General Posters
General Posters
Poster Session B
Monday, June 27 • 6:15 pm – 7:30 pm
●Use of Immunization Registry Data to Evaluate Provider
Compliance with Recommendations for Pneumococcal
Conjugate Vaccine Conservation During the 2004
Shortage
Norma Allred, MSN, Ph.D., Abigail Shefer, M.D., John
Stevenson, MA, Maureen Kolasa, MPH, Richard Schieber,
M.D., MPH, Kyle Enger, MPH
Presented By: Norma Allred, MSN, Ph.D., Epidemiologist,
National Immunization Program, Centers for Disease Control
and Prevention, 1600 Clifton Road, NE, MS-E52, Atlanta, GA
30076; Tel: (404)639-8722; Fax: (404)639-8614; Email:
NAllred@cdc.gov
Research Objective: To evaluate the usefulness of
immunization registry data to monitor provider compliance
with CDC recommendations for conservation of
pneumococcal conjugate vaccine (PCV) during the 2004
vaccine shortage.
Study Design: We used registry data from the Michigan Child
Immunization Registry (MCIR) to evaluate changes in third
and fourth dose PCV coverage in Michigan. Data for
individual immunization records were obtained for a cohort of
children enrolled in MCIR as of February 29, 2004.
Vaccination data were collected through July 2004. The
proportion of children who received DTaP3 and PCV3 at seven
months of age was calculated for each birth month. The
proportion who received MMR1 and PCV4 at sixteen months
of age was also calculated. DTaP3 and MMR1 vaccine
coverage was used for comparison as these vaccines were not
in short supply during this time period and they are given at
the same ages as PCV3 and PCV4, respectively. Coverage
rates were compared between public and private providers
and by practice specialty.
Population Studied: All children born between January 1,
2000 and February 29, 2004 were eligible for inclusion in the
study. Over 600,000 children had at least one shot record
and were included in the analysis. All public providers and
74% of private providers in Michigan supply vaccination data
to the registry.
Principal Findings: As of July 2004, 597,000 (94%) of
600,826 children in the registry had at least one shot record.
Coverage for DTaP3 and MMR1 remained steady while PCV
coverage declined at each time point when recommendations
were announced. The sharpest decline was observed for PCV
3 at seven months of age when coverage dropped from 28%
to 10% when recommendations to withhold the third dose
were announced in March 2004. PCV coverage trends were
similar for public and private providers as well as for
pediatricians and family practitioners.
Conclusions: Michigan immunization providers appear to be
complying with CDC recommendations for PCV
administration during the vaccine shortage. However, it is
unknown if the third and fourth doses of PCV were not given
by providers due to a shortage of vaccine or due to adherence
to the guidelines. Additional information on variability of
vaccine supply at the individual provider level would be
needed to answer this question.
Implications for Policy, Delivery, or Practice: Immunization
registries can be useful in evaluating vaccination coverage
trends during a vaccine shortage. These data may also be
used to determine the extent to which children who had doses
withheld during a shortage received those doses at a later
date.
Primary Funding Source: CDC
●Extending a Broken Chain? The Continuum of Care
Implications of Rural Hospital Safety Problems
Joseph Angelelli, Ph.D., Mary Fennell, Ph.D., Vincent Mor,
Ph.D., Dequan Jiao
Presented By: Joseph Angelelli, Ph.D., Assistant Professor,
Health Policy & Administration, Penn State, 116 Henderson,
University Park, PA 16802; Tel: (814)865-5177; Email:
jangel@psu.edu
Research Objective: To examine the relationship between the
pressure ulcer (PU) rates of rural hospitals and the PU rates of
nursing homes that admit patients discharged from those
hospitals.
Study Design: The four most discharged to nursing homes
for each of 440 rural hospitals were identified via matched
Medicare claims from the year 2000. The AHRQ pressure
ulcer prevalence was computed for each hospital based on
discharge claims. Two independent measures of PU
prevalence for each nursing home were obtained via the CMS
Nursing Home Compare site (admission PU prevalence) and
the Online Survey Certification and Reporting (OSCAR) survey
(PU prevalence that includes long-stay residents). Logistic
regression models were used to examine the effect of being in
the worst performing quartile of rural hospitals on the odds of
having a referral relationship with a nursing home in the worst
quartile of PU performance.
Population Studied: Medicare beneficiaries over age 65
discharged from a nationally representative sample of 440
rural hospitals in the year 2000.
Principal Findings: For every 1% increase in a hospital's
pressure ulcer rate, the odds of that hospital having a low
quality NH partner as measured by admission PU prevalence
increase 9%. For every 1% increase in a hospital's pressure
ulcer rate, the odds of that hospital having a low quality NH
partner as measured by OSCAR PU prevalence increase 13%.
Conclusions: Patient safety problems in rural hospitals have
"downstream" implications for quality of care problems
commonly observed in settings further along the continuum
of care.
Implications for Policy, Delivery, or Practice: These findings
highlight the need for hospitals to devote more attention and
resources to inter-organizational relationships as they attempt
to "extend the chain" and improve the transition from acute to
post-acute care.
Primary Funding Source: NIA
●A Social Indicator Methodology for Estimating Need for
Substance Abuse Treatment Services
Hermik Babakhanlou-Chase, MPH, William E. McAuliffe,
Ph.D., Teresa E. Anderson, Ph.D.
Presented By: Hermik Babakhanlou-Chase, MPH,
Epidemiologist, Department of Public Health, Executive Office
of Health and Human Services, 250 Washington Street,
Boston, MA 02108; Tel: (617) 624-5170; Email:
Hermik.Babakhanlou-Chase@state.ma.us
Research Objective: The Social Indicator Study developed
indexes of the level of drug, alcohol, and substance abuse
treatment need in 1997-2001 among Massachusetts’s
community network areas (CHNAs). The analysis used the
indexes to assess existing gaps in the utilization of treatment
services relative to needs.
Study Design: The study focused on indicators of serious
substance-use disorders rather than on indicators of casual
use of alcohol or controlled drugs. Using data obtained from
state and federal agencies, the need indicators were mean
rates of drug and alcohol related mortality, hospital
discharges, and arrests. The dependent variable was treatment
admission rates.
Population Studied: The population is the entire state
population from 1997-2001.
Principal Findings: The psychometric analysis of the
indicators found that overall they possessed good reliability
and validity. Cronbach’s alpha reliability estimates were .99 for
treatment admission rates, between .86 and .91 for the
mortality rates, and between .95 and .98 for the hospital
discharge rates. The arrest rates obtained from the Federal
Bureau of Investigation (FBI) had missing data, especially
small towns but also in some larger cities. The study imputed
missing data, but as a result could not assess the reliability of
the arrest indicators. The drug indicators had clear evidence of
convergent and discriminate validity. There was good evidence
of convergent validity for the alcohol mortality and hospital
discharge rates, but such evidence was limited for the alcohol
(driving under the influence) arrest rates. Despite the
limitations of the alcohol arrest rates, the alcohol need index
performed better with the arrest variable included. The Drug
Need Index (DNI), the Alcohol Need Index (ANI), and the
Substance Abuse Need Index (SNI) were unweighted linear
composites of standardized versions of the mortality, hospital
discharge, and arrest rates. The Cronbach’s alpha estimates of
the reliability for the DNI was .86, for the ANI was .58, and for
the SNI was .81. The study developed evidence of construct
validity for the DNI and to a lesser extent for the ANI.
Conclusions: The study found that there was a close match
between relative need and existing services delivered in the
CHNAs. The DNI correlated .89 with drug treatment
admission rates, the ANI correlated .79 with alcohol treatment
admission rates, and the SNI correlated .90 with substance
abuse treatment admission rates. Thus, 80% of the variance
in the average treatment admission rates for 1997-2001 was
attributable to variations in the substance abuse treatment
needs of the CHNA residents.
Implications for Policy, Delivery, or Practice: Analysis of
CHNA substance abuse treatment admission rates between
1997-2001 found that there was a six-fold difference between
the highest and lowest rates. The range was greater for drug
treatment admissions rates than for alcohol treatment
admission rates. A primary goal of the study was to determine
the extent to which these wide differences in rates reflected
differences in treatment needs or some other factor such as
differences in access to treatment.
Primary Funding Source: Massachusetts Department of
Public Health
●Deny, Delay, or Pay: Consequences of Barriers to
Coverage for Immigrant Parents Seeking Healthcare for
their Children.
Tamar Bauer, JD, Linda Weiss, Ph.D., Cayce Hill
Presented By: Tamar Bauer, JD, Director, New York Forum
for Child Health, The New York Academy of Medicine, 1216
Fifth Avenue, New York, NY 10029; Tel: (212) 822-7200; Fax:
(212) 822-7369; Email: tbauer@nyam.org
Research Objective: Medical debt and health-related financial
problems affect many Americans. For immigrant families,
these issues may be compounded by immigration status,
language proficiency and lack of familiarity with our health
care system. This study examines the causes and
consequences of health-related financial problems among
immigrant parents seeking healthcare for their children.
Study Design: We conducted 75 semi-structured interviews of
immigrant parents living in New York City, from August 2003 December 2003. Respondents were recruited using purposive
sampling through collaboration with community-based
organizations. Respondents had to be an immigrant parent
caring for a child (under age 19).
Population Studied: The population studied was Haitian,
Latino, and Russian immigrant parents and children living in
New York City. We limited our sample to children who were
uninsured at the time of the parent's interview, or publicly
insured with a period of uninsurance in the past two years.
Principal Findings: Difficulties enrolling, recertifying and
navigating public insurance, and inadequate coverage, create
financial difficulties for immigrant families. Payment issues
affected access in 67% of the families. Providers turned
children away when their parents could not provide a working
insurance card or cash in advance. Some participants delayed
bringing children to doctors or purchasing medicine during
gaps in insurance. Well-child care was often skipped because
of uninsurance. Parents cared for sick children as well as they
could, using over-the-counter medications and home
remedies. Pharmacy costs were managed by splitting
prescriptions or using leftover medications.
Rather than delay care, 49% of the parents paid cash for care
at the point of service, despite financial hardship. In some
cases, parents thought their children were insured, only to
learn they were under- or uninsured. When billed by
providers, parents felt compelled to pay, unsure whether they
would be reimbursed. These out-of-pocket funds were often
meant for other basic necessities like rent and food, and
ranged from $50 for a doctor’s visit to $10,000 in bills for a
surgery not covered by insurance. 39% of participants
currently, or recently, had unpaid medical bills. Haitians in
particular reported struggling with debt. Immigrants with
strong personal networks turned to them for financial help;
others paid by credit card, or were struggling to pay off large
bills in small monthly payments. Some providers helped
uninsured but eligible patients seek reimbursement or
accepted payment over time.
Conclusions: Barriers to coverage, and inadequate coverage,
often lead to denied or delayed health care for the children of
immigrants, or to out-of-pocket payment for their children’s
health care, threatening both the health of the children and
their parents’ financial stability. Parents frequently pay for care
with cash they can ill afford, or incur burdensome debt to
providers, on credit cards or by borrowing from family. This
debt negatively influences immigrants’ health-seeking
behavior and ability to pay for basic necessities, further
reducing their ability to care for their children's health.
Implications for Policy, Delivery, or Practice: Hardships
reported by participants underscore the difficulty of
navigating public insurance systems, and the essential role of
charity care funding streams in New York City hospitals. Such
funds should be more systemically available to patients in
need.
Primary Funding Source: Foundation for Child Development
●Gender and Race Disparities in In-Hospital Coronary
Artery Bypass Surgery Mortality Rates: 1998-2002 - Have
Things Improved?
Edmund Becker, Ph.D.
Presented By: Edmund Becker, Ph.D., Professor, Health
Policy and Management, Emory School of Public Health, 1518
Clifton Road, NE, Atlanta, GA 30322; Tel: (404) 727-9969; Fax:
(404) 727-9198; Email: ebeck01@sph.emory.edu
Research Objective: The growing scrutiny of disparities in
coronary artery bypass surgery in (CABS) in-hospital mortality
rates for the nation’s over 350,000 hospital admissions raises
questions about whether the trends persist over time after
controlling for relevant patient, clinical, hospital, and area
characteristics. We control for 41 covariates and evaluate
CABS patient in-hospital mortality rate trends by gender and
race for the 1998-2002 period.
Study Design: With in-hospital mortality as the dependent
variable, the logistic regression model controls for: patient
characteristics (gender, six age categories, patient=s race Caucasian, African American, and Asian, and insurance
coverage - Medicare, Medicaid, private, self-pay, no charge,
and other); risk factors and co-morbid conditions (smoker,
history of tobacco use, COPD, S/P CABG, S/P PTCA, insulindependent diabetes, non-insulin dependent diabetes,
conduction disorders, intracranial hemorrhage, chronic renal
failure, unspecified renal failure, cardiogenic shock,
hypertension, acute MI, old MI, cardiomyopathy, congestive
heart failure, peripheral vascular disease, unstable angina,
acute liver necrosis, endocarditis, mitral valve disease, aortic
valve disease, mitral and aortic valve disease, and chronic
hepatitis); procedure characteristics (number of vessels
bypassed, diagnostic cath, intra-aortic balloon pump,
hypothermia use, and heart pump); medications (GP2B3A and
thrombolytics); year dummies; and site characteristics
(dummy variables for each of the sites performing CABS
surgery with one site excluded). Procedures, complications,
and co-morbid conditions were identified using ICD-9 codes.
Population Studied: A total of 1,194,159 patients whose
primary procedure was a CABS graft during the years 1998
through 2002 in the Healthcare Cost and Utilization Project
(HCUP) national databases were analyzed.
Principal Findings: For the 5-year period, for all CABS
patients, unadjusted in-hospital mortality rates averaged 2.7%
but had fallen 17.1% - from 2.98% in 1998 to 2.47% in 2002.
Female in-hospital CABS mortality rates average more than
1.5% higher than male mortality rates (3.79 vs. 2.26; p<0.001).
With the exception of African-Americans, who experienced no
change in in-hospital mortality, over the 5-year period, white
in-hospital mortality declined 17.5%, Hispanics declined
30.4%, and Asian’s declined 11.9%. Multivariate results reveal
that over each successive year of the study, in-hospital
mortality rates have declined significantly for all races
although they remain higher for females and African American
patients.
Conclusions: The analysis provides evidence that U.S. gender
and race disparities in CABS in-hospital patient in-hospital
mortality appear to be declining and some of the underlying
gender and race disparities are ameliorated when other
patient comorbidities and risk factors are included. For CABS
patients, our findings suggest that gender differences both
within and across the races may be greater than the
differences among racial groups.
Implications for Policy, Delivery, or Practice: It is essential
that analyses of disparities account for the influence of other
patient characteristics and be sensitive to their interactions.
Primary Funding Source: No Funding Source
●What's Up Doc? Mixing Web and Mail Methods in a
Survey of Physicians
Timothy Beebe, Ph.D., G. Richard Locke, M.D., Sunni Barnes,
Ph.D.
Presented By: Timothy Beebe, Ph.D., Associate Professor of
Health Services Research, Department of Health Sciences
Research, Mayo Clinic, 200 First Street SW, Rochester, MN
55905; Tel: (507) 538-4606; Fax: (507) 284-1180; Email:
beebe.timothy@mayo.edu
Research Objective: To increase response rates, household
surveys often turn to mixed-mode designs whereby
instruments are designed to be administered via mail, web,
telephone, and/or in-person and respondents are allowed to
respond to the form most appropriate for them. The
application of mixed-mode designs to physician surveys
seems natural given that low response rates to single-mode
physician surveys are common. Recent evidence suggests
that one particular mode combination, mail and web, might
prove useful in extending the coverage of the survey to a
broader mix of physicians because the profile of providers
responding online was somewhat different from those
responding to a mail survey.
Study Design: The paper will present the results of an
experiment testing two different mixed-mode designs
representing two combinations of mail and web surveys. The
survey focused on physician evaluations of the Mayo
Electronic Medical Record (EMR). Physicians were randomly
assigned to receive either an initial mail survey with a web
survey follow-up to nonrespondents or its converse – an initial
web survey followed by a mailed survey to nonrespondents.
In both conditions, all physicians received a reminder one
week after the initial mailing via the medium corresponding to
the initial contact (web v. mail).
Population Studied: 500 Mayo Clinic Department of
Medicine physicians representing several specialties such as
allergic diseases, cardiovascular diseases, endocrinology,
gastroenterology, hematology, infectious diseases,
nephrology, pulmonary and critical care medicine, and
rheumatology.
Principal Findings: The data collection is on-going at the
time of the writing of this abstract. Key research questions to
be addressed in the analysis include: Can mixing mail and web
methods increase response rates among physicians? Which
of the two combinations tested proved most effective? How
does mixing modes impact the participation of different types
of physicians? What effect do the different combinations have
on the resulting evaluations of the EMR?
Conclusions: Studies that use only a single data collection
methodology may face the increased risk of skewing the
composition of the responding sample and potentially biasing
the survey findings on certain topics. For physician surveys
where a web-based method is an option, it may be best to
couple it with a mailed version to extend sample coverage.
Implications for Policy, Delivery, or Practice: Investigating
the attitudes, beliefs, behaviors, and concerns of physicians
via survey is vitally important given their role in shaping the
rapidly changing health care system. In order to ensure that
the perspectives of physicians in one’s responding physician
sample represent those of all physicians in the frame, it is
incumbent on health policy survey researchers to employ the
best methods for achieving that goal. If the results of the
present investigation prove positive, the use of mixed-mode
web and mail surveys may be among those “best methods.”
Primary Funding Source: Mayo Department of Medicine
●Quality Measurement & Reporting System Used by
Academic Medical Centers
Raj Behal, M.D., MPH, Richard Bankowitz, M.D., MBA, Jodi
Neikirk, MA
Presented By: Raj Behal, M.D., MPH, Medical Director,
Clinical Informatics, University HealthSystem Consortium,
2001 Spring Road Suite 700, Oak Brook, IL 60523; Tel:
(630)954-4892; Email: rbehal@uhc.edu
Research Objective: Develop a quality measurement and
reporting system (QMRS) for national quality and patient
safety indicators for use by academic medical centers in the
U.S.
Study Design: Quality and safety indicators developed by the
AHRQ, the Leapfrog Group, the JCAHO and the CMS were
organized in a scorecard. Individual performance of 120 U.S.
academic medical centers and their affiliates belonging to the
University HealthSystem Consortium databases was shown
with percantile rankings for each indicator. The QMRS was
distributed to senior leadership at each of the medical centers.
Population Studied: U.S. academic medical centers.
Principal Findings: The QMRS is positively received by the
medical center leaders and quality staff as an effective
screening tool for identifying potential opportunities for
improving quality and safety.
Conclusions: Use of comparative data and relative ranking
among peer academic medical centers in a quality
measurement and reporting system is an effective modality
for stimulating improvement initiatives.
Implications for Policy, Delivery, or Practice: Hospital
performance on quality and safety indicators does not have to
be publicly reported to stimulate quality improvement.
Distribution of report cards among peer hospitals showing
relative rank may be similarly effective.
Primary Funding Source: No Funding Source
●Are We Overstating the General Health Disparity
Between Latinos and Whites?
Jeanne Black, MBA, Ron D. Hays, Ph.D., Ninez Ponce, Ph.D.
Presented By: Jeanne Black, MBA, Doctoral Candidate, Health
services, UCLA, 4396 Keystone Avenue, Culver City, CA 90232;
Tel: (310)836-8876; Email: jtblack@ucla.edu
Research Objective: Self-reported health status is widely used
as an indicator of population health, based on the question,
“In general, would you say your health is excellent, very good,
good, fair, or poor?” Using this measure, Latinos report
significantly worse health than non-Latino Whites. The
objective of this research is to compare the performance of
the single-item measure with the Physical Component
Summary (PCS) and Mental Component Summary (MCS)
scores derived from the SF-12 to evaluate whether the general
health question has cross-cultural validity as a measure of
health status.
Study Design: This cross-sectional study used data from the
random-digit-dial California Health Interview Survey 2001. We
used weighted logistic regression to examine the impact of
demographic characteristics, socioeconomic status (SES),
acculturation-related factors, and health conditions on the
odds of reporting fair or poor health, and weighted OLS
regression to evaluate the effect of these same variables on
PCS and MCS scores. Acculturation-related factors were
English proficiency (LEP), language(s) spoken at home, years
in the US, citizenship status, and immigrant generation.
Scoring weights for the PCS and MCS allowed the two
summary scores to be correlated. The internal consistency
reliability of the PCS and MCS was examined using
Cronbach’s alpha, with results for Latinos stratified by English
proficiency.
Population Studied: 10,942 Latino and 25,679 non-Latino
White non-elderly adults residing in California.
Principal Findings: The unadjusted odds of reporting
fair/poor health were 3.3 for Latinos compared with nonLatino Whites (p<0.0001). Controlling for demographics, SES,
acculturation-related factors, BMI and chronic conditions
reduced these odds to 1.5. However, there was no LatinoWhite difference in either the PCS or MCS scores after
controlling for age, gender, and poverty level. Cronbach’s
alpha for the PCS was similar for non-Latino Whites and both
Latino sub-groups. However, the PCS item-rest correlation for
the general health question was 0.63 for whites and 0.47 for
Latinos with LEP. Smaller group differences were observed in
the MCS.
Conclusions: Prior US studies of the cross-cultural validity of
measures from the Medical Outcomes Study were not based
on representative population samples that include the
uninsured, recent immigrants, or those who do not speak
English. The fact that in a representative sample, the singleitem general health measure shows significant disparities
between Latinos and non-Latino Whites, while the scale
measures of physical and mental health show none, calls into
question whether the general health question should be used
alone to measure health status differences in a culturally and
economically diverse population. The difference between
Whites and Latinos in the correlation between the general
health question and the other SF-12 items suggests that the
general question may not represent the same construct in the
two groups.
Implications for Policy, Delivery, or Practice: Further
psychometric analysis of the SF-12 should be conducted in
diverse population samples. Analysis of health disparities
should be based on specific clinical outcomes or use multiple
measures of self-reported health. Using the general health
question to adjust for health status in studies of utilization or
satisfaction with care should be done with caution in culturally
diverse populations.
Primary Funding Source: No Funding Source
●Hospital Characteristics Associated with Pediatric
Splenic Injury Management
Steve Bowman, MHA, PhC, Fred Zimmerman, Ph.D., Dimitri
Christakis, M.D., Sam Sharar, M.D., Diane Martin, Ph.D.
Presented By: Steve Bowman, MHA, PhC, Epidemiologist,
Washington State Department of Health, Office of EMS and
Trauma System, PO Box 47853, Olympia, WA 98504-7853; Tel:
(360) 236-2873; Fax: (360) 236-2829; Email:
steve.bowman@doh.wa.gov
Research Objective: We examined hospital characteristics
associated with pediatric splenic injury management and
tested two hypotheses: 1) children are more likely to receive
non-operative, conservative management in children's
hospitals than in general hospitals, and 2) children are less
likely to receive non-operative management in for-profit
hospitals than in not-for-profit hospitals.
Study Design: Retrospective cohort study of data from the
Kid's Inpatient Database (KID) for year 2000. Multivariate
logistic regression was used to control for patient and hospital
characteristics. The main outcome measure was splenectomy
performed within 2 days of hospital arrival.
Population Studied: All children aged 0-16 years who were
hospitalized with a traumatic (non-iatrogenic) spleen injury in
non-federal short-stay hospitals in any of the 27 states
participating in KID (N=2851).
Principal Findings: A total of 370 children (13%) received
splenectomies within 2 days. In logistic regression analyses
adjusting for patient characteristics, injury severity and
hospital characteristics including trauma designation,
splenectomy was found to be less likely among children
treated at children's hospitals (OR, 0.24; 95% CI, 0.11-0.55)
than among children treated in general hospitals.
Splenectomies were found to be more likely among children
treated at for-profit hospitals (OR, 2.44; 95% CI, 1.32-4.50)
than in not-for-profit hospitals.
Conclusions: Variation in the management of pediatric
splenic injuries remains. Children's hospitals have adopted
spleen-conserving management practices. For-profit hospitals
perform more unnecessary splenectomies than not-for-profit
hospitals. Additional pediatric education and training for
providers in general hospitals and especially in for-profit
hospitals may be needed to increase the use of spleenconserving management practices.
Implications for Policy, Delivery, or Practice: By identifying
factors associated with pediatric spleen management
variation, state and/or local governments can strengthen
organized trauma systems. By demonstrating the level of
variability in current medical practice, decision-makers will
receive information on the potential for improved efficiency
through the adoption of a decision rule – either as a
requirement (administrative rule) or as a guideline.
Primary Funding Source: No Funding Source
●Changes in Prescribing Patterns, Medication
Management, and Hospital and Emergency Room
Utilization: The Impact of an Asthma Population Disease
Management Model and Individual Asthma Care
Management
Joan Branin, Ph.D.
Presented By: Joan Branin, Ph.D., Associate Professor, Health
Services Managment, University of La Verne, 1950 3rd Street,
La Verne, CA 91750; Tel: (909) 593-3511 x4247; Fax: (909) 3922702; Email: braninj@ulv.edu
Research Objective: The purpose of this research was to
investigate the impact of an asthma population disease
management model coordinated with an individual asthma
care management program for adult asthma patients on
prescribing patterns, medication management, and hospital
and emergency room utilization.
Study Design: An asthma population disease management
model coordinated with an individual asthma care
management program to monitor and facilitate treatment of
adult asthma patients was initiated at a health maintenance
organization in Southern California. Patients were enrolled in
an asthma care management program that emphasized the
use of preventative asthma control measures. These
measures included increased use of anti-inflammatory
medications and non-pharmaceutical methods such as dust
control and peak flow meter usage and better recognition of
asthma triggers. One-on-one asthma self care management
training, patient education materials, and an individualized
follow up program involving an interdisciplinary asthma team
approach were instituted. A retrospective review of medical
records and data sources was conducted before and after the
implementation of the individual asthma care management
program for adult asthma patients.
Population Studied: A total of 2,423 asthmatic patients
between the ages of 18 and 65 years of age identified as having
moderate and severe asthma and a history of hospitalizations
and emergency room visits for asthma were continuously
enrolled in the asthma population disease management
program during 2003 and 2004.
Principal Findings: There was a statistically significant
reduction in uncontrolled acute asthma episodes,
hospitalizations, and emergency room visits after the
implementation of the asthma population disease
management model coordinated with the individual asthma
care management program. There was a significant reduction
in the number of oral corticosteriod courses, the number of
prescribers, and the ratio of inhaled anti-inflammatory
medications to beta-agonist usage (p <.05). The number of
asthma hospitalizations decreased by 18%. Similarly, the
number of emergency room visits decreased by 21%. There
was a positive correlation between the number and type of
prescribers and the rate of emergency room visits (r = .63) and
hospitalizations (r = 54). Within one year of implementation
of the asthma care management program, the number of
asthma patients identified with moderate and severe high-risk
characteristics was reduced by 27%. These findings support
the findings of an earlier study.
Conclusions: An asthma population disease management
model and individual asthma care management can reduce
the number of prescribers and result in better medication
management and fewer emergency room visits and
hospitalizations for asthma among adult asthma patients.
Implications for Policy, Delivery, or Practice: These findings
suggest that an asthma population disease management
model coordinated with individual asthma care management
can lead to (1) better self-care medication and symptom
management, (2) improved quality of care, (3) changes in
prescribing patterns, and (4) reduced hospital and emergency
room utilization.
Primary Funding Source: ULV Faculty Research Grant
●IRT Evaluation of IHI Safety Climate Survey
Sandra Bruggeman, Rosa Cabanela, Ph.D., Arthur R. Williams,
Ph.D., Erin K. Mc Murtry, James M. Naessens, MPH
Presented By: Sandra Bruggeman, Master's Health Services
Analyst, Health Care Policy and Research, Mayo Clinic
Rochester, 200 1st Street SW, Rochester, MN 55905; Tel: (507)
284-4582; Email: Bruggeman.Sandra@mayo.edu
Research Objective: To evaluate reliability and validity of the
IHI 19 item Safety Climate Survey using groups of healthcare
providers at a large mid-western hospital as respondents.
Study Design: Questionnaires containing the 19 IHI Safety
Climate Survey items were distributed via intranet to a
random sample of 1476 hospital nursing staff including
registered nurses, licensed practical nurses, and patient care
assistants; 1106 consulting physicians with recent hospital
experience; and 641 resident physicians who had participated
at least one year in the Residency Program at the hospital. The
response rate was 45.4%. Respondents’ answers were
analyzed using principal component factor analyses and Item
Response Theory (IRT). A scree test of the eigenvalues from
the factor analysis was used to examine dimensionality.
MULTILOG 7.03 software (Samejima’s model) was used to
calculate item parameters and produce Item Characteristic
Curves (ICC) and Total Information Curves.
Population Studied: 1451 clinical survey respondents
consisting of 733 nurses, 485 physicians and 232 residents at a
large mid-western hospital.
Principal Findings: After principal component factor analysis
(varimax rotation) was done, a scree test identified 2 factors.
The factors loaded on 13 of IHI questionnaire items, with one
loading on both factors. The first factor loaded on 8 items,
and the second loaded on 6, including the cross-loading. The
maximum variance accounted for on both factors combined
was 38.6%. MULTILOG parameter calculations found that
each of these factors had 2 items with alphas less than 1.00,
indicating a very poor discrimination of traits. For items on
each of the factors, MULTILOG produced four beta values,
almost all were negative. As a consequence, no Total
Information was provided on the upper part of the trait
distributions (> 1 SD) on these factors.
Conclusions: It is not clear what exactly is being measured on
either of these factors. The Total Information provided on
either factor is poor, with information being concentrated at
the lower ends of the trait distributions. Many of the 19 items
on the IHI questionnaire also appear to be redundant, since 11
alphas are less than 1.00. This suggests that many items
could be dropped from the questionnaire.
Implications for Policy, Delivery, or Practice: Although
measuring “Safety Climate” has become popular, the
generalized use of non-validated instruments and unjustified
confidence in the results of their use may lead to undesirable
consequences including less safety for patients not more.
Primary Funding Source: No Funding Source
●Assessing the Validity of the Current Asthma HEDIS
Measure to Distinguish Quality Asthma Care
Christopher Cantrell, Ph.D., Paul G. Solari, M.D., Deborah L.
Fritz, Ph.D.
Presented By: Christopher Cantrell, Ph.D., Senior Manager,
Applied Outcomes and Analysis, GlaxoSmithKline, 5 Moore
Drive, Research Triangle Park, NC 27709-3398; Tel: (919)4838686; Fax: (919)483-0611; Email:
christopher.r.cantrell@gsk.com
Research Objective: The current asthma Health Employer
Data and Information Set (HEDIS) measure is a ratio of the
number of persons receiving at least one prescription for a
HEDIS-defined asthma controller during the measurement
year (numerator) among identified “persistent” asthmatics in
the previous year (denominator). Higher HEDIS scores are
intended to reflect better asthma care within an organization,
however there is some concern around the validity of this
measure to distinguish quality care. First, the numerator
criterion (one controller prescription) is potentially too
conservative. A single controller prescription is insufficient for
maintaining control in a “persistent” asthma patient. Second,
while HEDIS technical specifications for the measure state
that “the best available evidence indicates that inhaled
corticosteroids are the preferred primary therapy”, the
measure itself does not distinguish between types of
controllers. Finally, the medication usage criteria used to
identify “persistent” asthma patients may include persons
who are not asthmatic and/or who are not chronic in nature
(e.g. exercise-induced, rhinitis, etc.). Therefore, these patients
may not benefit from future controllers and have very little risk
of asthma exacerbation thereby diluting the measurement
sample. The purpose of this research was to determine if
being numerator compliant is associated with better
measurement year outcomes; lower Emergency Department
and hospitalization (ED/hospitalization) rates.
Study Design: A retrospective longitudinal design replicating
the current asthma HEDIS measure using two years, 20022003, of national administrative claims data. Rates per 100
and odds ratio were calculated and chi-square was utilized to
test for significance (p<0.05).
Population Studied: Integrated Healthcare Information
Services’ Managed Care Benchmarks database (Waltham,
MA) was utilized to replicate the asthma HEDIS measure and
identify 30,687 “persistent” asthma patients.
Principal Findings: Of the 30,687 patients identified, 21,124
were numerator compliant yielding a HEDIS score of 68.84%
(NCQA reported national average for 2002 was 67.9%).
ED/hospitalization rates were 6.9 and 3.7 per 100 for
numerator compliant patients and non-numerator compliant
patients respectively. The odds ratio for numerator compliant
patients = 1.95 (CI = 1.73 - 2.20) with a chi-square value of
112.2 (p<0.0001). This indicates that numerator compliant
patients are 95% more likely to have and ED/hospitalization
versus their counterparts.
Conclusions: The findings of this study suggest that the
current asthma HEDIS measure does not validly assess
quality asthma care in terms of ED/hospitalizations. In fact,
our results indicate that the measure reflects the opposite of
what is intended. Numerator compliant patients are
significantly associated with higher ED/hospitalization rates
and therefore a higher asthma HEDIS score in this case would
not reflect better care.
Implications for Policy, Delivery, or Practice: The National
Committee for Quality Assurance (NCQA), the organization
responsible for HEDIS scores, reports that about 90 percent
of health plans collect HEDIS data and 60 percent of large
employers and public purchasers use HEDIS data to help
guide contracting decisions, set performance targets or
employee contributions based on plan performance. Our data
suggests that the asthma measure may not be useful for the
purposes in which it is being employed and that these
concerns should be addressed.
Primary Funding Source: GlaxoSmithKline
●Racial/Ethnic Health Care Disparities in a Managed Care
Medicare Population
Joyce Co, MPH, Beatriz Jaramillo, DrPH
Presented By: Joyce Co, MPH, Assistant Director, Health
Services Analysis, Medical and Quality Informatics, HIP
Health Plan of New York, 55 Water Street, 5th Floor, New York,
NY 10041; Tel: (646) 447-6372; Fax: (646) 447-3164; Email:
jco@hipusa.com
Research Objective: Disparities in health care are among the
nation’s most serious health care problems. A recent report by
the Institute of Medicine found that racial and ethnic minority
groups tend to receive a lower quality of health care than nonminorities, even when access-related factors such as income
and insurance coverage are controlled. At HIP, the availability
of race/ethnicity data for Medicare members makes it possible
to determine whether racial and ethnic disparities exist within
managed care, and if so where.
Study Design: This analysis focuses on selected HEDIS
Effectiveness of Care measures for Medicare members. These
measures are: breast cancer screening; HbA1c testing and
LDL-C screening for members with diabetes; antidepressant
medication management: optimal practitioner contact, acute
phase treatment, and continuation phase treatment; mental
health follow-up after hospitalization: 7 days and 30 days; and
osteoporosis. Administrative data was collected for these
measures. Using this administrative data, rates for the
selected HEDIS 2004 measures were calculated by
racial/ethnic group. The race/ethnicity groups existing in
HIP’s system are African-American, American Indian/Alaskan
Native, Asian, Hispanic, Other, Unknown, and White. Due to
the small number of members in American Indian/Alaskan
Native, Asian, Other, and Unknown categories for measures
such as breast cancer screening and the two diabetes
measures, these groups were collapsed into one group,
“Other”. In addition, due to the small number of members
within the Hispanic ethnic category for the mental health
measures and the osteoporosis measure, Hispanic members
were also included in the “Other” category for these
measures. Rates by racial/ethnic groups were compared for
each measure using a chi-square statistic. Statistical
significance was established at alpha < 0.05.
Population Studied: Medicare members who fit criteria for
the following HEDIS measures: breast cancer screening;
HbA1c testing and LDL-C screening for members with
diabetes; antidepressant medication management: optimal
practitioner contact, acute phase treatment, and continuation
phase treatment; mental health follow-up after hospitalization:
7 days and 30 days; and osteoporosis.
Principal Findings: The following measures showed no
significant difference across the races measured: breast cancer
screening and osteoporosis. Two sets of measures showed
significance: mental health measures and both diabetes
measures. For all mental health measures, the AfricanAmerican and Other groups had lower rates than the White
group. For the diabetes HbA1c testing measure, the two
groups with the lowest rates were the Hispanic and Other
groups, and for the diabetes LDL-C screening measure, the
two groups with the lowest rates were the African-American
and Other groups.
Conclusions: This analysis suggests that some racial and
ethnic disparities in health care exist at HIP, specifically in the
areas of mental health treatment and diabetes management.
Therefore, factors associated with certain races and
ethnicities, including specific cultural beliefs and attitudes
about diet and nutrition, perceptions of mental health,
treatment, and the health care system in general warrant
increased attention.
Implications for Policy, Delivery, or Practice: By gaining a
clearer understanding of the race- and ethnic-specific factors
that influence treatment and management, specific
interventions may be designed to break down the barriers to
obtaining quality health care and eliminate the disparities that
are currently observed.
Primary Funding Source: HIP Health Plan of New York
●Measuring Patient Safety Climate: A Review of Surveys
Judith Colla, Sc.D., Ann Bracken, M.D., Ph.D., Linda Kinney,
MPA, William Weeks, M.D., MBA
Presented By: Judith Colla, Sc.D., Research Associate,
Community & Family Medicine, Dartmouth Medical School,
Center for Evaluative Clinical Studies, Hanover, NH 03755; Tel:
(802)295-9363 x5806; Fax: (802)291-6286; Email:
judith.colla@dartmouth.edu
Research Objective: Five years ago, the Institute of Medicine
recommended improving patient safety by addressing
organizational cultural issues. Since then, surveys measuring
a patient safety climate considered predictive of outcomes
have begun to emerge. The objective of this work is to
compare the following aspects of patient safety climate
surveys: history, dimensions covered, strength of
psychometrics, and use in patient outcomes studies.
Study Design: We conducted a systematic review that
included Medline search, review of abstracts, published
manuscripts, references from papers, relevant websites, and
contact with authors.
Population Studied: Not applicable.
Principal Findings: We found nine surveys that measure an
organization’s patient safety climate. Most cover five
common dimensions of patient safety climate: leadership,
policies and procedures, staffing, communication, and
reporting. All surveys used Likert scales. The thoroughness of
psychometric testing varied considerably. While all of these
surveys have been used to compare units within or between
hospitals, only one has been used to explore the association
between organizational climate and patient outcomes, such as
mortality, reductions in medication errors and length of stay.
Conclusions: Although several good surveys of patient safety
climate exist, we found considerable variation in the length,
dimensions covered, and reported reliability of these surveys.
While achievement of a patient safety culture is an admirable
goal, more effort should be expended on understanding the
relationship between measures of patient safety climate and
patient outcomes.
Implications for Policy, Delivery, or Practice: Patient safety
climate surveys may detect employee concerns and may help
foster communications around this topic. However, since
there is only limited evidence that patient safety climate scores
are associated with patient safety outcomes, administrators
and policymakers should be cautious in their use of these
surveys.
Primary Funding Source: No Funding Source
●Establishing the True Effect of Dental Insurance on
Dental Use.
Philip Cooper, Ph.D., Richard J. Manski, DDS, MBA, Ph.D.
Presented By: Philip Cooper, Ph.D., Health Economist, Center
for Financing, Access and Cost Trends (CFACT), Agency for
Healthcare Research and Quality, 540 Gaither Road, Rockville,
MD 20850; Tel: (301)427-1675; Email: pcooper@ahrq.gov
Research Objective: Identify the true insurance component of
dental care coverage or pre-paid dental care.
Study Design: We attempt to determine the true effect of
dental coverage by isolating the health seeking behavioral
component of dental care. We use health insurance and self
identified measures of attitudes toward risk as proxies for
health seeking behavior.
Population Studied: Representative sample of U.S.
population aged 19 in 2001 from the Medical Expenditure
Panel Survey - Household Component and Insurance
Component.
Principal Findings: While roughly 88 percent of the U.S.
population had some type of Medical coverage in 2001, 46
percent had dental coverage. Virtually all persons with dental
coverage also had medical coverage. While nineteen percent
of those without any coverage had a dental visit, thirty-nine
percent with only medical coverage (no dental) had a dental
visit and fifty percent of those with dental coverage had a
similar visit.
Conclusions: Since medical coverage generally does not
provide for dental reimbursement, the positive effect of
medical insurance on the dental use suggests a indirect health
seeking behavior component of having medical insurance on
the use of dental care.
Implications for Policy, Delivery, or Practice: By isolating
and understanding the health seeking behavioral component
of dental care coverage, employers and other plan sponsors
may be able to more accurately design future dental care plans
that better meet the needs of employees and their
dependents.
Primary Funding Source: AHRQ
●A Comparison of Four States' Strategies for Reducing the
Use of Physical Restraints in Nursing Facilities
Leslie Cortes, M.D., Jennie Yu Chou, MS, RPh
Presented By: Leslie Cortes, M.D., Director, Medical Quality
Assurance, Quality Assurance / Quality Improvement,
Department of Aging and Disability Services, 701 West 51st
Street, W-510, Austin, TX 78751; Tel: (512)438-2567; Fax:
(512)438-4415; Email: leslie.cortes@dads.state.tx.us
Research Objective: This project compares the impacts of
four states’ quality improvement strategies for reducing
restraint use in nursing facilities. The strategies include usual
regulation, technical assistance provided by Quality
Improvement Organizations or QIOs to volunteer facilities,
and the technical assistance provided by QIOs to volunteer
facilities combined with a state-based technical assistance
program in which all facilities are required to participate. The
effect of restraint reduction on the prevalence of falls in each
state is examined, and the relative impacts of the voluntary
and compulsory technical assistance programs in Texas are
compared.
Study Design: Two-year, statewide quality indicator trends for
the four states with the highest prevalence of restraint use
during the first quarter of 2002 are examined. The impact of
restraint reduction on fall prevalence is examined through
time-series analysis. The relative impacts of Texas’ voluntary
and compulsory technical assistance strategies are
determined through analysis of attributable fractions.
Population Studied: The study population consists of nursing
home residents in Medicaid-certified nursing facilities in
Arkansas, California, Louisiana, and Texas.
Principal Findings: The state of California, with no technical
assistance program for restraint reduction, achieved a 19.7
percent reduction in restraint use. Arkansas and Louisiana,
states providing QIO-based technical assistance for restraint
reduction to 10 and 15 percent of their facilities, respectively,
achieved 23.5 and 16.8 percent reductions in restraint use.
Texas, the state providing voluntary QIO-based technical
assistance to 13 percent of facilities and compulsory technical
assistance to all facilities achieved a 47.5 percent reduction in
restraint use. In Texas, 89.7 percent of the total reduction in
restraint use was attributable to the state’s compulsory
technical assistance program; the remainder was attributable
to the voluntary QIO-based intervention. Cross-correlation
analysis shows that the variance in fall prevalence attributable
to restraint reduction varies among the states. In California
and Texas, there was a moderate to strong tendency for fall
prevalence to decrease as restraint use was reduced. In
contrast, Arkansas and Louisiana showed a moderate
tendency for fall prevalence to increase as restraint use was
reduced. Since the first quarter of 2002, only Louisiana has
experienced an absolute increase of 1.7 percent in fall
prevalence.
Conclusions: Both voluntary and compulsory quality
improvement initiatives showed a positive impact on reducing
restraint use. The combined use of both strategies was
associated with the largest decrease in restraint use, with the
compulsory quality improvement strategy showing a greater
impact than the voluntary strategy. Major reductions in
nursing home restraint use can be achieved without
increasing the prevalence of falls.
