Call for Student Posters
Call for Student Posters
Poster Session A
Sunday, June 6 • 6:45 p.m.-8:00 p.m.
• Diagnosis Patterns for Psychological Symptoms in
Medicaid Primary Care
Natalie Blevins, M.S., M.H.A., Eleni Dimoulas, M.S., Robert
Frank, Ph.D.
Presented by: Natalie Blevins, M.S., M.H.A., Graduate
Research Assistant, Clinical and Health Psychology, Florida
Center for Medicaid and the Uninsured, PO Box 100227,
Gainesville, FL 32610; Tel: 352.273.5130; Fax: 352.273.5061; Email: nblevins@phhp.ufl.edu
Research Objective: It has been estimated that fifty percent
of all individuals with psychological symptoms seek treatment
from a primary care physician, and approximately twenty-five
percent of patients seen in a primary care physician’s office
suffer from a psychological disorder. Primary care patients
rarely present with prototypical symptoms, and when they do,
they are often complicated by somatic complaints related to a
physical condition. Thus, it is quite difficult to make an
accurate assessment of the presenting psychological problem.
The accuracy of diagnoses for psychological symptoms in
Medicaid primary care has never been evaluated. The purpose
of this study is to assess and describe the diagnosis patterns
of Florida Medicaid enrollees with clinical (i.e., meets DSM-IV
criteria for a specified disorder, e.g. Major Depressive
Disorder) and sub-clinical (i.e., diagnosed as Not Otherwise
Specified in DSM-IV) psychological conditions who seek
treatment in primary care medical facilities.
Study Design: Medicaid claims data were extracted and
analyzed using descriptive statistics. The Florida Agency for
Healthcare Administration provided the researchers with
electronic data files used to compare IDC-9 code frequencies.
Population Studied: Study participants included all Florida
Medicaid Medipass recipients with a diagnosis of a
psychological condition made by a primary care physician
during the month of June 2001.
Principal Findings: In our sample, we identified 613 Medicaid
recipients with an index diagnosis of psychological disorder in
June of 2001 made by a primary care physician. These
recipients were continuously eligible for Medicaid during the
previous six months and were all between the ages of 18 and
65. Four hundred and ninety-two (79.6%) were female and
355 (57.4%) were white. The mean age of our sample was 40.5
years. Fifty-six percent were SSI recipients, indicating
significant disability. Two sub-clinical psychological conditions
accounted for almost 69% of all diagnoses. Two hundred and
ten diagnoses of Anxiety State, Unspecified (ICD-9 code
300.00) were made and 210 diagnoses of Depression Not
Otherwise Specified (ICD-9 code 311) were made. Sixty-three
percent of primary diagnoses made during the initial
encounter did not change upon subsequent encounters. Of
those that did change, 35% switched from a sub-clinical to a
clinical diagnosis, while 38% switched from a clinical to a subclinical diagnosis.
Conclusions: We found that 63% of our sample maintained
the same diagnosis for the year following initial system
encounter. Sub-clinical diagnoses are often given to patients
who do not meet specific diagnostic criteria. The high
proportion of sub-clinical psychological conditions diagnosed
in our sample is consistent with literature suggesting that
limited symptom presentation in primary care serves as a
major barrier to accurate and consistent diagnosis. This may
be especially relevant in a Medicaid sample, given the
association between poverty and psychological distress.
Implications for Policy, Delivery or Practice: Few studies
have examined the diagnosis patterns of non-psychotic
psychological conditions in the Medicaid population.
Understanding this interaction in primary care, where most
individuals seek treatment for non-psychotic psychological
conditions, allows for more appropriate management of these
diseases, improvement of clinical outcomes, and reduction of
costs.
Primary Funding Source: Florida Agency for Health Care
Administration
• Factors Associated with Second-Generation
Antipsychotic Use in California Medicaid (Medi-Cal)
Patients with Schizophrenia
Lei Chen, M.A., Jeffrey McCombs, Ph.D.
Presented by: Lei Chen, M.A., Graduate Research Assistant,
Pharmaceutical Economics & Policy, University of Southern
California, 1540 E. Alcazar Street, CHP-140, Los Angeles, CA
90033; Tel: 323.442.3405; Fax: 323.442.1462; E-mail:
leichen@usc.edu
Research Objective: Olanzapine and risperidone are the two
most widely used second-generation antipsychotic
medications by California Medicaid (Medi-Cal) patients with
severe mental disorders. This analysis investigates the factors
associated medication choice for Medi-Cal patients with
schizophrenia who restart therapy after a break in treatment.
Study Design: Paid claims data were analyzed to identify
antipsychotic 're-starter' mono-therapy episodes initiated
between January 1999 and March 2003. A 'restarter episode'
is defined each time when a patient starts an episode of drug
treatment after a significant gap (>15 days) in prescriptions
following a prior episode. Re-starter episodes with either
olanzapine or risperidone only were selected if 6 months of
pre-treatment and 12 months of post-treatment data were
available. Multivariate logistic regression was used to
determine the factors that affected drug choice for re-starter
episodes.
Population Studied: Patients with schizophrenia, 18 years old
or above, eligible for California Medicaid Program
Principal Findings: 186,338 re-starter treatment episodes met
study selection criteria (56% olanzapine). Mean age was 44
years; mean duration of uninterrupted therapy was 140 days
(olanzapine) vs. 135 days (risperidone). Patients 35-65 years of
age were between 6% to 9% more likely to receive olanzapine,
as were male patients (+21%) and patients with a prior
psychiatric hospitalization (+4%). The likelihood of using
olanzapine increased with the prior use of non-institutional
care. Risperidone patients were more likely to be urban
residents (+5%), classified as disabled (+6%), supplemental
security income (+17%) or AFDC (+6%) eligible, Hispanic
(+12%), black (+10%), diabetic (+22%) and have a history of
prior nursing home use (+14%). Risperidone patients were
more likely to be age 65-75 (+7%) or 75+ (+19%), with no
differences observed in the under 35 population (p<0.05 for all
results).
Conclusions: Physicians in California used olanzapine and
risperidone differentially to treat patients with schizophrenia.
The observed differences in patient characteristics for
olanzapine and risperidone use may affect both treatment
outcomes and post-treatment costs and must be adjusted for
before comparing the outcomes achieved using these agents.
Implications for Policy, Delivery or Practice: Olanzapine
and risperidone are used differently in treating California
schizophrenic patients. Further research is needed to justify
whether or not such differential drug therapy is associated
with clinical or economic benefit to the patients. Also the
observed differences in patient characteristics for olanzapine
and risperidone use must be adjusted for the studies that
compare the outcomes achieved by using these agents.
Primary Funding Source: Eli Lilly & Co.
reassurance/confirmation of drug therapy (38%) and
modification drug therapy (21%).
Conclusions: An evaluation of survey responses revealed not
only a high satisfaction rate of requestors with the DIC service,
but also a positive impact of information on clinical outcomes.
Future implications include a cost analysis of the service
relative to patient care outcomes.
Implications for Policy, Delivery or Practice: The quality
assurance of DI services has traditionally relied on obtaining
feedback on the operational efficiency of the service without
measuring its impact as a health intervention. It is clear from
this study that these aspects are linked and access of clinical
imipact should be included in the quality assurance process
routinely.
• Quality Improvement of a Drug Information Center
(DIC): Focus on Customer Satisfaction and Patient
Outcomes Assessment
Chih-Ying Chen, B.S., Bethany Fedutes, Pharm.D., Nicole
Ansani, Pharm.D., Lin, Chyongchiou Jeng, Ph.D.
Presented by: Janet Coffman, M.A., M.P.P, Doctoral Student,
Health Services and Policy Analysis Program, University of
California, Berkeley, 1068 Kains Avenue, Apt. #8, Albany, CA
94706; Tel: 510.524.9851; Fax: 510.643.4281; E-mail:
janetmc@uclink.berkeley.edu
Research Objective: One of the most noteworthy innovations
in hospital care during the 1990s was the development of the
“hospitalist” role. Instead of relying on primary care
physicians to manage their patients’ hospital care, many
hospitals and medical groups now utilize hospitalist
physicians who focus exclusively on inpatient care on a
permanent or rotating basis. The use of hospitalists has been
controversial. Advocates assert that hospitalists improve both
efficiency and quality of care, whereas critics charge that
hospitalists reduce quality of care and patient, family, and
provider satisfaction. The objectives of this study are to
systematically review and synthesize research findings
regarding the impact of hospitalists on resource use, quality of
care, and satisfaction.
Study Design: Bibliographic searches were conducted using
the National Library of Medicine’s PubMed database and the
ProQuest/ABI Inform database. Evaluations were deemed
eligible for inclusion in the study if they: 1) were published in
a peer reviewed journal, 2) examined patients hospitalized in
the United States, 3) assessed the use of hospitalists on
general medical wards, 4) utilized randomized designs or
quasi-experimental designs with multivariate analysis to
control for potential confounders.
Population Studied: The intervention groups consisted of
hospitalized patients whose care was managed by hospitalists.
The control/comparison groups consisted of patients whose
care was managed by office-based primary care physicians or
academic ward teams composed of faculty, residents, and
medical students.
Principal Findings: Twenty-one evaluations met our criteria
for inclusion. Five evaluations used randomized designs and
16 used quasi-experimental designs with multivariate methods
to control for potential confounders. Most studies analyzed
data on the hospitalist intervention for one year or less. Most
studies, including those with randomized designs, found that
patients managed by hospitalists had lower total hospital
costs or charges. These reductions were achieved primarily by
Presented by: Chih-Ying Chen, B.S., Health Policy and
Management, University of Pittsburgh, 101 N Dithridge Street,
Apt. 504, Pittsburgh, PA 15213; Tel: 412.298.5466; E-mail:
chc23@pitt.edu
Research Objective: Essential elements of a drug information
service include: accurate responses, positive impact of
information on patient care, and caller satisfaction. There is
limited literature regarding the impact of a DIC on clinical
outcomes. Our objective was to design, implement, and
analyze a quality improvement (QI) and outcomes
assessment tool to evaluate DIC requestor satisfaction and
overall impact on patient outcomes; and improve the quality
of service provided.
Study Design: This was a prospective, randomized, singleblind evaluation. Monthly, a random sample of requestors
(50% of total callers) were mailed a 10-question survey which
evaluated satisfaction (Likert scale, 0 = not satisfied to 5 = very
satisfied) with the DIC response and the impact of that
information on patient care outcomes. All data was entered
into an access database and analyzed by descriptive statistics.
Population Studied: Requestors (health professionals) of the
Drug Information Center at University of Pittsburgh
Principal Findings: Sixty-eight surveys were received during a
six-month period (43% response rate) and 87% were patientspecific questions (i.e., not academic detailing). 97% of
respondents reported that answers were provided in time to
be applied to patient care (4.9 +/- 0.4). In addition, 94.1% of
the respondents felt the question was answered fully and to
their satisfaction (4.8 +/- 0.6). All respondents agree that they
would recommend the DIC to colleagues (5 +/- 0.2) and use
the service again (5 +/- 0.2). Clinical outcomes analysis
revealed that 34% of responses helped to resolve a therapeutic
problem, 29% optimize drug administration, 16% and 15%,
respectively prevent and identify an adverse drug event.
Additionally, the information often led to
• The Impact of Hospitals on Cost, Quality and
Satisfaction with Inpatient Care in the United States: A
Research Synthesis
Janet Coffman, M.A., M.P.P.
reducing length of stay rather than by reducing use of ancillary
services or specialty consultations. Most studies found no
differences in quality of care or satisfaction. Findings were
consistent for evaluations that were conducted in teaching
and non-teaching hospitals and for evaluations that analyzed
adult and pediatric patients.
Conclusions: The findings of this research synthesis suggest
that hospitalists reduce the cost of inpatient care without
compromising quality of care or satisfaction. Further research
is needed to identify the mechanisms by which hospitalists
reduce length of stay, and to assess which types of hospitalist
programs are most effective and which patients are most likely
to benefit.
Implications for Policy, Delivery or Practice: The study’s
implications for hospitals and medical groups vary with the
forms of payment received. Use of hospitalists probably
would improve the financial performance of hospitals and
medical groups that are paid primarily on a capitated or
prospective basis because these organizations maximize
revenue by reducing length of stay. On the other hand,
hospitalists probably would not benefit hospitals or medical
groups that are paid primarily on a per diem or fee-for-service
basis. There is little evidence that using hospitalists would
enable hospitals or medical groups to improve quality of care
or satisfaction.
Bivariate analyses and multiple logistic regression models
were used to evaluate variations in and predictors of onsite
IUD availability.
Population Studied: All VA medical centers and affilitated
community-based outpatient clinics which delivered clinical
services to at least 400 unique women during Fiscal Year
2000.
Principal Findings: While 96% of facilities offer onsite
prescription and management of hormonal contraception,
58% offer onsite placement of the IUD. In preliminary logistic
models that control for patient volume, those sites with a
separate gynecology clinic, p=0.0008, a separate budget for
the women's health program, p=0.01, and a formal women's
health training program, p=0.03, were predictive of the
availability of onsite IUD placement.
Conclusions: Onsite VA provision of contraception is
variable. Enhanced clinical specialization and increased
control over financial resources in the women's health
program may contribute to increased access to various
contraceptive methods.
Implications for Policy, Delivery or Practice: Contraception
is an important component of women's health care. More
research on how practice structure can facilitate prescription
and use of effective contracetpion is needed.
