Management & Organization
Call for Papers
The Delivery System Counts : Organizational Structure
& the Quality of Care
Chair: Jane Banaszak-Holl, Ph.D., M.A.
Sunday, June 6 • 9:30 a.m.-11:00 a.m.
• Variations in Quality Outcomes among Hospitals in
Different Types of Health Systems, 1995 – 2000
Askar Chukmaitov, M.D., M.P.A., Gloria Bazzoli, Ph.D., Mei
Zhao, M.H.A.
Presented by: Askar Chukmaitov, M.D., M.P.A., Research
Assistant/Doctoral Student, Health Administration, Virginia
Commonwealth University, 1008 East Clay Street, P.O. Box
980203, Richmond, VA 23298-0203; Tel: 804.828.5218; Fax:
804.828.1894; E-mail: achukmaitov@vcu.edu
Research Objective: External and internal forces to reduce
costs and improve quality of care stimulated hospitals to join
health systems in the 1990s. Prior research has identified five
main types of health systems: centralized health system,
centralized physician/insurance health systems, moderately
centralized health systems, decentralized health systems, and
independent health systems. Prior research also has found
differences in costs across these system types. This study
assesses whether there are differences in quality of care
provided by hospitals in different system types and whether
these differences changed over time.
Study Design: Rates for AHRQ inpatient quality and patient
safety indicators (IQIs and PSIs) are determined for hospitals
for 1995 and 2000 years. The measures are risk adjusted for
patient’s age, gender, and APR-DRG and smoothed to
eliminate random variation in rates. We selected five most
commonly treated inpatient IQIs and eight PSIs that involve
the largest number of patients who are at risk of adverse
outcomes. Descriptive analysis and GLM procedures are used
in the analysis.
Population Studied: All short term general medical-surgical
hospitals from 11 states (AZ, CA, CO, FL, IA, MD, MA, NJ, NY,
WA, and WI) in operation between 1995 and 2000 that
participated in the AHRQ’s HCUP State Inpatient Databases
(SID) program.
Principal Findings: We found that hospitals in independent
health systems had significantly poorer IQIs and PSIs in 1995,
shown by 7 indicators (4 IQIs and 3 PSIs) out of 9 indicators
that demonstrated any significant differences between groups.
However, hospitals in independent systems showed better
quality outcomes measured by PSI 15 – accidental puncture
and laceration in 1995. In 2000, 8 indicators (5 IQIs and 3
PSIs) demonstrated that hospitals in centralized
physician/insurance (shown by 7 indicators ) and centralized
health systems (1 indicator) provided significantly better
quality than hospitals in other systems. Again, PSI 15 stands
out – hospitals in centralized physician/insurance health
systems have poorer quality in this category.
Conclusions: Mortality and patient safety rates differ by
hospital system type. We found that hospitals in independent
health systems had the poorest quality indicators in 1995 and
that there was no clear quality leader in this year. However, by
2000, hospitals in centralized health systems were quality
champions with significantly better mortality and patient
safety indicators when compared to hospitals in other system
types. PSI 15– accidental puncture and laceration – fell out
from the overall picture. Hospitals in independent health
systems are usually smaller and located in rural areas; thus,
the clinical staff may be more attentive to their patients.
Implications for Policy, Delivery or Practice: Preliminary
findings indicate that hospitals in more centralized health
systems have better quality outcomes over time than hospitals
in other systems. Future research needs to examine what
internal processes and mechanisms are adopted by these
systems that lead to higher quality of care.
Primary Funding Source: AHRQ
• Adoption and Use of Handheld Computers in Clinical
Practice
Ann McAlearney, Sc.D., Sharon Schweikhart, Ph.D., Sarah
Hoshaw, Mitchell Medow, M.D., Ph.D.
Presented by: Ann McAlearney, Sc.D., Assistant Professor,
Division of Health Services Management and Policy, The Ohio
State University, 1583 Perry Street, Atwell 246, Columbus, OH
43210-1234; Tel: 614.438.6869; Fax: 614.438.6859; E-mail:
mcalearney.1@osu.edu
Research Objective: Despite rapid technology innovation and
adoption outside the health care industry, most observers
believe that the health industry is significantly lagging in the
adoption of new information technology--IT. In the patient
care delivery area, handheld computers can be used to
simplify operational transactions and to support decisionmaking. Physicians often use these devices at their own
initiation, but use may be part of an organization’s clinical IT
strategy. Our research objective was to examine the adoption
and diffusion of handheld computers in clinical practice from
the perspectives of both organizations and physicians.
Study Design: We performed an extensive qualitative study
including case studies of seven healthcare organizations and
eight physician focus groups. Interviews and focus groups
were transcribed and analyzed using both inductive and
deductive methods.
Population Studied: Case study organizations included
academic medical centers, community hospital systems, and
independent practice associations. Key informant interviews
were held with 67 organizational representatives and
physicians. Focus groups included 54 physicians, and
represented both handheld computer users and non-users
across diverse clinical specialties and practice settings.
Principal Findings: Handheld computer adoption and use
proved an excellent example of innovation diffusion in
healthcare organizations. The relative advantage of handheld
computers over portable computers or paper was frequently
noted, as was the compatibility of handheld computers with
existing technologies and workflow was also often noted.
Physicians have distinct adopter characteristics, and
perceptions about the benefits and risks of the adoption
decision. In addition, perceptions about the complexity of
handheld computers varied, with some physicians reporting
they felt the handheld computer was intuitive and others in
disagreement. The adoption process for tended to be
impacted by both the trialability and observability of handheld
computers. Formal pilot projects were used to introduce the
device in four of our seven case studies. In addition, all
organizations could refer us to several power users, and
reported trying to leverage the enthusiasm of peer champions
to promote device adoption by other physicians. Finally,
change agents were used at the majority of institutions we
studied. Clinical change agents--nurse informaticists--worked
to facilitate and promote handheld computer use among
physicians at three of our seven case study organizations.
Conclusions: The success of technology diffusion is affected
by how the technology is introduced, demonstrated, and
promoted to potential adopters. Developing organizational
strategies to accommodate and support physician use of
handheld computers can help both organizations and
physicians improve care and service. Healthcare
organizations can leverage the opportunities presented by
handheld computers to both build user confidence in
technology and demonstrate success with technology
implementation and adoption.
Implications for Policy, Delivery or Practice: For
organizations interested in promoting clinical information
technology solutions, understanding the implications of our
findings about handheld computer adoption and diffusion can
help in other technology implementation projects. In
particular, the critical roles of clinical change agents and peer
champions can help promote and expand technology
adoption and diffusion among physicians who might
otherwise be uninterested or reluctant to experiment with new
information technologies.
Primary Funding Source: Center for Health Management
Research
• Does Primary Care Practice Autonomy Influence
Colorectal Cancer Screening Rates?
Patricia Parkerton, Ph.D., M.P.H., Elizabeth Yano, Ph.D., Lynn
Soban, M.P.H., David Etzioni, M.D., M.S.H.S.
Presented by: Patricia Parkerton, Ph.D. M.P.H., Assistant
Professor, Health Services, UCLA School of Public Health, 650
Charles Young Drive South, Los Angeles, CA 90095-1772; Tel:
310.825.2926; Fax: 310.825.3317; E-mail: parkert@ucla.edu
Research Objective: We question how management structure
influences the structures, processes, culture, and climate of
primary care and, ultimately, organizational performance and
quality of care. The provision of primary care services to a
defined population of 4.6 million veterans by 2010 physicians
offers the opportunity to examine the effectivity of
management structures. Although colorectal cancer (CRC)
screening rates within the Veterans Health Administration
(VHA) are well above national averages, there is substantial
variability in the delivery of this service and they are among the
lowest of all preventive services for which performance is
measured at the VHA medical center level. Because links
between authority over clinical care arrangements and
responsibility for outcomes might influence care, this study
examines the relationship between primary care practice
autonomy and CRC screening rates to measure determinants
of current practice.
Study Design: This cross-sectional design examined VHA
primary services distributed nationally. To measure the
variation in CRC screening across facilities and influence of
primary care practice organization, the data were merged from
the External Peer Review Program (CRC screening rates) and
the VHA Primary Care Practices Survey (organizational
structures and processes). We used principal components
analysis to create a scale of practice autonomy (k=4,
alpha=.89) comprised of measures of primary care leaders’
authority over establishing clinical procedures and new
primary care components as well as to provide guidelineconcordant care. Medical chart reviews found evidence of
CRC screening if there were documentation of 1) fecal occult
blood test in the last year, 2) flexible sigmoidoscopy in the last
five years or 3) colonoscopy in the last ten years. Bivariate and
multivariate analyses were performed leading to a series of
equations run as ordinary least squares regressions.
Population Studied: A stratified sample of 71,041 veterans
between 52 and 85 years of age visiting VHA physicians at 235
facilities at least three times in 2001
Principal Findings: CRC screening rates vary from 55% to
62% by region and from 25% to 88% by facility. The degree of
primary care leader practice autonomy was significantly and
positively associated with the delivery of CRC screening, even
after adjusting for size and academic affiliation.
Conclusions: This measure of primary care leader authority
estimated clinical autonomy and distinguished facility delivery
of colorectal cancer screening. Increasing primary care
authority over clinical arrangements related to screening may
enhance Veterans’ receipt of preventive services. To achieve
improvement in care for all, we must better understand
variations in practice organization associated with quality
performance.
Implications for Policy, Delivery or Practice: Because
colorectal cancer is the second greatest cause of cancer
mortality and early detection reduces mortality, we can
decrease mortality by increasing primary care authority over
clinical arrangements related to screening. Definition and
measurement of mutable practice characteristics is vital to
designing interventions and achieving improved care
Primary Funding Source: VA
• Improving the Performance of the Safety Net: Findings of
the "Urgent Matters" Project
Bruce Siegel, M.D., M.P.H., Marcia Wilson, M.B.A., Khoa
Nguyen, M.P.H., Marsha Regenstein, Ph.D.
Presented by: Bruce Siegel, M.D., M.P.H., Research
Professor, Health Policy, George Washington University
School of Public Health and Health Services, 2021 K Street,
N.W., Suite 800, Washington, DC 20006; Tel: 202.530.2399;
Fax: 202.530.2336; E-mail: siegelmd@gwu.edu
Research Objective: Emergency Department (ED)
overcrowding is a worsening problem for Americans, with
implications for quality and patient safety. EDs in major safety
net hospitals appear to be especially affected, reporting more
overcrowding and episodes of ambulance diversion. Many
factors have been cited as causes of overcrowding, including
decreases in inpatient capacity, staff shortages, physician
unwillingness to take call, and increased demand for services
from uninsured as well as insured patients. However, the
ability of hospitals to make management changes to address
overcrowding has not been conclusively demonstrated. Our
objective was to reduce ED overcrowding in ten safety net
hospitals by focusing on operational improvements, using
rapid cycle change techniques in an enhanced collaborative
approach.
Study Design: We selected ten hospitals via a national
competitive process. Criteria for selection included safety net
mission, charity care burden, indications of crowding and
demonstrated organizational commitment. These hospitals
then formed a structured “learning network,” in which they
worked collaboratively to implement rigorous performance
measures, assessed current processes and used techniques of
rapid cycle change to improve ED throughput and output.
Each hospital formed its own interdisciplinary project team
including representatives from the ED, inpatient and other
services. Limited expert technical assistance and extensive
web-based resources were provided to each site. Progress was
measured using 17 performance indicators.
Population Studied: Our sample was large urban and
suburban teaching hospitals, all of which were level I or II
trauma centers. The median number of yearly hospital
admissions was 23,800; the median number of yearly ED
visits was 70,000. Half were public hospitals; half were private
not-for-profit institutions. All functioned as safety net
providers in their respective communities.
Principal Findings: The hospitals were able to reduce
overcrowding without infusion of significant new resources.
All reduced wait times and delays, increasing ED throughput
and output. Many reduced the frequency and duration of
being on “diversion” or “bypass.” Better management of
inpatient capacity appears to have been critical to these
outcomes. Organization-wide interdisciplinary commitment,
physician participation and robust metrics were the most
essential elements for achieving improvement.
Conclusions: Better management of existing hospital
resources can reduce ED overcrowding, even in highly
complex, resource-constrained environments. While many
factors that drive overcrowding may be outside of a hospital’s
control, there are clearly changes that safety net institutions
can make to improve their performance, without large
infusions of new resources. This requires a significant
commitment to view overcrowding as an institution-wide
problem, to measuring the problem, and to breaking down the
organizational barriers between the ED and the rest of the
hospital.
Implications for Policy, Delivery or Practice: Some experts
and observers have held that ED overcrowding can only be
solved through expanded health insurance, increased hospital
funding and capacity, or relaxations of access statutes like the
Emergency Medicine Treatment and Active Labor Act
(EMTALA). Our work indicates that overcrowding can in large
part be addressed through better hospital capacity and patient
flow management, with a highly structured approach using
mainly existing resources.
Primary Funding Source: RWJF
• Are Practice Structure and Market Competition Related
to the Quality of Care Delivered by Office-Based
Physicians?
Carol Simon, M.S., Ph.D.
Presented by: Carol Simon, M.S., Ph.D., Associate Professor,
Health Services, BUSPH, 715 Albany Street, T3W, Boston, MA
02118; Tel: 617.414.1421; Fax: 617.638.5374; E-mail:
cjsimon@bu.edu
Research Objective: The goal of this project is to examine
whether the quality of care delivered by office-based physicians
is related to practice structure and market competition. It will
use current survey data on: (1) physician practice structure; (2)
practice finance; (3) physician compensation, and (4)
physician practice styles relative to clinical guidelines to
address the following questions:
1. Practice scale: Are physicians in larger practices more likely
to deliver care in accordance with clinical practice guidelines?
2. Practice technologies: Is the availability of computerized
administrative systems and computerized medical record
systems associated with adherence to practice guidelines?
3. Market competition: Are physicians who practice in more
competitive markets -- measured alternatively by the structure
of the physician market or the insurer/managed care
organization (MCO) market -- more likely to deliver care in
accordance with clinical guidelines
Study Design: This project will take advantage of a large,
national survey of physicians and practices. A 30-minute
computer-assisted telephone survey was administered to a
practice physician and the associated practice manger. Data
was collected on practice finances, practice structure,
managed care contracting, patient characteristics and use of
guidelines.
All primary care physicians and pediatricians are administered
a series of clinical case vignettes characterizing patients with
asthma, hypertension and depression. Questions probe the
ability of the physician to correctly diagnose the case and
document choice of diagnostic and treatment strategies.
Vignettes are designed to permit an assessment of the degree
to which the physician treats in accordance with accepted
(AHRQ and or specialty society) treatment guidelines. The
survey also collects general information from all physicians on
the practice's use of clinical guidelines and on the extent to
which there is feedback on adherence to guidelines.
Results from this survey are compared with findings from the
Community Tracking System Survey of Physicians(1996-97,
and 98-99 waves)
Data are analyzed using multivariate regression techniques,
controling for physician training, practice characteristics,
managed care involvement, incentive structures and
charcteristics of the local market and patient base. Analyses
are weighted to account for sampling design. Endogeneity of
managed care penetration and contracting are examined.
Population Studied: We study non-federal, post-residency,
office-based patient-care physicians in 5 states:
Massachusetts, Texas, California, Missouri, and Wisconsin.