Implications for Policy, Delivery, or Practice: Greater
statewide quality improvements are achieved through
compulsory state-based technical assistance. However, other
factors can influence the degree of improvement. These
factors include the effectiveness of the technical assistance
interventions used, the readiness of nursing facilities to
implement recommended changes, the types of technical
assistance provided, the frequency of on-site contacts with the
facilities, and the training of the quality consultants who
provide the technical assistance. Future studies should
examine the impact of these factors on the effectiveness of
quality improvement programs.
Primary Funding Source: Title XIX funding for Medicaid
services
●Relation of Member Characteristics and Utilization
Patterns to Response to Reminders Sent for Overdue
Health Screenings
Jun Zhu, Ph.D., James Davis, Ph.D., Deborah A. Taira, Sc.D.
Presented By: James Davis, Ph.D., Research Analyst, Care
Management, HMSA (BCBS of Hawaii), 818 Keeaumoku
Street; PO Box 860, Honolulu, HI 96808-0860; Tel: (808)9485495; Fax: (808)948-6043; Email: james_davis@hmsa.com
Research Objective: To understand the relation of member
characteristics, physician specialty, and previous medical
utilization to the response to screening reminders sent for
breast, cervical, colorectal cancer, diabetes and cholesterol
screening. Further, to examine the relation of reminders sent
for multiple health screenings on the likelihood of members
receiving the screenings.
Study Design: A longitudinal design examining member
characteristics and medical history in the year before
reminders were sent on the rates of subsequent health
screenings. The study utilized administrative data from a
large health plan in Hawaii.
Population Studied: Health plan members who were sent
reminders for overdue health screenings between 1999 and
2003. The number of people receiving reminders was 44,331
for breast cancer screening, 73,875 for cervical cancer, 130,593
for colon cancers, 84,584 for diabetes, and 54,843 for
cholesterol.
Principal Findings: Screening rates ranged from 21% for
colorectal cancer to 31% for diabetes in response to an initial
reminder. Rates consistently decreased for members
requiring increased numbers of further reminders. In
multivariable models, hazard ratios indicated that the
likelihood of receiving screening after reminders were sent
declined with age for all the screenings except for cholesterol.
The highest hazard ratios occurred for members having an
intermediate morbidity level, suggesting that moderate-ill
members were most likely to get screened. Screening rates
were 17% to 26% higher in June than in November and
December. The number of office visits before the reminders
were sent was significantly associated with diabetes screening
but not other health screenings. Members seeing an OB/GYN
in the past year had increased rates of cancer screenings,
whereas members seeing a primary care physician or an
endocrinologist had significantly increased rates of diabetic
and cholesterol screenings. Members sent multiple reminders
for overdue screenings were less likely to obtain health
screenings. However, of these members, those who received
one cancer screening were more likely to get another cancer
screening; and those obtaining a non-cancer related screening
were more likely to get another non-cancer related screening.
Conclusions: Member characteristics and medical history in
the year before reminders were sent were associated with
receiving health screenings. For members receiving multiple
reminders, those who responded to one reminder were more
likely to respond to others. This finding was especially strong
among cancer related screenings, and between diabetes and
cholesterol screening.
Implications for Policy, Delivery, or Practice: Barriers to
obtaining health screenings may be identified prior to sending
health screening reminders. Directed efforts may increase
health screening, such as efforts to encourage greater
cholesterol screening at earlier ages, or possibly mailing
additional reminders in summer when screening rates are
greatest.
Primary Funding Source: HMSA (BCBS of Hawaii)
●Member and Physician Characteristics Associated with
Variations in Receiving Care Recommended by a Physician
Quality Service Recognition Program
James Davis, Ph.D., Deborah Taira, Sc.D.
Presented By: James Davis, Ph.D., Research Analyst, Care
Management, HMSA (BCBS of Hawaii), 818 Keeaumoku
Street; PO Box 860, Honolulu, HI 96808-0860; Tel: (808) 9485495; Fax: (808) 948-6043; Email: james_davis@hmsa.com
Research Objective: To examine member and physician
characteristics associated with receiving health screenings and
recommended practices for the management of acute and
chronic conditions
Study Design: The study employed a cross-sectional design
examining the associations between member and physician
characteristics and 30 indicators of recommended clinical
care. The study used measures of clinical outcomes based on
administrative data for a one-year interval (April 2002 through
March 2003).
Population Studied: The eligible population included all
members in the fee for service, health maintenance
organization, or Medicare managed care plans of the largest
secondary insurer in Hawaii. Members were included in the
analysis for specific clinical indicators if they met the eligibility
criteria for the indicator. Eligibility criteria varied from simple
age, gender criteria to more complex clinical algorithms. The
number of members eligible for the various indicators ranged
from 839 for follow-up after emergency visits for asthma to
70,542 for compliance with anti-hypertensive drugs.
Principal Findings: Twenty of the 30 recommended practices
varied significantly (p < 0.05) by age. Older members received
recommended care more often for 13 practices whereas
younger members received the recommended care more often
for seven. Thirteen indicators varied significantly by gender;
males received the recommended practice more often for 12
of the 13 indicators. The one measure where females had a
better result was osteoporosis screening for patients on
corticosteroids. Members with a high morbidity index
received recommended care more often for 10 practices,
including diabetic retinal exams, shoulder x-ray for adhesive
capsulitis and beta blocker use in coronary artery disease.
Members with a low morbidity index only did better on
endoscopy or barium enema after diagnosis of diverticulitis.
With physician characteristics, one or more of four specialties
examined (primary care, obstetrics and gynecology (ob/gyn),
endocrinology) was significantly associated with receiving
recommended care for 24 of the 30 practices examined.
Seeing an ob/gyn or a primary care physician was more
frequently associated with receiving recommended health
screenings. All four specialties showed associations with
several disease management indicators. For example, seeing
an endocrinologist was positively associated with ace inhibitor
and lipid lowering drug use in coronary artery disease,
whereas seeing a cardiologist was associated with ace
inhibitor use in congestive heart failure and beta blocker use
in coronary artery disease.
Conclusions: The results suggest that recommended
practices for health screening and for the management of
acute and chronic conditions vary by both member and
physician characteristics. The characteristics associated,
however, varied substantially by the recommended practice.
The results should be interpreted cautiously as they are based
on administrative data using a single statistical model chosen
to facilitate comparisons across the clinical indicators.
Implications for Policy, Delivery, or Practice: The results
suggest efforts to improve recommended clinical practice
might focus on either member or physician characteristics.
Targeted interventions may selectively improve adherence to
recommended clinical guidelines.
Primary Funding Source: HMSA (BCBS of Hawaii)
●Response to Health Screening Reminders Related to
Office Visits with New and Previously Seen Physicians
James Davis, Ph.D., Jun Zhu, Ph.D., James Davis, Ph.D.,
Deborah A. Taira, Sc.D.
Presented By: James Davis, Ph.D., Research analyst, Care
Management, HMSA (BCBS of Hawaii), 818 Keeaumoku
Street; PO Box 860, Honolulu, HI 96808-0860; Tel: (808)9485495; Fax: (808)948-6043; Email: james_davis@hmsa.com
Research Objective: To examine the association between the
characteristics of physicians seen in the months following the
mailing of health-screening reminders and the likelihood of
receiving screening for breast, cervical, and colorectal cancers,
and for diabetes and cholesterol.
Study Design: The study was a longitudinal study focusing on
the year after reminders were sent for health screenings.
Results were analyzed using a pooled logistic regression
procedure examining office visits and other health care by
months after the reminders were sent. We specifically
investigated whether members seeing new physicians, defined
as physicians they had not visited in the past year, were
especially likely to obtain health screenings.
Population Studied: Members of the largest health insurer in
Hawaii who received reminders for overdue health screenings
between 1999 and 2003. The population was studied by
analyzing their administrative data. The number of people
receiving reminders was 44,331 for breast cancer screening,
73,875 for cervical cancer, 130,593 for colon cancers, 84,584 for
diabetes, and 54,843 for cholesterol.
Principal Findings: Health screenings were significantly
increased in the months after reminders were sent, peaking
for all five screenings during the second month after the
reminders were mailed. Other results were also consistent
across the various health screenings. In adjusted,
multivariable models, members who had visited new
physicians had odds ratios for obtaining health screenings 7-9
times higher than other members. This enhancement in
response from seeing a new physician remained among
members receiving their second and third reminders, the
most recalcitrant members. Odds ratios for these members,
however, were about half as great. In general, regardless of
the number of reminders, the more new physicians visited the
more likely members were to receive health screenings. Other
physician characteristics were also associated with obtaining
the recommended health screenings. Members having more
overall office visits (new and old physicians) were more likely
to be screened. Having an office visit with an OB/GYN
improved the odds for cancer screenings, whereas having an
office visit with a primary care physician enhanced the odds
for diabetes and cholesterol screenings.
Conclusions: Members seeing physicians they had not visited
in the past year had significantly higher screening rates than
members only seeing physicians they had previously visited.
Other physician characteristics were also associated with
obtaining recommended health screenings.
Implications for Policy, Delivery, or Practice: If seeing a new
physician proves to have a causal association with obtaining
recommended health screenings, then better understanding
of the management of new versus previously treated patients
may offer insights into how to improve the rates of
recommended health screenings.
Primary Funding Source: HMSA (BCBS of HawaiI)
●Group Medical Visits for Patients with Type 2 Diabetes:
Patient and Physician Perspectives
Lynn Deitrick, RN Ph.D., Deborah Swavely, RN, MSN, Larry N.
Merkle, M.D., W. Glenn Stern, MA, Sam Bub, M.D., Jack
Lenhart, M.D.
Presented By: Lynn Deitrick, RN Ph.D., Ethnographer, Health
Studies Unit, Lehigh Valley Hospital and Health Network, 17th
& Chew Streets, PO Box 7017, Allentown, PA 18105; Tel:
(610)402-2293; Fax: (610)402-2247; Email:
Lynn.Deitrick@lvh.com
Research Objective: Recent research suggests that group
medical visits for patients with chronic illness are clinically
effective as well as time efficient. Group visits for chronically ill
patients might also facilitate patient empowerment and
activation. This study looks at the value of group medical visits
conducted in a primary care practice as a treatment option for
patients with type 2 diabetes, from both the patient and
physician perspective.
Study Design: Type 2 diabetic patients who completed 10
hours of diabetes education were invited to participate in
group medical visits conducted by their primary care
physician. Group medical visits in both practices were
structured in a similar way. Each group visit was scheduled
for 90 minutes during a weekday morning. Groups were held
in a room in the physician’s office. Group visits included
didactic education sessions by the physician or diabetes
educator, a question and answer period, socialization, nurse
and physician assessment of vital signs, lab data and foot
exams. The hospital ethnographer observed several cycles of
group medical visits at both primary care practices. Interviews
were conducted with patients, the diabetes educator and
physicians in both groups to elicit information about patient
empowerment, activation and patient and physician
perspectives on the value of group medical visits. The Patient
Activation Measure was used to quantify activation among
the patients.
Population Studied: Two groups of type 2 diabetic patients
n=20 at two different primary care practices engaged in
monthly group medical visits for the first three months, then
quarterly group visits for the next year. Group 1 patients n=8,
6 females, and 2 males and Group 2 patients n=12, 9 females
and 3 males were homogenous for ethnicity and age.
Principal Findings: Interviews with diabetic patients
participating in group medical visits suggest that patients are
very positive about the value of these visits. Group visit
patients report benefits including peer learning, peer support
and physician and diabetes educator encouragement as
factors that enable them to better care for themselves and
manage their diabetes. These patients also reported that
participating in group visits allowed them to connect with
their peers and provided helpful information and
encouragement for them as they learned to live with their
diabetes. Interviews with both participating physicians and
two certified diabetes educators verify these findings.
Physician perspectives of group medical visits indicate that
connection with peers and provision of an extended support
network, as well as development of a trusting relationship with
the physician, are added benefits of group medical visits.
Patient Activation Measurements to quantify patient activation
in group visit participants from both practices have been
collected and are being analyzed.
Conclusions: Group medical visits appear to be a useful
model for providing continuing education, medical
management, and empowering patients to self-manage their
type 2 diabetes in the primary care setting.
Implications for Policy, Delivery, or Practice: Group medical
visits appear to be a useful model for providing continuing
education, medical management, and empowering patients to
self-manage their type 2 diabetes in the primary care setting.
Primary Funding Source: AHRQ
●Influence of Medicare Reimbursement on Prescribing
Patterns of TNF-alpha Inhibitors
Esi DeWitt, M.D., Henry A. Glick, Ph.D., Daniel A. Albert,
M.D., Marshall Joffe, M.D., Ph.D., Frederick Wolfe, M.D.
Presented By: Esi DeWitt, M.D., Clinical Research Fellow,
Rheumatology, The Children's Hospital of Philadelphia, 3405
Civic Center Boulevard, Room 236, Philadelphia, PA 19104;
Tel: (267)251-8071; Fax: (215)590-4750; Email:
dewitt@email.chop.edu
Research Objective: Anti-TNF alpha biologic therapies for the
treatment of rheumatoid arthritis have shown comparable
efficacy in randomized clinical trials. Thus, there is no well
defined clinical rationale for differential prescribing of these
therapies in RA. However, preferential Medicare
reimbursement for infusion drugs such as infliximab, INF, in
contrast to the injection drug etanercept, ETN, may influence
prescription. Our objective is to characterize prescribing
patterns for ETN and INF in clinical practice. We hypothesize
that physicians, aware of differential reimbursement, prescribe
drugs in part to maximize insurance coverage. Controlling for
insurance plan may thus account for some of the observed
differences between groups prescribed the two drugs.
Study Design: Observational cohort study of patients with RA
on anti-TNF-alpha biologic drugs. Disease and demographic
variables prior to start of the two drugs were compared,
without and with stratification by insurance type, private or
public. Multivariate logistic regression models were
constructed to characterize predictors of biologic prescription
choice.
Population Studied: 1808 RA patients, referred from the
practices of 447 doctors, who were newly started on ETN or
INF after enrollment in the National Data Bank for Rheumatic
Diseases.
Principal Findings: 42.4% of patients were initially prescribed
ETN and 57.6% INF. Overall, ETN patients were quite different
than INF patients. They had 0.15 (p<0.001) lower HAQ
functional disability scores, were 7 years younger (p<0.001),
and were 49% (p<0.001) less likely to have public insurance
than were INF patients. However, stratification by insurance
type narrowed these differences. Between ETN and INF
groups the difference in HAQ scores among privately insured
patients fell to 0.08, and there was only a 0.04 difference in
HAQ scores among the publicly insured. Within the privately
insured strata, the difference in mean age between groups was
only 1.1 years. Compared to those with private insurance,
regression analyses revealed publicly insured patients to be
less likely to receive ETN, with an adjusted odds ratio for ETN
prescription of 0.55 (CI 0.40-0.69, p<0.001). Predictors of
INF prescription were, in addition to having public insurance,
advanced age and prior methotrexate use. Whereas higher
education and SF-36 physical function component score had a
weak effect in favor of ETN prescription. Evaluation of the
covariates disability (HAQ), disease duration, sex, and income
did not affect the result.
Conclusions: This observational cohort study demonstrates
differential prescribing of ETN and INF for treatment of RA.
In multivariate analyses, public insurance was a strong
predictor of INF prescription, a reflection of preferential
Medicare reimbursement for infusion drugs. But controlling
for insurance type did not always equate patient
characteristics in the two groups, suggesting other factors also
influence this prescribing.
Implications for Policy, Delivery, or Practice: This finding
adds to the evidence that insurance reimbursement policies
influence physicians’ prescribing behavior. These results raise
questions about the current policy of differential governmental
reimbursement for drugs with similar efficacy but different
routes of administration.
Primary Funding Source: Arthritis Research Center
Foundation
●Emergency Colorectal Cancer Resection: A Measure of
Disparities?
Jessica Diggs, BS, Siran Koroukian, Ph.D., Mireya Diaz-Insua,
Ph.D., Gregory Cooper, Ph.D.
Presented By: Jessica Diggs, BS, M.D./Ph.D. Candidate in
HSR, Epidemiology and Biostatistics, Case Western Reserve
University School of Medicine, 10900 Euclid Boulevard, LOC
4945, Cleveland, OH 44106; Tel: (412)877-7438; Fax: (216)7911416; Email: jessica.diggs@case.edu
Research Objective: Colorectal cancer, presenting as a
surgical emergency is associated with increased morbidity and
mortality, which is influenced by disease stage, comorbidity,
and patient age. An acute presentation of colorectal cancer
may reflect deficiencies in previous care, including issues of
access, quality, screening policy, and healthcare utilization. It
therefore has the potential to be used as an indicator of health
disparities. The factors that determine whether a patient will
present with a surgical emergency have not been described
previously. The objective of this study is to characterize this
population and to determine the impact of age, comorbidity,
and insurance on the likelihood of presenting with a surgical
emergency.
Study Design: This is a cross sectional study using data from
the 2002 National Inpatient Sample of the Healthcare Cost
and Utilization Project. ICD9 codes were used to identify
25,789 colorectal cancer patients undergoing resection
procedures. A subset, 2,548 patients, presenting with a
diagnosis requiring emergency intervention, including
peritonitis, occlusion, or perforation, were identified. Patients
were stratified into younger, less than 65, and older, 65 and
over, age groups. Bivariate relationships between age,
comorbidity, and insurance status were assessed using chi
squared analysis. Multivariate logistic regression was used to
predict the association between patient characteristics and the
likelihood of an emergent presentation.
Population Studied: The study population includes all
colorectal cancer patients undergoing a colorectal resection
procedure.
Principal Findings: The majority, 71 percent of this
population was over age sixty five and 63 percent were insured
by Medicare. In both the younger and older age groups, the
privately insured had the lowest percentage of emergent
presentations, 8.1 percent, 9.3 percent compared with
Medicaid, 15.6 percent, 13.8 percent, and those who self pay
19.6 percent , 11.9 percent. Multivariate analysis showed that
among younger people, those without private insurance had
an increased risk of emergency presentation compared to
privately insured patients, with odds ratios of 1.75 to 3.12.
Among older patients, being dually eligible for Medicaid and
Medicare significantly increased the risk of emergency
presentation, with an odds ratio of 1.47 compared to Medicare
alone. There was no consistent association of comorbidity and
emergent presentation. For example, among patients less
than 45 years of age, individuals with three or more
comorbidities were less likely to present emergently and other
conditions such as diabetes, that require more frequent
interactions with healthcare professionals, were associated
with a lower likelihood of emergent presentation.
Conclusions: These results show a significant effect of
insurance status on the risk of presenting with a surgical
emergency, placing those lacking private insurance at
increased risk of emergent presentation, and therefore at
greater risk of morbidity and mortality. The lack of association
between comorbidity and emergent presentation, suggests
that contact with the healthcare system may increase the
probability of early detection.
Implications for Policy, Delivery, or Practice: Emergency
presentation may be an indicator of healthcare disparities and
may contribute to increased healthcare expenditures. Early
identification of patients at risk may reduce disparities,
decreasing the burden of these procedures on both the
healthcare system and patients.
Primary Funding Source: No Funding Source
●Early Effects of the Healthy City Program on Social and
Living Environments in Jing-An District of Shanghai
Xiaocang Ding, MSMHM, Jay J. Shen, Ph.D.
Presented By: Xiaocang Ding, MSMHM, Deputy Director,
Jiang-An District Bureau of Health, 422 Jiang-Ning Road,
Shanghai, 200041; Tel: 86-21-627733; Fax: 86-21-6279375;
Email: dingxc2001@21cn.com
Research Objective: Although China’s economy has grown
dramatically during the last two decades, it has been
concerned that its social development is behind the economic
development. In order to address health issues resulting from
the rapid urbanization, such as degradation of the ecological
and social environments, the government of Jing-An District,
Shanghai, China, in 2001, adopting the World Health
Organization (WHO)’s concept of “healthy city,” started
implementing a planning process and the following goalattaining program to enhance infrastructures of social and
health systems that supports the fast growing economic
development. This research is to examine whether any
progress has been made since the initiative.
Study Design: Descriptive analysis on comparing a set of
social and health indicator measures before and after the
implementation of the plan. Measures being used covered
aspects of housing or living space, green coverage, air
pollution, health insurance coverage, access to care,
unemployment insurance coverage, and social security. Only
were some short-term measures examined and more
measures will be assessed in the future.
Population Studied: There were about 305,000 people
residing in Jing-An District in 2004.
Principal Findings: Since 2003, with 90 million yuan (unit of
Chinese currency) being spent on varied projects, 190,000
square meters of old style subdivisions have been renovated,
80,000 square meters of public space and facilities have been
upgraded, and kitchens and toilets of 40,000 households in
7,000 old-style buildings have been remodeled. A two-year
project (2004-2005) of installing fire protection devises in old
style buildings, which is spending 52.5 million yuan and will
affect 50,062 households in 10,148 buildings, is on its halfway. The percentage of green areas has been increased from
12.7% in 2001, 14.1% in 2003, to 15.0% in 2004. The average
green space per capita increased to 0.91 square meter in
2004. Passing rates of the automobile emission test were 86,
91, 100, and 96 in 2001, 2002, 2003, and 2004, respectively.
By 11/30/2004, all coal-burning stoves were replaced and coalburning stoves no longer were used in the district.
Percentages of days that the air quality meeted the national
standard were 85%, 77%, and 85% in 2001, 2002, and 2004,
respectively. Finally, in 2004, almost 100% of employees had
health insurance coverage, social security, and unemployment
insurance.
Conclusions: Some short-term progress has been observed
since 2001 in improving the area’s social and living
environments, which, along with the economic progress, have
improved local residents’ living standards, quality of life, and
general wellbeing.
Implications for Policy, Delivery, or Practice: Using the
healthy city concept to enhance social and living environments
is important in developing countries like China that has placed
its major focus on economic development and growth in
recent years. Although some short-term improvement has
been observed in Jing-An, more measures including health
status and longer effects need to be assessed to see weather
the progress is broader and sustainable in the long-run.
Primary Funding Source: Jing-An District Bureau of Health
●Expanding Organ Donation among African Americans in
the United States through Religious Organizations:
Results from an Experimental, Educational Intervention
Roger Durand, Ph.D., Phillip J. Decker, Ph.D., Lamon Atkins,
BS, Kimberly Davis, RN, CPTC, Samuel Holtzman, BS
Presented By: Roger Durand, Ph.D., Professor of Healthcare
Administration, University of Houston-Clear Lake, 2700 Bay
Area Boulevard, Houston, TX 77058; Tel: (281)283-3141; Fax:
(281)283-3136; Email: durand4321@aol.com
Research Objective: Among African Americans in the United
States, the number of organ donors continues to be low
relative to the demand for transplantable human organs.
Among the oft-cited reasons for this low donation rate is that
many African Americans believe organ and tissue donation to
be against their religion. In view of this reported belief, an
educational intervention aimed at influencing African
American attitudes toward, behavior regarding, and intentions
about organ donation, was designed for implementation in
predominantly African American religious organizations
(churches, tabernacles, and mosques). In this research, the
results of this educational intervention were studied.
Study Design: A true experimental design was utilized. A total
of 60 experimental subjects and 41 control subjects were
studied over a two-year period. All subjects were African
Americans enrolled in formal religious education classes at
one of four predominantly African American congregations. A
pretest, consisting of a survey designed to ascertain subjects’
attitudes, behavior (especially engaging in family discussion
regarding donation) and behavioral intentions was initially
administered to study subjects. Experimental subjects were
then presented with educational materials on donation,
materials that especially emphasized religion and donation.
Finally, approximately two years later, a post-test of the same
subjects, again consisting of a survey eliciting the same
information gathered on the pre-test, was administered. A
university IRB approved the study design and measuring
instruments.
Population Studied: The population studied consisted of
African Americans who attended adult, religious education
classes at one of four religious organizations in the greater
Houston, Texas, area.
Principal Findings: In comparison to controls, experimental
subjects were found to have substantially increased (as
indicated principally by lambda and Kendall’s Tau-C statistics)
in their attitude that organ donation is important to the
community, in their feeling that donation is a comfortable
topic for discussion, in their trust in healthcare professionals
regarding the declaration of brain death, and, perhaps most
importantly, in their belief that organ donation is consistent
with their religion. On the other hand, no differences between
experimental and control subjects were found with regard to
either family discussion regarding organ donation or in
intention to donate upon death.
Conclusions: Educational programs offered through religious
organizations appear to offer an important means to improve
the attitudes of African Americans in the United States
regarding organ donation. This is especially so with regard to
the feeling reportedly held by many African Americans that
donation is against one’s religion. On the other, education
alone does not seem likely to bring about appreciable shifts in
actual donation behavior (i.e., engaging in family discussion
about the subject) or in intention to donate.
Implications for Policy, Delivery, or Practice: The findings
and conclusions of this research suggest that organ
procurement organizations (OPOs) can alter the beliefs of
African Americans regarding donation by designing
educational programs for religious organizations and by
working with those organizations to implement the programs
in formal classes. However, increasing the supply of
transplantable organs from among African Americans
depends upon behavioral changes that seem to be difficult to
influence through religious classroom instruction alone.
Primary Funding Source: HRSA
●Patient-Physician Colorectal Cancer Discussions in
Primary Care
Jennifer Elston Lafata, Ph.D., Christina Moon, MA, George
Divine, Ph.D., L. Keoki Williams, M.D., MPH
Presented By: Jennifer Elston Lafata, Ph.D., Director, Center
for Health Services Research, Henry Ford Health System, 1
Ford Place, Suite 3A, Detroit, MI 48202; Tel: (313)874-5454;
Fax: (313)874-7137; Email: jlafata1@hfhs.org
Research Objective: To describe how primary care physicians
and patients discuss colorectal cancer (CRC) screening and
how these discussions impact CRC screening use.
Study Design: We used a mailed survey and retrospective
claims data to compile information on a cohort of insured,
primary care patients eligible for CRC screening. The survey
collected information on the content of patient-physician CRC
screening discussions (including the “5 As:” Assess, Advise,
Agree, Assist, and Arrange) as well as patient preferences for
shared decision making. Survey responses were linked with 5year claims data on prior CRC screening use. We estimate the
proportions of primary care patients receiving recommended
CRC screening, discussing CRC screening with their physician
and, among those discussing CRC with their physician,
reporting different elements of discussion content.
Population Studied: 4,966 health plan enrollees aged 50-80
years with a recent visit to a primary care physician.
Principal Findings: Among the 2,513 survey respondents
(50.6% response rate), 58.7% were female, 68.1% were
married, 53.7% were employed, and 34.4% were African
American. Just over half (54.0%) received recommended CRC
screening and 79.6% reported discussing CRC screening with
their physician. The most frequently discussed screening
modality was colonoscopy (70.7%), followed by
sigmoidoscopy (41.4%) and fecal occult blood testing
(40.6%). Approximately two thirds indicated discussing their
interest in screening (“assess”), 36.1% reported being offered
a choice among different screening modalities (“advise”) and
31.1% were asked about their preferences for different types of
tests (“agree”). Over half (55.5%) reported receiving help
making an appointment (“assist”) and 60.9% indicated
receiving information on how to get test results (“arrange”).
Approximately half of respondents (50.3%) indicated that they
prefer to share decision-making responsibility with their
doctor, 74.7% indicated they were involved in the CRC
screening decision-making process as much as they wanted,
and 13.9 % indicated there was information they wanted but
did not discuss with their physician.
Conclusions: The majority of primary care patients report
discussing CRC screening with their physicians. Yet, the
content of these discussions varies and almost half have not
received recommended CRC screening. Although only a third
reported being offered a choice among available screening
modalities or asked about their preferences, the majority
indicated being involved in the CRC decision-making process
as much as they wanted to be.
Implications for Policy, Delivery, or Practice: Routine
screening is known to be effective at reducing CRC morbidity
and mortality. Yet, many people (including those receiving
routine primary care) fail to receive recommended screening.
Given the limited time physicians and patients have to discuss
CRC screening it is important that discussions be as
productive as possible. Whether the use of a shared decisionmaking process and the “5 As” will lead to improved CRC
screening adherence remains an important question.
Primary Funding Source: Henry Ford Research Fund
●Brand and Generic Medication Prescribing for Medicare
Beneficiaries with Hypertension
Alex Federman, M.D., MPH, Ethan A. Halm, M.D., MPH,
Tsivia Hochman, MS, Albert L. Siu, M.D., MSPH
Presented By: Alex Federman, M.D., MPH, Assistant
Professor of Medicine, Mount Sinai School of Medicine, 1470
Madison Avenue, Box 1087, New York, NY 10029; Tel:
(212)241-8605; Email: alex.federman@msnyuhealth.org
Research Objective: Little is known about the use of generic
drugs by elderly patients in different income and insurance
strata. We examined the relationship of income and
prescription coverage with use of generic and brand
antihypertensive medications in Medicare beneficiaries with
hypertension.
Study Design: We conducted a cross-sectional analysis of
2001 data from the Medicare Current Beneficiary Survey (n =
12,864, 71% response rate). MCBS interviewers record drug
names verbatim from pill bottles or pharmacy receipts 3 times
per year. We included community-dwelling beneficiaries over
65 with hypertension and excluded those with end-stage renal
disease. We further selected respondents who used one or
more drugs from 5 classes: angiotensin converting enzyme
inhibitors (ACEI, 2/10 agents available as generics), alpha1antagonists (AA, 3/3 generics), beta-blockers (BB, 9/9
generics), calcium channel blockers (CCB, 4/8 generics), and
thiazides (3/4 generics). The primary outcome was use of a
brand drug in any of the 5 drug classes. Multisource drugs
listed by brand name were coded as brand agents. When
respondents used both brand and generic drugs we coded the
outcome as generic, although coding as brand in such cases
produced similar analytic results. We modeled the outcome
using generalized estimating equations with a logit link
function in SUDAAN to correct standard errors for the MCBS
sampling design. Income was coded as percent of poverty:
less than 100%, 100-135%, 136-150%, 151-200%, 201-300%,
greater than 300%. Prescription coverage included none,
Medicaid, managed care, self-purchased, employersponsored, and other. All analyses adjusted for age, sex, race,
ethnicity, urban residence, Census region, and number of
chronic diseases and number of antihypertension medications
used.
Population Studied: Community-dwelling Medicare
beneficiaries over 65 with hypertension who used one or more
antihypertension drugs in 2001 (n = 4,639).
Principal Findings: Fifty-five percent of subjects had incomes
less than 200% of poverty and 26% lacked prescription
coverage. Rates of brand antihypertension medication use in
each class were: ACEI, 87%; BB, 25%; CCB, 69%; thiazides,
29%; and AA, 45%. In multivariate analysis income had no
significant association with brand use, either in the primary
analysis or in subgroup analyses of each drug class. In
contrast, lack of prescription coverage and managed care
coverage were inversely associated with brand use compared
to private coverage (adjusted OR 0.74, 95% CI 0.61-0.89, and
AOR 0.80, 0.64-0.99, respectively). The effect was driven by
BB use: in the subgroup of BB users, brand BB use was lower
for those without prescription coverage (AOR 0.67, 0.49-0.91)
and those with managed care (AOR 0.62, 0.43-0.91), whereas
there were no differences by coverage type in the 4 other drug
class subgroups. In the full cohort, neither income nor
prescription coverage were associated with whether a
beneficiary used any type of BB.
Conclusions: Type of prescription coverage has a limited
association with the use of brand versus generic
antihypertension medications by Medicare beneficiaries, and
income has no association.
Implications for Policy, Delivery, or Practice: Physicians are
missing opportunities to reduce the out-of-pocket healthcare
spending of many low-income and underinsured elderly
hypertensives, and reduce future costs for Medicare itself.
Current policy and interventions that promote generic
prescribing should be reevaluated and enhanced.
Primary Funding Source: RWJF
●A Comparison of Dental Costs for Medicaid and S-SCHIP
Programs
Stephen Flach, M.D., Ph.D., Peter Damiano, DDS, MPH,
Elizabeth Momany, Ph.D., Knute Carter, BS
Presented By: Stephen Flach, M.D., Ph.D., Assisstant
Professor, University of Iowa, Public Policy Center, 217 South
Quadrangle, Iowa City, IA 52242; Tel: (319) 384-8266; Email:
stephen-flach@uiowa.edu
Research Objective: The State Children’s Health Insurance
Programs (S-SCHIP) extended dental coverage to children not
eligible for Medicaid. Creation of this newly covered
population led us to ask whether dental costs would be higher
than in traditional Medicaid programs due to pent-up demand
derived from untreated dental need. Using administrative
data, we evaluated the costs of the first episode of dental care
for newly enrolled children in the Iowa Medicaid program and
the three different S-SCHIP dental plans.
Study Design: We identified all new enrollees (who had not
been enrolled in the previous 12 months) in the Iowa
Medicaid and S-SCHIP programs from July 1, 2001 to June 30,
2003, who utilized dental care and were enrolled for at least
four months after their initial dental visit. We defined the four
months following the initial dental visit as the first “episode of
care”, based on dental judgment and an analysis that
indicated that 94% of the six-month aggregate dental costs
after the first visit occurred within the first four months. We
used claims data to record all dental care utilization, and
categorized services into: preventive/ diagnostic, routine
restorative, complex restorative, and all other services using
procedure codes. Costs were applied to procedure codes
using charges from the 2003 American Dental Association
(ADA) survey of dental fees. We categorized subjects as “early
utilizers”; first dental visit within three months of enrollment,
“middle utilizers”; first seen in 4-12 months, and the “late
utilizers”; first seen after more than 12 months. We performed
multivariate ordinary least squares (OLS) regression with total
costs and the natural logarithm of total costs as dependent
variables, and the time to first visit and health plan type as the
key explanatory variables, controlling for age, gender, and
urbanicity.
Population Studied: Enrollees in the three S-SCHIP and the
Medicaid programs in Iowa.
Principal Findings: The mean total cost for the first episode
of dental care was significantly higher in Medicaid ($376
versus $285, $223, and $ 328 for the three S-SCHIP plans).
More S-SCHIP subjects were seen within three months of
enrolling (37%, 50%, and 46%) than in Medicaid (33%). All SSCHIP dental plans had a greater share of expenses spent on
preventive and diagnostic care (42%, 49%, 40%) compared to
Medicaid (33%), while children in the Medicaid program had a
higher percent of total costs devoted to complex restorative
costs (24% verses 19%, 17%, and 18% for the S-SCHIP plans).
OLS regressions indicated that costs for “early utilizers”
during the initial episode of care was $71 higher than “middle
utilizers” and $35 higher than “late utilizers”. Each S-SCHIP
plan was less costly than the Medicaid plan, with average
differences of $99, $193, and $37 per first episode of dental
care.
Conclusions: Total costs of the first episode of dental care are
greater for those seeking care in the first 3 months after
enrolling in the program. Costs were lower for children in the
S-SCHIP program, and more focused on prevention.
Implications for Policy, Delivery, or Practice: This report
provides important information for policymakers concerning
the costs of dental coverage in S-SCHIP plans.
Primary Funding Source: AHRQ
●Direct Cost of Treatment in Autism: The Burden of
Illness
Scott Flanders, Ph.D., MS, Julie Whitworth, PharmD, MPA,
Mohamed A. Hussein, MSCS, MSPH, Daniel R. Vanderpoel,
PharmD, Timothy Sandman, MBA, Luella Engelhart, MS
Presented By: Scott Flanders, Ph.D., MS, Associate Director,
Outcomes Research, Janssen Medical Affairs, 740 Waterford
Drive, Grayslake, IL 60030; Tel: (847)548-8977; Fax: (847)5489008; Email: sflander@janus.jnj.com
Research Objective: To compare the direct treatment costs
for children newly diagnosed with the pervasive
developmental disorder autism, versus children newly
diagnosed with diabetes or asthma, in a privately insured
population.
Study Design: A retrospective database analysis was
completed using claims derived from the administrative
database of a health benefits organization. Six months of prediagnosis and 12 months of post-diagnosis direct healthcare
cost claims were analyzed for children newly diagnosed with
autism, diabetes, or asthma. Healthcare costs included
inpatient, outpatient, pharmacy, and special costs, which
included physical and speech therapy, and emergency room
visits. Non-parametric (Dunn Test) and parametric
(Generalized Linear Model) comparisons of post-diagnosis
costs were completed. Age, gender, insurance plan type, and
costs in the pre-diagnosis period were controlled for within the
multivariate model.
Population Studied: The study population was comprised of
children aged 3 – 17 years newly diagnosed with autism (N =
470), diabetes (N = 522), or asthma (N = 550). All subjects
were continuously enrolled in an HMO, PPO, or Medicaid
plan type throughout the study’s duration.
Principal Findings: The autistic cohort exhibited a higher
proportion of male subjects (80.6%) and a lower mean age
(9.4 years) than the diabetic children (49.8%, 12.6 years) or
asthmatic children (52.9%, 9.9 years). Autistic children
exhibited significantly greater median total healthcare costs
than children with asthma ($2103.58 vs. $850.27, P < 0.05) or
diabetes ($2103.58 vs. $1605.20, P < 0.05) in the 12-month
post-diagnosis period. After controlling for confounders,
autistic children exhibited significantly greater 12-month postdiagnosis total healthcare costs than asthmatic children (P <
0.0001); the difference in total healthcare cost between
autistic and diabetic children was non-significant (P = 0.84).
Conclusions: Results from this study in a privately insured
population suggest that autistic children may incur equivalent
or significantly greater healthcare costs than children
diagnosed with diabetes or asthma in the 12-month postdiagnosis period of their diseases.
Implications for Policy, Delivery, or Practice: This study
highlights the costs of care associated with autism as they
compare to other growing public health concerns for children,
such as asthma and diabetes.
Primary Funding Source: Janssen Medical Affairs
●Using the SF-12 to Predict Medical Expenditures
John Fleishman, Ph.D., Joel Cohen, Ph.D., Williard Manning,
Ph.D., Mark Kosinski, MA
Presented By: John Fleishman, Ph.D., Senior Sociologist,
AHRQ, 540 Gaither Road, Rockville, MD 20850; Tel: (301)4271674; Fax: (301)427-1276; Email: jfleishm@ahrq.gov
Research Objective: Relatively few studies have used selfreported health status in models to predict medical
expenditures, and most of these have used the SF-36. The
extent to which the shorter SF-12 predicts expenditures is not
known. This study examines the extent to which the SF-12
measure of health status prospectively predicts medical
expenditures in a nationally representative sample.
Study Design: Interviews obtained data on demographics and
selected chronic conditions. Respondents completed the SF12 in a questionnaire. Data on expenditures incurred
subsequent to the interview were obtained in part from
provider records. We examined different regression model
specifications and compared different statistical estimation
techniques (e.g., 2-part OLS models versus generalized linear
models).
Population Studied: We used nationally representative data
from the 2000-2001 panel of the Medical Expenditure Panel
Study. Analyses were based on 5,542 respondents with
complete data.
Principal Findings: Adding the SF-12 to a generalized linear
regression model with a Poisson distribution improved the
prediction of subsequent medical expenditures. In a model
with only age and gender, adding the SF-12 increased Rsquared from 0.06 to 0.13. The coefficients for the Physical
Component Summary (PCS) and the Mental Component
Summary (MCS) of the SF-12 for this model were -0.045
(p=<.01) and -0.012 (p< .01), respectively. In a model
including demographic characteristics, chronic conditions and
prior expenditures, adding the SF-12 increased the R-squared
from 0.26 to 0.29. The coefficients for the PCS and the MCS
for this model were -0.025 (p<.001) and -0.005 (p=.15),
respectively. Models estimated using ordinary least squares
had undesirable properties. In terms of R-squared, a
generalized linear model (GLM) with a Poisson variance
function was consistently superior to a GLM with a gamma
variance function.
Conclusions: Information on self-reported health status,
derived from the SF-12, is useful in predicting medical
expenditures. The extent to which the SF-12 adds predictive
power over a comprehensive array of diagnostic data remains
to be examined.
Implications for Policy, Delivery, or Practice: The
association between SF-12 scores and medical expenditures
illustrates the potential use of self-reported health status in
the risk stratification of patients. The SF-12 may be useful for
disease management programs and for adjusting capitation
rates.
Primary Funding Source: AHRQ
●Using the SF-12 Health Status Measure to Predict
Medical Expenditures
John Fleishman, Ph.D., Joel W. Cohen, Ph.D., Willard G.
Manning, Ph.D., Mark Kosinski, MA
Presented By: John Fleishman, Ph.D., Senior Social Scientist,
Center for Financing Access and Cost Trends, Agency for
Healthcare Research and Quality, 540 Gaither Road, Rockville,
MD 20850; Tel: (301)427-1674; Fax: (301)427-1276; Email:
jfleishm@ahrq.gov
Research Objective: Relatively few studies have used selfreported health status in models to predict medical
expenditures, and most of these have used the SF-36. The
extent to which the shorter SF-12 predicts expenditures is not
known. This study examines the association between SF-12
summary scores and prospective expenditures, controlling for
a variety of demographic and clinical variables.
Study Design: Interviews obtained data on demographics and
selected chronic conditions. Respondents completed the SF12 in a questionnaire. Data on expenditures incurred
subsequent to completing the questionnaire the were
obtained in part from provider records. We examined
different regression model specifications (e.g., including
versus excluding information on selected chronic conditions)
and compared different statistical estimation techniques (e.g.,
2-part models versus generalized linear models).
Population Studied: We used data from the 2000-2001 panel
of the Medical Expenditure Panel Study, which comprises a
nationally representative sample. Analyses were based on
5,542 respondents with complete information and who
completed the SF-12 themselves.
Principal Findings: Adding the SF-12 to a generalized linear
regression model with a Poisson distribution improved the
prediction of subsequent medical expenditures. In a model
with only age and gender, adding the SF-12 increased Rsquared from 0.06 to 0.13. The coefficients for the Physical
Component Summary (PCS) and the Mental Component
Summary (MCS) of the SF-12 for this model were -0.045
(p=<.01) and -0.012 (p< .01), respectively. In a model
including demographic characteristics, chronic conditions and
prior expenditures, adding the SF-12 increased the R-squared
from 0.26 to 0.29. The coefficients for the PCS and the MCS
for this model were -0.025 (p<.001) and -0.005 (p=.15),
respectively. Models estimated using ordinary least squares
had undesirable properties. In terms of R-squared, a
generalized linear model (GLM) with a Poisson variance
function was consistently superior to a GLM with a gamma
variance function.
Conclusions: The link between SF-12 scores and medical
expenditures illustrates the potential use of self-reported
health status in the risk stratification of patients. Information
on self-reported health status, derived from the SF-12, is useful
in predicting medical expenditures. The extent to which the
SF-12 adds predictive power over a comprehensive array of
diagnostic data remains to be examined.
Implications for Policy, Delivery, or Practice: The SF-12 may
be useful for disease management programs and for adjusting
capitation rates.
Primary Funding Source: AHRQ
●Variations in Educational Debt Among USMGs
Completing Graduate Medical Training in New York State,
2000-2003
Gaetano J. Forte, BA, David P. Armstrong, BA
Presented By: Gaetano J. Forte, BA, Director of Information
Management, Center for Health Workforce Studies, University
at Albany, School of Public Health, 1 University Place, B334,
Rensselaer, NY 12144; Tel: (518)402-0250; Fax: (518)402-0252;
Email: gjf01@health.state.ny.us
Research Objective: To describe variations in educational
debt among new physicians. To explore the impact of
variations in educational debt on career decisions upon
completion of graduate medical training.