Primary Funding Source: VA
• Determinants of Onsite Availability of the Intrauterine
Device at Medical Facilities in the Department of
Veteran's Affairs
Jacqueline Cope, M.D., M.P.H., Martin Lee, Ph.D., Elizabeth
Yano, Ph.D.
• Look Who's Talking: Shared Decision-Making with
Children
Elizabeth Cox, M.D. M.S., Maureen Smith, M.D., Ph.D.,
M.P.H.
Presented by: Jacqueline Cope, M.D., M.P.H. in progress,
Women's Health and Health Services Research Fellow,
Internal Medicine, Department of Veteran's Affairs; UCLA
School of Public Health, 16111 Plummer Street (152),
Sepulveda, CA 91343; Tel: 818.895.9555; Fax: 818.895.9555; Email: jcope@ucla.edu
Research Objective: Federal legislative mandates and a
rapidly increasing population of women veterans and women
in the military has necessitated and accelerated the
development of women's health services, including
contraceptive services, throught the VA healthcare system. A
safe and effective form of contraception, the intrauterine
device, IUD, is already underutilized in the general U.S.
population, so availability in VA practice settings, where
women are a vulnerable minority, is of even greater concern.
While insurance coverage may explain variations in IUD
availability in part, no such limitation exists in the VA. In this
study, we aim to describe the variation in IUD provision
among VA facilities and evaluate the role that contextual and
organizational factors play in the onsite availability of this
contraceptive.
Study Design: We created a composite database consisting
primariy of facility-level data obtained form the 2001 VA
Survey of Women Veterans Health Programs and Practices,
which was completed by 136 VA medical facilities. This survey
was a cross-sectional assessment of organizational structure
and practice, with information obtained through clinical keyinformants in each facility. Data from public use data sets and
VA administrative databases were linked to each facility to
further characterize the contextual environment at each site.
Presented by: Elizabeth Cox, M.D. M.S., Assistant Scientist,
Population Health Sciences, University of Wisconsin Medical
School, 610 Walnut Street, Madison, WI 53726; Tel:
608.263.9104; Fax: 608.263.2820; E-mail: ecox@wisc.edu
Research Objective: Children’s participation in medical visits
produces improved outcomes and teaches skills for shared
decision-making, SDM. Child talk during the medical visit
increases with age, creating opportunities to involve children
in SDM. No study has examined how the physician, child and
parent share talk in a medical visit or how the child's age
influences this sharing. We investigate the sharing of SDMrelevant talk--relationship building, information giving and
information gathering--among physician, child and parent for
children of different ages.
Study Design: Data from a cross-sectional observational
study of children’s primary care visits included videotapes of
the visits, demographics, practice characteristics and
healthcare utilization data. Using the Roter Interaction
Analysis System, all utterances in each videotape were coded
into mutually exclusive categories, which were aggregated to
reflect SDM-relevant talk: relationship building, information
giving and information gathering. Linear regression models
analyzed the impact of child age on distributions of SDMrelevant talk for physician, parent and child. All models were
adjusted for physician, parent and healthcare utilization
characteristics as well as for clustering of visits by physician.
Population Studied: 100 children visiting one of 8
pediatricians or 7 family physicians purposively sampled to
reflect diversity in practice setting, age, gender, ethnicity and
specialty.
Principal Findings: Children’s mean age was 5.4 years, range
0-18 years. Physicians spoke 63% of visit talk with no
significant change across child ages. Parents spoke 31% of
visit talk, decreasing by 1.4% for each year of child age,
p<0.001. Children spoke the remaining 6% of visit talk,
increasing by 1.4% for each year of age, p<0.001. For
physicians, per year of child age, relationship building talk
decreased by 1.0% and information gathering talk increased by
0.7%, each p<0.001; information giving talk was unchanged.
For children, per year of age, relationship building talk
decreased by 2.5% and information giving talk increased by
2.8%, each p<0.001; information gathering talk was
unchanged. For parents, per year of child age, the distribution
of talk categories was unchanged.
Conclusions: Physician talk consistently dominates visit talk
regardless of child age, while child talk occurs at the expense
of parent talk. With regard to SDM-relevant talk, as children
mature they engage in more information giving while
physicians engage in more information gathering, both at the
expense of less relationship building talk. For parents, the
distribution of SDM-relevant talk remains relatively unchanged
across child ages.
Implications for Policy, Delivery or Practice: As children
approach maturity, troubling changes occur in the distribution
of SDM-relevant talk for both physicians and children.
Reductions in relationship building talk by both physician and
child and the lack of increasing information gathering talk by
children may reduce the ability to effectively address the
difficult health issues faced by adolescents. Physicians should
work to enhance both relationship building and information
gathering talk by children as they mature.
Primary Funding Source: AHRQ
• The Impact of Anxiety Disorders on Emergency
Department Utilization Patterns
Eleni Dimoulas, M.S., Natalie Blevins, M.S., M.H.A, Robert
Frank, Ph.D.
Presented by: Eleni Dimoulas, M.S., Graduate Research
Assistant, Clinical and Health Psychology, Florida Center for
Medicaid and the Uninsured, HSC Box 100165, Gainesville, FL
32610; Tel: 352.273.5130; Fax: 352.273.5061; E-mail:
elenid@grove.ufl.edu
Research Objective: Emergency department (ED) healthcare
is expensive and episodic, yet a major component of
healthcare services to low-income Americans (Shah-Canning
et al, 1996). Multiple factors are associated with increased ED
utilization, including lack of insurance, demographic and
psychosocial factors, and poor access to a primary care
provider (Padgett & Brodsky, 1992). Studies employing
Medicaid samples find increased ED utilization as a function
of available primary care services (deAlteriis & Fanning, 1991).
Uncoordinated care occurs when the patient, independent of
having a usual source of care, does not contact his or her
primary care provider before utilizing care in the ED (ShahCanning et al, 1996). PCCM (primary care case management)
programs have been implemented to improve access to
primary care providers, simultaneously increasing overall
service use with a reduction in ‘inappropriate’ utilization, such
as ED use for non-emergency health events (Gill & Diamond,
1996). Anxiety disorders represent one such type of health
problem that has a strong physiological component, often
misinterpreted as life-threatening (e.g., heart racing in a panic
attack can mimic non-psychological cardiac pain) and
accompanied by a salient affective component (e.g., feeling
anxious, worried, or hypervigilant of somatic symptoms) that
may prompt immediate service utilization in the ED. Few
studies have examined the patterns of ED utilization for
individuals with anxiety disorders in a Medicaid PCCM.
Study Design: The Agency for Health Care Administration
administers the Medicaid program in Florida and provided
claims data as part of a contractual agreement with study
investigators. Claims were available for adult enrollees (age 1864) in MediPass, a PCCM program. The study consisted of a
retrospective data analysis with a quasi-experimental design,
which specified a 6-month“pre” and a 12-month“post” anxiety
disorder diagnosis period of ED utilization. An 18-month study
period spanned from December 2000-June 2002. ED
utilization variables were constructed from outpatient facility
claims. Visits were designated as “pre” or “post” and whether
or not diagnosis at the emergency visit type was medical,
psychological, or both.
Population Studied: Participants who received a diagnosis of
any type of anxiety disorder from a primary care provider (i.e.,
family practice, general practice, internal medicine, or
OB/GYN) in June 2001 but did not have a diagnosis in the
prior 6 months.
Principal Findings: 210 MediPass enrollees (173 women) met
study criteria. The predominant anxiety disorder diagnosed
was nonspecific (N=166 diagnosed with “Anxiety, Not
Otherwise Specified”). Racial and ethnic composition of the
sample (62% European American, 8.3% African American,
11.1% Latino American, and 18.5% Other) was consistent with
the 2000 US Census demographics for Florida. Significant
correlations were observed between utilization variables with
the greatest association between post-diagnosis ED use
associated with medical and psychological diagnoses (r =
.499, p< .05).
Conclusions: Differential patterns of ED use prior to and
following anxiety diagnosis is suggestive of a moderating
effect of psychological distress on increased utilization in the
ED in this sample of Medicaid beneficiaries in a PCCM.
Implications for Policy, Delivery or Practice: If greater use
of the ED occurs after misclassification of a health event as
“emergency” then educational interventions should be
targeted to patients and providers to reduce inappropriate
utilization.
Primary Funding Source: Florida Agency for Health Care
Administration
• Chronic Disease Self-Management Programs for Elders:
Provider Perspectives
Almas Dossa, M.P.H., M.S.
Presented by: Almas Dossa, M.P.H., M.S., Part Time Ph.D.
Student, Heller School for Social Policy and Management,
Brandeis University, (home) 92 Francis Street, Brookline, MA
02446; Tel: 617.566.1861; E-mail: adossa@brandeis.edu
Research Objective: Health and social care services required
by disabled elders is a growing economic burden and a major
societal concern for the U.S. due to the increasing number of
elders. Since significant association exists between chronic
disease and disability in elders with chronic disease, strategies
to effectively manage chronic illness and prevent physical
disability are essential to reduce long-term care costs and
improve quality of life for elders. Disability prevention
programs such as chronic disease self-management programs
are effective in improving function and preventing disability,
but few of these programs exist in medical and community
settings. The purpose of this pilot qualitative study was: 1) to
explore provider attitudes, skills, and knowledge regarding
self-management programs for elders with chronic disease. 2)
to explore the following systems issues regarding these
programs: a) coordination and administrative barriers to
development and implementation of self-management
programs, b) barriers to linkages between medical and
community organizations for development and
implementation of self-management programs.
Study Design: Pilot qualitative study using structured
interviews with open-ended questions to explore provider
issues and systems issues. The interviews were audiotaped.
Following each interview, a “line-by-line” coding technique
was used for each interview. Codes were sorted into
categories, with development of memos. Finally, themes were
identified across all participant perspectives as well as those
unique to participants
Population Studied: Subjects included four health care
providers involved with self-management programs. Two
subjects were nurses, one was a geriatrician, and one was the
physician-director of a self-management program.
Principal Findings: The following themes were identified:
Client and provider awareness of programs; acute care culture
versus chronic care focus for elders; client compliance issues;
financing and reimbursement issues; coordination and
communication problems in health care settings; optimal
providers for self-management programs; optimal
organizations; medical and community linkage options and
issues; and skills and knowledge needed.
Conclusions: Specific barriers to these programs exist and
research questions developed from the themes are as follows:
How do health care providers in different settings such as
HMOs and MCOs, PCPs in hospitals, and private physicians
vary in their knowledge and awareness of self-management
programs?; What are organizational, provider, and client
predictors of compliance and participation in selfmanagement programs?; What is the attrition rate of different
chronic disease self-management programs?; How do
outcomes compare with lay-persons versus health
professionals or a combination of the two leading the
programs? How does this interact with complexity of
disease/co-morbidity?; What are elder perspectives on the
best setting for this type of program?; Are outcomes more
effective with linkage programs between medical and
community settings?
Implications for Policy, Delivery or Practice: It appears
essential to obtain provider perspectives on disability
prevention programs in order to get more information on
barriers to these programs. This information can assist in
improving access and dissemination of these programs for
elders with chronic disease.
Primary Funding Source: Heller School, Brandeis University
• Predictors of Senior Center Usage in Elders across Two
Different Cohort Groups
Almas Dossa, M.P.H., M.S.
Presented by: Almas Dossa, M.P.H., M.S. Part Time Ph.D.
Student, Heller School for Social Policy and Management,
Brandeis University, (home) 92 Francis Street, Brookline, MA
02446; Tel: 617.566 1861; E-mail: adossa@brandeis.edu
Research Objective: Since senior centers are the most
ubiquitous delivery site in the aging services network, policy
makers and practitioners need a clear understanding of the
factors that differentiate senior center participants and nonparticipants in order to make effective use of limited resources
and determine the roles that senior centers can play in
supporting elders. The purpose of this cross-sectional project
was to study predictors of senior center usage in elders aged
70 and older from the Longitudinal Study of Aging data. In
addition, the study compared both 1984 and 1994 data to
determine whether predictors had changed across cohorts,
which may indicate changes in senior centers across the tenyear span.
Study Design: A multivariate regression using logit
regression for the dependent variable “used senior center” or
“no usage of senior center” in the last 12 months, determined
predictors of usage, which included: Total family income,
Family relationship, Health Status, Activity Limitation Status,
Race, Marital Status, Region, Difficulty walking quarter mile,
Having difficulty walking, Having difficulty getting outside,
Difficulty with ADL/IADL, Falls, Diabetes, Arthritis,
Hypertension, Heart Disease, Cancer, and Transportation.
Population Studied: Elders aged 70 years and older
Principal Findings: Increasing age and education, and low
income showed significantly higher odds of attending senior
centers for both cohorts, but gender (being female), race
(being black), and having activities of daily living
difficulty/instrumental activities of daily living difficulty
(ADL/IADL difficulty) showed significantly greater odds for
attendance only for the 1994 cohort. Age-square was
significant only for the 1994 cohort with lower attendance at
youngest and oldest ages.
Conclusions: Senior centers in 1994 appear to be more
accessible to the black population and to those with
ADL/IADL difficulty. Thus, it appears that senior centers have
worked on making changes to improve access to these
populations. In addition, since elders at increased ages
appear to participate less in 1994, senior centers need to
provide more programs for this population.
