If this rate of morbidity and mortality
were to be continued, there will be an overwhelming impact in
the near future, considering that the baby boomers are soon
approaching late life. AD is a neurodegenerative disease with
known defect in the inner mitochondrial membrane. Oral
administration of CoQ10 therefore may show similar promise
in patients with AD. Further research to evaluate the effects of
CoQ10 in slowing the cognitive decline, and improving quality
of life to patients with dementia is warranted.
Primary Funding Source: NIMH supported PREMIER
Program, Duke University Medical Center.
• Clinical and Demographic Correlates of Suicidal Ideation
in Older Patients with Bipolar Disorder
A. Joyce Young, M.D., John Beyer, M.D., Maragatha
Kuchibhatla, Ph.D., Frederick Cassidy, M.D., K.. Ranga
Krishnan, M.D.
Presented by: A. Joyce Young, M.D., Post Doctoral Fellow,
Psychiatry, PREMIER Program Duke University Medical
Center, 114 Crosswood Drive, Durham, NC 27703; Tel:
919.957.7985; Fax: 919.681.7504; E-mail:
young109@mc.duke.edu
Research Objective: Studies have shown that the elderly are
the fastest growing population in the United States, and that
the risk of suicide in this population is twice the rate of suicide
in teenagers. However, there is limited information on the
presence of suicidal ideation in this population. This study
was conducted to better understand the clinical and
phenomenological correlates of elderly patients with bipolar
disorder who experience suicidal ideation.
Study Design: We conducted a cross-sectional study of 49
older adults (ages 50-89) with bipolar disorder, assessing their
history of suicidal ideation. Using a bivariate analysis, we
evaluated potential clinical and demographic characteristics
that may be associated with suicidal ideation.
Population Studied: Patients with bipolar disorder, age 50 to
89, N equals 49.
Principal Findings: In bipolar patients 50 years and older, 30
subjects (61%) reported a history of suicidal ideation. Positive
correlations of suicidal ideation included being of Caucasian
race (p=0.04), and having prominent sleep difficulties in the
depressed phase (p=0.008). Interestingly, those with a
history of suicidal ideation were younger (mean age 58)
compared to elders without a history of suicidal ideation
(mean age 64).
Conclusions: Suicidal ideation is highly ubiquitous in bipolar
disorder. Risk factors for older adults include Caucasian race
and sleep disruption during depression. This study supports
previous findings of risk factors for suicide, and may assist
clinicians in the assessment for suicidal ideation in this
vulnerable population.
Implications for Policy, Delivery or Practice: Suicide
completion is highly associated with suicide ideation. This
study may assist clinicians in the assessment of suicide,
particularly in this vulnerable group.
Primary Funding Source: NIMH supported PREMIER
Program, Duke University Medical Center.
• Unequal Utilization of New Technologies by Race:
Adjusting for Geography in the use of TUNA and TUMT
among Medicare Beneficiaries
Xinhua Yu, MB, Ph.D., Alexander McBean, M.D., MS, Debra
Caldwell, M.S., Janet Anderson
Presented by: Xinhua Yu, MBA, Ph.D., Research Associate,
Division of Health Services Research and Policy, University of
Minnesota, MMC 79 Mayo, 420 Delaware Street SE,
Minneapolis, MN 55455; Tel: 612.624.1411; Fax: 612.378.4866;
E-mail: yuxx0131@umn.edu
Research Objective: Many studies have documented lower
rates of surgical procedures among Black Americans than
Whites. Little is known about the availability and accessibility
of new technologies. Two new surgical procedures,
transurethral microwave thermotherapy (TUMT) and
transurethral needle ablation of prostate (TUNA) have recently
been introduced as alternatives for the traditional surgical
treatment of benign prostate hypertrophy (BPH), transurethral
resection of prostate (TURP). This study compares the
availability and accessibility (utilization) of these three
procedures among elderly black Medicare beneficiaries with
white beneficiaries. Rates of TURPs were included to provide
information on the usual variation in BPH surgical treatment
by race.
Study Design: Data source: Medicare administrative claims
data from 1999-2001. Institutional and physician claims for
BPH were extracted from Center for Medicare and Medicaid
Services’ (CMS) National Claim History repository. National
race-specific age-adjusted procedure rates were computed.
Geographic areas (counties) were identified where the new
technologies were available. The same rates were calculated
for residents of these counties and which had more than 10
black males beneficiaries using generalized estimate equation
models to adjust for geographic variation.
Population Studied: Black and White male Medicare
beneficiaries age 65+ years of age with a diagnosis of BPH
who had a TUMT, TUNA, and TURP procedure during 19992001 (N=140,207). Those who were enrolled in managed care
or who had ESRD or prostate cancer during the study years
were excluded.