States were chosen to span variation in physician practice
structure, characteristics of the managed care market,
variation in state regulation and Medicaid policy and local
sociodemographic characteristics.
Principal Findings: Preliminary results suggest that
physicians in larger practices are more likely to self-report the
ability to provide higher quality care, and are more likely to
practice in accordance with guidelines. Results are sharpest in
moving from solo and 2-3 physician practices to mid sized
groups (10-25 physicinas) Positive results may be linked to the
availablity of information technology and feedback on clinically
benchmarked performance.
Conclusions: Practice size and infrastructure may affect ability
to deliver high quality care.
Implications for Policy, Delivery or Practice: ? Adopting and
monitoring quality-enhancing activities is costly. Physician
practices frequently report the need to invest in new
information systems and to augment formal and informal
monitoring, education and management systems in order to
effectively use clinical practice guidelines. Many management
systems have considerable fixed costs, suggesting economies
of scale in investments in quality-enhancing systems. While
the trend has been towards larger practices, over 20% of all
office-based physicians still practice in solo settings. Another
20-25% practice in groups with fewer than 5 physicians. These
findings suggest that adoption of quality-enhancing measures
may be limited by practice size. Antitrust concerns over the
growth of larger groups might be weighed against potential
quality enhancements that come from larger scale operations.
Primary Funding Source: AHRQ
Call for Papers
Key Challenges in the Management of Health Care
Organizations
Chair: Thomas Rundall, Ph.D.
Monday, June 7 • 2:00 p.m.-3:30 p.m.
• PDA Prescribing in Outpatient Settings: Barriers and
Solutions
Kimberly Galt, Pharm.D., James Bramble, Ph.D., Bart Clark,
Ph.D., Mark Siracuse, Pharm.D., Ph.D., Wendy Taylor, B.B.L.,
Ann Rule, Pharm.D.
Presented by: James Bramble, Ph.D., Assistant Professor,
Pharmacy Sciences, Creighton University, 2500 California
Plaza, Boyne Room 143, Omaha, NE 68178; Tel: 402.280.4129;
Fax: 402.280.4809; E-mail: jbramble@creighton.edu
Research Objective: Personal digital assistants (PDAs) offer
great potential for improving quality at the point-of-care. The
PDA offers the opportunity to access drug information, enter
data, and print information pertaining to the patient including
the prescription. PDA use allows for easy access to electronic
information at the point-of-care that has the potential to
reduce prescribing errors. Additionally, computer generated
prescriptions reduce legibility problems. However introducing
PDA’s will meet with user adoption barriers. This research
identifies barriers perceived by physicians using PDAs and the
strategies physicians employed in response to these barriers.
Study Design: Forty primary care physicians recruited from a
larger study participated in this study to assess adaptation and
adoption behaviors related to using PDAs as a prescribing tool
in their outpatient practices. We provided PDAs with both
drug information and prescription writing software. After
successful completion of an initial training program, subjects
used the PDA as both their drug information source and
prescription generation tool. We conducted qualitative
interviews two weeks after initiation of the PDA’s to elicit the
barriers subjects experience and how they overcame these
barriers with regard to their PDA use. Employing a content
analysis process, five experts identified various themes and
patterns that emerged from the physician interviews.
Population Studied: We recruited 80 primary care physicians
(85% family practitioners, 33% female). The final sample
included 40 physicians randomized to the PDA arm of the
study.
Principal Findings: We identified five major themes that
inhibited full PDA adoption. These themes included:
Technology, Time, Environment, Patient Centeredness and
Personal Views. Generally, the software did not always meet
physicians’ needs and that the time to learn, the speed of the
PDA, and the work environment were not conducive to full
adoption. We also categorized the responses to these barriers
into four themes, including self-help, seeking assistance,
avoidance, partial adoption. Most commonly physician either
“gave up” and returned to their “old” ways or partially adopted
the piece of technology that was easiest to learn and more
efficient to use in their practice.
Conclusions: Barriers and solutions to PDA use exist on both
an individual and systems level. From a systems perspective,
the interviews clearly showed the necessity to customize PDAs
to the physician’s practice; thus, contributing to the office’s
efficiency. While on an individual level, physicians need to
have the time to learn how to implement the technology so it
is an asset and not an inhibitor to their daily practice.
Throughout all the interviews it was clear that when using the
PDA interfered with “seeing” patients then the technology was
not worth it.
Implications for Policy, Delivery or Practice: This research
demonstrates the need to address the barriers to adoption.
Despite the potential benefit of drug information and
prescription generation, if policy makers and administrators
fail to reduce barriers to adoption, advance technology will not
be fully accepted and implemented.
Primary Funding Source: AHRQ
• Are Community-Based Primary Care Services a Substitute
or Complement for Specialty and Inpatient Services?
John Fortney, Ph.D., Diane Steffick, Ph.D., James Burgess Jr.,
Ph.D., Matt Maciejewski, Ph.D., Laura Petersen, M.D.
Presented by: John Fortney, Ph.D., Associate Professor,
Psychiatry/HSR&D, UAMS/CAVHS, 5800 W. 10th Street, Suite
605, Little Rock, AR 72204; Tel: 501.660.7527; Fax:
501.660.7542; E-mail: fortneyjohnc@uams.edu
Research Objective: In an effort to practice population-based
medicine and contain health expenditures, many health
systems have attempted to shift the locus of care from
specialty and inpatient settings to the primary care setting.
However, it is not clear whether increased use of primary care
services actually decreases use of specialty and inpatient
services. The objective of this study was to test whether more
primary care results in decreases (substitution) or increases
(complementation) in the use of specialty and inpatient
services.
Study Design: We exploited the VA’s natural experiment of
increasing access to primary care by establishing new
Community Based Outpatient Clinics (CBOC) to estimate the
substitutabilty/complementarity of primary care for other
types of health services. Specifically, a quasi-experimental prepost study design was employed to estimate the impact of
increased use of primary care services on the change in
utilization of specialty medical visits, specialty mental health
visits, ancillary services, physical health admissions, and
mental health admissions. Ordinary Least Squares (OLS)
regression analysis is likely to be biased due to unmeasured
severity of illness and heterogeneous preferences for health
care services. We controlled for selection bias by conducting
an Instrumental Variables (IV) analysis that capitalized on the
establishment of CBOCs to provide an exogenous
instrumental variable (change in travel distance to the nearest
VA primary care clinic).
Population Studied: All veterans in the catchment area of a
new CBOC were included in the sample if they used VA
medical services in the pre-period. Veterans outside the
catchment areas of new CBOCs were matched according to
pre-period utilization, VA region, and distance to closest VA
primary clinic in the pre-period. Veterans in CBOC catchment
areas experienced a decrease in travel distance to primary care
services while the matched veterans experienced no change in
travel distance. The sample size was 52,801 patients.
Principal Findings: Change in travel distance was a
significant and substantial predictor of change in primary care
visits. OLS analyses indicated that an increase in primary care
service use was associated with increases in the use of
specialty outpatient services, ancillary services, and inpatient
services. In contrast, IV analyses indicated that an increase in
primary care visits was associated with a decrease in specialty
medical visits and was not associated with inpatient service
use. The IV analyses confirmed the OLS findings that
increased use of primary care services was associated with
increased use of ancillary and mental health services.
Conclusions: The OLS analyses indicated that primary care is
a complement to specialty outpatient and inpatient services.
The policy interpretation of these biased results is that
organizational innovations designed to increase use of
primary care will lead to increased use of other services,
resulting in higher costs. In contrast, the IV analyses
indicated that primary care was a substitute for specialty
medical services and was not associated with inpatient
services. Follow up analyses indicated that increased use of
primary care was not associated with higher outpatient or
inpatient costs.
Implications for Policy, Delivery or Practice: These results
provide evidence that health systems can implement
organizational changes to encourage primary care utilization
without driving up costs.
Primary Funding Source: VA
• Gender Disparities in Healthcare Experiences: The
Impact of Managed Care Practices
Shannon Mitchell, Ph.D., M.P.H, Mark Schlesinger, Ph.D.
Presented by: Shannon Mitchell, Ph.D., M.P.H, Associate
Research Scientist, Epidemiology and Public Health, Yale
University, 1216 5th Avenue, New York, NY 10029; Tel:
212.419.3532; Fax: 212.822.7369; E-mail:
shannon.mitchell@yale.edu
Research Objective: This paper seeks to explain underlying
causes of gender disparities in healthcare by focusing on
organizational characteristics of health insurance plans that
have not received attention in the literature on gender
disparities, but may differentially affect the way care is
delivered to men and women. Specifically, we examine the
impact of common managed care practices, including extra
fees for seeking care outside a closed networks of providers,
mandatory selection of primary care providers, referrals for
specialty care, and prior approval for treatment, employed by
most health plans on reports of problems experienced by men
and women with health insurance. We examine the extent to
which gender disparities in problem reporting exist, are
magnified among vulnerable populations, including persons
with chronic illness, disabilities, and low-income, and are
associated with specific managed care practices.
Study Design: The study employs nationally representative
cross-sectional survey data of 5000 respondents to assess the
independent effects of gender and health plan practices on
problematic healthcare experiences. Logistic regression is
used to model the probability of experiencing problems with
healthcare and experiencing serious financial or health
consequences as a result of the problem controlling for
respondent characteristics, health plan characteristics, and
environmental factors. Because the extent to which men and
women judge particular episodes to be “problems” may be
affected by their expectations as well as their experiences, we
conduct the analysis in two stages. In the first stage, to
control for potential bias in problem reporting due to
expectations, we estimated a model predicting respondents
general expectations of all health plans. From this model, we
obtain predicted values of respondents general expectations of
all health plans. We include the predicted values of
respondent’s general expectations of plans as an explanatory
variable in all second stage models to control for expectation
effects.
We estimated separate models for men and women and
conducted tests for significant differences in the effects of our
primary variables of interest. This analytic strategy was
repeated among vulnerable sub-groups of respondents,
including those with chronic illness , disabilities, and lowincome.
Population Studied: The study employs data from the
Consumer Trust in Healthcare Survey (CTHS), a nationally
representative survey of 5000 people. The survey asked
respondents about their health insurance and healthcare
experiences in the past 12 months. Subjects included 3314
women and 1686 men. Respondents who indicated that they
experienced a problem with their healthcare in the past 12
months are included in the study population. 2707 (54%) of
respondents reported experiencing at least one problem with
their healthcare in the previous 12 months.
Principal Findings: In this nationally representative survey,
women and vulnerable groups of women were significantly
more likely to report experiencing a problem and experiencing
significant health and financial consequences as result of the
problem compared to men, controlling for respondent's
general health plan expectations, socio-demographic
characteristics, health plan managed care practices, other
health plan characteristics, and environmental factors. The
magnitude of gender disparities in problems reported was not
trivial. The increased likelihood of experiencing a problem
associated with being female was greater than that associated
with being chronically ill or reporting poor health status.
These problems were associated with specific health plan
managed care practices for both men and women. Managed
care practices associated most strongly with problematic
healthcare experiences include out-of-network charges and
prior approval requirements. Gender disparities in the
impact of managed care practices on problem reporting were
large. Women enrolled in health plans that charged more for
out of network care, required referrals for specialty care and
prior approval for treatments were significantly more likely to
experience problems, and the magnitude of gender disparities
were greater among vulnerable groups of women. However,
not all managed care practices were detrimental to women.
Mandatory requirements for primary care providers were
associated with fewer problems among women compared to
men, especially among disabled women.
Conclusions: Health plan managed care practices that limit
access to care seem to disproportionately have negative
effects on the healthcare experiences of women and
vulnerable groups of women, in particular. Women with
chronic illness seem to be particularly affected by health plan
restrictions, suggesting that plan practices impede needed
flexibility in treating complex chronic conditions. As women
are increasingly enrolled in managed care plans, the problems
associated with restrictive health plan practices are likely to
increase. What is needed is better ways to assess quality of
care in health plans, including both technical indicators as well
as patient satisfaction and experiential-based measures. Not
only do these measures need to be incorporated into quality
assessment tools, they must sufficiently designed to address
gender specific issues.
Implications for Policy, Delivery or Practice: Because prior
research demonstrates that consumers have difficulty
negotiating the healthcare system and may not understand
complex organizational characteristics of their health plan,
informing consumers about health plan practices is key to
helping consumers make informed choices. Because the
findings of this study suggest that women may be a greater
risk for problems related to health plan practices, there is need
for more information and education among women, and
vulnerable groups of women, regarding organizational
characteristics of health plans. Additionally, as regulations
aimed at improving access to physicians and services for
certain populations (women in particular) increase, the
importance of consumer education is heightened. Although
such regulations are aimed at protecting consumers, they
increase the complexity of plan rules. Increasing women’s
knowledge of health plan characteristics will enable them to
make better informed choices among plans, an implicit goal
of may policy proposals emphasizing consumer choice.
Primary Funding Source: Atlantic Philanthropic
• Trustbusters: The Prevalence and Predictors of Trust
Violations in American Medicine
Mark Schlesinger, Ph.D., Nicole Quon, B.S.
Presented by: Nicole Quon, B.S., Doctoral Candidate, Health
Policy and Administration, Yale University, P.O. Box 208034,
New Haven, CT 06520-8034; Tel: 203.589.9188; Fax:
203.785.6287; E-mail: nicole.quon@yale.edu
Research Objective: Researchers are increasingly recognizing
the importance of trust as a marker for health system
performance and a prerequisite for effective health care, but
there has been little study on the prevalence or predictors of
violations of trust. This study uses seven measures to examine
trust violations in three health care domains: health plan
interactions, physician-patient relationships, and
hospitalization experiences. We explore the types of problems
that are most often associated with violations of trust and
then estimate regression models to determine the extent to
which perceived trust violations are a function of consumer
expectations and health status, attitudes and behaviors
associated with medical consumerism, organizational
characteristics, and local market conditions. Comparing the
predicted impact on trust across three domains allows for
additional analytic insights about trust violations.
Study Design: The data came from a cross sectional
telephone survey of 5,000 adults about their health plans,
hospitals, and physicians. Patients with chronic or recent
health conditions were over sampled to increase the
proportion of respondents who had interacted with the health
care system in the previous year. Expectation questions
captured dimensions of health care delivery. Experience
questions included an assessment of problematic events as
well as whether these events led to a decrease in trust.
Because we expect that perceived violations of trust are
affected by expectations and experience, our regression
models control for expectations while identifying the correlates
of trust violations at the individual, organizational, and market
levels.
Population Studied: Randomly selected adults with health
insurance. Statistical analyses are weighted to adjust for the
over sampling of respondents with health conditions.
Principal Findings: Over twenty percent of respondents
reported that they perceived a trust violation in their health
plans, with a roughly equal prevalence among hospitalized
patients. More than half the respondents reported a violation
of trust by their physicians. These violations were most
strongly associated with reports of health plan refusal to
approve needed services, plan staff treating the patient
unfairly, being treated with less respect during hospital visits,
and being discharged early from hospitals. The multivariate
analyses revealed factors that were consistently related to
reported trust violations across the three domains. Individual
level factors included expectations about health care,
educational attainment, and perceived vulnerability which
were positively related to trust violations, as well as minority
status which was negatively related to trust violations. At the
organizational level, nonprofit ownership and scale were
negatively related to violations of trust. Market effects were
mixed, with increased competition among plans increasing
the reported violations of trust but no similar effects for
hospitals.