Implications for Policy, Delivery or Practice: Since more
elders with disability can access senior centers, these centers
need to gear more programs towards elders with disabilities
to prevent further disability and maintain functional ability.
This is important from a health policy standpoint as programs
for this frail group often need better trained staff and more
funding than many centers currently have. With the increasing
life expectancy, senior centers need to gear up even for the
very old population and provide programs for disability
prevention to avoid future long-term care costs, and policy
makers need to be aware of this and provide funding for this
purpose. There is considerable potential for senior centers to
be considered as part of the long-term care continuum with
their high degree of visibility, sheer numbers, recognition by
state and national legislature as an important component in
the community-based network, and their diverse funding base.
Primary Funding Source: Heller School, Brandeis University
• Psychological Traits and Preference for Control over
Health Care Decisions
Kathryn Flynn, M.S., Maureen Smith, M.D., M.P.H., Ph.D.
Presented by: Kathryn Flynn, M.S., Ph.D. Candidate,
Population Health Sciences, University of Wisconsin, 632
WARF Bldg, 610 Walnut Street, Madison, WI 53726; Tel:
608.263.4416; Fax: 608.263.2820; E-mail: keflynn@wisc.edu
Research Objective: Shared decision-making, SDM, is
becoming the ethical standard for health care decisionmaking. Attempts have been made to increase SDM, e.g.,
through the use of decision aids, but not all patients want to
share their health care decisions. If preferences for control
over decisions are related to underlying stable psychological
traits, the effectiveness of these attempts may be limited
because some patients cannot be motivated to participate. No
study has examined the importance of psychological traits in
preferences for control over health care decisions. Our
objective is to explore the relationship between psychological
traits and preferences for control over health care decisions in
a longitudinal study of older individuals.
Study Design: Data were obtained from the 2003 Wisconsin
Longitudinal Study, WLS, a 1/3 random sample of graduates
from Wisconsin high schools in 1957, N=10,317, who have
been followed via telephone and mail surveys for 46 years. The
dependent variable representing preference for control over
DM was, The important medical decisions should be made by
my doctor, not by me, coded on a five-point scale from
strongly agree to strongly disagree. Psychological traits,
previously collected in 1992, included the five-factor model of
personality -- extraversion, openness, conscientiousness,
neuroticism, and agreeableness -- and Ryff’s six-factor
psychological well-being scale -- autonomy, environmental
mastery, personal growth, positive relations, purpose in life,
and self-acceptance. Multinomial logistic regression analyses
adjusted for respondent’s gender, education, marital status,
insurance, self-rated health, chronic conditions including high
blood pressure, joint problems, and high cholesterol, health
care utilization, length at usual place of care, length of
relationship with provider, and provider specialty.
Population Studied: 1279 respondents aged 63-65 from the
first three replicates of the WLS; each replicate represents a
1/10th random sample of the original study. The 2003 WLS is
still underway; current average response rate for the 2003
telephone survey is 80%.
Principal Findings: 24% of respondents strongly agreed or
agreed that important medical decisions should be made by
their doctor, i.e., preferred doctor control, about 20% were
neutral, and the remaining 56% disagreed or strongly
disagreed, i.e., preferred to have personal control over
decisions. After adjustment, increasing openness OR=1.10,
95% CI=1.03-1.17; autonomy OR=1.09, CI=1.03-1.16; and
personal growth OR=1.10, CI=1.03-1.18 were associated with
preference for personal control compared to doctor control.
Other variables significantly and positively associated with
preference for personal control included female gender,
increased education, and lack of chronic joint problems.
Autonomy and self-acceptance were significantly associated
with a neutral preference for DM control compared to those
who preferred doctor control.
Conclusions: Over half of respondents preferred to have
personal control over decisions about their health care but
nearly as many did not. Personality and psychological wellbeing measured a decade previously strongly predicted
preferences for health care DM.
Implications for Policy, Delivery or Practice: Attempts to
involve patients in SDM, e.g., decision aids, should recognize
that preferences for participation in health care decisions are
related to underlying psychological traits. For certain patients
this may limit the success of strategies to involve them in
SDM.
Primary Funding Source: AHRQ
• Perceptions of Racial Barriers to Health Care in Southern
Rural Populations
Angela Fowler-Brown, M.D., Evan Ashkin, M.D., Giselle
Corbie-Smith, M.D., M.S.C.E., Samruddhi Thaker, M.B.B.S.,
M.H.A., Donald Pathman, M.D., M.P.H.
Presented by: Angela Fowler-Brown, M.D., General Medicine
Research Fellow, University of North Carolina at Chapel Hill,
5039 Old Clinics, CB#7110, Chapel Hill, NC 27516; Tel:
919.966.2276; Fax: 919.966.2274; E-mail:
agfbrown@med.unc.edu
Research Objective: Perceived racism may be an important
barrier to care, especially in the Southeast. We sought to (1)
determine how commonly people in the rural Southeast
perceive racial barriers to health care in their communities (2)
identify the characteristics of individuals in whom this
perception is most common and (3) examine the relationship
between this perception and people´s use of and satisfaction
with health care.
Study Design: This study is cross-sectional design using data
from a 25-minute random digit dialing telephone survey.
Subjects were asked, “How much do you agree with the
statement: `In my community, people´s race or ethnicity is
often a barrier to receiving health care.´” Multiple logistic
regression was used to examine the relationship between the
perception of racial barriers and participant characteristics,
and its relationship with health care satisfaction and use.
Population Studied: The survey was conducted in the rural
areas of 7 southeastern states (AL, AK, GA, LA, MS, SC, TX).
There were 1362 African American and 2667 non-Hispanic
White adults included in this analysis.
Principal Findings: 53% of African Americans and 24%
percent of Whites perceived racial barriers to care in their
communities. There were no significant differences by state in
the proportion of African Americans or Whites that perceived
racial barriers to care. Perceptions of racial barriers among
African Americans were more common among those older
(p= 0.011) and male (p=0.032). Among Whites, perceived
racial barriers to care were more common among those older
(p = 0.008) and those with less education (p<0.005). The
perception of racial barriers to care was associated with a
greater adjusted likelihood of dissatisfaction with overall
health care for both African Americans (p=0.005) and Whites
(p=0.02). Subjects who perceived racial barriers were also less
satisfied with getting health questions answered by
physicians(African Americans p=0.045, Whites p=0.027) and
less likely to have confidence in their physician (African
Americans p=0.035, Whites p=0.003). The perception of racial
barriers was not associated with the use of preventive
services, such as mammography and cholesterol screening in
African Americans or Whites.
Conclusions: The perception of racial barriers to health care
is common in the rural southeast, particularly among African
Americans, and is related to age, gender and people´s
satisfaction with the care they receive.
Implications for Policy, Delivery or Practice: Efforts to
address perceptions of racial barriers to care may serve to
improve satisfaction with care and confidence in the care
received. The source and accuracy of perceived racial barriers
to care deserves further investigation.
• Effect of Insurance and Changes in Insurance on Stroke
and Death
Angela Fowler-Brown, M.D., Giselle Corbie-Smith, M.D.,
M.S.C.E., Joanne Garrett, Ph.D., Nicole Lurie, M.D., M.P.H.
Presented by: Angela Fowler-Brown, M.D., General Medicine
Research Fellow, University of North Carolina at Chapel Hill,
5039 Old Clinics, CB#7110, Chapel Hill, NC 27599; Tel:
919.966.2276; Fax: 919.966.2274; E-mail:
AGFBrown@med.unc.edu
Research Objective: Previous studies have established that
the uninsured have reduced access to care. Few prospective
studies have examined the effects of lack of coverage or
changes in coverage on physiologic outcomes. We examined
whether being uninsured or having intermittent insurance was
associated with the likelihood of future stroke and death.
Study Design: We analyzed data from the Atherosclerosis and
Risk in Communities (ARIC) study, a prospective cohort study.
Participants' insurance status was assessed during visits every
three years, for a total of 4 visits, between 1986 and 1998.
Endpoints were ascertained until 2000. We used an adjusted
Cox model with insurance status as a time varying variable to
estimate the hazard ratios (HR) of being uninsured or having
intermittent insurance on rates of stroke and death within 3
years of each visit (adjusted for age, gender, race, income). In
addition, we used logistic regression to determine the
incremental effect of number of visits with insurance on stroke
and death (adjusted for age, income).
Population Studied: The study population was a sample of
African American and White adult residents of four
communities in the U.S.
Principal Findings: Of the 13,540 participants included in the
Cox model, those who reported being uninsured had 1.7 times
the rate of stroke (HR 1.69, 95%CI 0.97-2.93) and 1.6 time the
rate of death (HR 1.61, 95% CI 0.86-3.01) compared to those
who were insured for the comparable period of time.
Particpants who reported changes in insurance status suffered
stroke at 1.7 time the rate (HR 1.73, 95% CI 1.17-2.59) and
death at 2 times the rate (HR 1.97, 95% CI 1.32-2.95) as those
who were insured. For the logistic regression model, we used
the 11,003 participants with insurance status recorded at each
of the four visits. Of these, 87% were insured at all 4 visits,
and the remainder were uninsured during at least 1 visit. We
found a dose response relationship with insurance status,
those with fewer visits insured had a higher odds of stroke
compared to persons who were insured at all 4 visits: reported
insured at no visits-OR 3.00 (95% CI 1.34, 6.68), insured at 1
visit-OR 2.44 (95% CI 1.18,5.04); insured at 2 visits-OR 1.77
(95% CI 0.96,3.25), insured at 3 visits-OR 1.4 (95% CI
0.90,2.20).
Conclusions: Persons with no insurance or intermittant
insurance suffered strokes and death at a higher rate than
those with stable insurance. In addition, there was a dose
response relationship between insurance and stroke, with
fewer visits insured associated with higher adjusted odds of
stroke.
Implications for Policy, Delivery or Practice: Health
insurance appears to be a significant factor influencing health
outcomes.
• Access to Health Care for Disadvantaged Persons in the
United States and Canada: A Qualitative Inquiry
Laurie Goldsmith, M.Sc., Ph.D. Candidate
Presented by: Laurie Goldsmith, M.Sc., Ph.D. Candidate,
Visiting Fellow, Centre for Health Economics and Policy
Analysis, McMaster University, HSC 3H27, 1200 Main Street
West, Hamilton, Ontario, L8N 3Z5; Tel: 905.525.9140 Ext.
22033; Fax: 905.546.5211; E-mail: goldsml@mcmaster.ca
Research Objective: This study examines the contextual and
holistic nature of access to care by giving voice to the
individual health care consumer's perspective, examining the
interaction between the individual's experience and the health
care system, and employing a hypothesis-generating
approach. Specific research questions include: What is the
access to care experience, including barriers and supports,
from the disadvantaged individual's viewpoint? How does the
disadvantaged individual's access to care experience interact
with the health care system? How does the disadvantaged
individual conceptualize access to care?
Study Design: This grounded theory study employs in-depth,
semi-structured interviews to explore access to care from the
individual's point of view. Individuals most likely to experience
trouble using the health care system and to have the most
need for care were purposefully sampled from four rural or
remote communities -- two in North Carolina and two in
Ontario.
Population Studied: 38 individuals were interviewed
individually; another 8 individuals were interviewed in twoperson interviews, for a total of 42 interviews. At least 10
interviews were conducted in each community. Participants
met at least one of the following disadvantage criteria: lower
income, not college or university educated, of racial or ethnic
minority, unemployed, uninsured, or underinsured.
Participants also varied by age, sex, self-rated health status,
and chronic illness status.
Principal Findings: Lack of insurance, underinsurance, and
health care costs were strong access barriers. These factors
impeded the perceived and actual availability and receipt of
care. Many of the participants were highly dependent on one
source of care, for a variety of reasons, and "would not know
where to turn" if that source was no longer available. Positive
relationships between patients and providers were access
supports. Participants' experiences varied depending on their
health status, health beliefs, and competing demands, and
were often dependent on a particular problem or issue.
Current experiences and expectations were highly dependent
on previous experiences. With the exception of the barrier of
drug affordability, great variation in access to care experiences
exists among the four communities. This variation is more
strongly linked to the local community context than to the
health care system. With respect to theoretical implications,
"good" patients and "good" providers are main themes in
individual access conceptualizations. Individual experiences
are best considered as “access careers” rather than a series of
separate interactions. Preliminary typologies that make
different barriers and supports salient include the well person,
the chronically ill person, the poor and uninsured person, the
disenfranchised person, and the person with significant life
challenges.
Conclusions: While the access experiences were highly
context dependent, important universal access themes were
identified. This study builds on current access to care theory
through detailing the interaction between the individual and
the health care system and providing typologies of these
interactions.
Implications for Policy, Delivery or Practice: These results
can inform revisions to access to care theory, develop new
access to care theory, better design empirical research on
access to care, and help policy makers design programs that
better meet individuals' access to care needs.
Primary Funding Source: AHRQ
• Organizational Implementation of Clinical Practice
Guidelines: A Systematic Literature Review
Christian Helfrich, M.P.H., Bryan Weiner, Ph.D., Lucy Savitz,
Ph.D., M.B.A.
Presented by: Christian Helfrich, M.P.H., Doctoral candidate,
Health Policy and Administration, University of North Carolina
at Chapel Hill, CB #7411, Chapel Hill, NC 27599-7411; Tel:
919.968.6150; E-mail: helfrich@unc.edu
Research Objective: To determine what are the known
organizational barriers and facilitators to guideline
implementation in primary-care settings in the United States.