Study Design: The data analyzed for this report were collected
via an annual survey of all physicians completing a residency
or fellowship training program in New York State. The survey
was conducted in collaboration with the teaching hospitals in
the state from 2000 to 2003. The questionnaire, completed
by each individual resident, collected extensive information on
their demographic and educational backgrounds, their posttraining plans and their perceptions of the job market for new
physicians. Between 2000 and 2003 almost 12,000
physicians completing training in New York State responded
to the survey (approximate response rate of 65%). A general
linear model was used to estimate levels of educational debt
among graduates of medical schools in the US (USMGs)
controlling for a number of important variables, including age,
gender, race/ethnicity, type of medical education, and
specialty training. A multivariate logistic regression model
was employed to explore the effects of educational debt on
decisions to continue training in a subspecialty among
USMGs completing General Pediatrics and General Internal
Medicine training programs.
Population Studied: USMG residents and fellows completing
a residency training program in New York State between 2000
and 2003.
Principal Findings: Average levels of debt increased in each
year of the survey. Levels of educational debt varied
significantly by specialty, type of medical education (allopathic
and osteopathic), and race/ethnicity. Educational debt varied
by as much as two to one across the specialties. Higher levels
of education debt were associated with increased likelihood of
going into patient care practice rather than going on to
subspecialty training.
Conclusions: Educational debt continues to increase for new
physicians. There are a number of important factors that
affect the educational debt of new physicians. The findings of
this study suggest that specialty, type of medical education,
and race-ethnicity are among the most influential factors
affecting levels of educational debt of new physicians. Level of
debt is associated with specific career choices among new
physicians.
Implications for Policy, Delivery, or Practice: With a
renewed discussion of bolstering the national physician supply
through the expansion of medical education capacity in the
US, determining how to finance this endeavor will have to
consider the role educational debt plays in the career
decisions of physicians. Because levels of educational debt
vary significantly, certain groups are saddled with high and
increasing debt upon completion of their graduate medical
training. Understanding the relationship between educational
debt and career choices is critical in developing policies that
are most likely to ensure that appropriate care is available to
those who need it.
Primary Funding Source: HRSA
●Use of Indirect Measures of Race/Ethnicity to Examine
Disparities in Managed Care
Allen Fremont, M.D., Ph.D., Arlene Bierman, M.D., MS, Mona
Shah, MS, Chloe Bird, Ph.D., Steve Wickstrom, MS
Presented By: Allen Fremont, M.D., Ph.D., Natural Scientist,
Health, RAND, 1776 Main Street, Santa Monica, CA 90407;
Tel: (310) 663-7916; Email: fremont@rand.org
Research Objective: Although managed care plans routinely
track quality measures, few examine whether their
performance differs by enrollee race/ethnicity, in part because
plans do not collect that information. We sought to assess
the validity of using indirect measures of race/ethnicity based
on geocoding to examine disparities in care.
Study Design: Validation study comparing estimates of
managed care enrollee’s racial characteristics and associated
disparities in quality of care for diabetes and cardiovascular
disease. Enrollee’s address was used to determine the Census
Block Group (e.g. a small neighborhood) where they lived.
Those living in a predominantly black neighborhood (i.e., with
> 66% of the residents black) were identified as likely to be
black. Medicare+Choice enrollee race data was also obtained
from the CMS Denominator file. Individual-level measures of
race were not available for commercial enrollees. Quality was
measured by performance (i.e., percentage of eligible patients
who received indicated care) on six NCQA HEDIS 2000
process of care measures including: in diabetics, an annual
check of glycosolated hemoglobin (HgbA1c), low density
lipoprotein (LDL), and urine protein levels, as well as a dilated
eye exam; beta-blocker prescription for myocardial infarction
(MI) patients; and LDL check in patients after a cardiac event.
Population Studied: Managed care enrollees from nine
Medicare+Choice and 10 commercial plans serving
approximately 195,116 Medicare and 2,151,050 commercially
insured enrollees across four regions. The analytic sample
included the 16,262 Medicare+Choice enrollees and 37,404
commercial enrollees who were met NCQA eligibility criteria
for the HEDIS diabetic or cardiovascular measures.
Principal Findings: 89% of Medicare+Choice enrollees
identified as black in CMS files were also identified as likely to
be black based on geocoding. Of the 11% of black patients
misclassified, 9% of those were black enrollees living outside
of predominantly black neighborhoods. In the analyses using
geocoded measures, racial disparities were present on 5 of 6
measures, with the largest disparities between racial groups
on Beta-blocker after MI and LDL checks, which both exceeded
20 percentage points (P<.01). Estimated disparities were
nearly identical in the analyses using the CMS measure of race
with all estimated disparities within 1 percentage point of the
estimates using the geocoded measure of race. A similar
pattern of racial disparities was observed among commercial
enrollees when race was based on a geocoded measure.
However, no individual-level measure of race was available for
commercial enrollees to assess disparities or compare results
to those based on the geocoded measure.
Conclusions: Using geocoded measures of race, we found
disparities within both Medicare+Choice and commercial
plans on HEDIS measures of diabetes and cardiovascular care
effects. Estimated disparities in Medicare+Choice were
similar regardless of whether a geocoded measure of race or
one based on CMS data was used.
Implications for Policy, Delivery, or Practice: Our study
suggests that health plans can use indirect measures of race
based on geocoding to begin examining racial and SES
disparities among their enrollees. However, additional
validation of the use of such indirect measures in commercial
plans is still needed.
Primary Funding Source: AHRQ
●The Effect of Depression and Functional Impairment on
Healthcare Services Use of Functionally Impaired Elderly
Primary Care Patients
Bruce Friedman, Ph.D., MPH, Yeates Conwell, M.D., Rachel L.
Delavan, MS
Presented By: Bruce Friedman, Ph.D., MPH, Assistant
Professor, Community and Preventive Medicine, University of
Rochester, 601 Elmwood Avenue, Box 644, Rochester, NY
14642; Tel: (585)273-2618; Fax: (585)461-4532; Email:
Bruce_Friedman@urmc.rochester.edu
Research Objective: For functionally impaired, elderly
primary care patients living in the community (not in nursing
homes), to describe how use of 24 healthcare services
compares (1) among those with major depression, clinically
significant depressive symptoms but not major depression,
and no depression, and (2) among those with mild, moderate,
and severe functional impairment.
Study Design: A longitudinal observational design examining
health services use data from the control group (N=343) of the
Medicare Primary and Consumer-Directed Care
Demonstration. Patients and/or their caregivers completed a
daily healthcare services utilization diary over 24 months. Data
on hospital, nursing home, and assisted living use were
obtained from facilities. Baseline data were collected on
depression and functional impairment. Mild impairment was
defined as dependence in 3-6 instrumental activities of daily
living (IADL) but no activities of daily living (ADL), moderate
impairment as dependence in 1-3 ADLs, and severe
impairment as dependence in 4-6 ADLs. Chi Square tests and
tests for trend were used to compare probability of use, and
amount of use conditional on some use.
Population Studied: Elderly Medicare primary care patients
living in the community in 8 New York, 6 West Virginia, and 5
Ohio counties. Individuals had to be functionally impaired (2+
ADLs or 3+ IADLs) with recent significant healthcare services
use.
Principal Findings: Comparing major depression with no
major depression at the time of study entry, probability of use
differed significantly for only one of 24 services over the next 2
years. Patients with major depression were more likely to use
adult day care. Among users, amount of use differed
significantly for only one service. Patients with major
depression had fewer psychiatrist office visits.
Among the 283 cognitively intact patients, probability of use
was lowest for those with no depression, intermediate for
clinically significant depression but not major depression, and
highest for major depression for specialist physician office
visits, hospital admissions, emergency room visits, therapist
office visits, and taxi/van trips. The opposite pattern occurred
for physician home care visits. Among users, depressed
patients had significantly more podiatrist office visits and
taxi/van trips while patients with no depression had the most
audiologist office visits.
Among the 301 patients who had at least 3 IADLs at baseline
(42 other patients were no longer impaired by that time),
probability of use was lowest for those with mild functional
impairment, intermediate for moderate impairment, and
highest for severe impairment for physician assistant/nurse
practitioner, nurse, therapist, home health aide/personal care
aide, and companion home visits and for adult day care. The
opposite pattern occurred for primary care and dentist office
visits. Among users, hospital admissions and days and
ambulance trips were highest for the severely functionally
impaired.
Conclusions: Depression appears to affect different
categories of healthcare services than does functional
impairment, both for probability of use and for amount of use
conditional on some use.
Implications for Policy, Delivery, or Practice: More
attention should be paid to the differential impacts of
depression and functional impairments on health services use
of elderly Medicare primary care patients.
Primary Funding Source: NIMH
●Geographic Factors and Hospital Characteristics that
Prevent Admission to High-volume Surgical Hospitals in
Japan
Kiyohide Fushimi, M.D., Ph.D., Sayuri Shimizu, Noritoshi
Yoshii, M.D., Toshiro Kamata, M.D., Hidenori Imai, Kaname
Yamamoto, M.D.
Presented By: Kiyohide Fushimi, M.D., Ph.D., Associate
Professor, Department of Health Care Informatics, Tokyo
Medical and Dental University Graduate School of Medicine,
1-5-45 Yushima, Bunkyo-ku, Tokyo, 1138519; Tel: 81(3)52835788; Fax: 81(3)5283-5788; Email: kfushimi.hci@tmd.ac.jp
Research Objective: It has been shown that the quality of
surgical care of hospitals may be associated with the volume
of surgical procedures. Measures have recently been taken to
increase the volume of surgical procedures in regional
operation centers by Japanese government; however, the
effectiveness of the measures has not been confirmed. It has
been pointed out that geographic factors may prevent,
especially in the rural areas, the establishment of regional
operation centers to effectively provide high-quality surgical
cares. The purpose of this study was to elucidate geographic,
hospital, and patient factors that determine the admission to
high-volume surgical hospitals or low-volume alternative ones.
Study Design: High-volume surgical hospitals for cardiac
surgery, lung surgery, brain surgery, percutaneous coronary
intervention (PCI) were determined as the number of the
corresponding operations being 50 or greater per hospital per
year according to the government guidelines. Low-volume
surgical hospitals were determined as other hospitals where at
least one corresponding operation was performed per year.
Hospital factors were obtained from the Survey of Medical
Care Institutions and patient factors were obtained from the
Patient Survey operated by the Ministry of Health, Labour and
Welfare of Japan in 1996, 1999, and 2002. The distances
between patient residences and hospitals were determined
from the location of the hospitals and the representative
points of patient residence areas. Multivariable logistic
regression models were used with dichotomous dependent
variable for the admission to high-volume hospitals or lowvolume hospitals. Independent variables were bed volume,
teaching status, ownership, facilities, work force, transfer
status, and distances from patient residence of admitted
hospitals and of control alternative hospitals. The control
alternative hospitals were determined as the nearest lowvolume hospitals for the patients admitted to high-volume
hospitals and as the nearest high-volume ones for the patients
admitted to low-volume ones. Covariates included gender,
age, outcome, and the length of stay of patients. Statistical
analyses were performed by Stata/SE 8.0.
Population Studied: Records for 1387 patients with cardiac
surgery, 1848 with lung surgery, 2759 with brain surgery, 12252
with PCI admitted for acute care from a nationally
representative sample of 2,047,289 discharged patients from
the Patient Survey were analyzed.
Principal Findings: Factors in favor of admission to highvolume hospitals were transfer from other hospitals (OR=2.58,
CI: 1.82-3.67), referral by physicians (OR=2.59, CI=1.82-3.67),
teaching status of high-volume hospitals (OR=2.57, CI: 1.624.04), and private ownership (OR=1.73, CI: 1.05-2.88) of lowvolume hospitals. Factors against to the admission to highvolume hospitals were distances to high-volume hospitals
(OR=0.997 per km, CI: 0.995-.999). The distances to lowvolume hospitals were not significant (OR=1.00).
Conclusions: We found that physicians referral and teaching
status contributes to induce patients to high-volume surgical
hospitals and that geographic factors are statistically
significant but substantial only when the high-volume hospital
is very far.
Implications for Policy, Delivery, or Practice: Health policy
measures to promote referral to high-volume surgery
hospitals and to provide information of ‘good’ hospitals to
patients who might choose low-volume surgery hospitals will
improve the quality and efficiency of surgical care.
Primary Funding Source: Other Govt, Health and Labour
Sciences Research Grants for Research on Applied use of
Statistics and Information, for Comprehensive Research on
aging and Welfare, and for Special Researches from the
Ministry of Health, Labour and Welfare of Japan
●Analysis of Obesity in Hawaii's Children
Krista Gronley, MPH, MBA, Deborah A. Taira, Sc.D.
Presented By: Krista Gronley, MPH, MBA, Project Manager,
Research, Care Management, Blue Cross Blue Shield of
Hawaii, 818 Keeaumoku Street, Honolulu, HI 96814; Tel:
(808)948-6979; Fax: (808) 948-6043; Email:
krista_gronley@hmsa.com
Research Objective: To evaluate the rate of obesity of
Hawaii’s children age 2 through 14.
Study Design: This study used data from the 2004 member
satisfaction survey conducted by a large health plan to
investigate the rate of obesity by age, island, and ethnicity
grouping in children age 2 through 14 (n=4,096). We
converted self-reported height and weight to a body mass
index (BMI) and used the Clinical Growth Charts (body massfor-age) from the National Center for Health Statistics to
categorize the BMI’s into underweight, normal, at risk and
overweight. Members who did not report height and weight
were excluded from the data. Zip-codes were used to identify
isle of residence and ethnicity was self-reported. Members
who indicated more than one ethnicity were place in a mixed
category, except for Hawaiian. Members who marked
Hawaiian along with any other ethnicity were categorized as
Hawaiian.
Population Studied: The study sample included health plan
members ages 2 through 14 who completed, or whose parents
completed, the 2004 member satisfaction survey and reported
their height and weight (n=2,280). Each of the children
participating in the survey had seen a physician at least once
in the prior 12 months.
Principal Findings: We found that 21.3% of the population
are above the 95th percentile of the Clinical Growth Charts
and considered to be overweight and 11.8% are in the risk
category, between the 85th and 95th percentile. Those in the
overweight category were more likely to be female, age 2
through 5, live on Maui or Molokai and be of Hawaiian,
Samoan or Filipino ethnicity. The rate of over-weight or atrisk-weight declines as age increases.
Conclusions: A full third of the study population are above
the 85th percentile on the Clinical Growth Charts (body mass
index-for age). There are significant differences by age and by
ethnicity but not by island of residence, gender or health plan
product.
Implications for Policy, Delivery, or Practice: Targeted
interventions that are age and ethnicity specific may provide
members with the needed information and tools to achieve
and maintain a healthy body-mass-index.
Primary Funding Source: No Funding Source
●Child Health Beliefs and Behaviors of Child Care
Directors: Head Start vs. Non Head Start Centers
Ruchi Gupta, M.D. MPH, Paula Duncan, M.D., John M
Pascoe, M.D., MPH, Linda Southward, Ph.D., Peter Gorski,
M.D., MPA, Robert Greenberg, M.D.
Presented By: Ruchi Gupta, M.D., MPH, Pediatrics, Institute
for Health Services Research and Policy and Children's
Memorial Hospital, 339 East Chicago Avenue., Room 712,
Chicago, IL 60611-3071; Tel: (312)503-0429; Fax: (312)503-2936;
Email: r-gupta@northwestern.edu
Research Objective: Approximately 75% of preschool children
(23 million) are in some form of child care. Head Start is the
only national child care program developed to provide
comprehensive education, health, and nutrition services to
low-income children. Our objective was to compare directors
child health beliefs and practices in both Head Start and nonHead Start child care centers.
Study Design: A random telephone survey was conducted
with directors of licensed child care centers in four states. Chisquared and T-tests were used to evaluate differences between
Head Start and non-Head Start programs.
Population Studied: Child care directors in four states
including Mississippi, Vermont, Florida and New Mexico were
randomly selected for the study.
Principal Findings: 2201 surveys were completed (response
rate of 89%), of which 191(9.1%) were Head Start centers. Forprofit and non-profit centers were analyzed together after
preliminary analysis showed concordance. Fewer non-Head
Start centers reported screening for health problems
compared to Head Start centers (63% vs. 93%, P<0.01). 97%
of Head Start programs felt screening was
moderately/extremely useful compared to 81% of non-Head
Start programs (p<0.01). 98% of Head Start programs provide
parents with information about their child's health needs
compared to 91% of non-Head Start programs (p<0.01). Head
Start centers used more consultation by health professionals
including physicians, nurses, dentists, dental hygienists,
dieticians and mental health professionals (p<.01).
Barriers including, lack of time, someone to provide
information, funds and English comprehension were not
significantly different between the Head Start and non-Head
Start centers.
Conclusions: Head Start continues its strong commitment to
child health by providing universal screening and 2-3 times
more consultation by health professionals than non-Head
Start child care centers.
Implications for Policy, Delivery, or Practice: Improving the
health of preschool children may involve using Head Start as a
model and advocating for similar health services in all child
care centers.
Primary Funding Source: SSRC, Mississippi State University
●Reduction in Emergency Room Visits, Hospital
Admissions, and Clinical Outcomes After Enrollment in a
Mediation Access Program
Gary Harmon, MPH, Robert Federici, MSPH, Wendy Roy, BS,
Keith Ashby, M.D., Danny Jackson, John Lefante Jr., Ph.D.
Presented By: Gary Harmon, MPH, Epidemiologist,
Biostatistics, Tulane University School of Public School and
Tropical Medicine, 1440 Canal Street, New Orleans, LA 70112;
Tel: (504)988-2891; Fax: (504)988-1706; Email:
gharmon@tulane.edu
Research Objective: To determine change in emergency
room visits, hospital admissions, and clinical outcomes for
participants in the Cenla Medication Access Program in rural
central Louisiana.
Study Design: Pre-post longitudinal cohort where outcomes
for participants are assessed before and after enrollment to
look for change. Participants are enrolled in the CMAP and
begin receiving chronic care prescription medications at
greatly reduced costs ($3 per prescription). Participants are
consented to allow the evaluators access to their hospital
records. Emergency room visits and hospital admissions in
the 6 months prior to enrolling in CMAP are compared to
usage in the 6 months after enrollment to assess change.
Chart abstractions are performed to look for changes in blood
pressure, blood glucose, and blood lipids from the period
before enrollment into CMAP compared to the period after
enrollment.
Population Studied: Over 7000 residents of central Louisiana
who access the public hospital in Pineville, Louisiana.
Patients are eligible if they are receiving medications for a
chronic illness, meet income guidelines, and do not have any
type of insurance that pays for medications. The top five
diagnoses for this population are hypertension, diabetes
mellitus, hyperlipidemia, arthritis, and gastroesophageal reflux
disease. Patients are seen in the hospital clinic and are
enrolled through Social Services after meeting eligibility
requirements.
Principal Findings: Through the first 2 years of the project,
there has been an observed reduction of 33.6% in ER visits
and a 72.2% reduction in hospital admissions when
comparing 6 months prior to enrollment to 6 months post
enrollment. Reductions of 4% and 5% for systolic and
diastolic blood pressure, respectively, have been observed
after adjusting for numerous covariates (age, race, gender,
primary diagnosis, number of medications patient receives).
There has been an observed reduction of 17% in average
blood glucose, and an 11% reduction in average hemoglobin
A1c. Reductions in total cholesterol and LDL cholesterol of
20% and 25%, respectively, have been observed.
Conclusions: Preliminary analyses indicate that patients in
the Cenla Medication Access Program have reductions in the
use of the emergency room and fewer hospital admissions.
Participants have also experienced reductions in blood
pressure, blood glucose, and blood lipids.
Implications for Policy, Delivery, or Practice: Results
indicate that providing medications at greatly reduced costs to
individuals who otherwise cannot afford them results in
reduced usage of emergency care and hospital admissions.
Also demonstrated is that patients will experience reductions
in clinical measures targeted by the medications. The
reduction in emergency room admissions and hospital
admissions can lead to a lowering of the financial burden
incurred by state hospitals, and the clinical improvements
seen in the patients can lead to better quality of life.
Primary Funding Source: The Rapides Foundation
●Exploring the Link between Asthma Hospital Services
and Air Quality in New Hampshire
Aichatou Hassane, MA, Ross Gittell, Ph.D., Robert Woodward,
Ph.D., Cameron Wake, Ph.D.
Presented By: Aichatou Hassane, MA, Ph.D. Student,
Whittemore School of Business and Economics, University of
New Hampshire, 15 College Road, McConnell Hall, Durham,
NH 03824; Tel: (603) 862-7071; Fax: (603) 862-3461; Email:
ahassane@cisunix.unh.edu
Research Objective: This study used the spatial, temporal,
and age-specific patterns of asthma hospital services to
identify potential asthma triggers.
Study Design: We merged hospital respiratory services data
with data on air pollutants for Ozone (O3), Sulfur Dioxide
(SO2), and Carbon Monoxide (CO) obtained from local
Environmental Protection Agency (EPA) and University
monitoring sites. To analyze the relationship between asthma
admission and air pollution, we first ran multiple OLS
regression of asthma daily services on daily air pollutants and
weather. Second, we compared cumulative daily asthma
services relative to cumulative daily concentrations of air
pollutants for various age groups, locations, and years.
Pollutants were measured in parts per billion (ppb) with data
on daily 1-hour maximum for O3 and CO and daily average for
SO2.
Population Studied: We collected detailed admissions and
outpatient contacts (services) from three New Hampshire
Seacoast area hospitals.
Principal Findings: We found a strong seasonal variation
with the lowest services in the summer and a strong peak in
the fall, but at different times in different years. We also
observed that individuals age 0-4 and 18-24 had the highest
rates of asthma services and the largest seasonal variation.
The multiple OLS regression of daily asthma on pollutants
(CO, SO2, and O3), controlling for daily outside temperature
and relative humidity, but without seasonal adjustment,
revealed only one significant correlation, a negative
relationship between asthma services and O3. An increase of 1
ppb in the daily 1-hour maximum O3 led to a 0.6% decrease in
the number of daily asthma services (P=0.08). The O3
regression coefficient became insignificant when a dummy for
August was added. Our second and more detailed method of
analyzing the cumulative daily asthma services relative to the
cumulative daily concentration of air pollutants showed no
evidence of a link between asthma services and the levels of
air pollutants. The occasional changes in the slope of the
cumulative daily asthma graphs occurred at substantially
different times than the changes in the slope of the
accumulative concentration levels of CO, SO2, or O3.
Conclusions: In contrast to the substantial literature
establishing a link between air quality and asthma, our
preliminary analyses of more detailed data found no
confirmation of causality. We note that our finding that high
levels of ozone were associated with lower asthma services is
similar to that reported by Neisdell (2004). He argued that
California smog alerts in period of high ozone led to
avoidance behavior. The EPA also issued smog alerts in New
England during this period.
Implications for Policy, Delivery, or Practice: An
understanding of the exact causes of asthma hospital services
is important both for hospital management teams and
employee benefit managers. Our study confirmed the
findings of Bates et al. (1998) and Silverman (2003), which
identified low summer and high fall asthma services and
greater fluctuations in the very young. But our results conflict
with Garty, et al. (1998) and Schwartz et al. (1993) who linked
asthma services to poor air quality. Additional studies of
other pollutants, pollen, and weather conditions are necessary
to determine the environmental triggers of asthma services.
Primary Funding Source: National Oceanic and Atmospheric
Administration
●Health Care Experiences among Working-Age Adults with
Physical Disabilities Enrolled in a Medicaid Managed Care
Program
Pei-Shu Ho, Ph.D., Susan E. Palsbo, Ph.D., Phillip W. Beatty,
MA
Presented By: Pei-Shu Ho, Ph.D., Senior Research Associate,
Center for Health & Disability Research, National
Rehabilitation Hospital, 102 Irving Street NW, Room 1067,
Washington, DC 20010; Tel: (202) 877-1787; Fax: (202) 7267521; Email: pei-shu.ho@medstar.net
Research Objective: We compared the health care
experiences of fee-for-service versus a Medicaid managed care
program among working-age adults with physical disabilities
living in Minneapolis/St. Paul metropolitan area. We
hypothesized that the need for care, quality of care and access
to care would increase in the Medicaid managed care program
that used care coordinators and disability-sensitive provider
panels.
Study Design: We used retrospective, one-group pretestposttest study design in which adults age 18-64 with physical
disabilities were asked about their health care experiences
before and after they enrolled in a Medicaid managed care
program. Study participants responded to the CAHPS®-like
survey over the phone at enrollment and one year later. Data,
collected from the longitudinal surveys and intake
assessment, were used for analyses. We used paried
McNemar test and Marginal Homogeneity test for
comparative analyses.
Population Studied: Study participants were 124 adults
enrolled in the Minnesota Disability Health Options
(MnDHO) program, a demonstration Medicaid managed care
program for working age adults with physical disabilities.
Principal Findings: The need for care of our study
participants was greater in the year after they enrolled in the
MnDHO program except for rehabilitation therapy and
alternative care. In particular, the need for primary care doctor
(p=0.005), personal care attendants (p=0.001), and
transportation assistance (p<0.001) was significantly
increased after enrolled in the MnDHO program. The
percentage of participants who reported having received
needed care also increased in the year following MnDHO
enrollment, especially in accessing their primary care doctor
(p<0.001) and getting needed medical equipment (p=0.008).
Significant improvement was also found in areas such as
health care coordination, quality of interaction with health care
providers, and promptness of care.
Conclusions: Our findings show that the use of communitybased health care services has significantly increased after the
MnDHO enrollment. The respondents are also more likely to
receive needed care and are satisfied with the care they have
received after they enrolled in the MnDHO program.
Implications for Policy, Delivery, or Practice: Our results
underscore the positive impact of disability literate care
coordinators and providers on meeting the health care needs
and providing quality care to people with physical disabilities.
Primary Funding Source: RWJF
●Gender Disparities in Percutaneous Coronary
Interventions for Acute Myocardial Infarction in
Pennsylvania
Christopher Hollenbeak, Ph.D., Carol Weisman, Ph.D.,
Michael Rossi, M.D., Steven Ettinger, M.D.
Presented By: Christopher Hollenbeak, Ph.D., Assistant
Professor, Surgery and Health Evaluation Sciences, Penn State
College of Medicine, 500 University Drive, H113, Hershey, PA
17033; Tel: (717)531-5890; Fax: (717)531-4185; Email:
chollenbeak@psu.edu
Research Objective: Guidelines for the management of
patients with acute myocardial infarction (AMI) recommend
percutaneous coronary interventions (PCI) as an alternative to
thrombolytic therapy when the procedure can be performed in
a timely manner by experienced personnel. The purpose of
this research was to determine whether there were gender
disparities in the use of PCI in the treatment of AMI in
Pennsylvania and, if so, whether outcomes were affected.
Study Design: We performed a retrospective analysis of a
statewide database. Multivariate analyses were performed
using binary logistic regression, controlling for relevant
covariates. Retrospective matching on propensity scores was
performed using a “greedy” matching algorithm.
Population Studied: Data were provided by the Pennsylvania
Health Care Cost Containment Council (PHC4) and included
all 31,351 AMI patients at all acute care hospitals in the state of
Pennsylvania during the year 2000. The population was
stratified by gender to identify disparities in treatment and
outcomes.
Principal Findings: During the year 2000, 10,170 (32.4%)
AMI patients were treated with PCI and 21,181 (67.6%)
patients were medically managed in Pennsylvania hospitals.
Across all patients, women were significantly less likely to
undergo PCI than men (23.9% vs. 39.9%, p<0.0001) and were
also more likely to die in the hospital during the index
admission (12.7% vs. 9.7%, p<0.0001). Restricting the
sample to patients treated at hospitals where PCI was
available, women were still significantly less likely than men to
undergo the intervention (34.4% vs. 65.4%, p<0.0001). They
were also more likely to die at hospitals offering PCI than men
(10.1% vs. 7.3%, p<0.0001). These disparities in treatment
and outcomes were confirmed in multivariate analyses. After
controlling for age, race/ethnicity, severity at admission,
location of infarct, and source of admission, women still had
24% lower odds than men of receiving PCI (p<0.0001)
regardless of the availability of PCI. Finally, we used
propensity score methods to match 3,023 women who
received PCI to 3,023 women who did not. Results showed
that women who received PCI were significantly less likely to
die than similar women who did not (2.3% vs. 10.4%,
p<0.0001). We also matched 3,329 women who received PCI
to 3,329 similar men who received PCI. Among these
patients, the difference in mortality was not statistically
significant (1.59% vs. 1.92%, p=0.39).
Conclusions: In the Commonwealth of Pennsylvania, women
appear to be less likely to receive primary PCI for treatment of
AMI. Furthermore, women who received this form of therapy
experienced better outcomes.
Implications for Policy, Delivery, or Practice: These results
suggest that the morbidity and mortality associated with AMI
in women could be reduced by increased utilization of primary
PCI. The reasons for the gender disparity in treatment are not
understood and require further investigation in order to
improve treatment outcomes for women.
Primary Funding Source: No Funding Source
●Performance Evaluation of the Multipurpose Australian
Comorbidity Scoring System (MACSS)
C D'Arcy J Holman, MBBS MPH Ph.D., David B. Preen, Ph.D.,
James B Semmens, Ph.D., Judith C Finn, Ph.D.
Presented By: C D'Arcy J Holman, MBBS, MPH, Ph.D.,
Professor of Public Health, School of Population Health, The
University of Western Australia, 35 Stirling Highway,
Nedlands, Western Australia, 6009; Tel: 61-8-6488-1251; Fax:
61-8-6488-1188; Email: darcy@sph.uwa.edu.au
Research Objective: To characterise the MACSS, a new 102item comorbidity scoring system, in terms of its performance
in risk adjustment, validation of item-recording, and
optimisation of look-back.
Study Design: A series of large population-based cohort
studies using the Western Australian Data Linkage System;
and hospital chart and primary medical care record validation
reviews in a random sample.
Population Studied: Hospital separations of adult medical
(n=326,456), surgical (n=349,686) and pyschiatric
(n=16,895)patients; and a cross-section validation study based
on 2,037 patients.
Principal Findings: MACSS substantially outperformed the
Charlson index. Administrative health data identify only 45% of
comorbid conditions. Optimal look back varies with clinical
group and health outcome.
Conclusions: MACSS is a high-performance comorbidity
scoring an adjustment system, but relies on good
ascertainment of comorbid conditions and use of the
appropriate look back period.
Implications for Policy, Delivery, or Practice: Health
services researchers may consider using the MACSS in studies
requiring risk adjustment for comorbidity due to its high
performance across a wide range of patient groups.
Primary Funding Source: Australian National Health and
Medical Research Council
●Cope with National Health Insurance: Strategic
Behaviors of Taiwan's Hospitals
Kuo-Cherh Huang, Dr.Ph, MBA, Ning Lu, Ph.D., MPH, Yi-Hua
Chen, Ph.D., Hui-Chih Chang, MHA
Presented By: Kuo-Cherh Huang, Dr.Ph, MBA, Associate
Professor, Graduate Institute of Health Care Administration,
Taipei Medical University, 250 Wu-hsing Street, Taipei, 110;
Tel: +886-2-23785339; Fax: +886-2-23789788; Email:
kchuang@tmu.edu.tw
Research Objective: The primary goals of this study were to
profile the strategic behaviors of Taiwan hospitals under the
National Health Insurance Program, identify the predictive
factors for such behaviors, and assess the influences of
hospitals' strategic behaviors on performance.
Study Design: Self-administered questionnaire survey.
Population Studied: Our study population included 127
district teaching hospitals or above in Taiwan. Upper level
managers or executives of the hospitals such as
superintendent, vice-superintendent, or other upper-level
administrators who were knowledgeable of their hospital
practice were explicitly asked to respond to the survey, to
ensure the accuracy and reliability of the data collected.
Principal Findings: 1. The findings indicated that the most
popular strategic behavior adopted by hospitals was strategic
alliance, while the least likely embraced strategy was merger
and acquisition. 2. Multinomial logistic regression analysis
results demonstrated that hospital ownership and level were
significant predictors of hospitals' strategic behaviors. Private
and non-profit private-sector hospitals were significantly more
likely to embrace the low-cost strategy, as opposed to the
unrelated diversification strategy, compared to public
hospitals. Furthermore, compared to medical centers and
regional hospitals, district teaching hospitals were more likely
to implement various strategies such as low cost, as opposed
to the strategic behavior of unrelated diversification. 3.
Multiple regression analysis results showed that the strategies
of differentiation and focus exerted significantly positive
influences on hospitals' performance. 4. Finally, we observed
that the degree of local market competition had no impact on
hospitals' choices of strategies and performance.
Conclusions: This investigation shows that Taiwan's
hospitals conduct a variety of strategies when they encounter
emerging opportunities and threats created by important
forces, in this case, the creation of a universal healthcare
system. The findings also suggest the correlates of such
behaviors. Moreover, we demonstrate that different strategic
behaviors exert different degrees of impact on hospitals'
performance.
Implications for Policy, Delivery, or Practice: This empirical
research embarks on the issue of the strategic behaviors of
hospitals when they are facing a significant environmental
change. From a management perspective, it is imperative for
hospital administrators to embrace a more suitable strategy in
order to survive in today's highly competitive healthcare
market. Taken together, the study's results shed light on
some interesting issues regarding hospitals' strategic
behaviors in response to dramatic changes in the external
environment, and provide some suggestions for hospital
administrators.
Primary Funding Source: National Science Council, Taiwan.
●An Examination of Risk Factors For Stroke Among Two
Medicare Elderly Cohorts
Baqar Husaini, Ph.D., Barbara Kilbourne, Ph.D., Pamela C.
Hull, Ph.D., Darren Sherkat, Ph.D., Robert Levine, M.D., Majaz
Moonis, M.D.
Implications for Policy, Delivery, or Practice: Our findings
add to the evidence that controlling risk factors is crucial for
prevention and reduction of high cost of treatment for stroke
patients.
Primary Funding Source: AHRQ
Presented By: Baqar Husaini, Ph.D., Professor and Director,
Center for Health Research, Tennessee State University, 3500
John A. Merritt Boulevard, Nashville, TN 38209; Tel: (615)3203005; Fax: (615)320-3071; Email: bhusaini@tnstate.edu
Research Objective: In this paper we estimate the direct and
indirect effects of various risk factors by race and gender on
the likelihood of developing stroke for two sub-cohorts of
Tennessee Medicare beneficiaries. Medicare data provide a
unique opportunity to analyze physician diagnoses of
cardiovascular risk factors for stroke in order to assess
differential morbidity patterns across two age cohorts.
Study Design: Using ICD-9 codes we examined seven (7)
risk factors in 1996: (i) Transient ischemic activity, (ii) high
cholesterol, (iii) hypertension, (iv) diabetes, (v) myocardial
infarction, (vi) congestive heart failure and (vii) atrial
fibrillation. Outcome variables included whether or not an
individual was diagnosed with a stroke during 1997- 2000.
Further, we excluded individuals from the analysis individuals
with a diagnosis of stroke in 1996 as well as those who died
during 1997-2000. We then performed a set of block recursive
logistic regressions to estimate the direct and indirect effect of
risk factors on stroke.
Population Studied: Combined data from the Medicare
enrollment database (EDB 1996-2000) and physician billing
records was used for this paper. We used a closed cohort of
Tennessee Medicare beneficiaries, aged 65 or older in 1996
(n=698,697). We selected only African Americans and whites.
We used two cohorts of elderly in 1966: individuals 65-69
years old (n= 21,898) and another sub-cohort of individuals
70-74 year olds (n=25,723 ) as of January 1, 1996.
Principal Findings: Our analyses show that among the 65 –
69 year-old cohort, 160 individuals were diagnosed with stroke
during 1997-2000. Race did not appear to directly affect the
likelihood of the diagnosis. Over this period, a diagnosis of
hypertension increased the likelihood of stroke 52% (p<0.001).
African Americans were significantly more likely to receive
diagnoses of diabetes and hypertension than their white
peers. Thus, among this cohort race disparities occur
primarily in the conditions that predict stroke rather their
incidence. Among the 70-74 year-old cohort, 263 individuals
were diagnosed with stroke. Race did not directly predict the
incidence of stroke. However, African Americans were more
than twice as likely (p<0.001) than Whites to be diagnosed
with diabetes or hypertension, and 69% more likely (p<0.001)
to be diagnosed with congestive heart failure; all three
conditions increase the likelihood of stroke.
Conclusions: The incidence of stroke increases markedly
between the younger and older cohort. Among the younger
cohort of beneficiaries race does not appear directly
associated with a diagnosis of stroke. However significant
indirect associations between race and stroke appear through
diabetes among African American elders. In the older cohort
(70-74 years old), while a direct association between race and
stroke is non significant, Race indirectly associated with
stroke through diabetes, congestive heart failure and
hypertension.
●Socio-Economic Determinants Associated with Length of
Psychiatric Hospitalization
hirohisa imai, M.D., Ph.D.
Presented By: hirohisa imai, M.D., Ph.D., associate professor,
health science, asahikawa medical college, midorigaoka, E2-11-1, asahikawa, 078-8510; Tel: +81-166-68-2400; Fax: +81-16668-2409; Email: hiroimai@asahikawa-med.ac.jp
Research Objective: The present study examined socioeconomic determinants associated with length of stay in
regional psychiatric hospitals in Japan, in order to identify
variables that might help to reduce length of stay.
Study Design: This cross-sectional study analysed the
complete database of one district in Japan. Analyses were
conducted using aggregate data from 24 hospitals. Multiple
regression analysis was performed to determine socioeconomic factors influencing length of stay in psychiatric
hospitals. The information contained the patient profiles, the
basic demographic data, the economic factors, the admission
and a diagnostic assessment according to ICD-10 as the
patient characteristics and the number of medical stuffs, the
number of outpatient and inpatient.
Population Studied: All 24 psychiatrics hospitals and a total
of 6854 patients staying with them in Miyazaki prefecture
during 1 April 1998 to 1 March 1999 formed the study
population. The patients comprised 46.2% males and 53.8%
females. As their age distribution 4 groups were divided under
20, from 21 to 40, from 41 to 65, over 65 years old.
Principal Findings: Significant positive associations were
identified between length of stay and proportion of involuntary
admissions as social factors. Our finding of an association
between involuntary admission and longer length of stay
supports the results of previous investigations. Unlike many
other developed countries, time in seclusion is not limited in
Japan. A system of periodic reviews or audits for psychiatric
hospitals is thus needed to safeguard against unnecessary
confinement and excessive length of stay.
Multiple linear regression analysis revealed that proportion of
patients receiving public aid was independently associated
with shorter length of stay. Shorter length of stay for patients
receiving public aid may reflect the fact that the stigma
associated with mental illness remains high in Japanese
families. Historically, hospitalisation has represented the most
socially acceptable solution for many families of psychiatric
patients in Japan, and a researcher indicated that many
families do not want mentally ill family members to return
home. In our experience, patients who have no family and
receive no other financial support sometimes receive public
aid. These patients may be discharged more rapidly because
no pressure is exerted to delay the process.
Conclusions: Our study clarified socio-economic
determinants associated with length of stay in regional
psychiatric hospitals. To date, policy makers have not
implemented evidence-based health policies for mental care.
The factors identified in this study offer a basis for effective
psychiatric health policies to reduce length of stay and should
contribute to health policies promoting de-institutionalisation.
Implications for Policy, Delivery, or Practice: Average length
of stay for inpatients in psychiatric hospitals has consistently
been longer in Japan than in any other developed nation, at
330 days in 1996. If government authorities or policy makers
focus on data regarding socio-economics determinants
affecting length of stay at individual psychiatric hospitals when
devising and implementing psychiatric care policies, and if
policies can in fact alter practices at individual psychiatric
hospitals, hospital length of stay for individual psychiatric
patients may be effectively shortened.
Primary Funding Source: No Funding Source
●Analysis of Pediatric Emergency Care in Massachusetts How Can It be Improved?
Rachel Immekus, MS/MPH
Presented By: Rachel Immekus, MS/MPH, Health Policy
Analyst, Health Systems Measurement and Improvement
Group, Division of Health Care Finance and Policy, 2 Boylston
Street, Boston, MA 02116; Tel: (617) 988-3273; Email:
rachel.immekus@hcf.state.ma.us
Research Objective: To provide a comprehensive picture of
emergency medical services utilized by children in the state of
Massachusetts in order to better direct pediatric care.
Study Design: Analysis was conducted on all emergency
visits, including those that resulted in a hospital admission or
observation stay. Detailed patient-level data from the Division
of Health Care Finance and Policy’s Emergency Department
Database, Outpatient Observation Database, and the
Inpatient Discharge Database were used to obtain total
volume, regional areas of high visit concentration, common
diagnoses and procedures, mode of transportation, and
admission patterns. ArcView software was used to produce
maps illustrating zip code areas by concentration of patient
utilization in relation to emergency department locations.
Population Studied: Children between the ages of 0 and 14
who visited a Massachusetts emergency department in the
hospital fiscal year 2003
Principal Findings: In FY 2003, 427,132 ED visits were made
by children. These visits accounted for 15.4% of all ED visits in
Massachusetts. Approximately 11% of outpatient visits were
registered in the early morning hours between midnight and
8:00, 34% were admitted between 8:00AM and 4:00 PM,
while the majority of visits, 55%, were registered between 4:00
PM and midnight. Five diagnoses, based on ICD-9 codes,
accounted for 20% outpatient visits and included 1)
Unspecified otitis media, 2) Fever. 3) Acute upper respiratory
infection 4) Unspecified viral infection, and 5) Acute
pharyngitis. The majority of pediatric visits resulted in an
outpatient discharge with only 7% being admitted to inpatient
or observation care. Those that were admitted however carried
the more emergent diagnoses common to inpatient
admissions: 1). Volume depletion, 2) Asthma with (acute)
exacerbation 3) Pneumonia 4) Single live born (where the
mother was admitted through the ED for the birth of a child)
and 5) Acute appendicitis. Private insurers and Medicaid
covered 92% of the visits (64% and 28% respectively) that did
not result in admission.
Conclusions: The majority of pediatric ED visits occur in the
day and evening hours when most physicians’ offices should
or could be open. Also, the top outpatient diagnoses suggest
treatment at a clinic or physician’s office to be feasible. The
vast majority of the kids who presented for ED care were
insured (92%) theoretically facilitating their primary and
secondary care in a non-ED setting.
Implications for Policy, Delivery, or Practice: Given the high
volume of pediatric visits to the ED during day and evening
hours, especially for non emergent conditions, policy makers
and insurers might want to consider incentives to large
pediatric providers and CHCs to expand hours into the early
evening for sick calls and/or visits.
Primary Funding Source: No Funding Source
●Employment of Mid-level Providers in Primary Care
Programs and Control of Diabetes
George Jackson, Ph.D., MHA, Shoou-Yih Daniel Lee, Ph.D.,
David Edelman, M.D., MHS, Morris Weinberger, Ph.D.,
Elizabeth Yano, Ph.D., MSPH
Presented By: George Jackson, Ph.D., MHA, Postdoctoral
Fellow, HSR&D Service (152), Durham Veterans Affairs
Medical Center, 508 Fulton Street, Durham, NC 27705; Tel:
(919)286-0411 x7103; Fax: (919)416-5836; Email:
george_jackson@alumni.unc.edu
Research Objective: Considering the different training
orientations of nurse practitioners (NPs) [biopsychosocial]
and physician assistants (PA’s) [biomedical], we examined the
association between employing mid-level providers in
Veterans Affairs primary care practices on diabetes control, as
measured by hemoglobin A1c (HbA1c).