Conclusions: Consumers frequently observed untrustworthy
behavior among plans, hospitals, and physicians. The negative
experiences were concentrated among particular groups of
consumers, particularly those who are less capable of acting
as empowered consumers.
Implications for Policy, Delivery or Practice: Because most
quality improvement initiatives, e.g. report cards and outcome
monitoring, focus on dimensions of quality that are easiest to
measure, they will be least relevant to the dimensions of
health care that demand trust. This point has potentially
problematic consequences that are unevenly distributed
among health care consumers; these disparities may merit
remediation.
Primary Funding Source: RWJF
• Medicaid Managed Care: Determining Predictors of
Provider Organizations’ Use of Organized Processes to
Improve Care
Diane Rittenhouse, M.D., M.P.H., James Robinson, Ph.D.,
M.P.H.
Presented by: Diane Rittenhouse, M.D., M.P.H., Assistant
Professor, Family and Community Medicine, University of
California, San Francisco, 500 Parnassus Avenue, Room MU
308-E, San Francisco, CA ; Tel: 415.514.9249; E-mail:
DianeR@itsa.ucsf.edu
Research Objective: Over the past decade most states have
shifted large proportions of Medicaid beneficiaries into
managed care plans, hoping to increase quality and access
under increased financial restraints. California’s provider
organizations (medical groups, independent practice
associations, community clinics and health care systems)
have pioneered the development of care management
processes (CMPs) to improve patient care quality, but little is
known about the extent of adoption of such processes within
California’s Medicaid program (Medi-Cal). The aim of this
study was to determine the extent of adoption of CMPs for
chronic disease and preventive services among provider
organizations contracting with Medi-Cal HMOs; to determine
whether CMP use was associated with organizations’ level of
involvement with Medi-Cal managed care; and to determine
which internal (organizational) characteristics and external
(marketplace) incentives were associated with CMP use.
Study Design: 30-minute telephone survey conducted in
Spring 2003 focused on CMP use for care of patients with
asthma and diabetes and for preventive services for children
and adolescents. Multivariate analysis was performed to
determine the effects of organizational characteristics (e.g.
size, extent of capitation, profitability); type of organization;
proportion of clinical revenue and patient visits from MediCal; information technology infrastructure; internal and
external performance incentives on CMP use.
Population Studied: The CEO or medical director from every
provider organization with at least six primary care physicians
and at least one Medi-Cal HMO contract. N=123; completion
rate = 64.4%.
Principal Findings: Over half of organizations provided
physicians with easy access to lists or registries of patients
with asthma or diabetes; 48.8% sent reminders for routine
care to patients with asthma, and 53.7% sent reminders to
patients with diabetes. 75% provided flow sheets for patient
medical charts for asthma and diabetes. 2/3 of organizations
provided physician training on established asthma and
diabetes guidelines and provided physicians with feedback on
their clinical performance. Similar proportions of
organizations used CMPs for preventive services for children
aged 0-2, but a lesser proportion of organizations used CMPs
for preventive services for adolescents.
The use of CMPs by provider organizations for the care of
patients with diabetes was associated with a high level of
organizational involvement in Medi-Cal managed care, the use
of CMPs by health plans, type of organization, and the
presence of external incentives for clinical performance. CMP
use for asthma was also associated with higher organizational
IT capabilities. CMP use for preventive services for children
aged 0-2 and adolescents was associated with level of
involvement with Medi-Cal, use of CMPs by health plans, the
presence of external incentives for clinical performance, and
profitability of the organization. (p<0.05)
Conclusions: Based on 8 measures analyzed in this study,
provider organizations that serve Medi-Cal beneficiaries are
actively involved in developing and implementing CMPs. Our
findings suggest that the Medi-Cal managed care program,
health plans, and marketplace incentives stimulate the use of
CMPs by these organizations.
Implications for Policy, Delivery or Practice: Our findings
inform the effort by the Institute of Medicine and others to
improve health care quality by spurring systems
improvements and organizational change – an effort that is
particularly important and challenging for organizations
serving low-income populations.
Primary Funding Source: California HealthCare Foundation
Related Posters
Poster Session A
Sunday, June 6 • 6:45 p.m.-8:00 p.m.
• Examining the Systemic Implications of Innovation in
Care Delivery: The Case of Telecare
James Barlow, Ph.D., Steffen Bayer, MA, MSC, Ph.D., Richard
Curry, BSc Hons, Ph.D.
Presented by: James Barlow, Ph.D., Chair in Technology &
Innovation Management, Business School, Innovation Studies
Centre, Imperial College London, South Kensington Campus,
London, SW7 2AZ; Tel: 02075945928; Fax: 020 7823 7685; Email: j.barlow@imperial.ac.uk
Research Objective: The provision of health and social care
for the growing elderly population is a challenge facing many
societies. Policy makers and health professionals are seeking
to develop innovative approaches to the delivery of care
services. Elements of new approaches include an increased
emphasis on rehabilitation, the delivery of care in new settings
(such as in intermediate care facilities and the patients’ own
home) and the use of information and communications
technologies (ICT) to support care delivery (e.g. telecare
systems).
In this paper we examine the systemic implications of a
particular service innovation: telecare. We define telecare as
the use of the use of ICT to support the delivery of care
directly to individuals in their own homes or their daily
environment. Studying such service innovations in the
numerous telecare pilot projects gives important insights into
their cost and benefits. However, these pilot projects are
limited in the extent to which they can give reliable indications
of the systemic impact of the implementation of the service
innovations. The distribution of cost and benefits between
different institutions and individuals, and influences on other
parts of the care system and at later times, cannot be captured
if innovations are studied in isolation.
Study Design: In this paper we employ both qualitative
research methods and a system dynamics simulation model
to assess the systemic impact of an innovation within the local
health and social care system, partly prospectively. The paper
builds on work carried out within a three year UK research
project on telecare implementation. This included qualitative
research with stakeholders involved in the development and
operation of a telecare scheme for frail elderly people, case
studies of other schemes in the UK, the use of system
dynamics simulation modelling to explore the impact of
telecare on resource and patient flows within a local care
system, and scenario-development to explore wider policy
options.
Population Studied: The research focused on the health and
social care system in a specific region (North West Surrey,
England). Drawing on data and experience from a variety of
contexts (in Surrey, the UK and elsewhere), we present our
assessment of the likely consequences of the implementation
of different types of telecare services at a systemic level.
Principal Findings: Unintended consequences can arise
when innovations are implemented in a complex service
delivery system such as health and social care.
Conclusions: Systemic benefits and costs depend crucially on
specific assumptions about the impact of the medical
intervention and on the structure of the wider care delivery
system.
Implications for Policy, Delivery or Practice: Demands for
high quality proof of efficacy are necessarily important in
healthcare delivery. However, the lack of evidence for systemic
cost/benefit impacts of telecare potentially inhibits care
providers from making the necessary investment. This
problem is compounded in situations where budgets are split
between health and social care services and costs and benefits
may accrue differentially. A systems approach can help to
make more informed policy decisions on the implementation
of health care delivery innovations.
Primary Funding Source: EPSRC (UK)
• Organizational Factors Affecting Enrollment of Medicare
Beneficiaries into CMS’ Lifestyle Modification
Demonstration Program (LMDP) for Heart Disease
Sarita Bhalotra, M.D., Ph.D., Donald Shepard, Ph.D., William
B. Stason, M.D., A. James Lee, Ph.D., Gail Strickler, M.A.,
M.S., Grant Ritter, Ph.D.
Presented by: Sarita Bhalotra, M.D., Ph.D., Assistant
Professor, Schneider Institute for Health Policy, Brandeis
University, 415 South Street, Mailstop 035, Waltham, MA
02454; Tel: 781.736.3960; Fax: 781.736.3985; E-mail:
bhalotra@brandeis.edu
Research Objective: Brandeis University is performing an
evaluation of the LMDP that includes a process evaluation of
planning and implementation, and an outcomes evaluation of
effectiveness and cost-effectiveness. The goal is to provide an
evidence base for lifestyle modification practices in the
Medicare population. As recruitment of a sufficient number
of participants into LMDP is crucial, the evaluation includes a
study of organizational factors that impact on enrollment.
Specific aims are to identify the critical variables in health care
organizations that affect enrollment, and to determine their
sequencing and interactions. These findings will be used to
model the structure and processes of a successful
organization in terms of Medicare beneficiary enrollment in a
Lifestyle Modification program.
Study Design: The process evaluation uses a qualitative, case
study design incorporating on-site observation (including
participant-observation), semi-structured interviews, and
reviews of written materials, with quantitative evaluation of
marketing, recruiting, enrollment, and retention processes.
Data are triangulated and analyzed using principles of
grounded theory.
Population Studied: Of the multiple health care
organizations across the US that are implementing one of two
Lifestyle Modification programs for Medicare beneficiaries
with established heart disease; twelve will be studied in detail;
ten such assessments have been completed and two more are
scheduled.
Principal Findings: Although clinical components of the
program are well-developed, planned, and implemented at
sites, all sites enrolled fewer participants than projected.
Barriers to enrollment are identified at patient, provider and
organizational levels. Managerial components are unevenly
formulated and supported. Linkages with area physicians and
related programs (e.g. cardiac rehabilitation), internal
marketing to the organization’s existing referring physicians
and patients, and external marketing are all essential.
Conclusions: Enrollment is a critical step in the success of
any lifestyle modification program. Barriers occur at multiple
levels, need to be addressed through multi-pronged and
interconnected strategies and buttressed by effective tactics.
In addition to clinical leadership, managerial and political
entities within organizations need to play a vital role in
developing and implementing these structures and processes.
Social marketing tools may be effective for encouraging
enrollment in lifestyle modification programs.
Implications for Policy, Delivery or Practice: To improve
health status and control costs of heart disease, it is
imperative that the health care system respond to the
demographic and epidemiological trends in the U.S. by
innovating in the field of lifestyle modification. Engagement in
preventive services is difficult as indicated by relatively low
utilization rates even for single contact services such as pap
smears, mammography, and flu vaccination (33 percent, 43
percent, and 64 percent of Americans over age 65,
respectively). Engagement in multiple contact programs such
as lifestyle modification is likely to be an even greater
challenge. While provider and patient factors continue to be
explored for their contribution to participation, little is known
about organizational factors that affect the implementation of
such programs and contribute to their success. This study
identifies a set of organizational critical success factors:
structural, procedural and cultural, that are essential to
achieving sustainable engagement of Medicare beneficiaries in
such programs.
Primary Funding Source: CMS
• Specialty Internist Gender and Patient Care
Amy Arouni, M.D., James Bramble, Ph.D., Eugene Rich, M.D.
Presented by: James Bramble, Ph.D., Assistant Professor,
Pharmacy Sciences, Creighton University, 2500 California
Plaza, Boyne Room 143, Omaha, NE 68178; Tel: 402.280.4129;
Fax: 402.280.4809; E-mail: jbramble@creighton.edu
Research Objective: Though previous research has shown
that patients from primary care, Obstetrics and Gynecology,
and surgery receive different services based on their
physician’s gender, no similar studies are available from
Internal Medicine subspecialties. Despite the steady increase
in the number of women entering these fields in the last 3
decades, no data are available that assess the potential
variation in patient care due to physician gender. To better
understand the potential implications of changing physician
demographics within Cardiology and Pulmonary Medicine,
this study examines if comparable patients receive different
care based on their physician’s gender. Specifically, we
examine if patients of female Cardiologists and
Pulmonologists have longer lengths of stay, higher laboratory
and imaging costs, and fewer discretionary procedures than
patients of male physicians within these subspecialities.
Study Design: We used a quasi-experimental cross-sectional
study to examine the association of physician gender and
variations of patient care. We created a unique data set by
combining Arizona hospital discharge data from year 2001
with data on physician characteristics from the American
Medical Association’s physician master file and hospital
characteristics from the American Hospital Association’s
annual survey of hospitals. We identified patients using the
principal ICD9 code to determine the appropriate diagnoses
for each specialty. Hierarchical regression models tested the
hypotheses controlling for patient, physician, and hospital
characteristics.
Population Studied: All patients over 18 with a length of stay
>1 day diagnosed with angina or acute respiratory failure were
considered for the study. The final sample consisted of
patients diagnosed with angina whose discharge physician
was a Cardiologist (n = 674) and patients with acute
respiratory failure whose discharge physician was a
Pulmonologists (n = 526).
Principal Findings: Not surprisingly, compared with female
Cardiologists and Pulmonologists, the male specialists had
practiced more years since medical school graduation (p <
0.0001 and p < 0.001, respectively). Patients treated for
angina had relatively similar lengths of stay (1.8 days)
irrespective of physician gender. However, patients with acute
respiratory failure treated by male Pulmonologists had an
average length of stay of 14.4 days, compared to 12.4 days for
patients treated by female Pulmonologists. Preliminary
evidence suggests that there is no difference in discretionary
procedures as measured by the percent of cardiac
catheterizations and bronchoscopes preformed.
Conclusions: It appears that, as in the primary care setting,
similar hospitalized patients may receive different care based
on the gender of their sub-specialist physician. Further
research is required to identify and understand the factors
underlying these seeming variations in care.
Implications for Policy, Delivery or Practice: These results
indicate the need for future studies to shape our
understanding of factors associated with variations of care;
thus, potentially aiding policy-makers and educators in
training future physicians.
Primary Funding Source: Health Futures Foundation
• Economic Evaluations of Community-Based Care:
Lessons From 12 Studies in Ontario
Gina Browne, Ph.D., R.N., Jacqueline Roberts, M.Sc., Reg.N.,
Amiram Gafni, Ph.D., Carolyn Byrne, Ph.D., Reg.N., Robin
Weir, Ph.D., R.N., Basanti Majumdar, Ph.D., R.N.
Presented by: Gina Browne, Ph.D., R.N., Founder & Director,
System-Linked Research Unit on Health and Social Service
Utilization; Professor, Nursing & C.E.&B., School of Nursing,
McMaster University, Faculty of Health Sciences at Frid Street,
75 Frid Street, Building T30, Hamilton, Ontario, L8P 4M3; Tel:
905.525.9140 Ext. 22293; Fax: 905.528.5099; E-mail:
browneg@mcmaster.ca
Research Objective: A series of 12 randomized trials
examined clients in community settings in Southern Ontario
suffering from a variety of chronic physical and mental health
conditions. These studies funded by Health Canada and the
Ontario Ministry of Health are appraised using a framework
for evaluating possible outcomes of economic evaluation.
Study Design: Each study was designed to quantify the wellbeing outcomes and expenditures associated with different
community-based approaches to care provided in the context
of a system of national heatlh insurance. Multiple-perspective
client wellbeing outcome measures were used. In two studies,
caregiver burden also was analysed. A common approach to
quantificatio and evalaution of expenditures for service
consumption was used in all 12 studies.
Population Studied: In the 12 studies, sample composition
and size varied. Studies werer of vulnerable adults,
adolescents, seniors with a variety of chronic illnesses and
circumstances.
Principal Findings: The nature of community-based health
services (health vs. disease care orientation) was found to
have direct and measurable impact on total expenditures for
health service utilization and client well-being outcomes. In
most cases, a recurring pattern of equal or better client
outcomes, yet lower expenditures for use of community-based
health services, was associated with well-integrated health
oriented services.