Also to assess assumptions adopted by existing studies, and
to propose avenues for future research.
Study Design: Systematic literature review
Population Studied: All available articles published through
September 2, 2002 contained in Medline, the Cochrane
Controlled Trials Register, and Science Citation Index.
In total, 687 abstracts were reviewed; 99 (14.4%) received full
article review and 36 (5.2%) met the inclusion criteria.
Principal Findings: Interventions to promote guideline
implementation appear to fall into nine categories, with two,
"reminders" and "task redesign," showing stronger
association with improved guideline adherence. Seven of
eight controlled studies employing reminders showed
statistically significant increases associated with reminders,
and the eighth saw improvements in both intervention and
control groups. Task redesign interventions were special
instances where clinics sought to "automate" procedures, e.g.,
the creation of special positions to carry out
recommendations for specific disease conditions. These
interventions tended to delegate responsibilities down the
hierarchical chain, e.g., from physician to nurse, or from nurse
to front desk support staff, and to minimize the number of
points where an active decision had to be made to initiate or
sustain action on the guideline recommendation.
Although 22 of the studies employed multiple interventions,
multiple interventions did not appear to be independently
associated with greater rates of adherence. This contradicts
findings from previous literature reviews suggesting that on
average "complex" or multiple interventions tend to be more
effective.
The most common barrier to effective implementation was
time constraints.
Over 40% of articles failed to identify all individual guideline
recommendations, and where outcomes were reported by
individual recommendation, there was considerable variation
in adherence rates. In particular, recommendations dealing
with patient education appear to have particularly low
adherence rates across the board, even where adherence to
other recommendations improved. Overall, median reported
adherence rates remain below 50% for most guidelines.
Few studies explicitly established whether guidelines had been
formally adopted (or even recognized) by the providers being
studied. Even fewer assessed the organization's prior
experience with guidelines and whether these were the first
guidelines to be implemented on an organizational level.
Conclusions: The previous finding that multiple interventions
tend to be more effective in implementing guidelines may be
an artifact of the greater probability one has of employing an
effective intervention when multiple interventions are
deployed. In fact, given that time constraints were widely cited
as an impediment to guideline implementation, to the extent
that each additional intervention absorbs marginally more
time from the provider, multiple interventions per se may
weaken implementation.
Implications for Policy, Delivery or Practice: Reminders and
task redesign may marginally improve guideline adherence.
Greater attention needs to be paid to the issue of time
constraints and how recommendations can be formulated to
actually help save time.
Authors need to include more information on the specific
guideline recommendations being implemented and about
how the interventions were deployed; this latter piece may
help promote research translation by providing a rough
outline of what constitutes the key components of the
interventions.
Primary Funding Source: CDC
• Primary Prevention of Breast Cancer with Tamoxifen: A
Meta-Analysis and Cost-Effectiveness Analysis
Jon-Erik Holty, M.D., Kelvin Tan, B.A.
Presented by: Jon-Erik Holty, M.D., Fellow and M.S. student
in HSR, Center for Health Policy and Primary Care Outcomes
Research, Stanford University, 117 Encina Commons, Stanford,
CA 94305-6019; Tel: 650.723.2114; Fax: 650.723.1919; E-mail:
jholty@stanford.edu
Research Objective: Breast cancer is the most common
malignancy in women. Recent evidence suggests that selective
estrogen receptor modulators (SERM) may have benefit in
preventing breast cancer. We examined the cost-effectiveness
of prescribing tamoxifen to women for the primary
chemoprevention of breast cancer.
Study Design: We developed a decision and costeffectiveness analyses utilizing a transitional-probability semiMarkov simulation life model. The probabilities of breast
cancer, other adverse or positive effects and death were
obtained from performing a meta-analysis on four published
randomized control trials and quality-of-life estimates were
obtained from the literature. Costs were estimated from a
literature review.
Population Studied: Caucasian women age 50 years of age
with at least a GAIL model risk score of 1.6% were analyzed.
Chemoprevention was used for five years then stopped and
was compared to no-therapy. The percentage of women
having had a previous hysterectomy for reasons other than
endometrial cancer was varied from 0% to 100%. The longterm protective effects of SERM after discontinuation of
chemoprevention were evaluated from 0 to 15 years.
Principal Findings: Our meta-analysis determined that
tamoxifen significantly reduces both invasive (risk ratio 0.65;
95% CI: 0.55 to 0.77) and non-invasive (risk ratio 0.50; 95% CI:
0.35 to 0.72) breast cancer. However, endometrial cancer (risk
ratio 2.44; 95% CI: 1.47 to 4.06), ischemic stroke (risk ratio
1.50; 95% CI: 1.03 to 2.20), pulmonary embolus (risk ratio 1.85;
95% CI: 1.05 to 3.25), deep vein thrombosis (risk ratio 1.90;
95% CI: 1.25 to 2.87) and hot flashes (risk ratio 1.21; 95% CI:
1.21 to 1.30) were all significantly increased. Osteoporotic
fracture incidence, cardiac events (all case), myocardial
infarction and death had no significant differences compared
to placebo. Our cost-effectiveness model showed a decreased
life expectancy for women treated with tamoxifen with an
intact uterus (-0.01 years), but slightly increased (+0.02 years)
for those with a removed uterus. For all groups analyzed, the
no-therapy groups dominated the use of tamoxifen (both
negative QALY's and increased costs). These findings were
not sensitive to changes in the risk ratios or duration of
protection after discontinuation of chemoprevention. We
estimate that a 50 year old women with an initial relative risk
of breast cancer > 1.0% may benefit from tamoxifen
chemoprevention.
Conclusions: Tamoxifen is not cost-effective in women aged
50 years of age at average risk for breast cancer when used as
primary chemoprevention and is likely harmful. In women who
have a higher initial relative risk of breast cancer, tamoxifen
may be cost-effective.
Implications for Policy, Delivery or Practice: The routine use
of tamoxifen for the primary chemoprevention of breast
cancer is not recommended. Further studies are needed to
determine if women at higher risk for breast cancer may
benefit from tamoxifen.
Primary Funding Source: VA
• The Predictive Accuracy of the New York Coronary
Bypass Report Card and Its Impact on Volume and
Surgical Practice
Ashish Jha, M.D., Arnold Epstein, M.D., M.A.
Presented by: Ashish Jha, M.D., Fellow, General Medicine,
Brigham and Women's Hospital, 1620 Tremont Street,
Boston, MA 02120-1613; Tel: 617.732.5500 Ext. 32515; Fax:
617.732.7063; E-mail: ajha@partners.org
Research Objective: New York State´s public reporting
system of coronary artery bypass surgery mortality has been
operating for nearly 15 years and is widely heralded as an
important quality improvement tool. We sought to determine
its usefulness to patients in choosing providers, its impact on
hospital and surgeon volume, and surgical practice patterns.
Study Design: We used prospectively collected data reported
by New York State to assess whether the latest available report
would allow consumers to choose providers with better than
average outcomes; whether better performance was
associated with increased volume subsequent to the report
card release; and whether finally, performance was associated
with subsequent decisions by surgeons to retire or leave
practice. We used both chi square tests and repeated
measures logistic regression to adjust for age, gender, and
experience in these analyses.
Population Studied: We studied volume, performance scores
and decisions to remain in clinical practice for surgeons and
hospitals performing cardiac bypass surgery in New York.
Principal Findings: From 1989 through 1999, we found that
potential users who picked a top performing surgeon or
hospital from the last available report card (top decile of
performance), would have had a better than average out-come
in the year they used the data 75% and 92% of the time
respectively. Through 1999, there was no evidence of
performance driving subsequent changes in volume for
hospitals. However, poor performing surgeons were more
likely to retire or leave practice in New York. While 4% of
surgeons in the top three quartiles of performance left practice
in New York (retired or moved) after release of a given report
card, 18% of surgeons in the bottom quartile did so These
patterns persisted for report cards released through-out the
decade (p=0.003).
Conclusions: The New York State reporting system can help
guide patients´ choice of providers. However, there is no
evidence that it is being used for this purpose. Physicians with
poor performance on the reporting system are more likely to
retire or leave practice in New York.
Implications for Policy, Delivery or Practice: Public available
report cards are potentially useful but are not widely used.
Given that they can have a profound impact on physician
practice, accurate risk adjustment is critical.
Primary Funding Source: AHRQ
• Trends in Use of Major Procedures among Black and
White Elderly: Is the Gap Narrowing?
Ashish Jha, M.D., Elliott Fisher, M.D., MPH, Arnold Epstein,
M.D., M.A.
Presented by: Ashish Jha, M.D., Research Fellow, General
Medicine, Brigham and Women's Hospital, 1620 Tremont
Street, Boston, MA 02120-1613; Tel: 617.732.5500 Ext. 32515;
Fax: 617.732.7063; E-mail: ajha@partners.org
Research Objective: Racial disparities in high cost surgical
procedures are well known, and both national and regional
efforts have been launched to address these differences.
However, whether the gap in the rates of these services
between black and white patients has narrowed is unknown.
Study Design: We used the 100% data file from the Medicare
Part A program from 1992 through 2001 to calculate age and
sex adjusted rates of major high cost, high morbidity
procedures for black and white enrollees sixty-five years of age
or older. The procedures studied were coronary artery bypass
surgery (CABG), carotid endarterectomy (CEA), total hip
replacement (THR), total knee replacement (TKR), cardiac
valve replacement (VR), and lumbar disc procedures (LDP).
Population Studied: Patients enrolled in the Medicare Part A
program at any point between 1992 through 2001.
Principal Findings: Procedures rates increased for all
Medicare enrollees from 1992 through 2001 for all six
procedures studied. While the age and sex adjusted CABG rate
for whites was 5.49 per 1,000 enrollees, it increased to 6.19
per 1,000 enrollees in 2001. Similarly for black Medicare
enrollees, rates of CABG increased from 2.14 to 3.35 per 1,000
enrollees. The white minus black (W - B) gap decreased for
CABG (3.35 in 1992 versus 2.88 in 2001) but the gap widened
for the other five procedures. The smallest increase, 14%, was
in valve replacement surgery (W-B gap 0.68 in 1992 versus
0.79 in 2001) and the largest increase, 39%, was in lumbar
disc procedures (W-B gap 1.26 in 1992 versus 2.06 in 2001).
Conclusions: The racial gap in absolute procedure rates
widened during the 1990s for five of the six procedures
studied. Whether these trends reflect worsening underuse
among blacks or growing overuse among whites is unknown.
Implications for Policy, Delivery or Practice: These data
provide no evidence that efforts to narrow the gap in use of
major procedures between blacks and whites have been
successful.
Primary Funding Source: RWJF
• A Meta-Analysis of the Effect of Hospital-Based Case
Management on Reducing Hospital Length of Stay and
Readmission
Young Ju Kim, M.S.N., R.N., Karen Soeken, Ph.D.
Presented by: Young Ju Kim, M.S.N., R.N., Ph.D. Student,
School of Nursing, University of Maryland, 1035 Maiden
Choice Lane # 1, Baltimore, MD 21229; Tel: 410.536.7120; Fax:
410.706.2550; E-mail: ykim007@son.umaryland.edu
Research Objective: The purpose of this study was to
investigate the effect of hospital-based case management
compared with usual care on length of hospital stay and
readmission rate.
Study Design: Meta-analytic method was employed to
analyze the effect sizes of case management intervention on
outcomes. The effect size, 95% confidence interval, quality of
study, sensitivity, homogeneity, and publication bias were
analyzed.
Population Studied: Studies were included if they met the
following criteria: (a) sample included adults aged 18 years
and over; (b) inclusion of hospital-based case management
intervention for inpatients; (c) randomized experimental study
design; (d) inclusion of information regarding the difference in
LOS or readmission rate as outcome measures; (e) report of
the number of participants in the study groups. Eligible
studies were retrieved using computerized database searches,
footnote chasing, and contact with content experts. The final
12 studies were reviewed by the authors, and then coded by
variables selected for inclusion.
Principal Findings: 11 studies had a nurse-led case
management intervention and one study had a physician-led
intervention. The studies included in this meta-analysis were
for the elderly with a mean age of 72.2 years. Eight of the
studies were conducted in U.S. hospital settings. Overall, the
studies were of moderate to high quality, with six of 12 studies
scoring more than 8 out of maximum 11 scores. No study was
assigned a low quality rating. The overall average weighted
effect size (AWES) on length of stay was .094 with a 95% CI of
-.032 to .220. The overall odds ratio on readmission was .87
with a 95% CI of .69 to 1.04. The hospital-based case
management interventions were not significantly effective in
reducing length of stay and readmissions. In sensitivity
analyses, the case management interventions for patients with
heart failure (effect size of .241 with a 95% CI of .012 to .470)
was significantly effective in reducing length of stay, whereas
they were not effective for stroke patients (effect size of -.226
with a 95% CI of -.542 to .089) and frail elders (effect size of
.126 with a 95% CI of -.073 to .324). The funnel plots and
values of NFS provided evidence that publication bias is
unlikely to be a problem for this meta-analysis.
Conclusions: The findings of this meta-analysis demonstrate
a 6% decrease in readmission rate for patients who were
received hospital-based case management interventions. The
further meta-analysis studies need to be conducted to test the
effectiveness of case management on other various outcomes.