Study Design: A cohort of 224,221 diabetes patients (alive
October 1, 1999) was identified using the Veterans Health
Administration (VHA) Diabetes Registry and Dataset and VHA
Medical SAS Datasets. Data on the organization of programs
at large VA facilities (>= 4000 patients and >= 20,000
outpatient visits in 1998) was obtained via the 1999 VHA
Survey of Primary Care Practices (n = 219).
To simultaneously control for the impact of individual and
organizational characteristics on the individual outcome of
HbA1c, two-level hierarchical modeling was used to assess the
association between having NPs and PA’s in primary care
programs and the last HbA1c value recorded during the
follow-up period (fiscal year 2000-2001). Organizational-level
covariates that represent integration of providers into
programs included: staffing sufficiency, on-site training, and
practicing at multiple VA locations for both nurses and
NPs/PAs. Also included were nursing full-time equivalents
per 1000 general medicine patients, state of transition to
service-line structure, needed primary care staff hired year
before survey, total facility general medicine patients,
geographic region, academic affiliation, and location in a
hospital. At the individual level, results were risk adjusted
based on comorbidities, gender, body mass index,
race/ethnicity, service-connected disability rating, VA meanstest category (partial proxy for socioeconomic status), use of
glucose control medication, and primary care utilization.
Population Studied: The analysis included 82,692 VA primary
care patients with diabetes at 190 separate facilities.
Principal Findings: Presence of NPs in primary care
programs was associated with patients’ HbA1c results being
lower by 0.34%. Having PAs in the program was not
associated with HbA1c. Also significant at the p=0.05 level
were: (1) having NPs/PAs practice at multiple VA sites (HbA1c
higher by 0.20%), (2) sites reporting NP staffing was barely or
not at all sufficient compared to being more sufficient (HbA1c
higher by 0.20%), (3) having a partially as opposed to fully
implemented service-line structure (HbA1c higher by 0.18%)
and (4) having needed new staff acquired the year before the
survey (HbA1c lower by 0.13%).
Conclusions: Inclusion of NPs in primary care practices was
associated with better control of diabetes. Further, programs
reporting that staffing of mid-level providers is sufficient,
having the mid-level providers practice only at one facility,
having a fully implemented service-line structure, and actively
acquiring needed staff are also associated with better diabetes
control.
Implications for Policy, Delivery, or Practice: The
associations reported here point to the possibility that
including NPs in primary care programs may lead to better
diabetes outcomes.
Primary Funding Source: No Funding Source
●Institutional Factors Associated with ADL Decline in
Pennsylvania Nursing Homes
Amy Jessop, Ph.D., MPH, Jocelyn Andrel, MSPH, Naomi
Hauser, RN, MPA, David Wenner, DO
Presented By: Amy Jessop, Ph.D., MPH, Senior
Epidemiologist, Quality Insights of Pennsylvania, 585 East
Swedesford Road, Wayne, PA 19087; Tel: (877)346-6180; Fax:
(610)688-5276; Email: ajessop@wvmi.org
Research Objective: In 2002, the Centers for Medicare &
Medicaid Services (CMS) implemented the National Nursing
Home Quality Initiative, designed to improve quality of care
and provide public access to MDS-based quality measures.
Pennsylvania nursing homes consistently lead the nation in
reported decline in activities of daily living (ADL) (PA 24%,
National 15%), while other quality measures approximate the
national averages. No reason is readily apparent for the
comparatively high level of ADL decline. The research
objective of this project was to explore and identify nursing
home characteristics associated with ADL decline in
Pennsylvania nursing homes.
Study Design: This was a cross-sectional study. CMSreported quality measures for 2002 were merged with facility
characteristic data from the 2002 Pennsylvania Department of
Health’s Long-term Care Facility Questionnaire.
Characteristics explored included type of ownership (size,
profit status, hospital ownership, reimbursement rates,
occupancy, agreements, and special units), utilization
characteristics (length of stay, admission and discharge
profiles, and payor profile), resident characteristics (age, race,
gender), and staffing characteristics (medical, nursing, and
therapy staff hours). Univariate and multivariate analyses were
employed to identify factors associated with ADL decline.
Population Studied: The study population consisted of 622
nursing homes in Pennsylvania licensed by the Pennsylvania
Department of Health, who completed the 2002 PA LongTerm Care Facility Questionnaire, and had ADL decline
measures reported for at least one quarter in 2002. Federal
facilities and intermediate care facilities were excluded.
Principal Findings: Significant and non-significant
associations will be presented. Factors positively associated (p
less than 0.05) with ADL decline included hospital
governance, occupancy level, Medicare covered days, days
paid by private insurance, percentage of residents admitted
from hospital, higher percentage of residents 65-74, and more
therapy staffing hours. Factors negatively associated with ADL
decline were a higher percentage of residents admitted from
other nursing homes, length of stay, and a higher percentage
of residents 85-94, and more nursing hours. Data was
analyzed using SAS version 8.2.
Conclusions: This study was the first step toward
understanding ADL decline within Pennsylvania nursing
homes, as well as the first time that these existing data
sources were linked to explore ADL decline. The analysis
showed that there was no one obvious explanatory variable,
nor did the multivariate model explain much of the variance in
ADL decline. Future examination of ADL decline will include
collecting primary data such as nursing home practices and
staff experience. In addition, we plan to examine
characteristics that distinguish states from one another, such
as regulatory policy, and plan to make comparisons between
states and state characteristics.
Implications for Policy, Delivery, or Practice: Identification
of facility-level factors provides a basis for development of
facility and statewide initiatives designed to address ADL
decline in nursing homes.
Primary Funding Source: CMS
●Regional Trends in Racial Disparities in Major Procedure
use among the Elderly
Ashish Jha, M.D., MPH, Elliott S. Fisher, M.D., MPH,
Zhonghe Li, MA, E. John Orav, Ph.D., Arnold M. Epstein, M.D.
Presented By: Ashish Jha, M.D., MPH, Assistant Professor,
Health Policy & Management, Harvard School of Public
Health, 677 Huntington Avenue, Boston, MA 02115; Tel: (617)
432-5551; Fax: (617) 648-5000; Email: ajha@hsph.harvard.edu
Research Objective: Racial disparities in major procedure
rates are well known and data suggest that national gaps in
care have remained stable. However, given substantial
regional variation in disparities, we sought to identify local
regions that have successfully eliminated gaps in care.
Study Design: We used 100% data file from the Medicare
Part A program from 1992 through 2001 to calculate ageadjusted procedure rates for black and white enrollees 65
years of age or older. We calculated the white minus black gap
for men and women separately for three procedures (coronary
artery bypass graft surgery, carotid endarterectomy, and total
hip replacement).
Population Studied: Medicare enrollees who received
procedures in hospital referral regions large enough to provide
stable estimates for both blacks and whites.
Principal Findings: During 1992-1994, compared with white
enrollees, black enrollees received lower rates of all three
procedures in all 158 HRRs examined (p<0.05 in 152 HRRs).
During the decade of monitoring, the white minus black gap
widened in 89 HRRs (p-value for trend <0.05 in 42 HRRs) and
narrowed in 69 HRRs (p-value for trend <0.05 in 22 HRRs). At
the end of the study period, in 1999-2001, blacks still received
less of each procedure in all 158 HRRs examined (p<0.05 in
154 HRRs).
Conclusions: We found that while the white minus black gap
narrowed in a few regions, the large gaps present in the early
1990s persisted at the end of the decade.
Implications for Policy, Delivery, or Practice: Despite the
national attention on racial disparities, we found no evidence
that any local regions have eliminated the racial gap in care for
the three procedures examined. New efforts are needed to
reduce the gaps in care between white and black Americans.
Primary Funding Source: RWJF
●Follow Up Rate and Related Factors of Medical
Utilization after an Abnormal Result in Korean National
Cancer Screening Program
Heui Sug Jo, M.D., MPH, Ph D, MS, Ji Sook Choi, M.D., MPH,
Ph D, Joo Hon Sung, M.D., MS, Yong Jun Choi, M.D., MPH,
DrPh D, Sang Soo Bae
Presented By: Heui Sug Jo, M.D., MPH, Ph D, Assistant
Professor, Dept. of Preventive Medicine, Kangwon National
University, 192-1 Hyoja- Dong, Chunchon city, 200-701; Tel:
82-33-250-8872; Fax: 82-33-250-8875; Email:
choice@kangwon.ac.kr
Research Objective: Cancer is a primary cause of death and
its prevalence and mortality rate has increased in Korea. These
truths have caused economic loss because of loss of human
resources and productivity not only on the country level but
also on the individual level. In order to minimize the losses
from cancers, secondary preventive activities, which can raise
the survival rate through early detection and treatment as well
as primary preventive activities which reduce the risk factors,
should be performed progressively. The Korean government
has provided organized cancer screening programs such as a
gastro-scope, a Colono-scope, a mammogram, and a cervical
pap-smear test to the people enrolled in the Korean national
health insurance system since 1999 through National Health
Insurance Corporation (NHIC) cancer screening program.
There is not, however, a management program for people with
abnormal results in screening tests but only an
announcement of the results to an individual exists. The
purposes of this study are to identify the follow up rate and to
analyze related factors of medical utilization among the
people with an abnormal result in cancer screening tests
through the Korean National Cancer Screening Program.
Study Design: We studied cross sectional study. We used
three kinds of data; the Korean normative cohort data, the
data from cancer screening tests of NHIC, and medical
insurance claim data from hospitals. Also we set up an
individual serial data file through merging the data according
to their Korean identification number.
Population Studied: The Korean medical insurance cohort
includes 1,205,470 people who were selected representatively
according to the same rate of age, sex, and region registered
in the Korean national health insurance system from 1996 to
2001. Finally, 8,284 people in the Korean cohort took a
screening test from January 1, 2001 to December 31, 2001.
There were 2,647 people of these who received abnormal
results from cancer screening tests. Medical utilization for
diagnosis was defined as medical care according to the
problems with organs related to those examined through that
cancer screening test as well as the International Classification
of Disease code within one year after the announcement of
abnormal results. A chi-square test was performed to identify
the differences in follow-up rates by kinds of cancer tests,
gender, age, economic state, and amount of time before
follow-up. A logistic regression analysis was also performed to
examine variables that account for the differences.
Principal Findings: 1. Approximately 54.6% of people with an
abnormal result did not utilize medical care after notification
of an abnormal result. Concerning each cancer form, 44.4% of
the people with an abnormal result for stomach cancer, and
52.1%, 51.8%, and only 41.8% results for colorectal cancer,
breast cancer, and cervical cancer respectively used medical
care after abnormal results. 2. Furthermore, medical
utilization of people with an abnormal result within 1 month
after the notification was very low; 38.4% for stomach cancer,
and 32.0%, 37.9%, and 28.2% of the people with an abnormal
result for colorectal cancer, breast cancer, and cervical cancer,
respectively. 3. If all other factors are controlled, female was
more likely to use follow up care after an abnormal result
(odds ratio=1.47, 95% confidence interval: 1.22-1.78). Older
people over the age of 60 were also more likely to use followup care (odds ratio= 1.61, 95% confidence interval: 1.05-2.58).
Conclusions: In conclusion, the follow-up rate after an
abnormal result was very low. It can be one of the factors that
may cause the low effectiveness of the National Cancer
Screening Program. Due to the high coverage rate of medical
insurance, owing to the national health insurance system,
barriers to medical care are not a serious problem to people
with a low incom
Implications for Policy, Delivery, or Practice: To Improve
the effectiveness of National Cancer Program, younger people
should be targeted as groups needing assistance in adhering
to follow-up recommendations.
Primary Funding Source: This work was supported by Health
technology Planning & Evaluation Project Grant, No. 01PJPG1-01CH10-0007.
●Quality Control of Disease Coding Error on Health
Insurance Claim Data - The Korean Burden of Disease
ProjectHeui Sug Jo, M.D., MPH, Ph.D., Joo Hon Sung, M.D., MPH,
Ph.D., MS, Ji Sook Choi, MS, Moon Sun Hwang, Heon Jae
Jeong, M.D.
Presented By: Heui Sug Jo, M.D., MPH, Ph.D., Assistant
Professor, Dept. of Preventive Medicine, Kangwon National
University, 192-1 Hyoja- Dong, Chunchon city, 200-701; Tel:
82-33-250-8872; Fax: 82-33-250-8875; Email:
choice@kangwon.ac.kr
Research Objective: We attempted to verify and to improve
the quality of disease coding on health insurance claim data
used in assessing of Korean Burden of Disease. Also, we
understood health care organizational characteristics and
patient’s characteristics affecting to coding error.
Study Design: 1. We organized reviewer group consisting of
clinical specialists and researchers of health care
management. The target diseases for validation are epilepsy,
coronary heart disease, cerebro-vascular disease, rheumatoid
arthritis, asthma, lumbar hernrated disc disease, frequently
utilized disease . 2. Considering the amount of the medical
service use, the hospitals to be examined were selected by
stratified sampling; onsequently, 30 specialized general
hospitals, 52 general hospitals, and 49 hospitals were
chosen(a total of 131 medical facilities). 3. The validation of
data was performed by turning out the agreement rates
among the diagnostic code of insurance claim, diagnosis
based upon medical records, and judgement by medical
recorders. 4. The medical records and electric database of
total 5,842 cases within our Korean disease cohort -700 of
coronary heart diseases, 892 of stroke, 977 of rheumatoid
arthritis, 399 of systemic lupus erythematous disease, 787 of
bronchial asthma, 834 of epilepsy, and 1253 of the frequent
diseases were checked from May 2003 to December 2003.
Principal Findings: 1. The accuracy rates were 79.7% in
epilepsy, 61.4% in coronary heart disease, 75.8% in cerebrovascular disease, 84.1% in rheumatoid arthritis, 52.6% in
asthma, 81.0% in lumbar herniated disc disease, 84.1% in
frequently utilized diseases. 2. Agegroup, utilization type,
type of operation, Admission length,and medicare expenditure
are related factor. 3. We also developed adjustment Model.
Conclusions: Our results show that the validity of data is
various among diseases,and also suggest that there are many
related factors related validity. As a results, our health
insurance cohort through validation and adjustment can be
used in broad researches of health care management area
such as, assessment of health status and health related
quality, choice of priorities in health sector, allocation of
resources, and international comparative study.
Primary Funding Source: This work was supported by
Ministry of Health and welfare in Republic of Korea. Grant
No. 01-PJPG1-01CH10-0007
●Doctors’ Attitude and Satisfaction about the Review
System of National Health Insurance Claims in Korea
Heui Sug Jo, M.D., MPH, Ph.D., Heon Jae Jeong
Presented By: Heui Sug Jo, M.D., MPH, Ph.D., Assistant
Professor, Dept. of Preventive Medicine, Kangwon National
University, 192-1 Hyoja- Dong, Chunchon city, 200-701; Tel:
82-33-250-8872; Fax: 82-33-250-8875; Email:
choice@kangwon.ac.kr
Research Objective: The purposes of this study are to
understand the doctors’ attitude and satisfaction about the
review system of national health insurance claim in Korea and
to suggest the way to improve this system.
Study Design: The national health insurance system in Korea
has adopted fee-for-service payment system and has
performed retrospective review system about claimed service
as the method of quality control and evaluation of appropriate
services. However, as review system has been carried out, it
has been engaged in a policy for the restriction of medical
service expenditure, and consequently in a policy of the
curtailment of medical service claim; therefore, considering
doctors’ perspective, this review system is thought to be very
distorted from the quality control policy originally intended.
Moreover, the fact that the clear criteria and cases of the
criteria have not been offered, and the complex and long-term
needed procedure for interposing objections have been
suggested as the obstacles for doctors to better
understanding of the review system.
Population Studied: This study conducted a survey of the
doctors registered in the medical association in Seoul city. The
survey was performed as a form of self-administered
questionnaire form January 2004 to February 2004. The
contents of questionnaire dealt with doctors’ attitude and
satisfaction about the review system of medical service claim.
Principal Findings: 536 doctors opening their clinics replied.
1. About the influences of the review system on improvement
of medical service quality, 88.6% of repliers showed a negative
attitude. 2. 97.2% of repliers have had experiences that they
have given distorted-insufficient-medical services in order to
evade the curtailment of service claim. Also, 91.4% of repliers
stated that they have had experiences of intentional
modification or alteration of diagnostic code to shun the
curtailment. 3. Moreover, 50.5% could not raise an objection
owing to the complex administrative procedure and loss of
time; 23.2% did not even check out the causes of their
curtailment. 4. 32.7% of doctors said that they could not gain
any information about the criteria of curtailment, and 64.4%
were in state of being partially aware of the curtailment
criteria. 5. For 47.6%, it was from the peer group of doctors
that doctors had obtained information about the criteria of
curtailment; however, merely 7.7% of doctors have acquired
information from formal education materials.
Conclusions: Most of the doctors showed negative attitude to
the curtailment procedure and the review system of service
claim originally intended to be one of the quality control
methods of medical service in Korea; also, the development of
both scientific and reasonable parameters and criteria for
claim is needed.
Implications for Policy, Delivery, or Practice: 1. Through the
improvement of review system for appropriate medical
service, there is a need of a way to increase the satisfaction of
medical service providers, and to encourage the motivation for
quality control. 2. Education is strongly needed to provide
doctors with sufficient information about review criteria and
curtailment cases.
Primary Funding Source: No Funding Source
●Factors Associated with Screening Behavior of Stomach
Cancer Based on Socio-Ecological Model: Korean National
Study
Heui Sug Jo, M.D., MPH, Ph.D., Dong Hyun Kim, M.D.,
Ph.D., Sang Soo Bae, M.D., Ph.D., Hun Jae Lee, Ph.D., Hyung
Won Cho, M.D.. MS, Yong Jun Choi
Presented By: Heui Sug Jo, M.D., MPH, Ph.D., Assistant
Professor, Dept. of Preventive Medicine, Kangwon National
University, 192-1 Hyoja- Dong, Chunchon city, 200-701; Tel:
82-33-250-8872; Fax: 82-33-250-8875; Email:
choice@kangwon.ac.kr
Research Objective: Stomach cancer is one of the most
frequent cancers in Korea. In order to reduce the mortality and
occurrence rate of stomach cancer, early detection through
cancer screening, proved to be effective especially in stomach
cancer, as well as primary preventive activities reduce the risk
factors, should be recommended intensively. The purposes of
this study were to investigate screening rates of stomach
cancer and to analyze factors associated with screening
behavior based on socio-ecological model.
Study Design: A socio-ecological model was used as the
theoretical model for variables, which included the intrapersonal level factors such as anxiety for cancer, individual
value on efficiency of test, economic burden for test, difficulty
of accessibility, interpersonal level such as familial
recommendation, familial tendency for regular check-up,
doctors recommendation, and societal level such as
recognition and knowledge for national cancer screening,
experience of health education, social norm about cancer
screening.
Population Studied: Screened (n=600) and non-screened
(n=800) people were surveyed by telephone interview. The
sample was selected by random digit dialing method
according to the same rate of age, sex, and region in Korean
population.
Principal Findings: For intra-personal factors, anxiety for
cancer (odds ratio=1.62, 95% confidence interval: 1.07-2.45)
was associated with having been screened. For interpersonal
factors, people with familial member who regularly have a
check-up (odds ratio=2.10, 95% confidence interval: 1.47-2.99)
were more likely to have been screened. In addition, many
experiences of health education about importance of cancer
screening test were associated with having been screened on
the societal level (odds ratio=4.45, 95% confidence interval:
1.30-15.22).
Conclusions: These findings suggest that aggressive
education and promotion should be performed to improve the
cancer screening rates. Also multi-disciplinary approaches
should be favored for improving rates based on socioecological model.
Implications for Policy, Delivery, or Practice: The
socioecologic framework is a good explanatory model for
stomach cancer screening behavior. These results can guide
intervention amied at ncreasing cancer screening rates.
Primary Funding Source: Supported by Korean National
Cancer Institute Grant. no 0320460-1
●Practice-Based Electronic Billing Systems and their
Impact on Immunization Registries
Maureen Kolasa, RN, MPH, Janet Cherry, MA, Andrew
Chilkatowsky, BA, David Reyes, MS, MPH, James Lutz, MPA
Presented By: Maureen S Kolasa, RN, MPH, Lead
Epidemiologist, National Immunization Program, Centers for
Disease Control and Prevention, 1600 Clifton Road, E52,
Atlanta, GA 30333; Tel: (404)639-8759; Fax: (404) 639-8615;
Email: mkolasa@cdc.gov
Research Objective: Many providers of children’s
immunizations rely on electronic billing systems to report
information to computerized immunization registries. If
billing systems fail to capture some administered
immunizations, the registry will not reflect a child’s true
immunization status. This study assessed differences
between immunizations administered and immunizations
reported to a registry via provider’s electronic billing systems
in Philadelphia, Pennsylvania.
Study Design: In Philadelphia, 45 private and public
immunization practices served >50 children age 7-35 months
and submitted immunization data to the registry via electronic
billing systems in 2002-2003. The Philadelphia Department of
Public Health (PDPH) conducted chart audits for all children
who had received their last known immunization at one of
these 45 practices and for whom the registry identified as
missing at least one recommended immunization. Chart
records were compared to registry records to identify
immunizations administered in these practices but not
reported to the registry by electronic billing systems. Lost
revenue was calculated conservatively by considering only
potential reimbursement of administrative fees.
Population Studied: All 45 immunization practices serving >
50 children age 7-35 months and using electronic billing
systems to report data to Philadelphia’s immunization registry
were evaluated. A total of 20,611 children, about 43% of all
children age 7-35 months in Philadelphia, had at least one
immunization recorded in the immunization registry and had
received their last known immunization at one of these 45
practices.
Principal Findings: The registry identified 12,321 (60%) of the
20,611 children served by the 45 study practices that were
missing recommended immunizations. Of the 256,969
immunizations administered to the 20,611 children in the
study practices, 62,213 (24%) were not in the registry. The
electronic billing systems submitted all administered
immunizations for 69% of immunization visits, some but not
all for 11% of visits, and none for 20% of visits.
Pneumococcal conjugate vaccine was the vaccine most
frequently administered but not reported to the immunization
registry. Immunizations administered but not billed cost
these providers up to $980,477 in lost revenue from
administrative fees alone.
Conclusions: When providers used electronic billing systems
to enter data into Philadelphia’s immunization registry, the
electronic billing systems did not report almost 25% of
immunizations administered, resulting in incomplete registry
data. Improvement of billing data quality would result in more
complete registries, higher reported immunization coverage
rates, and recovered revenue for immunization providers.
Implications for Policy, Delivery, or Practice: A national
Healthy People 2010 objective is to increase the proportion of
children <5 years fully participating in an immunization
registry to 95%. In order to meet this objective, policies and
interventions are needed to improve the completeness of data
reported to immunization registries via electronic billing
systems.
Primary Funding Source: CDC
●Evaluation of Physician Compliance with Pneumococcal
Conjugate Vaccine Shortage Recommendations within a
Managed Care Organization in 2004
Maureen S Kolasa, RN, MPH, Stephen M. Tannenbaum, M.D.
Presented By: Maureen S Kolasa, RN, MPH, Lead
Epidemiologist, National Immunization Program, Centers for
Disease Control and Prevention, 1600 Clifton Road, E52,
Atlanta, GA 30333; Tel: (404)639-8759; Fax: (404) 639-8615;
Email: mkolasa@cdc.gov
Research Objective: Shortages of pneumococcal conjugate
vaccine (PCV) were experienced in the first half of 2004. To
maintain adequate vaccine for high risk children, the Advisory
Committee for Immunization Practices recommended delay of
administration of the 3rd and 4th doses of PCV (PCV3 and
PCV4, respectively) to healthy children, but no delay in
administration of the 1st and 2nd doses of PCV (PCV1 and
PCV2, respectively). This study assessed the pattern of PCV
administration during periods of vaccine shortage and
changing recommendations in a managed care setting.
Specific research objectives were to determine physician
compliance with PCV shortage recommendations, describe
the overall pattern of vaccination of children with high risk
diagnoses and whether this was in accordance with
recommendations, and demonstrate the usefulness of Kaiser
registry data in assessing immunization administration
patterns related to vaccine shortages.
Study Design: Using their immunization registry, Southern
California Kaiser Permanente evaluated PCV doses
administered to all enrolled children at age 3 months, 5
months, and 7 months in 2004. PCV coverage prior to
shortage-related recommendations was compared to coverage
after recommendations were made to discontinue PCV dose 3
and 4 to healthy children. PCV coverage of children with
diagnoses placing them at high risk for pneumococcal disease
will be compared to PCV coverage for children without high
risk diagnoses.
Population Studied: This study included all Kaiser
Permanente providers in Southern California that immunize
children < 17 months of age. All children < 17 months of age,
enrolled with Southern California Kaiser Permanente in 2004,
and receiving at least one immunization from Kaiser
Permanente providers in Southern California were included in
the analysis.
Principal Findings: Immunization coverage levels with PCV1
for children age 3 months remained similar (range 80-86%)
between January and July 2004. The same pattern was seen
with PCV2 for children age 5 months. PCV3 immunization
coverage for children age 7 months dropped significantly (p<
.0001) from 73% coverage in February to 17% coverage in
April, one month after ACIP recommendations to suspend
this dose to healthy children. PCV3 coverage among 7 month
olds remained <20% through July 2004.
Conclusions: Southern California Kaiser Permanente
immunization providers decreased delivery of PCV3 to
enrolled children in accordance with ACIP recommendations.
These providers demonstrated rapid adoption of
recommendations and maintained compliance with the
recommendations through July 2004.
Implications for Policy, Delivery, or Practice: The methods
used by the Advisory Committee for Immunization Practices
and by Kaiser Permanente Advisory in Southern California
were effective in communicating vaccine-related
recommendations to Kaiser Permanente providers. Use of
these same methods therefore may promote compliance with
future vaccine-related recommendations. On a programmatic
level, this type of study can assist managed care organizations
in identifying and intervening with providers not following
recommendations.
Primary Funding Source: No Funding Source
●Children Victims of Homicide are Unlikely to use Injury
Related Health Services Prior to the Fatal Event
Angelique Stubblefield, BSN, MPH, Siran Koroukian, Ph.D.
Presented By: Siran Koroukian, Ph.D., Assistant Professor,
Epidemiology and Biostatistics, Case Western Reserve
University, School of Medicine, 10900 Euclid Avenue,
Cleveland, OH 44106-4925; Tel: (216)368-3197; Fax: (216)3683970; Email: skoroukian@case.edu
Research Objective: Numerous studies have reported
increased incidence of violence induced fatalities or VIF
among socioeconomically disadvantaged subgroups of the
population, especially among children. However, the extent to
which victims of violence could be identified through their
pattern of utilization of health services is unknown. This study
aims at describing patterns of use of injury related services by
Ohio Medicaid children victims of homicide, in the period
preceding the fatal event.
Study Design: This was a retrospective study using linked
Ohio Medicaid and death certificate files, 1992 to 1996. All
Medicaid children under age 10 and victims of homicide as
identified through the cause of death documented in the
death certificate files, were included in the analysis, with a final
sample of 138 children. Bivariate associations were tested
using chi square tests to assess statistical significance in the
difference between proportions. Odds ratios were obtained
using multivariable logistic regression analysis, adjusting for
demographics and months of enrollment in Medicaid prior to
the fatal event.
Population Studied: All Medicaid children under age 10 and
victims of homicide as identified through the cause of death
documented in the death certificate files, were included in the
analysis.
Principal Findings: The yearly average of violence induced
fatalities during the study period was 27.6 deaths. The
majority,70 percent of decedents had no prior contact for
injury related services and 86 percent were 0 to 4 years old.
Fatal child abuse, fatal assault, and death by firearms were
listed as the cause of death on the death certificate
respectively for 46 percent, 37 percent, and 17 percent of the
victims. Children age 0 to 4 were more likely than their older
counterparts not to have had previous contact with the health
care system for injury related services after controlling for
demographics and length of enrollment in Medicaid prior to
the fatal event. The adjusted odds ratio is 4.11 with a 95
percent Confidence Interval of 1.03 to 16.5. Those residing in
Metropolitan, Appalachian, and Suburban counties were 14.8
times more likely not to have received injury related services
when compared to those living in rural counties, with a
Confidence Interval of 3.2 to 69.1.
Conclusions: We estimated that a rather small proportion,
thirty percent, of children may have been in contact with the
health care system prior to the fatal event for injury related
services, a statistic that translates into a limited window of
opportunity for health care providers to prevent such events
from happening.
Implications for Policy, Delivery, or Practice: The analysis of
patterns of use of injury related services in the period
preceding the fatal event may be used to develop a risk
assessment tool for health practitioners to identify children at
risk for becoming victims of homicide, and hopefully prevent
VIFs. Although our study indicated that a rather small
proportion of children have any contact with the health care
system for injury related services, this finding should by no
means impede further research efforts in this direction, as all
such deaths are preventable.
Primary Funding Source: Ohio Department of Public Safety
●The Impact of Interstate Migration Patterns on Nursing
Workforce Planning Efforts
Linda M. Lacey, MA
Presented By: Linda M. Lacey, MA, Associate Director:
Research, North Carolina Center for Nursing, 222 North
Person Street, Raleigh, NC 27601; Tel: (919) 715-3523; Fax:
(919) 715-3528; Email: lmlacey@northcarolina.edu
Research Objective: Policy decisions are currently being
made to enlarge nursing education programs in order to
attenuate the expected shortage that will develop in the next
10 years. Given the expensive nature of these programs it is
important for states to be able to accurately estimate the need
for expansion. The objective of this research was to
understand the relative impact of interstate migration versus
production of new professionals in the growth of the nursing
workforce at the state level.
Study Design: Repeated cross-sectional analyses of annual
RN licensure files were conducted to identify newly licensed
RNs and to determine whether they were new graduates and
where they had received their entry-to-practice education.
Eleven years of data (from 1991 - 2001) were examined.
Population Studied: This study focused on the population of
newly licensed registered nurses acquiring an initial license to
practice in North Carolina during the period from 1991 to
2001.
Principal Findings: During the 1990s, approximately 6,000 7,000 RNs each year obtained an active license to practice in
North Carolina for the first time. Throughout the decade,
more than half of those newly licensed nurses were found to
have received their entry-into-practice education in a state
other than North Carolina.
Conclusions: As states institute solutions to the growing
nursing shortage, it becomes important to understand the
dynamics operating within that labor force. Patterns of
interstate in- and out-migration should be taken into account
when planning for educational expansion. The impact could
be either positive or negative.
Implications for Policy, Delivery, or Practice: Entry-level
nursing education programs are expensive both in terms of
faculty manpower and clinical resources. Knowing how both
in- and out-migration patterns across state lines are affecting
the nursing labor force in a particular state will allow for more
accurate planning and budgeting.
Primary Funding Source: The Duke Endowment and the
North Carolina Center for Nursing
●Estimates of Potential Health Gains from Reducing
Multiple Risk Factors of Stroke in Korea
Heeyoung Lee, M.D., MPH, Seok-Jun Yoon, M.D., Ph.D.,
Hyeong-sik Ahn, M.D., Ph.D., Ok Ryun Moon, M.D., Ph.D.
Presented By: Heeyoung Lee, M.D., MPH, Principle
Researcher, Department of Preventive Medicine, College of
Medicine, Korea University, 126-1, 5ka Anamdong, Seongbukku, Seoul, 136-705; Tel: 82-2-920-6346; Fax: 82-2-927-7220;
Email: imstone@korea.ac.kr
Research Objective: We estimated the burden of diseases
caused by stroke using SMPH (Summary Measure of
Population Health), and compared the attributable burden of
risk factors with the avoidable burden of risk factors.
Study Design: Firstly, the disease burden of stroke due to
premature death and disability was estimated by using
morbidity and mortality data in 2001. Secondly, we selected
the risk factors and exposure variables of stroke and decided
the prevalence and relative risk of risk factors by systematic
reviews. Thirdly, we calculated the attributable burden of
stroke at the present prevalence of risk factors and the
avoidable burden of stroke at the counterfactual prevalence of
risk factors were calculated.
Population Studied: Korean(South) people
Principal Findings: The burden of stroke for a 1,000,000
population was 3322.62 person-years for males and 2532.20
person-years for females. The burden of stroke at present
prevalence for males per 100,000 population was attributed to
smoking (1940.41 person-years), alcohol (864.31 personyears), and hypertension (667.28 person-years). The burden of
stroke at present prevalence for females per 100,000
population was attributed to alcohol (462.76 person-years),
physical inactivity (455.65 person-years), and smoking (407.68
person-years). The joint population attributable fraction (PAF)
by risk factors was 80.2% percent for males and 52.4%
percent for females.
Conclusions: For reducing the burden of stroke, a
management policy for risk factors is required essentially.
Modifying the risk factors reduced the burden of stroke could
be more effective intervention to consider an initial
consideration of the differences of risk factors, gender, and
age could be more effective intervention.
Implications for Policy, Delivery, or Practice:
Primary Funding Source: Korea Health 21 R&D Project,
Ministry of Health & Welfare, Republic of Korea
●Estimation of the Burden of Disease in Korea
Heeyoung Lee, M.D., MPH, Seok-Jun Yoon, M.D., Ph.D.,
Sang-Cheol Bae, M.D., Ph.D., Heuisug Jo, M.D., Ph.D., Jin
Yong Lee, M.D., MPH, Hycjung Chang, M.D., Ph.D., Jaehyun
Park, M.D., MPH
Presented By: Heeyoung Lee, M.D., MPH, Principle
Researcher, Department of Preventive Medicine, College of
Medicine, Korea University, 126-1, 5ka Anamdong, Seongbukku, Seoul, 136-705; Tel: 82-2-920-6346; Fax: 82-2-927-7220;
Email: imstone@korea.ac.kr
Research Objective: We estimated the burden of diseases in
Korea using disability adjusted life year(DALY), a composite
measure of premature mortality and disability that equates to
years of healthy life lost.
Study Design: We calculated DALYs of 123 diseases for the
year 2002. The burden of disease due to premature death was
estimated by using years life lost due to premature
death(YLLs) measurement developed by the global burden of
disease study group. For the calculation of the years lived with
disability(YLD), the following parameters were estimated in
the formula; incidence rate, mortality, prevalence rate and
disability weight of disease.
Population Studied: Korean(South) People
Principal Findings: By disease category, DALYs per 100,000
population were attributable mainly to cancer(1,525 personyear), cardiovascular disease(1,492 person-year), digestive
disease(1,140 person-year), diabetic mellitus(970 person-year),
respiratory disease(951 person-year). The leading five diseases
of DALYs for males per 100,000 population in Korea were
diabetic mellitus(1020 person-year), cerebrovascular
accident(937 person-year), cirrhosis of the liver(671 personyear), asthma(663 person-year), ischemic heart disease(601
person-year). For females, the leading five diseases of DALYs
per 100,000 population were diabetic mellitus(919 personyear), cerebrovascular accident(900 person-year), peptic ulcer
disease(794 person-year), asthma(755 person-year),
rheumatoid arthritis(531 person-year).
Conclusions: These results presented a substantially different
ranking of disease burden than did mortality rates alone. Also,
we found differences in the rank order by gender and age
group.
Implications for Policy, Delivery, or Practice: We found the
DALY method emplyoed was appropriate to quantify the
burden of disease. Thereby, it would provide a rational bases
to plan a national health policy regardiing the burden of
diasese in Korea.
Primary Funding Source: Korea Health 21 R&D Project,
Ministry of Health & Welfare, Republic of Korea
●Predictors of Prescription Drug Skimping among
Enrollees in SeniorCare
Musetta Leung, MS, Donald S. Shepard, Ph.D., William
Stason, M.D, MS, Grant Ritter, Ph.D.
Presented By: Musetta Leung, M.S., The Heller School for
Social Policy and Management, Brandeis University, MS 035,
Waltham, MA 02454-9110; Tel: (617) 699-5239; Email:
mleung@brandeis.edu
Research Objective: Increasing concerns over prescription
drug affordability has prompted states to adopt measures that
ensure access among low-income populations. Previous
research has shown that people who could not afford
prescriptions often did not fill their prescribed medicines,
“split pills,” skipped doses, or went without other lifenecessities in order to pay for drugs. This study evaluated the
predictors of prescription drug skimping, defined as skipping
doses or not filling prescriptions for financial reasons, among
elders enrolled in two states’ pharmacy assistance programs
(PAPs).
Study Design: In mid-2002, Illinois and Wisconsin
implemented “SeniorCare,” the states’ Pharmacy Assistance
Waivers (Pharmacy Plus) program that provided low-income
persons aged 65+ with Medicaid-funded prescription drug
assistance. A random sample of SeniorCare enrollees
participated in a survey, which asked pre- and post-SeniorCare
questions on topics including drug utilization, affordability,
and insurance. Questions on health encompassed selfperceived health status, as well as number of conditions that
were later defined as perceived life threats (e.g. heart disease,
cancer) or not (e.g., osteoporosis, ulcer). Multivariate logistic
regression was used to assess predictors of skimping.
Population Studied: A random sample of communitydwelling SeniorCare enrollees was interviewed via telephone
by an academic survey research organization in Spring 2004.
Proxy respondents (7%), such as a family member, were
accepted, and a response rate of 61% was obtained. All
enrollees with non-missing data were included in the analysis.
Principal Findings: A total of 1,824 respondents (54%
Wisconsin and 46% Illinois) were included in the analysis. The
average age was 77 years, and the majority of respondents was
white (84%), female (73%) and had annual household income
at or below 160% of federal poverty level (66%). On a scale
from 1 to 7 (very poor to excellent), the mean health status
was 3.7, and respondents reported having an average of 3
medical conditions. Fifty-seven percent of enrollees had
coverage through private health insurance plan prior to PAP,
and 19% of the entire sample reported using private insurance
to pay for medications. Logistic regressions (odds ratios with
95% confidence intervals) showed that having more comorbid
conditions was associated with a higher probability of
skimping (OR=1.3, CI=1.18-1.44), but having life-threatening
conditions was associated with less skimping (OR=0.83,
CI=0.71-0.98). Being less poor, older, having better selfperceived health, and having private drug insurance were all
associated with less medication skimping (OR=0.49, CI=0.350.70; OR=0.94, CI= 0.93-0.96; OR=0.80, CI=0.70-0.90;
OR=0.69, CI=0.50-0.95, respectively). Gender, marital status,
and race did not have a statistically significant effect on preSeniorCare medication skimping.
Conclusions: Prescription drug skimping was more prevalent
among those who were poor, uninsured, and sicker (i.e., those
with worse self-perceived health and more comorbid
conditions). Having life-threatening conditions, however, was
associated with better medication adherence.
Implications for Policy, Delivery, or Practice:
Understanding who is at risk of medication non-adherence
may help policy makers to better design programs and target
them to persons with the greatest need of assistance.
Primary Funding Source: CMS
●“Do the Conclusions Look as Good as They Seem?” A
Review of Quality Improvement Intervention Studies
Linda Li, B.Sc.(PT), Ph.D., Lorenzo Moja, M.D., MSc, Alberto
Romero, M.D., MSc, Jeremy Grimshaw, M.D., Ph.D.
Presented By: Linda Li, B.Sc.(PT), Ph.D., Post-Doctoral
Fellow, Clinical Epidemiology Program, Ottawa Health
Research Institute, 1053 Carling Avenue, Administration
Building, Room 2-010, Ottawa, Ontario, K2B 7T4; Tel: (613)
798-5555x19749; Fax: (613) 761-5402; Email: lli@ohri.ca
Research Objective: To assess the appropriateness of
conclusions reported in recently published quality
improvement (QI) intervention studies in relation to the study
design.
Study Design: This study consisted of a systematic review
and an expert rating panel. We hand-searched 11 major
medical journals or health services research journals for
randomized and non-randomized evaluations of QI
interventions (RCTs, non-RCTs) published between January
2002 and December 2003. Eligible studies were those
evaluating interventions that aimed to change health
professional behaviours based on research evidence. Two
independent reviewers extracted data for each trial, including
study characteristics, methodology, and all statements
addressing the causal effect between the intervention and
outcomes in the abstract and the main text.
Population Studied: A 38-member expert panel was
assembled to assess the strength of causal inference
suggested by the causal statements. This panel consisted of
clinical epidemiologists, clinical trial methodologists, health
services researchers, and clinical researchers. Half of the
panelists were English first-language speaking. They rated the
strength of causality of each quote on a Likert scale (range 1-7,
higher = stronger causal relationship), assuming that all
quotes were from well designed RCTs. Each panelist rated 60
to 70 randomly assigned quotes and each quote was rated by
10 to 12 panelists. Student’s t-tests were used to compare the
ratings from RCTs and non-RCTs. Separate analyses were
done for statements recorded from the abstract and those
recorded from the main text. Subgroup analyses were
conducted for studies that reported statistically significant
results and those reported no effect or mixed results.
Principal Findings: Of the 4543 titles hand-searched, 73
articles were included (RCTs = 38; non-RCTs = 35) and 207
causality quotes were extracted (abstract = 68; main text =
139). 7 studies had no abstract quote and 5 had no main text
quote. In studies where more than one quote was extracted,
only the highest score was used since the strongest causal
statement provided the most definitive message to readers.
Hence, ratings of 66 abstract quotes (RCTs = 34; non-RCTs =
32) and 68 main text quotes (RCTs = 34; non-RCTs = 34) were
included in the analysis.
Preliminary analysis was conducted with the 29 responses that
we have received thus far. Among the abstract quotes, the
mean causality rating was significantly higher in the non-RCTs
(5.09 ± 1.12, versus 4.02 ±1.62 in RCTs; p=0.03). 26.5% of
RCTs versus 56.3% of non-RCTs reported positive results in
the abstract (p=0.01). A similar trend was found in the main
text quotes (RCTs = 4.60 ± 1.62; non-RCTs = 5.22 ± 1.29;
p=0.09). In the subgroup analysis, a statistically significant
difference was only found in studies reporting no effects or
mixed results in the abstracts (RCTs = 3.38 ± 1.34; non-RCT =
4.50 ± 1.26; p=0.015).
Conclusions: RCTs are the gold standards for examining
causal relationships between interventions and outcomes.
Conclusions from non-RCTs are expected to be more
conservative due to intrinsic weaknesses of the study design.
However, our preliminary results suggest that non-RCTs
evaluating QI interventions might have overstated the
strength of causality in their abstracts and main text.
Implications for Policy, Delivery, or Practice: QI studies
often employ quasi-experimental or observational designs.
Conclusions of these studies can be misleading to policy
makers and clinicians if authors are overzealous in stating the
causal relationship. Findings of this study will be the first step
in improving the appropriateness of conclusions stated in QI
intervention studies.
Primary Funding Source: No Funding Source
●Predictors of Adherence to Colorectal Cancer Screening
Recommendations
Su-Ying Liang, Ph.D., Kathryn A Phillips, Ph.D., Jennifer Haas,
M.D., Mika Nagamine, Ph.D.