Principal Findings: During 1999-2001, the national ageadjusted rates for TUMT, TUNA, and TURP among Whites
were 5.7, 1.7, and 40.7 per 10,000, respectively. Among Blacks,
the rates were 2.6, 0.9 and 36.6 per 10,000. Residents of 631
counties had TUMT available. TUNA was available in 406
counties. The ‘TUMT-available’ counties accounted for 57% of
the White male Medicare elderly enrollees and 69% of the
Black enrollees. The ‘TUNA-available’ counties had 46% of the
Whites and 57 % of the Blacks. In these counties, after
adjusting for age and geographic variation, Whites had higher
procedure rates per 10,000: 6.9 for TUMT, and 2.6 for TUNA,
than Blacks: 4.0 for TUMT, and 1.7 for TUNA. The rate ratios
(W/B) were 1.73 (95%CI: 1.52-1.96) for TUMT, and 1.51
(95%CI: 1.18-1.95) for TUNA. For comparison, the adjusted
rates for TURP were 41.8 per 10,000 for Whites and 38.1 per
10,000 for Blacks, and the rate ratio was 1.10 (95%CI: 1.001.20).
Conclusions: Interestingly, the new procedures for BPH were
more available to a greater percentage of Blacks than Whites.
However, after adjusting for the availability of the new
procedures, elderly Black Medicare beneficiaries were less
significantly likely to receive the new BPH procedures than
Whites, while the utilization of TURP did not differ
significantly between Blacks and Whites.
Implications for Policy, Delivery or Practice: One of the two
major goals of Healthy People 2010 is to reduce racial
difference in health care. This study demonstrates although
there is no known greater effectiveness using the new
procedures, these services are more frequently used on White
beneficiaries. Differences by race in the use of new
technologies with proven greater effectiveness should be
monitored.
Primary Funding Source: CMS
• Employer-Sponsored Health Insurance with No
Employee Contributions towards Premiums
Alice Zawacki, Ph.D., M.B.A., Amy Taylor, Ph.D.
Presented by: Alice Zawacki, Ph.D., M.B.A., Economist,
Center for Economic Studies, Census Bureau, 4700 Silver Hill
Road, Washington, DC 20233-6300; Tel: 301.763.1862; Fax:
301.457.1235; E-mail: alice.m.zawacki@census.gov
Research Objective: In response to rapidly rising health
insurance costs, many insurers are cutting back on their
contributions to premiums. Contribution levels vary across
firms and the share of premiums paid by employers and
employees has been a major issue in the negotiation of union
contracts. Despite the problem of increased medical care
costs, there are still some firms that continue to pay 100
percent of the cost of insurance premiums for their
employees. The goal of this analysis is to identify the
characteristics of these firms and the policies they offer.
Study Design: We analyze data from 1997 through 2000 from
the Medical Expenditure Panel Survey – Insurance Component
(MEPS-IC), which collects establishment level data on the
health insurance plans offered to employees, as well as
establishment and workforce characteristics. We focus on
establishments that offer health insurance and contribute 100
percent of the premium cost for at least one of the plans they
offer. These businesses represent approximately 25 percent of
U.S. establishments and employ 50 percent of the workforce.
We describe the characteristics of establishments that offer
one plan and contribute 100 percent towards its premium,
establishments that offer more than one plan and contribute
100 percent towards the cost of at least one of these plans,
and establishments that do not offer health insurance. Next,
we look at whether the number of establishments offering
health insurance at no cost to their employees has been
changing. Finally, we look at the characteristics and
enrollment of these plans with premiums entirely paid by
employers.
Population Studied: The nationally representative sample of
public and private establishments found in the MEPS-IC from
1997 to 2000.
Principal Findings: Establishments that are unionized, older,
larger, and that have more full-time employees and fewer lowwage employees are more likely to contribute 100 percent of
the premium cost for single coverage, than others. From 1997
to 2000, we find that the number of establishments that offer
one health plan and contribute 100 percent towards its
premium cost for single coverage has increased approximately
3 percent. In contrast, the number of establishments that
offer more than one plan and contribute 100 percent towards
the premium for at least one of these plans with single
coverage fluctuated. Finally, plans with exclusive health care
providers, self-insured indemnification, and lower average
premiums for single coverage are less likely to be plans for
which establishments fully contribute towards the premium
cost.
Conclusions: The provision of employer-sponsored health
insurance at no cost to employees is related to specific
organizational, workforce, and plan characteristics.
Implications for Policy, Delivery or Practice: This research
examines employment related health insurance plans offered
to employees with premiums fully funded by employers. By
describing the associated establishment, workforce, and
health characteristics over time, the analysis shows under
what conditions the primary source of health insurance in this
country provides access with no premium contribution by
employees. In turn, this will enable us to better understand
changes in employee cost sharing in an era of increasing
health care expenditures.
Primary Funding Source: AHRQ
• Economic Burden of Lyme Disease in an Endemic Area
Xinzhi Zhang, M.D., Ph.D., Martin Meltzer, Ph.D., M.S., César
Peña, D.V.M., M.H.S., Annette Hopkins, R.N., M.S., Alan Fix,
M.D., M.S.