Conclusions: Integrated services aimed at factors which
determine health are superior when compared to individual,
fragmented, disease oriented, and focussed approaches to
care. The main lessons from the 12 studies are that it is as or
more effective and as or less expensive to offer complete,
proactive, community health services to persons living with
chronic circumstance than to provide focussed, on-demand,
piecemeal services.
Implications for Policy, Delivery or Practice: Complete
services would have a psychosocial and mental health focus
included with the physical care approach. Furthermore,
people with coexisting risk factors (age, living arrangements,
mental distress and problem-solving ablity) are the ones who
most benefit at lower expense from health oriented, proactive
interventions.
Primary Funding Source: Health Canada and the Ontario
Ministry of Health
• The Surgical Hospital: Threat or Non-Threat to the Local
Hospital
Robert James Cimasi, ASA, CB., AVA, FCBI
Presented by: Robert James Cimasi, ASA, CB., AVA, FCBI,
President, Health Capital Consultants, 9666 Olive Boulevard,
Suite 375, St. Louis, MO 63132; Tel: 800.394.8258; Fax:
314.991.3435; E-mail: rcimasi@healthcapital.com
Research Objective: The objective of this research is to
expand our preliminary analysis conducted previously on the
financial and utilization impact on general, acute care
hospitals deriving from the presence of surgical hospitals
within specified, representative healthcare markets. In the
research conducted to date, we have attempted to examine a
variety of smaller to mid-size healthcare markets, classified as
being either “with” or “without” a surgical hospital, to seek
out evidence which would indicate the effect, if any, of the
presence of a surgical hospital on selected measures of
operating performance and the financial condition of the
general acute care hospitals.
Study Design: The following variables were selected and
preliminarily analyzed as representative indicators for various
measures of utilization and financial condition in determining
the existence of negative effects, if any, on local hospitals due
to the presence of surgical hospitals.
1.
“Admissions per Bed”;
2.
“Average Length of Stay”;
3.
“Surgical DRGs as a Percentage of Total DRGs”;
4.
“Net Income per Admission”;
5.
“Net Income per Bed”;
6.
“Case Mix Adjusted Cost of Surgery”; and,
7.
“Case Mix Index”.
We propose to examine additional variables, i.e., market
entrance timing, incursion of managed care, payor mix,
demographics, and facility capacity.
Population Studied: Our preliminary analysis compared
general acute care hospitals in selected markets “with a
surgical hospital” to general acute care hospitals in similar
markets “without a surgical hospital.”
We are proposing to present an expansion of our research
analysis to all markets including surgical hospitals in the U.S.
Principal Findings: Of the 7 variables examined in our
preliminary analysis, 5 appeared more favorable for the general
acute care hospitals in markets which have a surgical hospital.
The other 2 variables, appear to be approximately identical for
the general acute care hospitals in markets which have a
surgical hospital.
Conclusions: Notwithstanding the limitations of our
preliminary analysis, we have concluded that, in the sample of
markets reviewed to date, there was no statistically valid
indication of any significant negative effects on the general
hospitals in the market, due to the presence of a surgical
hospital.
This proposal is for the presentation of the findings from our
expanded research which should determine whether or not
these findings are valid throughout the U.S. and whether they
may be impacted by other variables.
Implications for Policy, Delivery or Practice: Passage of the
Medicare Prescription Drug, Improvement and Modernization
Act of 2003 included the “Breaux Amendment” which places
an 18 month moratorium on the “Whole Hospital Exemption”
for new specialty hospitals under the Stark self-referral laws.
During the moratorium the Medicare Payment Advisory
Commission will produce a report and the Secretary of HHS
will examine issues related to referrals and quality issues.
Research such as that proposed here will be important to
providing empirical guidance to the process of the
determination of the future course of action regarding surgical
and specialty hospital development as well as the future
direction of hospital market competition.
• Cost-Effectiveness of an Intervention to Improve
Physician Follow-up of Positive Tests for Colorectal Cancer
Nancy Archibald, M.H.A., M.B.A., Stacy Dale, M.P.A., Craig
Thornton, Ph.D.
Presented by: Stacy Dale, M.P.A., Researcher, Health,
Mathematica Policy Research, Inc., 600 Alexander Park,
Princeton, NJ 18044; Tel: 609.936.2726; Fax: 609.799.0005; Email: sdale@mathematica-mpr.com
Research Objective: Complete diagnostic evaluation or CDE
(i.e., colonoscopy or combined flexible sigmoidoscopy plus
barium enema x-ray) is often not performed for persons with
an abnormal screening fecal occult blood test (FOBT+) result.
Our objectie is to examine the cost-effectiveness of an
intervention designed to increase the rate at which physicians
refer and perform CDE for patients who have a positive fecal
occult blood test (FOBT).
Study Design: The study recruited physician practices where
patients received annual FOBTs mailed by a managed care
organization. Physicians at 584 practices were sent surveys;
those practices with one or more physicians completing the
survey were randomized either to an intervention group
(N=120 practices with 280 physicians) or to a control group
(N=198 practices with 380 physicians). Control group
practices received only the FOBT screening program, while
treatment group practices received the FOBT screening
program and an intervention consisting of CDE reminderfeedback and educational outreach designed to increase CDE.
The cost of this intervention was estimated on the basis of
accounting records and physician participation logs. We then
use a previously published decision-analytic model of
colorectal cancer screening to evaluate the cost of the
intervention per life year saved.
Population Studied: Physician practices affiliated with a
managed care organization
Principal Findings: The intervention increased the rate of
CDE recommendation by 16.3 percentage points and CDE
performance by 12 percentage points. The cost of the
intervention was $3,942 per practice. The cost per life-year
saved depends on the effort needed to sustain the CDE
recommendation rate. If the increase in CDE rates could be
sustained for 35 years after delivering the full intervention
(reminder-feedback and educational outreach) once, it would
cost $3,500 per life-year saved; if the full intervention needed
to be delivered every two years for 35 years in order to sustain
the increase in CDE rates, it would cost $44,000 per life-year
saved. A one-time intervention with ongoing reminders and
feedback would cost $18,000 per life-year saved.
Conclusions: This intervention is more expensive than other
published interventions designed to change physician
behavior. At the same time, it tries to affect a more complex
set of physician and patient behaviors than in the other
studies. The resulting cost per life-year saved of an FOBT
screening program that includes the intervention to improve
CDE compares favorably with the cost-effectiveness of other
cancer screening tests.
Implications for Policy, Delivery or Practice: Cost-effective
interventions, such as CDE, do not always become routine
practice. This intervention indicates that it is possible to
change physician behavior in a large managed care
organization, and that changing physician behavior can be
cost-effective.
Primary Funding Source: NCI
• Literacy and Health Outcomes
Nancy Berkman, Ph.D., MLIR, Darren DeWalt, M.D., Darren
DeWalt, M.D., Michael Pignone, M.D., M.P.H., Stacey
Sheridan, M.D., M.P.H., Kathleen Lohr, Ph.D., Linda Lux,
M.P.A.
Presented by: Darren DeWalt, M.D., RWJ Clinical Scholar,
Department of Internal Medicine and Pediatrics, University of
North Carolina, Chapel Hill, 5034 Old Clinic Building, CB
#7105, Chapel Hill, NC 27599-7105; Tel: 919.966.3712; Fax:
(919) 843-9237; E-mail: darren_dewalt@med.unc.edu
Research Objective: To conduct systematic reviews of the
literatures on (a) the relationship between literacy and health
outcomes and (b) impacts of interventions intended to
improve the health of people with low literacy.
Study Design: The RTI International-University of North
Carolina Evidence-Based Practice Center examined two key
questions (KQ). KQ 1 asked: Are literacy skills related to (a)
use of health care services? (b) health outcomes? KQ 2
asked: For individuals with low literacy, what are effective
interventions to (a) improve the use of health care services?
(b) improve health outcomes? Eligible studies were published
from 1980 on. We searched all appropriate databases
including MEDLINE, CINAHL, ERIC, PAIS, and ILRR and
consulted technical experts and Web-based bibliographies.
We graded the quality of individual studies and rated the
strength of the overall literature.
Population Studied: Individuals of all ages in the developed
world. We retained only studies in which researchers had
determined participants’ literacy levels through measurements
using the REALM, WRAT, or various other instruments or had
limited their studies to populations known from previous
assessments to have poor literacy skills.
Principal Findings: We identified 44 articles that met our
inclusion criteria for KQ1. Literacy levels were positively
related to knowledge of the use of various health care services
and health promotion and disease prevention interventions.
Literacy levels were also found to be positively associated with
knowledge of health outcomes and global health status.
Results were mixed concerning the relationship between
literacy and adherence to medical regimens or clinical trial
protocols, control of HIV, and self-reported depression. Low
literacy was associated with poorer health outcomes for, for
example, chronic diseases (e.g., asthma, diabetes), childhood
ailments, and HIV and for some utilization measures (e.g.,
preventive care) but not for higher costs or charges for care.
We identified 29 articles that met our inclusion criteria for
KQ2. Generally, patient knowledge improved after receiving
the intervention (typically informational materials in various
media). Several studies of the effect of interventions on health
behaviors produced mixed results as did studies measuring
changes in biochemical or biometric markers. Few studies
examined interactions between literacy and the intervention.
Conclusions: Lower literacy skills are generally related to
poorer health outcomes, particularly those concerning
knowledge and use of information, according to fair to good
evidence. Interventions to mitigate the effects of low literacy
are less well supported at this time.
Implications for Policy, Delivery or Practice: Because of
limitations in their reading ability, patients with low literacy
may realize fewer benefits from health care and may not be
able to use and retain self-care information adequately.
Additional interventions and studies are needed to determine
effective interventions to combat the impact of low literacy,
and these should be of longer duration, take explicit account
of literacy levels, and designed to make clear, for multimodality studies, what “actually” worked. A final issue
involves the relative utility of making information simpler for
such patients versus teaching them to read.
Primary Funding Source: AHRQ
• A Multi-Disciplinary Doctor-Nurse Practitioner Model: An
Alternative Approach to Reducing the Costs of Patient
Care?
Susan Ettner, Ph.D., Jenny Kotlerman, M.S., Abdelmonem
Afifi, Ph.D., Sondra Vazirani, M.D., M.P.H., Ron Hays, Ph.D.,
Martin Shapiro, M.D., Ph.D.
Presented by: Susan Ettner, Ph.D., Professor, Medicine,
UCLA, 911 Broxton Plaza, Los Angeles, CA 90095; Tel:
310.794.2289; Fax: 310.794.0732; E-mail:
settner@mednet.ucla.edu
Research Objective: Hospitals seek to adapt to changing
healthcare market conditions by exploring new models of care
that allow them to maintain high quality of care while
containing costs. Our objective was to examine the net cost
savings associated with a hospital intervention involving care
management by teams of physicians and nurse practitioners,
along with daily multidisciplinary rounds and follow-up
contact of patients post-discharge.
Study Design: Patients were randomized to the intervention
versus the usual mode of care delivery. The cost of the
intervention was compared to the difference in nonintervention costs, estimated using a quasi-experimental
design in which pre-/post-admission changes in regressionadjusted costs were compared for the intervention versus
usual care patients. Intervention costs were calculated by
tracking the time spent by different types of providers on the
intervention and assigning hourly costs. Patient costs during
the index hospital stay were estimated from administrative
records and during the four-month follow-up period by
weighting self-reported utilization by unit costs.
Population Studied: 1,207 general medicine inpatients in a
large academic medical center
Principal Findings: The intervention cost was $1,187 per
patient and was associated with a significant $3,331 reduction
in non-intervention costs. About $1,947 of the cost offset was
realized during the initial hospital stay, with the remainder
attributable to reductions in the use of services postdischarge. After adjustment for possible attrition bias, a
reasonable estimate of the cost offset was $2,165, for a net
cost savings of $978 per patient associated with the
intervention.
Conclusions: Because net costs were lower on average for the
intervention patients, while health outcomes and patient
satisfaction were comparable for the two groups, the
intervention was, by definition, cost-effective.
Implications for Policy, Delivery or Practice: Wider adoption
of multi-disciplinary interventions in similar settings might be
considered. The savings previously reported with pure
hospitalist models of care may also be achievable with other
care models that focus on efficient inpatient care and assuring
appropriate post-discharge care.
Primary Funding Source: AHRQ
• Improving Depression Care: Primary Care-Mental Health
Collaboration
Jacqueline Fickel, Ph.D., Louise Parker, Ph.D., Elizabeth Yano,
Ph.D., Joann Kirchner, M.D., Mona Ritchie, M.S.W.
Presented by: Jacqueline Fickel, Ph.D., Postdoctoral Fellow,
Department of Psychiatry, University of Arkansas for Medical
Sciences, 5800 W. 10th, Slot 755, Little Rock, AR 72204; Tel:
501.257.1728; Fax: 501.257.1844; E-mail: jjfickel@uams.edu
Research Objective: Collaboration between primary care and
mental health services offers promise for improving detection
and treatment of depression through formalization and
coordination of professional roles. There is a lack of evidence,
however, about provider attitudes and practices regarding
collaboration. We evaluated baseline variations in the degree
of provider collaboration, and in perceived barriers, prior to
the Translating Best Practices for Depression into VA Care
Solutions (TIDES) initiative. This initiative is designed to use
an evidence-based quality improvement process to implement
a collaborative-care model for depression in primary care
clinics.
Study Design: TIDES has implemented the collaborative care
model in seven Veterans Administration (VA) primary care
clinics. Three additional clinics serve as control sites. We
conducted baseline assessment of structures of care using
semi-structured telephone interviews. Interview topics
included primary care (PC) and mental health (MH) provider
perspectives on depression detection and management and
on collaboration.
Population Studied: The study group included 10 PC leaders
and 12 MH care leaders from the 10 practice sites.
Principal Findings: There was a wide range in extent and
quality of PC-MH collaboration at the sites. Perceptions about
barriers to appropriate management of depression and about
collaboration differed between MH and PC providers in
several ways. PC doctors reported moderately-high comfort
levels with depression care, but noted inadequate time and
too few PC providers for managing depression. MH providers
identified more barriers to appropriate management than did
PC providers, including inadequate PC training and experience
with depression. MH providers also identified more barriers
to collaboration, including insufficient staffing and resources
for both PC and MH. Finally, although there was consensus
that MH providers are very available for informal consultation
with PC providers, there were few formal joint case conference
activities.
Conclusions: Many barriers exist to collaboration between PC
and MH providers, with fair-to-poor levels of collaboration in
half the sites. PC and MH providers view collaboration
differently. Better understanding of these barriers and
differences in perceptions is needed to improve collaboration
and the quality of depression care.
Implications for Policy, Delivery or Practice: Effective quality
improvement must acknowledge the impact of provider
attitudes and readiness to collaborate on the rollout of
interventions into these and other practice settings.
Primary Funding Source: VA
• Managed Care’s Spill-over Effects on the Quality of Care
for Fee-for-Service Medicare Beneficiaries with Diabetes
Paul Hebert, Ph.D., Matthew Maciejewski, Ph.D., Jane Sisk,
Ph.D., A. Marshall McBean, M.D., M.Sc.