Implications for Policy, Delivery or Practice: This metaanalysis study provides the critical information for hospital
managers and researchers who are interested in hospitalbased case management. Furthermore, it will help them make
the evidences-based research conclusions.
• Potential Cost Savings from Smoking Cessation in the
Veterans Affairs Patient Population
Bruce Lee, M.D., Kevin Volpp, M.D., Ph.D.
Presented by: Bruce Lee, M.D., Fellow, Department of
Medicine, University of Pennsylvania, 1125 Blockley Hall,
Philadelphia, PA 19104; Tel: 215.746.0019; Fax: 215.573.8779; Email: brucelee@mail.med.upenn.edu
Research Objective: To quantify the potential savings in
future health care expenditures that could result from
increasing tobacco cessation rates within the Veterans Health
Administration (VA). The purpose of this is to determine the
amount of money that could be spent on tobacco cessation
programs per smoker while remaining at least cost neutral.
Study Design: A predictive economic model was constructed
using data from the 2002 National VA Budget (annual
expenditures for Ambulatory Services, Acute Hospital Care,
Pharmacy, and miscellaneous health services); a 1999 VA
survey (numbers of current and ex-smokers); and age-and sexadjusted estimates of the fraction of health expenditures
attributable to smoking (SAF) calculated from the National
Medical Expenditure Survey. The SAF were multiplied by total
expenditures in each category to calculate smoking-related
excess expenditures. The net present value (NPV) of the
dollar savings from tobacco cessation was calculated using
rates of 5.9% for medical inflation and 2.9% for general
inflation (average annual rates from 1998-2001). Estimates
were calculated for the next 10 and 15 years, which are below
the actuarial life expectancy of the average age VA patient. To
calculate the component of smoking-related expenditures that
are preventable, it was assumed that ex-smokers incur one
half the expenditures that current-smokers do for the base
case scenario.
Population Studied: All current and ex-smokers currently
enrolled in the VA.
Principal Findings: 30.0% (918,000) of the total VA
population currently smoke and 45.4% (1,388,766) are exsmokers. The NPV of the preventable smoking attributable
health care expenditures over the next ten years is $19.685
billion for the entire VA population and an average of $21,444
per current VA smoker. Over the next fifteen years comparable
figures are $30.909 billion and $33,670, respectively. These
figures represent the total amount that could be spent on
smoking cessation efforts per patient who successfully quits
while still saving money.
Sensitivity analyses varied the ratio of health costs incurred by
ex-smokers relative to those of current-smokers. A ratio of 0.8
yielded a total 10 year NPV of $15.643 billion ($17,040 per
current VA smoker); a ratio of 0.2 yielded $26.544 billion
($28,915 per current VA smoker).
Conclusions: The amount of money that could be used to
increase tobacco cessation rates while not increasing net
expenditures within the next 10-15 years is substantial.
Improvements in health that save money could potentially be
achieved through more extensive and innovative smoking
cessation efforts.
Implications for Policy, Delivery or Practice: These results
suggest that we are substantially under-investing in treatment
of nicotine addiction and prevention of smoking-related
illnesses. Greater investments in tobacco cessation and
related incentive programs could lower the burden of
smoking-related illnesses while potentially reducing health
expenditures.
Primary Funding Source: VA
• Alignment of Group Incentives on Quality with Individual
Physician Financial Incentives on Quality in Physician
Organizations
Rui Li, Master of Medicine
Presented by: Rui Li, Master of Medicine, Graduate Student
Researcher, Health Services and Policy Analysis, University of
California, Berkeley, 140 Warren Hall #7360, School of Public
Health, Berkeley, CA 94720-7360; Tel: 510.643.0551; E-mail:
rli@uclink.berkeley.edu
Research Objective: In “Crossing the Quality Chasm”, the
Institute of Medicine (IOM) proposed the implementation of
organizational processes to improve quality and emphasized
the importance of providing physician organizations with
incentives for quality-enhancing processes. But providing
incentives for quality to individual physicians may also be
important since it is the individual physician who practices
medicine and responds to financial incentives. As an
intermediary between insurer and individual physicians, the
physician organizations may need to aligning the group level
incentives with individual level incentives. This paper analyzes
the alignment of the individual physician level incentives for
quality of care and patient satisfaction with the group level
incentives for quality, and the influence of managed care,
ownership, economies of scale and scope on the variance in
physician compensation based on quality.
Study Design: We examined distributions of both group level
and individual level incentives for quality. We also use OLS
regression model to examine the relationship between
percentage of physician payment based on quality/ patient
satisfaction and the incentives for quality at the physician
organization level, including reporting quality data to outside
organizations, getting additional income for quality, getting
public recognition for quality, and getting better contracts for
quality, as well as other market and organizational
characteristics of physician organizations.
Population Studied: The National Study of Physician
Organizations and the Management of Chronic Illness
surveyed physician organizations with 20 or more physicians
in the United States between September 2000 and September
2001. From 1590 eligible physician organizations, 1104
(69.5%) responded to the survey. These organizations
included 738 medical groups and 366 independent physician
associations. 641 physician organizations provided detailed
information on physician payment method.
Principal Findings: At the group level, 33% of physician
organizations reported quality data to an outside
organizations. 39% received additional income for quality.
25% received public recognition for quality, and 23% received
better contracts for quality. At individual level, 15% of
physician organizations paid their primary care physicians to
some extent based on quality and 9% paid their specialists
partially on quality. The mean percentage of compensation
that was based on quality and patient satisfaction was 0.87%
for primary care physicians and 0.49% for specialists. The
ranges for both primary care physicians and specialists were 0
to 20%. Physician organizations were more likely to pay their
individual physicians on quality and patient satisfaction if they
were larger, older, required to report quality data to
organizations, and received additional income for quality.
Conclusions: Physician compensation for quality and/or
patient satisfaction in the physician groups is still quite small.
But some alignment of incentive on quality at the group and
individual physician levels was observed.
Implications for Policy, Delivery or Practice: The physicianphysician organization relationship is in many ways an agentprincipal relationship. As rational individuals, agents do what
they are paid to do. Much research has found that physicians
do respond to financial incentives. If leaders of physician
organizations want to improve quality, they may want to
consider aligning their group incentives with the individual
physicians to achieve their goal of improving quality of care.
Primary Funding Source: RWJF
• Myth-Busting: Minority Status and Use of the Emergency
Department for Non-Emergent Conditions
Yia-Wun Liang, MSHA, Janice Probst, Ph.D.
Presented by: Yia-Wun Liang, MSHA, Department of Health
Services Policy and Management, University of South
Carolina, 800 Sumter Street, Columbia, SC 29208; Tel:
803.594.6096; Fax: 803.777.1836; E-mail:
liang6288@hotmail.com
Research Objective: Many studies have documented higher
emergency department visit rates among minorities than
among whites. Investigators and practitioners are divided
over whether higher rates indicate lack of access to primary
care, or cultural preferences coupled with legal requirements
for emergency room access. We used a newly developed
categorization of emergency department visits to assess
whether African Americans were more likely than whites to
visit emergency departments for non-emergent conditions.
This likelihood may provide an indication of cultural choice,
rather than acute illness, as the basis for emergency
department visits.
Study Design: Cross sectional analysis of the 1999-2000
National Hospital Ambulatory Medical Care Survey—
Emergency Departments, a nationally representative survey of
patient visits to emergency departments. Non-emergent
conditions were identified using an algorithm developed by
Billings and associates. The algorithm classifies visits into
eight categories, the first three of which address the probable
level of urgency and potential preventability of the visit: (1)
non-emergent; (2) emergent, primary care treatable; (3)
emergent, emergency department care required,
preventable/avoidable; (4) emergent, emergency department
care required, not preventable/avoidable; (5) injury; (6) mental
health; (7) drug; or (8) alcohol related. The algorithm classifies
visits based on primary diagnosis. The data contained 46,725
visits, of which 25,403 could be classified. Logistic analysis
was used to identify individual and contextual factors
associated with non-emergent visits.
Population Studied: Nationally representative sample of
emergency department visits during 1999 and 2000.
Principal Findings: African Americans were more likely than
whites to have visited emergency departments for ambulatory
care sensitive (ACS) conditions (odds ratio 1.25, 95% CI 1.151.36); other minorities did not differ from whites. Women and
the publicly insured were more likely to have ACS visits, and
persons under 24 or over 75 were less likely. ACS visits were
more common outside normal working hours. Within ACS
visits, nonemergent visits were no more common for African
Americans than for whites (OR 0.93, CI 0.78 – 1.11). Factors
reducing the likelihood that a visit would be non-emergent
included male sex and age less than 15 years. Persons covered
by Worker’s Compensation were more likely to have a
nonemergent visit than the privately insured. Non-emergent
visits were more common between midnight and eight in the
morning than during the work day.
Conclusions: African Americans may be no more likely than
whites to use emergency departments as a preferred source of
care. Results suggest associations between race and
emergency department use for ACS conditions, but no
association between race and visit urgency. This suggests
that African Americans seeking care in emergency
departments may have reduced availability of primary care.
Implications for Policy, Delivery or Practice:
Disproportionate emergency department use by African
Americans may indicate reduced access to other types care.
Policy makers desiring cost-effective care should assess
emergency department visit rates in light of available
resources for minorities. Cultural or financial barriers that
limit accessibility of other sources of outpatient care should be
addressed.
Primary Funding Source: WKK
• The Effects of Gender and Age on Health-Related Quality
of Life and Overall Health in Renal Transplant Recipients
Hongxia Liu, M.S.N., Irene Feurer, Ph.D., Kathleen Dwyer,
Ph.D., Theodore Speroff, Ph.D., David Shaffer, M.D., C. Wright
Pinson, M.D., M.B.A.
Presented by: Hongxia Liu, M.S.N., Ph.D. student, School of
Nursing, Vanderbilt University School of Nursing and
Vanderbilt Transplant Center, 511 Chesterfield Avenue Apt.# 2I, Nashville, TN 37212; Tel: 615.460.9932; Fax: 615.343.8204; Email: hongxia.liu@vanderbilt.edu
Research Objective: The purpose of this research was to test
whether gender and age affect health-related quality of life
(HRQOL) and overall health in renal transplant recipients.
Study Design: Patient-reported HRQOL was measured
following organ transplantation (at months 1, 3 and 6, and
annually) by the physical and mental component scales (PCS
and MCS, respectively) of the Short Form Health Survey (SF-
36(r)) and a visual analogue scale of overall health (OH).
Analyses of variance (ANOVA) methods were used to evaluate
the main and interaction effects of gender and age group (2534, 35-44, 45-54, 55-64, >=65 years) on the PCS, MCS, eight
individual SF-36(r) scales, and on OH. Data are summarized
as mean ± SD.
Population Studied: Subjects included 138 adult renal
transplant recipients (66 females, 72 males) who reported
HRQOL and OH between October, 2002 and October, 2003.
Principal Findings: The mean age in years was 48±12 for the
females and 49±11 for the males (p=0.523). The mean number
of months post transplantation was 65±71 and 71±81 for the
females and males, respectively (p=0.659). Analyses
demonstrated no significant effects of gender or age group on
OH (all p>=0.202). Two-way ANOVA demonstrated a
statistically significant main effect of gender (females = 38±12,
males = 41±11; p=0.025), and a statistically marginal main
effect of age group (45±11, 40±11, 40±11, 36±12, 37±12;
p=0.052) on PCS. Additionally, a statistically marginal gender
by age group interaction effect (p=0.058) was observed for
PCS. Average PCS scores over the five age groups,
respectively, were 45±12, 39±11, 37±11, 38±12, 27±5 for females,
and 45±11, 43±11, 42±11, 34±11, 46±9 for males. There were no
significant main or interaction effects of gender or age group
on MCS scores (all p>=0.104). Among the eight individual SF36(r) scales, females reported significantly lower physical
functioning, role physical, and bodily pain scores (all p<0.05).
There was a significant effect of age group on the physical
functioning scale (p=0.005), with the youngest patients
reporting the highest scores.
Conclusions: Female renal transplant recipients report
slightly lower (3 point average difference) physical component
scores than males. While this overall difference would be
considered clinically insignificant, females demonstrated a
greater reduction in physical functioning with age than did
males. There were no effects of gender or age group on overall
health in renal transplant recipients.
Implications for Policy, Delivery or Practice: Nurses should
consider and develop gender-specific interventions to help
renal transplant recipients to maintain their physical quality of
life.
Primary Funding Source: AHRQ, Roche Laboratories, Inc.
• A Study of Rowing and Steering by Local Health Agencies
Kusuma Madamala, M.P.H., Ph.D. Candidate, Michele Issel,
Ph.D.
Presented by: Kusuma Madamala, M.P.H., Ph.D. Candidate,
Health Policy and Administration, University of Illinois at
Chicago, 1603 W. Taylor Street M/C 923, Chicago, IL 606124310; Tel: 312.902.3305; E-mail: kmadam1@uic.edu
Research Objective: Public health researchers and
practitioners do not know if their resources and work are being
optimized to meet fundamental public health objectives
described in the Essential Public Health Services. Changes in
service delivery, such as privatization and their relationship to
strategic activities by local health departments (LHDs), need
to be examined because there is little consensus by local
health administrators on the role these activities should play.
The perception exists that decreased direct service (rowing)
implies increased strategic activities (steering). There is a
need to test the validity of this assumption in order to inform
practice patterns and contribute improvements to that
practice.