Presented By: Su-Ying Liang, Ph.D., Assistant Research
Professor, Clinical Pharmacy, University of California, San
Francisco, 3333 California Street, Suite 420, San Francisco, CA
94143; Tel: (415)514-0457; Fax: (415)502-8271; Email:
sliang@itsa.ucsf.edu
Research Objective: The objective of this study was to
examine the associations of health plan and individual
characteristics with adherence to colorectal cancer (CRC)
screening recommendations and whether the associations
differ between specific types of CRC tests.
Study Design: Data were from the 2000 National Health
Interview Survey. The main outcome measure was selfreported adherence with CRC screening within the
recommended timeframe (i.e., , having home fecal occult
blood test (FOBT) in the prior year or sigmoidoscopy in the
last 5 years or colonoscopy in the last 10 years). The primary
independent variable was the referral requirements of a health
plan – the one specific health plan characteristic that may be
relevant to CRC tests. Other individual level variables included
were individual socioeconomic status (age, gender, household
income, education), types of health plans (private vs public,
Medicare, Medicaid, private managed care vs private nonmanaged care, public managed care vs public non-managed
care), having a usual source of care, and clinical risk factors
(family history of colorectal and non-colorectal cancer,
personal history of non-colorectal cancer). Sub-analyses were
conducted for each of the three CRC tests. All analyses were
conducted using sampling weights to reflect the U.S. civilian,
non-institutionalized population and standard error
adjustment to account for complex survey design.
Population Studied: The population contained a nationally
representative sample of adults ages 50 and over without a
history of CRC. Our sample included 11,574 individuals who
meet our selection criteria.
Principal Findings: Thirty-seven percent of individuals had
received CRC screening consistent with current
recommendations. Among those ever screened, 69% was
adherent to the screening recommendations. Specifically,
14% was adherent using combinations of CRC tests while
17%, 11%, and 27% were adherent to FOBT only,
sigmoidoscopy only, and colonoscopy only, respectively. We
found that enrollment in plans with referral requirements and
enrollment in managed care plans were not significantly
associated with the overall adherence measure but their
associations with adherence to specific types of CRC tests
were different. Individuals enrolled in plans with referral
requirements were less likely to be adherent to colonoscopy
guidelines (p=0.002) than those without referral
requirements, while individuals enrolled in plans with referral
requirements had a trend to be adherent to FOBT (p=0.11)
and sigmoidoscopy (p=0.22) guidelines. Individuals enrolled
in public managed care plans were more likely to be adherent
to FOBT (p=0.08) and sigmoidoscopy (p=0.02) guidelines
than those enrolled in public non-managed care plans, while
the trend was reversed for colonoscopy (p=0.28). As for other
individual level variables, we found in our bivariate analyses
that individuals were more likely to be currently adherent if
they were male (p=0.07), race/ethnicity being White (p=0.09),
non-Medicaid beneficiaries (p=0.09), having a personal
history of non-CRC cancer (p=0.02), having a family history of
colorectal cancer (p=0.08), and having a usual source of care
(p=0.04).
Conclusions: The overall adherence rate was low (37%),
however, the adherence rate of those ever screened was high
(69%). Most people who get screened are up-to-date on
screening so the adherence rate of all eligible adults including
never screened gives a less optimistic picture than may be
warranted. In addition, we found one health plan
characteristic - referral requirements - was negatively
associated with adherence to colonoscopy guidelines while
this specific health plan characteristic did not have a negative
impact on adherence to FOBT and sigmoidoscopy guidelines.
Other individual level predictors of overall adherence were
similar and consistent to the literature.
Implications for Policy, Delivery, or Practice:
Understanding the predictors of utilization of and adherence
to CRC recommendations can help identify and reduce
barriers to health care. Furthermore, it is important to
understand whether specific health plan structures have
differential impacts on various types of CRC tests. Insurance
benefit designs that may wish to promote specific screening
tests should take into account the potential differential
impacts of health plan organizational structures on these
tests.
Primary Funding Source: NCI
● Implementing a Voluntary Prescribing Error Reporting
System in Outpatient Primary Care Practices
Benjamin Littenberg, M.D., Amanda Kennedy, PharmMD
Presented By: Benjamin Littenberg, M.D., Professor of
Medicine, University of Vermont, 371 Pearl Street, Burlington,
VT 05401; Tel: (802) 847-8268; Fax: (802) 847-0319; Email:
benjamin.littenberg@vtmednet.org
Research Objective: To design a voluntary outpatient
prescribing error reporting system for primary care practices,
implement the system in a sample of practices, analyze the
reports, and provide feedback to prescribers about reported
errors.
Study Design: We asked triage nurses and office staff to
submit copies of all phone or fax communications with
community pharmacists about prescribing errors for inclusion
in our database. Reports could be telephoned, mailed, or
collected weekly by a courier. We did not specify a standard
reporting form because we wished to minimize office
intrusion and encourage participation. Although the reporting
system was designed to be a job function of the triage nurses
and office staff, prescribers were encouraged to report their
own errors.
Population Studied: Seven outpatient primary care practices
in Northwestern Vermont.
Principal Findings: All 7 practices have contributed reports
and the majority of practices have submitted reports via
courier. To date, 143 prescription error reports have been
submitted to the database. Only 6 reports were contributed
directly by prescribers. Preliminary analysis of the reports
reveals 43 omission errors, 52 commission errors, 17
clarifications due to illegibility, 10 pharmacy errors, and 14
pharmacist clarifications that were not errors. 7 reports could
not be categorized due to missing data. Reports most
frequently concerned antidepressants (33/143) and
antihypertensives (22/143). 43 reports involved problems with
strength, including 11 prescriptions written for strengths not
commercially available. At least 10 reports described errors
with the potential to harm patients if not detected or corrected
by pharmacists prior to dispensing.
Conclusions: Implementing a voluntary outpatient
prescribing error reporting system using triage nurses and
office staff is feasible. Alternative methods for submitting
reports need to be explored, as courier services are expensive.
Striking a balance between data collection and office burden
requires continued assessment.
Implications for Policy, Delivery, or Practice: Many of the
errors described in the reports can be prevented using
inexpensive, available, and accessible tools. Continued
surveillance, with deeper analysis of specific reports, and the
development of appropriate mechanisms for feedback to
prescribers require continued research.
Primary Funding Source: AHRQ
●Care Fragmentation and Psychiatric Illness is Associated
with Increased Emergency Department Use Among
Complex Diabetic Patients
Connie Liu, M.D./Ph.D. Candidate, Andrew O'Connor, DO,
MPH, Doug Einstadter, M.D., MPH, Randall Cebul, M.D.
Presented By: Connie Liu, M.D./Ph.D. Candidate,
Department Epidemiology and Biostats, Case Western
Reserve University, 10900 Euclid Avenue, Cleveland, OH
44106; Tel: (216)650-2745; Email: cwl6@case.edu
Research Objective: The care of complex diabetic patients
often is fragmented among multiple specialists. The objective
of the current investigation is to determine if the presence of
psychiatric (Psych) comorbidity among diabetic patients
aggravates their already fragmented care and results in
excessive use of the Emergency Department (ED).
Study Design: This is a retrospective analysis of ED use in
diabetic patients with chronic kidney disease (CKD). Diabetes,
CKD, Psych and non-Psych comorbidities, visit adherence, a1c
levels and ED visits were identified from visit records,
recorded lab values and ICD-9-CM codes from the system´s
electronic medical record; Psych comorbidities were classified
as mood/anxiety, psychotic, or “other” disorders.
“Fragmentation” was defined as the number of separate nonpsych specialty clinics visited. A negative binomial model was
used to estimate the effect of Psych disorders and
Fragmentation on the number of ED visits after adjusting for
age, sex, ethnicity, number of non-Psych comorbidities,
diabetes control (average a1c level over 2 years), adherence
(proportion of “kept” primary care appointments), and
insurance (commercial, Medicare, Medicaid, uninsured)
status.
Population Studied: Diabetic continuity patients with chronic
kidney disease (CKD, estimated GFR 20-60) seen at 10
primary care practices in a large urban health care system over
a 2-year period. "Continuity" was defined as having at least
one primary care visit per year within the system during the
study period.
Principal Findings: Of 3873 patients with diabetes seen
during 2002-2003, 623 (16.1%) had CKD, of whom 241
(38.7%) had one or more Psych co-morbidities. Psych patients
were younger (66.7 yrs vs. 69.7 yrs, p < 0.0005), had more
non-Psych comorbidities (2.92 vs. 2.56, p<0.0003), poorer
adherence (84.7% vs. 87.8% kept primary care visits,
p<0.004), and a greater level of Fragmented care (1.77 vs. 1.47
specialty clinics visited, p<0.0009) than non-Psych patients.
On bivariate analysis, the 141 (22.6%) diabetic CKD patients
with mood and anxiety disorders were more likely than those
without to have at least one ED visit (63.1% vs. 44.6%; OR
1.42, 95% CI, 1.21 to 1.66). After adjusting for age, sex,
ethnicity, non-Psych comorbidities, diabetes control,
adherence, and insurance, the presence of a mood/anxiety
disorder increased the predicted number of ED visits by a
factor of 1.50 (95% CI: 1.14 to 1.98), while greater
Fragmentation increased the number of ED visits by a factor
of 1.32 (95% CI: 1.19 to 1.47) for each additional clinic visited.
Psych diagnoses other than mood or anxiety disorders were
not associated with increased number of ED visits.
Conclusions: Mood and anxiety disorders are prevalent
among patients with complicated diabetes, and are associated
with increased fragmentation of care and increased use of the
ED.
Implications for Policy, Delivery, or Practice: We believe
that fragmentation of non-psychiatric care further exacerbates
the discontinuous nature of psychiatric care, and may
contribute to poorer self-management of diabetes and its
complications.
Primary Funding Source: No Funding Source
create bad medicines. Some propose that US Medicare reduce
the rates so that doctors are reimbursed at prices much closer
to what is actually paid. The NHI in Taiwan has long
recognized potential conflicts of interest in the system and
determined to gradually decrease drug profits through large
scale reimbursement rate reduction initiatives. As little
empirical evidence is available concerning effects of such
regulatory initiatives on cost control and prescribing patterns,
results obtained from this study should help health service
researchers and health policy officials design similar policies
in the US or elsewhere.
Primary Funding Source: National Science Council, Taiwan
●Do Drug Reimbursement Rate Reductions
Work?Evidence from Taiwan’s Outpatient Hypertension
Treatments in the Elderly
Shuen-Zen Liu, Ph.D, James Romeis, Ph.D., Hsuan-Lien Chu,
Ph.D.
●Variations in Depression Treatment Quality: Medicaid
versus Commercial Claims
Stacey Long, MS, Rebecca Robinson, MS, Stella Chang, MPH,
Stephen Able, Ph.D., Onur Baser, Ph.D., Ralph Swindle, Ph.D.
Presented By: Shuen-Zen Liu, Ph.D, Professor, Accounting,
National Taiwan University, Room 1009, Building II, College of
Management, Taipei, 106; Tel: 011 886 2 2736-7817; Fax: 011
886 2 2738 5108; Email: sliu@mba.ntu.edu.tw
Research Objective: This study investigates the initial effects
of Taiwan’s prescription drug reimbursement rate reduction
policy (a supply-side cost control mechanism) in the elderly
with hypertension based on outpatient treatment data.
Study Design: We use regression analysis to examine whether
average prescription drug cost decreases as a result of the
nation’s drug reimbursement rate reduction program. The
probit model is invoked to investigate changes in prescribing
behavior for drugs with and without reimbursement rate
reductions. In addition, we further investigate whether or not
the drug rate reduction policy results in potential adverse
effects on health status.
Population Studied: About 137,000 patients aged 65 and
older with hypertension were drawn from 21 hospitals in the
Taipei area for the study.
Principal Findings: We found that average drug cost per
prescription increased slightly despite the implementation of
the rate reduction policy after controlling for relevant variables
in regression analyses. About 8,900 items of drugs (roughly
45% of the total) experienced rate reductions in the National
Health Insurance [NHI] formulary. Those drugs, however,
appeared only in about 3% of prescriptions. Thus, the policy
had limited impact on total outpatient drug expenditures. As
expected, in the probit model, we found evidence that
physicians substituted drugs experiencing rate reductions with
drug experiencing no rate reductions.
Conclusions: Physicians appeared to be reluctant in reducing
the use of essential drugs even when facing rate reductions,
possibly attempting to avoid an adverse health outcome. The
result may suggest less concern over the quality of health
service because of the policy. Overall, the National Health
Insurance reimbursement rate reduction policy offers a
mechanism to change prescription behavior of physicians by
reducing excessive profits on certain drug items based upon
reliable database of reported drug transaction prices.
Implications for Policy, Delivery, or Practice: In the US,
chemotherapy concessions, referring to drug profits
oncologists earn in treating US Medicare patients, have
recently sparked heated criticisms as conflicts of interest that
Presented By: Stacey Long, MS, Director, Outcomes Research
& Econometrics, Medstat, Inc., 39 Sophie Lane, Hampden,
ME 04444; Tel: 207-862-6360; Fax: 207-862-6360; Email:
stacey.long@thomson.com
Research Objective: Achieving universal access to quality
health care is challenging. We compared antidepressant
treatment patterns between patients with Medicaid and
private insurance claims to assess differences in treatment
quality.
Study Design: MarketScan Commercial Claims and
Encounter (CCAE) and Medicaid claims data from the same
three states (2001-Q12003)were used to assess depression
treatment quality based on antidepressant dose, duration, and
"appropriate use" as defined by National Committee for
Quality Assurance (NCQA) guidelines.
Population Studied: Adults with employer-sponsored
commercial insurance or Medicaid coverage residing in the
same three states with depression claims and initiating on
antidepressants were followed for 12 months. Claimants with
prior antidepressant use or diagnoses of schizophrenia,
bipolar, and psychoses were excluded.
Principal Findings: Of the 10,383 CCAE and 20,170 Medicaid
claimants, Medicaid patients were younger, sicker, and more
likely to have capitated insurance (all p<0.001). 13.6% of
commercial and 1.3% of Medicaid patients were compliant
across all 3 NCQA measures. After controlling for
demographics and antidepressant type, Medicaid patients
were more likely than commercial patients to initiate below
recommended doses (OR 1.55) and less likely to have
continuous therapy (OR 0.54), or switch/augment therapies
(OR: 0.27-0.67) (all p<0.001). Mental health specialty care
was also associated with less early discontinuation (OR 0.76)
and more continuous care (OR 1.18) (all p<0.001).
Conclusions: Compliance with NCQA guidelines was less
than optimal in both datasets but significantly worse in
Medicaid. Greater equity of care and patient follow-up could
result in less illness burden.
Implications for Policy, Delivery, or Practice: 1. Participants
will learn about variations across Medicaid and Commercial
data sources in antidepressant treatment patterns and
associated care in terms of appropriate use according to
NCQA guidelines and dose recommendations over time. 2.
Participants will recognize demographic, clinical
characteristics including medical comorbidities, and
antidepressant classes variations associated with utilization
patterns and guideline compliance. 3. Participants will be
able to identify trends in drug utilization and associated care
across various antidepressants in both public and private
settings.
Primary Funding Source: Eli Lilly and Company
●Evaluating the Patient Safety Indicators (PSIs): How Well
Do They Perform on VA Data?
Susan Loveland, MAT, Peter E Rivard, MHSA, Shibei Zhao,
MPH, Anne Elixhauser, Ph.D., Patrick Romano, M.D., Ph.D.,
Cindy L Christiansen Ph.D., Amy K Rosen, Ph.D.
Presented By: Susan Loveland, MAT, Research Systems
Manager, Bedford VAMC, Center for Health Quality,
Outcomes and Economic Research, 200 Springs Road (152),
Bedford, MA 01730; Tel: (781)687-2961; Fax: (781)687-3106;
Email: slvland@bu.edu
Research Objective: Although the VA has established a
National Center for Patient Safety (NCPS) and taken initiatives
to improve patient safety, accurate information on the
epidemiology of patient safety events in the VA remains
unavailable. The Agency for Healthcare Research and Quality
(AHRQ) has developed the Patient Safety Indicators (PSIs),
which are increasingly being used to screen for potential
inpatient safety problems. Our objectives were to: 1) apply the
AHRQ PSI software to VA administrative data to identify
potential instances of compromised patient safety; 2)
determine occurrence rates of PSI events in the VA; and 3)
examine the construct validity of the PSIs.
Study Design: Because VA administrative databases differ
from standard databases in both structure and data
definitions, we developed algorithms to create an “acute-only”
hospital database from the VA 2001 inpatient administrative
data, adding cost information to each hospitalization. We
applied the PSI software to calculate VA unadjusted and riskadjusted safety event rates, based on HCUP case-mix, and
compared them to non-VA rates – AHRQ’s 2000 HCUP
National Inpatient Sample (NIS) and Medicare (2000
MedPAR) data. We also examined construct validity of the
PSIs by investigating the difference in outcomes between
hospitalizations with and without a PSI event.
Population Studied: Veterans discharged from VA hospitals
during the time period 10/1/00 through 9/30/01.
Principal Findings: We identified 11,411 PSI events in the VA.
Observed PSI rates per 1,000 discharges ranged from 0.007
for “transfusion reaction” to 155.5 for “failure to rescue.”
Risk adjustment decreased the observed rates of seven PSIs
and slightly increased the rates of seven others. VA riskadjusted rates were significantly lower than both HCUP-NIS
and Medicare event rates for four indicators: “decubitus
ulcer,” “infection due to medical care,” “postoperative
respiratory failure,” and “postoperative sepsis.” Conversely,
VA PSI event rates were significantly higher than both HCUPNIS and Medicare event rates for two indicators:
“postoperative physiologic and metabolic derangements” and
“technical difficulty with procedure.” Among the remaining
relevant indicators, VA PSI event rates were significantly
higher than HCUP-NIS event rates, but were significantly
lower than Medicare event rates, for “death in low mortality
DRGs,” “failure to rescue,” “postoperative hip fracture,” and
“postoperative pulmonary embolism/DVT.” Hospitalizations
with PSI events usually had longer lengths of stay, higher
mortality, and higher costs than those without events.
Conclusions: Our results suggest that the PSIs may be useful
in the VA as a tool to screen for potential patient safety events
that warrant further investigation. Our PSI rates were
consistent with the national incidence of low rates; however,
significant differences between VA and non-VA rates indicate
that inadequate case-mix adjustment may be contributing to
these findings.
Implications for Policy, Delivery, or Practice: The PSIs can
serve as case-finding tools, providing an initial assessment of
the potential scope of patient safety events in the VA.
Primary Funding Source: VA
●The Role of Poster Presentations in Knowledge Transfer
and Exchange in Quality Improvement or QI
Collaboratives
Anu MacIntosh-Murray, Ph.D.
Presented By: Anu MacIntosh-Murray, Ph.D., Postdoctoral
Fellow, Knowledge Translation Program, University of
Toronto, 122 Langley Avenue, Toronto, M4K1B5; Tel:
(416)466-4725; Email: anu.macintosh@utoronto.ca
Research Objective: Many organizations have
multidisciplinary teams collaborating with both clinical experts
and improvement experts to improve patient care processes
and outcomes;e.g., IHI's Breakthrough Series, Vermont
Oxford Network. Collaboratives often invest considerable time
in poster presentations to share lessons learned beyond
teams who initially test changes. Little is known about how
this actually works and what information exchange takes place.
Study aim: to learn how poster presentations facilitate
dissemination and exchange of improvement knowledge
between teams in an improvement collaborative, and between
the teams and others in the organization.
Study Design: Case study of the final poster presentation
session of an organization's two improvement collaboratives,
one with ten teams, the other with twenty. Data are based on:
observation of the poster presentation activities; two sets of
semi-structured interviews with the collaborative coordinator
and five presenters from four improvement teams, two weeks
and two months after the presentation session; document
review of posters, templates, guidelines used; and a survey of
100 staff attending the event. Qualitative methods,
interpretive and discourse analysis, are used for the interviews
and observations, which are the focus here.
Population Studied: Team members and staff particpating in
and attending a QI collaborative presentation session in a
large, muliti-site, urban academic health sciences centre.
Principal Findings: 1. Most posters were based on a template
provided by the organizers and were professionally prepared;
large format, colour-printed, and laminated. They reflected a
summative approach, chronicling the background, aim,
changes, and results of the projects, not unlike formal
research posters. Of the 19 posters displayed for the 75 min.
session, six never had a team member there to answer
questions, and several others were left unattended at various
times. The level and duration of interactions between
presenters and viewers varied markedly, depending in part on
the efforts of presenters to engage viewers. No presenters had
handouts of the posters available at the session. 2. Interview
participants said they did not prepare an oral component - the
project "story" - to present at the poster, nor were they
instructed to do so. They reported that the posters did not
prompt any discussion about explicit information about
improvement methods, such as rapid cycle, PDSA, change
ramps, during or after the session. Most questions were
requests for copies of the more portable "tools" that tangibly
embodied change ideas, such as education posters, or cards
and pens with pain scales. 3. Interview participants spoke
more about the conceptual, or awareness raising, and
symbolic uses of the poster and the presentation session;
instrumental use, to gain ideas for making improvements, was
secondary.
Conclusions: 1. The purpose and communicative intent of the
presentations vary depending on the stage of the
collaborative, so formats need to be adapted for each stage.
Posters for communicating the work in progress during
ongoing learning sessions can be flexible and less elaborate;
e.g., pages of Powerpoint slides. These are often referred to as
storyboards. Posters for the final presentations may resemble
research posters in format and style, and may be a more
formal end-product used for multiple purposes; e.g., produced
as a single large panel. Problems arose when the purposes
were unclear. 2. The poster presentation session had both
practical and symbolic functions. It provided opportunities to
network with staff from other units about practice issues
unrelated to the projects. However, the dominant themes
were the more symbolic aspects of the presentation session,
including the rituals of celebration and recognition of the
collaboratives as team and organizational accomplishments.
Implications for Policy, Delivery, or Practice: Persons
designing collaboratives and staff who are participating need
to understand the purposes and formats of poster
presentations. In addition to guidance about the structure and
design of posters, poster presenters could benefit from
coaching about how to prepare an oral component to support
their presentation. Organizers should also consider how to
prepare viewers to get the most out of the poster sessions.
Primary Funding Source: Canadian Health Services Research
Foundation Postdoctoral Fellowship
●Building Relationships Between a Health Plan and an
Academic Medical Center
Richard Mathis, BA, MA, Ph.D., Ken Patric, M.D., Steve
Martin, RN, BS, MS.Ed, John Barnes, MBA, MA
Presented By: Richard Mathis, BA, MA, Ph.D., Manager,
Medical Policy Research and Development, BlueCross
BlueShield of Tennessee, 801 Pine Street, Chattanooga, TN
37402; Tel: (423) 755-5801; Fax: (423) 785-8149; Email:
richard_mathis@bcbst.com
Research Objective: To improve the quality of health care
delivery and to foster relationships between a health plan and
an academic medical center.
Study Design: Qualitative study.
Population Studied: Academic medical center staff; Payor
staff; patients.
Principal Findings: Collaborations between BlueCross
BlueShield of Tennessee (BCBST) and the University of
Tennessee College of Medicine Internal Medicine Department
have the potential of improving health care delivery to the
patients served by the Internal Medicine Department. BCBST
has worked with the Internal Medicine Department to provide
deidentified data that assists in addressing conditions treated
by Internal Medicine at Erlanger hospital. Among these are
potential improvements in treating patients presenting with
such diagnoses as intoxication. The Internal Medicine
Department and BCBST also gain in their knowledge of one
another's approach to such issues as fostering and
implementing evidence based medicine.
Conclusions: Health Plans and academic medical centers
should work more closely together to foster quality and
evidence based medicine.
Implications for Policy, Delivery, or Practice: New
relationships need to be forged between provider, payors, and
researchers. This is an example of one effective approach.
Primary Funding Source: No Funding Source
●Financial Incentives in Outlier Utilization Early in the
Medicare Home Health Prospective Payment System
Ann Meadow, Sc.D., Philip Cotterill, Ph.D.
Presented By: Ann Meadow, Sc.D., Social Science Research
Analyst, Division of Payment Research, Centers for Medicare
& Medicaid Services, 7500 Security Bouleveard, Mail Stop C319-26, Baltimore, MD 21244; Tel: (410)786 6602; Fax:
(410)786 5534; Email: ameadow@cms.hhs.gov
Research Objective: Since October 2000, Medicare has paid
for home health services under a case-mix adjusted
prospective payment system. The unit of payment is a 60-day
period of care. Outlier payments are available for care
periods with high numbers of visits. Medicare’s outlier
payment per period of care is 80% of the difference between
total standard per-visit costs and the sum of the PPS payment
plus a large deductible. Unlike outlier payments in the
hospital DRG system, the provider’s specific costs do not
affect the outlier payment. As a result, providers may face
varying incentives to serve outlier cases depending on how
their cost structure compares with the standard per-visit costs
in the payment formula. They may also seek to limit losses on
outliers by adjusting delivery practices for outlier cases to
reduce costs. The objective of this research is to develop
evidence on financial factors potentially affecting the operation
of the outlier policy.
Study Design: This is an observational study using
administrative data from the Medicare program. We compare
outlier cases from a 10% random sample of claims with
nonoutliers from a 2% random sample. Data from claims
detail clinician time in the home during each visit, payments,
and the case mix group. We linked to each record the
standardized clinical assessments used for case mix
assignment, known as the Outcome and Assessment
Information Set (OASIS), for purposes of measuring clinical
and social characteristics of the patient. We also linked
Medicare administrative files describing agency characteristics
and, for agencies with usable cost reports, we linked cost
report data. Analytic methods include bivariate tables and
multivariate models to test several hypotheses, such as: (1)
The probability that a case is an outlier is negatively related to
the agency’s cost per visit for the services associated with
outlier cases, skilled nursing and home health aide services.
(2) Outlier cases have shorter average visit lengths for skilled
nursing care, after controlling for clinical and social
characteristics of the patient and agency practices.
Population Studied: The study population consists of
Medicare 60-day service periods for Medicare beneficiaries
nationally during 2002. The main sample covers more than
5,000 home health agencies representative of Medicarecertified agencies throughout the nation. Usable cost reports
came from approximately 1,200 agencies broadly
representative of the nation.
Principal Findings: Outlier cases average 88 visits, compared
to 19 visits for nonoutlier cases. Outliers predominantly use
skilled nursing (68 visits on average) and aide services (14
visits on average). After controlling for case mix group,
disability program coverage, other demographic variables,
urban residence, caregiver and living arrangement variables,
cognition, receipt of home health aide services, and measures
of clinical nursing need (such as diagnoses for wound
conditions and diabetes care, intravenous or infusion
treatments, and need for assistance in managing injectable
medications), the probability that a case is an outlier varies
inversely with the agency’s cost per visit for both skilled
nursing care and home health aide visits: Odds ratios for
skilled nursing cost (relative to the highest cost quartile)
ranged from 4.3 for the lowest quartile to 1.61 for the secondhighest quartile (p <.0001). Odds ratio estimates for home
health aide services were about 1.25 for the lowest and secondlowest cost quartiles (p <.05). Plots of average length in
minutes per skilled nursing visit exhibited a marked reduction
for outlier cases throughout the range of total visits per 60-day
period. After adjusting for selected clinical and social patient
characteristics, case mix group, type of agency ownership and
affiliation, total visits, and the agency’s ownership, affiliation,
and state location, we estimated that outlier cases’ average
nursing visit length was shorter by about 6 to 8 minutes (in
models with and without random intercepts for agencies, p
<.0001), a reduction of approximately 15%. The average
length of a home health aide visit is about one hour, but in
outlier cases using home health aide services (about 48% of
outlier cases), it was 3 to 5 minutes longer (p <.05 in random
intercept model).
Conclusions: The results suggest that the incidence of outlier
cases is influenced by home health agency production costs,
as well as clinical and social characteristics of patients and
service delivery practices in large urban areas. The evidence
of shorter nursing visits for outliers is consistent with a
strategy of either targeting outlier admissions towards
patients with needs (unmeasurable here) that lend themselves
to shortened visits, or adjusting visit lengths for patients with
large numbers of visits likely to lead to outlier payments. Such
responses may serve to reduce agency losses incurred from
serving especially costly patients. Home health aide services
appear less liable to be length-adjusted in outlier cases, and a
slightly longer visit length for outliers could be due to
unmeasured patient service needs, labor market factors, or an
interaction with nursing services which remains to be
explored.
Implications for Policy, Delivery, or Practice: Outlier
payment policies are intended to supplement the case mix
adjustment of payments in situations where poorly
understood factors influence the cost of care and put
providers at high financial risk. The home health outlier
payment formula warrants continued study of its potential for
introducing financial incentives that may affect patient access
and service delivery.
Primary Funding Source: No Funding Source
●A Comparative Study of Canadian and U.S. Academiclinked Health Policy Centers
Michele Mekel, JD, MHA, MBA, Samuel E.D. Shortt, MPA,
M.D., Ph.D.
Presented By: Michele Mekel, JD, MHA, MBA, Visiting
Fulbright Scholar, Centre for Health Services and Policy
Research, Queen's University, Abramsky Hall, 3rd Floor,
Kingston, ON K7L 3N6; Tel: (613) 533-6387; Fax: (613) 533-6353;
Email: michelemekel@yahoo.com
Research Objective: Identify and compare structural models
and operational success strategies of university-linked health
policy centers in Canada and the United States.
Study Design: This largely qualitative, descriptive study was
conducted using semi-structured telephonic interviews with
Canadian and U.S. health policy center directors. The
interview tool, containing approximately 50 questions, covered
five overarching areas of center operations: 1. history; 2. target
audience; 3. staffing and structure; 4. funding; and 5.
performance evaluation. The U.S. component concluded in
2003, and the Canadian component was completed in 2004.
Population Studied: Selected centers were university-linked,
devoted to health policy research, and located in either
Canada or the United States. For inclusion in the Canadian
study, centers had to have a: 1. primary focus on health
services and or health policy research; 2. designation in name
as center, unit, institute, group, or an equivalent; 3. Canadian
situs; and either 4. university affiliation; or 5. inclusion in the
Canadian Health Services Research Foundation’s Network of
Applied Health Services Research Centre Directors. The U.S.
study’s inclusion criteria were similar, except centers had to
have a: 1. designation in name as a health policy center or an
equivalent; 2. university affiliation; and 3. United States situs.
Thirteen, 87 percent, of the identified Canadian centers and 12,
48 percent, of the identified U.S. centers participated.
Principal Findings: While the health systems in which they
operate differ greatly, health policy centers on both sides of
the border share numerous similarities in terms of function
and structure. These commonalities included: dependence
on governmental funding; governmental policy makers as key
audiences; significant funding challenges; utilization of
affiliated investigators and collaborative partners in research
initiatives; and a dearth of systematic, center-specific
performance measurement tools. Nevertheless, some
significant differences emerged, including: Canadian centers’
greater focus on provincial health issues than that devoted by
U.S. centers to state health concerns; Canadian centers’
discomfort with engaging legislative policy makers; Canadian
center differentiation based on health care data access, i.e.,
whether the center served as a delegated repository for
provincial health data, versus U.S. center differentiation based
on the type of research undertaken; and a more collaborative
environment among Canadian centers than exhibited among
their U.S. counterparts.
Conclusions: Similarities dominated as Canadian and U.S.
health policy centers face virtually identical challenges and
utilize analogous operational strategies. Where Canadian and
U.S. centers differ, these divergences are primarily attributable
to the health systems and governmental structures under
which the centers function.
Implications for Policy, Delivery, or Practice: While sample
sizes were small, results from this study are important
because they allow health policy centers to identify, explore,
and adopt success strategies that are particularly suited to
their operational model. By doing so, centers can enhance
their contributions to health policy debates and formation,
ultimately benefiting the end users of health services.
Moreover, identification of challenges shared by both
Canadian and U.S. centers, such as the lack of systematic,
center-specific performance metrics, presents a prime
opportunity for international collaboration.
Primary Funding Source: Fulbright Grant for Research
Abroad
●Primary Care Physician Characteristics and Involvement
in a Program to Improve Outpatient Clinic Operations
David Mohr, Ph.D., Carol VanDeusen Lukas, EdD, Mark
Meterko, Ph.D., Marjorie Nealon Seibert, MBA
Presented By: David Mohr, Ph.D., Health Services
Researcher, VA Boston Healthcare System (152M),
Department of Veterans Affairs, 150 South Huntington
Avenue, Boston, MA 02116; Tel: (617)232-9500 x5679; Email:
david.mohr2@med.va.gov
Research Objective: The study sought to 1.) identify factors
that predict primary care physician involvement in an
innovative program designed to improve outpatient access to
care and coordination and 2.) determine if extent of
involvement predicts patient satisfaction and diffusion of the
innovation.
Study Design: A total of 454 primary care physicians from 78
medical facilities in the Veterans Health Administration
system responded to a survey about their level of participation
in Advanced Clinic Access (ACA), a program designed to
improve clinic operations and access to care, and their
perceptions of the extent to which ACA had been
implemented and diffused at their facilities. The program
consisted of ten specific practice activities. Respondents
indicated their extent of participation in each activity. An
overall extent of involvement score was computed from these
data for each physician and regressed at the individual-level
on two control variables (clinic size and number of exam
rooms per clinician) on four individual characteristics (fulltime status, tenure, supervisory role, and belief in the
effectiveness of ACA) and degree of management support for
the innovation. In a separate, facility-level analysis, extent of
physician involvement was used to predict patient satisfaction
with several dimensions of their VA healthcare as measured by
an independent survey and employee judgments regarding the
extent of program diffusion.
Population Studied: Primary care physicians and outpatients
in a cross-national hospital system.
Principal Findings: Factors significantly associated with
individual extent of involvement were tenure of more than one
year in the clinic, having a supervisory role (e.g. team leader),
belief of program effectiveness and management support (adj
r-sq = .18). After including the variables from the individualmodel, extent of involvement significantly improved the
percent of variance accounted for patient satisfaction with
overall coordination (change in r2 = .05, p <.05, overall adj r-sq
= .19), but not with access to care or overall quality.
Additionally, extent of involvement significantly improved the
percent of variance accounted for program diffusion (change
in r2 = .06, p = .01, overall adj r-sq = .47).
Conclusions: Physicians who have been with the clinic for a
year or more, hold a supervisory role, and see the benefits of
the innovation program will be more likely to actively
participate in the program. Management support also
positively influenced individual’s participation rates in the
program. After controlling for these and other factors, higher
levels of participation also impact patient satisfaction with
overall coordination of care and spread of the program
practices to other clinic areas within the medical facility.
Implications for Policy, Delivery, or Practice: Individual
physician participation in the change program may be
facilitated with management support and a greater level of
individual belief in the program benefits. Greater participation
by physicians can produce noticeable benefits to patients and
with the spread of the program to other clinic areas.
Primary Funding Source: VA
●Perspectives of Persons with Opioid Dependence: An
Analysis of Online Discourse
Robert O. Morgan, Ph.D., Loralee Capistrano, MPH,
LeChauncy D. Woodard, M.D., MPH, Paul Haidet, M.D.,
MPH, Richard L. Street, Ph.D., Robert O. Morgan, Ph.D.,
Barbara F. Sharf, Ph.D.
Presented By: Robert O. Morgan, Ph.D., Associate Professor,
Houston Center for Quality of Care and Utilization Studies,
Baylor College of Medicine, Michael E. DeBakey VA Medical
Center, 2002 Holcombe Boulevard (152), Houston, TX 77030;
Tel: (713)794-8601; Email: rmorgan@bcm.tmc.edu
Research Objective: Efforts to integrate opiate addiction
treatment into medical practice has the potential to
significantly expand access to care. However, studies indicate
that physicians feel unprepared to treat patients with opiate
addiction. We conducted this study to explore issues
surrounding patients’ perspectives of opiate addiction.
Study Design: We conducted a thematic analysis of postings
by an Internet discussion group for people actively using or
recovering from opiate addiction. We collected discourse from
July 13 to July 20, 2004, which generated 180 pages of text.
Four investigators analyzed transcripts to identify key themes.
Analyses were guided by a focus on the cause, control,
severity, treatment, and meaning of opiate addiction from the
patients’ perspective.
Population Studied: “The Patient Buprenorphine Web Board”
consisted of 857 members, of which 665 posted information.
Principal Findings: Four themes emerged. First, participants
discussed the meaning of addiction, including their reasons
for opiate use and feelings about their addiction. One
participant commented, “Addiction fills the void. When you
get clean, you’re like a doughnut with an even bigger void. You
suck in meaninglessness; drown in a sea of futility. Unless you
can replace it with something solid, it seems only a matter of
time before you’re back where you started.” Second,
participants described the impact of addiction on daily life.
One participant stated, “We are not rich by any means ($38k
per year gross) and I have been spending $1200 per month on
my habit. It has put us in bad debt and I have to stop.” Third,
participants conveyed their experiences with recovery, stating
that relapse is common. One participant noted, “I have
detoxed and relapsed before and I know the tricks, traps, and
lies we fall into before we start getting high again. It is an
ongoing process, and instead of being anxious, frustrated and
impatient, look at the things that are better.” Finally, patients
perceived their addiction to be a health problem similar to
other chronic illnesses and described the impact of addiction
on interactions with their physicians. One participant stated,
“Some people need an opiate to function, just as a diabetic
needs insulin.” Another commented, “I was at my doctor’s
office today for the second time in almost a year. The first
time, I never told him I was on meth (methadone). Today, he
asked me three times if I was on any type of meds, and I told
him no.”
Conclusions: Our analysis identified patients’ views regarding
the meaning of addiction, the impact of addiction on their
daily lives, their experiences with recovery, and their
perception that addiction is a health problem similar to other
chronic illnesses. These findings provide valuable insight into
patients’ views of opiate addiction and reveal a complexity and
depth that is often not solicited or understood by physicians
Implications for Policy, Delivery, or Practice: Because
patients’ perspectives often impact illness behaviors, such as
disclosure during the medical interview, further work is
needed to promote sharing and understanding of patient and
physician perspectives regarding substance abuse.
Primary Funding Source: AHRQ
mix of drugs used drove trends over time. Regional variation
in age-standardized drug utilization was greatest for
antidepressants, analgesics, and lipid reducing agents:
coefficients of variation = 17.5, 14.8, and 14.2 percent,
respectively. Populations in urban areas had lower
standardized rates of drug utilization and expenditure than
populations in rural areas.
Conclusions: The methodology developed in this study allows
the analyst to track across region, years, and populations
multiple factors related to drug utilization and expenditure.
While the findings show variations in prescription use are on a
scale lower than previous studies have documented for
medical and hospital services, the results draw policy
attention to potentially important regional and urban-rural
disparities.
Implications for Policy, Delivery, or Practice: The challenge
for policy makers is to ensure that drug use is both
appropriate and cost-effective. Our analysis -- based on
methods that can be applied in other settings -- helps policy
makers identify therapeutic areas deserving of investigation for
potentially inappropriate prescribing and to identify factors
driving drug costs that may be amenable to policy
intervention.
Primary Funding Source: Canadian Institutes of Health
Research
●Mapping Drug Utilization Patterns: A Canadian Case
Study
Steve Morgan, Ph.D., Sherin Rahim-Jamal, MSc, Peter Schaub,
BA, Meghan McMahon, BA, Dawn Mooney, BA, Lixiang Yan,
MSc
●The Association of Depression Status with Functional
Status, Role Function, and Disease Impact among adults
with Persistent Asthma
David Mosen, Ph.D., MPH, Renee N. Saris-Baglama, Ph.D.,
Michael DeRosa, MA, Elizabeth Fortin, MSW
Presented By: Steve Morgan, Ph.D., Assistant Professor,
Centre for Health Services and Policy Research, University of
British Columbia, 429 - 2194 Health Sciences Mall, Vancouver,
BC, V6T 1Z3; Tel: (604)822-7012; Fax: (604)822-5690; Email:
morgan@chspr.ubc.ca
Research Objective: Expenditure on prescription drugs in
North America has been growing at double-digit rates since
the mid-1990's. The objective of this study was to develop and
implement methods to examine population trends and
regional variations in drug utilization and cost.
Study Design: A model was developed to quantify causes of
trends and variations in drug spending. The model depicts
per capita expenditure as a function of the average individual's
needs, the rate at which they receive drug therapy, the type of
drugs selected, and the prices of the drugs purchased. The
study utilized a dataset containing a record of every
prescription filled by residents of British Columbia from 1996
to 2002 to quantify the components of the analytical model.
The magnitude and causes of trends and regional variations
were illustrated using geographic information systems.
Population Studied: The study cohort included all of the 4.1
million residents of BC except for registered First Nations,
veterans, and the Royal Canadian Mounted Police -approximately 4 percent of the provincial population.
Analyses were conducted for five age categories in sixteen
geographic regions.
Principal Findings: Per capita expenditures on
pharmaceuticals increased by 87 percent over the period 1996
to 2002, with cost growth being most rapid among residents
aged 45 to 64. Increased volume therapy and changes in the
Presented By: David Mosen, Ph.D., MPH, Program
Evaluation Consultant, Care Management Institute, Kaiser
Permanente, 500 NE Multnomah, Portland, OR 97236; Tel:
(503)813-3827; Fax: (503)813-2428
Research Objective: Depression may impact the ability of
persistent asthmatics to manage their asthma symptoms,
possibly leading to poorer functional health status, decreased
role function, and decreased productivity. However, despite
these possible health effects, little is known regarding the
association of depression on health outcomes for adults with
persistent asthma. The objective of this study is to twofold: 1)
identify the prevalence of likely depression within the
persistent asthma adult population and 2) examine the
association of depression status with physical function status,
role function and disease-specific asthma impact.
Study Design: Survey and administrative data for 428 adult
persistent asthmatics enrolled in a large staff model HMO
were examined. Persistent asthmatics were identified during
calendar year 2002 using HEDIS inclusion criteria. In Fall
2003, the same patients were surveyed regarding functional
health status using the SF-8™ Health Survey, which yields a
physical component summary score (PCS), a mental
component summary score (MCS), and two role functioning
scale scores (role-physical and role-emotional). Based on
previously published research, patients with an MCS score of
42 are likely to have depression. Additionally, asthma impact
was measured using the Asthma Impact Survey™ (AIS-6), a
valid and reliable six item scale that measures the extent to
which asthma interferes with usual activities such as work,
school, or social activities (78 = highest disease impact, 36 =
lowest disease impact). Ordinary Least Squares Regression
was used to examine the independent association of
depression status on physical functional status, role function,
and disease-specific asthma impact, adjusting for age, gender,
race/ethnicity, educational attainment, and geographic
location.
Population Studied: Adults (predominantly white women
with a mean age of 46.9) with persistent asthma enrolled in
large staff model HMO in the United States.
Principal Findings: Overall, 28% of those studied had MCS
scores below the cut-off of 42, indicative of a high likelihood of
depression. Those with a high likelihood of depression
reported poorer physical functional status (Standardized Beta
Coefficient = -0.27, t = -5.31, p< .0001), poorer role functioning
due to emotional problems (Standardized Beta Coefficient = 0.73, t = -19.5, p< .0001), poorer role functioning due to
physical problems (Standardized Beta Coefficient = -0.44, t = 8.97, p< .0001), and greater disease-specific asthma impact
(Standardized Beta Coefficient = 0.40, t = 7.94, p< .0001);
even after adjusting for age, gender, race/ethnicity,
educational attainment, and geographic location.