Presented by: Paul Hebert, Ph.D., Assistant Professor, Health
Policy, Department of Health Policy, Mount Sinai School of
Medicine, One Gustave Levy Plaza, Box 1077, New York, NY
10029; Tel: 212.659.9191; Fax: 212.423.2998; E-mail:
paul.hebert@mssm.edu
Research Objective: Recent studies have documented the
systemic changes in local health care markets resulting from
the growth in the market share of managed care organizations
(MCOs). MCO penetration has been linked to slower
adoption of expensive technology, reductions in hospital bed
capacity, and decreases in physician incomes. However,
MCOs also have incentives to promote the use of preventive
care, both as a means to avoid future costs, and as a way to
enhance their ratings on report cards, which are increasingly
used to compare the quality of care delivered by MCOs. We
investigated whether these incentives for parsimonious and
preventive care in the managed care sectors had an influence
on the care delivered to fee-for-service (FFS) Medicare
beneficiaries with diabetes. Specifically, we addressed whether
MCO market share and the level of competition among MCOs
in an area affected: 1) the provision of eye exams, influenza
vaccinations, HbA1c and lipid panel blood tests , which are
recommended for persons with diabetes; 2) the provision of
Magnetic Resonance Imaging (MRI) services and referral to
specialists, the use of which are believed to be restrained by
MCOs; and 3) the incidence of diabetes-related complications,
including amputation, which are believed to be avoidable
given high quality preventive care.
Study Design: A claims-based algorithm was used to
construct a database of 3.4 million Medicare beneficiaries with
diabetes in the FFS sector in 1994. Use of preventive and
other services were derived from Medicare claims for these
beneficiaries over the 1995-98 period and were aggregated to
the Metropolitan Statistical Area (MSA) level for each year.
We estimated cross-sectional time series models with fixedeffects for MSA. The dependent variables were the percent of
beneficiaries who received a given service and the key
explanatory variables were the MSA-level MCO market
penetration and the MSA-level Herfindahl index of MCO
market competition.
Population Studied: FFS Medicare beneficiaries with
diabetes, 1995-98.
Principal Findings: The effect of MCO market penetration on
preventive care for FFS Medicare beneficiaries with diabetes
was small and not statistically different from zero. A 10%
increase in MCO penetration was associated with a .25 (95%
C.I. -0.17, 0.61) percentage point increase in eye exams, and a
0.26 (-0.01, 0.60) percentage point increase in influenza
vaccinations rates. Similarly we found no significant effect of
MCO penetration on high cost services such as MRIs (0.07%;
-0.01, 0.02), or referral to endocrinologists (0.017%; -0.001,
0.28), and no effect on avoidable diabetes-related
complications including amputation (-0.04%; -0.11, 0.03).
MCO measures of competition were similarly unrelated to
these measures.
Conclusions: We found no evidence of a spillover effect of
MCO market penetration on the care provided to FFS
Medicare beneficiaries with diabetes.
Implications for Policy, Delivery or Practice: A suggested
benefit of expanded MCO market penetration is that the
orientation toward prevention that MCOs advocate could
spillover to the FFS sector. We found no evidence to support
this. Advocates of expanded enrollment of Medicare and
Medicaid beneficiaries into MCOs should not consider
spillovers of this nature a potential added benefit.
Primary Funding Source: RWJF
• Finding Research Subjects in the Age of HIPAA
Rachel Hess, M.D., Melissa McNeil, M.D. M.P.H., ChungChou Joyce Chang, Ph.D., Cindy Bryce, Ph.D.
Presented by: Rachel Hess, M.D., Fellow-General Internal
Medicine, General Internal Medicine, University of Pittsburgh,
230 McKee Place, Suite 600, Pittsburgh, PA 15213; Tel:
412.692.2025; Fax: (412) 692-4838; E-mail: hessr@upmc.edu
Research Objective: Privacy regulations associated with the
Health Insurance Portability and Accountability Act (HIPAA)
have complicated the conduct of outcomes research. To
facilitate such research, we created the Functional Assessment
System Tablet (FAST), a computerized touch-screen form that
collects general patient information, facilitates longitudinal
follow-up, and systematically queries all patients regarding
willingness to be: 1) included in the research registry project
(RRP) and 2) contacted about future research studies (the
prospective subject list (PSL)). Within our implementation
cohort, we investigated systematic bias in RRP and PSL
participation.
Study Design: All patients presenting to our outpatient
practice self-complete the FAST. Real time information is
provided to clinicians and placed in a de-identified research
database. Upon completion, the computer asks patients to
participate in the RRP and PSL. The RRP identifiably links the
FAST with patients´ complete medical records for use in
research. Using the PSL, researchers of IRB approved studies
may query the RRP, identify study eligible patients, and
approach them regarding participation. We examined the
impact of clinical variables (i.e., gender, age, marital status,
educational attainment, hazardous drinking, social support,
self-reported disease, and health related quality of life via
RAND-36) on RRP and PSL participation using Fisher´s exact
and Student´s t-tests.
Population Studied: Consecutive patients presenting to a
General Internal Medicine outpatient practice.
Principal Findings: 54 sequential patients completed the
FAST; none refused. These patients included: 93% women;
average age of 48 years (range 19-76); 53% married or in a
committed relationship; 58% with at least a college degree; 7%
hazardous drinkers; RAND-36 mental health composite
(MHC) of 43±12.7 and physical health composite (PHC) of
45±12.6. The most common self reported diseases included:
hypertension (45%); arthritis (32%); and depression (38%). 31
patients (57%) participated in the RRP. We were unable to
detect any significant association between RRP participation
and clinical characteristics (p-values: 0.13-0.86). 87% of RRP
subjects also consented to the PSL. We examined association
between PSL consent and: age; educational attainment;
arthritis; and depression and detected no significant
differences (p-values: 0.16-0.67).
Conclusions: In our preliminary sample, over half of
sequential patients seen in a University based outpatient
practice consented to participate in a research registry. We
were unable to detect any systematic difference in this novel
cohort inception method between those who participated and
those who did not, suggesting that participants were
representative of the overall patient population.
Implications for Policy, Delivery or Practice: Use of a
computerized data collection instrument, such as the FAST,
along with a research registry and PSL, represents a promising
mechanism for facilitating both outcomes research and
enrollment in clinical trials while adhering to current privacy
regulations.
• Impact of Transformational Leadership on Employee
Motivation, Satisfaction, and Performance in Healthcare
Organizations
Naresh Khatri, Ph.D., Andrew Felker, Medical Student
Presented by: Naresh Khatri, Ph.D., Assistant Professor,
Health Management and Informatics, University of Missouri,
324 Clark Hall, Columbia, MO 65211; Tel: 573.884.2510; Fax:
573.882.6158; E-mail: KhatriN@health.missouri.edu
Research Objective: To examine the impact of three
transformational leadership attributes (socially skillful, bold
and change seeking, and knowledgeable and experienced) of
healthcare professionals and managers (physicians, physician
managers, nurses, senior managers, finance managers,
human resource managers, and administrators) on
motivation, satisfaction, unit morale, and performance of
employees in healthcare organizations.
Study Design: We surveyed the employees of eight health
care organizations in Missouri using a transformational
leadership instrument consisting of three dimensions –
socially skillful, bold and change seeking, and knowledgeable
and experienced. The survey was mailed to 400 employees. In
all, 216 subordinates responded and rated 106 managers on
the above transformational leadership dimensions and their
impact on subordinates’ motivation, satisfaction, performance
(quantity & quality of work), and unit morale.
Population Studied: Health care professionals and managers
of 8 eight health care organizations in Missouri.
Principal Findings: Social skillfulness consisting of
social/interpersonal skills, sensitivity to the needs and values
of subordinates, flexibility and openness to ideas, and being a
caring and friendly person had highly significant impact on
employee motivation, satisfaction, unit morale, and quality of
work. Especially noteworthy were its effects on employee
motivation (F = 22.16, p< .001) and satisfaction (F = 6.07, p<
.001). Being bold and change seeking showed a significant
impact on employee motivation, unit morale, quantity of work,
and quality of work. Its effects were particularly pronounced
on employee motivation (F = 4.74, p< .001), unit morale (F =
3.22, p< .001), and quantity of work (F = 4.87, p< .001). Being
knowledgeable and experienced affected employee motivation
and quality of work, but to a lesser extent than social
skillfulness and bold and change seeking. Health care
managers and professionals were found to be relatively high
on knowledgeable and experienced dimension (mean score of
5.23 on a scale of 1 to 6), but low on bold and seeking change
(mean score of 4.26 on a scale of 1 to 6) and social skillfulness
(mean score of 4.81 on a scale of 1 to 6). Three leadership
attributes together explained 88% of employee motivation,
36% of employee satisfaction, 27% of unit morale, 15% of
quality of work, and 21% of quality of work.
Conclusions: The three critical leadership attributes of health
care professionals and managers (physicians, physician
managers, nurse managers, top management, finance
managers, & human resource managers), namely, social
skillfulness, being bold and seeking change, and being
knowledgeable and experienced showed a highly significant
effect on employee motivation, satisfaction, unit morale,
quantity of work, and quality of work of health care employees.
Whereas health care managers and professionals were high
on knowledgeable and experienced dimension, they were low
on social skillfulness and bold and change-seeking behavior,
the two dimensions that had much greater impact on
employee motivation, satisfaction, and performance than
being knowledgeable and experienced. Consequently, health
care managers and professionals need to improve upon their
social skills and be bolder and change seeking in their
approach.
Implications for Policy, Delivery or Practice: Health care
organizations need to gear their recruitment and selection
methods to identify socially skillful and bold and change
seeking professionals, managers, and leaders. They also need
to develop training and development methods to improve
social skillfulness and bold and change seeking attributes of
their current professionals and managers.
• The Evolution of Rural Primary Care Physician Practice,
1999-2002
Astrid Knott, Ph.D., Jill Klingner, M.S., Ira Moscovice, Ph.D.
Presented by: Astrid Knott, Ph.D., Research Associate, Rural
Health Research Center, University of Minnesota, 2221
University Avenue, S.E., #112, Minneapolis, MN 55414; Tel:
612.624.3566; E-mail: knott008@umn.edu
Research Objective: To understand the changes in rural
primary care practice in the United States since 1999,
especially as they relate to the breadth and scope of practice,
the implementation of quality improvement activities, and the
use of technology.
Study Design: This panel study used a nationally
representative sample of rural primary care physicians. Two
rounds of telephone surveys with a cohort of rural primary
care physicians were conducted in 1999 (84% response rate)
and 2002 (78% response rate). The survey collected
information on physician and practice characteristics, breadth
and scope of practice, environmental pressures, QI activities,
and computer use. Descriptive and bivariate analysis
techniques were used to analyze the data.
Population Studied: A nationally representative sample of
rural (non-MSA) primary care physicians – family
practitioners, general practitioners, and internists – who
provided at least 20 hours of office-based patient care per
week in 1999. The sample was drawn from the AMA
Physician Masterfile.
Principal Findings: Practice sizes increased slightly but
practices remain small. Productivity – measured by the
number of office visits - declined for both FP/GPs and
internists over the 3-year period. Fewer FP/GPs are providing
inpatient care and care in nursing homes. However, the
percentage of FP/GPs and internists that treated COPD and
chronic cardiac conditions themselves increased, while the
percentage of FP/GPs treating chronic GI bleeds,
uncomplicated pregnancies, localized colon cancer, surgical
hernia, and cataracts declined.
More than half of rural PCPs used the top three quality
assessment tools inquired about – monitoring of recall for
Pap smears/mammograms, monitoring other preventive care,
and monitoring immunizations schedules/rates. Patient
satisfaction surveys and the monitoring of referral letters were
used by less than half of physicians.
The study found limited computer use among rural PCPs.
Less than 40% use computers daily for internet use, accessing
hospital records and x-rays, drug information, information for
patient care, or CME. Computer users were younger, more
likely to be board certified, graduated from medical school
later, and practice in larger practices.
The number of physicians receiving utilization profiles
declined. The use of profiles did not affect a change in a
clinical practice for most physicians (56%), the single largest
change made was to prescribing patterns.
Conclusions: The findings indicate that rural primary care
practice is changing. Changes in the scope and breadth of
practice are likely related to the changing availability of
specialists in rural areas and changes in treatment regimens,
especially medications, available to PCPs. The percentage of
physicians engaging in quality assessment is encouraging,
especially given the small size and limited resources of rural
practices.
Implications for Policy, Delivery or Practice: The results of
this study are useful to providers, administrators and
organizations interested and engaged in rural primary care
and to those interested in quality of care issues and
technology use in primary care.
Primary Funding Source: RWJF
• Use of Preventive Services and Self-Management
Activities among Diabetes Disease Management Enrollees
Natalia Oster, R.N., M.P.H., Verna Lamar-Welch, Ph.D.,
M.P.H., Junling Ren, MED, Claire Spettell, Ph.D., Elizabeth
Lowry, R.N., B.S.N., Joette Majerus, B.S.
Presented by: Verna Lamar-Welch, Ph.D., M.P.H., Researcher,
Health Policy and Management, Emory University, Rollins
School of Public Health, Emory Center on Health Outcomes
and Quality, 1518 Clifton Road, Atlanta, GA 30322; Tel:
404.712.8531; Fax: 404.727.9198; E-mail:
vlamar@sph.emory.edu
Research Objective: 1.) To assess the degree that those
enrolled in a managed care organization’s (MCO’s) diabetes
disease management program use preventive services and
self-management activities (e.g., regular exercise, blood
glucose checks); 2.) and to assess whether self-management
and use of preventive services varies by race and ethnicity.
Study Design: A 40-item self-administered health assessment
was mailed to 19,078 people enrolled in a MCO’s diabetes
disease management program. The health assessment
included questions regarding demographics, health status,
participation in self-management activities such as regular
exercise and daily glucose checks, and use of preventive
services such as eye and dental exams, influenza and
pneumococcal shots, glycosolated hemoglobin and
cholesterol checks, and urinalysis. A cross-sectional analysis of
all returned health assessments was conducted and
racial/ethnic differences in utilization were examined using
Chi-squared statistics.
Population Studied: Enrollees in a managed care
organization's diabetes disease management program
(n=19,078).
Principal Findings: Of the 19,078 health assessments mailed,
6,433 were returned for a response rate of 34%. Twenty-two
percent of participants reported that their health was
‘excellent’ or ‘very good’, with higher prevalences among men
and whites. There were no statistically significant differences
between the racial and ethnic groups of interest (black, white
and Hispanic) in regards to receipt of a urinalysis or eye exam
in the past year. However, there were differences in use of
preventive services in regards to glycosolated hemoglobin
checks (78% blacks, 82% whites, 77% Hispanics, p =0.002),
cholesterol checks (86% blacks, 92% whites, 86% Hispanics,
p <0.001), receipt of influenza (57% blacks, 72% whites, 62%
Hispanics, p<0.001) and pneumococcal shots (49% blacks,
62% whites, 41% Hispanics, p<0.001), and receipt of a dental
exam in the past year (42% blacks, 55% whites, 47%
Hispanics, p<0.001). There were also differences in selfmanagement activities in regards to regular exercise (49%
blacks, 54% whites, 56% Hispanics, p<0.001) and daily
glucose checks (66% blacks, 81% whites, 79% Hispanics,
p<0.001).
Conclusions: Lack of access to care is often cited as one
rationale for racial/ethnic disparities in preventive service
utilization; however, these results show that use of preventive
services and the level of self-management activities vary by
race/ethnicity even among people enrolled in a MCO.
Compared to blacks and Hispanics, whites most often
reported higher levels of self-management activities and use of
preventive services.