This study sought to clarify the relationship between service
delivery/rowing and strategic activities/streering done by local
health departments, and to examine whether community (i.e.
demographics, health resources and economic) and
organizational factors are related to either rowing or steering.
A conceptual model of five organizational typologies
according to rowing and steering activity was tested.
Study Design: The design was secondary analysis data from
the 2001 National Association of County and Community
Health Organizations (NACCHO) and CityMatCH survey of
313 agencies. An expert panel provided face validity of rowing
and steering constructs with the survey items. The NACCHOCityMatCH survey was also merged with 1999 NACCHO
Infrastructure survey of 694 agencies to examine
organizational characteristics of local health departments in
terms of rowing and steering activity. These data were merged
with Area Resource File (ARF), for a final n of 188, to examine
the relationship of community variables to rowing and
steering. Correlations, ratio scores, and regression analysis
were conducted.
Population Studied: The sample was 188 U.S. local health
departments that were CityMatCH and NACCHO members.
Principal Findings: High inter-rater reliability of rowing and
steering constructs was attained. A significant association
(r=.318, p<.001) was found between the rowing and steering
scores. Majority of LHDs perform average levels of rowing and
steering. Rowing scores were significantly correlated (r=.303,
p<.05) with types of FTEs. LHDs performing the least amount
of rowing and steering had a greater percentage budget from
city/town sources than other groups of LHDs. Nine datadriven organizational typologies were revealed in terms of
rowing and steering performance levels.
Conclusions: The study provides an examination of the
relationship between rowing and steering among LHDs. Few
LHDs primarily row or steer. Organizational typologies
provide a means to evaluate the performance of these local
governmental agencies.
Implications for Policy, Delivery or Practice: The findings
that decreased direct service (less rowing) does not
necessarily imply increased strategic activities (increased
steering) suggests that administrative practices may be
unfocused. Majority of LHDs perform average amounts of
rowing and steering. Policy decisions regarding the extent of
service delivery and strategic activities can be informed by
recognizing the relationship between these functions.
Informed policy decisions around governmental public health
practice patterns can contribute to improvements in
population health status.
• The Effects of Open Access on Drug Therapy Outcomes
for Patients with Bipolar Disorder in the California
Medicaid (MEDI-CAL) Program
Sangeeta Narayan, Pharm.D, Jeffrey McCombs, Ph.D.
Presented by: Sangeeta Narayan, Pharm.D, Research Fellow,
Pharmaceutical Economics and Policy, University of Southern
California, 1540 East Alcazar Street, Los Angeles, CA 90089;
Tel: 323.442.1825; Fax: 323.442.1462; E-mail:
sangeetn@usc.edu
Research Objective: The California Medicaid program (MediCal) initiated open access to atypical antipsychotic
medications in October 1997. This analysis evaluates the
impact of open access on drug therapy outcomes and
treatment costs in patients with bipolar disorder.
Study Design: We conducted a retrospective database
analysis of patients diagnosed with bipolar disorder who
initiated at least one episode of drug therapy. Episodes were
required to have a minimum of 6 months of pre-treatment
and 12 months of post-treatment data. Episodes were then
separated into three time periods: a “closed-access period”
prior to October 1997, a “transition period” covering the first 6
months of open access, and an “open access period” for
episodes initiated after April 1, 1998. Multivariate regression
models were used to estimate the impact of open access on
total healthcare costs and duration of therapy. COX
proportional hazard models were estimated for time to
discontinuation.
Population Studied: California Medicaid beneficiaries
diagnosed with bipolar disorder between July 1994 and
December 1999.
Principal Findings: The number of patients re-starting drug
therapy or augmenting an existing therapy increased
immediately with open access due to increased use of secondgeneration medications. Episode initiation rates returned to
pre-open access levels within 6 months (transition period).
Open access significantly reduced total costs primarily due to
significant savings in nursing home care ($1700 and $1807 for
re-starters and augmenters, respectively). However, drug
persistence also declined with open-access:
42 fewer days for re-starters and 33 fewer days for augmenters.
Augmenters and re-starters were 16% and 12% more likely to
discontinue therapy if their episodes were initiated in the open
access period.
Conclusions: The decision to include atypical antipsychotics
by the Medi-Cal program resulted in lower persistency of drug
therapy and lower total health care costs.
Implications for Policy, Delivery or Practice: Decision
makers and program administrators must use caution in
evaluating the impact of open access to new antipsychotic
medications on patient outcomes and costs.
Primary Funding Source: Eli Lilly and Company
• Factors Associated with Second-Generation
Antipsychotics in the California Medicaid (MEDI-CAL)
Patients with Bipolar Disorders
Jinhee Park, M.S., M.A., Jeff McCombs, Ph.D.
Presented by: Jinhee Park, M.S., M.A., Doctoral Candidate,
Department of Pharmaceutical Economics and Policy,
University of Southern Caifornia, 1540 E. Alcazar Street
CHP140, Los Angeles, CA 90089; E-mail: jinheepa@usc.edu
Research Objective: Olanzapine and risperidone are the two
most widely used second-generation antipsychotic
medications by California Medicaid (Medi-Cal) patients with
severe mental disorders. This analysis investigates the factors
associated medication choice by Medi-Cal patients with
bipolar disorders who restart therapy after a break in
treatment.
Study Design: Paid claims data were analyzed to identify
antipsychotic ‘re-starter’ treatment episodes initiated between
January 1999 and March 2003. An episode was defined each
time a patient re-started therapy on a new medication or
restarted the same drug after a break of 15 days or more. Only
re-starter episodes with olanzapine or risperidone were
selected if 6 months of pre-treatment and 12 months of posttreatment data were available. Multivariate logistic regression
was used to investigate the factors that affected treatment
choice.
Population Studied: Bipolar patients in the California
Medicaid program (Medi-Cal) who were treated with either
olanzapine or risperidone between January 1999 and March
2003.
Principal Findings: 90,282 treatment episodes meet study
selection criteria. Olanzapine was the initial medication in
56% of re-starter episodes. Mean age was 39 and the mean
duration of uninterrupted treatment was 170 days. Patients in
every age category over 25 years of age were between 24% to
46% more likely to receive olanzapine, as were Asian patients
(+11%) and patients with prior use of psychiatric hospital care
(+6%). The likelihood of using olanzapine also increased
significantly with the cost of non-institutional care consumed
in the prior 6 months. Risperidone patients were more likely
to be female (+10%), AFDC recipients (21%), urban (+6%) or
rural (6%) residents, Hispanic (+7%), black (+9%), other
minority (+7%) diabetic (+23%) and have a history of prior
nursing home use (+10%)(p<0.05 for all results).
Conclusions: Bipolar patients who are treated with the two
study medications were different in terms of demographic
characteristics, comorbidities, and previous healthcare
utilization patterns.
Implications for Policy, Delivery or Practice: The observed
differences in patient characteristics for olanzapine and
risperidone patients will affect both treatment outcomes and
post-treatment costs and must be adjusted for before
comparing the outcomes achieved using these agents.
Primary Funding Source: Eli Lilly & Co
• Tracking of SARS Transmission in the United States
Using Secondary Analysis: The Asian Connection
William Pearson, M.H.A., Yia-Wun Liang, MSHA
Presented by: William Pearson, M.H.A, Research Associate,
Health Services Policy and Management, University of South
Carolina, 800 Sumter Street, Columbia, SC 29208; Tel:
803.594.6096; Fax: 803.777.1836; E-mail:
pearsows@mailbox.sc.edu
Research Objective: To determine the relationship between
air travel from countries with known SARS cases and the
transmission of the disease into the United States.
Study Design: Secondary analysis of national cross-sectional
data sets. Data from three years (1998-2000) of the Air
Transport Association, T-100 International Market Survey and
the National Ambulatory Medical Care Survey were used. A
first-order, auto-regressive model, with a one-month time lag,
was used to correlate the number of passengers flying from
countries with diagnosed SARS cases and the number of
SARS probable cases presenting in an ambulatory care setting
in the US.
Population Studied: Persons from countries with diagnosed
SARS cases and flying into the United States during the years
1998-2000 were identified using national transportation flight
data. Cases of upper-respiratory infections and meeting the
CDC criteria as being SARS probable were identified in an
ambulatory care setting in the United States during the same
time.
Principal Findings: From our study population, we estimated
those with SARS probable visits to be 5,864,085 cases.
Bivariate analyses of the URI cases demonstrated significant
differences between the number of SARS and non-SARS
probable cases for age. Children below the age of 15 years had
a larger proportion of SARS probable visits. We then used
lagged, OLS regression to determine the relationship between
number of passengers flying into the US from countries with
known SARS cases and the resulting number of SARS
probable cases in the US. Results of this regression
demonstrated no significant effects. Multivariate logistic
regression showed no significant differences among those
with SARS probable cases, except for age. People older than 15
years of age were less likely to present with a SARS probable
case.
Conclusions: There was no significant correlation between
the number of passengers flying into the US from countries
with diagnosed SARS cases and the number of SARS probable
cases presenting in an ambulatory care setting in the US.
However, we did notice an increase in the number of SARS
probable cases over the study period. Children under the age
of 15 years were significantly more likely to present to an
ambulatory care setting with a SARS probable case.
Implications for Policy, Delivery or Practice: Even though
these results did not demonstrate a significant association
between the number of persons from countries with identified
SARS cases traveling into the US and an increase in probable
SARS cases in the US, we still believe that quarantine is an
effective method for suppressing the spread of SARS.
Furthermore, safeguards for protecting children from the
spread of infectious respiratory diseases should be followed.
• Individual Factors Influencing Improvements in ADLs
among Home Health Care Patients
Tanya Scharpf, M.S., Penny Hollander Feldman, Ph.D., John
Bridges, Ph.D.
Presented by: Tanya Scharpf, M.S., Graduate Student,
Epidemiology and Biostatistics, Case Western Reserve
University, 1131 Castleton Road, Cleveland Heights, OH 44121;
Tel: 216.381.5128; E-mail: tanya.scharpf@cwru.edu
Research Objective: This paper investigated improvements in
physical functioning among home health care patients.
Physical functioning was measured by eight activities of daily
living (ADL) namely, grooming, dressing the upper body,
dressing the lower body, bathing, toileting, transferring,
ambulation, and feeding. The research objective was to
evaluate individual patient characteristics that may influence
changes in physical functioning as measured by these ADLs.
Study Design: Regressions utilizing a Linear Probability
Model estimated risk-adjusted improvements for each ADL.
Patient characteristics included in each model were age, sex,
race, baseline ADL status for the ADL improvement being
modeled, payment source, income, tobacco usage, alcohol
usage, and drug dependency, in addition to several baseline
diagnostic, clinical severity, and co-morbid symptom variables.
Baseline ADL status was included in the models and episodes
in which patients were at ceiling at the start of care were
excluded. This was done to eliminate potential ceiling effects
in the results.
Population Studied: 56,346 episodes of home health care
assessed using a standardized data collection instrument
used by all certified home health agencies, the Outcomes and
Assessment Information Set (OASIS). The OASIS is used to
collect information at multiple time points in the home health
care episode (admission, transfer, discharge, and death). The
mean age of the patients represented by these episodes was
71 years old with two-thirds of the population female. The
racial/ethnic composition was 40% white, 26% black, 24%
Hispanic, 4% Asian, and 6% other ethnicity. The most
common clinical diagnoses were diabetes (13%), hypertension
(8%), and congestive heart failure (5%).
Principal Findings: Results show that elderly patients ages
eighty-five and older were significantly (p<0.0001) less likely to
have improvements in any of the ADLs measured when
compared to home health care patients less than eighty-five
years of age. Elderly patients seventy-five to eighty-four years
old were also significantly (p<0.05) less likely than younger
patients to have improvements in three of the eight ADLs
(grooming, transferring, and feeding). Blacks were
significantly (p<0.001) less likely to have improvements in six
of the eight ADLs as compared to whites. Asians were also
significantly (p<0.05) less likely to have improvements in five
of the eight ADLs as compared to whites as were, Hispanics
(p<0.05) for three of the ADLs measured. In contrast, females
were significantly (p<0.05) more likely to improve in three of
the ADLs as compared to males.
Conclusions: Improvements in ADLs were less likely to occur
among elderly home health care patients, particularly those
over eighty-five and among minority patients, even after
controlling for baseline clinical and diagnostic conditions. In
contrast, females were more likely to show improvements in
some of the ADLs measured as compared to males after
controlling for baseline clinical and diagnostic conditions.
Implications for Policy, Delivery or Practice: Home health
care workers may need to direct more resources towards the
very old, minority, and male patients in order to increase their
rates of physical functioning improvements.
Primary Funding Source: AHRQ
• How Intense Patient Physician Interactions Affect Trust
Rahul Shenolikar, M.S., Rajesh Balkrishnan, Ph.D., Mark Hall,
J.D.
Presented by: Rahul Shenolikar, M.S., Doctoral Student,
Management and Policy Sciences, University of Texas School
of Public Health, RAS E-327, 1200 Herman Pressler, Houston,
TX 77030; Tel: 713.500.9181; Fax: 713.500.9171; E-mail:
rshenolikar@sph.uth.tmc.edu
Research Objective: Patients’ trust in physicians and in the
medical profession is vital for a successful patient-physician
relationship. Trust is especially salient in more intense
experiences with physicians, such as serious side-effects,
hospitalizations, and diagnoses of serious medical conditions,
but most trust studies have been done with the general
population or in routine primary care settings. This study
examined the association between intense patient-physician
interactions and patients’ trust in their physician and in the
medical profession.