Conclusions: Results of this study suggest that a large
proportion of the adult asthma population is likely to
experience depression. Compared to asthmatics with MCS
scores above the cut-off of 42, asthmatics who were likely to
be depressed reported significantly lower physical functional
status, role function, and disease-specific asthma impact.
Implications for Policy, Delivery, or Practice: Because
depression is associated with poorer health outcomes for
adults with persistent asthma as compared to persistent
asthmatics without depression, further efforts are needed to
better recognize and treat depression in this population.
Future research should evaluate the impact of interventions
designed to recognize and treat depression on health-related
outcomes.
Primary Funding Source: Kaiser Permanente
●Initial Stroke Severity and Health of Informal Caregivers
of Stroke Patients; the Minnesota Stroke Survey
Melissa Nelson, BS, Maureen A. Smith, M.D., MPH, Ph.D.,
Brian Martinson, Ph.D., Russell Luepker, M.D.
Presented By: Melissa Nelson, BS, Graduate School Fellow,
Health Services Research and Policy, School of Public Health,
University of Minnesota - Twin Cities, Mayo Mail Code 729,
420 Delaware Street SE, Minneapolis, MN 55455; Tel: (612)
331-5627; Email: nels2404@umn.edu
Research Objective: In 1999, 1.1 million Americans had
difficulties with everyday activities resulting from strokes. The
large proportion of care provided informally to stroke
survivors suggests that stroke may significantly impact
caregiver health. Studies have examined the impact of the
stroke caregiving experience on caregiver burden, but few have
examined the impact on caregiver health and none have
examined whether initial stroke severity affects subsequent
caregiver health. The objective of this study is to examine the
relationship between initial stroke severity and subsequent
caregiver health.
Study Design: Preliminary data were obtained from an
ongoing longitudinal study of stroke patients and their
caregivers in the Minneapolis-St. Paul metro area. Medical
records for index stroke hospitalizations were abstracted and
patients or their proxies and caregivers were interviewed 2
months and 12 months after the patient was discharged from
the hospital. The patient/proxy response rate was 66% and
caregivers were interviewed for 98% of patients or proxies who
reported the presence of a caregiver. Caregiver health was
measured using self-reported health on a scale of excellent to
poor, with higher values indicating worse health. The
patient’s stroke severity was measured using the Canadian
Neurological Scale, with scores reversed so that higher values
indicated worse health. Other patient characteristics included
sociodemographics, previous stroke, functioning prior to
stroke and upon discharge, and comorbidities. Caregiver
characteristics included age, gender, and education.
Environmental characteristics included coresidence of
caregiver and patient after discharge and the use of paid
caregiving services.
Population Studied: Caregivers and their corresponding
patients or proxies who responded to the 2 month interview
(N=211).
Principal Findings: 53% of caregivers reported excellent or
very good health, 34% reported good health, and 13% reported
fair or poor health at the 2 month interview. The average
stroke severity was 2.3 (standard deviation = 2.1) on a scale
from 0-11.5. After adjustment for patient, caregiver, and
environmental characteristics using ordinal logistic regression,
the odds of poorer caregiver health at 2 months were 1.21
times greater for each unit increase in stroke severity, Odds
Ratio (OR) = 1.21, 95% Confidence Interval (CI) = 1.03-1.42.
Other factors associated with poorer caregiver health were
greater caregiver age, OR = 1.04, 95% CI = 1.02-1.07, and the
patient having less than a high school education, OR = 3.77,
95% CI = 1.42-10.03, while use of paid care prior to stroke was
associated with better caregiver health, OR = 0.31, 95% CI =
0.10-0.92.
Conclusions: These data suggest that increasing stroke
severity was associated with poorer caregiver health 2 months
after hospital discharge. Subsequent research will incorporate
additional 2 month data and measures of caregiver health at
12 months after discharge.
Implications for Policy, Delivery, or Practice: The potential
negative impact of stroke severity on caregiver health
emphasizes the need for improved understanding of factors
that place caregivers at risk. This could assist in developing
interventions targeted at caregivers who are at risk for
deteriorating health.
Primary Funding Source: National Institute of Neurological
Disorders and Stroke
●Use of Prescription Medications in the Treatment of
Pervasive Developmental Disorders
Donald Oswald, Ph.D., Neil Sonenklar, M.D.
Presented By: Donald Oswald, Ph.D., Professor, Psychiatry,
Virginia Commonwealth University, Box 980489, Richmond,
VA 23298; Tel: (804)828-9900; Fax: (804)828-2645; Email:
doswald@vcu.edu
Research Objective: The study examines the use of
prescription medicine among individuals with a diagnosis of
an autism spectrum disorder. We characterize patterns in the
use of psychoactive medications and examine trends with
regard to demographic variables.
Study Design: The study consisted of a descriptive analysis of
prescribed medications in a large sample of individuals with
an autism spectrum disorder. Comparisons of type and
number of medications were made across groups defined by
age and gender. Pooled administrative data of the 2002
MarketScan® Research Database from MedStat, a healthcare
information company, were used to investigate medications
prescribed for enrollees with a diagnosis of an autism
spectrum disorder. Diagnosis data for inpatient admissions
and outpatient services were used to identify subjects with an
autism spectrum disorder and to capture comorbid
diagnoses. Outpatient pharmaceutical data were used to
identify medications prescribed.
Population Studied: The sample consisted of all persons with
a diagnosis of an autism spectrum disorder who had at least
one prescription drug claim from an outpatient provider in the
year 2002 (n= 2,206). The mean age for persons in the
sample was 14.7 years (SD=10.95; range 0 – 64)
Principal Findings: The number of drug claims during the
year varied considerably across individuals (mean = 17; SD =
23.49; range 1 – 770). The number of different drugs
prescribed to an individual over the course of the year also
varied substantially. The median number of drugs was 5
(mean=6.05; SD = 4.93; range 1 – 41). Prescribed drugs came
from 143 different therapeutic classes. The five most frequently
prescribed classes of drugs were: “Pyschotherapeutic,
Antidepressant” “Antibiotic, Penicillins” “Stimulant,
Amphetamine Type” “Psychotherapeutic, Tranquilizers /
Antipsychotics” and “Antihistamines and Comb NEC”.
Prescribed medications were also examined in relation to
comorbid diagnoses to characterize the number, type, and
probable target of psychoactive drugs employed in the
treatment of individuals with autism spectrum disorder.
Frequency of use of psychoactive medications was examined
by gender and age.
Conclusions: Individuals with autism are treated with a wide
variety of psychoactive medications over the course of their
lives. Prescription patterns reflect extensive use of
antidepressants, stimulants, and antipsychotics. Use of these
drugs varies across subgroups of the population.
Implications for Policy, Delivery, or Practice: The study
offers the first large-scale investigation of prescribing practices
based on drug claims for the population of individuals with an
autism spectrum disorder. Characterization of patterns for the
prescription of psychoactive drugs in the population provides
valuable baseline data. Age and gender differences reflect
different targets of treatment across these groups. The
findings from this study will serve as a point of comparison as
the number and type of medications targeting common
symptoms in the population increase.
Primary Funding Source: CDC
●Parent's and Youth's Perception of Mental Health
Services
MariaEva Pangilinan, Ph.D., Bruce Copley, MA, Jaime Lopez,
MA, Teea Gilbert, MA
Presented By: MariaEva Pangilinan, Ph.D., Health Program
Specialist, Mental Health Department, Santa Clara County,
828 South Bascom Avenue, San Jose, CA 95128; Tel: (408)8855768; Email: eva_pangilinan@yahoo.com
Research Objective: The Youth Satisfaction Survey for
Families (YSSF) and the Youth Satisfaction Survey (YSS) were
developed to help monitor performance in mental health
services. Its developer had reported observed differences in
domain average scores between parents and their adolescent
children, except for the General Satisfaction domain on these
surveys. Given that these instruments were used statewide for
the first time in California in November 2003 no baseline data
and studies on the association between parents and youths
perceptions of services as measured by these instruments
were available at the state and county levels. This study
examined baseline information on the association between
perceptions of parents and youths receiving mental health
services at the Santa Clara County.
Study Design: Following the statewide protocol, all Santa
Clara County family and children (F & C) consumers receiving
face-to-face mental health services, case-management, day
treatment, and medication services from county and noncounty operated organizations were recruited from November
3 to 17, 2003, regardless of the funding source. Excluded were
consumers served in acute hospitals, Psychiatric Health
Facility (PHF), crisis (stabilization, residential and
intervention), jail and jail hospital settings, long-term care
residential placements, such as: State hospitals, Institute for
Mental Disease (IMD), and individual / group contract
managed-care network providers.
The YSSF and YSS surveys were to be completed by the
consumers on their own, as much as possible. HIPAA
Guidelines were followed and confidentiality was observed.
To assess the parents’ perceptions in relation to their
adolescent children, correlation analysis for matched ParentYouth data was performed between the parent YSSF domain
average scores and the YSS Youth domain average scores.
Paired sample t-test was also performed by domain and by
item.
Population Studied: Data from clients who have at least one
question answered on the Youth Satisfaction Survey for
Families (YSSF) and Youth Satisfaction Survey (YSS) were
included for analysis. This sample included a total of 660
YSSF for Parents and 470 YSS for Youths. From which, a total
of 188 matched Parent-Youth records across domains was
found.
Principal Findings: Results showed low correlations between
Parent and Youth ratings for Services Access (r = 0.20 at p <
.015, n = 155) and Service Outcomes (r = 0.21 at p < .010, n =
154). No significant correlations were found for the rest of the
domains. The Parent-Youth domain score differences were
found to be significant for Involvement in Treatment Planning
Good Services Access, General Satisfaction and Cultural
Sensitivity domains but not for Good Service Outcomes. The
Parent-Youth item score differences were also found to be
significant except for all of the Good Service Outcomes items
as well as for 2 of 4 items for Cultural Sensitivity (at p<.01).
Except for Outcomes measures, the Youths tended to have
lower ratings of services than their Parents.
Conclusions: This finding provided additional evidence
regarding the observed difference in perceptions of services
between Parents and Youths on the YSSF and the YSS. The
study suggests independent perceptions about Involvement in
Treatment Planning, General Satisfaction and Cultural
Sensitivity and a trend towards agreement regarding Services
Outcomes and Good Service Access and sensitivity to
religious beliefs and cultural background.This study
acknowledges that in addition to the simple correlational
analyses performed in this study, analyses of simultaneous
effects that may well be related to age, ethnicity and gender in
relation to perceptions of services could still be conducted.
Implications for Policy, Delivery, or Practice: Findings
certainly lent support to maturational differences. From the
health services perspective however, findings suggest the
need to assess the age-appropriateness and sensitivity of
survey questions to assess perceptions vis-à-vis ageappropriateness of conditions of services that could benefit
quality improvement efforts to yield a more similar experience
of services by all consumers. Caution is recommended in
application of findings.
Primary Funding Source: Work related
●Nursing Care Job Design and Care Quality in Long-Term
Care Facilities
Victoria Parker, DBA, Gary H. Brandeis, M.D., Amy Rosen,
Ph.D., Fei Wang, Ph.D., Elaine Hickey, MS, Denise A. Tyler,
MA
Presented By: Victoria Parker, DBA, Assistant Professor,
Health Services, Boston University School of Public Health,
200 Springs Road (152), Bedford, MA 01730; Tel: (781)2757500 x6054; Fax: (781)687-3106; Email: vaparker@bu.edu
Research Objective: To determine the relationships between
nursing care job design characteristics and care quality in
long-term care facilities.
Study Design: Observational study of nursing care workers in
long-term care facilities, employing primary data collection
through surveys and secondary analysis of minimum data set
(MDS) records to assess resident outcomes. Employeeperceived job design characteristics (skill variety, task
identification, task significance, autonomy, intrinsic feedback)
were assessed via the Job Diagnostic Survey (JDS). MDS
data were used to assess 3 resident outcomes (pressure ulcer
incidence, decline in late-loss activities of daily living (ADLs)
and increase in problem behavior) over two consecutive
quarters. Employee data were linked with resident-level MDS
data via a facility identifier. Logistic regressions were
developed for risk-adjustment models, while linear models
were used to examine the relationships between risk-adjusted
resident outcomes and individual job design characteristics.
Population Studied: 1146 nurses and nursing assistants
employed in 20 facilities were surveyed. MDS records for
1,976 residents residing in one of those 20 facilities for at least
45 consecutive days during the study time frame were
analyzed to ascertain changes in condition between two
assessments. Facilities were recruited on a convenience basis
to fill pre-specified categories (size, profit status, ownership,
location). Subsequent analysis of these 20 with reference to
national and state comparison groups revealed that they were
at or near average in terms of quality indicators and survey
deficiencies. Within each facility, study personnel recruited
employees to complete the JDS on all three shifts and
weekends until a 60-70% response rate was achieved within
each facility.
Principal Findings: We found significant inter-facility
variation in characteristics of nursing care job design. Three
aspects of job design (task identity, intrinsic feedback and
autonomy) were positively linked (p<.01) with lower rates of
decline in late-loss ADLs. There were mixed findings (at
p<.05) for increase in problem behavior (positive association
with intrinsic feedback; negative for skill variety and task
significance). No characteristics of job design were
significantly linked to rates of pressure ulcer development.
Conclusions: These mixed findings are consistent with prior
attempts to link employee variables to resident outcomes.
The more significant positive links between job design and
ADL decline suggest that nursing employees who identify a
piece of work as their own, receive feedback provided by the
work itself, and have control over the timing and pacing of
their work are better able to work with residents in ways that
support ADL maintenance. The mixed findings with respect
to problem behavior may reflect the bi-directional nature of
this relationship in that resident problem behavior may reduce
the employees’ perceptions of more positive job design
attributes. The lack of any significant association with pressure
ulcer incidence rates is likely due to the very low incidence rate
of pressure ulcers within the study population.
Implications for Policy, Delivery, or Practice: Concern about
the adequacy of the long-term care workforce to meet the
projected increase in demand for this type of health care
service implies that knowledge of employee perceptions of job
design must be improved in order to help employers optimize
job design for both care quality and employee retention.
Primary Funding Source: AHRQ
●Parents’ Quest for Knowledge: The Search, Utilization
and Meaning of Child Psychiatric Diagnosis
Vaishali Patel, MPH, Ph.D. Candidate, Susan DosReis, Ph.D.
Presented By: Vaishali Patel, MPH, Ph.D. Candidate, Health
Policy and Management, Johns Hopkins Bloomberg School of
Public Health, 6 Char Street, Edison, NJ 08820; Tel: (732)2618323; Email: vapatel@jhsph.edu
Research Objective: Understanding parental help-seeking
processes is vital as parents’ recognition of their children’s
mental problem and the need for professional intervention
serves as an important link to access, use, and continuity of
care. This qualitative study sought to explore how parents
obtain mental health services on behalf of their children by
identifying strategies parents employ and the resources
parents rely upon, especially clinicians, during this process.
Study Design: We applied a grounded theory approach that
consisted of successive iterations of data collection, inductive
analysis of interview and focus group transcripts and field
notes, and development of theory. First, we conducted two
semi-structured interviews with parents of children who had
received mental health services (n=7). Second, we conducted
semi-structured interviews with child mental health providers
(n=7). Third, we conducted a parent focus group (n=4) to
elaborate on emergent themes from the in-depth interviews.
Population Studied: Two mental health consumer advocacy
organizations recruited parents and clinicians were recruited
through professional contacts of the research team. All the
parents were middle-aged; a majority of participants were
female, the biological parent and married. The clinicians
consisted of three psychiatrists, a mental health hospital
administrator (and former clinician), a psychologist, and two
school-based clinicians (clinical social worker; licensed clinical
professional counselor).
Principal Findings: As parents became aware of their
children’s mental health problems, they began a “quest for
knowledge,” a search for information related to their children’s
psychiatric diagnoses and services available. Parents
knowledge of their child’s psychiatric diagnosis was cited by
parents as enabling them to better advocate on behalf of their
children to obtain care and deal with stigma. Clinicians’ views
regarding the value and utility of diagnosis differed from
parents: clinicians were more wary of diagnosis’ meaning and
reported that diagnosis did not necessarily inform treatment.
Clinicians instead emphasized providing parents with skills to
manage their child’s illness. Parents attributed clinicians’
reluctance to disclose diagnosis due to stigma and fears of
labeling a child with a severe psychiatric disorder. Parents in
this study were unaware of providers’ concerns regarding the
ambiguous nature of diagnosis, and the complexity involved
with making a proper diagnosis in children. Parents use of
alternative resources, such as the Internet, books, consumer
advocacy organizations and other parents of children with
mental health problems was in part fueled by parents’ inability
to obtain information from traditional mental health
providers.
Conclusions: Parents’ “quest for knowledge” emerged as a
key mechanism that enabled parents to circumvent barriers to
care and cope with their children’s mental health problems.
Differences between parents and providers regarding the value
of diagnosis potentially limits their communication,
contributing to parents’ use of alternative resources to search
for information regarding their child’s mental health and
services available.
Implications for Policy, Delivery, or Practice: These findings
highlight parents’ struggles to obtain and make sense of
information that potentially impacts their ability to make
informed treatment decisions for their children. To address
parents’ need for information, clinicians can potentially play
an important role in providing comprehensive psychoeducation or referring parents to programs provided by
consumer advocacy organizations that educate parents about
mental illness.
Primary Funding Source: NIMH
●The Role of Sociocultural and Discrimination Factors in
predicting Support for Health Policy among US Latinos
Debra Joy Pérez, MA, MPA, Ph.D.
Presented By: Debra Joy Pérez, MA, MPA, Ph.D. Program
Officer, WKKELLOGG Fellow in Health Policy, Research,
Multicultural Mental Health Research Fellow, NIMH mentee,
Research & Evaluation Unit, Interfaculty Program in Health
Policy at Harvard, The Robert Wood Johnson Foundation,
Harvard University, PO Box 3311, Princeton, NJ 08543; Tel:
(917)586-5955; Email: djperez@fas.harvard.edu
Research Objective: Latino politics influence policy agendas
and candidate support. There is little research on the specific
importance of health policy to the Latino electorate. This study
explores how Latinos differ in the following domains: support
for healthcare policy as a priority for government action and
healthcare as a determinant of voting. This study uses
national data to model how Latinos who consider healthcare
as an important factor for government action might differ
from those Latinos who do not. It explores the relationship
between support for health policy issues and multiple
demographic, socioeconomic, acculturation and
discrimination measures on this important question. This
study compares Latinos to whites with regard to support for
health policy issues. This study examines which SES, sociodemographic and political factors are correlates for supporting
a health policy agenda.
Study Design: This study estimates a model using logistic
regression to predict which Latinos are more likely to support
health policy issues and to vote on health issues. This study
tested the following four hypotheses: 1. Latinos with low
acculturation are less likely to identify health policy as an
important issue as compared to Latinos with high
acculturation. 2. Latinos who experience barriers to care are
more likely to identify health policy as an important issue than
those who do not report barriers. 3. Latinos with low
acculturation are more likely to support larger government
and increase taxes as compared to Latinos with high
acculturation. 4. Latinos reporting greater barriers to care are
more likely to say that healthcare is a factor in vote decision as
compared to those reporting fewer barriers. 5. Latinos who
report higher levels of perceived discrimination are less likely
to support health policy as priority issue as compared to those
Latinos reporting little or no discrimination. DATA AND
METHODOLOGY: The data was collected by the Kaiser
Family Foundation/The Pew Hispanic Center in their 2002
National Survey of Latinos from April 4 to June 11, 2002. A
nationally representative sample of 4,214 adults, 18 years and
older were selected at random for this phone survey. The
Random Digit Dial sample includes over-samples of Puerto
Ricans, Salvadorans, Dominicans, Colombians and Cubans.
Of the total sample, 2,929 were self-identified Latino or
Hispanic. The sample was weighted to reflect the distribution
of Latino adults in the US by country of origin, age, gender
and region. There are 1008 non-Hispanic whites in the sample
and 171 African Americans. The margin of sampling error
varies for each of the different subgroups.
Population Studied: Latino voters and non-voters, Puerto
Ricans, Cubans, Mexicans
Principal Findings: Results showed that Latinos with higher
levels of acculturation were morely to report health policy
issues as important determinant of their presidential vote.
More than 40% of US born Latinos reported using health
policy as a voting determinant compared to 32% of foreing
born voter (P = 0.0001.) Latinos who have been in the US for
more generations were more likely to support health policy
issues compared to Latinos who have been in the US for fewer
generations. Thirty two percent of first generation reported
that health policy was a determinant of their presidential vote
compared to 48% of third and fourth generation Latinos (P =
0.0000.)Language was a strong predictor of support for
health policy issues. Only 31% of Spanish dominant Latinos
reported health policy issue as important to their vote
compared to support 40% of English speaking Latinos (P =
0.0000.) Finally, Latinos who identified themselves as having
an American identity were more likely to report health policy
as an important determinant of their vote compared to only
30% of Latinos with a national origin Latino identity.
Conclusions: Latino voting behavior differed based on the
degree of acculturation (nativity, generational difference, and
language dominance) and identity differences (Puerto Rican,
Cuban, Mexican, and other Latinos). Latinos are heterogenous
in their knowledge and support for health policy issues.
Important changes in demographics among Latinos will
influence how central platforms for political parties
incorporate health policy issues.
Implications for Policy, Delivery, or Practice: Few studies
attempt to explain the significance of health policy to Latino
voters and how increases in number of Latino voters and
non-voters might affect the health policy agenda in the US.
This study is motivated by the need to better understand
Latino support for health policy and what if any factors might
galvanize Latinos to become part of a national call for
healthcare reform. This study helps estimate how Latinos will
impact health policy if projected changes to the
socioeconomic variables such as increases in income or
insurance status occur. Policymakers need to consider
acculturation in framing health policy issues among Latinos.
Primary Funding Source: WKK, NIMH
●Comparison of LDL Screening and Control Rates for
Various Reporting Entities and Populations
Donna Pillittere, MS, Philip Renner, MBA, Sarah Hudson
Scholle, MPH, DrPH
Presented By: Donna Pillittere, MS, Senior Health Care
Analyst, Quality Measurement, National Committee for
Quality Assurance (NCQA), 2000 L Street, NW, Suite 500,
Washington, DC 20910; Tel: (202)955-1736; Fax: (202)9553599; Email: pillittere@ncqa.org
Research Objective: Low density lipoprotein (LDL) has been
identified as the primary target for cholesterol-lowering
therapy; elevated levels have been shown to be a powerful risk
factor for coronary heart disease (CHD). Guidelines
recommend the LDL cholesterol goal for patients with CHD
and CHD risk equivalents (such as diabetes) to be LDL<100
mg/dL. As a consequence of these guidelines, there has been
much discussion in the clinical quality improvement world
around achievement of the suggested goal. The purpose of
this study is to examine how well different reporting entities
and populations are doing so.
Study Design: A comparison of LDL screening and control
(LDL<130mg/dL; LDL<100mg/dL)rates in two Health Plan
Employer Data Information Set (HEDIS) populations
(cardiovascular event and diabetes) covering services provided
by managed care, collected from administrative data
supplemented by medical record review and in two physician
level recognition program populations (iscemic vascular
disease (IVD) and diabetes) covering services provided by
physicians, collected from physician level medical record data.
All data are reported based on a standardized set of
performance measures using detailed specifications.
Recognition data probably represent top performers, as they
are physicians who voluntarily come forward to be measured
and if achieved, awarded recognition for quality of care in
heart/stroke and in diabetes.
Population Studied: 2000-2003 HEDIS commercial managed
care data, 1997-2003 physician level medical record data from
the Diabetes Physician Recogntion Program (DPRP) and 2003
physician level medical record field test data from the
Heart/Stroke Physician Recognition Program (HSRP).
Principal Findings: HEDIS commercial managed care data
showed a steady increase in performance for the diabetes and
CHD population for both the LDL screen and LDL<130
indicators. For example, from 2000-2003, mean LDL screen
rates for the diabetic population increased from 76.5 to 88.4
and mean LDL<130 rates increased from 44.3 to 60.4. From
2000-2003, mean LDL screen rates for the CHD population
increased from 74.2 to 80.3 and mean LDL<130 rates
increased from 53.4 to 65.1. For the first time with HEDIS
2004, NCQA collected rates at LDL<100 with the diabetic
population achieving a mean rate of 34.7 and the CHD
population achieving a mean rate of 47.6. In comparison,
1997-2003 physician level data from the DPRP showed an
increase in mean screen rates from 60 to 90, mean LDL<130
rates from 37-75, and mean LDL<100 rates from 17-45. Fieldtest data from the HSRP showed mean rates of 79.2 for LDL
screen, 68.7 for LDL<130 and 48.9 for LDL<100.
Conclusions: On average, physician level data showed better
performance on all three inidicators than healt plan data.
HEDIS health plan data showed LDL<130 and LDL<100 rates
were consistently higher in the CHD population than in the
diabetic population. On average, LDL<100 rates were 20-30
percentage points lower than LDL<130 rates in both health
plan and physician level data.
Implications for Policy, Delivery, or Practice: Recognized
physicians tend to be top performers, showing what is
possible to achieve. Lower LDL control rates for the diabetes
population may indicate more difficulty in getting this
population's cholesterol under control. Just as initial
measurement on the LDL<130 rates for different populations
and reporting entities showed improvement over time, as the
industry becomes more aware of the LDL<100 goal, rates here
should also improve with time.
Primary Funding Source: NCQA
●Health Care Needs of Women in Shelter
Stacey Plichta, Sc.D., Terri Babineau, Sc.D., Elizabeth Vogel,
MS
Presented By: Stacey Plichta, Sc.D., Associate Professor,
School of Community and Environmental Health, Old
Dominion University, 105 Spong Hall, Norfolk, VA 23529; Tel:
(757) 683-4989; Fax: (757) 683-4410; Email: splichta@odu.edu
Research Objective: This study examines the acute and
chronic health care needs of women seeking refuge in a
domestic violence shelter. The battered women's shelter
movement in the U.S. began as a feminist grassroots effort in
the 1970's and grew to over 1800 places sheltering 200,000+
women per year. Abused women have worse physical and
mental health status than other women but few studies have
examined the health care needs of women in shelter.
Study Design: 65 women sought medical care from a family
medicine MD and residents who work in an urban shelter one
day each month. Their medical records were abstracted with
no identifiers and entered into an SPSS dataset. Women were
predominately African-American (71%) with an average age of
35.2 years (80% are under 44). 60% were known to have
children and 18% were pregnant or postpartum. This study
was approved by the Medical School IRB.
Population Studied: Battered women seeking medical care at
a monthly program offered as a partnership between the local
medical school and a community-based domestic violence
shelter.
Principal Findings: Women presented with many conditions,
including injuries & pain (32%), mental health (19%), upper
respiratory infections (19%), gynecological concerns (16%),
hypertension (15%) and dermatological issues (8%). Half
(51% )had one or more preexisting diseases including:
hypertension (32%), asthma (22%), arthritis (19%), diabetes
(9%) and seizure disorders (5%).
Conclusions: Shelters provide an invaluable resource to
women who are harmed by interpersonal violence. However,
due to a lack of resources, few can help women address their
health concerns. These results clearly indicate a need for
further work towards models that bring medical care to
abused women in shelter.
Implications for Policy, Delivery, or Practice: The model of
partnering a medical school with a domestic violence shelter
needs to be better studied. Different mechanisms for
delivering care and ensuring continuity of care should be
explored.
Primary Funding Source: No Funding Source
●Diabetes Healthcare Quality Report Cards: How Accurate
Are The Grades?
Leonard Pogach, M.D.,MBA, Minge Xie, Ph.D., Yue Shentue,
BS, Chin-Lin Tseng, DrPH, Stephen Crystal, Ph.D., Monika
Safford, MD
Presented By: Leonard Pogach, M.D.,MBA, Director, Center
for Healthcare Knowledge Management, Medicine, VA New
Jersey Healthcare System, 385 Tremont Avenue, East Orange,
NJ 07018; Tel: (973)676-1000 x1693; Fax: (973)395-7111; Email:
len.pogach@verizon.net
Research Objective: To evaluate the accuracy and precision
of single random samples compared to bootstrapping
methodology in identifying facility outliers in adherence to
performance measures.
Study Design: Cross-sectional analysis of diabetes
performance measures obtained from administrative
databases from 79 Veterans Health Administration (VA)
facilities serving 250,317 diabetes patients (1,015-13,598/
facility) between October 1, 1999 and September 30,
2000.Patients with diabetes were identified using HEDIS
algorithms and had at least one face-to-face encounter in both
years as a proxy for continuous enrollment. To minimize bias
potentially attributable to non-random errors in measurement
or data collection, we eliminated facilities using nonstandardized laboratory methods and those greater than 4
standard deviations from the mean. Measures were poor
hemoglobin A1c (test not done or above threshold), good lowdensity lipoprotein cholesterol (LDL-C test performed and
below threshold), and good blood pressure (BP) control.
Facility adherence to each measure was calculated using 150
separate single random sample sets of 411 subjects
(comparable to HEDIS criteria) with and without age
adjustment. The accuracy and precision of the random sample
was determined by comparison to bootstrapping of 1000
samples as the criterion standard in defining outlier status
defined as greater than two standard deviations or 5%
difference from the mean, or classification within the 10th or
90th percentile.
Population Studied: The population was largely male
(97.5%), with 53.7% of patients > 65 years of age. For
glycemic control, 22.8% had last A1c>9.5% and 33.1% had
A1c>8.5%; for lipids, 53.1 % had last LDL-C<130 mg/dL and
29.8% had LDL-C<100 mg/dL; for BP, 44.7% had last
BP>140/90 mmHg and 67.3% had BP>130/80 mmHg.
Principal Findings: There was substantial variation among
the facilities, with 2 to nearly 3-fold differences between best
and worse performers. For A1c, the worst performing facility
had 34.7% of its diabetes patients with A1c >9.5% and the best
performing facility had just 13.2%. For LDL-C, the worst
performing facility had 32.3% of its diabetes patients with LDLC <130 mg/dl, and the best performing had 68.2%. For BP,
the worst performing facility had 43.2% of its diabetes patients
with BP <140/90 mmHg, and the best performing had
67.8%. Variations were similarly large across lower thresholds
for the performance measures (A1c >8.5%, LDL <100 mg/dl,
BP >130/80 mmHg). Evaluation of positive predictive value
(PPV) and sensitivity (Sn) suggested that all of the random
sampling approaches were both inaccurate and imprecise in
comparison to bootstrapping: PPV for A1c >9.5% mostly near
.65 (range .18 to 1); Sn mostly near .75 (range .17 to 1).The
results were similar for all performance measures for each of
two thresholds. Stratified random sampling on age did not
improve precision, and different outlier detection approaches
did not change the results.
Conclusions: The use of a single random sample to identify
VA facility outliers using individual diabetes performance
measures results in considerable misclassification compared
to the bootstrapping method applied to the eligible facility
population.
Implications for Policy, Delivery, or Practice: Currently used
methods to determine outliers on performance measures lack
sufficient reliability for accountability. Performance measures
that reflect the entire eligible population may greatly alleviate
this shortcoming.
Primary Funding Source: VA
●A Comparison of Populations and Orthopaedic Outcome
among an Elderly Patient Population Served by two
Distinct Urban Hospitals
Wendy Preisman, DrPH, Charles Cornell, M.D., Margaret
Peterson, Ph.D., Stephen Lyman, Ph.D., Laura Robbins, DSW,
Carol Mancuso, M.D.
Presented By: Wendy Preisman, DrPH, Research Analyst,
Hospital for Special Surgery, 535 East 70th Street, 8 West, New
York, NY 10021; Tel: (212)606-1201; Fax: (212)794-1309; Email:
preismanw@hss.edu
Research Objective: To assess postoperative patient
satisfaction outcome among elderly patients served by two
distinct New York City based institutions--a specialty
orthopaedic hospital and a general community hospital.
Study Design: From April to December 2004, patients from
both study institutions who had undergone total hip or total
knee arthroplasty were invited to participate in this survey
based study. Patients completed a self-administered measure
of patient satisfacion, "Patient Judgements of Hospital
Quality", during their 6 week postoperative visit.
Population Studied: 33 patients completed the satisfaction
measure; 21 from the specialty hospital and 12 from the
community hospital. The average age was 70 years for
patients treated at the specialty hospital, and 66.7 years for
those treated at the community hospital. 68% of the study
population was female at the specialty hospital, and 55% at
the community hospital.
Principal Findings: Those treated at the specialty orthopaedic
facility rated the following variables significanty higher (p=.05
or less) than those treated at the community institution:
medical facilities, overall efficiency, consideration of their
needs, ease of getting information, nursing skill and
competence, and information given by nurses. Moreover, the
condition of the hospital room and efficiency of discharge
were also rated significantly higher at the specialty institution
(p=.05 or less). Significant differences did not emerge in
regards to satisfaction with surgical care. Interestingly, a nonsignificant trend emerged among those treated at the
community hospital indicating that patients were more likely
to return for care or recommend that hospital to others.
Moroeover, this cohort reported nonsignificant, yet higher
overall satisfaction ratings than those treated at the specialty
institution. Those treated at community hospitals also
reported that the location of the institution (p=.002) and
financial considerations (p=.003) were important factors that
highly influenced their choice of hospital.
Conclusions: Despite significantly higher ratings on
questions that inquire about satisfaction within specific care
domains (ie: nursing care, discharge), patients treated at
community hospitals reported that they are generally satisfied
with their medical care and hospital stay. Moreover, they
stated they are likely to return to the same institution and
recommend it to others. The apparent importance of choosing
a local, affordable neighborhood institution may override
certain clinical and service factors in elderly patients'
assessment of their overall satisfaction with their hospital stay.
Implications for Policy, Delivery, or Practice: This study
highlights the importance that accessing local and affordable
medical care holds for elderly patient populations. Future
research should further investigate which care factors are
most valued by elderly patients.
Primary Funding Source: United Hospital Fund
●Psychometric Properties of Scales Measuring the Quality
of Cancer Care at an Urban Safety Net Hospital
Laurel Radwin, Ph.D., RN, Gail Wilkes, MS, RN, AOCN,
Joanne Garvey, MS, RN, Linda Curtin, MS, RN, John
Whitehouse, BS, Lisa Tracey, BS, RN
Presented By: Laurel Radwin, Ph.D., RN, Assistant Professor,
Nursing, University of Massachusetts Boston, 100 Morrissey
Boulevard, Boston, MA 02125; Tel: (617)287-7572; Email:
laurel.radwin@umb.edu
Research Objective: To assess the preliminary psychometric
properties of scales measuring the quality of cancer nursing
care in a diverse sample of hospitalized patients.
Study Design: Twenty-two cancer patients participated in a
qualitative study of the characteristics and outcomes of
excellent nursing care. Characteristics of excellent nursing
care, as described by those participants, were conceptualized
as patient-centered nursing interventions. Patient-centered
nursing interventions were operationalized by the Oncology
Patients’ Perceptions of the Quality of Nursing Care Scale
(OPPQNCS) and comprise the following: responsiveness,
individualization, coordination and proficiency. The
OPPQNCS demonstrated acceptable psychometric properties
in a sample of 436 patients with cancer in active treatment.
These patients were mainly female (66%), mainly White
(93%), and well educated (81% attended some college).
Desired outcomes of excellent nursing care, also described by
the qualitative study participants, were operationalized by the
Trust in Nurses Scale, Cancer Patient Optimism Scale,
Fortitude Scale, and Authentic Self-Representation Scale.
These scales demonstrated acceptable properties in a pilot
sample of 66 community-based cancer support group
attendees. These patients were mainly female (77%), mainly
White (97%) and well educated (80% attended some college).
The OPPQNCS and the outcome scales are being used to
measure the quality of cancer nursing care in an ongoing large
scale study of the relationships among nursing interventions,
patient and system characteristics, and outcomes. The study
will include psychometric analyses of the OPPQNCS and
desired outcome scales. Properties of the OPPQNCS and
outcome scales for the sample as of May 1, 2005 will be
described by computing the ranges, means, standard
deviations, quartiles, and skewness statistics of the items and
scales. Preliminary psychometric properties will be assessed,
including the scales’ internal consistency reliability measured
as Cronbach’s alpha; item-scale correlations; intra-scale
correlations; and item-level missing data.
Population Studied: Participants are being recruited from a
29-bed inpatient hematology-oncology unit at an urban
medical center that is the largest safety net hospital in New
England. January 1, 2005 analyses of patient (n=106)
characteristics revealed the following indicants of sample
diversity: 53% male; 59% White, 31% African American/Black;
1% Asian, 3% American Indian or Native Alaskan; and 12%
Hispanic. Most participants (63%) have a high school
education or less.
Principal Findings: The diversity of the current study sample
provides an opportunity to analyze the psychometric
properties of the OPPQNCS and the outcome scales in a
racially, ethnically, and educationally diverse sample. Analyses
as of January 1, 2005 indicate that psychometric properties for
the OPPQNCS in the current more diverse sample are similar
to those found in the earlier sample. However, properties for
the desired health outcome scales appear thus far to be
different in the current sample.
Conclusions: The results of this study will provide estimates
of the psychometric properties of scales measuring the quality
of care for hospitalized cancer patients at an urban safety net
hospital.
Implications for Policy, Delivery, or Practice: Reliable and
valid scales are needed to evaluate and improve the quality of
care for patients traditionally at risk for unequal treatment.
Primary Funding Source: AHRQ
●Clinical Practice Guideline for Acute Gastroenteritis in
Children
Virginia Rahm, MSN
Presented By: Virginia Rahm, MSN, Pediatric Nurse
Practitioner, Pediatric Care Center, Children's Mercy Hospital
and Clinics, 2401 Gillham Road, Kansas City, MO 64108; Tel:
(816)234-3898; Fax: (816)234-3081; Email: grahm@cmh.edu
Research Objective: Acute Gastroenteritis in the pediatric
population has traditionally been evaluated by laboratory
blood work and subsequently treated with intravenous fluids.
The research based literature has shown that there are more
cost efficient and less intrusive ways to treat Acute
Gastroenteritis. The objective was to translate cutting edge
research into the clinical environment by developing and
implementing a Clinical Practice Guideline (CPG.)
Study Design: A multidisciplinary team collaborated to create
an algorithm which reflects the care of a child with Acute
Gastroenteritis as well as review the current research literature
and assess the Evidence Based findings related to Acute
Gastroenteritis.
Population Studied: There are two populations effected by
the Acute Gastroenteritis CPG. These populations are the
patients, as practice changes, and the medical staff
(physicians, pediatric residents, nurse practitioners and staff
nurses) in three environments: inpatient, outpatient and the
community.
Principal Findings: The CPG went into effect December
2004. The literature findings proved that oral rehydration is
the gold standard for rehydrating mild and moderately
dehydrated patients rather than intravenous (IV) rehydration.
Also the evidence showed that the physical assessment of the
patient performed by the medical provider was superior to
obtaining blood work for determining the extent of the
dehydration. A major component of the CPG was educating
the medical staff on the rationale for changing their practice.
Conclusions: The main impetus for developing the CPG was
to determine best practice based on current evidence. There
is an identified lag time in translating research into practice.
In order to assist the medical staff, the CPG Team researched
and synthesized the literature, provided a working algorithm
as a visual, and created standardized order sets found in the
Physician Order Management computer system.
Implications for Policy, Delivery, or Practice: The use of this
CPG will benefit our families by educating them on how to
comfortably perform oral rehydration therapy in their own
environment, the home. It will also have an economic affect
on our organization evidenced by a decrease of laboratory
work and IV rehydration performed on these children. By
adopting these standards the organization should experience
a decrease in Emergency Department utilization for the
patient with Acute Gastroenteritis.
Primary Funding Source: No Funding Source
●3D: A Tool for Improving Patient Satisfaction and
Medication Safety at Discharge
Ahmed Rahman, BS, Danica Myhre, BS, Dennis M. Manning,
MD, FACP, FACC, John O’Meara, Pharm.D, Karyl Tammel,
Lisa Carter, RN, MSN, Arthur R. Williams, Ph.D.
Presented By: Ahmed Rahman, BS, Senior
Analyst/Programmer, Health Care Policy & Research, Mayo
Clinic, 200 First Street SW, Rochester, MN 55905; Tel:
(507)538-1543; Fax: (507)284-9542; Email:
rahman.ahmed@mayo.edu
Research Objective: To determine whether a newly designed
form, Durable Display at Discharge (3D) compared to a
standard form, Medication Discharge Worksheet (MDW)
improves patient satisfaction, understanding and safety of
hospital discharge medications.
Study Design: This is a randomized, prospective, clinical trial.
Over 200 adult subjects, discharged from medical services at
Mayo Clinic Rochester are being
randomized to either 3D or MDW. The 3D includes several
new elements: a) number of tablets/pills, b) indications, c)
cautions, d) reconciliation (medications you should no longer
take…), e) space for display of the tablets and f) suggested
time of day to take each medication. A secure custom webbased system was designed to generate 3D forms and
accommodate data collection. In order to assure accurate and
complete data collection, the system provides automatic data
validations and pre-loads patient data from enterprise
databases when possible. A study recruiter who has not been
involved in patient care enrolls and randomizes the patients
into the study using the web-based system. Before leaving the
hospital, patients in the 3D arm are given a personalized 3D
form generated by the web-based system. The MDW is
generated by the patient’s nurse in the usual fashion. A nurse
then educates the patient about their discharge medications
and the form they are given. A Study Investigator (blinded to
the hypothesis) calls the patient 7-14 days after the patient is
discharged and conducts a follow-up survey using the webbased system.
Population Studied: Adults 21 years of age and older being
discharged from a teaching hospital to home self care or to
the care of a relative. Patients are receiving 4 or more regularly
scheduled medications.
Principal Findings: At this point, subjects eligible for analysis
have exceeded 150. Qualitative analysis of our primary
endpoint (satisfaction) shows a 10% but non-significant
difference favoring 3D (85% vs. 75%, t-test = 1.47). We are
“under-powered” at present. At the study conclusion, we will
have final data on satisfaction, and secondary (though
important) endpoints related to medication errors and
medication knowledge – which have not yet been preliminarily
analyzed.
Conclusions: Little is known about the relative merits of types
of Medication Discharge Education tools. At the conclusion of
our 200+ subject study, our data will add several new
elements of knowledge to this seldom studied topic. The
strengths of the study are: a) focus on patient safety and
satisfaction, b) randomized design, c) web-based tool
application for data maintenance, d) endpoints of selfreported errors, and e) an objective test (quiz) of personalized
medication knowledge and understanding.
Implications for Policy, Delivery, or Practice: Optimizing
medication discharge education is a daunting challenge. Our
study will add to knowledge concerning efficacious methods
for medication regimens. Improving the design of a discharge
medication education tool may enhance patient knowledge
and lead to improvements in both patient safety and
understanding.
Primary Funding Source: Mayo Foundation for Medical
Education and Research
●Enhancing Patient-Centered Communication Behaviors
and other Outcomes: Do Physician and Patient
Interventions make a Difference?
Jaya Rao, M.D., MHS, Lynda Anderson, Ph.D.
Presented By: Jaya Rao, M.D., MHS, Medical Epidemiologist,
Health Care and Aging Studies Branch, Centers for Disease
Control and Prevention, 4770 Buford Highway NE, MS K-51,
Atlanta, GA 30341; Tel: (770)488-5091; Fax: (770)488-5486;
Email: jrao@cdc.gov
Research Objective: Effective physician-patient
communication, a critical component of health care quality
and patient safety, is associated with improved patientcentered outcomes. We conducted a systematic review of
interventions designed to enhance the communication
behaviors of physicians and patients in outpatient clinical
settings.