Implications for Policy, Delivery or Practice: Continued
focus needs to be directed at understanding disparities in the
use of preventive services and self-management among
minorities.
Primary Funding Source: Academic Medicine and Managed
Care Forum
• National Analytical Framework for Examining Hospitalbased Emergency Departments in Taiwan
Blossom Yen-Ju Lin, Ph.D., Shi-Ping Luh, M.D., Ph.D.
Presented by: Blossom Yen-Ju Lin, Ph.D., Assistant Professor,
Institute of Health Service Management, China Medical
University, 91 Hsueh Shih Road, North District, Taichung,
404; Tel: 886.922.709359; Fax: 886.4.22019901; E-mail:
yenjulin@mail.cmc.edu.tw
Research Objective: Managing the costs and quality of
healthcare outcomes have become the key issue in Taiwan
health care industry. While the hospital cares comprising the
largest portion of national health care costs, few studies have
focused on the performance of hospital emergency
departments (EDs) through a thorough examination. As a role
for patient life turnaround in hospital EDs, inefficiency might
threaten patient care quality, patient and staff satisfaction,
hospital cost concerns and hospital public relations. Given the
relative lack of empirical evidence to support either group’s
opinions about how to effectively manage a hospital ED, this
study proposed a theoretical contingency “context-processperformance” framework to give hospital managers some
evidences to examine thoroughly the dynamics of hospital
EDs.
Study Design: This is a national granted three-year (20033005) period project, with the individual hospital EDs as unit
of analysis. Three hundred and fifty individual EDs in Taiwan
accredited acute care hospitals in 1998-2001 were included in
this study. Using a contingency “context-processperformance” as a conceptual framework at hospital ED level,
the purpose of this study is aimed to 1) to determine the
relationship between hospital ED contextual variables and
hospital ED process, 2) to determine the relationship between
hospital ED process variables and hospital ED performance,
and 3) to determine the relationship between hospital ED
contextual variables and hospital ED performance. Data will
be collected in the ED units, ED medical staff and ED patients.
Population Studied: Three hundred and fifty individual EDs
in the accredited acute care hospitals in 1998-2001 were
included in this study.
Principal Findings: Three constructs are presented in the
contingency context-process-performance framework:
contextual factors, process factors and performance factors.
With individual hospital EDs as unit of analysis, the contextual
factors of a hospital ED can be characterized as the external
climate of a hospital ED, that is, hospital characteristics. These
factors will be viewed as the external environment that may
influence the management and organization of a hospital ED.
Process factors denote the concept what is actually done in
giving and receiving ED care. It can be described from both
technical and interpersonal processes. Performance factors
can be defined narrowly or broadly. In the health services
organizational research, a hospital ED performance can be
designed broadly from financial, customer, internal business,
learning and growth, and external relationship perspectives,
respectively modified from the concept of Balanced Scorecard.
Conclusions: Conceptual framework will be proposed to
provide researchers, hospital managers, and policy makers to
reexamine the hospital ED design and dynamics.
Implications for Policy, Delivery or Practice: New insights
from this study will give hospitals’ decision-makers and ED
units’ managers some guidance for establishing an emergency
department that is both effective and efficient.
Primary Funding Source: National Health Research Institute
• Hospitalists: Changing Inpatient Medicine to Help Cross
the Quality Chasm
Ann McAlearney, Sc.D.
Presented by: Ann McAlearney, Sc.D., Assistant Professor,
Division of Health Services Management and Policy, The Ohio
State University, 1583 Perry Street, Atwell 246, Columbus, OH
43210-1234; Tel: 614.292.0662; Fax: 614.438.6859; E-mail:
mcalearney.1@osu.edu
Research Objective: The emergence of hospitalist physicians
as inpatient care specialists has generated considerable
medical and policy discussion. This research was designed to
review the hospitalist literature to understand how hospitalists
can help in efforts to cross the quality chasm in healthcare.
Study Design: A comprehensive review of the literature was
conducted by database searches, by hand, and by internet.
Medline, Lexis Nexis, and Academic Universe were the
primary databases for the literature search, and google.com
was the primary internet search engine. Literature review
continued until saturation was achieved with respect to
considering the issues and implications of the expansion of
hospitalists, with special attention paid to risks and
opportunities to help healthcare organizations cross the
quality chasm.
Principal Findings: Hospitalists have a substantial
opportunity to improve patient safety and effectiveness
because of their dedicated focus on inpatient care, and may be
motivated to initiate systems improvements and
organizational changes that can work to improve safety and
reduce errors. Hospitalists can also help to improve the
patient-centeredness of care by working constantly to
communicate with patients, families, primary care physicians,
and other involved caregivers to provide coordinated,
responsive care. The timeliness and efficiency of inpatient
care are potentially improved by hospitalists who are
continuously available to manage inpatient care and who can
develop specialized expertise and insight in hospital-based
medicine. Equity may even be minimally addressed because
hospitals typically assign all unattended patients to
hospitalists, regardless of insurance status, thus expanding
access to high-quality physicians for uninsured and
underinsured patients. Risks, however, are not insubstantial.
The hospitalist model creates a purposeful discontinuity of
care that can lead to problems with patient safety,
effectiveness, or timeliness when information is missed or
care is not well-coordinated. The patient-centeredness of care
may be at risk when consumers are presented with a new
provider who is unfamiliar with their individual circumstances.
In some cases, emphasis on organizational efficiency may
create conflicting incentives regarding patient care. Further,
patients typically are not able to change providers under the
hospitalist model, and this restricted choice may not be
appreciated by patients who feel disconnected from their
regular physicians.
Conclusions: While hospitalists do have the potential to help
hospitals cross the quality chasm, such opportunities are not
without risks. It is hoped that providers who become
hospitalists choose to leverage their new role as inpatient care
specialists to help improve the performance of health care
systems for the benefit of both patients and health care
organizations.
Implications for Policy, Delivery or Practice: Hospitalists
currently practice in most U.S. communities, and evidence is
growing that shows a positive impact on the health care
system with respect to improvements in both efficiency and
quality of care. Health services research can help provide
practical guidance for healthcare organizations by evaluating
the benefits and risks of the hospitalist model through welldesigned studies of different programs and providers. Such
research can be structured to detect potential problems with
the hospitalist model so that they can be addressed in
program design and implementation.
• Cost Inefficiency and Mortality Rates in Florida Hospitals
Mary Deily, Ph.D., Niccie McKay, Ph.D.
Presented by: Niccie McKay, Ph.D., Associate Professor,
Health Services Administration, University of Florida, 3029
N.W. 38th St, Gainesville, FL 32606; Tel: 352.273.6076; Fax:
352.273.6075; E-mail: nmckay@phhp.ufl.edu
Research Objective: To examine the relationship between
cost inefficiency and health outcomes in Florida hospitals over
the period 1999-2001, with health outcomes being measured
by in-hospital mortality rates.
Study Design: The key independent variable is cost
inefficiency, by hospital and year, estimated using the
stochastic cost frontier approach. The observed in-hospital
mortality rate is regressed on cost inefficiency, the riskadjusted predicted mortality rate, and other variables affecting
mortality rates.
Population Studied: Urban, acute-care hospitals in Florida
over the period 1999-2001.
Principal Findings: Increased cost inefficiency is significantly
associated with higher observed in-hospital mortality rates,
holding patient risk and other factors constant. At the mean
values of the control variables, a 1 percentage point reduction
in cost inefficiency was associated with 1 fewer death per
10,000 discharges.
Conclusions: The results suggest that eliminating cost
inefficiency also improves in-hospital mortality rates, at least
for the study population of Florida hospitals over the period
1999-2001.
Implications for Policy, Delivery or Practice: A key
implication for hospitals is that reducing inefficiency may also
lead to reductions in mortality rates. The results also suggest
that cost control and quality improvement are not conflicting
policy goals, and provide further evidence that policy makers
should take both costs and outcomes into account in the
design of new programs.
Primary Funding Source: Univ of Florida
• Examining Operating Room Nursing Factors and Patient
Outcomes
Robin Newhouse, Ph.D., R.N., Meg Johantgen, Ph.D., R.N.,
Peter Pronovost, M.D., Ph.D.
Presented by: Robin Newhouse, Ph.D., R.N., Nurse
Researcher/Assistant Professor, Nursing
Administration/Nursing, The Johns Hopkins Hospital/
University School of Nursing, 1863 Crownsville Road,
Annapolis, MD 21401; Tel: 410.614.2805; Fax: 410.614.1115; Email: rnewhou1@jhmi.edu
Research Objective: The importance influence of nurses work
environment on patient safety was highlighted in a recent
IOM report. This study examined the relationship between
operating room (OR) organization (nurse certification, twentyfour hour staffing, the performance of multidisciplinary code
drills, nurse staffing, agency use) on patient outcomes
(surgical complications, mortality, and length of stay) for
patients discharged post abdominal aneurysm repair and
aortic-iliac-femoral bypass.
Study Design: Survey and cross-sectional descriptive
correlational.
Population Studied: Discharge abstracts from 1894 patients
undergoing abdominal aneurysm repair and aortic-iliacfemoral bypass in 2000-2003 in 32 Maryland hospitals were
studied. Perioperative Directors provided organizational data
via mail survey.
Principal Findings: For hospitals with no night coverage, a
lower chance of complications was found as compared to
hospitals with no assigned coverage (OR 0.54, 95% CI, 0.37,
0.79). The estimated odds of death decreased significantly
per 10% increase in RN agency use (OR 0.67, 95% CI 0.56,
0.80). The proportion of RNs with certification (CNOR) was
also found to decrease the odds of complications or death by
approximately 6 to 8% percent per 10% increase in the
proportion of CNOR RNs, although these results are not
statistically significant (p = .056).
Conclusions: Organizational factors within ORs showed
significant influence on patient outcomes. However,
confounding variables may have contributed to this finding.
ORs without staffed night shifts are commonly in smaller
hospitals with lower volumes and no teaching component.
Furthermore, these hospitals attract a lower complexity patient
that may have not been captured in this study’s risk
adjustment methodology. The significant relationship
between agency use and mortality was unexpected but
explainable, since OR agency nurses are usually experienced
with specific expertise in a specialty service (i.e.vascular). The
use of a higher proportion of CNOR RNs was expected to
relate to lower complications; while this was in the right
direction, the relationship was not significant. As with other
outcomes studies, many factors influence patient outcomes.
The limitations of self-report survey and secondary data
analysis limited the variables to a structure orientation instead
of processes.
Implications for Policy, Delivery or Practice: Organizational
structures and processes are increasingly targeted as
opportunities to improve staff morale and patient safety.
While several studies have examined the effects of ICU
workgroup processes, this is one of the first studies examining
ORs. If consistent relationships are demonstrated,
administrators would have a better understanding of how their
decisions influence patient care, as well as data to support
their decisions. Additional research is needed to study these
and other nurse structural factors and their effect on patient
care.
Primary Funding Source: Association of periOperative
Registered Nurses (AORN)
• Managed Care and Changing Conceptions of Health Care
Quality
Amit Nigam, M.A.
Presented by: Amit Nigam, M.A., Ph.D. Candidate,
Management and Organizations, Northwestern University,
2001 Sheridan Road, Evanston, IL 60208; Tel: 847.467.7105; Email: a-nigam@northwestern.edu
Research Objective: To assess whether the spread of
managed care since the early 1980s was accompanied by a
shift from professional to more bureaucratic conceptions of
health care quality.
Study Design: Content analysis of abstracts focused on health
care quality in JAMA. Content analysis used grounded theory
techniques supported by quantitative techniques. The
investigator inductively coded abstracts and developed a list of
key words. The investigator then did an automatic coding of
abstracts using the Atlas ti text analysis software. Based on
the inductive coding, the abstracts were grouped based on
cluster analysis techniques. They were then inductively
analyzed, by group, to assess themes in discussions of quality
and to identify trends over time.
Population Studied: JAMA abstracts classified under the
"Quality of Care" MESH subject heading, excluding abstracts
focused only on "processes and outcomes" of care. A total of
499 abstracts were analyzed from 1983-2002.
Principal Findings: While the analysis of the abstracts
revealed a number of distinct themes, two themes, suggesting
distinct conceptions of health care quality, were both robust
across our various cluster analyses and showed marked trends
over time. We do both qualitative and quantitative analysis of
articles grouped through partition clustering methods into
four groups. One group focuses exclusively on professionals,
on their skills and knowledge and on the social structures by
which they are certified and credentialed. A second group also
discusses professionals and professional education, but in
conjunction with clinical and practice guidelines and
adherence to standards defined by consensus panels or
evidence based medicine. The first group of articles showed a
strong decrease in time, going from 51 percent of the abstracts
from 1983-87 to 15 percent from 1998-2002. The second
group increased substantially, from 2 percent in 1983-87 to 32
percent from 1998-2002
Conclusions: The text analysis of discussions of health care
quality suggests a shift in conceptions of health care quality.
With conceptions grounding quality in broad professional
education and in the skills and knowledge of individual
practitioners decreasing in prominence over time, while
conceptions focused on clinical guidelines and expert-defined
standards, enforced in part through bureaucratic mechanisms,
increasing in prominence over time.
Implications for Policy, Delivery or Practice: Conceptions in
health care quality have the potential to influence attempts to
improve quality. Conceptions of quality that are grounded in
skill, knowledge and professional education would suggest
that quality improvement efforts can focus on improving
professional education, training and mentoring. Conceptions
grounded in adherence to guidelines can suggest that quality
improvement would involve more targeted efforts to educate
physicians about specific guidelines and to involve a variety of
health care providers in efforts or programs to make medical
care more consistent with guidelines.
• A National Survey of Primary Care Practice-Based
Research Networks
Daniel Gaylin, M.P.A., William Tierney, M.D., Caitlin
Oppenheimer, M.P.H., Brenda Hudson, M.A., Atif Zafar,
M.D., Jennifer Benz, B.A., Amy Finn, B.A., David Lanier, M.D.
Presented by: Caitlin Oppenheimer, M.P.H., Senior Research
Scientist, Health Survey, Program, and Policy Research,
NORC, 1350 Connecticut Avenue, N.W., Suite 500,
Washington, DC 20036; Tel: 202.223.6340; Fax: 202.223.6104;
E-mail: oppenheimer-caitlin@norc.uchicago.edu
Research Objective: Practice-based research networks
(PBRNs) are a potential resource for performing relevant
research in real-world settings and translating research into
everyday practice. Our objective is to describe the universe of
primary care PBRNs in the U.S.
Study Design: Using data collected from a Web-based survey
and structured interviews with PBRN directors, we assessed
PBRNs' history, size, location, organization, resources, and
operations.
Population Studied: 111 PBRNs composed of primary care
practices that aim to perform research and/or translate
research into practice were identified through AHRQ'S PBRN
initiative, the Robert Wood Johnson Foundation's Prescription
for Health program, or through membership in the Federation
of PBRNs.
