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.