Study Design: Nine online databases were searched between
1966 and 2004 using search terms focusing on
communication partners and behaviors, relationship-building
behaviors, and intervention type(s), and the references of
potentially relevant articles were hand searched. Eligible
studies: 1) tested an intervention designed to improve the
communication skills of physicians or patients; 2) were
randomized controlled trials (RCTs); 3) objectively assessed
verbal communication behaviors as the primary outcome; and
4) were published in English. Two investigators abstracted
information on the study sample, intervention, and
communication and non-communication outcomes.
Interventions were characterized by type (e.g., information,
modeling, feedback, practice), delivery strategy, and overall
intensity. Communication outcomes were categorized into
interpersonal or information-exchanging behaviors within the
context of patient-centered care principles. The intervention’s
effects on communication and non-communication outcomes
were assessed.
Population Studied: Physicians and patients in outpatient
clinical settings
Principal Findings: Thirty-two RCTs were reviewed: 14
involved physicians; 15, patients; and 3, both physicians and
patients. Nearly all physician interventions were rated as
moderately or highly intense, 78% included 3 or 4 types, and
most were delivered over time. Of all patient interventions,
half were low intensity, 41% involved only 1 type, and most
were delivered in the clinic waiting room. Compared to
controls, physicians receiving these interventions were more
likely to exhibit a patient-centered communication style and
elicit patients’ perspectives. Similarly, intervention patients
obtained more information per question and exhibited greater
involvement in the visit than controls. Most studies found no
post-intervention effects on visit length or satisfaction. Some
studies, especially those involving patient interventions, found
improved patient adherence, recall and health status.
Conclusions: Interventions to enhance communication were
associated with improved communication behaviors among
physicians and patients. The intervention intensity appeared
to be clearly related to improvements in physicians’
communication behaviors, but this relationship was less
pronounced among interventions involving patients.
Communication interventions directed toward patients
resulted in improved health status, adherence and recall.
Implications for Policy, Delivery, or Practice: The studies
included in this review demonstrate that the communication
behaviors of patients and physicians are modifiable.
However, most of the interventions examined are not feasible
for practice because they require additional personnel and
multiple sessions. The future challenge in this field is to
design effective communication interventions that can be
integrated into routine practice.
Primary Funding Source: No Funding Source
●Quantity and Cost of Informal Care Before Death Among
Community Dwelling Elderly
YongJoo Rhee, Dr.PH.
Presented By: YongJoo Rhee, Dr.PH, Norfolk, VA 23513; Tel:
(757)853-5230; Email: yjrst@yahoo.com
Research Objective: This study estimates informal care cost
for the dying elderly in communities.
Study Design: The replacement cost for informal care was
estimated using a two-part model owing to skewed data
distribution. A probit model is used to estimate the probability
of informal care use. For cases with positive hours, ordinary
lease squares regression is used to estimate the natural
logarithm of hours. The derivative of expected hours is
estimated for each observation and, then averaged over full
sample. The derivates of expected hours are summed to get
the effect of the independent variables on total hours of care
Population Studied: This study uses data from the 1993
Asset and Health Dynamics Study, a nationally representative
survey of people age 70 or older (N = 7,443). Proxy informants
for people who died (n=727) before 1995 follow-up were
interviewed
Principal Findings: These adjusted hours are multiplied by
1998 national average home aide wage ($8.20 per hour). .
Sensitivity tests are performed using the 10th percentile wage
rate ($5.90) and 90th percentile wage rate ($10.80). All
analyses are conducted using sample weights to generate
estimates of the economic costs of informal caregiving before
death at a national level.
Conclusions: Family burden is still significant to take care of
the dying elderly. The reasonable financial estimates should be
prepared when this informal care is replaced with formal care
givers.
Implications for Policy, Delivery, or Practice: This study
results could use this estimation in planning for individual or
family, community for the end-of-life. These estimates should
be compared with institutionalized care, nursing home and
home care. It should take into consideration to provide
federal funded programs or support for families who deal with
the dying elderly at their homes.
Substantial financial support should be designed for family
caregivers in communities
Primary Funding Source: Other
●Controlling for Patient Case Mix at the End of Life: Issues
in Identifying Cause of Death
Samuel Richardson, BA, Wei Yu, Ph.D.
Presented By: Samuel Richardson, BA, Research Health
Science Specialist, Health Economics Resource Center, VA
Palo Alto Health Care System, 795 Willow Road (152 MPD),
Menlo Park, CA 94025; Tel: (650) 493-5000 x22816; Fax: (650)
617-2639; Email: Samuel.Richardson3@med.va.gov
Research Objective: Researchers investigating health care at
the end of life often control for patient case mix using the
death certificate underlying cause of death. It is unclear
whether the reported underlying cause of death is consistent
with the reason to control for case mix. The purpose of this
study was to examine whether the reported underlying cause
of death was consistent with the medical condition that
required the most resource use or the last important principal
diagnosis during the final year of life.
Study Design: We obtained underlying cause of death as
reported on the death certificate for 12,808 VA patients who
died in California between October 1999 and September 2001.
Using administrative data from both VA and Medicare, we
compared the reported underlying cause of death with the
major principal diagnosis closest to death and with the
diagnosis responsible for the plurality of health care costs in
the final year of life. We measured agreement between
methods at three different levels of identification: the top two
causes of death, the top four causes of death, and the top 10
causes of death, using CDC cause of death categories.
Population Studied: Our study sample consisted of veteran
decedents in California, but the results should be
generalizable to a broader population of decedents.
Principal Findings: All three methods classified similar
numbers of patients into each cause of death category.
However, neither of the methods using administrative data
was consistent with the death certificate underlying cause of
death at the patient level. For the top 10 causes of death, the
patient-level consistency was slightly above 50%. As a whole,
these methods were more consistent in identifying cancer
deaths than deaths due to other causes.
Conclusions: The three methods generate considerable
discrepancies in patient classification. The principal diagnosis
and cost-based methods are relatively consistent with one
another, but not with death certificate data.
Implications for Policy, Delivery, or Practice: Our results
suggest that methods using health utilization data should not
be used as a proxy for death certificate data. However, for
many research purposes, methods based on costs in the final
year of life or principal diagnoses near death may in fact be
more appropriate than death certificate data.
Primary Funding Source: VA
●Exploring Racial Differences in Infectious Disease
Mortality Risk in the United States
Kakoli Roy, Ph.D.
Presented By: Kakoli Roy, Ph.D., Economist, Office of
Workforce and Career Development, Centers for Disease
Control and Prevention, 1600 Clifton Road NE, MS E90,
Atlanta, GA 30333; Tel: (404)498-6298; Fax: (404)498-6145;
Email: kjr3@cdc.gov
Research Objective: To measure the extent to which blacks
and whites differ in their risk of infectious disease mortality
and whether these differences persist on controlling for
socioeconomic factors.
Study Design: Several multivariate logistic regressions were
used to measure the association between mortality risk and
race and examine whether racial differences in mortality risk
persist upon controlling for socioeconomic status (SES) and
other demographic factors.
Population Studied: The nationally respresentative National
Health Interview Surveys, 1990-1994, were linked to the
National Death Index, 1990-1997. The final sample includes
five cohorts with 335,918 persons aged 18 years or more, 5.13%
of whom died during the 4-8 years of follow-up.
Principal Findings: Mortality risk from infectious diseases is
higher among blacks compared to whites; controlling for SES
narrows the black-white gap with odds ratios declining from
1.88 to 1.60. Controlling for the same factors also narrows the
black-white gap in mortality risk for both all-cause and
noncommunicable diseases as odds ratios decline from 1.34
to 1.13 and 1.28 to 1.09, respectively. However, the race effect
on injury-related deaths, on adjusting for SES, was found to be
statistically insignificant.
Conclusions: Even after controlling for SES and other
demographic factors, we determined that blacks have an
increased risk of death from infectious diseases compared
with whites. However, because infectious diseases are diverse
with respect to race predilections, future research is needed to
examine whether race-based effects persist for specific
infectious diseases.
Implications for Policy, Delivery, or Practice: Such
information could also contribute toward more targeted policy
formulation by identifying individual diseases for which the
effect of race is most pronounced.
Primary Funding Source: No Funding Source
●Educating Culturally Competent Nurse Practitioners in
Virginia
Leorey Saligan, MS, APRN, BC-FNP, CCRN, Laurel Garzon,
DNSc, CPNP, Carolyn Rutledge, Ph.D., CFNP, Richardean
Benjamin, Ph.D., MPH, Stacey Plichta, Sc.D.
Presented By: Leorey Saligan, MS, APRN, BC-FNP, CCRN,
Lecturer, School of Nursing, Old Dominion University,
Hampton Boulevard, 2nd floor, Hughes Building, Norfolk, VA
23529; Tel: (757)683-5010; Fax: (757)683-5194; Email:
LSALIGAN@odu.edu
Research Objective: 1. To equip nurse practitioner students
with the knowledge, skills, awareness, encounters, and desire
to work with underserved or disadvantaged populations.
2. To create a Cultural Competency Infrastructure that will
facilitate the integration of cultural competency programs and
recruitment of diverse students and faculty into the family,
women’s health, and pediatric nurse practitioner programs.
Study Design: Utilized both qualitative and quantitative
methodologies. Qualitative data gathered from focus groups
using people representing various ethnic, economic, religious,
gender and sexual preference situations, as well as special
health needs such as mental illness, HIV and AIDS.
Data gathered from these focus groups are utilized by
standardized cases using professional actors as patients,
where nursing students practice their cultural sensitivity skills.
These actors represent patients from various socioeconomic
backgrounds and they provide feedback to nursing students to
better understand patient care. This role-playing is part of a
program with the Eastern Virginia Medical School’s Thomas
Center in Norfolk, Virginia, but they also travel to several Old
Dominion University’s TELETECHNET sites to provide similar
experiences to the distance learning nursing students. The
entire didactic sessions would include utilizing lectures, guest
speakers, and panels representing various cultures; clinical
activities; training and feedback utilizing standardized
patients; and participation in community multicultural
experiences. Pre, middle, and post cultural competency
measurements are obtained from the participants utilizing
Campinah-Bacote's cultural competency model.
Population Studied: Nurse Practitioner students enrolled in
the Family, Women's health, and pediatric nurse practitioner
programs of Old Dominion University, School of Nursing.
Principal Findings: Ongoing study
Conclusions: Ongoing study
Implications for Policy, Delivery, or Practice: The goals of
this project are consistent with the national goals of improving
access to quality health care through appropriate preparation,
composition, and distribution of the health profession’s
workforce; and to improve access to a diverse and culturally
competent and sensitive health profession’s workforce.
Primary Funding Source: HRSA
●Factors Associated with Depression Screening by
Certified Nurse Midwives/Certified Midwives
Lorraine Sanders, DNSc, CNM
Presented By: Lorraine Sanders, DNSc, CNM, Assistant
Professor of Nursing, Adelphi University, 3087 Shore Drive,
Merrick, NY 11566; Tel: (516)867-7840; Email:
sanders@adelphi.edu
Research Objective: To describe the depression screening
practice of CNMs/CMs and to examine relationships, using
the Theory of Planned Behavior, among attitude, perceived
ability, knowledge, and significant demographics on
depression screening.
Study Design: Self-report survey.
Population Studied: Certified nurse midwives/certified
midwives (n=387) attending the 2004 American College of
Nurse Midwives annual meeting.
Principal Findings: Only 25% of respondents (n=95) reported
that they always screened women for depression and only 12.4
% of respondents (n=47) knew of the depression position
statement published by ACNM. Using multiple regression, a
relationship was established between attitude (pr =.27, p =
.000), perceived ability (pr =.25, p = .000), knowledge ( pr
=.16, p = .004), education level (pr =.12, p = .036) and
depression screening with attitude and perceived ability
having the strongest relationship.
Conclusions: Attitude, perceived ability, knowledge, and
education account for 20% of the variance of depression
screening among CNMs/CMs. Study findings suggest that
depression screening is not fully integrated into the practice of
many CNMs/CMs.
Implications for Policy, Delivery, or Practice: Educational
intervention may positively influence attitude, ability, and
knowledge, which in turn, may increase integration of
depression care into midwifery practice. The provision of
universal depression screening may improve health outcomes
to women and their families. Further research is needed to
assess screening methods, interventions for the treatment of
depression, and evaluation of institutional barriers to
depression screening.
Primary Funding Source: No Funding Source
●Emerging Uses of Historical New Jersey Health Statistics
Information in Statewide Reports from 1877 to 2000
Marcia M. Sass, Sc.D., Mark C. Fulcomer, Ph.D., Brian Little,
DO, Donna DiBruno, DO, Michael W. Holton, Ann Jones,
Presented By: Marcia M. Sass, Sc.D., Assistant Professor,
Health Systems and Policy, UMDNJ-SPH, 32 Rebecca Court,
West Trenton, NJ 08628; Tel: (609) 771-9086; Fax: (609) 7719086; Email: MarciaSass@aol.com
Research Objective: Research Objectives: (1) to describe the
background and methods employed in developing a major
resource of historical health information; and (2) to describe
some of the primary uses of the resulting electronic reports,
particularly in student projects.
Study Design: After first describing the development of
electronic versions of the historical New Jersey health
statistics reports from 1877 to 2000, this presentation
highlights emerging uses of the unique collection that
resulted. Work on assembling this complete collection of
public documents began in 1999 as part of the preparation of
two major bibliographies that have been described earlier
(Fulcomer et al, 2002; Fulcomer et al., 2003; and Fulcomer et
al., 2004). Containing over 1,000 distinct entries, the first
bibliography was started in 1969 and covers the literature
related to discriminant functions and classification up until
1978. Based on some research on the application of
somewhat similar prediction methods to sudden infant death
syndrome (Fulcomer et al., 1981), a second bibliography on
infant mortality (IM) and adverse reproductive outcomes
(AROs) was organized and continues to expand, now in
excess of 300 entries.
Population Studied: Population of New Jersey from 1877 to
2000.
Principal Findings: Initially a few of New Jersey health
statistics reports, particularly those from decennial years, were
viewed as a small subset of the ARO collection and
incorporated into a 1999 epidemiology course. However, as
that set of reports joined some other contributions from early
peer-reviewed sources (e.g., Holt, 1913), in subsequent
courses, it soon became apparent that a complete set of the
reports in conveniently accessible electronic formats would
provide a valuable resource for courses. Because the reports
are one of the country’s earliest series of uniformly collected,
population-based health statistics, the information they
contain can provide valuable insights into the evolution of the
public health system, not only within the state and the nation
but also in some instances with international perspectives.
After completing the systematic copying of the over 45,000
pages found in the 131 reports, a process that began in the fall
of 2002, the scanning of the page images and converting
them into PDF versions (for use with Acrobat 5.0 or later) was
finished by August, 2004. First used in their entirety in the fall
2004 epidemiology courses, the entire collection is now
available for distribution at minimal cost on three CDs or a
single DVD.
Conclusions: In addition to dissemination to libraries
throughout New Jersey and the integration of some of the
information into lectures, including bioterrorism preparedness
and health disparities, this presentation focuses primarily on
the use of the reports in student projects. Among some of the
reports that will be summarized are: (1) preventing infant
mortality through vaccination; (2) the impact of milk safety on
infant mortality; (3) an overview of segregation and economic
status on infant mortality; (4) the influence of maternal age on
fetal mortality; (5) a critical review of risk factors for infant
mortality from an international and historical perspective; and
(6) a history of the reporting of fetal deaths.
Implications for Policy, Delivery, or Practice: Clearly,
despite the large number of years they span, the reports
provide historical perspectives that enrich the understanding
of many current-day health issues.
Primary Funding Source: No Funding Source
●Smoking Status, Health Status and Health Care
Utilization among Chinese Americans
Donna Shelley, M.D., MPH, Marianne Fahs, Ph.D., Rajeev
Yerneni, Ph.D. candidate
Presented By: Donna Shelley, M.D., MPH, Assistant
Professor, Sociomedical Sciences, Columbia University
Mailman School of Public Health, 722 West 168th Street, New
York, NY 10032; Tel: (212)305 0068; Fax: (212)305 0506; Email:
drs26@columbia.edu
Research Objective: Chinese Americans constitute the largest
segment of Asian Americans in the U.S. and are at particularly
high-risk for excess tobacco-related morbidity and mortality.
Yet, health care access, health status and utilization of health
care services among Chinese Americans remain largely
undocumented, and there are no studies examining the
association of smoking status with health care access and
utilization in this population. This National Cancer Institute
funded study describes and compares several indicators of
health care access and utilization among smokers and non
smokers in a representative sample of Chinese Americans
living in NYC.
Study Design: In-person interviews were conducted with 2357
representative adults ages 18-74 using a Chinese language
instrument based on validated questions from several national
surveys.
Population Studied: Chinese Americans
Principal Findings: Overall 67% of respondents were
employed, 70% had some type of health insurance, 67%
reported excellent health, 72% saw a health professional in the
past 12 months. Ninety seven percent were foreign born and
only 22% were acculturated based a composite of two
categorical variables regarding language and media. When
compared to ever smokers, never smokers were significantly
more likely to have health insurance (72% vs 64%, p<.001),
report health status as excellent (69% vs. 63% p<.05), and to
have seen a health professional in the past 12 months (75%
vs. 65%, p<.001). Results comparing current and former
smokers and the influence of acculturation and other
demographic characteristics will be presented.
Conclusions: This population based study demonstrates gaps
in access to care among Chinese American immigrants.
Results suggest that current and former smokers, both at
higher risk for tobacco related morbidity and mortality, are
less likely to receive preventive and treatment services.
Implications for Policy, Delivery, or Practice: Our findings
have important policy implications for immigrant health.
Results provide new information about health care access
among a high risk population and will inform future research
to reduce tobacco-related health disparities among Chinese
Americans.
Primary Funding Source: NCI, Centers for Disease Control
and Prevention
●Evaluation of a Maternity-Related Post-Discharge
Program in a Managed Care Organization
Alpa Sheth, MPH, Beatriz Jaramillo, Dr.PH, Joyce Co, MPH
Presented By: Alpa Sheth, MPH, Senior Health Services
Analyst, Medical and Quality Informatics, HIP Health Plan of
New York, 55 Water Street, 5th Floor, New York, NY 10041; Tel:
(646) 447-6371; Fax: (646) 447-3164; Email:
asheth@hipusa.com
Research Objective: In a given year, there are approximately
3.9 million births in the United States. Though most efforts for
pregnancy care are focused on the pre-birth period, post
delivery is also a very critical time for the health of the mother
and her baby. Problems, if not treated promptly and effectively
in the postpartum period, can lead to ill health and even death
for both the child and mother. It is recommended that
mothers receive postpartum visits and newborns receive initial
follow-up visits in a timely manner.
For women enrolled in HIP Health Plan of New York who
delivered a baby in 2001, only 43.23% had a postpartum visit
in a timely manner. For babies born to mothers enrolled in
HIP during 2001, only 6% received a follow-up visit during the
first 14 days of their life. Consequently, a post-discharge
program was developed at HIP in order to improve
performance of these measures and provide better care. The
post-discharge program consists of a survey administered
telephonically within 48 hours of discharge by HIP staff to all
females with a maternity-related discharge in order to followup on the adequacy of the hospital discharge plan and
facilitate member’s compliance with postpartum visit and
baby’s first pediatric visit. The program was initiated in 2002.
The objective of this study is to evaluate the effectiveness of
the post-discharge program in increasing compliance with
postpartum visits and newborn follow-up visits.
Study Design: The program was evaluated by: A) comparing
the proportion of female members having a postpartum visit
0 to 60 days after delivery between those members who
completed the survey and those who did not during 2002,
utilizing a Z-statistic B) comparing postpartum and newborn
follow-up visit rates over a period of three years (2001 through
2003) utilizing Bartholomew’s test. In both cases, significance
was set at alpha < 0.05.
Population Studied: All women with a maternity discharge
during 2001, 2002 and 2003 who were continuously enrolled
for the 60 days post delivery. All newborns continuously
enrolled in the plan for the 30 days after birth during the same
3 years.
Principal Findings: The proportion of female members with a
postpartum visit was statistically significantly higher among
the surveyed (39.93%) members compared to the nonsurveyed (30.07%) ones (z =2.16, p<0.05). In addition, there
were statistically significant upward trends in the proportion of
women complying with postpartum visits (p<0.05) and the
newborn follow-up visit rate (p<0.005) over the three-year
period from 2001 to 2003.
Conclusions: The results indicate that the post-discharge
survey program has been effective in increasing the proportion
of members with a maternity-related discharge who receive a
postpartum visit and the proportion of newborns with a
follow-up visit within 14 days after birth.
Implications for Policy, Delivery, or Practice: The positive
impact of the program shows that telephonic contact is
effective and may offer a useful avenue for identification and
timely treatment of postpartum depression. Since this
program has delivered significant results, it will continue at
HIP.
Primary Funding Source: HIP Health Plan of New York
●Perceptions of Racial/Ethnic Discrimination and SelfAssessed Mental and Physical Health among African
American, Hispanic, and Asian American Veterans
Linda Sohn, M.D., MPH, Nancy D. Harada, PT, Ph.D.
Presented By: Linda Sohn, M.D., MPH, Physician, Geriatrics,
VA GLAHS, 16111 Plummer Street, Sepulveda, CA 91343; Tel:
(818)891-7711 x4028; Fax: (818)895-5817; Email: Linda.Sohn
@med.va.gov
Research Objective: The objective of this research is to
examine the association between perceptions of racial/ethnic
discrimination and self-assessed mental and physical health
among African American, Hispanic, and Asian American
veterans.
Study Design: Secondary data analyses of the 2001 Veteran
Identity Program (VIP) Survey, which collected healthcare
utilization data from 3,227 veterans residing in the Veterans
Integrated Service Network 22 (VISN 22) covering Southern
California and Southern Nevada. The dependent variables,
mental and physical functioning, were measured by the SF-12
Health Survey. Independent variables included perceived
racial/ethnic discrimination (during past military service
and/or with a healthcare provider during an ambulatory care
visit in the past year) and sociodemographic variables (age,
race/ethnicity, income, education, employment status, marital
status, social support, racial/ethnic residential composition,
health insurance, regular source of medical care and smoking
history). Univariate and bivariate statistics were run to
examine distributions, frequencies, and associations between
pairs of variables. Ordinary least squares (OLS) regression
was conducted to model the mental and physical functioning
scores as a function of the two discrimination variables and
the sociodemographic variables.
Population Studied: 1,737 African American, Hispanic and
Asian American veterans were included in the analytical
sample. The average age of the sample was 57 years, about
50% of the sample was married, and 97% reported having a
regular source of care. Fifty-five percent of the sample used
the Veteran’s Administration (VA) exclusively for health care,
32% used the VA in addition to another source for health care,
and 13% were non-VA users.
Principal Findings: Most sociodemographic characteristics
were significantly associated with SF-mental and SF-physical
measures of health status. Preliminary results of the OLS
regression find that both discrimination variables significantly
influence mental and physical functioning, controlling for
sociodemographic characteristics. In both models, perceived
racial/ethnic discrimination is associated with poorer mental
and physical health status.
Conclusions: In non-veterans, racial/ethnic discrimination
has been demonstrated to adversely affect the health of
minority populations. Discrimination may be a source of
stress, thus contributing towards a decreased sense of well
being. Our study demonstrates that this may also be true for
veteran populations: Racial/ethnic discrimination (occurring
during past military service and/or during the health care visit)
may adversely influence the health of veterans, although the
mechanism by which this occurs remains to be studied.
Implications for Policy, Delivery, or Practice: Our findings
point to the need for the Department of Veterans Affairs to
begin to develop policies and programs to minimize
perceptions of discrimination during the healthcare encounter.
This may be achieved by empowering minority veterans with
social resources to reduce perceptions of discrimination
during a healthcare interaction, or by educating healthcare
providers on how to provide culturally sensitive healthcare for
specific racial/ethnic groups.
Primary Funding Source: No Funding Source
●What Care Management Processes do Medical Groups
have for Chronic Disease Care?
Leif I. Solberg, M.D., Greg Pawlson, M.D., MPH, Stephen
Asche, MA, Sara Hudson Scholle, DrPH, Sarah Shih, MPH,
Merry Jo Thoele, MPH, RDH
Presented By: Leif I. Solberg, M.D., Director for Care
Improvement Research, HealthPartners Research Foundation,
PO Box 1524, MS 21111R, Minneapolis, MN 55440; Tel: (952)
967-5017; Fax: (952)967-5022; Email:
leif.i.solberg@healthpartners.com
Research Objective: To describe the presence and
functionality of various care management processes
important to quality care for patients with chronic diseases in
a varied sample of medical groups in Minnesota.
Study Design: We recruited private medical groups for pretesting and assessment of a new survey instrument developed
by the National Committee for Quality Assurance (NCQA) for
documenting the presence and function of eight care
management processes in ambulatory care practices (PSAS or
Practice System Assessment Survey). This survey, based on
the chronic care model, also included questions about the
characteristics and culture of these medical groups. Survey
reliability was assessed by both test-retest and inter-rater
comparisons and validity was assessed by comparison of
survey responses to on-site audits of the processes. The
findings were analyzed for presence and function by medical
group and in relation to each group’s organizational features.
Population Studied: Twenty medical groups that are
members of a quality improvement collaborative in Minnesota
were identified as representing varied locations, sizes, and
quality sophistication, and 17 agreed to participate in this
study. The 11 groups that completed the final study (3 others
participated in the pretest) had from 1-33 clinic sites apiece.
Six medical groups were from rural and five from urban areas,
and five of the groups were relatively new to quality
improvement. Complete survey responses were obtained
from 328 people at 42 clinics in the 11 medical groups out of
the 452 mailed out to those with selected roles and
professions in each group (73% response rate).
Principal Findings: All data have been collected and analysis
is underway. We will report on the frequency and perceived
function of each of the following processes:
1. Continuity of care 2. Clinical information system 3. Registry
4. Systematic monitoring 5. Clinician reminders 6.
Performance tracking 7. Clinical quality evaluation and
improvement 8. Care management
We also gathered information about each organization’s
characteristics as well as the collegiality, quality emphasis, and
autonomy as reported by the physicians, nurses, and other
selected personnel in each group. This will allow us to
suggest possible relationships between the processes, cultural
features, and organizational characteristics.
Conclusions: The data available from this survey provides
information about practice systems important for quality care
of people with chronic conditions
Implications for Policy, Delivery, or Practice: Although
these results are from a relatively small sample of medical
groups, they illustrate the type of information on systems and
processes now readily available from the PSAS instrument, as
well as the extent to which these care management processes
are present in these medical groups. This information will be
helpful for those interested in measurement of the systems
needed for quality care of patients with chronic conditions,
whether for internal process improvement, public
accountability or performance payment.
Primary Funding Source: RWJF
●"It's Broke. Can We Fix It?": A Community Forum
Theatre Dialogue on Disparities in Access to Health Care
John Sullivan, MA, Mathew Stanford, BA
Presented By: John Sullivan, MA, Co-Director: Public Forum
& Toxics Assistance Division, Preventive Medicine /
Community Health, NIEHS / Sealy Center for Environmental
Health & Medicine, 301 University Boulevard, Galveston, TX
77555-1071; Tel: (409)747-1246; Fax: (409)772-1790; Email:
josulliv@utmb.edu
Research Objective: Purposes of the Forum included: 1)
using images and performative tools of TO to analyze social,
economic and cultural implications of health care disparities,
2) framing issue experientially to illustrate impacts of service
denial, and encourage audience empathy, 3) using interactive
facets of TO to encourage participatory dialogue and problemsolving among audience members and performers. (Dialogue
was expressed as actions by audience volunteers who entered
scene(s), replaced the oppressed protagonist or allied with
protagonist, and proposed solutions through stage actions.)
Study Design: A workshop convened for training in Theatre of
the Oppressed dramaturgy. Participants learned: 1) how
image tableaus may represent affective and conceptual
elements of the issue, 2) uses of dramatic structure to
sequence and focus personal stories, 3) development of
scenarios through improvisation, 4) uses of special structures
to deconstruct significance of scenic actions, and 5) using
audience interaction to invite dialogue, novel actions and
processing of spectator interventions. The show was
performed for community members in an informal space,
using an issue-specific sociometric exercise as a warm-up.
Audience selected one scene for the Forum process, and
spectators initiated interventions. Interventions were
processed, and closure scene was performed by original
protagonist.
Population Studied: 15 Workshop participants varied by SES /
Race / Ethnicity but all had direct experience with denial of
access to health care. Audience (64) varied across categories,
but medical students and health care professionals composed
>50%.
Principal Findings: The following perceptions, biases,
attitudes and differentiating characteristics emerged: 1) <12%
of audience had direct experience with denial of care, 2)
audience interventions express judgement that UTMB’s
Demand & Access Management Program (DAMP) for
rationing care poses a problem for medical ethics, 3) health
care access disparities compromise the social fabric of
communities, 4) strong ameliorative action is necessary to
“transform the system,” 5) none of the proposed interventions
gave the scenes satisfying closure.
Conclusions: This Theatre of the Oppressed Forum provided
a dynamic structure for dialogue and predisposed audiences
toward direct/authentic engagement with real life aspects of a
difficult and frustrating issue. Though no clear solutions
emerged, the audience demonstrated active empathy for the
uninsured, and political will to engage public policy-makers.
All participants, including primary care physicians, voiced an
urgent need for more detailed understanding of DAMP.
Audience members generally agreed that DAMP should be
simplified and infused with social justice.
Implications for Policy, Delivery, or Practice: Care
consumers and providers need basic information on
mechanics of DAMP – and similar systems – as well as the
fiscal parameters behind health care resource allocation. The
health care community also needs to engage in further
dialogue to develop ethical guidelines for navigating the health
care crisis that transcend free market pragmatism, the
designation of health care as solely a commodity, and moves
the dialogue into the realm of disparities in social justice (eg.
John Rawls’s difference principle, per audience member
suggestion).
Primary Funding Source: Institute for the Medical
Humanities @ UTMB / Health Care for All Texas (HCFAT)
●Evaluation of a Diabetes Care Connection Program Using
Episode Treatment Groups
Deborah Taira, Sc.D., MPA, Kenneth Buchanan, Deborah A.
Taira, Sc.D.; MPA, Richard S. Chung, M.D., Brent Hamar, Bill
Gandy, James Pope, M.D.
Presented By: Deborah Taira, Sc.D., MPA, Health economist
and research manager, Care Management, HMSA (BCBS of
Hawaii), 818 Keeaumoku Street PO Box 860, Honolulu, HI
96808-0860; Tel: (808)948-5337; Fax: (808)948-6043; Email:
deb_taira@hmsa.com
Research Objective: To examine the impact of a diabetes
disease management program on cost and quality.
Study Design: In mid-2000, a comprehensive diabetes care
management program was implemented at a large health plan
in Hawaii. For this retrospective, observational study,
administrative data (1999-2002) was grouped into Episode
Treatment Groups (ETGs). Medical directors reviewed the
types of episodes and categorized them as being: 1) diabetes
(4 ETGs); 2) complication of diabetes (e.g. acute myocardial
infarction); 3) comorbidity of diabetes (e.g. obesity); 4)
unrelated (e.g. cancer). We estimated pre-program costs for
each category, adjusted them using a trend factor based on
premium increases, and compared them to post-program
costs of care. Quality metrics were also examined pre- and
post-program implementation. Analyses were performed
separately according to insulin use and age.
Population Studied: The study sample included health plan
members with diabetes who incurred claims that were able to
be grouped into Episode Treatment Groups (n=44,334).
Principal Findings: Costs in the post-period were $18.6m less
than expected for non-insulin users and $13.6m less for
insulin users. For non-insulin users, the cost of complications
were $14.1m less than expected, while diabetes-related costs
were $2.3m more than expected. Complication reductions
were found for renal failure, coronary artery disease,
hypertension, and diabetic retinopathy. Rates of A1C, micro
albumin, and cholesterol screening all improved significantly
after program implementation.
Conclusions: Although direct diabetes costs were higher than
expected, cost of complications were lower than expected,
resulting in estimated overall cost avoidance of more than
$32.2m over 2.5 years. Findings were sensitive to trend factor
selection.
Implications for Policy, Delivery, or Practice: Further
research is needed to determine which aspects of the program
were most effective.
Primary Funding Source: HMSA (BCBS of Hawaii)
●Health-related Quality of Life Among Asian Pacific
Americans in Hawaii Compared to Whites
Deborah Taira, Sc.D., Kimberly Nakao, Richard Chung, M.D.
Presented By: Deborah Taira, Sc.D., Research Manager, Care
Management, HMSA (BCBS of Hawaii), 818 Keeaumoku
Street; PO Box 860, Honolulu, HI 96808-0860; Tel: (808)9485337; Fax: (808)948-6043; Email: deb_taira@hmsa.com
Research Objective: To examine ethnic disparities in healthrelated quality of life for Asian Pacific Americans compared to
whites, after adjustment for age, gender, educational
attainment, and area income level.
Study Design: The Center for Disease Control’s HealthRelated Quality of Life instrument was added to a member
satisfaction survey study. The survey had a 40% response
rate. Race, ethnicity, and education level were self-reported on
the survey. Area income was merged from census files using
zip code. We examined both mean number of unhealthy days
for each ethnic group and the likelihood of having no
unhealthy days. OLS regression and logistic regression
models were estimated to determine whether the level of
unhealthy days for each Asian Pacific group differed from
whites.
Population Studied: Adult members of a large health plan in
Hawaii who responded to health-related quality of life items
on a member satisfaction survey in June of 2004.
Principal Findings: After adjustment for age, gender, and
socioeconomic status, Japanese, Filipinos, and Chinese had
significantly fewer unhealthy days than whites, for both
physical and mental health. Hawaiians and patients of mixed
race were similar to whites in both areas. The largest
disparities were found for days in physical pain, with the odds
ratio of not having any pain days being OR=1.9, 95%CI[1.7,2.0]
for Japanese, OR=1.6, 95%CI[1.4,1.8] for Filipinos, and OR=1.4,
95%CI[1.2,1.5] for Chinese. The number of unhealthy days
increased with age, but decreased with education level.
Conclusions: Health-related quality of life differs by
race/ethnicity, among health plan members of a large insurer
in Hawaii, with Japanese, Filipino, and Chinese members
having fewer unhealthy days than whites.
Implications for Policy, Delivery, or Practice: Further
research is needed to determine whether there are ethnic
differences in response bias (i.e. possibly, an understatement
of unhealthy days by Asians) and to better understand the
implication of these findings on health care cost, utilization,
and outcomes.
Primary Funding Source: HMSA (BCBS of Hawaii)
●Do Comfortable Bed Positions have a Healing Effect on
Patients?
Kazue Takayanagi, M.D., Ph.D, Yuri Fujiwara, M.D., Kyoko
Sugiura, ME, Nahoko Kakudate, MP, Kazuhiko Okamoto,
Dr.Eng, Kazuhiko Nishide, Dr.Eng
Presented By: Kazue Takayanagi, M.D.,Ph.D, Associate
Professor, Health Services Administration, Nippon Medical
School, 1-1-5, Sendagi Bunkyo-ku, Tokyo, 113-8602; Tel:
(03)3822-2131; Fax: (03)3822-8144; Email: taka-y@nms.ac.jp
Research Objective: We investigated the position of the bed
in relation to the comfortableness and a healing effect on
human being.
Study Design: Apparatus: Four beds are placed parallel to
the wall in a narrow cubicle room. The ceiling has the sharp
paralleled grid pattern. White partitions between beds were
used for the privacy. And then, these beds are placed in slant
position to the wall. Procedure: Subjects lie down for
15minutes in each paralleled placed bed to wall. After 30min.
rest at outside of the room, subjects lie down for 15minutes in
each slant positioned bed to the wall. STAI, A Profile of Mood
test (POMS) were administered, and pulse, blood pressure,
and catecholamine, ACTH, cortisol, NK cell activity, blood
count, CD4/CD8 in the blood were measured, both before and
after bed ridden.
Population Studied: Fifty-two students (average age 23.1
years, 34 male, 18 female) in Nippon Medical School and The
University of Tokyo participated in the study. Informed
consent was obtained from all the participants.
Principal Findings: The subjects with low and stable anxiety
by STAI proved slower to adapt to the new lay down
circumstances either on parallel or on slant position of the
bed by POMS. On the other hand, the subjects with high and
unstable anxiety showed quicker to adapt to new lay down
circumstances. In comparison between the parallel and slant
bed, the blood pressure increased from av. 102/63 to 103/65
(p<0.05) and ACTH (Stress hormone) increased 5.5% on
subjects both in a slant positioned bed. This showed
increased stress. CD4 decreased in 5.5% (p<0.01) on subjects
in a slant positioned bed, which showed lower immunity. On
the contrary, NK cell activity increased on subjects in a slant
positioned bed. According to the questionnaire survey,
subjects lying down on the slant bed tend to feel a sense of
discomfort and some subject were nervous about slant grid
on ceiling and partitions.
Conclusions: Even healthy subjects showed stress and
decreased immunity in 15 minutes bed ridden. Increased
physiological indicator, stress hormone showed more stress in
the slant positioned bed as well as psychological change. In
general, patients may needs more comfortable circumstances.
Even subjects with low and stable anxiety by STAI proved
slower to adapt to the new lay down circumstances either on
parallel or on slant position of the bed by POMS. On the other
hand, the subjects with high and unstable anxiety showed
quicker to adapt to new lay down circumstances. It is
confirmed by the questionnaire survey. The subjects with slant
positioned bed may feel occluded space or opened space
according to the head position in relation of the wall. Most
subjects are used to lie down at a bed situated parallel to the
room at home. Position of the bed towards patient's room
may have more effect to the patient’s psychological and
physiological status in short time bed ridden. Although the
healthy subjects can accommodate new environment, it may
take time to be acclimatized to new environment for the
patient.
Implications for Policy, Delivery, or Practice: Bed
arrangement for the patient’s room should be chosen as a
parallel position to the room or non-grid ceiling should be
chosen.
Primary Funding Source: No Funding Source
●Health Care Delivery System in Rural Taiwan— What
Have we Learned from the Telemedicine Program in
Taiwan?
Hsiu-Fen Tan, Ph.D., Hung-Fu Tseng, Ph.D.
Presented By: Hsiu-Fen Tan, Ph.D., Assistant Professor,
Health Care Administration, Chang Jung Christian University,
396 Chang Jung Road, Section 1. Kway Jen, Tainan, 711; Tel:
011886-6-2785110; Fax: 011885-6-2785831; Email:
ttan@mail.cju.edu.tw
Research Objective: In 1995, the Taiwan Department of
Health (DOH) initiated a Telemedicine Pilot Program (TPP) to
improve the health services in rural areas, focusing in
specialized care, emergency services, and diagnosis
consultation. During the past 10 years, the DOH has provided
over 200 million NT dollars to the system and the number of
service areas has increased from 5 to 24. However, the
average number of visits in each location has dropped 80%.
The purpose of this study was to find out what the major
difficulties have been and what we have learned from the
experience of running this pilot program.
Study Design: This cross-sectional survey is the first
comprehensive evaluation on the TPP in Taiwan. The
questionnaire included subjects covering the quality,
accessibility, and acceptability of telemedicine care perceived
by patients and healthcare providers.
Population Studied: The face-to-face interview was
conducted among all healthcare providers using the
telemedicine system (n=144) and samples of residents living
in the areas where telemedicine were available (n=1129).
Principal Findings: About 8-20% of the residents were aware
of their local telemedicine services, less than 10% of the
residents have ever used the system. About 29% of the
residents did not think the telemedicine could provide better
care, and 25% of the residents would not increase their
willingness to seek care in town. About one third of the
residents did not agree that telemedicine improve accessibility
to specialized care and 10% of the residents expressed their
strong opinions against telemedicine. Over 82% of the former
telemedicine users expressed that they would have chosen
transferring or referral services instead of telemedicine had
they have choices. The top three reasons for choosing
telemedicine service were saving time and expenses in
commuting, needing opinions from specialists, and lack of
specialized care in local environment. The top three reasons
for not choosing telemedicine were critical emergency,
absence of physical contact with doctors, and inconvenient
schedule. The top three reasons for local health care
providers to initiate telemedicine contact with medical center
were consulting for second opinion, lack of specialty, and
confirmation of diagnosis. The top three reasons for not
initiating the system were self-confidence on diagnosis,
inconvenient schedule, and equipment malfunction.
Conclusions: Like other countries, part of the difficulty for
telemedicine in Taiwan is resistance from healthcare providers
and the low acceptability by the public. In small geographic
country like Taiwan, the value of the telemedicine is relatively
insignificant. Given the better transportation condition, wider
distribution of health resources, and freedom of choosing
services, the telemedicine inevitably became the last option for
rural residents in Taiwan.
Implications for Policy, Delivery, or Practice: In smaller
country, the value of the telemedicine may not be in providing
routine health care services to rural areas, rather, its value is in
assisting rural doctors in diagnosis to determine if transferring
or referral is necessary. Such value can improve the quality of
diagnosis so that the better quality of care.
Primary Funding Source: Taiwan Deparement of Health
●Fully Paid Employer Provided Health Insurance: Trends
in Benefits over Time
Amy Taylor, Ph.D., Alice Zawacki, Ph.D.
Presented By: Amy Taylor, Ph.D., Senior Economist, CFACT,
Agency for Healthcare Research and Quality, 540 Gaither
Road, Rockville, MD 20850; Tel: (301)427-1660; Fax: (301)4271276; Email: ataylor@ahrq.gov
Research Objective: Despite concerns about increasing
health insurance premiums, there continue to be
establishments which pay the full cost of health insurance for
their employees. As medical care costs and health insurance
premiums inevitably rise in the future, it will be important for
policymakers to understand the characteristics of these fully
paid plans and the benefits they provide. The goal of this
analysis is to examine the benefits of fully paid plans, and see
whether health care and health insurance are becoming more
expensive to employees in terms of higher co-payments,
coinsurance, and deductibles when employers pay 100
percent of premium costs.
Study Design: We analyze data from 1997 through 2002 from
the Medical Expenditure Panel Survey-Insurance Component,
which collects establishment level data on the health
insurance plans offered to employees. The survey provides
information on the plans’ premiums, contributions by
employers and employees, and covered benefits. We focus on
the plans offered by establishments that are fully paid by the
employer and present information on the benefits of these
plans, including premium levels, provider type arrangements
and out-of-pocket expenses. The benefits of fully paid plans
are compared with those of plans not fully paid by employers
and changes are examined over time.
Population Studied: The nationally representative sample of
private establishments found in the MEPS-IC from 1997-2002.
Principal Findings: Plans that were fully paid were more likely
to require referrals to see specialists, less likely to cover preexisting conditions or outpatient prescriptions, and had higher
out-of-pocket expense limits than plans that were not paid 100
percent by employers. These plans also were more likely than
plans not fully paid to have had the highest premiums, and
were less likely to be self-insured. The percentage of all plans
offered by employers who paid 100 percent for single coverage
decreased from 45 to 39 percent between 1997 and 2002 and
for family coverage the percentage decreased from 25 percent
to 21 percent. There was also a decrease in any provider type
arrangements between 1997 and 2002.