Principal Findings: 84 (76%) of the 111 PBRNs completed the
survey between May and December of 2003. They contain
2724 practices in 44 states and Puerto Rico caring for more
than 16 million patients, an average of 198,112 patients per
PBRN (range 1200 to 2.7 million). Of the 32 PBRNs with
practices in a single primary care specialty, 17 (53%) are family
medicine, 10 (31%) pediatrics, and 1 (3%) general internal
medicine [GIM]. Of the remaining 52 (62%) with multiple
specialties, 51 (98%) had family medicine practices, 39 (75%)
pediatrics, and 37 (71%) GIM. PBRN patients tend to be
young, 38% are under the age of 18, while only 18% are over
60; 60% of patients are white, 22% black, and 18% other
races; 18% are Hispanic. Insurance coverage is 45% private,
42% state/federal, and 13% self-pay. The majority of PBRNs
(76%) are affiliated with academic medical centers while 7%
are affiliated with professional societies. The average PBRN
has been operational for just over four years, with a range of
six months to 32 years. A quarter have completed no studies,
while nearly half have completed 4 or more. Research is both
descriptive (of populations 57%, diseases or treatments 54%,
and individual patients 27%), and interventional (28%). The
mean number of patients included per study is 1775 (median
888, range 16-20,000). Common research foci of the PBRN
include prevention (49%), diabetes (37%), cardiovascular risk
(31%), mental health (27%), and cancer (19%). The PBRNs
cite funding, community involvement and informatics as areas
for improvement, and research experience and administration
as strengths.
Conclusions: Primary care PBRNs are large and numerous,
but young. Minority and under-insured patients are overrepresented. Despite being "practice based," most have ties to
academia. Many PBRNs have performed large studies of
common primary care issues, and those that have not are in
the process of building the infrastructure to do so.
Implications for Policy, Delivery or Practice: PBRNs are a
potentially rich national resource for innovative, communitybased research. PBRNs have the ability to effectively access
patient populations, including members of ethnic and racial
minorities as well as underserved and urban populations,
which are more diverse and geographically representative than
individual clinician practices and/or academic medical
centers. Gaining stable funding and research experience is the
key to their sustainability.
Primary Funding Source: AHRQ
• Comparison of Utilization between Academic and
Community IPAs
Chih-Wen Pai, Ph.D.
Presented by: Chih-Wen Pai, Ph.D., Senior Research
Associate, Medical School, University of Michigan, M7325B
Medical Science Building I, Box 0624, Ann Arbor, MI 48109;
Tel: 734.615.7041; Fax: 734.615.5154; E-mail: cwpai@umich.edu
Research Objective: To compare between the academic and
community individual practice associations (IPAs) the
observed utilization and utilization adjusted for case mix and
practice pattern.
Study Design: A standardized fee schedule was used to
estimate all health care use in one common monetary unit,
including inpatient and outpatient services as well as
pharmacy and ancillary uses. Classification of case mix was
measured based on sex, 15 age groups, and the Adjusted
Clinical Group (ACG) Assessment System. Direct and indirect
standardization methods were used to adjust for the
difference in case mix and practice pattern.
Population Studied: Study population was commercial
members in one managed care organization (MCO) in
southeast Michigan. The MCO has contracts with one
academic medical group and several community IPAs. Only
those continuously enrolled in their respective IPAs for the
entire 12 months of 2001 were included for analysis.
Principal Findings: Regression modeling revealed that sex, 15
age groups, and ACGs together explained about 45% of the
variance in the utilization, or 88% in the logarithm of the
utilization. Compared to the Community IPA, the Academic
IPA had higher observed utilization by $372 (per member per
year, PMPY). To control for the difference in practice pattern,
utilization of both IPAs was standardized to the same set of
utilization pattern stratified by sex, 15 age groups, and ACGs,
resulting in the Academic IPA having higher adjusted
utilization by $140 due to the difference in case mix. Similarly,
if the population structure of both IPAs was standardized to
the same demographic structure of a standard population, the
adjusted utilization of the Academic IPA was higher than its
counterpart by $229 due to the difference in practice pattern.
Results from random sampling matched by the same case mix
classification indicated that the Academic IPA had higher
PMPY utilization by $362.
Conclusions: Demographic factors and ACGs are effective
case mix adjustors for total health care utilization. Both the
higher case mix and more lavish utilization pattern
contributed to the higher observed utilization at the Academic
IPA, with practice style serving a major factor.
Implications for Policy, Delivery or Practice: These results
support the long speculated argument that the academic
providers serve sicker patients and use more resources for the
same case-mix patients than the community providers.
Higher utilization does not necessarily imply over-utilization,
since the appropriateness of care results in better quality of
care and better health status, which might not be measurable
in the short run. It is not clear how higher the utilization by
the academic providers is justifiable for the higher quality of
care, if the academic providers do offer better care. With
missions of research and education at the academic IPAs, one
may argue if the academic providers should be held at the
same efficiency benchmark as their community counterparts,
or how much more the society as a whole is willing to pay in
order to support advancing medicine and training future
providers.
• Issues and Barriers to More Effective Measurement of
Quality of Care for Persons with Cancer
Philip Renner, M.B.A., Joachim Roski, M.P.H., Ph.D, Angeline
Carlson, Ph.D., L. Gregory Pawlson, M.D. M.P.H.
Presented by: Philip Renner, M.B.A., Director, Measures
Development, Performance Measure Development, National
Committee for Quality Assurance, 2000 L Street, N.W.,
Washington, DC 20036; Tel: 202.955.5192; Fax: 202.955.3599;
E-mail: renner@ncqa.org
Research Objective: Over the last decade there has been
growing interest among a variety of stakeholders in assessing
the outcomes or results of medical care. Treatment of patients
with cancer has been challenged by the same influences that
have stimulated this same broad interest. Among these are
the awareness of practice variation; the increased recognition
of the patient’s role in decision making; acknowledgement
that treatment decisions in oncology must be balanced
against the desire to prolong life and the need for a decent
quality of life in that process; growing pressure for cost
containment; and concern among the public, providers and
policymakers that efforts to control spending may result in
decreases in quality of care.
Study Design: A two-dimensional framework for measuring
quality of care in cancer was developed. The first dimension
spans the type of care being measured, which includes sitespecific technical clinical quality, clinical measures that can be
applied across sites, and experience of care measurement.
The second dimension consists of levels of the health system
against which measures can be applied. Barriers to
developing and implementing quality measures analyzed
within this framework, using the criteria of meaningfulness,
scientific soundness, and feasibility.
Population Studied:
Principal Findings: Development of quality measures in
cancer care is challenged by a number of factors, including the
lack of an accountable delivery system, the heterogeneity of
cancer treatment, the fragmentation of cancer care across
providers and settings, incomplete or fragmented data
sources, and the lack of broadly accepted evidence-based
guidelines for cancer treatment. In commercial health plans,
prevalence of the four most frequent cancers is 96.3 cases per
100,000 population, and 157.9/100,000 in Medicare plans.
The median commercial health plan would see only 90 cases
of breast, prostate, lung, and colorectal cancer in a year, while
the median Medicare plan sees 24 per year.
Conclusions: Methodological and logistical problems make
quality of care measures in oncology a difficult area for quality
measurement. However balancing this difficulty is the high
impact and importance of care for cancer patients as an
indicator of quality of care, and the opportunity for
development of quality measures to facilitate quality
improvement. The difficulties suggest an approach that relies
on incremental steps, focused 1) on the development of
measures in areas where there is some existing consensus,
and 2) further research into methods of data collection to
improve the relevance, completeness, and timeliness of
treatment data.
Implications for Policy, Delivery or Practice: There is a
growing concern among purchasers, payers, regulators, and
consumers regarding the lack of standardized quality data in
cancer care. Creative solutions will be required to develop and
report meaningful, reliable quality measures for the
assessment of cancer care delivered to people in the United
States.
• Roles of Adult Primary Care and Obstetrics/Gynecology
Practices In Providing Gynecologic Care to Women in a
Managed Care Organization
Douglas Roblin, Ph.D., Melissa Roberts, M.S.
Presented by: Douglas Roblin, Ph.D., Research Scientist,
Research Department, Kaiser Permanente Georgia, 3495
Piedmont Road, N.E., Building 9, Atlanta, GA 30305; Tel:
404.364.4805; Fax: 404.364.4798; E-mail:
Douglas.Roblin@KP.Org
Research Objective: In many managed care organizations
(MCOs), women may obtain their gynecologic care from
either an adult primary care (APC) or an obstetrics/gynecology
(Ob/Gyn) practice. We analyzed a multi-year dataset from a
mid-sized MCO to ascertain if patient characteristics or prior
visit experience were associated with women obtaining
gynecologic care in APC or Ob/Gyn.
Study Design: Retrospective observational study.
Membership, visit, chronic disease history, and patient
satisfaction survey records for 1997 through 2000 were
obtained from the MCO computerized databases. Logistic
regression was used to model the likelihood that an APC
practice (vs. Ob/Gyn practice) provided a gynecologic visit as
a function of patient characteristics (age, chronic disease
status) and care experience in the prior 12-months. In the
entire 4-year dataset (460,173 person-years), care experience
was defined by department of service (APC or Ob/Gyn) and
type of visit (general medical, gynecologic, obstetric). For the
subset of records (N=4,930) with a completed patient
satisfaction survey on a prior gynecologic visit, care experience
was defined by satisfaction with care (practitioner interaction,
case access, overall experience) by department of service.
Population Studied: 140,299 women at least 19 years of age
who were provided either general medical care or gynecologic
care on at least one visit to the 16 APC or 9 Ob/Gyn practices
of this MCO.
Principal Findings: From 1997-2000, between 20% and 26%
of women per year obtained gynecologic care from an APC
practice. Women who had an obstetric visit in the prior 12months, a gynecologic visit in Ob/Gyn only, or a general
medical visit in Ob/Gyn were significantly (p<0.01) less likely
to obtain a subsequent gynecologic visit in an APC practice
than an Ob/Gyn practice. On the other hand, women who
had a gynecologic visit only in an APC practice, who were 55
years of age or older, or who had a pre-existing chronic
disease were significantly more likely to obtain a subsequent
gynecologic visit in an APC practice than an Ob/Gyn practice.
High levels of satisfaction with practitioner interaction as well
as overall experience on an Ob/Gyn practice visit significantly
(p<0.01) decreased the likelihood that a woman obtained a
subsequent visit for gynecologic care in an APC practice.
Conclusions: In an MCO where women have a choice of
obtaining care from an APC or Ob/Gyn practice, prior
experience on a visit for gynecologic care in Ob/Gyn – notably
higher satisfaction with care from Ob/Gyn – shifts gynecologic
care to Ob/Gyn practices from APC practices. On the other
hand, gynecologic care shifts from Ob/Gyn practices to APC
practices among women with medical needs (older age,
chronic disease) typically attended by family practice or
internal medicine physicians.
Implications for Policy, Delivery or Practice: Where women
choose to obtain their gynecologic care has implications for
allocation of resources to APC and Ob/Gyn practices. In
capitated practices, adjustment for age, chronic disease, and
prior distribution of gynecologic visits may be warranted.
Primary Funding Source: Garfield Memorial Fund
• Health Promoting Behaviors of Emergency Room
Doctors: What is the Role of Physician Attitude?
Kent Rondeau, Ph.D., Louis Francescutti, M.D., Ph.D., M.P.H.
Presented by: Kent Rondeau, Ph.D., Associate Professor,
Public Health Sciences, University of Alberta, 13-126H Clinical
Sciences Building, Edmonton, Alberta, T6M1W7; Tel:
780.492.8608; Fax: 780.492.0364; E-mail:
kent.rondeau@ualberta.ca
Research Objective: This study reports on the health
promotion and disease prevention attitudes and behaviors of
a large sample of Canadian emergency room physicians. Its
objective is to assess the contribution of physician attitude
towards explaining physician health promotion and disease
prevention behaviors.
Study Design: A number of attitudinal components can be
identified that might explain health promoting and disease
preventing behaviors in emergency physicians. Attitudinal
components were investigated because they have the potential
to impact physician behaviors. These attitudinal components
include: a) general assessment of the utility of health
promotion in the practice of medicine (5-item measure); b)
assessment of the utility of health promotion in the
emergency setting (3-item measure); c) physician knowledge
of health promotion practice (9-item measure); d) physician
assessment of their responsibility for health promotion
practice (15-items); as well as e) physician-patient
commitment scale (8-items) and physician extra-role behavior
scale (4-items). Three physician health promoting / disease
preventing behaviors investigated including an assessment of:
a) physician screening behavior (12-items); b) physician
counseling behavior (10-items); and c) treatment behaviors (5items). It was hypothesized that many health
promoting/disease preventing behavioral modalities are
somewhat extra-role functions in an emergency room setting,
but when present would be strongly mediated by physician
attitude about health promotion and disease prevention.
Population Studied: In 2001, a survey questionnaire was sent
to one thousand five hundred (1500) Canadian emergency
physicians. The study database was provided by the Canadian
Emergency Physicians Association (CAEP) and is drawn from
all Canadian provinces and territories. In total, 428 usable
questionnaires were returned, and with 66 returned
undeliverable, produced a response rate of 29.8 percent.
Principal Findings: Multivariate estimations of physician
attitudinal components were conducted on physician health
promoting / disease prevention (screening, counseling, and
treatment) behaviors serving as dependent variables. Control
variables entered into each estimation included both physician
characteristics (gender, age, educational background) as well
as emergency room and institutional characteristics (size,
location, workflow).
Conclusions: Different attitudinal factors are associated with
health promoting / disease preventing screening, counseling,
and treatment behaviors. Our model best explained physician
counseling behaviors, somewhat strongly explains physician
screening behaviours, but only weakly explains physician
treatment behaviors. Physician counseling modalities for
health promotion is strongly predicted by physician attitude
and knowledge of health promotion practice as well as their
extra-role behavior. Screening modalities are somewhat
predicted by physician attitude and knowledge of health
promotion practice as well as their relative level of
commitment to their patients. Disease preventing treatment
modalities are not significantly related to physician attitude or
knowledge about health promotion in general or in the
emergency setting, but are found to be strongly to physician
extra-role behavior.
Implications for Policy, Delivery or Practice: Increasing the
frequency of health promotion and disease prevention
interventions by emergency room physicians will require
efforts aimed at facilitating physician knowledge and attitude
about the utility of health promotion / disease prevention in
the emergency room. Although emergency physicians
strongly believe in the potency of health promoting / disease
preventing interventions, far fewer believe such interventions
are appropriate in the emergency setting.
Primary Funding Source: Royal Alexandra Hospital
Emergency Physicians Group, Edmonton, Alberta, Canada
• The Effect of Financial Incentives on Physician Behavior
and Physician Groups
Dov Rothman, Ph.D.
Presented by: Dov Rothman, Ph.D., Assistant Professor,
Department of Health Policy and Management, Columbia
University, 600 West 168th Street, 6th Floor, New York, NY
10032; Tel: 212.342.4521; E-mail: dbr2104@columbia.edu
Research Objective: In this paper I investigate whether and
how individual physicians respond to financial incentives, and
whether and how the incentives provided to one set of
physicians in an organization affect the behavior of other
physicians in the organization.
Study Design: I use encounter-level claims data from
approximately 300 physicians employed by an IPA. These
data cover the period January 2001 to August 2003. Prior to
November 2002, IPA paid its specialists in different ways.
Some were entirely fee-for-service, some were capitated and
had a relatively large number of fee-for-service carveouts in
their employment contracts, and some were capitated and
had no fee-for-service carveouts. On November 1 2002, IPA
converted all specialists to all fee-for-service.