Study Design: A random national telephone survey was
conducted using validated multi-item questionnaire
measuring trust and satisfaction with physicians and with the
medical profession. A questionnaire naming seven medical
situations with dichotomous responses (Yes/No) was
developed to identify intense interactions with physicians
separately for the patient’s primary physicians and for other
physicians if their services were utilized. These intensity items
asked whether over the past five years, the subject had been
hospitalized, had undergone minor or major surgery (nonanesthesia), had been prescribed medications that they
thought could have serious side-effects, had been evaluated
for possible or actual cancer or for another serious medical
condition, or had been referred to a specialist.
Population Studied: A total of 1117 subjects aged 20 years
and older with health insurance were included for analysis.
Principal Findings: Prescription of medications by primary
care physicians that patients believed might have side effects
was negatively correlated with trust in physician (Spearmans
rho= -0.12, p<0.001) in multivariate analysis. A primary care
physician evaluating the patient for a condition the patient
believed was serious was positively correlated with trust in
physician (Spearmans rho= 0.08, p<0.01). Being hospitalized
was positively correlated with trust in the medical profession
(Spearmans rho=0.12, p<0.01).
Conclusions: Hospitalization, perceived seriousness of
condition, and concerns about the risks of medications were
found to be associated with patient trust in physicians or the
medical profession. These findings highlight the greater
salience of trust in more intense physician-patient interactions
and the role that patient vulnerability plays in determining
patient trust.
Implications for Policy, Delivery or Practice: The
associations highlighted by this study reflect the role that
vulnerability plays in the psychology of trust and identify
threats to patient trust and could assist in the design of
interventions to maintain patient trust and trustworthy
conditions. This is especially important in the current era in
which many people fear that trust in medical care is rapidly
eroding.
Primary Funding Source: RWJF
• Tracking Quality of Asthma Treatment for Children in
Maryland Medicaid over the Transition from Fee-ForService to Managed Care
Puneet Singhal, M.S., Ilene Zuckerman, Ph.D., Bruce Stuart,
Ph.D., Laurence Magder, Ph.D., Haya Rubin, Ph.D.
Presented by: Puneet Singhal, M.S., Graduate Assistant,
Pharmaceutical Health Services Research Program, University
of Maryland School of Pharmacy, 515 W Lombard Street, Suite
156, Baltimore, MD 21201; Tel: 410.706.1805; Fax:
410.706.1488; E-mail: psing001@umaryland.edu
Research Objective: To determine whether the quality of
prescribing for Medicaid children with asthma improved after
the transition from fee-for-service (FFS) to managed care
organizations (MCOs).
Study Design: We followed a cohort of asthmatic children
enrolled into four largest MCOs from FFS into managed care.
FFS claims data, plan enrollment data and MCO encounter
data spanning from June 1, 1996 to May 31, 2000 were
merged using a unique recipient identifier. A data file was
created to track, on a person-month basis, Medicaid eligibility,
setting (FFS, MCO with plan indicators), MCO enrollment and
disenrollment, and prescription drug use (total and asthma-
specific) during FFS and MCO periods. We applied a quality
indicator (QI) based on asthma prescription drug use. The QI
measured the proportion of study subjects filling two rescue
asthma medications who also filled at least one controller
asthma medication during the same 6-month period. Where
required, we adjusted observed MCO QI rates for plan
underreporting of prescription data. We compared FFS and
MCO QI rates at p<0.05 level.
Population Studied: Children aged 5-18 with asthma
(n=5804) were selected based on a review of Medicaid
enrollment records and medical and pharmacy FFS claims
filed between June 1, 1996 and December 31, 1997.
Principal Findings: Compared to FFS, all MCOs had lower QI
values at the beginning of the transition, although the changes
were not significant at p<.05. The MCO QI values were
consistently above FFS levels after a year, albeit the rise was
not statistically significant.
Conclusions: In the domain of medication use, quality of care
as measured by this indicator did not decline with the
transition to managed care. However, conclusions about
managed care impact are limited by secular trends that may
have increased controller use.
Implications for Policy, Delivery or Practice: Maryland
Medicaid MCOs provided similar or better asthma prescribing
than was the FFS system provided. Although not
comprehensive or definitive due to possible biases, our
findings are reassuring regarding quality of medication
prescribing under managed care for Medicaid enrollees
transitioning from FFS to MCOs.
Primary Funding Source: AHRQ
• Geographical Variation in the Type and Size of Physician
Practices in the United States: A Study from 1996-2001
Amy Smalarz, M.S.
Presented by: Amy Smalarz, M.S., AHRQ Fellow, Schneider
Institute, Brandeis University, 415 Winter Street, Waltham, MA
02454-9110; Tel: 508.405.1012; Fax: 781.736.3905; E-mail:
smalarz@brandeis.edu
Research Objective: To examine the characteristics of
distribution, according to site, of the type of physician
practices in the United States. I will also examine whether or
not any changes in the organizational structure of physician
practices present themselves over the study period from 19962001.
Study Design: This study used a retrospective, cross-sectional
analysis of the Community Tracking Study Physician Surveys
for the years: 1996-1997, 1998-1999 and 2000-2001. The
quantitative analysis used bivariate statistics and multivariate
logistic regression.
Population Studied: The CTS is a national study designed to
track changes in the health care system and the effects of the
changes on care delivery and on individuals. Central to the
design of the CTS is its community focus. Sixty sites (51
metropolitan areas and 9 nonmetropolitan areas) were
randomly selected to form the core of the CTS and to be
representative of the nation as a whole. Approximately 12,000
Physicians were surveyed each wave, for a total of
approximately 36,000 respondents over the three waves.
Principal Findings: The United States has seen a decline in 1)
the number solo practicing physicians and 2) Group and Staff
Model HMOs. There has been an increase in the number of
physicians who practice in freestanding clinics and community
health centers. Changes in other types of physicians practices
vary according to the site’s region: only the Midwest have seen
a decline in the number of physicians practicing in Medical
Universities, whereas only the South has seen a decline in the
number of physicians practicing in privately owned hospitals.
Conclusions: This research confirms that although there are
some common nationwide trends, the organizational
structures of physician practices are changing throughout the
United States. The structures of physicians’ practices vary
according to the region in which the physician lives.
Implications for Policy, Delivery or Practice: Insurance
companies as well as other third party payers are ever
changing with their means of providing the proper incentives
to their physicians. This research demonstrates there have
been changes during the time period of 1996-2001 in the
organizational structure of physician practices. If third party
payers are to be efficient, they should align their incentives,
financial and otherwise, to providers according to the type of
practices that exist. In addition because numerous insurers
function in various states across the nation, being aware of
the structure of physician practices in specific regions will
allow the insurers to be more efficient.
• Evaluating Home Health Care Nursing Outcomes with
OASIS and NOC
Julia Stocker, R.N., Ph.D. Candidate
Presented by: Julia Stocker, R.N., Ph.D. Candidate, Predoctoral NRSA Fellow, School of Nursing, University of
Michigan, 8433 Barrington Drive, Ypsilanti, MI 48198; Tel:
734.223.2285; Fax: 313.993.6175; E-mail: arbrrose@umich.edu
Research Objective: The purpose of this study was to explore
the sensitivity and responsiveness of the Outcome and
Assessment Information Set (OASIS) and the Nursing
Outcomes Classification (NOC) to the effects of home health
care nursing interventions on patient outcomes.
Study Design: A quasi-experimental before-after study design
was used. Cardiac patient outcomes were measured by home
health care Registered Nurses (RNs) at home care admission
and discharge using the OASIS and comparable measures
from the NOC. Nursing interventions were measured at each
visit using the Nursing Interventions Classification (NIC).
Nursing intensity was determined by totaling the number of
nursing interventions provided over the care episode.
Changes in patient outcomes were compared across four
areas, including cardiopulmonary status, activities of daily
living (ADLs), instrumental activities of daily living (IADLs),
and coping.
A univariate repeated measures ANOVA was used to analyze
the data to determine sensitivity. Risk adjustment was done
to control for significant variables including reason for home
care discharge and caregiver assistance with ADLs.
Instrument responsiveness was determined by using a
receiver operating characteristic curve to compare the ability
of the corresponding NOC and OASIS measures to
discriminate between patients whose condition had improved
and those who did not. Patient and nurse agreement on
improvement of condition was used for the criterion in this
analysis.
Population Studied: Patients referred to one of seven
participating Midwest home health care agencies for
treatment of a primary cardiac condition were recruited for the
study. The sample included 107 subjects, 38% with coronary
artery disease, 36% with congestive heart failure, and 25%
with other cardiac disease. The sample was 51% male, 98%
Caucasian, with a mean age of 77. The subjects received an
average of 9.17 home health care nursing visits.
Principal Findings: For each of the outcome areas examined,
no statistically significant relationship found between
intervention intensity and the outcome change as measured
by the NOC or the OASIS. In addition, the OASIS was not
responsive to change in any of the outcome areas examined.
However, NOC demonstrated responsiveness in measuring
change in patient condition for cardiopulmonary, ADL, coping,
and illness management behavior outcomes (p < .05).
Conclusions: Neither the OASIS nor the NOC are sensitive to
the effects of nursing interventions on patient outcomes in
home health care. With a larger sample size, statistical
significance may be achieved. Selected measures of the NOC
were found to be responsive to clinically discernable change,
while none of the OASIS measures demonstrated
responsiveness.
Implications for Policy, Delivery or Practice: Collection of
OASIS data has been mandated by Medicare for the purpose
of improving quality using an outcomes based approach.
However, this study did not find OASIS to be sensitive or
responsive to nursing interventions. Since nursing is the core
service provided in home health care, it is important that
patient outcome measures used in that setting can detect
changes that result from the provision of nursing care.
Further research should be done to identify and refine
outcome measures that are sensitive and responsive to the
effects of nursing interventions.
Primary Funding Source: National Institute for Nursing
Research
• Going the Distance: Cancer Care Capacity and Out-ofArea Care Utilization among Urban and Rural Women with
Breast Cancer
Indiana Strombom, M.S.N., CTR, Maureen Smith, M.D.,
Ph.D., M.P.H., Amy Trentham Dietz, Ph.D., Patrick
Remington, M.D., M.P.H., Polly Newcomb, Ph.D.
Presented by: Indiana Strombom, M.S.N., CTR, Doctoral
Student, Population Health Sciences, University of WisconsinMadison, 8038 Shag Bark Circle, Cross Plains, WI 53528; Tel:
608.263.9435; Fax: 608.263.2820; E-mail:
strombom@wisc.edu
Research Objective: Treatment for breast cancer is wellestablished and involves comprehensive services offered
predominantly at approved cancer centers. Not all women
have an approved cancer center in their residential area, and
no population-based studies have examined whether a lack of
comprehensive cancer care affects the decision to seek
treatment outside a woman’s residential area. We evaluate
the association between a woman’s local cancer care capacity
and utilization of cancer treatment outside the woman’s
residential area in rural and urban Wisconsin.
Study Design: We conducted a retrospective case cohort
study utilizing telephone interview data from the Women’s
Health Study. Patient socioeconomic and tumor
characteristics were combined with American Hospital
Association data aggregated to the level of Dartmouth Health
Service Area (HSA). The dependent variable was cancer care
within or outside the woman’s residential HSA. Cancer care
capacity was measured by the number of hospitals with
approved cancer centers in the HSA, categorized as 0, 1-2, or
more than 2 approved hospitals. Multivariable logistic
regressions were stratified by rural/urban and adjusted for
age, race, education, marital status, median household
income at the level of the census block group, and tumor
stage at diagnosis. All models accounted for clustering within
HSAs.
Population Studied: Wisconsin Women’s Health Study case
participants diagnosed with breast cancer between 1988 and
1994 (n=7,179), and identified through the state cancer
registry (83% participation).
Principal Findings: Seventy percent of rural and 15% of urban
participants lived in an HSA that did not have an approved
cancer program. Only 20% of rural women accessed cancer
care in approved hospitals within their residential HSA,
compared to nearly 60% of urban women. Among the 40% of
rural women treated outside their residential HSA, 64%
accessed approved care. Of the 20% of urban women who
went outside their HSA, 81% were treated at approved centers.
After adjustment, women living in rural HSAs with approved
hospitals had a higher likelihood of utilizing cancer care within
their HSA when compared to women living in HSAs with no
approved hospitals: OR=2.3, 95%CI=1.5-3.6 for 1-2 approved
hospitals; OR=2.3, 95%CI=1.3-4.2 for more than 2 approved
hospitals. Women living in urban HSAs with approved
hospitals did not have a higher likelihood of utilizing cancer
care within their residential HSA, although urban participants
diagnosed at the regional stage were half as likely as women
with localized tumors to be treated within their residential
HSA, OR=0.5, 95%CI=0.3-0.9.
Conclusions: The cancer care capacity of a woman’s
residential area significantly predicted where rural women with
breast cancer go for care. In contrast, individual
characteristics were more important in predicting where urban
women go for care, even if they live in an area without an
approved hospital.