Presented by: Xinzhi Zhang, M.D., Ph.D., Prevention
Effectiveness Fellow, CDC/NCID/OD/OS, MS # D-59,
CDC/NCID/OD/OS, 1600 Clifton Road NE, Atlanta, GA 30333;
Tel: 404.371.5364; Fax: 404.371.5445; E-mail:
XZhang4@cdc.gov
Research Objective: Caused by Borrelia burgdorferi, Lyme
disease (LD) is the most common vector-borne inflammatory
disease in the United States. In 2000, the overall incidence of
LD in the U.S. was 6.3 cases per 100,000 population, but in
Maryland the incidence was 13.0/ 100,000. Assessing the
burden of LD in endemic areas will help assess the economics
of current and future prevention and control efforts.
Study Design: Data were collected in five counties (Kent,
Caroline, Dorchester, Queen Anne, and Talbot) of the
Maryland Eastern Shore from 1997 to 2000. Patients were
divided into five categories: clinically-defined early stage LD,
clinically-defined late stage LD, suspected LD, tick bite, and
other related complaints. Direct medical costs of diagnosis
and treatment of LD were obtained from medical record
abstraction. Indirect medical costs and productivity losses
were acquired from a questionnaire sent in 1998 and 1999 to
approximately 10% of the patients. The perspective of this
study was societal and all costs were converted to 2000
equivalent.
Population Studied: Maryland Eastern Shore
Principal Findings: Of 3,415 patients, 11% had early stage LD
while almost 4% of all patients had late stage LD. Suspected
LD and tick bite accounted for 21% and 16% of all patients,
respectively. The mean direct medical cost of early stage LD
decreased from $1,631 in 1997 to $599 in 2000 (p < 0.05). The
mean direct medical cost of late stage LD decreased from
$4,377 in 1997 to $1,369 in 2000 (p < 0.05). However, the
mean direct medical costs of suspected LD and other related
complaints increased 10% and 19%, respectively, from 1997 to
2000 (p < 0.05). The median of all costs (direct medical cost,
indirect medical cost, and productivity loss), aggregated
across all categories of patients, was approximately $260 per
patient.
Conclusions: Although incidence of LD increased in the
studied endemic area, direct medical costs associated with
individual cases of clinically defined early and late stage LD
decreased from 1997 to 2000.
Implications for Policy, Delivery or Practice: Increasing
public awareness, early detection, and other prevention
interventions of LD may have contributed to this result.
Primary Funding Source: CDC
• A Behavior-Based Measure of Hospital Quality: The
Relationship between Inter-Hospital Transfer Rates and
Other Quality Indicators
James Zhang, Ph.D., Theodore Iwashyna, M.D., Ph.D.,
Nicholas Christakis, M.D., Ph.D.
Presented by: James Zhang, Ph.D., Director, Health
Econometrics, Medicine, The University of Chicago, 5841 S.
Maryland Avenue (Mc2007), Chicago, IL 60637; Tel:
773.834.1956; Fax: 773.834.2238; E-mail:
xzhang@medicine.bsd.uchicago.edu
Research Objective: To develop a novel indicator of hospital
quality that can be easily and inexpensively determined for all
hospitals; specifically, to determine if rates of transfer into and
out of hospitals is a credible indicator of hospital quality.
Study Design: The claims of all elderly fee-for-service
Medicare patient admissions for hospitalizations in 1993 were
reviewed for evidence of transfers between hospitals. These
were aggregated to the hospital-level to determine inbound
and outbound transfer rates. These data were then compared
descriptively, statistically, and graphically to a range of other
structure, process, and outcome indicators of hospital quality.
hospital structure (e.g., size, range of technology, range of
ancillary services), process (e.g., teaching hospital status,
charges) and outcome (30 day comorbidity-adjusted mortality,
nomination by physicians for quality in a national survey)
Population Studied: 4,923 fee-for-service hospitals, 9,194,743
elderly patients
Principal Findings: Hospitals could be divided into four
groups, based on the proportion of their patients that were
inbound and outbound transfers. Hospitals with high
inbound rates but low outbound rates were large, urban,
teaching institutions with the widest range of technological
and ancillary services, and the lowest risk-adjusted mortality.
All other hospitals could also be descriptively divided into four
quality categories. All differences were highly statistically
significant (p<0.001) in ANOVA tests.
Conclusions: Inter-hospital inpatient transfer rates provide a
new approach that assesses hospital quality upon a
comprehensive measure of patient flow among hospitals.
Implications for Policy, Delivery or Practice: The proposed
measure of inter-hospital inpatient tranfer rate incorporates
physicians' assessment (and thus patients') of the quality of
care. It includes both local and broader market. It suggests
that patient transfers among hospitals has embedded
information about the quality of service that hospitals provide.