The "effective" change in incentives was larger for capitated
specialists who had relatively few fee-for-service carveouts
prior to November 2002, and smaller for specialists who had
relatively more fee-for-service carveouts or were already
entirely fee-for-service. I use this variation to estimate
whether and how converting physicians to fee-for-service
affected: (1) the average amount billed per month per
physician, (2) the average number of encounters billed per
month per physician, (3) the average amount billed per
encounter per physician, (4) the average number of
procedures billed per encounter per physician, and (5) the
average cost per procedure billed per encounter per physician.
Population Studied: Physicians employed by an IPA located
in a large metropolitan area in the United States.
Principal Findings: I find that the change from capitation to
fee-for-service was associated with an increase of about 10
percent in the average amount billed per month, and that this
increase was due mostly to an increase in the number of
encounters billed per month - not to an increase in the
number of procedures billed per encounter or to a shift toward
more expensive procedures. In addition, I find that over the
same period, IPA’s primary care physicians – who were
capitated throughout the entire period of study - decreased the
average number of encounters billed per month.
Conclusions: Physicians converted to fee-for-service increased
the number of patient encounters per month, but did not
increase the number of procedures billed per encounter or
increase the use of more expensive procedures. At the same
time, converting specialists to fee-for-service led primary care
physicians to reduce the number of patients they saw and to
increase the number of referrals to specialists. In future
research, I plan to examine whether greater access to
specialists affected patient outcomes.
Implications for Policy, Delivery or Practice: Compensation
decisions within a health service organization are interdependent. Changing the financial incentives of one set of
physicians directly affects their behavior, and can indirectly
affect the behavior of other physicians in the organization.
Giving specialists stronger incentives to see more patients can
implicitly give (capitated) primary care physicians stronger
incentives to see fewer patients. A health services
organization should consider how the incentives of one set of
physicians indirectly affect other physicians in the
organization.
• Complex Adaptive System Behavior and Healthcare
Expenditures: Evidence and Implications
Randall Rupper, M.D., M.P.H.
Presented by: Randall Rupper, M.D., M.P.H., physician
investigator, Internal Medicine, Salt Lake City VA Healthcare
System and University of Utah School of Medicine, GRECC,
Building 2, 182, Salt Lake VA Healthcare System, 500 Foothill
Boulevard, Salt Lake City, UT 84148; Tel: 801.582.1565 Ext.
2456; Fax: 801.584.5640; E-mail: randall.rupper@hsc.utah.edu
Research Objective: For decades, five percent of the
population consistently accounts for the majority of health
care expenditures. The persistence of this distribution of
resource use across populations, episodes of care, and
decades of time in spite of vast changes in the organizational
structure and financing of health care delivery is not well
understood. This study calls upon recent advances in the
science of complex organizations to suggest an explanatory
model of health care resource utilization. The magnitude and
frequency of national healthcare expenditures were examined
for power-law behavior to provide quantitative support for the
notion that our healthcare system can be defined as a complex
adaptive system. This hypothesis was also tested for the
distribution of outpatient healthcare expenditures associated
with episodes of low-back pain occurring in a limited
geographic area.
Study Design: Annual total medical charges from the 1998
Medical Expenditure Panel Survey provided a nationally
representative sample of households and individuals. In order
to obtain the population frequencies of similar expenditure
levels, expenditures were rounded to the nearest 0.1 log.
Sample weights were incorporated to allow extrapolation to
the entire U.S. population. Those individuals with
expenditures less than 500 dollars were excluded from further
analysis, consistent with past economic studies using powerlaw models, leaving a sample of 10,092 individuals. The
number of participants in each grouping and the average
charges for each grouping were then calculated and plotted on
a log-log plot. Least squares regression determined the bestfit line, and Pearson’s correlation coefficient tested goodness
of fit. A parallel analysis was then conducted using twenty-four
week outpatient charge estimates associated with 1575 acute
episodes of low back pain collected during a similar historical
period. This analysis tested the hypothesis that charges for a
single episode of illness would be similarly distributed to the
annual national expenditures.
Population Studied: 1)1998 U.S. Population
2) Participants in the North Carolina Back Pain Project
Principal Findings: The logged frequency and average
amount of annual health care expenditures fit an inversely
proportional line of slope .92, with a Pearson correlation
coefficient of .96 (p<.001). For an outpatient episode of low
back pain, the log frequencies and charges are similar with a
slope of 1.18, and a Pearson correlation coefficient of .92 (p
<.001).
Conclusions: The presence of power-law behavior that scales
across multiple expenditure distributions may help to explain
the persistence of these distributions across time and
organizational structures. These features are typical of
systems displaying complex adaptive behavior.
Implications for Policy, Delivery or Practice: Recognizing
complex adaptive behavior in healthcare systems is crucial
because unique strategies are required to successfully effect
organizational change in such systems. Non-linear
interactions between components of the system threaten
unintended consequences from attempts to define
mechanistic rules to match their organizational complexity.
However, these systems can undergo remarkable evolution in
the presence of even simple rules. Decentralized, networked
organizations are ideally designed to propagate reforms, but
financing mechanisms must give incentives to encourage the
survival of successful changes. Because these systems have
properties that are more than the sum of their parts, attempts
to focus change at the individual rather than system level are
often counter-productive.
Primary Funding Source: RWJF
• Does the Squeaky Wheel Get the Oil? Analyzing the
Relationship Between Organizational Performance and
Case Mix Severity in the VA System
John Schneider, Ph.D., Lewis Kazis, ScD, Yu-Hui Huang,
M.P.H., Jon Yankey, M.S., Thomas Vaughn, Ph.D., Bradley
Doebbeling, M.D., M.S.
Presented by: John Schneider, Ph.D., Assistant Professor,
Health Management & Policy, University of Iowa, 200
Hawkins Drive, E204 GH, Iowa City, IA 52242; Tel:
319.384.5133; Fax: 319.384.5125; E-mail: johnschneider@uiowa.edu
Research Objective: We compare the effects of two different
VA Medical Center (VAMC) summary performance measures
on the SF-36 summary scores of patients treated at VAMCs,
controlling for differences in patient and facility characteristics.
Study Design: Diagnosis data were linked to the Large
Veterans Health Survey (n = 824,263) and merged with facilitylevel benchmarking data based on the External Peer Review
Program (EPRP) and the Veterans Health Survey (VHS). EPRP
is based on chart review of chronic disease quality measures
and VHS assesses preventive measures for a random sample
of primary care patients; both indicators measure adherence
to evidence-based practices (higher is better). Descriptive and
multivariable models were estimated to identify variables
associated with SF-36 summary scores.
Population Studied: VA Patients and VA medical centers
Principal Findings: In 1998, patients treated in VAMCs
characterized by higher EPRP scores had SF-36 physical
component scores 3.4 points lower, whereas those treated in
VAMCs characterized by higher VHS scores had physical
summary scores 0.80 points higher (p = 0.01). In 1999, both
the EPRP and VHS effects were negative but smaller in
magnitude (1.70 and 0.44 points, respectively; p = 0.01).
Conclusions: (1) There is a significant relationship between
facility performance scores and patient case mix; and (2) the
direction of the relationship differs according to the underlying
methodology and content of the performance measure.
Implications for Policy, Delivery or Practice: Understanding
the complexities of the relationship between organizational
performance and case mix severity is critical to the success of
efforts to enhance quality.
Primary Funding Source: VA
the clinic. Data used in the model were from the published
literature but any local data can be used.
Population Studied: asymptomatic women for sexually
transmitted diseases aged > 15 years who visited public-sector
family planning clinics
Principal Findings: The optimal screening and treatment
strategy for CT and NG varied with CT prevalence, NG
prevalence, and CT-NG co-infection rates and program
budget. CT screening is cost-saving when CT prevalence
exceeds 3.4%, while NG screening is cost-saving when NG
prevalence exceeds 2.9%. At CT prevalence of 5.0%, NG
prevalence of 1.0%, and no budget constraint, the optimal
cost-saving strategy was screening and treating all eligible
women for CT, and presumptively treating those with positive
CT tests for NG. Sensitivity analysis showed the optimal
strategy was strongly influenced by test cost but not treatment
cost.
Conclusions: Optimal strategies for CT and NG were highly
dependent on CT and NG prevalence and CT-NG co-infection
rates, suggesting that screening and treatment should be
targeted to populations at high risk for these infections. In
addition, the result that the optimal strategy was strongly
influenced by test cost but not treatment cost suggested that a
more optimal screening and treatment program can be
achieved by negotiating lower test costs.
Implications for Policy, Delivery or Practice: This binary
programming model provides a flexible, customizable tool for
programs to identify the screening and treatment strategy for
CT and NG that maximizes use of prevention resources. It
can be applied to other preventive and therapeutic services.
• A Customizable Decision-Making Tool to Optimize
Health Resource: The Example of Screening and Treating
Asymptomatic Women for Sexually Transmitted Diseases
Guoyu Tao, Ph.D., B. Abban, M.Sc., T. Gift, Ph.D., K. Irwin,
M.D.
• HEDIS Measure for Screening for Chlamydia
Trachomatis Infection in Reproductive-Age Women
Insured by Managed Care Organizations: Trends and
Associations
Guoyu Tao, Ph.D., C. Walsh, Ph.D., T. Chorba, M.D., K. Irwin,
M.D.
Presented by: Guoyu Tao, Ph.D., Health Scientist, Division of
STD, CDC, 1600 Clifton Rd,. MS-E80, Atlanta, GA 30333; Tel:
404.639.8180; Fax: 404.639.8607; E-mail: gat3@cdc.gov
Research Objective: Disparities in the prevalence of
Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG)
infection among different populations and the many available
screening tests and treatments, make it complex to select the
optimal CT or NG screening and treatment strategy for
asymptomatic women. The goal of this study is to apply a
binary programming model that would determine the optimal
screening and treatment strategy for CT and NG in a publicsector family planning facility.
Study Design: Several scenarios were considered for CT and
NG screening and treatments, including scenarios in which
patients who tested positive and were treated for one
pathogen were also presumptively treated for the other
pathogen. We developed a binary programming model to
define the optimal strategy in which the combination of
infections screened for, age groups screened, tests, and
treatments administered would maximize cost-savings. A
cost-saving program was classified as one in which the cost of
treating sequelae of CT and NG infection that would be
averted by screening and treatment was greater than the cost
of screening and treating all eligible women for CT and NG in
Presented by: Guoyu Tao, Ph.D., Health Scientist, Division of
STD, CDC, 1600 Clifton RD, MS-E80, Atlanta, GA 30333; Tel:
404.639.8180; Fax: 404.639.8607; E-mail: gat3@cdc.gov
Research Objective: In 2000, screening sexually active
adolescents and young women for Chlamydia trachomatis
(CT) was included in the Health Plan Employer Data and
Information Set (HEDIS) used by the National Committee for
Quality Assurance (NCQA) to improve performance of health
plans. The objective of this study is to estimate rates of sexual
activity and CT screening of sexually active women aged 16 to
26 years enrolled in health plans, and to determine screening
rates by plan type, region, accreditation status, and history of
publicly reporting CT screening rates.
Study Design: We analyzed HEDIS data from 337 commercial
and Medicaid health plans for trends in sexual activity and CT
screening of sexually active young women who were
continuously enrolled for at least one calendar year during
2000 to 2002.
Population Studied: women aged 15-25 years who were
served by managed care organizations.
Principal Findings: From 2000 to 2002, percents of enrollees
aged 16-20 years who were identified as sexually active
increased from 26% to 29%. Percents of enrollees aged 21-26
years who were identified as sexually active increased from
36% to 43% for commercially-insured enrollees, and from 37%
to 40% for Medicaid enrollees. CT screening rates of sexually
active women increased from 2000 to 2002: from 20% to
27% in commercially-insured enrollees, and from 28% to 38%
in Medicaid enrollees. Commercially-insured women aged 1626 were more likely to receive screening if enrolled in plans
accredited by NCQA, classified as health maintenance
organization (HMO) or point-of-service (POS) rather than
mixed-model (HMO/POS), or located in the Pacific region
rather than elsewhere.
Conclusions: Although screening rates remain low, small
increases in CT screening rates were seen from 2000 to 2002.
Differences in screening rates by plan characteristics suggest
that system-level factors may influence screening practices.
Implications for Policy, Delivery or Practice: CT screening
rates lag far behind rates of other preventive services for
women, such as breast and cervical cancer screening. An
understanding of health plan factors or initiatives that foster
CT screening is needed to increase screening of eligible
women.
Primary Funding Source: CDC
• Predictors of Primary Care Clinics' Willingness to Treat
Opioid Dependence
Barbara Turner, M.D., M.S.Ed., Kevin Lynch, Ph.D.
Presented by: Barbara Turner, M.D., M.S.Ed., Professor of
Medicine, University of Pennsylvania, 1123 Blockley Hall, 423
Guardian Drive, Philadelphia, PA 19104-6021; Tel:
215.898.2022; Fax: 215.573.8779; E-mail:
bturner@mail.med.upenn.edu
Research Objective: New federal initiatives attempt to
promote longterm primary care office-based management of
stabilized drug users. We assessed the willingness of a New
York statewide sample of primary care clinics to manage
opioid dependent patients with buprenorphine (BUP) or
methadone (METH) and predictors of willingness.
Study Design: Telephone and mail survey of primary care
clinic directors from 6/03-9/03. Survey addressed barriers and
facilitators to managing drug users with BUP or METH and
attitudes towards treating drug users. Predictors were
identified from stepwise ordinal logistic regression.
Population Studied: Of clinics with a primary care specialty
treating >=20 patients in 2000 based on NYS Medicaid
administrative data, we randomly selected 450 of which 405
were verified as delivering primary care services.
Principal Findings: We received 260 responses (64%) of
which 249 were complete. Few clinics were somewhat or very
willing to prescribe METH (33%) but more somewhat or very
willing to be trained to prescribe BUP (61%). 63% wanted
immediate phone access to an addiction expert and 69%
wanted to share care with an addication expert. Increased
adjusted odds of METH willingness was found for: clinics with
an HIV focus (2.27, CI 1.28, 4.02), belief that METH is well
tolerated (7.58, CI 2.20, 26.05), belief that drug users want
METH with primary care (3.80, CI 1.44, 10.04), and academic
affiliation (1.86, CI 1.06, 3.29). Predictors of willingness to
train to prescribe BUP were HIV focus (1.80, CI 1.01, 3.21) and
belief that: BUP is very valuable to treat opioid abuse (5.54, CI
2.74, 11.20), CME is very important for BUP training (2.03, CI
1.12, 3.67), and most clinic physicians think BUP prescribing is
good idea (7.54, 3.56, 15.95).
Conclusions: Over half of these primary care clinics were
willing to train to prescribe BUP while few would prescribe
METH. Willingness to train to use BUP was greater for clinics
with HIV specialists and positive attitudes about BUP. CME
credits appear to increase willingness to train to use BUP.
Implications for Policy, Delivery or Practice: Based on these
data: policymakers should: 1)promote BUP as the primary
mode of drug treatment in primary care clinics; 2) target BUP
training to clinics with an HIV focus; and 3) provide CME for
training and ready access to addiction experts.
Primary Funding Source: RWJF
Invited Papers
Evidence-Based Management: Translating Research into
Practice
Chair: Thomas Rundall, Ph.D.
Sunday, June 6 • 3:00 p.m.-4:30 p.m.
•
Panelists: Huw Davies, University of St. Andrews; JeanLouis Denis, University of Montreal; Jean Slutsky, Agency
for Healthcare Research and Quality (no abstracts
provided)