Conclusions: The characteristics and benefits of fully paid
health insurance plans, including premiums, out-of-pocket
limits, provider type arrangements and outpatient drug
coverage, differ in many ways from plans that are not fully
paid by employers and tended to be less generous in several
ways. The percent of plans that were fully paid for by
employers decreased during the time period 1997-2002.
Implications for Policy, Delivery, or Practice: As health care
costs continue to rise, it is important to look at employers’
responses to increasing health insurance premiums. While
some employers will continue to pay 100 percent of premium
costs for their employees, they may pass increasing costs on
by changing the benefit structure of these plans. Examining
the characteristics of fully paid health plans over time will shed
light on the financial burden borne by employees in the form
of rising deductibles, co-payments, and coinsurance and the
effect of these costs on the demand for health care services.
This has particular policy relevance in that these plans may
affect the attractiveness and growth of Health Savings
Accounts.
Primary Funding Source: AHRQ
●The Economic Impact of Unrecognized Bipolar Disorder
in the California Medicaid (MEDI-CAL) Program: a Six
Year Analysis
Thomas Tencer, BSc, Jeffrey S. McCombs, Ph.D., Jeonghoon
Ahn, Ph.D.
Presented By: Thomas Tencer, BSc, Graduate Student,
Pharmaceutical Economics and Policy, University of Southern
California, 1540 E Alcazar CHP-140, Los Angeles, CA 90033;
Tel: (323)442-1460; Fax: (323)442-1462; Email:
tencer@usc.edu
Research Objective: Compare the healthcare costs of
patients with unrecognized and recognized bipolar disorders
with depressed-only patients over 6 years.
Study Design: Retrospective cohort study.
Population Studied: Data from the Medi-Cal program were
used to identify 14,809 new episodes of antidepressant
therapy with 6 years of post-treatment data. Patients were
classified as recognized-BP (RBP) based on a bipolar
diagnosis and/or a mood stabilizer (MS) prescription claim
on or before initiation of AD therapy. Unrecognized-BP (UPB)
patients received a bipolar diagnosis or MS therapy after their
initial AD treatment episode. Patients were defined as having
switched into mania if they (1) terminated use of their initial
AD after one prescription; or (2) used an antipsychotic,
anticonvulsant, or MS within 30 days; or received a diagnosis
of mania within 180 days of starting AD therapy.
Principal Findings: Only 14.5% of new episodes of
antidepressant therapy were initiated by RBP patients, while
28.2% of antidepressant users ‘switched’ to a bipolar
diagnosis over a 6-year period. Depressed-only patients had
the highest health care costs during the first year ($5,465)
followed by UBP patients ($4,802) and RBP patients ($4,667).
Conversely, UBP patients exhibited the largest increase in total
cost per year after 6 years (+92.7%), followed by RBP patients
(+78.8%), then depressed-only patients (+57.8%). However,
RBP and UBP patients who show evidence of having switched
into mania after their initial antidepressant treatment episode
exhibit lower 6-year increases in total costs (49.3% and
60.6%, respectively) compared to patients with no evidence of
a switch to mania (83.6% and 98.3%, respectively).
Conclusions: UBP patients seeking treatment with
antidepressants are common and their unrecognized status
leads to an inflated trajectory of future cost increases
Implications for Policy, Delivery, or Practice: Failure to
recognize bipolar disorders in a timely manner may increase
healthcare costs.
Primary Funding Source: Eli Lilly and Company
parent proxies as a source of information about teens’ health
care experiences. For example, the National Committee for
Quality Assurance excludes 13-17 year olds from the sample of
patients surveyed as part of the accreditation processes while
the CAHPS Research Consortium allows parents to report for
their children up to age 17. Understanding parental
involvement in care and how it is related to the assessment of
care can be used to make evidenced-based decision about
whether adolescents should be included in samples for
research and evaluation and whether their information is best
provided by parents
Primary Funding Source: Minnesota Department of Human
Services
●Should Parents be Proxies? Parents’ Involvement in and
Assessment of Routine Care for Adolescents.
Annette Totten, MPA, Ph.D., Timothy J. Beebe, Ph.D.,
Kathleen Thiede Call, Ph.D.
●The Association of Distance to Care with Severity of
Disease, Length of Stay and Charges for Persons
Hospitalized with HIV/AIDS
Roberto Vargas, M.D., MPH, Paul Robinson, Ph.D., Susan
Ettner, Ph.D., William Cunningham, MD, Ph.D.
Presented By: Annette Totten, MPA, Ph.D., Research
Associate, Univ. of MN School of Public Health, SHADAC,
2221 University Avenue, Suite 345, Minneapolis, MN 55414;
Tel: (612)702-2616; Fax: (612)624-1493; Email:
tott0007@umn.edu
Research Objective: To determine how the evaluations of
quality of care made by parents serving as proxy respondents
for their adolescent children are influenced by the level of
involvement in their teen’s health care.
Study Design: 4,953 (54% response rate) enrollees in
Minnesota’s Medicaid program were selected and surveyed
between April and July 2003 as part of an effort to assess
disparities in and barriers to the use of preventative and other
health services. In cases where the selected Medicaid enrollee
was a child (under 17), data were collected from a parent. The
analyses focus on over 450 assessments provided by parents
of the health services received by adolescents 13-17. Parents’
ratings of the health care provided; of the health care provider;
of how well the provider listens; and of how well the provider
explains things were compared based on whether parents
accompany the teen to their appointments and whether the
parents go into the examination room.
Population Studied: Adolescents (13-17 years old) enrolled in
Minnesota’s Medicaid program and their parents who
responded to the survey on their behalf.
Principal Findings: Parental involvement in health care is less
likely with older teens, with both parental accompaniment to
the clinic and the examination room falling precipitously with
age. Parents who are more involved with their adolescent’s
care rate the care significantly better than parents who are less
involved. Ratings are more affected by whether the parent
goes into the exam room than whether the parent
accompanies the teen to the clinic.
Conclusions: Declining direct parental involvement in routine
health care and declines in parents’ ratings of the care with
the increasing age of the teens raise questions about the
ability of parents to serve as proxy respondents. Parents may
have limited opportunities to directly observe the care
provided to older teens and, as a result, their ratings must be
based on other sources of information.
Implications for Policy, Delivery, or Practice: Currently there
is no consistent approach to either the inclusion of
adolescents in evaluations of health services or the use of
Presented By: Roberto Vargas, M.D., MPH, Assistant
Professor, General Internal Medicine and Health Services
Research, UCLA School of Medicine, 911 Broxton Avenue, Los
Angeles, CA 90024; Tel: (310)794 3703; Fax: (310)794-0372;
Email: RBVargas@mednet.ucla.edu
Research Objective: Our study examines the association of
patient residential distance to the nearest HIV/AIDS medical
provider and nearest ancillary services site with severity of
disease, length of stay and hospital charges for patients with
HIV/AIDS admitted to acute care hospitals
Study Design: We combined data from the California Office
of Statewide Health Planning and Development 2000
discharge files, the AIDS Project Los Angeles list of HIV
services, and the 2000 Census. Our main predictors were
distances from the patient’s population-based zip code
centroid to the nearest HIV/AIDS medical provider site and
nearest ancillary care service site. Our outcomes were
dichotomized severity of disease indexes for conditions
present at the time of hospitalization: 1) Deyo Charlson 2)
Dartmouth Manitoba (DM) Charlson scores and 3) the
Severity Classification for AIDS Hospitalizations (SCAH);
length of stay and hospital charges were additional outcomes.
We used multiple logistic and linear regression to control for
differences in patient age, gender, race, and insurance status;
and levels of poverty, English language proficiency, racial and
ethnic segregation, education level and number of hospital
beds in the patient’s neighborhood of residence. Generalized
Estimating Equations were used to adjust the variance for
clustering by zip-code
Population Studied: We identified 3543 hospitalizations for
persons with HIV/AIDS in Los Angeles County in 2000.
Patients were 85% male, 56% white, 29% black, and 37%
Hispanic irrespective of race. Insurance coverage was 26%
Medicare, and 47% Medicaid and other indigent care
programs. Patients came from communities where, on
average, 35% of people had less than a high school education
and the ratio of households making less than $20,000 to
those making over $60,000 was 2:1
Principal Findings: Mean patient’s distance from care was
0.68 miles (range 0.03-13.3; s.d.0.82) from ancillary care
services and 1.81 miles (range 0.05-15.8; s.d.1.5) from medical
care services. Multiple logistic regressions suggested that a
greater distance to ancillary services was associated with a
significantly lower disease severity index among patients
admitted to acute care hospitals for both Charlson indexes,
Deyo: Odds Ratio (OR) 0.84, 95% Wald Confidence Interval
(CI) (0.73, 0.97) and DM: OR 0.86 CI (0.75,0.99) but not for
the SCAH index: OR 1.04 CI (0.93,1.16). Multiple linear
regressions suggested that greater distance from ancillary care
services was associated with a significantly greater length of
stay (estimate 0.078; p=0.002) but not with hospital charges
(estimate 0.044; p=0.120). Regression models did not show a
significant association between distance to medical care
provider and length of stay, charges or any severity indexes
Conclusions: Our results suggest that greater distance to
ancillary, but not medical, HIV services is associated with a
lower disease severity at admission and a longer length of
hospital stay during admission, implying a lower clinical
threshold for admission and a greater threshold for discharge
for patients from communities that are further away from
ancillary HIV care services
Implications for Policy, Delivery, or Practice: Improving
geographic access to ancillary services for persons with
HIV/AIDS may reduce hospitalizations and length of stay for
these patients
Primary Funding Source: National Center on Minority Health
and Health Disparities
●Methadone Treatment Sites Conduct their intake HIV
Testing Onsite
James Walkup, Ph.D., Rich Shank, MA, Guldeniz Yucelen,
Psy.M, Kevin Moore, Psy.D.
Presented By: James Walkup, Ph.D., Associate Professor,
IHHCPAR, Rutgers University, 30 College Avenue, New
Brunswick, NJ 08901; Tel: (212)724-8362; Email:
jaywalks@aol.com
Research Objective: To determine which methadone
maintenance treatment sites have opted to rely exclusively on
on-site HIV testing at intake. Centers for Disease Control
estimates suggest injection drug use plays an important role
in the spread of HIV, with more than one third of U.S. AIDS
cases traceable to it. Opiate addiction treatment settings offer
an opportunity for early detection and referral for treatment
initiation for clients with HIV. Studies of primary care and
MMT indicate on-site integration of services performs better
than referrals.
Study Design: A mailed survey regarding available treatment
policies and practices was sent to MMT sites statewide in a
state with a high rate of HIV infection. These data were
supplemented with data from the 200 Census regarding the
community setting of individual clinics. Descriptive
quantitative data were interpreted in the context of prior
qualitative work, based on a focus group with a sample of
administrators, interview and site visits with a stratified
sample of sites statewide
Population Studied: Statewide MMT treatment setting in a
state with a high rate of HIV among injection drug users.
Principal Findings: Response rate was 86% (31/36). Eleven
sites rely exclusively on on-site testing. None of these are for
profit. They also more commonly provide other, related
medical services (e.g., on-site general medical examination,
psychotropic prescribing), other HIV-related services (e.g.
condoms, specialized case management for clients with HIV),
and select mental health services (e.g. individual counseling
for those with mental illness). Approximately one fifth (6/31)
of sites do not offer HIV testing at intake.
Conclusions: Adoption of optimal integration of intake HIV
testing is limited, although not rare. Sites with this strategy
seem not to be located in more highly disadvantaged areas.
One limitation is that our findings provide no information
regarding the success of various intake HIV testing strategies
at these sites.
Implications for Policy, Delivery, or Practice: Optimal HIV
testing practices are needed across a range of MMT settings.
Research is need to determine (a) which strategies are in fact
most successful, under which circumstances; (b) which
instances of non-adoption may represent reasonable variation
vs. non-adoption that represents neglect or suboptimal service
design; (c) how institutional characteristics interaction with
service packages.
Primary Funding Source: NIMH
●Comparing the Costs and Outcomes of Hospitalists and
Private Practice Physician Groups in a Multi-hospital
Medical Center.
Thomas Wasser, Ph.D., Michael Pistoria, DO, Robert Murphy,
M.D., Zubina Mawji, M.D., John Fitzgibbons, M.D.
Presented By: Thomas Wasser, Ph.D., Biostatistician, Health
Studies, Lehigh Valley Hospital, 5754 Loyola Street, Macungie,
PA 18062; Tel: (610)402-2497; Fax: (610)402-2247; Email:
thomas.wasser@lvh.com
Research Objective: Hospitalists, whose ranks have swelled
to more than 8,000 physicians in their 15 year history, are the
frequent object of studies examining patient outcomes and
costs. Few studies break out cost by hospital service and track
this data over time. The objective of this research was twofold
and included (1) comparisons of aggregate mean values for
hospitalist and non-hospitalist medical groups, and (2)
examinations of trends in cost and Length of Stay (LOS) over
time.
Study Design: Retrospective review of existing cost data. Cost
data examined included Laboratory, Radiology, Pharmacy
variable cost as well as Total variable cost and LOS. Analysis
methods included Analysis of Variance (ANOVA) with Scheffe
Post-hoc tests. And regression analysis examining trends in
costs and length of stay over time. A p-value of 0.05 was used
to determine significance.
Population Studied: All patients (n=9,353) admitted and
followed at two hospitals whose care was provided by five
medical groups (two hospitalist groups, and three private
practice groups). Data were collected over a 16 month period
from the implementation of the hospitalist program in June
2003 to September 2004. The beginning of the study period
coincided with the implementation of the hospitalist programs
at both hospitals.
Principal Findings: ANOVA results indicated that one of the
hospitalist groups had lower costs for Laboratory, Radiology,
and Total costs than any other group (all p<0.001). This
hospitalist group also had the lowest LOS than all groups 3.37
± 3.1 (mean LOS and standard deviation) as well. This was
significantly lower than all non hospitalist groups (all
p<0.001), but not different from the second hospitalist group
3.62 ± 4.93 (p=0.534). The second hospitalist group had
generally lower costs and LOS than the non-hospitalist groups
but was not statistically significant except for Radiology which
was lower than two non-hospitalist groups (both p<0.001).
Interestingly there were few significant trends in costs and
LOS over time. It was the expectation that hospitalist
programs would show consistently lower trends over time as
they developed experience. This was not the case as the slopes
for Pharmacy cost and LOS decreased significantly for the
second hospitalist group (p=0.016 and p=0.024 respectively),
however another non-hospitalist group had similar results on
the same variables (both p<0.001).
Conclusions: These results, while only reflective of the first 16
months of the hospitalist program indicate that costs
Laboratory, Radiology, costs are both lower with hospitalist
groups as is LOS with Hospitalist care provided. It is
important to note that there were no observed differences in
Pharmacy costs between Hospitalist and Private Practice
groups.
Implications for Policy, Delivery, or Practice: This study
does not examine the changes in utilization of the hospitalist
with regard to severity of illness or diagnostic groupings. That
work is currently ongoing. However, these results indicate that
Radiology and Lab costs, when drilled down beyond total cost
are equally or more affected by the hospitalist. There was no
difference in Pharmacy costs. Our study found one hospitalist
group to be less expensive than one non-hospitalist group for
Pharmacy costs. This may be because Pharmacy costs are
highly variable from patient to patient and the resulting large
standard deviations require a longer trial to show
effectiveness.
Primary Funding Source: No Funding Source
●Examination of Practice Patterns and Case Mix in
Hospitalists and Private Practice Physician Groups Over
Time.
Thomas Wasser, Ph.D., Michael Pistoria, DO, Robert Murphy,
M.D., Zubina Mawji, M.D., John Fitzgibbons, M.D.
Presented By: Thomas Wasser, Ph.D., Biostatistician, Health
Studies, Lehigh Valley Hospital, 5754 Loyola Street,
Macungiep, PA 18062; Tel: (610)402-2497; Fax: (610)4022247; Email: thomas.wasser@lvh.com
Research Objective: One criticism of studies that show
Hospitalist programs to be effective is that the new programs
could have less severely ill patients which would affect cost
and patient outcomes. To examine this, the admission
diagnosis, severity of illness, risk of mortality and outcomes
(death and discharge location) in patients admitted to a
hospitalist service are compared to private practice physician
groups. This study examines the change in this patient mix
overtime from the implementation of the hospitalist program.
Study Design: Retrospective review over a 25 month period
(June 2002 through June 2004) of data abstracted from our
hospitals care management system. Severity of Illness (SI)
and Risk of Mortality (RM) were determined by using
APRDRG codes. Discharge (DC) information was coded as
Against Medical Advice (AMA), DC to long term facility,
Expired, Home, Hospice, or Skilled Nursing Facility (SNF).
Analysis methods included chi-square for the four point
severity of illness and risk of mortality against pre and post
hospitalist implementation. Regression analysis was used to
measure the proportion of adverse outcomes over time. Any
p-value less than 0.05 was considered significant.
Population Studied: Inpatient population (n=10,149) at two
hospitals within the same health network. Data included was
from a hospitalist program at each hospital and three private
practice groups at both hospitals. One hospitalist program
began at month 13 within the 25 month follow-up period.
Principal Findings: Upon implementation of the hospitalist
service there was not a significant difference in the admission
diagnosis between Hospitalists and Private Practice groups.
However SI was significantly lower in 10 of the 25 months
studied for Hospitalists (p<0.05), there was no difference in 12
of the 25 months (p>0.05) and private practice groups had
significantly lower SI in three of the months studied (p<0.05).
The same relationship was observed in RM as Hospitalists
had lower RM for 13 of the 25 months studied (p<0.05), there
was no difference in nine of the 25 months studied (p>0.05),
and private practice groups had significantly lower SI in three
of the months studied (p<0.05). There was no difference in
mortality rate between Hospitalists and Private Practice
groups, however there were only 293/10149 (2.89%). There
were no other significant differences in DC information
between any of the five groups studied.
Conclusions: This research examines the patient
characteristics in Hospitalist based care compared to private
practice physician groups in our network. There was no time
effect within the data indicating that Hospitalists saw less
severe patients immediately after program inception.
However, Hospitalist patients do not have the same SI or RM
as did private practice patients. There were no observed
differences in mortality within the groups.
Implications for Policy, Delivery, or Practice: There were no
patterns in the data suggesting that SI or RM rates occurred in
the initial stages of the Hospitalist program. These data
suggest that Hospitalist patients are in general not as severely
ill or at the same risk of mortality as private practice groups
however neither group lower in the beginning, or after the
implementation of the Hospitalist program. No difference in
observed mortality rate probably reflects the low mortality rate
in general within this patient population.
Primary Funding Source: No Funding Source
●Impact of a Multifaceted Quality Improvement Initiative
to Implement JCAHO Core Measures for AMI and CHF.
Thomas Wasser, Ph.D., Michael Rossi, M.D., Zubina Mawji,
M.D., Patricia Parker, RN, Joshua Skibba, M.D., Katrina Fritz,
RN, Tamara Masiado, MS
Presented By: Thomas Wasser, Ph.D., Biostatistician, Health
Studies, Lehigh Valley Hospital, 5754 Loyola Street, Macungie,
PA 18062; Tel: (610)402-2497; Fax: (610)402-2247; Email:
thomas.wasser@lvh.com
Research Objective: Over one million patients will suffer an
acute myocardial infarction (AMI) this year. Nearly half will be
a recurrent event. Associated congestive heart failure (CHF)
will consume more Medicare dollars than any other diagnosis.
In response to this disparity in clinical practice, the Joint
Commission on Accreditation of Healthcare Organizations
identified key quality indicators for the treatment of AMI and
CHF. The purpose of this research was to assess the impact of
a multifaceted quality improvement initiative to implement
Core Measures for AMI and CHF.
Study Design: Two hospitals within the same network are
participating. Three distinct observational phases including
Baseline (prior to 7/03), Phase one (7/03–6/04) data after
network campaign to promote the importance of secondary
cardiac disease prevention by issuing standardized admission
order sets. Phase two (7/04-Present) implemented a Cardiac
Core Measure Progress Note to serve as a memory tool and
cue physician compliance. Data were obtained by
retrospective chart review using a multi-system hospital
database. Chi-square was used to contrast Baseline versus
Phase one and two. Any p-value less than 0.05 were
considered significant for this analysis.
Population Studied: Patients who had a principle diagnosis
of AMI or CHF at discharge. Some patients were excluded
based on published JCAHO guidelines. Quality indicators for
this initiative were identified as the percentage of eligible
patients who met the Core Measures for AMI and CHF. Data
was analyzed at three intervals, baseline (7/02-6/03), phase
one, and first quarter of phase two. Combined quality
indicator data from both institutions is described below.
Principal Findings: For AMI: Ace inhibitor use for left
ventricular dysfunction (LVD) increased from 69% to 76%
(p=0.044) to 90% (p=0.002). Smoking cessation counseling
increased from 89% to 93% (p=0.028) to 97% (p=0.006).
Beta blocker use at discharge fluctuated from 86% to 95%
(p<0.001) to 93% (p=0.004). Inpatient mortality decreased
from 7% to 6% (p=0.465) to 5% (p=0.214). There was no
difference in the use of aspirin at admission or discharge
(95% and 97% respectively p>0.05). Beta blocker use at
admission declined minimally from 93% to 93% (p=0.897) to
91% (p=0.455) all comparisons are from Baseline to Phase
one and Baseline to Phase two respectively. For CHF:
Discharge instructions increased from 39% to 45% (p=0.013)
to 59% (p<0.001). Ace inhibitor use for LVD increased from
65% to 66% (p=0.496) to 72% (0.099). Smoking cessation
counseling increased from 43% to 44% (p=0.831) to 78%
(p=0.001). The assessment of left ventricular function
remained essentially unchanged at 93% to 92% (p=0.880) to
93% (p=0.610).
Conclusions: Clearly the interventions have progressively
increased compliance with the core measures defined above
and are showing progress on outcomes including mortality.
While some of the Phase two data have not increased to
significance levels the program data is only reflective of two
months and is currently being tracked.
Implications for Policy, Delivery, or Practice: This quality
improvement initiative is proving to be an effective
implementation of the JCAHO Core Measures for AMI and
CHF. The increased performance has resulted in decreased
inpatient mortality. It is likely that this model could be
replicated at other institutions.
Primary Funding Source: The Dorothy Rider Pool Health
Care Trust
●Insights into Provider Attitudes about Pay-for-Quality
Incentives in Health Insurance Markets
Bert White, MBA, D.Min., Mark Meterko, Ph.D., Gary Young,
Ph.D., JD, Matthew Guldin, MPH, Dan Berlowitz, M.D., James
Burgess, Ph.D.
Presented By: Bert White, MBA, D.Min., Project Director,
Health Services Department, Boston University School of
Public Health, 715 Albany Street, Boston, MA 02118; Tel: (617)
232-9500 x4380; Fax: (617)232-6140; Email: bertw@bu.edu
Research Objective: This research evaluates several
demonstration sites that are offering financial incentives to
providers. Programs involving monetary rewards to clinicians
who achieve certain quality goals are becoming increasingly
popular as a mechanism for improving health care and
controlling costs. The objective of this research is to make a
contribution to those who are involved in designing and
implementing pay-for-quality programs.
Study Design: Multiple data collection approaches are being
used including telephone interviews, written surveys, and site
visits in accordance with a conceptual frame work that
includes three primary domains: Awareness, Credibility and
Control. Practice executives with responsibility for physician
contracts in the health insurance market have been identified
in each of three demonstration projects. These practice
executives provide medical group demographic information
and access to physicians exposed to a demonstration’s
incentive plan. Practices executives have been interviewed,
physicians have been surveyed and lessons have been learned
from site visits.
Population Studied: A sample of contracting entities in each
demonstration has been used to identify and study the
practice executives and physicians.
Principal Findings: Initial conclusions are that physician
attitudes may differ from what is often presented in the media,
providers appear confused about administration of programs,
and providers, while comfortable with clinical relevance of
quality targets, are not impressed with the associated dollars,
reporting time lags and impact of the quality targets.
Conclusions: Some of the initial conclusions are that
physician attitudes may differ from public commentary,
providers appear confused about administration of programs,
and providers are comfortable with clinical relevance of quality
targets but are not impressed with the associated dollars.
Implications for Policy, Delivery, or Practice: The study
provides business case information to CMS and health
insurance markets that is required for a more robust
understanding of incentives and their application to providers.
With these findings additional research and demonstration
projects can be more strategically focused for more efficient
and effective rewarding results.
Primary Funding Source: AHRQ
●Improving Antipsychotic Adherence for Patients with Cooccurring Schizophrenia and Substance Use Disorders:
Assessing Patterns and Effectiveness of Clinical
Interventions
Josh Wilk, Ph.D., Joyce West, Ph.D., MPP, Steven Marcus,
Ph.D., Lisa Countis, Rebecca Hall, BS, Mark Olfson, M.D.,
MPH
Presented By: Josh Wilk, Ph.D., Research Scientist, Practice
Research Network, American Psychiatric Institute for Research
and Education, 1000 Wilson Boulevard, Suite 1825, Arlington,
VA 22209; Tel: (703)90-8618; Fax: (703)907-1087; Email:
jwilk@psych.org
Research Objective: 1) Characterize interventions used in
routine psychiatric practice in the U.S. to manage medication
non-adherence among patients with schizophrenia and cooccurring substance use disorders; and 2) Assess the reported
effectiveness of interventions for medication non-adherence
among patients with co-occurring schizophrenia and
substance use disorders.
Study Design: A national survey was conducted among a
random sample of psychiatrists treating schizophrenia from
the AMA Masterfile of Physicians. Each psychiatrist reported
on one adult outpatient with schizophrenia who had been in
treatment for at least one year and had been non-adherent
with oral medications at some point in the last year. 69.3% of
eligible psychiatrists responded, resulting in a sample of 295
patients. Patients with schizophrenia only were compared to
patients with schizophrenia and a history of a co-occurring
substance use disorder.
Population Studied: 295 adult outpatients with schizophrenia
who had been in treatment for at least one year and had been
non-adherent with oral medications at some point in the last
year.
Principal Findings: Psychiatrists were less likely to use
psychological interventions to manage medication nonadherence, such as discussing risks of non-adherence (?2 =
3.73, df=1, p=.05), linking adherence to personal goals (?2 =
7.44, df=1, p=.01), or exploring the meaning of taking
antipsychotic medications (?2 = 6.20, df=1, p=.01) among
their patients with co-occurring substance use disorders. They
were two times more likely to add another antipsychotic to
patients with substance use disorders (?2 = 6.93, df=1, p=.01).
There were generally few differences between the patient
groups in psychiatrists’ perceived effectiveness of
psychopharmacological, psychological, behavioral and family
interventions; however, depot antipsychotics (t=1.72, df=44,
p=.05) and daily observation of pill taking (t=2.06, df=99,
p=.03) were reported to be less effective in patients with
substance use disorders. Although simplifying dosing was the
most commonly used psychopharmacologic intervention
among patients with substance use disorders the intervention
reported to be most effective for these patients was adding
another antipsychotic medication.
Conclusions: The less frequent use of psychological
approaches by psychiatrists in treating medication nonadherence may reflect less of an emphasis on providing
psychosocial services to patients with co-occurring substance
use disorders or pessimism about the perceived effectiveness
of these interventions. This finding is troubling given that
these approaches are recommended by empirically-based
practice guidelines, and when used, psychological approaches
were found to be as effective in those with co-occurring
substance use disorders as in those without these disorders.
Implications for Policy, Delivery, or Practice: The practice of
providing fewer psychological interventions for medication
non-adherence for patients with co-occurring schizophrenia
and substance use disorders is troubling. These practices are
not only suggested by evidence-based practice guidelines, but
also were rated to be as effective for these patients as for
those without co-occurring substance use disorders. This
finding suggests a target for intervention in changing
psychiatrists' routine practice habits.
Primary Funding Source: NIMH
●Differences in the Impact of S-SCHIP for Children
Enrolled in the First Year vs the Third Year of the Program
Jean Willard, MPH, Peter C. Damiano, DDS, MPH
Presented By: Jean Willard, MPH, Senior Research Assistant,
Public Policy Center, University of Iowa, 227 South Quad, Iowa
City, IA 52242; Tel: (319)335-6815; Fax: (319)335-6801; Email:
jean-willard@uiowa.edu
Research Objective: The primary objective of this study was
to evaluated differences between the first and third years of
the Iowa S-SCHIP program.
Study Design: A pre-test, post-test panel study design was
used to evaluate the program. An 80-item questionnaire was
mailed to the parents of one randomly selected S-SCHIP
enrollee per household upon enrollment in the program. A
similar follow-up instrument was mailed regarding each child
around the 1-year enrollment anniversary. Telephone
interviews were attempted with nonrespondents.
Population Studied: Outcomes for children who initially
enrolled in S-SCHIP during approximately the first year of the
program- January, 1999 through November, 1999, were
compared to children who initially enrolled during
approximately the third year of the program- July 2001 through
June 2002. Data was only included for respondents for which
baseline and follow-up data were available- 463 cases for first
year enrollees and 1698 cases for third year enrollees. Tests on
the equality of proportions were used to determine statistically
significant differences for outcomes in first and third years.
Principal Findings: 81 percent of new enrollees in the first
year had a personal doctor or nurse upon entry into the
program vs. 86 percent in the third year. 89 percent of first
year enrollees had a personal doctor or nurse by the end of the
first year, while the percent for third year enrollees remained at
86 percent. First year enrollees were more likely to have an ER
visit in the year prior to enrolling than third year enrollees- 44
percent first year, 39 percent third year, however this declined
to about 36 percent after one year in the program for both
groups. Children in the first year were less likely to be rated in
excellent health- 37 percent vs. 45 percent, however, they were
more likely to be in excellent health after a year in the
program- 46 percent excellent, vs. 43 percent. Parents of first
year enrollees worried more about paying for health care
before joining the program- 95 percent worried, vs. 90
percent, however about 60 percent of both worried after one
year in the program. 27 percent of first year enrollees and 17
percent of third year enrollees unmet need for care upon
entering the program, however after one year in the program 6
percent of first year and 4 percent of third year enrollees
reported having unmet need for health care.
Conclusions: Children enrolling during the first year of the SSCHIP program were less healthy and less likely to have a
regular source of care than children enrolling in the third year.
Unmet need for care was significantly reduced in both years.
Implications for Policy, Delivery, or Practice: Early pent up
demand and/or changes in employer-sponsored health
insurance due to the slowdown in the economy and higher
insurance costs may have driven a different cohort of children
to be enrolled in the program by the third year. Although
children enrolling later may be coming in with fewer needs,
maintaining their insurance health coverage remains
important for the children’s ability to use services.
Primary Funding Source: The Iowa Department of Human
Services
●Validating a Structural Equation Model (SEM) of
Relationships Affecting Well Siblings and Mothers of
Chronically Ill Children.
Arthur Williams, Ph.D., Phoebe Williams, PhD, RN, FAAN,
Todd Huschka, BS, BA
Presented By: Arthur Williams, Ph.D., Chair, Health Care
Policy and Research, Health Care Policy and Research, Mayo
Clinic, 200 1st Street SW, Rochester, MN 55905; Tel: (507)2843356; Fax: (507)284-1731; Email: williams.arthur@mayo.edu
Research Objective: To determine the robustness of a
Structural Equation Model (SEM) that was estimated with
baseline data collected during a randomized clinical trial
(RCT).
Study Design: A SEM, parts of which had been developed,
tested, and reported by two of the authors in publications over
a 20-year period, was fit to endogenous and exogenous
variables obtained at baseline during the RCT (Journal of
Behavioral Medicine, 2002, 25: 411-424). Exogenous variables
consisted of age of the well sibling, treatment group
placement (full, partial, and control), and diagnosis of the ill
child. Endogenous variables consisted of mother’s mood, a
latent socio-economic status variable (derived from mother’s
education and family income), family cohesion, and the well
sibling’s attitude toward the illness of their chronically ill
brother or sister, sibling mood, knowledge of illness, selfesteem, social support, and behavior problems. All variables
were measured on instruments with known and published
psychometric properties. Using AMOS 5.0 and the RCT data,
the SEM was first reproduced to match against the published
model. The SEM was then fit with data from each of the
subsequent time periods and refit using baseline parameters
fixed over all time periods. Bootstrapped analysis was
performed over all periods.
Population Studied: Data were obtained at a large medical
center in the Midwestern USA over a 12-month period when
an intervention was provided to siblings and mothers of
chronically ill children. The mean age of the 252 study siblings
was 11 years. About 2/3 were older than the ill child, 50% were
male, and 86% were Caucasian. Most of the children (82.1%)
lived in two-parent families with median annual incomes
above $49,000.
Principal Findings: The SEM was robust over all time
periods. The SEM had relative chi-squares (CMIN/DF)
<=2.00, Comparative Fit Indices (CFI) > 0.90, and Root Mean
Square Error of Approximation (RMSEA) <=0.08 over all time
periods, exhibiting a good overall model fit. When each
subsequent period model was fit with their parameters fixed at
baseline estimates, the results were CMIN/DF <= 2.00, CFI >
0.84, and RMSEA <= 0.06.
Conclusions: The SEM developed with data from the RCT
appears to be valid and reliable, at least as it can be
reproduced in subsequent time periods under different
assumptions. This SEM provides a clinically useful picture of
critical psychosocial interactions that can affect the health and
well-being of siblings in families with chronically ill children.
Most notably, improved mother’s mood and family cohesion
are associated with improved sibling outcomes, and higher
levels of sibling knowledge of the chronic illness is associated
with positive outcomes on other sibling variables: reduced
behavior problems, attitudes toward the illness, mood, selfesteem, and feelings of social support.
Implications for Policy, Delivery, or Practice: Financial or inkind support to families with a chronically ill child can be
critical to positive outcomes of the well siblings. Further tests
of validity of this model should be performed using an
independent sample.
Primary Funding Source: NIH
●Temporal and Spatial Pooling of BRFSS Data to Describe
Overweight and Obesity by County
James Wilson, Ph.D., Denise Kirk, MS, Christopher Mansfield,
Ph.D.
Presented By: James Wilson, Ph.D., Associate Director, East
Carolina University, Center for Health Services Research and
Development, Physicians Quadrangle Building N, Greenville,
NC 27834; Tel: (252) 744-2785; Email: wilsonja@mail.ecu.edu
Research Objective: Interest in Behavioral Risk Factor
Surveillance System (BRFSS) data at the sub-state level has
been increasing in the health care research community.
However, many counties still have low response rates and this
contributes significantly to statistical instability across
counties. One way to improve stability over time is to pool
adjacent years of data into an average. To improve
geographic stability, there are various techniques that “borrow
strength” in numbers by pooling data from adjacent counties.
The operation of both techniques on the data results in the
smoothing of trends in time series charts and maps. Using
weight category data from the NC BRFSS, our study objectives
include 1) determine the steps necessary to create smoothed
maps using county level data and 2) demonstrate the
analytical utility and limitations of smoothing techniques used
in the description of sub-state distributions of overweight and
obese populations in Eastern North Carolina (ENC).
Study Design: SUDAAN was used to calculate weighted
percentages and confidence intervals for each county. Obesity
and overweight percentages were then mapped. A countystandard error map provided a relative measure of map
instability. The map was then smoothed spatially using
standard errors of adjacent counties as inverse weights.
Smoothed maps were then generated using ArcGIS (ESRI) for
studying trends in the distribution of overweight and obese
populations.
Population Studied: The total 1999 through 2002 BRFSS
study population for ENC weight categories was 4,849.
County respondents for this 41-county region numbered from
5 to 687. Regionally, the study was comprised of 67.3%
Whites and 23.9% African-Americans with the African-
American population under-represented by one-third.
Corrections in the survey analysis methodology were applied
to obtain a closer approximation to regional proportions.
Principal Findings: Regionally, the temporally aggregated
percentages for overweight and obesity were 36.5% and
24.6%, respectively. Whites (37.7%) were slightly more
overweight than African-Americans (34.4%). In contrast,
African-Americans were more obese. The percentage of obese
African-Americans was 35.0% compared to Whites at 20.8%.
For the observed map, there was variation among counties for
the two weight categories. In counties with proportionally
larger African-American populations, Whites were less
overweight and both groups were similar with respect to
obesity. Counties with higher White population proportions
had African-Americans with higher percentages of obesity,
while Whites were more overweight. Because larger counties
have higher proportions of Whites, they tended to be similar
to the regional weight category distribution. Spatially
smoothing the survey results removed extreme inter-county
variation, making neighboring counties more similar.
Conclusions: At present, the geographic coverage for BRFSS
data is not complete. Maps that have been smoothed did not
contradict the observed survey distributions and made trends
more intelligible where there were statistically sufficient
numbers.
Implications for Policy, Delivery, or Practice: The
geographical portrayal of survey data can have a great impact
on policy formation as well as assist in the locating problem
areas and the deployment of programs and resources. As
BRFSS data collection proceeds, statistical reliability will
improve, which will make assessment of programmatic efforts
in treating overweight and obesity possible.
Primary Funding Source: No Funding Source
●Health Services Use Among Older Women: The
Combined Roles of Self-rated Physical and Mental Health
Jacqueline Wiltshire, MPH, Ph.D., Michelle McQuirter, BSN,
MS, Orlando Taylor, Ph.D.
Presented By: Jacqueline Wiltshire, MPH, Ph.D., PostDoctoral Fellow, Center for Women's Health Reseach,
University of Wisconsin Medical School, 202 South Park
Street, 6W, Madison, WI 53717; Tel: (608)-267-5566; Fax:
(608)-267-5575; Email: wiltshire@wisc.edu
Research Objective: Research shows that high use of medical
care and low use of mental health care by older women is
partly attributable to misinterpreting mental health symptoms
as medical problems. While self-rated physical health is
commonly used to assess use of health services, self-rated
mental health is often overlooked, and little has been done to
evaluate how the combination of mental and physical health
influence health services use. The purpose of this study was to
examine the extent to which the combined roles of self-rated
physical health and mental health influences health services
utilization patterns among older women.
Study Design: Data for the study were drawn from the 200001 Household Component of the Community Tracking Study,
a nationally representative survey. The key independent
variable, a combination of SF-12 physical and mental health
summary scores, was measured as poor physical-poor mental,
poor physical-good mental, good physical-poor mental, and
good physical-good mental health. SF-12 mean scores of <50
are defined as poor health and scores >50 as good. Health
services were measured as yes/no to physician, mental health
(MH), medical professional (MP), and emergency room (ER)
visits. All regression analyses accounted for complex survey
design and were adjusted for race/ethnicity, age, marital
status, rural/urban, education, employment, federal poverty
level, usual source of care, and managed care.
Population Studied: The sample included 7,860 insured
women aged 55 and over.
Principal Findings: Overall, 18.4% of respondents were in
poor physical-poor mental health (both mean scores <50),
43.8 in poor physical-good mental health, 6.4% in good
physical-poor mental health, and 31.5 were in good physicalgood mental health. 90.6% of the women had physician
visits, 16.4% medical provider visits, 15.8% emergency room
visits, and 5.1% mental health visits. All comparisons made to
respondents in good physical-good mental health. Poor
physical-poor mental health was associated with higher
physician visits (OR=3.83, 95% CI: 2.86-5.13), MP visits
(OR=2.01, 95% CI: 1.64-2.47), ER visits (OR=3.56, 95% CI:
2.92-4.35), and MH visits (OR=6.28, 95% CI: 4.44-8.99), while
good physical-poor mental health was associated with lower
physician (OR=1.46, 95% CI: 1.05-2.03), MP (OR=1.18, 95% CI:
0.85-1.65), and ER visits (OR=1.53, 95% CI: 1.10-2.11). However,
women in good physical-poor mental health had more MH
visits (OR=4.55, 95%CI:2.98-6.95) than those in poor physicalgood mental (OR=1.62, 1.11-2.34).
Conclusions: While women in poor physical-poor mental
health may confuse mental health symptoms for physical
medical symptoms which may contribute to their higher
services use, there is less indication that women in good
physical-poor mental health misinterpret mental health
symptoms for medical symptoms.
Implications for Policy, Delivery, or Practice: Assessing the
combined effects of self-rated physical and mental health is
key to understanding older women’s use of health services.
Primary Funding Source: NIA
●The Effect of the Medicare Balanced Budget Act on Racial
Disparities -An Examination of the Impact of Hospital
Financial Stress on Time to Treatment and Mortality for
Patients with Acute Myocardial Infarction
Jingsan Zhu, MBA, Tamara Konetzka, Ph.D., Lori Parson, Eric
Peterson, Ph.D., Kevin Volpp, M.D., Ph.D.
Presented By: Jingsan Zhu, MBA, School of Medicine,
University of Pennsylvania, 1225 Blockley Hall, 423 Guardian
Drive, Philadelphia, PA 19104; Tel: (215) 573-9731; Fax: (215)
573-8778; Email: jingsan@mail.med.upenn.edu
Research Objective: The Balanced Budget Act of 1997
reduced Medicare reimbursement to hospitals by about $116
billion, forcing hospitals to operate under increased pressure
of cost containment. Hospital financial stress could
exacerbate existing disparities in care.
Study Design: A retrospective study using process and
outcome measures of patients admitted with acute myocardial
infarction (AMI) to 208 National Registry of Myocardial
Infarction (NRMI) hospitals from 1996 to 2001. We simulated
the impacts of BBA and its subsequent refinements to predict
the exogenous effects of Medicare reimbursement cuts on
hospital revenues. 1997-2001 Medicare Cost Report data were
used to determine pre-BBA payments and to calculate both
baseline and changes in actual hospital margins over time.
Changes in major outcome and process measures were
estimated for black patients and white patients using
multivariate linear or logistic regressions as appropriate. We
tested whether the BBA impacts were different for white and
black patients in a combined model by testing interactions
between race and impact group.
Population Studied: 226,773 patients admitted with AMI,
who were treated in hospitals that submitted at least 20 AMI
cases per year to NRMI registry from 1996 to 2001.
Principal Findings: Among black patients, we found time
from hospital arrival to thrombolytic therapy ordering
worsened to a greater degree in high vs. low impact hospitals
in post-BBA years 1999 (.12 hours, p=.03) and 2000 (.10
hours, p=.04). For white patients, this measure also worsened
in high vs. low impact hospitals in post-BBA years 1999 (.13
hours, p=.04) and 2000 (.14 hours, p=.01). Time to
thrombolytic therapy initiation worsened to a similar degree in
1999 and 2000 for both blacks and whites. For whites and
blacks, time from hospital arrival to cardiac catheterization
improved in high impact vs low hospital to similar degrees (.52 hours, p=.05 for blacks, -.63 hours, p=.04 for whites).
Hospital mortality rate for blacks increased in 2001 in high
impact relative to low impact hospitals (OR 1.17, p=.02) but
changed at similar rates in low and high impact hospitals for
whites. Operating margins decreased to a degree
commensurate with the estimated degree of revenue
reduction in high vs. low impact hospitals.
Conclusions: The Balanced Budget Act of 1997 created a
moderate financial strain on hospitals but hospital operating
margins seemed to have absorbed the bulk of these
reductions. Over the time period from 1997-2001, there was
no strong and systematic indication that the process of care
for patients with AMI was differentially affected based on race.
Implications for Policy, Delivery, or Practice: Continued
research is needed to examine whether more vulnerable
patient groups are disproportionately affected as the financial
health of hospitals comes under further pressure.
Primary Funding Source: Doris Duke Charitable Foundation