Implications for Policy, Delivery or Practice: Rural women
with breast cancer travel significant distances in order to
overcome area-level cancer care capacity deficits. These
deficits are significant barriers to cancer care quality and
equity. A cancer care delivery structure that involves
partnerships between “approved” cancer centers and rural
hospitals may ensure timely, comprehensive cancer care
delivery within all health service areas.
Primary Funding Source: NCI
• Understanding Barriers to Recommended Preventive
Care Use in Adults: The Role of Patient Beliefs and
Emotional Health
Joshua Thorpe, M.P.H., Carolyn Kalinowski, M.P.H., Mark
Patterson, M.P.H.
Presented by: Joshua Thorpe, M.P.H., Pharmaceutical Policy,
University of North Carolina at Chapel Hill, Beard Hall,
CB#7360, Chapel Hill, NC 27516; Tel: 919.928.8757; E-mail:
thorpej@unc.edu
Research Objective: This study analyzed patterns of
recommended preventive care utilization in the United States
adult population using the Andersen Behavioral Model of
Health Services Use. In addition to other predisposing,
enabling and medical need factors, we examined the impact of
patient health beliefs and self-reported symptoms of
anxiety/depression on preventive service utilization.
Study Design: We extracted adult respondent data from the
2000 Medical Expenditure Panel Survey (MEPS), a probability
sample designed to make nationally representative estimates
of healthcare utilization and expenditures for the U.S. civilian,
non-institutionalized, population. Guided by
recommendations from the U.S. Preventive Service Task Force
(USPSTF), dependent variables were a series of dichotomous
variables indicating the receipt of specific, age-appropriate,
preventive care services. The specific preventive services
included: annual checkups (18yrs+), cholesterol screening
(20yrs+), blood pressure screening (18yrs+), annual influenza
vaccination (65yrs +), annual fecal occult blood test or
sigmoidoscopy every 5 years (50yrs+), Papanicolaou test every
3 years (women, 18-64yrs), mammography every 2 years
(women, 50-69 yrs), and clinical breast examination every 2
years (women, 40yrs+). The Andersen model guided
selection of independent variables. In addition to
predisposing, enabling, and need variables commonly
included in applications of the Andersen model, we included 3
psychosocial factors as predisposing factors: patients’ beliefs
about their ability to overcome illness without medical help,
patients’ perceived level of risk-taking relative to others, selfreported anxiety/depression. Separate weighted logistic
regression models were conducted for each preventive service
type.
Population Studied: Adults (18 years or older) in the U.S.
civilian non-institutionalized population.
Principal Findings: Compared to adults reporting no
depression/anxiety, severely depressed adults were 70% less
likely to be screened for hypertension (OR=0.30, CI=0.12,
0.71), 50% less likely to receive an annual influenza
vaccination (OR=0.50, CI=0.26, 0.99), and 62% less likely to
receive a mammogram (OR 0.38, CI=0.20, 0.75). However,
severely depressed adults were more likely to have an annual
checkup (OR 1.53, CI=1.15, 2.05). Adults reporting moderate
depression/anxiety did not differ significantly from the nondepressed. Patients who more strongly believe they can
overcome illness without medical help were less likely to
receive 7 out of 8 recommended preventive services. Perceived
risk-taking was not significantly associated with use of any
preventive service. Having a usual source of care, being
married, having insurance coverage, having more education,
and having higher income were all positively associated with
utilizing preventive services. Compared to more rural areas,
living in an MSA (more urban) increased the likelihood of
receiving recommended cholesterol screens, fecal occult
blood tests, and mammograms. The pattern of preventive
care use by race/ethnicity was mixed. Blacks and Hispanics
were more likely to receive annual checkups, cholesterol
screening, and Papanicolaou tests, but were less likely to be
screened for high blood pressure and receive an annual
influenza vaccination.
Conclusions: In this nationally representative sample,
severely depressed adults were at significant risk for failing to
receive recommended preventive care, as were adults who
believed they could overcome illness without medical care.
Implications for Policy, Delivery or Practice: These results
suggest that adherence to recommended preventive care
guidelines may be improved, indirectly, by better recognition
and treatment of patient depression. Additionally, future
interventions to improve preventive care utilization should
address patient beliefs about the value of medical care.
Primary Funding Source: AHRQ, Sheps Center for Health
Services Research pre-doctoral fellow; American Foundation
for Pharmaceutical Education pre-doctoral fellow
• Informal Insurers and HIV/AIDS in South Africa
Jyothi Thrivikraman, B.A., M.P.H.
Presented by: Jyothi Thrivikraman, B.A., M.P.H., student,
Heller School of Social Policy and Management, Brandeis
University, 35-C Jacqueline Road, Waltham, MA 02452; Tel:
781.891.1056; E-mail: jthrivik@brandeis.edu
Research Objective: (i) How are informal insurers coping
with the increased morbidity and mortality due to HIV/AIDS?
(ii) What are the social, economic and cultural ramifications of
informal insurers coping strategies in HIV/AIDS endemic
areas for client households?.
Study Design: This project is an exploratory investigation;
very little information currently exists on the practices of
informal insurers as it relates to HIV/AIDS. Therefore, this
study hopes to contribute to theoretical understandings as
well as the development of further research via
questionnaire/survey development. Given that there is a lack
of verified numbers of informal insurers in South Africa,
random sampling would have been meaningless. Therefore
survey depth within one field-site was chosen to truly
understand the practices and range of informal insurers.
Interviews with informal insurers in one sub-district were
conducted over a three week period.
Population Studied: 32 members of informal insurers
(rotating savings and credit associations, accumulating
savings and credit assocications and burial schemes) in one
sub-district in KwaZulu-Natal Province
Principal Findings: All of the non-profit informal insurers are
(or shortly will be) struggling to pay claims with available
premiums. Membership numbers are dropping, households
are having difficulty keeping up to date with premiums due to
high unemployment rates and that even more secure
members are struggling to deal with increased premiums.
Informal insurers lack of policies to handle covariant risk is
more reflective of their success or failure. HIV/AIDS is
devastating the foundations upon which these informal
insurers were developed and the procedures through which
they operate. For example, some groups are limiting
membership which serves as an informal mechanism of
underwriting. These actions represent a paradox with the
informal insurers. In order to have any attempt at staying
viable, they must exclude larger and larger portions of the
community while simultaneously sacrificing the comunity
spirit under which they were founded. A successful strategy
with the informal insurers requires a crucial decision between
support of community needs or financial stability. All of the
informal insurers surveyed are headed towards failure given
the ever-growing mortality due to the HIV/AIDS. These
insurers have the hard chose of either continuing to pay out
(and require larger and larger cash infusions) or limiting
memberships.
Conclusions: Based upon the data and the analysis of the
results, institutional and financial strategies may not help the
viability of these non-profit informal insurers. Institutional
changes will force these organizations to deviate from their
founding objective: to provide services to their community.
The organizations over time will simply have to serve an every
dwindling segment of the population in order to remain
viable. Similarly financial changes may not realistically be
implemented with the current HIV/AIDS mortality rates
coupled with high unemployment rates: households may
simply be unable to afford increased premiums.
Implications for Policy, Delivery or Practice: i. Minimize the
impact of HIV/AIDS by facilitating access to medicines which
could reduce mortality rates
ii. Restructuring the non-profit informal insurers to pool
larger segments of the population from different communities
together.
iii. Targeted subsidies to poorest households and those
affected by HIV/AIDS to ensure insurance coverage of the
population.
iv. Establish linkages between these informal insurers and
national insurance organizations or national burial societies to
provide assistance these smaller groups.
Primary Funding Source: International Labour Organization
• Medicaid Managed Care for the Chronically Ill and
Disabled in Texas: Patient Experiences in Two Harris
County Specialty Clinics
Megan Ullman, M.A.
Presented by: Megan Ullman, M.A., Sr. Research Associate,
Pediatrics, University of Texas Health Science Center at
Houston, 6655 Travis Street, Suite 400, Houston, TX 77030;
Tel: 713.500.8378; Fax: 713.500.8364; E-mail:
megan.m.ullman@uth.tmc.edu
Research Objective: Texas has used managed care to control
Medicaid costs for several years and now is considering the
expansion of STAR+PLUS, its pilot program for disabled
beneficiaries. Enrollment in managed care may restrict
beneficiaries' access to the specialized services used by
medically complex patients. Anecdotal evidence suggests that
many beneficiaries lack a basic understanding of managed
care principles. Our study examines the experiences of specialneeds Medicaid enrollees to determine whether participation
in managed care impedes access to services and to measure
enrollees' understanding of their health care plans.
Study Design: A face-to-face survey was administered to 100
chronically ill or disabled Medicaid recipients as they
presented to two Houston-area specialty clinics. The survey
was based on the CAHPS 2.0 questionnaire, a validated survey
used by many states to evaluate consumer satisfaction with
Medicaid health care plans. Our analysis examines three
specific issues: (1) Respondents' overall rating of their health
plan; (2) their ability to access special services such as
medical equipment, therapy and home health care; and (3)
enrollees' knowledge of their Medicaid managed care plan.
Population Studied: Study participants were selected
randomly as they presented to clinic. Respondents had to
receive care at one of the two clinics, use Medicaid as their
primary form of health insurance, speak English or Spanish,
and have been covered by Medicaid for at least six months at
the time of the interview. A Spanish version of the survey was
available for non-English speaking participants. Slightly more
than half of respondents were Hispanic, reflecting Houston's
large Latino population.
Principal Findings: Most respondents rated their health plans
highly. Sixty percent reported needing a special service; more
than a quarter of these experienced difficulty obtaining it.
Respondents' understanding of coverage options within
Medicaid was weak -- nearly 30 percent did not know whether
or not their plan was a form of managed care. Chi square
analysis indicates that patients' knowledge level is associated
with language spoken, default status and health plan model
type.
Conclusions: Larger-scale studies are needed to determine
whether access issues are directly related to poor
understanding of managed care. It is likely that lack of
knowledge hinders patients' ability to benefit fully from the
potentially positive aspects of managed care. Respondents'
surprisingly high ratings (given their reported access
problems) may be more indicative of their fear of losing
Medicaid coverage than evidence of accessible health care.
Implications for Policy, Delivery or Practice: Nationally,
disabled persons account for 17 percent of all Medicaid
beneficiaries, but use nearly 40 percent of expenditures.
Although managed care offers states the potential for
improving the delivery and coordination of services, it
contains inherent financial incentives to provide fewer
services. Our survey results suggest that Texas policymakers
need to improve beneficiary education, particularly for
Spanish-speaking patients and those who are defaulted into a
plan. Additional access studies of this vulnerable population
are needed before Texas' STAR+PLUS pilot program is
expanded.
• Provider Responses to Public Reporting of Quality
Virginia Wang, MSPH, Shoou-Yih Daniel Lee, Ph.D.
Presented by: Virginia Wang, MSPH, Doctoral Student,
Health Policy and Administration, University of North Carolina
at Chapel Hill, McGavran-Greenberg Hall, CB#7411, Chapel
Hill, NC 27599-7411; Tel: 919.593.2832; Fax: 919.966.6961; Email: vwang@email.unc.edu
Research Objective: In the United States, concerns about
high healthcare costs, the growth of managed care, and
patient safety have prompted interest in information about the
quality of care delivered by healthcare providers. It is generally
assumed that public reporting of care quality may serve the
multiple interests of consumers, payers, and providers in the
health care system. In particular, researchers have attempted
to examine how healthcare providers respond to public
disclosure of their performance records and whether or not
such public reports of profiling may impact provider behavior.
This study conducted a systematic review of empirical findings
related to whether and how health care providers act on the
results of publicly-released provider performance and to
identify unanswered issues as well as researchable questions
in this area.
Study Design: Systematic MEDLINE search of published
literature on public reporting of provider quality/performance
and provider responses. Additional sources articles and
reports were drawn from citation lists of articles.
Population Studied: Empirical studies examining public
release of information on provider performance/quality and
associated changes in subsequent behaviors and
performances.
Principal Findings: Review of the published literature
revealed a paucity of studies examining the effect of public
reporting on provider behavior. Existing research tended to
center on the following themes: perceived usefulness and
salience of public information, use of this information, its
effect on clinical practice (processes), and its effect on patient
outcomes. Study methods in the literature varied from
retrospective analysis of administrative and clinical data,
surveys of healthcare providers (and/or organizations), case
analyses, focus groups, to a combination of methods. The
primary impetus for a majority of the published literature was
reporting and release of provider profiles within a state. Study
measures were generally consistent, with variation due to
respective study design, unit of analysis, and outcome of
interest. Results of the studies in this review offered mixed
conclusions about the influence of publicly-released quality
information on provider behavior. Critical analysis of the
various research methodologies and findings was discussed.
Conclusions: The publications reviewed serve as an excellent
jumping-off point for future research. Although research has
made incredible strides in evaluating the effect of public
release of information on providers’ provision of services,
continued development in this area is necessary. As the
science of quality assessment develops, so too must the
science of evaluating the evaluations.
Implications for Policy, Delivery or Practice: Public
dissemination of provider performance results has the
potential to benefit the entire health care community. Their
existence is an important mechanism in checking and
balancing the delivery of health services. Innovations in
sampling techniques and data collection will motivate the
development of new measures and instruments for analysis.
The closer we get to accurately determining the effect of public
quality reporting on provider behavior, the closer we come to
improving the measurement tools that health policymakers
and planners use to effectively facilitate change for
improvement in the health care system.